Inspection Reports for
Sunharbor Manor
255 Warner Avenue, Roslyn Heights, NY, 11577
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
The inspection was conducted as part of a Recertification and Abbreviated Survey, including a complaint investigation related to discharge planning for Resident #466.
Complaint Details
Complaint # NY 00320409 was investigated during the survey. The complaint involved inadequate discharge planning and failure to confirm home care services for Resident #466. The complaint was substantiated as the facility did not ensure home care acceptance prior to discharge.
Findings
The facility failed to develop and implement an effective discharge planning process ensuring confirmation of home care services prior to discharge. Resident #466 was discharged without confirmed acceptance by a Home Care Agency, resulting in an eight-day delay in receiving home healthcare services.
Deficiencies (1)
10 NYCRR 415.11(d)(3) The facility did not ensure confirmation of home care services before discharge. Resident #466 was discharged without acceptance from a Home Care Agency, causing a delay in service initiation.
Report Facts
Days delay in home care acceptance: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #2 | Documented discharge planning notes and communications with Managed Care Plan and Home Care Agencies. | |
| Case Manager/Discharge Coordinator | Interviewed regarding discharge planning process and failure to confirm home care services prior to discharge. | |
| Licensed Practical Nurse #8 | Documented resident discharge condition and instructions. | |
| Director of Social Work | Interviewed about Resident #466's care needs and discharge planning deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Mar 21, 2024
Visit Reason
The survey was a Recertification Survey initiated on 3/14/2024 and completed on 3/21/2024 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including medication administration errors, discharge planning deficiencies, hearing aid access delays, inadequate supervision of residents, improper medication storage, feeding tube labeling, intravenous catheter care, psychotropic medication management, dental care follow-up, and infection control signage.
Deficiencies (11)
F0656: The facility failed to ensure medication was administered as prescribed when a nurse applied a Menthol patch instead of the ordered Lidocaine patch for pain management.
F0660: The facility did not develop and implement an effective discharge planning process ensuring timely acceptance of home care services for a discharged resident.
F0685: The facility failed to ensure timely audiology consults and proper hearing aid replacement for a resident with hearing impairment.
F0689: The facility did not provide adequate supervision to prevent accidents when a resident was observed smoking unsupervised outside without proper authorization and another resident had medications unattended.
F0689: Resident #101 was observed with multiple unlabeled medications and inhalers in their room without staff supervision and was not assessed for self-administration.
F0693: The facility failed to label feeding tube and hydration bags with resident information and feeding start time as required.
F0694: Resident #216 had a peripheral intravenous catheter without physician orders for insertion or care, and no documentation of catheter assessment.
F0758: The facility did not limit as-needed psychotropic medication orders to 14 days nor provide rationale for continued use as required.
F0761: Medications including insulin pens were improperly stored outside refrigeration and expired insulin was found in medication carts.
F0791: The facility failed to assist a resident in obtaining timely dental care and did not follow up on dentist recommendations for tooth extractions and dentures.
F0880: Contact Precaution signage was not posted outside a resident's room with C-Diff infection, and incorrect signage was displayed, reducing infection control effectiveness.
Report Facts
Days Ambien administered: 38
Tube feeding volume: 1500
Tube feeding rate: 75
Tube feeding flush volume: 35
Duration of tube feeding: 8
Peripheral IV catheter removal order date: 2024
Insulin pen expiration days: 28
Dental consult renewal dates: 6
Tooth extractions recommended: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Medication Nurse | Named in medication error applying wrong patch to Resident #246. |
| Registered Nurse #1 | Unit Supervisor | Interviewed regarding medication administration and supervision issues. |
| Director of Nursing Services | Interviewed multiple times regarding medication errors, discharge planning, infection control, and medication storage. | |
| Physician #1 | Primary Care Physician | Interviewed regarding psychotropic medication order for Resident #68. |
| Registered Nurse #2 | Registered Nurse Supervisor | Admitted Resident #2 from hospital and involved in dental consult process. |
| Dentist | Interviewed regarding dental recommendations for Resident #2. | |
| Licensed Practical Nurse #6 | Interviewed regarding unlabeled feeding tube bags for Resident #161. | |
| Registered Nurse Supervisor #3 | Interviewed regarding peripheral IV catheter care for Resident #216. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 21
Date: Mar 21, 2024
Visit Reason
Multiple Level 2 standard health and life safety code citations related to quality of care and building safety, mostly isolated or pattern scope, corrected by May 2024.
Findings
Multiple Level 2 standard health and life safety code citations related to quality of care and building safety, mostly isolated or pattern scope, corrected by May 2024.
Deficiencies (21)
Develop/implement comprehensive care plan
Discharge planning process
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Infection prevention & control
Parenteral/iv fluids
Routine/emergency dental srvcs in nfs
Treatment/devices to maintain hearing/vision
Tube feeding mgmt/restore eating skills
Building construction type and height
Cooking facilities
Discharge from exits
Electrical systems - essential electric syste
Evacuation and relocation plan
Fundamentals - building system categories
Hazardous areas - enclosure
Interior wall and ceiling finish
Maintenance, inspection & testing - doors
Physical environment
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope, not corrected at time of report.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
One Level 2 standard health citation for reporting to national health safety network with widespread scope, not corrected at time of report.
