Deficiencies (last 5 years)
Deficiencies (over 5 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
116% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 11
Date: Nov 8, 2024
Visit Reason
Inspection identified 9 health and 2 life safety code deficiencies, all corrected shortly after the inspection date.
Findings
Inspection identified 9 health and 2 life safety code deficiencies, all corrected shortly after the inspection date.
Deficiencies (11)
Activities daily living (adls)/mntn abilities
ADL care provided for dependent residents
Care plan timing and revision
Comprehensive assessment after signifcant chg
Food procurement,store/prepare/serve-sanitary
Free of medication error rts 5 prcnt or more
Reporting of alleged violations
Residents are free of significant med errors
Respiratory/tracheostomy care and suctioning
Ep program patient population
Protection - other
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as a recertification survey and an abbreviated survey to assess compliance with regulations related to timely reporting of suspected abuse, neglect, or theft, and to ensure residents were free from significant medication errors.
Findings
The facility failed to timely report alleged violations of abuse and injuries of unknown source for two residents and did not submit required 5-day investigation reports. Additionally, the facility did not ensure residents were free from significant medication errors, including administering medications prescribed for another resident and failure to provide prescribed medication due to insurance pre-authorization delays.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and failure to submit required 5-day investigation reports for two residents.
Failure to ensure residents were free from significant medication errors, including administering medications prescribed for another resident and failure to provide prescribed medication due to insurance pre-authorization delays.
Report Facts
Residents reviewed for reporting of allegations: 5
Residents affected by reporting deficiencies: 2
Residents reviewed for medication errors: 2
Residents affected by medication errors: 2
Date of medication error for Resident #88: 2024
Date of missed medication for Resident #144: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Administered wrong medications to Resident #88 | |
| Director of Nursing #1 | Director of Nursing | Reported medication error and discussed reporting procedures |
| Administrator #1 | Administrator | Involved in reporting process and communication with Department of Health |
| Medical Director #2 | Medical Director | Initiated orders to hold medications and administer intravenous fluids for Resident #88 |
| Registered Nurse #3 | Registered Nurse | Attempted to notify physician about medication pre-authorization for Resident #144 |
| Medical Director #1 | Medical Director | Commented on medication pre-authorization process and physician notification |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Attempted to re-order medication requiring pre-authorization for Resident #144 |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as a recertification survey and an abbreviated survey to assess compliance with federal and state regulations regarding resident care, medication administration, reporting of abuse, significant changes in condition, and facility operations.
Findings
The facility was found deficient in timely reporting of suspected abuse, conducting significant change assessments, revising comprehensive care plans, providing appropriate communication aids, assisting with personal hygiene, ensuring safe respiratory care, maintaining medication error rates below 5%, preventing significant medication errors, and maintaining food service safety standards. Specific incidents included medication errors, failure to report injuries of unknown origin timely, lack of significant change assessments after fractures, failure to update care plans, inadequate communication support for a resident with aphasia, failure to assist with shaving, empty portable oxygen tanks, medication errors including wrong resident medication and missed medication due to insurance pre-authorization, and improper freezer temperatures in resident kitchenettes.
Deficiencies (9)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Did not ensure a Significant Change Minimum Data Set assessment was completed for a resident with fractured wrists.
Did not ensure Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs for two residents.
Did not provide appropriate communication aids and structured approach for a resident with speech impairment due to stroke.
Did not provide assistance with personal hygiene, leaving facial hair to grow on a resident's upper lip.
Did not ensure safe and appropriate respiratory care; portable oxygen tank was empty for a resident.
Medication error rate exceeded 5% during medication pass observations.
Residents were not free from significant medication errors including wrong resident medication and missed medication due to insurance pre-authorization.
Food was not stored, prepared, distributed, or served in accordance with professional standards; refrigerators and freezers were not operating appropriately.
