Inspection Reports for
New York Congregational Nursing and Rehabilitation Center
NY, 11226
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The visit was a Recertification and Abbreviated Survey to assess compliance with safety and supervision requirements, specifically related to elopement prevention.
Findings
The facility failed to ensure adequate supervision to prevent elopement of a cognitively impaired resident who left the building undetected due to a non-functioning wander alert device and distracted security staff.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent elopement of Resident #203 who left the building undetected due to a non-functioning wander alert device and distracted security staff.
Report Facts
Residents sampled: 35
Residents reviewed for wandering and elopement: 2
Resident #203 elopement time: 106
Safety visual checks frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #6 | Documented last sighting of Resident #203 and provided interview about elopement incident | |
| Assistant Director of Nursing | Interviewed regarding review of Resident #203's elopement incident and device malfunction | |
| Director of Nursing | Interviewed regarding review of Resident #203's elopement incident and device malfunction |
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 3
Date: Aug 14, 2025
Visit Reason
The inspection was conducted as part of the Recertification survey from 08/07/2025 to 08/14/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring accurate Minimum Data Set assessments, and timely review and revision of Comprehensive Care Plans. Specific issues included dirty floors with stains and odors in Unit 4, inaccurate resident assessments, and overdue care plan updates.
Deficiencies (3)
F 0584: The facility failed to maintain a safe, clean, and homelike environment in Unit 4, with dark stains, grease-like residues, and strong odors on floors. Housekeeping staff and management acknowledged the issue but cleaning was insufficient.
F 0641: The facility failed to ensure Minimum Data Set assessments accurately reflected residents' status for 2 residents, including unreported falls and incorrect diagnosis documentation.
F 0657: The facility did not ensure Comprehensive Care Plans were reviewed and revised quarterly after assessments for one resident, missing updates related to anticoagulation therapy and psychoactive drug use.
Report Facts
Residents in day room: 26
Sampled residents for Minimum Data Set assessment: 35
Residents with inaccurate Minimum Data Set assessments: 2
Residents reviewed for Unnecessary Medications: 5
Residents with overdue Comprehensive Care Plan review: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Interviewed regarding persistent dirty floors in Unit 4 | |
| Registered Nurse #2 | Nursing Supervisor | Interviewed about awareness of dirty floors and care plan updates |
| Housekeeping Staff #1 | Interviewed about cleaning responsibilities in Unit 4 | |
| Housekeeping Staff #2 | Interviewed about evening mopping duties in Unit 4 | |
| Director of Housekeeping | Interviewed about staffing and cleaning challenges in Unit 4 | |
| Minimum Data Set Coordinator | Interviewed regarding scheduling and monitoring Minimum Data Set assessments | |
| Registered Nurse #2 | Registered Nurse Supervisor | Interviewed about care plan review processes and overdue updates |
| Director of Nursing | Interviewed about care plan update responsibilities | |
| Administrator | Interviewed about care plan update oversight |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 3, 2025
Visit Reason
The visit was conducted as an abbreviated survey to investigate the facility's compliance with timely reporting of suspected abuse, neglect, or theft as required by state regulations.
Findings
The facility failed to report an alleged abuse incident involving Resident #3 within the required two-hour timeframe. The allegation was reported to the state Department of Health more than 24 hours after the incident was reported to facility staff.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse involving Resident #3 to the appropriate authorities within two hours as required by state law. The report was submitted to the New York State Department of Health over 24 hours after the allegation was made.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Named in relation to the delayed reporting of the abuse allegation | |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding the incident and reporting procedures |
| Certified Nursing Assistant #3 | Alleged perpetrator in the abuse allegation |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Sep 15, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 09/10/2023 to 09/15/2023 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including safeguarding resident property, implementing care plans, medication management, infection control, food safety, and waste disposal. Several residents did not receive care or services as ordered, and lapses in staff practices and facility procedures were noted.
Deficiencies (10)
F 0584: The facility did not ensure Resident #55's property was safeguarded and free from loss or theft. Missing personal items included 4-night gowns, and the facility failed to conduct a timely and thorough investigation.
F 0656: The facility did not ensure nursing staff implemented the interventions of a resident's care plan. Resident #25 was observed without heel booties as ordered for pressure ulcer prevention.
F 0657: The facility did not ensure comprehensive care plans were reviewed and revised as needed. Resident #46's Diabetes CCP and Resident #60's Dysfunctional Coping CCP were not updated quarterly or after significant changes.
F 0685: The facility did not ensure residents received proper treatment and assistive devices to maintain vision abilities. Residents #52 and #103 lacked recommended follow-up ophthalmology consultations.
F 0686: Resident #25 was observed without heel booties in place as ordered, indicating failure to provide appropriate pressure ulcer care consistent with professional standards.
F 0755: The facility did not ensure a system was established to record receipt and disposition of controlled drugs accurately. The 6th Floor medication cart narcotics log was incomplete and did not match medication counts.
