Deficiencies (last 5 years)
Deficiencies (over 5 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% better than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as a Recertification/Complaint Survey from 01/02/2025 to 01/08/2025 to investigate the facility's failure to timely report an injury of unknown source involving Resident #96 to the State Survey Agency within the required 2-hour timeframe.
Complaint Details
The complaint investigation found that the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. Resident #96 was found with injuries after a fall on 05/22/2024, but the incident was reported to the Department of Health only after hospital notification of a fracture. The incident was unwitnessed and reporting procedures were unclear among staff.
Findings
The facility failed to report injuries of unknown source involving Resident #96 within 2 hours as required by policy and regulation. Resident #96 was found with head swelling and a fractured left humerus after a fall, but the incident was not reported to the Department of Health until after hospital notification. Interviews revealed confusion about reporting procedures and that the incident was unwitnessed.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or injury of unknown source to the State Survey Agency within 2 hours.
Report Facts
Residents sampled: 23
Residents affected: 1
Incident time: 2330
Incident report submission time: 2339
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #5 | Registered Nurse | Nurse on unit at time of incident who assessed Resident #96 |
| Certified Nurse Assistant #9 | Certified Nurse Assistant | Reported finding Resident #96 on floor and called nurse |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Called to file complaint with Department of Health and discussed report submission |
| Director of Nursing | Director of Nursing | Provided information on incident and reporting process |
| Administrator | Facility Administrator | Interviewed regarding reporting procedures and clarity |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 8, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 01/02/2025 to 01/08/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, improper notification of Medicare non-coverage, environmental maintenance issues, inaccurate resident assessments, food safety violations, incomplete explanation of arbitration agreements, lack of full participation in Quality Assurance meetings, infection control lapses, and failure to offer pneumococcal vaccinations to all residents.
Deficiencies (9)
Facility did not ensure that the last 3 years of facility survey results were posted in a place readily accessible to residents, family members, public, and legal representatives.
Facility did not ensure residents or their representatives were provided appropriate notification at termination of Medicare Part A benefits, specifically notices were not mailed on the same day telephone notification was made.
Facility failed to maintain a clean, orderly, functional, and sanitary environment including broken window screens, damaged baseboards, dripping faucets, and insect presence.
Facility failed to ensure accurate resident assessments, including failure to document use of Wanderguard and inaccurate speech ability documentation.
Facility did not ensure food was stored and prepared in accordance with professional standards, including expired food items in refrigerator and freezer and dietary staff not wearing beard net.
Facility did not ensure Arbitration Agreement was explained to residents or representatives in a form or manner they understood.
Facility did not ensure Quality Assurance & Performance Improvement committee included Medical Director or designee at all required quarterly meetings.
Facility did not ensure infection prevention and control practices were maintained, including failure of staff to perform hand hygiene between residents and use of expired disinfecting wipes and hand sanitizer.
Facility did not ensure that each resident was offered the Pneumococcal immunization as required.
Report Facts
Residents sampled: 23
Residents affected by survey posting deficiency: 5
Residents reviewed for Medicare notification: 3
Residents with notification deficiency: 2
Residents sampled for immunization: 5
Residents not offered pneumococcal vaccine: 3
Quality Assurance meetings missing Medical Director: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | Observed assisting multiple residents with dining without performing hand hygiene between residents | |
| Director of Nursing | Interviewed regarding survey results posting and immunization responsibilities | |
| Administrator | Interviewed regarding survey results posting, arbitration agreement explanation, and QAPI meetings | |
| Minimum Data Set Coordinator | Interviewed regarding Medicare non-coverage notification process | |
| Maintenance Technician | Interviewed regarding environmental maintenance and repairs | |
| Food Service Supervisor | Interviewed regarding food safety and expired food items | |
| Food Service Worker | Interviewed regarding food storage and expiration dates | |
| Infection Preventionist | Interviewed regarding infection control practices and pneumococcal vaccination offering | |
| Admissions Director | Interviewed regarding explanation of arbitration agreement to residents | |
| Registered Nurse Supervisor #1 | Interviewed regarding resident communication and speech therapy | |
| Clinical Assistant | Attended QAPI meetings in place of Medical Director | |
| Certified Nursing Assistant #5 | Interviewed regarding awareness of hot water supply issue | |
| Certified Nursing Assistant #6 | Interviewed regarding awareness of hot water supply issue | |
| Registered Nurse #4 | Interviewed regarding unit rounds and maintenance reporting | |
| Director of Plant Operations and Maintenance | Interviewed regarding environmental maintenance and repairs | |
| Certified Nursing Assistant #3 | Interviewed regarding window condition on unit |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Dec 12, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with regulatory requirements related to resident notification, treatment, and care, specifically focusing on the handling of a urinary tract infection case for Resident #1.
