Deficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
One isolated Level 2 deficiency related to medication errors was identified and corrected.
Findings
One isolated Level 2 deficiency related to medication errors was identified and corrected.
Deficiencies (1)
Residents are free of significant med errors
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with medication administration regulations following a medication error involving Methadone dosing.
Findings
The facility failed to ensure residents were free from significant medication errors, as evidenced by a Licensed Practical Nurse administering 150 mg of Methadone instead of 35 mg to one resident. Corrective actions were taken, including removal of the nurse from the schedule, staff in-service training, and audits, resulting in substantial compliance prior to the surveyor's visit.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors. A Licensed Practical Nurse administered 150 milligrams of Methadone instead of the prescribed 35 milligrams to Resident #1 on 09/06/2024.
Report Facts
Residents sampled: 3
Residents affected: 1
Methadone dose given: 150
Prescribed Methadone dose: 35
Audit duration: 8
Audit duration: 3
Licensed Practical Nurses trained: 4
Registered Nurses trained: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in medication error finding for administering wrong Methadone dose | |
| Registered Nursing Supervisor #1 | Reported medication error and informed dialysis center | |
| Registered Nurse Supervisor #2 | Documented resident's condition during dialysis | |
| Attending Physician #1 | Provided clinical statement regarding medication error impact | |
| Director of Nursing | Managed investigation and corrective actions following medication error |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 10
Date: Mar 7, 2025
Visit Reason
Multiple Level 1 and Level 2 deficiencies related to quality of care and life safety code were identified, all corrected by May 1, 2025.
Findings
Multiple Level 1 and Level 2 deficiencies related to quality of care and life safety code were identified, all corrected by May 1, 2025.
Deficiencies (10)
Encoding/transmitting resident assessments
Food procurement,store/prepare/serve-sanitary
Increase/prevent decrease in rom/mobility
Nutrition/hydration status maintenance
Posted nurse staffing information
Qaa committee
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Sprinkler system - installation
Inspection Report
Annual Inspection
Capacity: 102
Deficiencies: 9
Date: Mar 7, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 03/02/2025 to 03/07/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, environmental maintenance, timely transmission of Minimum Data Set assessments, provision of appropriate care and equipment, therapeutic diet adherence, staffing shortages especially on weekends, incomplete nurse staffing postings, safe food storage, and Medical Director participation in Quality Assurance meetings.
Deficiencies (9)
F 0550: The facility failed to ensure residents were treated with respect and dignity. Resident #32's urinary drainage bag was not covered with a dignity bag and was visible from the hallway. Licensed Practical Nurse #2 was observed standing while feeding Resident #40, contrary to policy.
F 0584: The facility did not maintain a safe, clean, and homelike environment. Observations included mismatched paint, uneven floors, ripped door kick plates, mattresses in disrepair, and broken bedside tables in resident rooms.
F 0640: The facility failed to transmit Minimum Data Set assessments to CMS within 14 days for 5 residents, resulting in late submissions.
F 0688: Resident #41 with limited range of motion was observed multiple times without the prescribed left-hand roll, risking contractures. Staff failed to apply the device as ordered.
F 0692: Resident #3 with dysphagia was observed drinking juice without the prescribed thickener, increasing risk of aspiration. Staff responsibility for thickening liquids was unclear.
F 0725: The facility had insufficient nursing staff on weekends during July-September 2024, confirmed by Payroll Based Journal data and staffing schedules, with multiple documented shortages of Licensed Practical Nurses and Certified Nursing Assistants.
F 0732: The daily nurse staffing information posted did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care, contrary to updated requirements.
F 0812: Outdated food items including cottage cheese, skim milk, cut pears, and cranberry juice were found stored in the kitchen refrigerator, posing a health hazard.
F 0868: The Medical Director did not consistently participate in Quality Assurance & Performance Improvement meetings, missing 2 quarterly meetings without documented excuse.
