Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
The visit was conducted as an abbreviated survey to assess compliance with pressure ulcer care standards and evaluate the facility's management of pressure ulcers for residents.
Findings
The facility failed to provide appropriate care and timely treatment for pressure ulcers, resulting in actual harm to Resident #3. Delays in notifying the medical team and updating care plans led to deterioration and multiple new pressure injuries.
Deficiencies (1)
F 0686: The facility failed to ensure Resident #3 received necessary care to promote healing of a pressure ulcer, prevent infection, and prevent new ulcers. The medical team was not notified for five days after an open area was identified, and care plans were not promptly updated, resulting in actual harm.
Report Facts
Residents reviewed for pressure ulcers: 3
Pressure wound size: 9.5
Pressure wound size: 9.2
Pressure wound size: 0.2
Pressure wound size: 4
Pressure wound size: 7
Pressure wound size: 1.5
Pressure wound size: 1
Pressure wound size: 0.2
Braden Scale score: 16
Altered skin area size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #5 | Nurse Practitioner | Documented wound consult and deterioration of pressure ulcers; stated no request for earlier wound consult was made |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Documented altered skin integrity report and notified Clinical Coordinator; instructed CNA to apply moisturizer |
| Clinical Coordinator Licensed Practical Nurse #3 | Clinical Coordinator Licensed Practical Nurse | Notified of skin issues, ordered wound consults, responsible for notifying provider and obtaining orders; received additional training |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Reported reddened area on Resident #3's buttocks to Licensed Practical Nurse #2 |
| Registered Nurse #4 | Registered Nurse | Documented eschar on left ankle but no documented evidence of notifying medical team or treatments |
| Chief Nursing Officer | Chief Nursing Officer | Stated responsibility of Clinical Coordinator Licensed Practical Nurse #3 and noted additional training |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
One Level 3 deficiency for treatment/services to prevent/heal pressure ulcers with actual harm noted; corrected by February 20, 2025.
Findings
One Level 3 deficiency for treatment/services to prevent/heal pressure ulcers with actual harm noted; corrected by February 20, 2025.
Deficiencies (1)
Treatment/svcs to prevent/heal pressure ulcer
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Apr 16, 2024
Visit Reason
Multiple Level 2 deficiencies including bowel/bladder incontinence, infection prevention, services meeting professional standards, and life safety code issues such as fire alarm system and gas equipment; all corrected by June 7, 2024.
Findings
Multiple Level 2 deficiencies including bowel/bladder incontinence, infection prevention, services meeting professional standards, and life safety code issues such as fire alarm system and gas equipment; all corrected by June 7, 2024.
Deficiencies (6)
Bowel/bladder incontinence, catheter, uti
Infection prevention & control
Services provided meet professional standards
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storage
Subdivision of building spaces - smoke barrier
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with professional standards of quality, infection prevention, and resident care requirements.
Findings
The facility was found deficient in medication management for a resident self-administering medications unsafely, improper care and handling of urinary drainage bags for a resident with an indwelling catheter, and failure to implement proper infection prevention and control practices including hand hygiene and glove use during wound care.
Deficiencies (3)
F 0658: The facility failed to ensure safe self-administration of medications for Resident #330, who had multiple doses of medication left unattended at bedside without assessment of safety.
F 0690: The facility did not ensure appropriate care for Resident #78's urinary catheter, with the drainage bag observed uncovered on the floor and on a dining table above bladder level, contrary to policy.
F 0880: The facility failed to establish and maintain an infection prevention program, with staff observed not performing hand hygiene or changing gloves appropriately during wound care for Residents #62 and #238.
Report Facts
Medication tablets found: 35
Residents reviewed: 4
Wounds documented: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed regarding medication administration process and self-administration status of Resident #330 | |
| Registered Nurse Manager #1 | Interviewed and documented findings related to Resident #330's medication safety and urinary catheter care | |
| Certified Nursing Assistant #1 | Interviewed about urinary catheter bag care and resident behaviors | |
| Licensed Practical Nurse #4 | Interviewed about urinary catheter bag care and resident behaviors | |
| Chief Nursing Officer | Interviewed regarding policy adherence for urinary drainage bag care and infection control | |
| Nurse Practitioner #1 | Documented wound status for Resident #238 | |
| Licensed Practical Nurse #2 | Observed and interviewed regarding improper hand hygiene and glove use during wound care | |
| Licensed Practical Nurse #3 | Observed and interviewed regarding improper hand hygiene and glove use during wound care | |
| Registered Nurse Manager #2 | Interviewed about proper hand hygiene and glove use during wound care | |
| Infection Control Nurse | Interviewed about infection prevention practices and hand hygiene requirements |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 23, 2023
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 11, 2023
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Findings
One Level 2 deficiency for reporting to national health safety network; not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 22, 2022
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with federal and state regulations for nursing home operations, including resident care, safety, and facility licensing.
Complaint Details
The inspection included complaint investigations #NY00287538 and #NY00285375 related to abuse, neglect, and mistreatment. It was substantiated that the facility failed to maintain a safe environment for residents, contributing to falls and injuries due to failure to update care summaries.
