Inspection Reports for Richmond Center for Rehabilitation and Specialty Healthcare
91 Tompkins Avenue, Staten Island, NY, 10304
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 29, 2024, identified deficiencies related to inadequate supervision of a resident at risk for elopement during an outside clinic appointment. Earlier inspections showed a pattern of issues involving resident supervision, care planning, infection control, medication management, and food safety, with multiple citations corrected over time. Complaint investigations were mostly unsubstantiated, though one substantiated case involved failure to timely report a resident’s fall with injury. Enforcement actions included a prior immediate jeopardy finding for abuse and neglect in 2022, which was corrected, and no fines or license suspensions were listed in the available reports. The facility’s inspection history shows ongoing challenges with supervision and care processes, with some improvements noted in correction of cited deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety regulations, specifically focusing on supervision to prevent resident elopement during an outside clinic appointment.
Findings
The facility failed to ensure adequate supervision of a resident at risk for elopement during a clinic appointment, resulting in the resident eloping and being missing for several days before being found and hospitalized. The facility's policy lacked preventive measures for residents at risk of elopement during outside appointments.
Deficiencies (1)
Failed to ensure that a resident received adequate supervision to prevent elopement during a clinic appointment.
Report Facts
Resident elopement risk score: 8
Date of elopement: Feb 20, 2024
Date resident found: Feb 27, 2024
Monitoring frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Home Health Aide #1 | Escorted Resident #1 to clinic appointment and reported resident missing | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented resident's clinic appointment and instructed Home Health Aide #1 on supervision |
| Registered Nurse #1 | Registered Nurse | Documented that Home Health Aide #1 escorted Resident #1 to clinic appointment |
| Director of Nursing | Director of Nursing | Stated Home Health Aide #1 should have kept eyes on Resident #1 and is responsible for oversight |
| Administrator | Administrator | Notified of resident missing and stated Director of Nursing oversees escort staff |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 29, 2024
Visit Reason
One isolated Level 2 deficiency related to accident hazards and supervision; corrected by April 19, 2024.
Findings
One isolated Level 2 deficiency related to accident hazards and supervision; corrected by April 19, 2024.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 21, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey from 8/14/2023 to 8/21/2023, triggered by a complaint regarding failure to report an unwitnessed fall resulting in a head laceration of Resident #505.
Complaint Details
The complaint investigation (NY00318827) found that Resident #505's unwitnessed fall with head laceration was not reported to the NYSDOH. The facility's investigation ruled out abuse and neglect, but the reporting requirement was not met.
Findings
The facility failed to timely report suspected abuse or neglect involving Resident #505's fall and head laceration to the New York State Department of Health. The resident, who required assistance of two people for activities of daily living, fell when a CNA stepped away, resulting in injury. The facility's investigation ruled out abuse and neglect, but the incident was not reported as required.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to ensure a resident received adequate supervision and assistance to prevent accidents, resulting in a fall and head laceration.
Report Facts
Residents sampled: 35
Residents affected: 1
Date of fall: Jun 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed Resident #505 on the floor with laceration and stated two staff were assisting the resident when the fall occurred |
| DNS | Director of Nursing | Was immediately informed of the incident and stated the fall was not reported to NYSDOH after investigation |
| CNA #1 | Certified Nursing Assistant | Assisted Resident #505 and stepped away to the bathroom during which the resident fell |
| LPN #1 | Licensed Practical Nurse | Called to Resident #505's room after the fall and observed injuries |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Aug 21, 2023
Visit Reason
The inspection was conducted as a recertification survey from 8/14/2023 to 8/21/2023 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' rights to dignified existence, communication access, baseline care plan provision, comprehensive care planning, pressure ulcer care, nutritional status maintenance, pharmaceutical services, medication storage, food safety, garbage disposal, and infection prevention and control practices.
Deficiencies (12)
Resident #166 was not provided with adequate clothing to ensure a dignified existence.
