Inspection Reports for
St Marys Center Inc

516 West 126th Street, New York, NY, 10027

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Citations (last 4 years)

Citations (over 4 years) 5.3 citations/year

Citations are regulatory findings recorded during state inspections.

4% worse than New York average
New York average: 5.1 citations/year

Citations per year

16 12 8 4 0
2022
2023
2024
2025

Inspection Report

Annual Inspection
Capacity: 60 Citations: 5 Date: Feb 12, 2025

Visit Reason
Certification Survey found deficiencies in medication labeling, environment safety, and life safety code issues including egress doors, emergency lighting, and hazardous area enclosures; all corrected by April 11, 2025.

Findings
Certification Survey found deficiencies in medication labeling, environment safety, and life safety code issues including egress doors, emergency lighting, and hazardous area enclosures; all corrected by April 11, 2025.

Citations (5)
Label/store drugs and biologicals
Safe/clean/comfortable/homelike environment
Egress doors
Emergency lighting
Hazardous areas - enclosure

Inspection Report

Annual Inspection
Capacity: 60 Citations: 1 Date: Jul 10, 2024

Visit Reason
Abuse reporting documentation deficiency noted.

Findings
Abuse reporting documentation deficiency noted.

Citations (1)
R9-10-803.J — Abuse reporting documentation

Inspection Report

Annual Inspection
Citations: 3 Date: Sep 27, 2023

Visit Reason
The inspection was conducted as a recertification survey from 9/20/2023 to 9/27/2023 to assess compliance with regulatory standards for nursing home care.

Findings
The facility was found deficient in developing comprehensive, person-centered care plans for residents, providing respiratory care consistent with physician orders, and accurately documenting medication administration. Deficiencies involved incomplete care plans for infection, improper oxygen therapy management, and medication administration errors.

Citations (3)
F 0656: The facility failed to develop and implement a complete care plan addressing a resident's urinary tract infection, despite active diagnosis and antibiotic treatment.
F 0695: The facility did not provide respiratory care consistent with physician orders, including oxygen set at higher liters than ordered and lack of dated labels on oxygen tubing.
F 0842: The facility failed to ensure accurate medication administration documentation when a nurse signed for a dose of Suboxone that was left in the medication cart and not given to the resident.
Report Facts
Residents reviewed for infection care: 15 Residents reviewed for respiratory care: 15 Residents reviewed for medication administration: 8

Employees mentioned
NameTitleContext
RN #3Registered NurseSigned for medication dose not administered to Resident #27
RN #1Registered NurseAdministered delayed Suboxone dose to Resident #27 and provided interview about medication error
LPN #1Licensed Practical NurseInterviewed regarding respiratory care and oxygen therapy for Resident #87
LPN #2Licensed Practical NurseInterviewed regarding oxygen tubing labeling and oxygen flow rate for Resident #87
RN #2Registered NurseInterviewed regarding oxygen concentrator settings for Resident #87
Nurse PractitionerNurse PractitionerInterviewed regarding oxygen therapy orders for Resident #87
Medical DirectorMedical DirectorInterviewed regarding oxygen therapy and resident care
Director of NursingDirector of NursingInterviewed regarding care plans and oxygen therapy management
Assistant Director of NursingAssistant Director of NursingInterviewed regarding antibiotic use and medication administration policies

Inspection Report

Complaint Investigation
Capacity: 60 Citations: 10 Date: Sep 27, 2023

Visit Reason
Complaint Survey identified deficiencies in care planning, resident records, respiratory care, and multiple life safety code issues including corridor doors, electrical systems, emergency lighting, fire alarm testing, hazardous areas, smoking regulations, and stairways; all corrected by late 2023.

Findings
Complaint Survey identified deficiencies in care planning, resident records, respiratory care, and multiple life safety code issues including corridor doors, electrical systems, emergency lighting, fire alarm testing, hazardous areas, smoking regulations, and stairways; all corrected by late 2023.

Citations (10)
Develop/implement comprehensive care plan
Resident records - identifiable information
Respiratory/tracheostomy care and suctioning
Corridor - doors
Electrical systems - essential electric syste
Emergency lighting
Fire alarm system - testing and maintenance
Hazardous areas - enclosure
Smoking regulations
Stairways and smokeproof enclosures

Inspection Report

Recertification
Citations: 2 Date: Apr 11, 2022

Visit Reason
The inspection was conducted as a Recertification and Complaint survey to assess compliance with regulatory requirements, including investigation of abuse allegations and review of care plan processes.

Complaint Details
The complaint investigation found that the facility failed to timely report two allegations of resident-to-resident physical abuse involving four residents. The allegations were substantiated as the facility reported the incidents late to the NYSDOH.
Findings
The facility failed to timely report two incidents of resident-to-resident physical abuse to the State Survey Agency within the required 2-hour timeframe. Additionally, the facility did not ensure that the Comprehensive Care Plan was reviewed and revised by the interdisciplinary team with documented resident invitation for one resident after quarterly assessments.

Citations (2)
F 0609: The facility did not report two resident-to-resident abuse incidents to the State Survey Agency within 2 hours as required. One incident was reported nearly 2 days late and another was reported nearly 1 day late.
F 0657: The facility did not ensure the Comprehensive Care Plan was reviewed and revised by the interdisciplinary team with documented evidence that Resident #9 was invited to their quarterly care plan meeting held on 7/23/21.
Report Facts
Residents affected: 4 Date of survey completed: Apr 11, 2022

Employees mentioned
NameTitleContext
Director of NursingInterviewed regarding abuse reporting procedures and awareness of reporting timelines
AdministratorInterviewed regarding abuse reporting requirements and facility policies
Resident Service ManagerInterviewed regarding resident invitations to care plan meetings
Social WorkerResponsible for inviting residents to care plan meetings

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