Inspection Reports for
Northern Metropolitan Residential Health Care Facility Inc
225 Maple Avenue, Monsey, NY, 10952
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
267% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 31
Date: Jul 30, 2024
Visit Reason
Complaint survey with multiple standard health and life safety code citations, all corrected by late August or early September 2024.
Findings
Complaint survey with multiple standard health and life safety code citations, all corrected by late August or early September 2024.
Deficiencies (31)
Antibiotic stewardship program
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Label/store drugs and biologicals
Menus meet resident nds/prep in adv/followed
Notice requirements before transfer/discharge
Pain management
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Aisle, corridor, or ramp width
Cooking facilities
Corridor - doors
Develop ep plan, review and update annually
Egress doors
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Electrical systems - other
Emergency lighting
Exit signage
Fire drills
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Horizontal sliding doors
Illumination of means of egress
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subsistence needs for staff and patients
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jul 30, 2024
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulatory standards, including pain management practices for residents.
Findings
The facility failed to provide consistent pain assessment and monitoring for Resident #263, who required pain management. There was no documented evidence of follow-up pain assessments to determine the effectiveness of administered pain medications.
Deficiencies (1)
F 0697: The facility did not ensure consistent pain assessment and monitoring for Resident #263, resulting in a lack of documented follow-up pain assessments to evaluate medication effectiveness.
Report Facts
Residents reviewed for unnecessary medication: 5
Pain medication administration dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding pain medication administration and documentation for Resident #263. |
| Director of Nursing | Director of Nursing | Interviewed regarding the absence of a pain assessment order and documentation for Resident #263. |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Jul 30, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 7/23/24 to 7/30/24 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including resident dignity related to catheter privacy, environmental cleanliness, notification of resident transfers to the Ombudsman, comprehensive care planning for urinary catheters, pain management, medication storage, food service and menu adherence, food safety and sanitation, infection prevention and control, and antibiotic stewardship.
Deficiencies (10)
F 0550: The facility failed to maintain resident dignity for 2 residents by not ensuring urinary catheters had privacy bags, leaving drainage bags visible to roommates and visitors.
F 0584: The facility did not provide a clean, comfortable, and homelike environment on 1 of 4 units, with stained walls, chipped paint, missing moldings, and dirty floors observed.
F 0623: The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman of resident transfers or discharges for 2 of 4 residents reviewed.
F 0656: The facility did not develop or implement a comprehensive person-centered care plan for 1 resident with an indwelling urinary catheter.
F 0697: The facility failed to provide consistent pain assessment and monitoring of effectiveness of pain medication for 1 of 5 residents reviewed.
F 0761: The facility did not ensure all drugs and biologicals were labeled and stored properly, with expired and resident-specific medications found in medication carts and storage rooms.
F 0803: The facility did not ensure menus were followed for 5 of 32 residents, with multiple instances of missing food items on meal trays.
F 0812: The facility did not ensure food was stored and prepared in accordance with professional food safety standards, including unclean equipment, undated and expired foods, peeling paint, incomplete chemical testing logs, and elevated refrigerator temperatures.
F 0880: The facility failed to maintain an infection prevention and control program, including improper use of personal protective equipment, lack of environmental risk assessment for Legionella, inadequate wound care precautions, and incomplete infection surveillance.
F 0881: The facility did not implement an antibiotic stewardship program that included protocols and real-time monitoring of antibiotic use for 1 resident reviewed.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 5
Residents affected: 5
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in catheter privacy and pain management findings |
| Certified Nurse Aide #16 | Certified Nurse Aide | Named in catheter privacy finding |
| Director of Nursing | Director of Nursing | Named in catheter privacy, care plan, pain management, and antibiotic stewardship findings |
| Registered Nurse Supervisor #4 | Registered Nurse Supervisor | Named in care plan deficiency |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Named in infection prevention wound care deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection prevention PPE deficiency |
| Infection Control Practitioner | Infection Control Practitioner | Named in infection prevention and antibiotic stewardship deficiencies |
| Food Service Director | Food Service Director | Named in food service and food safety deficiencies |
| Administrator | Administrator | Named in food safety and Ombudsman notification deficiencies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Nov 22, 2021
Visit Reason
Complaint survey with standard health and life safety code citations, all corrected by early 2022.
Findings
Complaint survey with standard health and life safety code citations, all corrected by early 2022.
Deficiencies (11)
Posted nurse staffing information
Discharge from exits
Egress doors
Electrical equipment - power cords and extens
Ep testing requirements
Fire drills
Hazardous areas - enclosure
Illumination of means of egress
Maintenance, inspection & testing - doors
Physical environment
Sprinkler system - installation
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 16, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with staffing posting requirements and accuracy of staffing information.
Findings
The facility failed to post accurate daily staffing information for licensed and unlicensed nursing staff in a prominent location. Multiple days over a six-month period were missing complete staffing data for various shifts and total nursing hours.
Deficiencies (1)
F 0732: The facility did not post total and actual hours of licensed and unlicensed nursing staff daily as required. Staffing records for multiple days between May and November 2021 were incomplete or missing for day, evening, and night shifts.
Report Facts
Shifts with nursing hours posted: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed about staffing form completion and filing | |
| Director of Nursing | Interviewed regarding staffing omissions and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 18, 2018
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements related to resident assessments, care planning, and medication management.
Findings
The facility failed to ensure comprehensive assessments addressing psychosocial needs related to dementia care and psychoactive medication use for one resident. Additionally, the facility did not develop or implement a complete care plan to monitor fluid intake for a resident with a 2-liter fluid restriction, resulting in inadequate documentation and monitoring.
Deficiencies (2)
F 0636: The facility did not ensure the comprehensive assessment for one resident addressed psychosocial needs related to dementia care and psychoactive medication use, limiting the development of an appropriate person-centered care plan.
F 0656: The facility failed to develop and implement a complete care plan to ensure a resident with a 2-liter fluid restriction did not consume excess fluids and to monitor hydration status, resulting in lack of fluid intake documentation and monitoring.
Report Facts
Fluid intake documentation: 2000
Urine output documentation: 1170
Urine output documentation: 3100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager/Registered Nurse (RN #1) | Interviewed regarding resident behavioral symptoms and psychiatric evaluation | |
| Social Worker (SW) | Interviewed regarding psychosocial history and medication awareness | |
| Nurse Practitioner (NP) | Interviewed regarding resident's fluid restriction and medical condition | |
| Unit nurse in charge | Interviewed regarding care plan development and fluid restriction monitoring |
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