Inspection Report Summary
The most recent inspection on July 26, 2023, identified deficiencies related to care planning, baseline care plan summaries, and medication storage, as well as a substantiated complaint of financial abuse by a certified nursing assistant. Earlier inspections showed a pattern of issues with care plan development and revision, medication management, and environmental maintenance, along with some life safety code citations that were corrected. Inspectors cited themes including incomplete or untimely care plans, failure to protect residents from financial exploitation, and lapses in medication storage and documentation. Complaint investigations were mostly unsubstantiated except for the confirmed financial abuse case, which led to staff suspension and termination but no listed fines or enforcement actions. The facility’s inspection history indicates ongoing challenges in care planning and resident protection, with some corrective actions taken but no clear overall improvement trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The inspection was conducted as a recertification survey combined with a complaint investigation (NY00308289) regarding allegations of financial abuse by a Certified Nursing Assistant (CNA #1) towards Resident #19.
Complaint Details
The complaint was substantiated based on interviews with Resident #19, their roommates, and CNA #1, as well as review of investigation records. CNA #1 was found to have taken money from Resident #19 and other residents previously, leading to suspension and eventual termination. Resident #19's insight and judgment were limited per psychiatric evaluation.
Findings
The facility failed to ensure Resident #19 was free from financial abuse, as CNA #1 with a history of misappropriation allegations took money from the resident. Despite prior corrective actions and termination of CNA #1, the investigation confirmed misappropriation occurred, and the resident was refunded. The resident had limited financial decision-making capacity according to a psychiatric consult.
Deficiencies (1)
Failure to protect Resident #19 from financial abuse by CNA #1 who took money from the resident.
Report Facts
Residents sampled for abuse: 11
Residents affected: 1
Money given to CNA #1: 20
Previous incident date: Nov 26, 2022
Suspension duration: 1
Termination date: Jan 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in financial abuse and misappropriation findings |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding facility policies and CNA #1 incidents |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed Resident #19 and roommates about abuse allegations |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 26, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 7/19/23 through 7/26/23 to assess compliance with regulatory requirements for Park Gardens Rehabilitation & Nursing Center L L C.
Findings
The facility was found deficient in multiple areas including failure to provide residents or their representatives with a written summary of the Baseline Care Plan within 48 hours of admission, incomplete development and implementation of Comprehensive Care Plans (CCP) for residents' needs, failure to review and revise CCPs after assessments, and improper storage and documentation of controlled substances.
Deficiencies (4)
Failure to ensure residents and their representatives received a written summary of the Baseline Care Plan within 48 hours of admission for 3 residents.
Failure to develop and implement Comprehensive Care Plans to meet resident needs, including lack of pain management and UTI care plans for specific residents.
Failure to review and revise Comprehensive Care Plans after each assessment as required for 2 residents.
Failure to store narcotics in a double-locked compartment on the 6th Floor medication cart and discrepancies in narcotics count for a resident on the 4th Floor.
Report Facts
Residents sampled: 38
Residents affected: 3
Residents affected: 1
Residents affected: 2
Medication blister packs: 9
Clonazepam tablets: 34
Clonazepam tablets: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Stated that Baseline Care Plan is offered to residents but not always documented |
| Social Worker | Social Worker | Interviewed regarding Baseline Care Plan completion and documentation |
| MDS Coordinator | MDS Coordinator | Interviewed about Baseline Care Plan completion and distribution |
| Director of Social Service | Director of Social Service | Interviewed about Baseline Care Plan distribution and documentation |
| Director of Nursing | Director of Nursing | Interviewed about Baseline Care Plan and Comprehensive Care Plan compliance and narcotics storage |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about Comprehensive Care Plan development and narcotics investigation |
| Registered Nurse #1 | Registered Nurse | Observed medication cart and interviewed about narcotics storage and medication pass |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Observed narcotics locker and interviewed about narcotics count discrepancy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Jul 26, 2023
Visit Reason
Complaint Survey with 5 health citations and 3 life safety code citations, all Level 2 severity, all corrected by September 11, 2023 or August 18, 2023.
Findings
Complaint Survey with 5 health citations and 3 life safety code citations, all Level 2 severity, all corrected by September 11, 2023 or August 18, 2023.
Deficiencies (8)
Baseline care plan — quality of care
Care plan timing and revision — quality of care
Develop/implement comprehensive care plan — quality of care
Free from misappropriation/exploitation — quality of care
Label/store drugs and biologicals — quality of care
Discharge from exits — life safety code
Electrical systems - essential electric system — life safety code
Sprinkler system - maintenance and testing — life safety code
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Nov 8, 2022
Visit Reason
Complaint Survey with 3 standard health citations, all Level 2 severity, corrected by December 19, 2022.
Findings
Complaint Survey with 3 standard health citations, all Level 2 severity, corrected by December 19, 2022.
Deficiencies (3)
Investigate/prevent/correct alleged violation — quality of care
Reporting of alleged violations — quality of care
Resident records - identifiable information — quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
Covid-19 Survey with one standard health citation of Level 0 severity, no correction noted.
Findings
Covid-19 Survey with one standard health citation of Level 0 severity, no correction noted.
Deficiencies (1)
Responsibilities of providers; required notification — quality of care
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Apr 21, 2021
Visit Reason
The inspection was a recertification survey conducted from 04/14/2021 to 04/21/2021 to assess compliance with regulatory requirements for Park Gardens Rehabilitation & Nursing Center L L C.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, poor maintenance of resident rooms and environment, inaccurate resident assessments, inadequate assistance with activities of daily living, improper medication labeling and storage, inaccurate medical record documentation, and lapses in infection control practices.