Report Facts
Residents reviewed for Resident Assessment: 5
Residents sampled: 23
Facility capacity: 102
Staffing shortages: 20
Expired food items: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Interviewed regarding dignity bag use for Resident #32 | |
| Registered Nurse #1 | Interviewed about dignity bag policy and left-hand roll for Resident #41 | |
| Licensed Practical Nurse #2 | Observed and interviewed about feeding Resident #40 while standing | |
| Director of Nursing | Interviewed multiple times regarding dignity bags, MDS submissions, staffing, and staff postings | |
| Certified Nursing Assistant #8 | Interviewed about failure to apply left-hand roll for Resident #41 | |
| Director for Rehabilitation | Interviewed about Resident #41's left-hand roll | |
| Speech Language Pathologist | Interviewed about Resident #3's thickened liquid order | |
| Certified Nursing Assistant #2 | Interviewed about thickener administration responsibility | |
| Licensed Practical Nurse #1 | Interviewed about thickener administration responsibility | |
| Certified Nursing Assistant #4 | Interviewed about weekend staffing and resident assignments | |
| Certified Nursing Assistant #5 | Interviewed about weekend staffing and resident assignments | |
| Staffing Coordinator | Interviewed about staffing shortages and Payroll Based Journal data | |
| Administrator | Interviewed about staffing levels, Payroll Based Journal, and QAPI meetings | |
| Dietary Aide #1 | Interviewed about outdated food items in kitchen refrigerator | |
| Dietary Supervisor | Interviewed about outdated food items in kitchen refrigerator |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
One isolated Level 2 deficiency related to involuntary seclusion was identified and corrected.
Findings
One isolated Level 2 deficiency related to involuntary seclusion was identified and corrected.
Deficiencies (1)
Free from involuntary seclusion
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
The visit was an abbreviated survey conducted to investigate the facility's compliance with resident rights, specifically regarding involuntary seclusion of a resident.
Complaint Details
The investigation was triggered by observations and complaints regarding the use of plastic bags to lock Resident #1's door, which was substantiated. Several staff members were involved and terminated. The resident was assessed with no injuries and corrective actions were implemented.
Findings
The facility was found to have improperly used plastic garbage bags to lock a resident's door, constituting involuntary seclusion. Staff involved were terminated, and the facility implemented corrective actions including re-education and increased monitoring.
Deficiencies (1)
F 0603: The facility did not ensure a resident's rights to be free from involuntary seclusion by using plastic garbage bags to lock the resident's door from 06/23/23 to 07/05/23. Staff involved were terminated and the facility re-educated all staff on abuse, neglect, and mistreatment.
Report Facts
Residents Affected: 1
Staff involved: 11
Date range of incident: From 06/23/2023 to 07/05/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Admitted to using plastic bag to lock Resident #1's door and was sent home immediately. |
| LPN #1 | Licensed Practical Nurse | Documented Resident #1's condition and was present during the incident. |
| DON | Director of Nursing | Assessed Resident #1 after incident and oversaw corrective actions. |
| RNS #2 | Registered Nurse Supervisor | Stated no knowledge of incident and participated in investigation. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Oct 11, 2023
Visit Reason
Multiple Level 1 and Level 2 deficiencies related to quality of care and life safety code were identified, most corrected by December 6, 2023.
Findings
Multiple Level 1 and Level 2 deficiencies related to quality of care and life safety code were identified, most corrected by December 6, 2023.
Deficiencies (16)
Accounting and records of personal funds
Care plan timing and revision
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free from misappropriation/exploitation
Infection prevention & control
Pharmacy srvcs/procedures/pharmacist/records
Reporting of alleged violations
Respiratory/tracheostomy care and suctioning
Rn 8 hrs/7 days/wk, full time don
Safe/clean/comfortable/homelike environment
Subsistence needs for staff and patients
Fire drills
Infection control
Ramps and other exits
Sprinkler system - installation
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a Recertification survey combined with a complaint investigation regarding alleged financial abuse by a staff member toward a resident.
Complaint Details
The complaint investigation was triggered by a resident's allegation that a Certified Nursing Assistant (CNA) borrowed money and did not repay it. The CNA initially denied the allegation but later admitted to borrowing and repaying the money. The CNA was terminated. The incident was reported late to the New York State Department of Health.
Findings
The facility failed to ensure a resident was free from financial abuse when a staff member borrowed money and did not repay it. Additionally, the facility did not timely report the suspected abuse to the Department of Health.
Deficiencies (2)
F 0602: The facility did not protect a resident from financial abuse when a staff member borrowed money and failed to repay it. The resident's complaint was not documented in nursing or social worker notes.
F 0609: The facility failed to timely report suspected abuse and the results of the investigation to the Department of Health. The incident was reported several days after the investigation began.
