Inspection Reports for Salem Hills Rehabilitation and Healthcare
539 NY-22, Purdys, NY 10578, NY, 10578
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: May 16, 2024
Visit Reason
Complaint Survey with 8 health and 4 life safety citations, all Level 2 severity, corrected by July 2024.
Findings
Complaint Survey with 8 health and 4 life safety citations, all Level 2 severity, corrected by July 2024.
Deficiencies (12)
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Increase/prevent decrease in rom/mobility
Infection prevention & control
Quality of care
Reasonable accommodations needs/preferences
Resident rights/exercise of rights
Treatment/svcs to prevent/heal pressure ulcer
Discharge from exits
Electrical systems - essential electric syste
Fire drills
Smoking regulations
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 16, 2024
Visit Reason
The inspection was a recertification survey conducted from 5/9/2024 to 5/16/2024 to assess compliance with regulatory requirements for Salem Hills Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including resident dignity, call bell accessibility, care planning, treatment and care, pressure ulcer prevention, range of motion maintenance, accident prevention, medication administration safety, and infection prevention and control. Several residents were observed with unmet needs or unsafe conditions, and staff interviews confirmed lapses in policy adherence and supervision.
Deficiencies (8)
Residents #33 and #105 were not treated with respect and dignity; Resident #33 wore socks with visible name labels and Resident #105 had photographs depicting positioning devices visible from the door.
Resident #123's call bell was not within reach on multiple occasions.
Resident #3 did not have a comprehensive care plan for self-medication administration.
Resident #57 was observed multiple times without a footrest extender on their wheelchair as ordered.
Residents #33 and #105 did not receive appropriate pressure ulcer prevention care; Resident #33's right heel rested on metal footrest and Resident #105 lacked prescribed cushions.
Resident #89 did not receive 1:1 supervision as required, resulting in a fall; Residents #72 and #3 had medications and creams left unattended in their rooms on a dementia unit.
Resident #89 was observed on multiple occasions without the ordered right resting hand splint.
Staff failed to perform proper hand hygiene during dining assistance for Resident #21; infection surveillance and water management plan were inadequate or outdated.
Report Facts
Residents reviewed for dignity: 3
Residents reviewed for environment: 5
Residents reviewed for accidents: 7
Residents reviewed for pressure ulcers: 8
Residents reviewed for positioning: 3
Residents reviewed for range of motion: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Licensed Practical Nurse | Stated policy on clothing labels and dignity issue with visible name labels on socks |
| Staff #6 | Certified Nurse Aide | Reported socks labeled on outside and did not report to nursing |
| Staff #7 | Licensed Practical Nurse Charge Nurse | Acknowledged dignity issue with socks labeling |
| Staff #23 | Physical Therapist | Explained use of photographs for positioning devices |
| Director of Rehabilitation | Stated photographs should be placed inside closet door and discussed wheelchair footrest positioning | |
| Staff #24 | Registered Nurse | Described use of photographs for positioning devices |
| Staff #14 | Certified Nurse Aide | Stated call bells should be within reach |
| Staff #22 | Registered Charge Nurse | Stated call bells must be within reach and care plans updated timely |
| Assistant Director of Nursing | Discussed creams left in resident rooms and infection preventionist duties | |
| Staff #5 | Certified Nurse Aide | Forgot to apply footrest extender |
| Staff #11 | Certified Nurse Aide | Unaware of footrest extender requirement |
| Staff #10 | Physical Therapist | Observed not washing hands before meal assistance |
| Staff #12 | Licensed Practical Nurse | Left medications unattended in resident room |
| Staff #21 | Registered Nurse | Reported certified nurse aide left 1:1 supervision resident unattended |
| Staff #13 | Licensed Practical Nurse Supervisor | Educated certified nurse aide on 1:1 supervision requirements |
| Staff #17 | Certified Nurse Aide | Admitted leaving 1:1 supervision resident unattended |
| Staff #25 | Certified Nurse Aide | Reported offloading heels and positioning devices |
| Staff #3 | Certified Nurse Aide | Did not apply resident's right hand splint because it was dirty |
| Staff #4 | Registered Nurse | Unaware resident was not wearing right hand splint |
| Nurse Practitioner | Discussed medication safety and self-medication assessment | |
| Director of Nursing | Discussed call bell accessibility, medication safety, infection control, and supervision issues |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 16, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulations related to accident prevention, medication administration, and resident supervision.
Findings
The facility failed to ensure adequate supervision to prevent accidents for 3 of 7 residents reviewed, including failure to provide 1:1 supervision as per care plan resulting in a fall. Medications and medicated creams were left unattended in residents' rooms on a dementia unit, posing safety hazards. Staff interviews confirmed lapses in supervision and medication administration practices.
Deficiencies (3)
Resident #89 did not receive 1:1 supervision as per plan of care, resulting in a fall.
Resident #72 had multiple oral medications and eye drops left unattended in their room on a dementia unit with wandering residents.
Resident #3 had medicated creams left unattended in their room on a dementia unit with wandering residents.