Findings
The facility was found deficient in multiple areas including failure to implement proper employee abuse screening policies, lack of timely baseline care plans for residents, failure to update and post accurate resident care summaries leading to accidents, and noncompliance with fire safety codes regarding carbon monoxide detectors.
Deficiencies (4)
F 0607: The facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Nurse aide registry abuse screening was not completed prior to new employees beginning work.
F 0655: The facility did not ensure that a Baseline Care Plan was developed and implemented within 48 hours of admission that included minimum healthcare information and that a written summary was provided and reviewed with the resident or representative in a timely manner.
F 0689: The facility did not ensure that residents' environments were free from accident hazards and did not provide adequate supervision to prevent accidents. Updated care cards reflecting increased assistance needs were not posted in residents' rooms, resulting in falls with injuries.
F 0836: The facility was not in compliance with fire safety codes requiring carbon monoxide detectors in areas with fuel-burning appliances. No detectors were present in the kitchen, basement, ground floor, or lobby despite natural gas appliances and potential carbon monoxide sources.
Report Facts
Employees reviewed: 5
Residents reviewed for care plans: 35
Residents with deficient baseline care plans: 7
Residents reviewed for abuse, neglect, mistreatment: 7
Residents affected by care card posting deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in abuse screening deficiency; terminated after failing fingerprinting process. | |
| Director of Human Resources | Provided information about employee screening and corrective actions. | |
| Registered Nurse (RN) #1 | Registered Nurse | Documented fall incident involving Resident #121. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Provided interviews regarding care plan processes and care card updates. |
| Clinical Manager for rehab | Provided interviews regarding care card updates and responsibilities. | |
| Nurse Manager (NM) #1 | Nurse Manager | Provided interview about baseline care plan process. |
| Social Worker (SW) #1 | Social Worker | Provided interviews about care plan procedures and documentation. |
| Social Worker (SW) #2 | Social Worker | Provided interview about care plan information gathering. |
| RN educator | Provided interview about CNA training on care cards. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Sep 22, 2022
Visit Reason
Multiple Level 2 deficiencies including baseline care plan, abuse/neglect policies, accident hazards, licensing compliance, and life safety code issues such as cooking facilities, corridor doors, egress doors, electrical systems, fire alarm system, and portable fire extinguishers; all corrected by late 2022.
Findings
Multiple Level 2 deficiencies including baseline care plan, abuse/neglect policies, accident hazards, licensing compliance, and life safety code issues such as cooking facilities, corridor doors, egress doors, electrical systems, fire alarm system, and portable fire extinguishers; all corrected by late 2022.
Deficiencies (10)
Baseline care plan
Develop/implement abuse/neglect policies
Free of accident hazards/supervision/devices
License/comply w/ fed/state/locl law/prof std
Cooking facilities
Corridor - doors
Egress doors
Electrical systems - essential electric system
Fire alarm system - testing and maintenance
Portable fire extinguishers
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 30, 2022
Visit Reason
Two Level 2 deficiencies for free from abuse and neglect and reporting of alleged violations; corrected by August 29, 2022.
Findings
Two Level 2 deficiencies for free from abuse and neglect and reporting of alleged violations; corrected by August 29, 2022.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 7, 2020
Visit Reason
The inspection was a Recertification Survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to investigate alleged abuse, inadequate ambulation care, improper respiratory equipment maintenance, unsafe medication storage, and improper food preparation for residents on pureed diets.
Deficiencies (5)
F 0610: The facility did not investigate a reported concern of rough handling of a resident during care as required.
F 0688: The facility failed to provide appropriate care to maintain or improve residents' range of motion and ambulation, including inconsistent walking and lack of proper equipment use.
F 0695: The facility did not provide proper respiratory care; oxygen equipment was dirty and tubing was not changed as ordered.
F 0761: Medication carts were not properly secured or labeled, including unsecured controlled substances and unlabeled pre-poured medications.
F 0805: The facility did not ensure food was prepared in a form designed to meet individual needs; pureed lasagna portions were inconsistent and lacked a recipe.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for mobility: 3
Residents reviewed for activities of daily living: 6
Medication carts reviewed: 8
Lasagna servings prepared: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in abuse investigation deficiency and medication cart observation. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in medication cart lock deficiency. |
| Director of Nursing | Director of Nursing | Commented on abuse reporting and medication cart issues. |
| Director of Social Work | Director of Social Work | Commented on abuse reporting procedures. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding ambulation and splint use. |
| Occupational Therapist #1 | Occupational Therapist | Provided therapy plan and expectations for ambulation. |
| Clinical Coordinator | Clinical Coordinator | Commented on ambulation reporting and medication cart cleaning. |
| Nurse Manager | Nurse Manager | Discussed ambulation expectations and therapy evaluations. |
| Physical Therapist | Physical Therapist | Reported on resident decline and ambulation expectations. |
| Assistant [NAME] | Assistant | Prepared pureed lasagna without recipe. |
| Registered Dietician | Registered Dietician | Commented on pureed food portion sizes and recipe requirements. |
| Chef | Chef | Commented on lasagna portion sizes and preparation. |
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