Inspection Reports for
Mosholu Parkway Nursing & Rehabilitation Center

The facility failed to report an injury of unknown origin (fracture) within the required 2-hour window and did not ensure timely and appropriate care for two residents, including delayed transfer and delayed STAT x-ray orders. The investigation concluded no abuse or neglect occurred, but deficiencies in reporting and care coordination were identified.

The state logged 71 complaints about this facility; 10 led to on-site inspections. Eleven citations resulted from those complaints.

Across 12 inspections, 8 resulted in citations totaling 81, primarily Level 2 minor potential harm violations in both standard health and Life Safety Code categories. The facility had 71 complaints with 10 on-site inspections and no formal enforcement actions.

The facility failed to ensure that Resident #1 was free from physical restraints, as a bedsheet was tied around the resident's waist and wheelchair, which is against facility policy. The incident was investigated, corrective actions were implemented, and staff were re-trained on restraint policies.

The facility was found deficient in multiple areas including failure to honor resident bathing preferences, delayed reporting of suspected abuse, inadequate care to maintain range of motion, improper food storage and handling, unsanitary garbage disposal, incomplete medical record documentation, inadequate infection control practices, unsecured handrails, and ineffective pest control.

The complaint investigation revealed failures in abuse investigation, care planning, and supervision. The alleged abuse of Resident #12 was not properly investigated. Care plans were incomplete or not updated for Residents #76, #85, and #12. Resident #99 eloped due to inadequate supervision and unlocked facility doors.

The facility failed to thoroughly investigate an alleged abuse incident involving Resident #12, did not develop or implement comprehensive care plans for residents following incidents or for specific medical needs, and did not provide adequate supervision to prevent accidents, including an elopement by Resident #99.

The complaint investigation revealed failures in timely reporting of injuries of unknown origin, conducting thorough investigations of alleged abuse, and revising care plans following resident injuries.

The facility was found deficient in providing Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) at Medicare Part A termination, timely reporting and investigating injuries of unknown origin, revising comprehensive care plans after condition changes, monitoring blood pressure for residents on antihypertensive medication, and maintaining accurate medical records including documentation of ordered nutritional supplements and wandering guard placement.

The complaint involved an incident where Resident #73 was found with a spoon in his anal cavity. The facility did not conduct an investigation to rule out abuse. Interviews with staff and administration confirmed lack of awareness and failure to initiate required investigation procedures.

The facility failed to initiate an investigation after Resident #73 was found with a spoon in his anal cavity. The resident's care plans documented behavioral issues, but no investigation or updated care plan was initiated following the incident. Additionally, the facility failed to timely submit a Minimum Data Set (MDS) for Resident #1, which was submitted 8 days late.