Report Facts
Medication error rate: 24
Residents reviewed for significant changes: 42
Residents reviewed for care plans: 62
Residents reviewed for Activities of Daily Living: 9
Residents reviewed for oxygen administration: 4
Residents reviewed for medication errors: 4
Residents reviewed for medication errors: 2
Freezer temperature range: 9
Freezer temperature range: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Administered wrong medications to Resident #88. | |
| Director of Nursing #1 | Director of Nursing | Provided statements regarding reporting, care plan updates, and medication errors. |
| Administrator #1 | Administrator | Involved in discussion about 5-day report submission for medication error. |
| Minimum Data Set Coordinator #1 | Acknowledged missed significant change assessments for Resident #141. | |
| Registered Nurse #5 | Provided statements about weight monitoring and family meetings. | |
| Social Worker #1 | Provided statements about care planning meetings and health care proxies. | |
| Certified Nurse Aide #2 | Provided statements about communication with Resident #268. | |
| Certified Nurse Aide #3 | Provided statements about communication with Resident #268. | |
| Speech Therapist #1 | Speech Therapist | Provided statements about communication therapy for Resident #268. |
| Licensed Practical Nurse #8 | Observed attempting to remove empty oxygen tank from surveyor's view. | |
| Registered Nurse #6 | Provided statements about oxygen tank monitoring. | |
| Licensed Practical Nurse #3 | Administered medications late during medication pass. | |
| Nurse Educator #1 | Nurse Educator | Provided statements about nurse orientation and medication competency. |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Reviewed medication administration record for Resident #77. |
| Medical Director #2 | Medical Director | Ordered intravenous fluids after medication error for Resident #88. |
| Medical Director #1 | Medical Director | Provided statements about medication prior authorization process. |
| Registered Nurse #3 | Involved in medication re-order and physician notification for Resident #144. | |
| Licensed Practical Nurse #2 | Attempted to re-order medication requiring prior authorization for Resident #144. | |
| Director of Dining Services and Clinical Nutrition #1 | Director of Dining Services and Clinical Nutrition | Provided statements about food service safety and temperature logs. |
| Director of Plant Operations #1 | Director of Plant Operations | Provided statements about maintenance and temperature logs. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 3, 2024
Visit Reason
One health deficiency related to medication errors was identified and corrected.
Findings
One health deficiency related to medication errors was identified and corrected.
Deficiencies (1)
Residents are free of significant med errors
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 3, 2024
Visit Reason
The abbreviated survey was conducted to investigate medication errors involving two residents where one resident received another's antibiotic medication for 5 days.
Findings
The facility failed to ensure residents were free from significant medication errors as Resident #2 received Resident #1's antibiotic for 5 days, and the electronic medical record was inaccurate for both residents during that time. The root cause was identified as an order transcription error and failure to follow the Physician's Order Entry policy requiring a second nurse to confirm new orders.
Deficiencies (1)
Residents #1 and #2 did not receive their own medication as ordered; Resident #2 received Resident #1's antibiotic for 5 days.
Report Facts
Medication doses administered in error: 5
Medication administration frequency: 2
Medication administration duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Responsible for the medication transcription error and order entry; received one-on-one training and counseling. | |
| Registered Nurse Manager #2 | Assistant Director of Nursing | Documented the medication error, conducted investigation, and reported findings. |
| Physician/Medical Doctor #2 | Ordered antibiotic for Resident #1 and was notified of the medication error. | |
| Physician #1 | Notified about the medication error and discontinued antibiotic for Resident #2. | |
| Director of Nursing #1 | Director of Nursing | Provided statements about the incident and corrective actions. |
| Administrator | Reported facility's immediate response and corrective actions. |
Inspection Report
Capacity: 60
Deficiencies: 3
Date: Nov 30, 2023
Visit Reason
Three life safety code deficiencies related to electrical equipment, smoke barriers, and vertical openings were identified and corrected.
Findings
Three life safety code deficiencies related to electrical equipment, smoke barriers, and vertical openings were identified and corrected.
Deficiencies (3)
Electrical equipment - testing and maintenanc
Subdivision of building spaces - smoke barrie
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The inspection was conducted as an annual survey of Teresian House Nursing Home CO Inc to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 4, 2023
Visit Reason
One health deficiency related to reporting of alleged violations was identified and corrected.
Findings
One health deficiency related to reporting of alleged violations was identified and corrected.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 4, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate the facility's compliance with timely reporting requirements for suspected abuse, neglect, or injuries of unknown source involving residents.