Findings
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative about significant changes in treatment related to a urinary tract infection. There was a 26-day delay in treatment due to failure to notify the physician and family of positive urine test results. Nursing staff and medical doctors did not follow proper notification and documentation procedures as required by facility policy and regulatory standards.
Deficiencies (2)
Failure to immediately inform the resident, consult with the resident's physician, and notify the resident's representative about significant changes in treatment related to a urinary tract infection.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, resulting in a 26-day delay in treatment for Urinary Tract Infection.
Report Facts
Days delayed in treatment: 26
Colony-Forming Unit/Milliliter: 100000
Medication dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Doctor #1 | Physician | Ordered urine test on 08/07/2024 and was covering on 08/07/2024; did not notify family or follow up on positive urine test results |
| Medical Doctor #2 | Physician | Reviewed urine test results on 09/04/2024, ordered antibiotic treatment on 09/05/2024, did not document family notification |
| Registered Nurse #1 | Registered Nurse | Worked on 08/11/2024 shift; unaware of positive urine test results and stated Unit Manager was responsible for follow-up |
| Registered Nurse Unit Manager #3 | Unit Manager | Stated medical doctor should be notified immediately of abnormal labs and family should be notified by charge nurse or nurse manager |
| Director of Nursing | Director of Nursing | Confirmed lack of notification to family and physician about abnormal urine test results and treatment orders |
| Registered Nurse Unit Manager #1 | Unit Manager | Stated charge nurse responsible for checking lab results and notifying physician |
| Registered Nurse Unit Manager #2 | Unit Manager | Stated responsibility to check labs, notify physician and family; did not receive lab call or check computer on 08/11/2024 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 7, 2023
Visit Reason
The inspection was a Recertification survey conducted from 08/01/2023 to 08/07/2023 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to provide baseline care plan summaries to residents or their representatives within 48 hours of admission, incomplete comprehensive care plans for residents on anticoagulant therapy, improper food storage temperatures in the kitchen, and inadequate infection control practices related to sanitizing blood pressure cuffs between resident use.
Deficiencies (5)
Failure to ensure assessments accurately reflected residents' status, specifically not documenting use of Wander Alert Devices for two residents.
Failure to provide resident and/or representative with a written summary of the baseline care plan within 48 hours of admission for one resident.
Failure to develop comprehensive care plans related to anticoagulant therapy for three residents receiving such medications.
Cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit or below during food service.
Failure to sanitize blood pressure cuffs between use on different residents, risking infection transmission.
Report Facts
Total sampled residents: 27
Residents reviewed for Unnecessary Medications: 5
Temperature of ham/cheese sandwich: 54.8
Temperature of tuna salad sandwich: 41.9
Temperature of second ham/cheese sandwich: 57.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Nurse Manager, Day Shift | Responsible for creating, reviewing, and updating resident comprehensive care plans; acknowledged oversight in CCP creation for residents on anticoagulant therapy. |
| Director of Social Services | Interviewed regarding responsibility of Social Worker to provide baseline care plan copies to residents and representatives. | |
| Social Worker | Responsible for providing baseline care plan copies to residents and representatives and documenting this in medical records; unable to find documentation for Resident #219. | |
| Administrator | Interviewed about responsibilities related to baseline care plan distribution and documentation. | |
| Assistant Director of Nursing | ADON | Interviewed regarding lack of comprehensive care plan for Resident #91 on anticoagulant therapy and infection control practices. |
| Registered Nurse #1 | RN | Observed failing to sanitize blood pressure cuffs between residents; acknowledged not sanitizing BP cuffs between Resident #100, #42, and #103. |
| Food Service Director | FSD | Observed calibrating thermometer and interviewed regarding improper cold sandwich temperatures. |
| Director of Nursing | DON | Interviewed about responsibilities for CCP creation and infection control in-services. |
| MDS Coordinator | Interviewed and unable to explain why Wander Alert Device use was not captured on assessments; former MDS Assessor no longer employed. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's failure to notify a resident's Health Care Proxy (HCP) about an increased dose of medication prescribed for the resident.