Report Facts
Residents reviewed for abuse: 25
Residents with abuse findings: 1
Residents reviewed for abuse in complaint: 5
Residents affected: Few residents affected as stated
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in financial abuse finding and terminated for borrowing money from resident |
| Director of Nursing Services | Director of Nursing (DNS) | Interviewed regarding investigation and reporting of abuse |
| Social Worker | Social Worker (SW) | Conducted interviews and documented investigation |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 11, 2023
Visit Reason
The inspection was conducted as a recertification survey from 10/02/2023 through 10/11/2023 to assess compliance with federal regulations for nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly personal funds statements to residents or their representatives, inadequate cleanliness and odor control in resident areas, incomplete and untimely comprehensive care plans, lack of proper respiratory care supplies, improper staffing with the Director of Nursing acting as charge nurse, food safety violations including improper food storage and hygiene practices, and ineffective infection prevention and control practices.
Deficiencies (8)
F 0568: The facility did not provide quarterly personal funds statements to residents or their representatives as required, evidenced by lack of statements for Resident #61.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment, with observations of dirty shower tiles, urine odor, debris, and overflowing garbage in multiple resident areas.
F 0656: The facility did not develop and implement a complete care plan for Resident #36 with a suprapubic catheter and Resident #304 with liver cancer and hepatitis C.
F 0657: The facility failed to review and revise the comprehensive care plan after a new physician order for a positioning device for Resident #44 with limited range of motion.
F 0695: The facility did not provide safe and appropriate respiratory care; no extra tracheal cannula was available at bedside for Resident #56 and available supplies were expired.
F 0727: The Director of Nursing served as nursing supervisor on multiple occasions when no registered nurse was assigned, contrary to policy.
F 0812: Food was not stored, prepared, distributed, and served in accordance with professional standards; undated and open food packages were observed and staff failed to wash hands or wear facial hair coverings.
F 0880: The facility failed to implement an effective infection prevention and control program; no remediation plan was in place after positive legionella samples and blood pressure cuffs were not disinfected between resident use.
Report Facts
Residents reviewed for Personal Funds: 25
Residents reviewed for Care Plans: 25
Dates DNS assigned as Nursing Supervisor: 38
Legionella positive samples: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | RN | Unable to produce CCP for Resident #304's liver cancer and hepatitis C |
| Director of Nursing Services | DNS | Interviewed regarding care plans, infection control, and staffing |
| Director of Recreation | Interviewed about personal funds statements process | |
| Comptroller | Interviewed about mailing of personal funds statements | |
| Housekeeper #1 | Interviewed about cleaning practices and challenges | |
| Housekeeper #2 | Interviewed about cleaning supplies and housekeeping meetings | |
| Administrator | Interviewed about personal funds statements and housekeeping progress | |
| Unit Registered Nurse Supervisor #1 | RN Supervisor | Interviewed about respiratory care supplies |
| Dietary Aide #1 | Observed not washing hands before food preparation | |
| Food Service Director | FSD | Interviewed about hair covering policy in kitchen |
| Licensed Practical Nurse #4 | LPN | Observed not disinfecting blood pressure cuff between residents |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 17, 2022
Visit Reason
One widespread Level 2 deficiency related to reporting to the national health safety network was identified with no correction date provided.
Findings
One widespread Level 2 deficiency related to reporting to the national health safety network was identified with no correction date provided.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 18, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for residents, with errors in coding diagnoses and treatments for three sampled residents. Additionally, the facility did not maintain proper dishwasher wash temperatures as required for sanitation, posing a risk for foodborne illness.
Deficiencies (2)
F 0641: The facility did not ensure MDS assessments were accurately completed, resulting in miscoding of diagnoses including mood disorder, schizophrenia, mechanical ventilator use, and dialysis services for three residents.
F 0812: The facility failed to maintain dishwasher wash temperatures between 120 and 140 degrees Fahrenheit as required, with observed temperatures of 90 to 100 degrees Fahrenheit during the survey.
Report Facts
Residents sampled: 27
Residents affected: 3
Dishwasher wash temperature: 90
Dishwasher wash temperature: 100
Dishwasher recommended wash temperature: 120
Dishwasher recommended wash temperature: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding MDS assessment inaccuracies and responsibility | |
| RN/MDS Assessor | Interviewed regarding MDS assessment process and errors | |
| Food Service Director | Interviewed regarding dishwasher temperature observations and manufacturer recommendations |
Viewing
Loading inspection reports...