Deficiencies (8)
Facility did not ensure that notice of the availability of the survey results was posted in prominent and accessible areas.
Resident rooms were not maintained in good repair and homelike manner, including rusted heaters, peeling wallpaper, and rusted wheelchair guardrails.
Minimum Data Set (MDS) did not accurately code a resident receiving dialysis services.
Resident observed with untrimmed fingernails with black substance underneath, indicating inadequate assistance with activities of daily living.
An opened vial of insulin was observed undated, indicating improper medication labeling and storage.
Resident medical records were not accurately documented; resident refused to wear ordered splints/braces but documentation indicated devices were applied.
Infection control practices were not maintained; glucometer and pulse oximeter were not cleaned and sanitized between resident uses.
Staff bathrooms were dusty and in disrepair with mismatched paint, rust, peeling surfaces, and dusty vents.
Report Facts
Residents reviewed for Dialysis: 35
Residents reviewed for Activities of Daily Living: 35
Residents reviewed for Limited Range of Motion: 35
Units with observed deficiencies: 4
Dialysis schedule frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Social Worker | Interviewed regarding survey results communication with residents |
| Director Social Services | Director of Social Services | Interviewed regarding survey results communication with residents |
| Administrator | Administrator | Interviewed regarding posting of survey results and facility maintenance |
| Maintenance Worker #1 | Maintenance Worker | Interviewed regarding facility repairs and painting |
| Director of Maintenance | Director of Maintenance | Interviewed regarding facility maintenance and painting |
| RN #1 | Registered Nurse | Interviewed regarding MDS assessment and medication labeling |
| MDS Coordinator (RN #1) | MDS Coordinator | Interviewed regarding MDS assessment accuracy |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding resident grooming and splint device documentation |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding resident splint device compliance and documentation |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding insulin vial labeling |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding infection control practices and resident grooming oversight |
| LPN #3 | Licensed Practical Nurse | Observed and interviewed regarding glucometer cleaning |
| RN Supervisor | Registered Nurse Supervisor | Interviewed regarding medication cart checks and resident device compliance |
| Director of Nursing | Director of Nursing | Interviewed regarding medication labeling, CNA accountability, and infection control |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 11, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements including resident rights, privacy, abuse reporting, care planning, medication management, infection control, and environmental safety.
Complaint Details
The complaint involved an allegation of verbal abuse by a physical therapist assistant (PTA) toward Resident #175. The resident reported the incident to staff and a grievance was initiated. The facility failed to report the allegation to NYSDOH within 24 hours and did not interview the resident or witnesses in a timely manner. The Director of Nursing concluded there was no evidence of abuse based on inconsistencies and resident history. The PTA was in-serviced but not removed from duty during the investigation.
Findings
The facility was found deficient in multiple areas including failure to provide residents with information on how to contact the Ombudsman and NYSDOH complaint line, failure to respect resident privacy during blood draws, failure to timely report and investigate an allegation of verbal abuse, incomplete care plans for resident activity preferences, improper medication management including expired and unlabeled medications, inadequate infection control practices by staff, and unsanitary conditions in a shared resident bathroom.
Deficiencies (7)
Facility did not ensure residents received oral and written information on how to contact the NY State Long Term Care Ombudsman and NYSDOH Complaint Line.
Resident's right to privacy was not respected when blood was drawn in a public area during meal time.
Facility did not report an allegation of verbal abuse by a staff member to NYSDOH within 24 hours and did not thoroughly investigate the allegation.
No comprehensive care plan developed to address activity preferences for Resident #98.
Facility received and kept expired GlucaGen medication in active drug supply; medication carts contained expired and unlabeled medications including Flovent and Incruse inhalers.
CNA observed multiple times not practicing hand hygiene during meal service.
Shared resident bathroom had a strong odor of urine over multiple days due to inability to properly clean and maintain grout and toilet base.
Report Facts
Residents attending Resident Council Meeting: 10
Sampled residents: 35
Days expired: 97
Doses remaining: 59
Doses remaining: 16
Doses remaining: 13
In-service date: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #175 | Resident | Alleged victim of verbal abuse by PTA. |
| PTA | Physical Therapist Assistant | Alleged abuser in verbal abuse complaint. |
| LPN #4 | Licensed Practical Nurse | Charge nurse who received verbal abuse report from Resident #175. |
| DNS | Director of Nursing Services | Responsible for abuse investigation and reporting. |
| Administrator | Facility Administrator | Oversaw investigation and reporting of verbal abuse allegation. |
| CNA #1 | Certified Nursing Assistant | Observed failing to perform hand hygiene during meal service. |
| DOR | Director of Rehabilitation | Supervisor of PTA involved in verbal abuse allegation. |
| Pharmacy Consultant | Consultant Pharmacist | Responsible for monthly medication inspections. |
| ADON | Assistant Director of Nursing | Interviewed regarding medication expiration and labeling. |
| Pharmacist | Pharmacist and Director of Compliance | Vendor Pharmacy staff responsible for medication dispensing. |
| Activities Director | Activities Director | Witness to verbal abuse incident and provided statement. |
| Maintenance Supervisor | Maintenance Supervisor | Responsible for bathroom maintenance and repairs. |
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