Resident #225 was fed by staff standing over them instead of sitting, compromising dignity.
Facility did not ensure residents' right to communicate with individuals external to the facility on Saturdays due to mail delivery system.
Residents #170, #327, #351, and #334 were not provided with a written summary of their baseline care plan (BCP).
Resident #351 did not have a comprehensive care plan addressing dental needs despite poor dentition and missing teeth.
Resident #335 with sacral pressure ulcer had no dressing observed during wound care, risking infection.
Resident #166 experienced significant weight loss without documented interventions to prevent further loss.
Expired medication (Narcan) was found in the Emergency Medication Box on Unit 4.
Multiple bags of IV antibiotics stored in a refrigerator without a thermometer; an opened, undated vial of insulin was found in medication cart.
Food was stored and served at temperatures above 41°F, including refrigerators malfunctioning and containing items above safe temperature.
Garbage compactor located outside the facility lacked a lid or door, allowing flies to harbor and feed.
Infection prevention and control practices were not maintained for 5 residents, including improper hand hygiene during tracheostomy care, improper PPE use for residents on contact precautions, and failure to sanitize equipment between residents.
Report Facts
Residents sampled: 35
Residents affected: 2
Residents affected: 11
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Expired medication quantity: 2
Resident weight: 157.4
Resident weight: 127
Resident weight: 124
Resident weight: 123.1
Refrigerator temperature: 45
Refrigerator temperature: 60
Refrigerator temperature: 45
Food temperature: 44.2
Food temperature: 42.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Observed feeding Resident #225 while standing |
| RN #1 | Registered Nurse/Nurse Manager | Interviewed regarding wound care and infection control practices |
| RN #4 | Registered Nurse/Nurse Manager | Interviewed regarding medication storage and infection control |
| LPN #4 | Licensed Practical Nurse | Observed performing wound care and removing IV catheter without proper PPE |
| LPN #3 | Licensed Practical Nurse | Observed improper PPE use and infection control for Resident #99 |
| RT | Respiratory Therapist | Observed performing tracheostomy care without proper hand hygiene and glove changes |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan processes and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control practices |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed about Resident #166 clothing |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed about Resident #166 meal intake |
| Registered Dietician | Registered Dietician | Interviewed about Resident #166 nutritional status |
| Nurse Practitioner | Nurse Practitioner | Interviewed about Resident #166 weight loss and GI referral |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication storage and thermometer absence |
| LPN #8 | Licensed Practical Nurse | Interviewed about emergency medication box checks |
| Food Service Manager | Food Service Manager | Interviewed about refrigerator temperatures and food safety |
| Director of Housekeeping | Director of Housekeeping | Interviewed about garbage compactor |
| Administrator | Administrator | Interviewed about garbage compactor and medication storage |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 21, 2023
Visit Reason
Multiple Level 2 deficiencies in quality of care and life safety code including care plans, garbage disposal, food sanitation, infection control, resident rights, and fire safety systems; all corrected by October 10-17, 2023.
Findings
Multiple Level 2 deficiencies in quality of care and life safety code including care plans, garbage disposal, food sanitation, infection control, resident rights, and fire safety systems; all corrected by October 10-17, 2023.
Deficiencies (1)
Baseline care plan; Develop/implement comprehensive care plan; Dispose garbage and refuse properly; Food procurement, store/prepare/serve-sanitary; Free of accident hazards/supervision/devices; Infection prevention & control; Label/store drugs and biologicals; Nutrition/hydration status maintenance; Pharmacy services/procedures/pharmacist/records; Reporting of alleged violations; Resident rights/exercise of rights; Right to forms of communication w/ privacy; Subsistence needs for staff and patients; Treatment/services to prevent/heal pressure ulcer; Electrical systems - essential electric system; Gas equipment - cylinder and container storage; Means of egress - general; Portable fire extinguishers; Sprinkler system - maintenance and testing; Subdivision of building spaces - smoke barrier
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 18, 2022
Visit Reason
Level 4 immediate jeopardy deficiency for free from abuse and neglect, plus Level 2 deficiencies in administration and reporting of alleged violations; all corrected by March 7, 2022.