Complaint Details
The visit was complaint-related, investigating allegations that the facility did not report injuries of unknown source involving Resident #1 and Resident #2 within the required 2-hour timeframe. The facility reported the injury of Resident #2 to NYSDOH on 9/23/2022, which was delayed. The investigation found the facility failed to report Resident #1's injury timely as well.
Findings
The facility failed to ensure timely reporting of injuries of unknown source resulting in serious bodily injury to appropriate authorities within required timeframes for two residents. Specifically, delays were noted in reporting a left femoral fracture for Resident #1 and a right ulnar fracture for Resident #2 to the New York State Department of Health (NYSDOH).
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or injuries of unknown source resulting in serious bodily injury to proper authorities within required timeframes.
Report Facts
Date of injury for Resident #1: Mar 6, 2023
Date of injury for Resident #2: Sep 21, 2022
Date injury reported to NYSDOH for Resident #2: Sep 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Reported Resident #1's injury and expected timely reporting to NYSDOH |
| NP #4 | Nurse Practitioner | Ordered x-ray and assessed Resident #1's injury |
| Administrator | Responsible for reporting allegations to NYSDOH; acknowledged delay in reporting | |
| DON | Director of Nursing | Conducted investigation and acknowledged reporting delay |
| LPN #7 | Licensed Practical Nurse | Notified of Resident #2's injury and involved in care |
| NP #2 | Nurse Practitioner | Ordered x-ray for Resident #2's injury |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 7, 2022
Visit Reason
One life safety code deficiency related to electrical systems was identified and corrected.
Findings
One life safety code deficiency related to electrical systems was identified and corrected.
Deficiencies (1)
Electrical systems - essential electric syste
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 8
Date: Dec 23, 2021
Visit Reason
Multiple health and life safety code deficiencies including immediate jeopardy level 4 for accident hazards were identified and corrected.
Findings
Multiple health and life safety code deficiencies including immediate jeopardy level 4 for accident hazards were identified and corrected.
Deficiencies (8)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Personal privacy/confidentiality of records
Reporting of alleged violations
Egress doors
Ramps and other exits
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 23, 2021
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with federal and state regulations for nursing home operations.
Findings
The facility was found deficient in maintaining residents' privacy during vital sign checks, timely reporting of abuse allegations, supervision to prevent resident elopement, proper use of psychotropic medication PRN orders, and food service safety including dishwashing chemical concentration and kitchen cleanliness. Immediate jeopardy related to elopement was identified and subsequently lifted after corrective actions.
Deficiencies (5)
Failure to maintain residents' right to personal privacy and confidentiality during finger sticks and blood pressure checks in dining rooms.
Failure to timely report an allegation of abuse involving a resident to the Administrator.
Failure to provide adequate supervision to prevent elopement of a cognitively impaired resident, resulting in immediate jeopardy.
Failure to limit PRN psychotropic medication orders to 14 days without documented clinical justification.
Failure to maintain proper sanitizing chemical concentration in dishwashing machine and cleanliness of unit kitchens.
Report Facts
Sanitizing chemical concentration: 200
PRN psychotropic medication duration: 14
Elopement incident date: Dec 3, 2021
Elopement duration: 45
Staff re-education percentage: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Observed taking blood pressures loudly in dining room |
| LPN #1 | Licensed Practical Nurse | Observed obtaining finger stick and announcing blood sugar in dining room |
| LPN #3 | Licensed Practical Nurse | Received abuse allegation report from Resident #167 and spoke to CNA |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse reporting and PRN medication policies |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) #3 | Interviewed regarding abuse allegation awareness and investigation |
| Director of Environmental Services | Director of Environmental Services (DES) | Interviewed regarding door alarm and response to elopement incident |
| Director of Plant Management | Director of Plant Management (DPM) | Interviewed regarding door alarm desensitization and corrective actions |
| Administrator | Administrator (ADM) | Interviewed regarding door alarm compliance and corrective actions |
| Director of Dining Services | Director of Dining Services | Interviewed regarding dishwashing chemical concentration and kitchen cleanliness |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding PRN psychotropic medication regulations |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 13, 2021
Visit Reason
One health deficiency related to reporting to the national health safety network was identified; correction status unclear.
