Inspection Reports for Palm Gardens Center For Nursing And Rehabilitation
NY, 11218
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Census: 226
Deficiencies: 6
Aug 31, 2023
Visit Reason
The inspection was a recertification survey conducted from 8/24/2023 to 8/31/2023 to assess compliance with regulatory requirements for Palm Gardens Center for Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including inadequate surety bond coverage for residents' personal funds, inaccurate Minimum Data Set (MDS) assessments, failure to provide appropriate care to prevent contractures, improper narcotics reconciliation, failure to act on pharmacist medication irregularities, and inappropriate use and documentation of psychotropic medications for residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility did not ensure a surety bond was purchased to cover the total personal needs accounts (PNA) of residents. | Level of Harm - Minimal harm or potential for actual harm |
| Minimum Data Set (MDS) assessment did not accurately reflect a resident's left upper extremity range of motion impairment. | Level of Harm - Minimal harm or potential for actual harm |
| Resident with limited mobility was not provided appropriate services and assistance to prevent further contractures, specifically missing prescribed hand roll. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not maintain and periodically reconcile an accurate account of all controlled drugs for one unit. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to document in the resident's medical record that pharmacist-identified medication irregularities were reviewed and acted upon. | Level of Harm - Minimal harm or potential for actual harm |
| Residents were not free from unnecessary antipsychotic medications; failure to implement gradual dose reductions and document rationale for continued use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with personal needs accounts: 60
Total residents: 226
Surety bond coverage amount: 100000
Medication units observed: 6
Medication discrepancy count: 1
Residents reviewed for unnecessary medications: 35
Residents affected by unnecessary antipsychotic medication: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in narcotics count discrepancy for Resident #184 |
| ADON | Assistant Director of Nursing | Interviewed regarding narcotics discrepancy and pharmacy recommendations |
| DON | Director of Nursing | Interviewed regarding narcotics discrepancy and pharmacy recommendations |
| Physical Therapist Assistant | Interviewed regarding Resident #12's range of motion impairment and care | |
| MDS Coordinator | Interviewed regarding Resident #12's MDS assessment error | |
| RN #3 | Registered Nurse | Interviewed regarding Resident #12's hand roll application |
| Psychiatrist | Interviewed regarding psychotropic medication use and recommendations | |
| Attending Physician | Interviewed regarding psychotropic medication use and documentation | |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding care of Resident #199 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding care of Resident #199 |
| Nursing Supervisor/Assistant Director of Nursing | Interviewed regarding care and medication management of Resident #199 | |
| Director of Nursing DNS | Director of Nursing | Interviewed regarding pharmacy recommendations and documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Aug 31, 2023
Visit Reason
Complaint Survey with 6 standard health citations and 4 life safety code citations, all corrected by late 2023.
Findings
Complaint Survey with 6 standard health citations and 4 life safety code citations, all corrected by late 2023.
Deficiencies (10)
| Description |
|---|
| Accuracy of assessments |
| Drug regimen review, report irregular, act on |
| Free from unnec psychotropic meds/prn use |
| Increase/prevent decrease in rom/mobility |
| Pharmacy srvcs/procedures/pharmacist/records |
| Surety bond-security of personal funds |
| Electrical systems - essential electric syste |
| Hazardous areas - enclosure |
| Sprinkler system - installation |
| Subdivision of building spaces - smoke barrie |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Aug 30, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's failure to timely report suspected abuse, neglect, or theft and to ensure compliance with applicable laws regarding licensed nursing staff and medication administration.