Findings
One Level 2 standard health citation for reporting to national health safety network with widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 25, 2022
Visit Reason
The inspection was a Recertification Survey and Abbreviated Survey conducted 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 thoroughly investigate injuries of unknown origin, improper medication administration practices, inadequate pressure ulcer care, insufficient nursing staffing levels, failure to post nurse staffing data as required, medication error rates exceeding 5%, and incomplete COVID-19 vaccination compliance among staff.
Deficiencies (8)
F 0610: The facility failed to ensure injuries of unknown origin were thoroughly investigated, lacking complete staff and resident statements for a resident with an unwitnessed fracture.
F 0658: The facility did not ensure services met professional standards during medication administration when a nurse crushed and mixed 11 medications including an extended-release medication and administered them simultaneously.
F 0686: The facility failed to provide appropriate pressure ulcer care by not setting an air mattress to the physician-ordered weight setting for a resident with a Stage 4 pressure ulcer.
F 0725: The facility did not provide enough nursing staff to meet resident needs, resulting in missed floor ambulation, delayed call bell response, and late medication administration as reported by residents and staff.
F 0732: The facility failed to post nurse staffing information daily in a prominent place accessible to residents and visitors as required.
F 0759: The facility's medication error rate exceeded 5%, with 11 errors in 26 opportunities, including crushing and mixing multiple medications and supplements, including an extended-release medication, and administering them simultaneously.
F 0760: The facility failed to ensure residents were free from significant medication errors, specifically crushing and mixing seven medications and four supplements including an extended-release medication and administering them simultaneously.
F 0888: The facility failed to ensure 100% COVID-19 vaccination compliance among staff, with one Licensed Practical Nurse not fully vaccinated and providing resident care without exemption documentation.
Report Facts
Medication error rate: 42.3
Staff count: 341
Staff vaccination: 1
Medication count: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Administered crushed and mixed medications including extended-release medication to Resident #66 |
| LPN #1 | Licensed Practical Nurse | Staff member not fully vaccinated for COVID-19 and provided resident care |
| RN #1 | RN Supervisor | Interviewed regarding medication administration practices and extended-release medication handling |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding medication administration, staffing shortages, and vaccination compliance |
| Data Analysis Coordinator | Staffing Coordinator | Responsible for tracking staff vaccination and staffing levels |
| Assistant Director of Nursing Services | Infection Preventionist | Interviewed regarding staff vaccination status and PPE use |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 30, 2021
Visit Reason
One Level 2 standard health citation for responsibilities of providers and required notification, isolated scope, corrected by January 2022.
Findings
One Level 2 standard health citation for responsibilities of providers and required notification, isolated scope, corrected by January 2022.
Deficiencies (1)
Responsibilities of providers; required notif
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 5, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to timely transmit MDS discharge assessments, incomplete implementation of care plans, failure to update care plans to reflect resident status, inadequate nutritional monitoring and physician response to significant weight loss, failure to address pharmacist recommendations, improper medication storage, incomplete food handling policies, and lapses in infection control practices during wound care.
Deficiencies (9)
F0640: The facility failed to transmit the Minimum Data Set (MDS) Discharge Assessment to CMS within 14 days after completion for one resident.
F0656: The facility did not ensure a comprehensive person-centered care plan was implemented for a resident refusing a nursing rehabilitation standing program, and staff failed to report refusals.
F0657: The facility failed to review and revise a resident's Comprehensive Care Plan to reflect new vision impairment and use of an eye patch.
F0692: The facility did not provide adequate care to maintain nutritional status for a resident with significant weight loss over 7.5% in three months without updating the care plan or notifying the dietitian and physician.
F0711: The facility failed to ensure the resident's physician reviewed and addressed significant weight loss during visits, with no documented evaluation of nutritional issues.
F0756: The facility did not ensure the attending physician documented review or response to a pharmacist's recommendation regarding unnecessary medication for a resident.
F0761: Medications requiring refrigeration were stored improperly in a nursing unit refrigerator at 50°F with ice buildup and water accumulation, risking medication integrity.
F0813: The facility's policy on handling food from outside sources did not specify how staff would assist residents unable to access or consume such food.
F0880: During wound care for a resident with a Stage 4 pressure ulcer, the nurse failed to wash hands or change gloves after cleansing the wound, risking infection transmission.
Report Facts
Weight loss percentage: 7.5
Weight loss percentage: 8.33
Weight loss percentage: 9.57
Refrigerator temperature: 50
Standing program noncompliance days: 26
Standing program noncompliance days: 28
Standing program noncompliance days: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Unit Manager | Registered Nurse Unit Manager | Interviewed regarding failure to update resident's vision care plan and weight loss monitoring. |
| Physician Assistant | Physician Assistant | Interviewed regarding ophthalmology consult and weight loss monitoring. |
| Chief Clinical RD | Chief Clinical Registered Dietitian | Interviewed regarding nutritional assessment and weight loss protocol. |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding standing program refusals, wound care hand hygiene, and medication refrigerator issues. |
| Pharmacist | Consultant Pharmacist | Conducted medication regimen review and recommended discontinuation of folic acid. |
| LPN Medication Nurse | Licensed Practical Nurse | Observed medication refrigerator temperature and storage conditions. |
| RN Wound Care Nurse | Registered Nurse Wound Care Nurse | Observed wound care and noted failure to wash hands/change gloves. |
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