Inspection Reports for
Ozanam Hall of Queens Nursing Home Inc
42-41 201st Street, Bayside, NY, 11361
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Inspection Report — Oct 3, 2024
Certification/complaint State
Date: Oct 3, 2024
Visit Reason
State-compiled facility profile showing 15 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The facility received 299 complaints with 10 on-site inspections resulting from complaints. Three citations were issued related to complaints during the reporting period.
Findings
Across 15 inspections, 42 citations were issued, mostly related to standard health and life safety code violations. The facility had 3 enforcement actions with fines totaling $16,000 and numerous citations indicating minor potential harm.
Citations (23)
Standard Health Citation — quality of care: Activities did not meet interests or needs of each resident.
Standard Health Citation — quality of care: ADL care was not adequately provided for dependent residents.
Standard Health Citation — quality of care: Reporting of alleged violations was deficient.
Standard Health Citation — quality of care: Requirements before submitting a request were not met.
Standard Health Citation — quality of care: Resident rights and exercise of rights were not fully ensured.
Standard Health Citation — quality of care: Respiratory/tracheostomy care and suctioning were inadequate.
Standard Health Citation — quality of care: Residents were not given the right to participate in planning care.
Standard Health Citation — quality of care: Treatment/devices to maintain hearing/vision were insufficient.
Life Safety Code Citation — NFPA requirements: Corridor doors did not meet code requirements.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system were deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler system installation was inadequate.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing were deficient.
Life Safety Code Citation — NFPA requirements: Subdivision of building spaces - smoke barriers were inadequate.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient.
Standard Health Citation — quality of care: Accuracy of assessments was deficient.
Standard Health Citation — quality of care: Encoding/transmitting resident assessments was deficient.
Standard Health Citation — quality of care: Infection prevention and control was inadequate.
Standard Health Citation — quality of care: Sufficient nursing staff was not maintained.
Life Safety Code Citation — NFPA requirements: Cooking facilities did not meet code.
Life Safety Code Citation — NFPA requirements: Egress doors were deficient.
Life Safety Code Citation — NFPA requirements: Electrical equipment testing and maintenance were deficient.
Life Safety Code Citation — NFPA requirements: Portable fire extinguishers were deficient.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures were deficient.
Report Facts
Inspections on page: 15
Total violations/deficiencies cited: 42
Inspections with violations: 11
Inspections without violations: 4
Total complaints: 299
On-site complaint inspections: 10
Citations issued from complaints: 3
Enforcement actions: 3
Total fines: 16000
Inspection Report — Oct 3, 2024
Annual Inspection CMS
Date: Oct 3, 2024
Visit Reason
The inspection was a Recertification survey conducted from 09/26/2024 to 10/03/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, lack of resident participation in care planning, inadequate assistance with activities of daily living, insufficient activity programming, lack of hearing assistive devices and audiology consultation, and inadequate respiratory care including failure to monitor oxygen saturation and change oxygen tubing as required.
Citations (6)
F 0550: Staff were observed feeding residents while standing and a resident was not served their meal for an additional 30 minutes after others were served, violating resident dignity during mealtimes.
F 0553: Resident #103 or their representative were not invited to attend care planning meetings after the initial meeting, limiting resident participation in care planning.
F 0677: Resident #43 was observed unkempt with dirty clothing and strong urine odor due to refusal of showers, indicating failure to provide necessary assistance with activities of daily living.
F 0679: Residents #347 and #409 were not engaged in any activity programs on their unit, and no activity leader was assigned to the rehabilitation unit.
F 0685: Resident #287 with hearing impairment did not receive audiology consultation or assistive devices to improve hearing ability.
F 0695: Residents #58 and #127 receiving continuous oxygen did not have pulse oxygen saturations appropriately monitored and oxygen tubing was not dated or changed as required, posing infection control and respiratory risks.
Report Facts
Residents affected: 6
Residents reviewed: 38
Residents reviewed for Activities of Daily Living: 6
Residents reviewed for Activities: 38
Residents reviewed for Communication/Sensory: 38
Residents reviewed for Respiratory Care: 36
Inspection Report — Jul 19, 2022
Annual Inspection CMS
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as a Recertification and Complaint survey to assess compliance with federal regulations for nursing home care.
Complaint Details
The survey included a complaint investigation (#NY00298552) triggered by concerns about staffing and resident care, substantiated by findings of inadequate staffing and missed care such as showers.