F 0761: An expired influenza vaccine vial was found in the 6th Floor medication room refrigerator, indicating improper storage of drugs and biologicals.
F 0812: Food was not stored, prepared, distributed, and served in accordance with professional standards. Staff were not wearing hair nets, personal items were on food prep counters, food was stored too close to the ceiling, and some food was uncovered and unlabeled.
F 0814: Garbage and refuse were not properly disposed of. Trash was scattered near dumpsters, dumpsters were overflowing, and the dumpster area was not maintained to prevent pests.
F 0880: Infection control practices were not maintained. RN #1 and LPN #5 failed to perform proper hand hygiene and glove changes during wound care for Resident #120, risking infection.
Report Facts
Residents reviewed for Pressure Ulcer: 7
Residents reviewed for Activities of Daily Living: 8
Residents reviewed for Unnecessary medications: 5
Medication cart floors reviewed: 5
Medication discrepancy: 1
Expired vaccine: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Interviewed regarding narcotics log discrepancy and medication administration. |
| RN #5 | Registered Nurse | Interviewed regarding narcotics log oversight and medication administration supervision. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding wound care protocols, care plan updates, and infection control. |
| RN #1 | Registered Nurse | Observed and interviewed regarding wound care and infection control lapses. |
| LPN #5 | Licensed Practical Nurse | Observed and interviewed regarding wound care and infection control lapses. |
| Food Service Director | Food Service Director | Interviewed regarding food safety violations and kitchen observations. |
| Dietary Aide (Other Staff #12) | Dietary Aide | Interviewed regarding personal bag found in kitchen and food storage. |
| Porter/Dietary Aide (DA) #4 | Porter/Dietary Aide | Interviewed regarding garbage disposal and dumpster maintenance. |
| Director of Facilities Management | Director of Facilities Management | Interviewed regarding dumpster maintenance and garbage disposal. |
Inspection Report
Recertification Complaint
Deficiencies: 7
Date: Jan 3, 2022
Visit Reason
Recertification and complaint survey conducted from 2021-12-27 to 2022-01-03 to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The survey included a complaint investigation related to resident dignity, infection control, and care planning deficiencies.
Findings
The facility was found deficient in multiple areas including resident dignity, environmental cleanliness, care planning, activity provision, mobility support, food safety, infection control, and water management. Specific issues included uncovered Foley catheter bags, stained tubs, lack of comprehensive care plans for wounds and respiratory care, inadequate activity programming, improper use of mobility devices, unsafe food temperatures, lapses in infection control practices, and absence of a water management plan for Legionella.
Deficiencies (7)
F 0550: Resident dignity was compromised as a Foley catheter bag was left uncovered and exposed to public view on multiple occasions.
F 0584: Patient tubs on the 2nd and 3rd floors had persistent rust and discoloration stains, and the facility lacked a policy for tub cleaning.
F 0656: The facility failed to develop and implement comprehensive care plans addressing residents' actual skin breakdown and respiratory care needs.
F 0679: The facility did not provide an ongoing program of activities to meet residents' interests and support their physical, mental, and psychosocial well-being.
F 0688: A resident with limited range of motion was observed not consistently wearing a physician-ordered palm guard, and documentation lacked clarity on device use.
F 0812: Potentially hazardous foods, including baked chicken and fish, were held and served at temperatures below the safe minimum of 135°F, risking foodborne illness.
F 0880: Infection control lapses included oxygen tubing touching the floor, staff entering isolation rooms without proper PPE, and absence of a water management plan for Legionella.
Report Facts
Temperature of baked chicken on meal trucks: 121.4
Temperature of baked chicken on meal trucks: 121.5
Temperature of baked chicken on meal trucks: 113.1
Temperature of baked chicken on meal trucks: 128
Temperature of baked chicken on meal trucks: 127.9
Temperature of baked chicken in 2nd floor dining room: 108.6
Temperature of baked fish in 2nd floor dining room: 131
Temperature of chopped fish in 2nd floor dining room: 104.5
Temperature of chopped chicken stored under steam table: 100.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Interviewed regarding Foley catheter bag privacy and care |
| RN #2 | Registered Nurse | Interviewed regarding catheter bag privacy and supervision |
| DON | Director of Nursing | Interviewed regarding catheter bag privacy, care plans, and infection control |
| RN #1 | Registered Nurse | Interviewed regarding care plans and infection control procedures |
| CNA #6 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and infection control |
| Cook #1 | Cook | Interviewed regarding food temperature standards and food truck issues |
| FSM | Food Service Manager | Interviewed regarding food temperature monitoring and equipment maintenance |
| DOR | Director of Recreation | Interviewed regarding activity programming and staffing |
| DSS | Director of Social Services | Interviewed regarding resident activity interests and communication with recreation |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding splint use and CNA accountability |
| CNA #8 | Certified Nursing Assistant | Interviewed regarding splint use and care |
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