Inspection Reports for
St Marys Center Inc
516 West 126th Street, New York, NY, 10027
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 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
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 12, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 02/05/2025 to 02/12/2025 to assess compliance with regulatory requirements for continued certification and licensing of the nursing home.
Findings
The facility failed to maintain a safe, clean, and homelike environment across multiple units, with issues including torn window screens, dirty rooms, broken furniture, ceiling leaks, and unclean resident equipment. Additionally, the storage for controlled drugs was found insecure due to a malfunctioning lock on the narcotic box.
Deficiencies (2)
F 0584: The facility did not ensure residents' right to a safe, clean, and homelike environment. Multiple areas had torn window screens, dirty windowsills, embedded dirt in floors, broken furniture, unclean equipment, and ceiling leaks.
F 0761: The facility did not ensure controlled drugs were stored securely. The narcotic box in Unit 2 was locked with a padlock due to a faulty primary lock, but the outer door remained not firmly closed, compromising security.
Report Facts
Units with environmental issues: 3
Number of black metal framed chairs missing cushions: 3
Number of windows replaced: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding narcotic box lock issue |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about narcotic box lock issue |
| Housekeeper #1 | Interviewed about cleaning responsibilities | |
| Lead Housekeeper | Interviewed about housekeeping oversight | |
| Maintenance Worker #1 | Interviewed about maintenance and leaks | |
| Assistant Administrator | Interviewed about maintenance and housekeeping issues | |
| Administrator | Interviewed about monitoring and compliance rounds |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 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.
Deficiencies (5)
Label/store drugs and biologicals
Safe/clean/comfortable/homelike environment
Egress doors
Emergency lighting
Hazardous areas - enclosure
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
Abuse reporting documentation deficiency noted.
Findings
Abuse reporting documentation deficiency noted.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as a recertification survey from 09/20/2023 to 09/27/2023 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility failed to develop and implement a comprehensive, person-centered care plan related to infection control for Resident #29 who had an active urinary tract infection. The deficiency was identified based on observations, interviews, and record reviews during the survey.
Deficiencies (1)
F 0656: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. The facility did not ensure a care plan related to urinary tract infection was developed for Resident #29 with an active UTI diagnosis.
Report Facts
Residents sampled: 15
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding antibiotic use and care plans |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Interviewed about residents with UTI and urine/hydration checks |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about antibiotic administration and resident behavior |
| Director of Nursing | Director of Nursing | Interviewed about care plans and infection control |
Inspection Report
Annual Inspection
Deficiencies: 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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Signed for medication dose not administered to Resident #27 |
| RN #1 | Registered Nurse | Administered delayed Suboxone dose to Resident #27 and provided interview about medication error |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding respiratory care and oxygen therapy for Resident #87 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding oxygen tubing labeling and oxygen flow rate for Resident #87 |
| RN #2 | Registered Nurse | Interviewed regarding oxygen concentrator settings for Resident #87 |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding oxygen therapy orders for Resident #87 |
| Medical Director | Medical Director | Interviewed regarding oxygen therapy and resident care |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans and oxygen therapy management |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding antibiotic use and medication administration policies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 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.
Deficiencies (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
Deficiencies: 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.
Deficiencies (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
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding abuse reporting procedures and awareness of reporting timelines | |
| Administrator | Interviewed regarding abuse reporting requirements and facility policies | |
| Resident Service Manager | Interviewed regarding resident invitations to care plan meetings | |
| Social Worker | Responsible for inviting residents to care plan meetings |
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