5 Reports
Inspection Report — May 30, 2025
State
Date: May 30, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2026 with citation and complaint history.
Complaint Details
The facility received 262 complaints with 8 on-site inspections conducted. One citation resulted from those complaints.
Findings
Across 7 inspections, 4 had no citations and 3 resulted in 28 citations total, all Level 2 minor potential harm. The facility had 262 complaints with 8 on-site inspections and no formal enforcement actions.
Citations (28)
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficiency noted.
Standard Health Citation — quality of care: Infection Control deficiency noted.
Standard Health Citation — quality of care: Quality Of Care deficiency noted.
Standard Health Citation — quality of care: Quality Of Life deficiency noted.
Standard Health Citation — quality of care: Resident Records - Identifiable Information deficiency noted.
Standard Health Citation — quality of care: Right To Be Free From Physical Restraints deficiency noted.
Standard Health Citation — quality of care: Right To Survey Results/advocate Agency Info deficiency noted.
Standard Health Citation — quality of care: Self-determination deficiency noted.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer deficiency noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiency noted.
Life Safety Code Citation — NFPA requirements: Emergency Lighting deficiency noted.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiency noted.
Life Safety Code Citation — NFPA requirements: Vertical Openings - Enclosure deficiency noted.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices deficiency noted.
Standard Health Citation — quality of care: Baseline Care Plan deficiency noted.
Standard Health Citation — quality of care: Reporting Of Alleged Violations deficiency noted.
Life Safety Code Citation — NFPA requirements: Cooking Facilities deficiency noted.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions deficiency noted.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Testing And Maintenance deficiency noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System deficiency noted.
Life Safety Code Citation — NFPA requirements: Emergency Lighting deficiency noted.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance deficiency noted.
Life Safety Code Citation — NFPA requirements: Fundamentals - Building System Categories deficiency noted.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage deficiency noted.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure deficiency noted.
Life Safety Code Citation — NFPA requirements: Horizontal Sliding Doors deficiency noted.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiency noted.
Life Safety Code Citation — NFPA requirements: Standards Of Construction For New Existing Nursing Home deficiency noted.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 28
Inspections with violations: 3
Inspections without violations: 4
Total complaints: 262
On-site complaint inspections: 8
Citations from complaints: 1
Total enforcement actions: 0
Inspection Report — May 13, 2025
Abbreviated Survey CMS
Date: May 13, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety and supervision requirements, specifically focusing on fall prevention and resident safety following incidents involving residents being found on the floor after being left unsupervised.
Findings
The facility failed to provide adequate supervision to prevent accidents for two residents at high risk for falls, resulting in multiple falls with injuries including abrasions and a subdural hematoma. Investigations concluded no abuse or neglect, but staff failed to maintain proper supervision during assigned dining room and bathroom monitoring duties.
Citations (1)
Failure to provide adequate supervision to prevent accidents, resulting in falls of two residents with injuries including abrasions and subdural hematoma.
Report Facts
Residents affected: 2
Fall risk score: 19
Fall risk score threshold: 7
Fall risk assessment date: Dates not specified for fall risk assessments for residents
Tylenol dosage: 650
Subdural hematoma size: 4
Dining room watch duty duration: 30
Scheduled dining room coverage: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Left dining room unsupervised leading to Resident #2 fall | |
| Registered Nurse #1 | Responded to Resident #2 fall and assessed injuries | |
| Registered Nurse Supervisor #1 | Assessed Resident #2 after fall | |
| Medical Doctor #1 | Assessed Resident #2 and Resident #5, ordered hospital transfers | |
| Certified Nursing Assistant #4 | Left Resident #5 unattended in bathroom leading to fall | |
| Registered Nurse Supervisor #2 | Assessed Resident #5 after bathroom fall and hospital transfer | |
| Certified Nursing Assistant #5 | Was on dining room assignment but was inattentive during Resident #5 fall | |
| Registered Nurse #2 | Responded to Resident #5 fall in dining room | |
| Registered Nurse #3 | Documented Resident #5 fall and assessment | |
| Director of Nursing | Director of Nursing | Notified of incidents and provided statements on staffing and investigations |
| Administrator | Administrator | Provided statements on staff training and incident investigations |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements on fall incidents and staff counseling |
Inspection Report — Apr 24, 2023
Annual Inspection CMS
Date: Apr 24, 2023
Visit Reason
The inspection was conducted as a Recertification survey from 4/17/2023 to 4/24/2023 to assess compliance with regulatory requirements including timely reporting of injuries, baseline care planning, and other care standards.
Findings
The facility failed to timely report an injury of unknown source involving Resident #197 to the New York State Department of Health within 2 hours as required. Additionally, the facility did not complete the baseline care plan within 48 hours of admission nor provide a written summary of the baseline care plan to Resident #129 or their representative.
Citations (2)
Failure to timely report suspected abuse or injury of unknown source involving Resident #197 to the State Survey Agency within 2 hours.
Failure to complete baseline care plan within 48 hours of admission and failure to provide resident or representative with a written summary of the baseline care plan for Resident #129.
Report Facts
Residents reviewed for Falls: 38
Residents reviewed for Care Planning: 38
Residents reviewed for Falls with deficiency: 1
Residents reviewed for Care Planning with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Interviewed regarding Resident #197 fall incident and reporting. | |
| Director of Nursing (DON) | Interviewed regarding reporting procedures and fall incident involving Resident #197 and baseline care plan completion. | |
| Assistant Director of Nursing (ADON) | Interviewed regarding responsibility for reporting incidents to NYSDOH and knowledge of reporting requirements. | |
| Registered Nurse (RN) #2 | Interviewed regarding baseline care plan creation and responsibilities. | |
| Social Worker (SW) | Interviewed regarding baseline care plan responsibilities and completion. | |
| Director of Social Services (DSS) | Interviewed regarding oversight of baseline care plan completion and distribution. | |
| MDS Coordinator (MDSC) | Interviewed regarding baseline care plan completion and provision to residents. | |
| Director of Rehab (DR) | Interviewed regarding therapist sections of baseline care plan and monitoring. |
Inspection Report — Sep 14, 2020
Annual Inspection CMS
Date: Sep 14, 2020
Visit Reason
The document is an annual inspection report for the New York Center for Rehabilitation & Nursing conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Aug 2, 2018
Annual Inspection CMS
Date: Aug 2, 2018
Visit Reason
The inspection was conducted as an annual survey of the New York Center for Rehabilitation & Nursing to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
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