Findings
Level 4 immediate jeopardy deficiency for free from abuse and neglect, plus Level 2 deficiencies in administration and reporting of alleged violations; all corrected by March 7, 2022.
Deficiencies (1)
Administration; Free from abuse and neglect; Reporting of alleged violations
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jun 30, 2021
Visit Reason
The survey was conducted as a recertification annual inspection to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify family of medication changes, incomplete care plans, delayed diagnosis and treatment of a fall injury, improper respiratory care, medication storage issues, food service problems including temperature and palatability, improper storage of resident food, and lapses in infection control practices.
Deficiencies (8)
Failure to immediately notify a resident's representative of changes to psychotropic medication regimen.
Comprehensive Care Plan related to cognition was not complete with individualized interventions.
Delayed diagnosis and treatment of left clavicle fracture after fall; x-ray not ordered timely.
Residents on oxygen therapy received oxygen at incorrect flow rates.
Medication refrigerator had melting ice causing water leakage; insulin pen stored improperly submerged in water.
Food service issues including late delivery, cold food, missing items, and poor palatability reported by residents.
Improper storage of residents' personal food items with undated, unlabeled, and spoiled food found in pantry refrigerator.
Failure to perform proper hand hygiene during wound care and after resident care by staff.
Report Facts
Deficiencies cited: 8
Oxygen flow rate: 2
Oxygen flow rate: 3.5
Oxygen flow rate: 4
Food temperature: 133
Food temperature: 129
Food temperature: 127
Food temperature: 59
Medication refrigerator ice cream expiration: 2022
Medication refrigerator ice cream expiration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse Manager | Named in failure to notify family of medication changes |
| LPN #3 | Licensed Practical Nurse | Observed medication refrigerator water leakage and improper insulin pen storage |
| CNA #2 | Certified Nursing Assistant | Failed to perform hand hygiene during wound care |
| LPN #1 | Licensed Practical Nurse | Failed to perform hand hygiene during wound care |
| BHS #1 | Behavioral Health Specialist | Failed to perform hand hygiene after resident care |
| DON | Director of Nursing | Interviewed regarding infection control and hand hygiene |
| IP | Infection Preventionist | Interviewed regarding hand hygiene observations and infection control |
| RN #5 | Registered Nurse | Interviewed regarding storage of spoiled food in pantry refrigerator |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 31, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident personal funds management, environmental cleanliness, care planning participation, and infection prevention and control practices.
Findings
The facility was found deficient in providing timely quarterly statements for residents' personal funds, maintaining a clean and homelike environment with properly sanitized medical equipment, ensuring resident participation in care planning meetings, and enforcing proper hand hygiene practices among staff.
Deficiencies (4)
Failure to provide timely quarterly statements to residents for their personal funds, specifically resident #38.
Medical equipment, including feeding pumps and poles, were observed dirty and not properly sanitized in 2 of 4 units.
Residents #193, 249, and 262 were not afforded the right to participate in the planning of their care as evidenced by interviews and lack of documentation.
Staff failed to implement proper hand hygiene procedures during direct resident contact, specifically a respiratory therapist did not wash hands prior to suctioning resident #72.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cashier/Patient Accounts | Interviewed regarding resident #38's personal funds quarterly statements | |
| RN #1 | Registered Nurse Manager | Interviewed about cleaning procedures for feeding pumps and poles |
| Employee #6 | Director of Housekeeping | Interviewed about cleaning schedule and inability to provide cleaning logs |
| Employee #3 | Unit Social Worker | Interviewed about care plan meeting notifications and lack of documentation |
| Employee #2 | Respiratory Therapist | Observed and interviewed regarding failure to perform hand hygiene before suctioning resident #72 |
| RN #3 | Assistant Director of Nursing / Educator | Interviewed about hand hygiene training and education |
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