Inspection Reports for
Warren Center for Rehabilitation and Nursing
42 Gurney Lane, Queensbury, NY, 12804
Back to Facility ProfileCitations (last 5 years)
Citations (over 5 years)
10 citations/year
Citations are regulatory findings recorded during state inspections.
96% worse than New York average
New York average: 5.1 citations/year
Citations per year
20
15
10
5
0
Inspection Report
Abbreviated Survey
Citations: 1
Date: Jul 9, 2024
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with care plan requirements, specifically reviewing whether comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment.
Findings
The facility failed to ensure that comprehensive care plans were reviewed and revised to include significant incidents such as falls and a resident-to-resident sexual abuse incident for three residents. Care plans did not document these events or related interventions despite assessments and incident documentation.
Citations (1)
F 0657: The facility did not develop a complete care plan within 7 days of the comprehensive assessment and failed to revise care plans after incidents for three residents. Care plans lacked documentation of multiple falls for Resident #1, a sexual abuse incident for Resident #2, and a fall for Resident #3.
Report Facts
Falls documented for Resident #1: 5
Date of sexual abuse incident for Resident #2: Apr 18, 2024
Fall documented for Resident #3: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing #1 | Provided interview statements about assessment and documentation practices | |
| Registered Nurse Manager #1 | Provided interview statements about care planning responsibilities for Residents #1, 2, and 3 |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Jul 9, 2024
Visit Reason
One standard health citation for care plan timing and revision, no life safety citations.
Findings
One standard health citation for care plan timing and revision, no life safety citations.
Citations (1)
Care plan timing and revision
Inspection Report
Abbreviated Survey
Citations: 1
Date: May 31, 2024
Visit Reason
The abbreviated survey was conducted to investigate compliance with resident care plans and prevention of neglect following an incident involving Resident #3.
Findings
The facility failed to ensure residents were free from neglect when a Certified Nurse Aide did not follow Resident #3's care plan requiring two staff for bed mobility, resulting in the resident falling and sustaining fractures to both legs. The facility took corrective actions including staff education and termination of the responsible aide.
Citations (1)
F 0600: The facility failed to protect residents from neglect when Certified Nurse Aide #1 attempted to roll Resident #3 without the required assistance of another staff member, causing the resident to fall and sustain fractures to both legs.
Report Facts
Date of incident: Jan 15, 2024
Date of survey completion: May 31, 2024
Staff education completion rate: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Failed to follow Resident #3's care plan and caused resident fall | |
| Director of Nursing #1 | Director of Nursing | Provided information on staff education and facility response |
| Registered Nurse #2 | Registered Nurse | Assessed Resident #3 immediately after the fall |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Assessed Resident #3 the morning after the fall and notified physician |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: May 31, 2024
Visit Reason
One standard health citation for free from abuse and neglect, no life safety citations.
Findings
One standard health citation for free from abuse and neglect, no life safety citations.
Citations (1)
Free from abuse and neglect
Inspection Report
Annual Inspection
Citations: 3
Date: Nov 6, 2023
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans, proper medication storage and labeling, food service safety standards, and ensuring care plan interventions were consistently followed.
Citations (3)
F 0656: The facility failed to develop and implement complete care plans meeting all resident needs, including ensuring oxygen was provided as ordered for Resident #5 and positioning interventions for Resident #47 were not consistently implemented.
F 0761: The facility did not ensure drugs and biologicals were stored and labeled according to professional standards, including improperly labeled and stored insulin pens and medication bottles on medication carts.
F 0812: The facility failed to procure food from approved sources and did not store, prepare, distribute, or serve food in accordance with professional standards, including uncalibrated thermometers, soiled kitchen equipment, and inadequate sanitizer test kits.
Report Facts
Residents affected: 2
Medication carts inspected: 4
Food thermometers: 3
Sanitizer concentration range: 200
Sanitizer concentration range: 400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Responsible for oxygen administration documentation and insulin pen handling |
| LPNUM #1 | Licensed Practical Nurse Unit Manager | Interviewed regarding oxygen administration and CNA responsibilities |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan implementation and medication storage policies |
| CNA #5 | Certified Nurse Aide | Interviewed regarding care plan implementation for Resident #47 |
| LPN #2 | Licensed Practical Nurse | Observed medication cart and interviewed about medication labeling |
| LPN #6 | SW Unit Manager | Interviewed about insulin pen storage and labeling policies |
| Food Service Director | Food Service Director | Interviewed about food thermometer calibration and kitchen sanitation |
| Administrator | Administrator | Interviewed about corrective actions for food service and medication cart compliance |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 5
Date: Nov 3, 2023
Visit Reason
Two standard health citations and three life safety code citations related to care plan, food sanitation, fire alarm system, door maintenance, and smoke barrier.
