Inspection Reports for
St Marys Center Inc
516 West 126th Street, New York, NY, 10027
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Inspection Report — Feb 12, 2025
State
Date: Feb 12, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2023 to 2025 with deficiency history and complaint data.
Complaint Details
The facility received 50 complaints from June 2022 to May 2026, with one on-site inspection resulting from complaints. The complaint rate was above state average at 145.7 complaints per 100 beds.
Findings
Across three inspections, the facility received 15 citations, including 5 standard health and 10 Life Safety Code citations, all classified as Level 2 minor potential harm. The facility had 50 complaints with one on-site inspection resulting from complaints and no formal enforcement actions.
Citations (15)
Standard Health Citation — quality of care: Label/store Drugs And Biologicals citation noted.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment citation noted.
Life Safety Code Citation — NFPA requirements: Egress Doors citation noted.
Life Safety Code Citation — NFPA requirements: Emergency Lighting citation noted.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure citation noted.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan citation noted.
Standard Health Citation — quality of care: Resident Records - Identifiable Information citation noted.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning citation noted.
Life Safety Code Citation — NFPA requirements: Corridor - Doors citation noted.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System citation noted.
Life Safety Code Citation — NFPA requirements: Emergency Lighting citation noted.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance citation noted.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure citation noted.
Life Safety Code Citation — NFPA requirements: Smoking Regulations citation noted.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures citation noted.
Report Facts
Inspections on page: 3
Total violations/deficiencies cited: 15
Inspections with violations: 2
Inspections without violations: 1
Total complaints: 50
On-site complaint inspections: 1
Total enforcement actions: 0
Inspection Report — Feb 12, 2025
Annual Inspection CMS
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.
Citations (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 — Sep 27, 2023
Annual Inspection CMS
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
| 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 — Apr 11, 2022
Recertification CMS
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
| 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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