Inspection Reports for
The Wartburg Home
Bradley Avenue, Mount Vernon, NY, 10552
Back to Facility Profile6 Reports
Inspection Report — Jul 28, 2025
State
Date: Jul 28, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022 to 2025 with deficiency history and complaint details.
Complaint Details
The state logged 36 complaints about this facility; 9 led to on-site inspections. Complaint surveys resulted in 5 citations.
Findings
Across 8 inspections, 37 citations were issued including 20 standard health and 17 Life Safety Code citations. Most deficiencies were Level 2 with minor potential harm, and no formal enforcement actions were recorded.
Citations (27)
Standard Health Citation — quality of care: Essential Equipment, Safe Operating Condition found deficient with widespread issues.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary found deficient with widespread issues.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals found deficient with isolated issues.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning found deficient with isolated issues.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notification found deficient with limited scope.
Standard Health Citation — quality of care: Grievances found deficient with isolated issues.
Standard Health Citation — quality of care: Reporting - National Health Safety Network found deficient with widespread issues.
Standard Health Citation — quality of care: Baseline Care Plan found deficient with isolated issues.
Standard Health Citation — quality of care: Notice Of Bed Hold Policy Before/upon Transfer found deficient with pattern issues.
Standard Health Citation — quality of care: Required In-service Training For Nurse Aides found deficient with pattern issues.
Standard Health Citation — quality of care: Treatment/services To Prevent/heal Pressure Ulcer found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Alcohol Based Hand Rub Dispenser found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Corridor - Doors found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Egress Doors found deficient with pattern issues.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System found deficient with pattern issues.
Life Safety Code Citation — NFPA requirements: Emergency Lighting found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance found deficient with widespread issues and potential for minimal harm.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage found deficient with pattern issues.
Life Safety Code Citation — NFPA requirements: HVAC found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress found deficient with isolated issues.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General found deficient with pattern issues.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing found deficient with isolated issues.
Standard Health Citation — quality of care: Discharge Planning Process found deficient with isolated issues.
Standard Health Citation — quality of care: Reporting - National Health Safety Network found deficient with widespread issues.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices found deficient with isolated issues.
Standard Health Citation — quality of care: Reporting Of Alleged Violations found deficient with isolated issues.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 37
Inspections with violations: 7
Inspections without violations: 1
Complaints received: 36
On-site complaint inspections: 9
Complaint citations issued: 5
Enforcement actions: 0
Inspection Report — Jul 28, 2025
Annual Inspection CMS
Date: Jul 28, 2025
Visit Reason
The inspection was a recertification survey conducted from 7/22/25 to 7/28/25 to assess compliance with regulatory standards for The Wartburg Home nursing facility.
Findings
The facility was found deficient in several areas including improper respiratory care for a resident, unsecured medications in resident rooms, unsanitary food storage and preparation conditions, and broken essential kitchen equipment affecting safe operation.
Citations (4)
Failure to provide safe and appropriate respiratory care; nasal cannula tubing observed in resident's mouth instead of nostrils.
Medications not secured in locked storage; Symbicort inhaler found unsecured in resident's room.
Food stored, prepared, and distributed in unsanitary conditions including expired and unlabeled food, personal items in food prep areas, and poor pantry sanitation.
Essential kitchen equipment not maintained in safe operating condition; broken dishwashers, food warmers, freezer, steam table, and main kitchen dish machine not reaching proper sanitization temperatures.
Report Facts
Physician's Order Oxygen Flow: 2
Medication Nebulization Frequency: 2
Expired Food Dates: 7
Broken Equipment Count: 6
Dishwasher Wash Temperature: 124
Dishwasher Final Rinse Temperature: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Responsible for monitoring nasal cannula placement; unaware nasal cannula was in resident's mouth | |
| Licensed Practical Nurse #3 | Responsible for monitoring oxygen administration; did not notice nasal cannula misplacement | |
| Director of Nursing | Stated residents cannot keep medications in rooms; explained self-administration policy | |
| Registered Nurse #4 | Admitting nurse for Resident #35; responsible for asking about resident medications | |
| Certified Nurse Aide #14 | Observed not wearing hair net in kitchen | |
| Dietary Aide #8 | Reported broken kitchen equipment in Unit 1 South pantry | |
| Dietary Aide #11 | Confirmed procedure for reporting broken equipment | |
| Food Service Director | Provided information on medication policies, food safety deficiencies, and broken equipment | |
| Administrator | Reported being informed of broken equipment on 7/23/25 and described environmental rounds |
Inspection Report — Jan 16, 2024
Abbreviated Survey CMS
Date: Jan 16, 2024
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with grievance policies following a complaint from Resident #1's Family Representative regarding incontinence care and bathroom ambulation needs not being rendered.
Complaint Details
The complaint was substantiated as Resident #1's Family Representative verbally complained about incontinence care and bathroom ambulation needs not being met. The grievance was not documented or formally filed, and the facility did not follow its grievance process. The Family Representative was unaware of the grievance process and was not informed about it by staff.