Findings
Two standard health citations and three life safety code citations related to care plan, food sanitation, fire alarm system, door maintenance, and smoke barrier.
Citations (5)
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Fire alarm system - testing and maintenance
Maintenance, inspection & testing - doors
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 5
Date: Mar 27, 2023
Visit Reason
Multiple standard health citations related to grievances, investigation of alleged violations, notification of changes, reporting violations, and resident records.
Findings
Multiple standard health citations related to grievances, investigation of alleged violations, notification of changes, reporting violations, and resident records.
Citations (5)
Grievances
Investigate/prevent/correct alleged violation
Notify of changes (injury/decline/room, etc. )
Reporting of alleged violations
Resident records - identifiable information
Inspection Report
Abbreviated Survey
Citations: 5
Date: Mar 27, 2023
Visit Reason
The survey was conducted as an abbreviated survey to investigate complaints and allegations related to resident notifications, grievance handling, abuse reporting, incident investigations, and documentation accuracy at the Warren Center for Rehabilitation and Nursing.
Findings
The facility failed to immediately notify resident representatives and physicians of injuries, did not thoroughly investigate incidents, did not properly report alleged abuse to authorities, inadequately handled resident grievances, and failed to maintain accurate and timely documentation in resident records.
Citations (5)
F 0580: The facility did not immediately inform Resident #2's representative or physician of a facial injury, delayed obtaining an x-ray, and failed to document notifications of the x-ray results.
F 0585: The facility did not ensure timely investigation, communication, or resolution of grievances for Residents #11, #23, and #24, and closed grievances before corrective actions were taken.
F 0609: The facility failed to report 5 of 5 alleged abuse or neglect incidents, including sexual abuse and resident-to-resident altercations, to the State Survey Agency within required timeframes.
F 0610: The facility did not thoroughly investigate an allegation of abuse involving Resident #2's facial injury and did not follow its policy for incidents and accidents.
F 0842: The facility failed to maintain complete and accurate resident records for Resident #2, including delayed documentation of a facial bruise and incomplete communication with the resident's family.
Report Facts
Residents reviewed for notifications: 4
Residents reviewed for grievances: 5
Reportable incidents not reported: 5
Grievances reviewed: 3
Call light audits performed: 4
Days delay in bruise documentation: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Assessed Resident #2's facial bruise and documented late entry nursing progress note |
| NHA | Nursing Home Administrator | Interviewed regarding notification failures, grievance handling, abuse reporting, and investigation processes |
| DON | Director of Nursing | Interviewed regarding notification failures, grievance handling, abuse reporting, and investigation processes |
| DSW | Director of Social Work / Grievance Officer | Assisted residents with grievances and described grievance process |
| Resident #2's family member | Reported noticing facial bruising and lack of notification by facility |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Mar 14, 2023
Visit Reason
One standard health citation for free of accident hazards/supervision/devices with immediate jeopardy.
Findings
One standard health citation for free of accident hazards/supervision/devices with immediate jeopardy.
Citations (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Citations: 1
Date: Mar 14, 2023
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with regulations regarding resident supervision and accident prevention, specifically focusing on an elopement incident involving Resident #1.
Findings
The facility failed to provide adequate supervision to prevent Resident #1, who was cognitively impaired, from eloping through the front door. Staff did not follow the facility's elopement policy or properly respond to the wanderguard alarm, resulting in immediate jeopardy to resident health and safety, though no actual harm occurred.
Citations (1)
F 0689: The facility failed to ensure adequate supervision to prevent Resident #1 from eloping through the front door despite the alarm sounding. Staff did not follow elopement procedures, including initiating a headcount or notifying administration and law enforcement.
Report Facts
Distance Resident walked: 5.2
Staff reeducation percentage: 96
Temperature: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Documented Resident #1's behavior and exit seeking prior to elopement. |
| LPN #3 | Licensed Practical Nurse | Documented the incident and described alarm procedures and staff expectations. |
| LPN #4 | Licensed Practical Nurse | Described staff responsibilities regarding alarm investigation and headcount. |
| RN #1 | Registered Nurse - Charge Nurse | Was charge nurse during elopement incident and described response to alarm and POA call. |
| Director of Social Work | Director of Social Work | Met with Resident #1 regarding exit seeking behaviors. |
| Nursing Home Administrator | Nursing Home Administrator | Provided information on wanderguard system and facility security. |
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 1
Date: Sep 26, 2022
Visit Reason
One standard health citation for free from abuse and neglect, no life safety citations.