Findings
The facility failed to notify the resident's representative that the resident was given an increased dose of Paxil from 10 mg to 20 mg despite the HCP's refusal to approve the change. The medication was administered without family consent from 09/09/2022 to 09/26/2022, and the issue was only addressed after the family became aware during a care plan meeting on 09/27/2022. Interviews with staff and the medical director confirmed the lack of communication with the family.
Deficiencies (1)
Failure to notify a resident representative of an increased medication dose despite the representative's refusal to approve the change.
Report Facts
Residents affected: 1
Medication dose increase dates: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Notified the Health Care Proxy about the medication increase on 09/08/2022. |
| LPN #2 | Licensed Practical Nurse | Documented observation of Resident #1 on Paxil 20mg on 09/27/2022. |
| MD | Medical Doctor | Ordered the increase of Paxil to 20mg and later discontinued it after learning the family did not consent. |
| DON | Director of Nursing | Acknowledged the issue with the medication increase without family consent. |
| Administrator | Stated the facility policy to notify residents or representatives of treatment changes before proceeding. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Date: Sep 26, 2022
Visit Reason
No violations.
Findings
No violations.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 3, 2022
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
487.10 (e) (2) — Records and reports
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 5, 2021
Visit Reason
One violation related to records and reports.
Findings
One violation related to records and reports.
Deficiencies (1)
485.11 (b) — Records and reports
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 5, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with federal regulations regarding resident care, environment, and treatment.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper use and monitoring of physical restraints, development and implementation of comprehensive care plans, and appropriate treatment and follow-up for residents with chronic conditions such as diabetes and constipation.
Deficiencies (4)
Failure to maintain a safe, clean, comfortable, and homelike environment, including corroded radiator covers, unpainted areas, mismatched paint, sticky floors, and stained garbage cans.
Failure to ensure residents were free from physical restraints unless medically necessary; hand mittens were not removed every two hours as ordered.
Failure to develop and implement complete, person-centered care plans with measurable goals and timeframes for residents with Bipolar Disorder, fracture, and chronic constipation.
Failure to provide appropriate treatment and care according to orders and resident preferences; specifically, no documented medical follow-up for a resident with diabetes who had persistently elevated blood glucose levels and Hemoglobin A1C.
Report Facts
Residents reviewed: 25
Blood glucose readings: 600
Hemoglobin A1C levels: 10.7
Physician's insulin order: 5
Physician's insulin order: 25
Senna with Docusate Sodium tablets: 4
Sorbitol solution: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse/Unit Manager | Interviewed regarding care plan and monitoring of Resident #83's bowel movements and medication compliance |
| RN #3 | Registered Nurse | Interviewed regarding blood glucose monitoring and physician notification for Resident #40 |
| RN #5 | Registered Nurse Unit Manager | Interviewed regarding responsibility for care plan completion and inability to locate care plan for Resident #156 |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding care and bowel movement assistance for Resident #83 |
| CNA #7 | Certified Nursing Assistant | Interviewed regarding maintenance reporting and repair procedures |
| HSK #1 | Housekeeper | Interviewed regarding cleaning procedures and observed missed cleaning of garbage cans |
| FM | Facility Manager | Interviewed regarding maintenance work orders and environmental concerns |
| Administrator | Interviewed regarding awareness of environmental concerns and responsibility of Facility Manager | |
| ADON | Assistant Director of Nursing | Interviewed regarding care plan updating and staff education |
| DON | Director of Nursing | Interviewed regarding care plan initiation and staff re-education |
| AP | Attending Physician | Interviewed regarding resident non-compliance, blood glucose monitoring, and endocrinology referral |
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