Findings
The facility failed to ensure prompt efforts were made to resolve a resident's grievance as no grievance form was initiated or completed, and there was no documented evidence that the complaints were addressed. Interviews revealed that verbal complaints were not properly documented or processed according to facility policy.
Citations (1)
Failure to honor the resident's right to voice grievances without discrimination or reprisal and failure to establish a grievance policy with prompt efforts to resolve grievances.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Licensed Practical Nurse | Documented the Family Representative's complaint and referred the incident to the Director of Nursing. |
| Staff #5 | Social Worker | Stated no grievance or complaint was filed despite verbal concerns and mentioned grievance procedure is posted in the facility. |
| Staff #7 | Director of Nursing | Did not file a grievance form stating the problem was addressed immediately and did not need a grievance because there was no harm. |
| Administrator | Stated verbal complaints should be written down or emailed and grievance forms should be completed and investigated. |
Inspection Report — Jun 20, 2023
Abbreviated Survey CMS
Date: Jun 20, 2023
Visit Reason
The inspection was conducted as part of recertification and abbreviated surveys to assess compliance with regulatory requirements, specifically focusing on notification of the facility Bed Hold Policy to residents or their representatives during hospital transfers.
Findings
The facility failed to ensure that residents or their representatives were notified in writing of the Bed Hold Policy for 4 of 5 residents reviewed who were transferred to the hospital, violating the facility's own policy and regulatory requirements.
Citations (1)
Failure to provide written notice of the facility Bed Hold Policy to residents or their representatives upon hospital transfer for Residents #257, #103, #74, and #97.
Report Facts
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding failure to provide Bed Hold Policy notice | |
| Admissions Director | Interviewed regarding current practice of not providing Bed Hold Policy notice |
Inspection Report — Jun 20, 2023
Annual Inspection CMS
Date: Jun 20, 2023
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify residents or their representatives in writing about the bed hold policy during hospital transfers, lack of baseline care plans within 48 hours for residents on anticoagulants, inadequate pressure ulcer care for a resident with a knee immobilizer, and failure to provide required nurse aide training in dementia care and abuse prevention.
Citations (4)
Failure to notify residents or representatives in writing of the facility Bed Hold Policy for 4 of 5 residents reviewed for hospitalization.
Failure to initiate baseline care plans within 48 hours of admission for 2 of 5 residents prescribed anticoagulants.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 3 residents reviewed, including lack of physician orders and care plans related to a knee immobilizer.
Failure to ensure certified nurse aides received the required 12 hours of training and annual in-service on dementia care management and resident abuse prevention for 8 of 10 CNAs reviewed.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 1
CNAs lacking mandatory training: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #2 | Registered Nurse Unit Manager | Interviewed regarding baseline care plans and pressure ulcer care deficiencies |
| Admissions Director | Interviewed regarding Bed Hold Policy notification practices | |
| Director of Nursing | Director of Nursing | Interviewed regarding baseline care plans and nurse aide training |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding resident refusal to remove immobilizer |
| Nurse Educator | Nurse Educator | Interviewed regarding nurse aide training records |
| Administrator | Administrator | Interviewed regarding compliance with nurse aide training |
Inspection Report — May 17, 2021
Annual Inspection CMS
Date: May 17, 2021
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for The Wartburg Home nursing facility.
Findings
The survey identified multiple deficiencies including incomplete care plans for residents with complex medical conditions, inadequate respiratory care and oxygen tubing management, improper storage and labeling of insulin medications, unsafe food storage practices, and failure to follow proper infection prevention and control procedures during wound care.
Citations (5)
Failure to develop and implement complete, person-centered care plans with measurable objectives and appropriate interventions for residents with End Stage Renal Disease on Hemodialysis, cardiovascular conditions, and Chronic Obstructive Pulmonary Disease.
Failure to ensure safe and appropriate respiratory care including lack of documented protocols for oxygen tubing changes and failure to monitor resident oxygen use and notify physician.
Failure to follow accepted professional standards for storage and labeling of multi-dose insulin pens, including undated pens and improper refrigeration.
Failure to ensure proper labeling, dating, and monitoring of refrigerated food items to prevent use past expiration or use-by dates.
Failure to implement an effective infection prevention and control program, including improper hand hygiene and gloving techniques during wound care, leading to cross-contamination risks.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 2
Containers of liquid egg whites: 15
Deli meat packages: 3
Raw chicken bags: 4
Raw turkey breasts: 2
Days insulin should be discarded after opening: 28
Days chicken should be used after pull date: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in infection control deficiency related to wound care procedures and hand hygiene failures |
| NM #1 | Nurse Manager | Interviewed regarding respiratory care and oxygen tubing procedures |
| RN #1 | Registered Nurse | Interviewed regarding oxygen tubing changes and resident oxygen use |
| RN #2 | Registered Nurse | Interviewed regarding oxygen tubing changes |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding insulin storage and labeling |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding insulin storage and labeling |
| FSD #1 | Food Service Director | Interviewed regarding food storage and labeling deficiencies |
| Cook #2 | Cook | Interviewed regarding food storage and labeling deficiencies |
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