Findings
The facility failed to implement policies and procedures for timely reporting of reasonable suspicion of a crime, specifically reporting an incident 4 days late and not reporting to local law enforcement. A Certified Nursing Assistant (CNA #1) administered medications to 15 residents without a nursing license, posing as a Licensed Practical Nurse (LPN). The facility allowed CNA #1 to perform licensed nurse activities without verification of credentials, violating New York State Education Laws.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Permitting an unlicensed person (CNA #1) to perform licensed nurse activities including medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to comply with New York Education Law Sections 6512 and 6509 regarding unauthorized practice and professional misconduct. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 15
Medications administered: 106
Date of incident: Jul 10, 2023
Date reported to NYSDOH: Jul 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Administered medications without nursing license, posed as Licensed Practical Nurse. |
| RNS #1 | Registered Nurse Supervisor | Did not verify CNA #1's job title or check staffing schedule; permitted CNA #1 to perform licensed nurse activities. |
| LPN #1 | Licensed Practical Nurse | Showed CNA #1 how to administer medications and gave keys to medication cart. |
| Director of Nursing | Director of Nursing | Received report of incident; stated misunderstanding of reporting requirements. |
| Administrator | Administrator | Did not report incident to local law enforcement; assumed agency staff would report. |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated RNS must verify staff names against nursing schedule. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Aug 30, 2023
Visit Reason
Complaint Survey with 2 standard health citations related to licensing compliance and reporting of alleged violations, both corrected by October 2023.
Findings
Complaint Survey with 2 standard health citations related to licensing compliance and reporting of alleged violations, both corrected by October 2023.
Deficiencies (2)
| Description |
|---|
| License/comply w/ fed/state/locl law/prof std |
| Reporting of alleged violations |
Inspection Report
Capacity: 60
Deficiencies: 1
Jun 21, 2022
Visit Reason
Covid-19 Survey with 1 standard health citation for reporting to national health safety network, not corrected at time of report.
Findings
Covid-19 Survey with 1 standard health citation for reporting to national health safety network, not corrected at time of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Dec 20, 2021
Visit Reason
Complaint Survey with 1 standard health citation for accident hazards and supervision, corrected by January 2022.
Findings
Complaint Survey with 1 standard health citation for accident hazards and supervision, corrected by January 2022.
Deficiencies (1)
| Description |
|---|
| Free of accident hazards/supervision/devices |
Inspection Report
Annual Inspection
Deficiencies: 1
Jun 16, 2021
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with medication storage and labeling regulations.
Findings
The facility failed to ensure that medications and biologicals were discarded by their expiration dates, with expired medications found in the medication room. Staff interviews and record reviews confirmed lapses in checking and discarding expired medications despite existing policies and training.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Expired medications, including a bottle of eye vitamins with an expiration date of 08/2019, were found in the medication room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of expired medication: 201908
Date of survey completion: Jun 18, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Responsible for medication room checks and medication pass; interviewed regarding expired medication |
| RN #1 | RN Supervisor | Observed expired medication in medication room and noted need for discard |
| RN #2 | Registered Nurse | Supervises 2nd and 3rd floors; interviewed about medication expiration checks |
| Assistant Director of Nursing | ADNS | Interviewed regarding medication checking policies and audits |
| Pharmacy Consultant Supervisor | PCS | Conducts monthly medication room inspections and reports findings |
| Director of Nursing Services | DNS | Interviewed about medication checking frequency and labeling procedures |
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 5, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements and evaluate the facility's care and medication practices.
Findings
The facility was found deficient in ensuring accurate resident assessments, developing comprehensive care plans with measurable goals, and appropriate use of psychotropic medication. Specifically, Resident #22 was inaccurately assessed with a diagnosis of Non-Alzheimer's Dementia, and the use of Seroquel was not justified by documented delirium or psychotic disorder. Resident #160 lacked a comprehensive care plan addressing depression with measurable objectives. The psychiatrist did not provide a definitive diagnosis of dementia for Resident #22, and the facility failed to demonstrate that antipsychotic medication was used appropriately.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure accurate resident assessment, specifically misdiagnosis of Non-Alzheimer's Dementia for Resident #22. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a comprehensive care plan with measurable goals for Resident #160's depression. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate use of antipsychotic medication (Seroquel) for Resident #22, prescribed for non-FDA approved indication (delirium) without documented evidence of delirium or psychosis. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 35
Residents affected: 1
Residents affected: 1
Medication doses: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #22's condition and medication use |
| RN #2 | Registered Nurse | Interviewed regarding care plan updates for Resident #160 |
| RN #3 | Registered Nurse | Interviewed regarding behavior and care plan for Resident #160 |
| Psychiatrist | Interviewed regarding diagnosis and medication for Resident #22 | |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Resident #22's behavior and care |
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