Report Facts
Residents reviewed for accidents: 7
Residents with deficiencies: 3
Duration of 1:1 supervision planned for Resident #89: 3
Number of residents on dementia unit: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided statements regarding Resident #89 supervision and medication safety | |
| Registered Nurse (Staff #21) | Reported certified nurse aide left Resident #89 unsupervised | |
| Licensed Practical Nurse Supervisor (Staff #13) | Educated certified nurse aide on supervision requirements | |
| Certified Nurse Aide (Staff #17) | Assigned to 1:1 supervision of Resident #89 and admitted leaving resident unsupervised | |
| Assistant Director of Nursing | Observed removal of medications from Resident #72's room and commented on medication safety | |
| Licensed Practical Nurse (Staff #12) | Admitted leaving medications unattended in Resident #72's room and creams in Resident #3's room | |
| Registered Charge Nurse (Staff #22) | Stated oral medications should never be left unattended in residents' rooms | |
| Nurse Practitioner | Expressed concerns about medication and cream safety and resident confusion |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 10, 2023
Visit Reason
Complaint Survey with 2 health citations related to abuse and reporting, corrected by February 24, 2023.
Findings
Complaint Survey with 2 health citations related to abuse and reporting, corrected by February 24, 2023.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 10, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and mistreatment of a resident by a housekeeper at Salem Hills Rehabilitation and Nursing Center.
Complaint Details
The complaint involved allegations that Housekeeper #1 cursed at Resident #1 and aggressively repositioned the resident's wheelchair on 01/24/2023. The incident was witnessed by Housekeeper #2 and confirmed by video footage. The facility investigation found the abuse substantiated. The housekeeper was terminated, but the facility failed to report the abuse to the NYSDOH within the required 2-hour timeframe, reporting it instead nearly two days later.
Findings
The facility failed to ensure that one resident was free from abuse and mistreatment by a housekeeper who was observed cursing at and aggressively repositioning the resident. The facility also failed to report the abuse to the New York State Department of Health within the required 2-hour timeframe. The housekeeper was terminated, and the facility revised its abuse prevention and reporting policies.
Deficiencies (2)
Failure to protect a resident from abuse and mistreatment by a housekeeper who was observed cursing at and aggressively repositioning the resident.
Failure to timely report suspected abuse to the New York State Department of Health within 2 hours of occurrence.
Report Facts
Residents sampled: 12
Residents affected: 1
Date of abuse incident: Jan 24, 2023
Date of survey completion: Feb 10, 2023
Date abuse reported to NYSDOH: Jan 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Named in abuse and mistreatment finding; terminated for cursing at and aggressively repositioning resident |
| Housekeeper #2 | Housekeeper | Witnessed abuse incident and reported it to supervisor |
| Housekeeper Lead | Housekeeper Lead | Received report from Housekeeper #2 and reported incident to Director of Housekeeping |
| Director of Nursing | Director of Nursing (DON) | Conducted physical assessment of resident after incident |
| Director of Housekeeping and Laundry | Director of Housekeeping and Laundry (DHL) | Oversaw abuse prevention training and confirmed termination of Housekeeper #1 |
| Administrator | Administrator | Oversaw investigation and policy revision following delayed abuse reporting |
Inspection Report
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Salem Hills Rehabilitation and Nursing Center, summarizing the findings of a facility survey completed on 08/05/2021.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 31, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#NY00218018) and recertification survey to evaluate compliance with care plan implementation, medication use, and treatment standards.
Complaint Details
Complaint #NY00218018 involved concerns about care plan implementation, medication use, and injury of unknown origin to Resident #374. The investigation found failure to use mechanical lift as per care plan, resulting in injury. The facility self-reported and corrected the noncompliance prior to survey.
Findings
The facility was found deficient in developing and implementing complete care plans for residents, including failure to address medication use and positioning devices. One resident was transferred without the required mechanical lift assistance, resulting in injury. The facility corrected this issue prior to survey. Additionally, the facility failed to ensure physician follow-up on pharmacy consultant recommendations for lab tests.
Deficiencies (4)
Failure to develop and implement a complete care plan meeting all resident needs, including use of mechanical lifts and medication management.
Failure to revise comprehensive care plan within 7 days of assessment, specifically not updating for use of left leg skil care relief boot.
Failure to provide appropriate treatment and care according to orders, resident preferences and goals, including improper use of positioning devices.
Failure to ensure attending physician acted upon pharmacy consultant's recommendations regarding medications and lab tests.
Report Facts
Deficiencies cited: 4
Medication dosage: 3000
Medication dosage: 9500
Medication dosage: 15000
Medication dosage: 25
Medication dosage: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Named in investigation for transferring Resident #374 unassisted without mechanical lift |
| Director of Nursing | Director of Nursing | Completed investigation of injury to Resident #374 |
| RN #1 | Registered Nurse Manager | Interviewed regarding care issues and physician follow-up on pharmacy recommendations |
| CNA #1 | Certified Nursing Assistant | Reported resident refusal to use positioning devices |
| Physical Therapist | Physical Therapist | Provided information on purpose of left leg skil care relief boot and hip abductor pillow |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
One inspection resulted in no citations.
Findings
One inspection resulted in no citations.
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