Findings
The facility was found deficient in multiple areas including failure to submit Minimum Data Set (MDS) assessments timely, inaccurate MDS assessments, inadequate assistance with activities of daily living (ADLs) such as showers, insufficient nursing staff to meet resident needs, and lapses in infection control practices during meal service.
Citations (5)
F 0640: The facility did not ensure that the Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to CMS within 14 days of completion for resident death.
F 0641: The facility did not ensure that the MDS assessment accurately reflected a resident's discharge status, incorrectly documenting discharge to hospital instead of community.
F 0677: The facility did not provide care and assistance for activities of daily living, specifically showers or bed baths, to residents according to their needs and preferences due to staff shortages and poor documentation.
F 0725: The facility did not provide enough nursing staff daily to meet resident needs, with staffing consistently below required levels and residents missing scheduled showers for weeks.
F 0880: The facility did not ensure infection control practices during meals, as CNAs failed to perform hand hygiene between sanitizing residents' hands prior to meal service.
Report Facts
Resident sample size: 38
Residents affected: 2
CNA staffing levels: 26
CNA staffing levels: 28
CNA staffing levels: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Named in interviews regarding shower assistance and documentation | |
| CNA #2 | Named in interviews regarding shower assistance and documentation | |
| CNA #3 | Named in interviews regarding shower assistance and documentation | |
| CNA #7 | Named in interviews regarding shower assistance and documentation | |
| CNA #8 | Named in interviews regarding shower assistance and documentation | |
| CNA #10 | Named in interviews regarding staffing shortages and care provision | |
| CNA #11 | Named in interviews regarding staffing shortages and care provision | |
| RN #3 | Registered Nurse | Named in interviews regarding resident care and documentation |
| RN #4 | Registered Nurse Supervisor | Named in interviews regarding staffing and supervision |
| RN #5 | Registered Nurse | Named in interviews regarding staffing shortages |
| LPN #2 | Licensed Practical Nurse | Named in interviews regarding staffing and care provision |
| MDS Coordinator #1 | Named in interviews regarding MDS assessment accuracy | |
| MDS Coordinator #2 | Named in interviews regarding MDS assessment accuracy | |
| Director of Nursing Services | Director of Nursing | Named in interviews regarding staffing and quality assurance |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in interviews regarding staffing and documentation |
| Administrator | Facility Administrator | Named in interviews regarding staffing and facility operations |
| Staffing Coordinator for Nurses | Named in interviews regarding nurse scheduling | |
| Infection Preventionist | Named in interviews regarding infection control practices |
Inspection Report — Oct 21, 2019
Annual Inspection CMS
Date: Oct 21, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, untimely transmission of resident assessments, inaccurate resident assessments, incomplete care plan updates for pressure ulcers, and improper medication storage and labeling.
Citations (5)
F 0577: The facility did not ensure survey results were posted in a place readily accessible to residents and the public. Survey results were kept in a closed drawer and not prominently displayed as required.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessments electronically to the State within 7 days for 1 of 5 residents reviewed, missing the 14-day transmission requirement.
F 0641: The facility did not ensure resident assessments accurately reflected status. One resident was incorrectly coded as receiving ventilator care and another's significant weight loss was not captured.
F 0657: The facility failed to revise and update the comprehensive care plan to reflect a resident's left heel Stage 3 pressure ulcer in a timely manner. Weekly wound assessments were not documented between 7/24/19 and 8/20/19.
F 0761: The facility did not ensure medications were stored under proper temperature controls, were not dated when first accessed, and were not discarded within 28 days of opening. Multiple medications lacked proper labeling and refrigeration.
Report Facts
Residents reviewed: 38
Residents reviewed for Resident Assessment task: 5
Residents reviewed for Resident Assessment Facility Task: 4
Residents reviewed for Pressure Ulcer: 2
Opened medication discard timeframe: 28
Medication discard date observed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #3 | MDS Coordinator | Named in inaccurate ventilator care coding deficiency |
| MDS Director | MDS Director | Responsible for verifying MDS assessments before submission |
| Registered Dietician | Registered Dietician | Named in weight loss assessment deficiency |
| RN #1 | Registered Nurse | Named in care plan update deficiency |
| RN #2 | Unit Charge Nurse/Registered Nurse | Named in care plan update deficiency |
| RN #3 | MDS RN | Named in care plan update deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in care plan update deficiency |
| LPN #1 | Licensed Practical Nurse | Named in medication storage deficiency |
| LPN #2 | Licensed Practical Nurse | Named in medication storage deficiency |
| RN #6 | Registered Nurse | Named in medication storage deficiency |
| RN Supervisor | RN Supervisor | Named in medication storage deficiency |
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