Findings
One health deficiency related to reporting to the national health safety network was identified; correction status unclear.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Oct 7, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect during meals, notification of financial liability for rehabilitative services, use of physical restraints, coordination of mental health assessments, development of comprehensive care plans, provision of activities, accident hazard prevention and supervision, food safety and handling, policies on foods brought by visitors, and antibiotic stewardship.
Deficiencies (11)
Staff did not ensure residents in Broda chairs were treated with dignity during meals and did not raise chairs to proper height; staff engaged in personal conversations instead of interacting with residents.
Residents were not provided with SNF ABN Form CMS-10055 to inform them of potential financial liability for non-covered rehabilitative services.
Resident was restrained with a Merry walker without proper care planning and least restrictive use.
Facility did not refer residents with newly evident mental illness for level II resident review as required by PASRR.
Comprehensive care plans were not developed or implemented for multiple residents' medical and psychosocial needs.
Facility did not provide activities based on residents' mental and physical abilities; televisions in common areas were often set to inappropriate channels.
Resident environment was not free from accident hazards and supervision was inadequate to prevent accidents; a resident with a roam alert left the facility unsupervised and the front door alarm did not sound.
Facility did not have a policy with time frames for monthly Medication Regimen Review process steps and actions when irregularities are identified.
Food service safety was deficient: dishwashing machines did not meet water pressure requirements, kitchen and equipment were soiled, and staff did not follow safe food handling practices including glove use and hand hygiene.
Facility policy on foods brought in by visitors did not include provisions for safe and sanitary storage, handling, consumption, or staff assistance for dependent residents.
Antibiotic stewardship program was not fully implemented; antibiotics were prescribed without appropriate indications or monitoring, including lack of urine cultures prior to antibiotic use.
Report Facts
Residents reviewed for comprehensive care plans: 32
Residents with deficient care plans: 5
Residents reviewed for PASRR: 2
Residents affected by restraint deficiency: 1
Residents affected by dignity deficiency: 3
Residents affected by financial liability notification deficiency: 2
Residents affected by activity deficiency: 1
Residents affected by accident hazard deficiency: 1
Dishwashing machine rinse pressure: 0
Dishwashing machine rinse pressure: 35
Resident straight catheterizations: 54
Resident straight catheterizations: 10
Resident antibiotic doses: 14
Resident activity attendance: 12
Resident activity attendance: 9
Resident activity attendance: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | LPN | Named in dignity and respect deficiency during meals and staff interaction. |
| Director of Nursing | DON | Named in dignity and respect deficiency, restraint deficiency, care plan deficiency, activity deficiency, and antibiotic stewardship. |
| Minimum Data Set Coordinator | Named in notification of financial liability deficiency. | |
| Certified Nursing Assistant #4 | CNA | Named in restraint deficiency. |
| Registered Nurse Manager #4 | RNM | Named in restraint deficiency and activity deficiency. |
| Registered Nurse Manager #2 | RNM | Named in care plan deficiency. |
| Director of Social Worker #1 | Social Worker | Named in PASRR deficiency. |
| Activity Coordinator #7 | AC | Named in activity deficiency. |
| Family Member #1 | Named in activity deficiency. | |
| Family Member #2 | Named in activity deficiency. | |
| Risk Manager | Named in accident hazard and supervision deficiency. | |
| Activities Coordinator #11 | AC | Named in accident hazard and supervision deficiency. |
| Director of Maintenance | Named in accident hazard and supervision deficiency. | |
| General Manager | Named in food safety deficiency. | |
| Certified Nursing Assistant #1 | CNA | Named in food safety deficiency. |
| Food Service Manager #6 | Named in food safety deficiency. | |
| Assistant Director of Nursing | ADON | Named in antibiotic stewardship deficiency. |
| Infection Control Registered Nurse | RN | Named in antibiotic stewardship deficiency. |
| Registered Nurse Manager #5 | RNM | Named in antibiotic stewardship deficiency. |
| Registered Nurse Manager #6 | RNM | Named in antibiotic stewardship deficiency. |
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