Inspection Reports for
Sprain Brook Manor Rehab
77 Jackson Ave, Scarsdale, NY, 10583
Back to Facility Profile6 Reports
Inspection Report — May 14, 2024
Annual Inspection CMS
Date: May 14, 2024
Visit Reason
The inspection was a recertification survey conducted from 5/7/24 to 5/14/24 to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete and untimely updates to care plans following falls, inadequate identification and reporting of skin impairments, delayed provision of dental services, and improper food storage practices.
Citations (5)
F 0550: The facility did not ensure Resident #95's urinary catheter tubing and drainage bag were concealed to maintain dignity and privacy.
F 0657: The facility failed to timely review and revise Comprehensive Care Plans for 2 residents after unwitnessed falls, lacking new interventions to prevent further falls.
F 0684: The facility did not identify or report skin impairments for Resident #55, despite observations of excoriated areas and scratch marks.
F 0791: Resident #13 did not receive replacement dentures until six months after loss, delaying timely dental services.
F 0812: The facility failed to properly cover opened perishable food and did not discard expired food, violating food safety standards.
Report Facts
Residents Affected: 1
Residents Affected: 2
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Certified Nurse Aide | Named in dignity/privacy deficiency for not covering catheter bag |
| Staff #6 | Registered Nurse | Supervised night of fall incident and acknowledged care plan update deficiencies |
| Director of Nursing | Acknowledged care plan update practice and provided education to nurses | |
| Staff #8 | Registered Nurse | Unaware of resident's skin impairments during observation |
| Staff #9 | Certified Nurse Aide | Stated nail filing was not part of their task assignment |
| Staff #2 | Registered Nurse Unit Manager | Commented on delay in denture replacement |
| Registered Dietician | Commented on denture replacement timeline and resident weight | |
| Dentist | Provided information on denture replacement process and timeline | |
| Dietary Supervisor | Observed food storage deficiencies |
Inspection Report — May 14, 2024
State
Date: May 14, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-2024 with deficiency history and complaint details.
Complaint Details
The state logged 29 complaints about this facility; 5 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across three inspections, inspectors issued 17 citations including 7 standard health and 10 Life Safety Code citations. The facility had 29 complaints with 5 on-site inspections and no formal enforcement actions.
Citations (17)
Standard Health Citation — quality of care: Care Plan Timing And Revision was deficient.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve sanitary conditions were deficient.
Standard Health Citation — quality of care: Quality Of Care was deficient.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights was deficient.
Standard Health Citation — quality of care: Routine/emergency Dental Services In Nursing Facility were deficient.
Life Safety Code Citation — NFPA requirements: Develop Emergency Plan, Review And Update Annually was deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extensions were deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was deficient.
Life Safety Code Citation — NFPA requirements: Interior Wall And Ceiling Finish was deficient.
Life Safety Code Citation — NFPA requirements: Organization And Administration was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Life Safety Code Citation — NFPA requirements: Standards Of Construction For New Existing Nursing Home was deficient.
Life Safety Code Citation — NFPA requirements: Subdivision Of Building Spaces - Smoke Barrier was deficient.
Standard Health Citation — quality of care: Reporting - National Health Safety Network was deficient.
Standard Health Citation — quality of care: Quality Of Care was deficient.
Report Facts
Inspections on page: 3
Total violations/deficiencies cited: 17
Inspections with violations: 3
Inspections without violations: 0
Total complaints: 29
On-site complaint inspections: 5
Total enforcement actions: 0
Total citations from complaints: 2
Inspection Report — May 14, 2024
Abbreviated Survey CMS
Date: May 14, 2024
Visit Reason
The inspection was conducted as part of recertification and abbreviated surveys to assess compliance with dental service provision requirements.
Complaint Details
The complaint investigation was initiated after a family member reported the resident's dentures were missing on 6/28/2023. The complaint was substantiated with findings of delayed denture replacement.
Findings
The facility failed to ensure timely replacement of dentures for one resident, resulting in a six-month delay from loss to replacement. Multiple interviews and progress notes confirmed the delay and the impact on the resident's diet and weight.
Citations (1)
F 0791: The facility did not provide timely dental services for a resident whose dentures were lost on 6/28/2023 and not replaced until 12/6/2023, six months later.
Report Facts
Duration of denture replacement delay: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Interviewed regarding delay in denture replacement | |
| Registered Dietician | Interviewed regarding resident's weight and denture replacement timeline | |
| Director of Nursing | Interviewed regarding reasons for denture replacement delay | |
| Dentist | Interviewed regarding denture replacement process and timeline |
Inspection Report — Mar 6, 2023
Abbreviated Survey CMS
Date: Mar 6, 2023
Visit Reason
The visit was an abbreviated survey to evaluate the facility's compliance with care standards related to bowel management for residents, specifically reviewing care provided to Resident #1 for constipation.
Findings
The facility failed to ensure that Resident #1 received appropriate monitoring and interventions for bowel regularity as required by the care plan and facility bowel management protocol. Resident #1 had multiple days without documented bowel movements and no evidence of physician notification or new medication orders during those times.
Citations (1)
F 0684: The facility did not provide appropriate treatment and care according to orders and resident preferences. Resident #1's bowel movements were not consistently monitored, and necessary interventions were not implemented per the care plan and bowel management protocol.
Report Facts
Residents reviewed for constipation: 3
Days without bowel movement: 14
Hydration volume: 450
Medication doses: 17
Senna tablets: 2
Inspection Report — Jun 2, 2021
Annual Inspection CMS
Date: Jun 2, 2021
Visit Reason
Annual inspection survey of Sprain Brook Manor Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Feb 19, 2019
Annual Inspection CMS
Date: Feb 19, 2019
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in timely notification to the Long Term Care Ombudsman of resident transfers, appropriate care for urinary incontinence, proper food storage and preparation practices, and sanitary disposal of garbage and refuse.
Citations (4)
F 0623: The facility failed to provide timely notification to the Office of the Long Term Care Ombudsman of resident transfers or discharges for 2 of 4 residents reviewed.
F 0690: The facility did not ensure appropriate care for a resident with urinary incontinence, failing to identify incontinence and develop a plan of care to restore bladder continence.
F 0812: The facility did not ensure proper preparation, storage, and service of food; perishable foods were unlabeled and undated, and thermometers were not properly sanitized.
F 0814: The facility failed to maintain the trash compactor area in a sanitary condition, with debris and refuse improperly contained and disposed of.
Report Facts
Residents affected: 2
Residents affected: 1
Unlabeled food items: 4
Trash compactor area size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding notification of resident transfers to Ombudsman | |
| Facility Administrator | Interviewed regarding notification of resident transfers and bed hold policy | |
| Unit Manager | Interviewed regarding resident continence and toileting care | |
| Certified Nursing Aide (CNA) | Interviewed regarding resident continence and toileting care | |
| MDS Coordinator - Registered Nurse (RN) | Interviewed regarding reporting of changes in resident continence | |
| Director of Nursing (DON) | Interviewed regarding documentation of incontinence and EMR changes | |
| Food Service Director (FSD) | Interviewed regarding food labeling and sanitation practices | |
| Director of Maintenance (DOM) | Interviewed regarding trash compactor area maintenance | |
| Cook | Interviewed regarding thermometer sanitation practices |
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