Findings
One standard health citation for free from abuse and neglect, no life safety citations.
Citations (1)
Free from abuse and neglect
Inspection Report
Annual Inspection
Citations: 10
Date: Sep 15, 2021
Visit Reason
The survey was a recertification and abbreviated annual inspection to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, comprehensive care plan development and implementation, assistance with activities of daily living, treatment and care according to physician orders, accident hazard prevention, medication management, food service sanitation, and quality assurance and performance improvement (QAPI) program implementation.
Citations (10)
F0550: The facility did not ensure Resident #63 was treated with dignity and respect when staff used personal cell phones and inappropriate language during care.
F0656: The facility failed to develop and implement comprehensive, resident-specific care plans with measurable objectives for 7 residents, including pain management and behavioral interventions.
F0677: The facility did not provide necessary assistance with activities of daily living for 3 residents, including hygiene and transfers.
F0684: The facility did not provide treatment and care consistent with professional standards for 2 residents, including failure to obtain ordered urine tests and implement wound care orders.
F0686: The facility did not provide appropriate pressure ulcer care for Resident #10, failing to follow physician orders and professional standards.
F0689: The facility did not ensure the resident's environment was free from accident hazards and failed to reassess fall risk or investigate root causes after a fall with injury for Resident #2.
F0757: The facility did not ensure Resident #272's medication regimen was free from unnecessary drugs, lacking documentation to support opioid use and increase, and missing non-pharmacological pain interventions.
F0758: The facility did not ensure Resident #272's psychotropic medication use was supported by documentation of behaviors, non-pharmacological interventions, and monitoring of side effects including lethargy and refusal to eat.
F0812: The facility did not maintain food service equipment and surfaces in a clean and sanitary manner; grease and food debris were observed on multiple kitchen surfaces and equipment, and the ice machine gasket was ripped.
F0865: The facility lacked an effective QAPI program to identify and correct repeat deficiencies in quality of care, care planning, food procurement, and environment maintenance.
Report Facts
Residents reviewed for Comprehensive Care Plans: 22
Residents reviewed for Quality of Care: 22
Residents reviewed for ADLs: 5
Residents reviewed for pressure ulcers: 4
Residents reviewed for unnecessary medication: 6
Residents reviewed for accident hazards: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in fall incident and failure to complete incident report for Resident #2 |
| LPNUM #3 | Licensed Practical Nurse Unit Manager | Named in wound care and lethargy reporting for Resident #272 and Resident #10 |
| ADON | Assistant Director of Nursing | Named in multiple interviews regarding deficiencies in care, wound assessments, and medication monitoring |
| DON | Director of Nursing | Named in interviews regarding care expectations, medication monitoring, and QAPI program |
| Administrator | Named in interview regarding QAPI program improvements and kitchen sanitation | |
| CNA #3 | Certified Nursing Assistant | Named in interviews regarding ADL assistance and resident care |
| CNA #5 | Certified Nursing Assistant | Named in interviews regarding Resident #272 care and behaviors |
Inspection Report
Annual Inspection
Citations: 15
Date: Sep 26, 2019
Visit Reason
The survey was a recertification annual inspection to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident accommodations, notification of transfers, care planning, treatment and care, nutrition, staff training, food service safety, medical record maintenance, and equipment maintenance.
Citations (15)
F 0558: The facility did not ensure Resident #33 was provided a bed long and wide enough, limiting his mobility and comfort.
F 0582: The facility failed to provide SNF ABN Form CMS-10055 to Resident #48 regarding potential financial liability for non-covered rehabilitative services.
F 0584: Floors on two resident units were soiled with dirt and urine odor was noted, indicating ineffective housekeeping and maintenance.
F 0623: The facility did not provide timely written notification to residents and representatives about transfers or discharges for Residents #8, #58, and #68.
F 0655: The facility failed to provide written summaries of baseline care plans to residents and representatives for Residents #51, #57, and #68.
F 0656: Comprehensive care plans were incomplete or missing measurable objectives and interventions for Residents #9, #44, #48, #50, and #66.
F 0657: Care plans were not reviewed and revised after assessments for Residents #7 and #17, missing updates on psychotropic medication and hearing loss.
F 0684: Resident #17 did not receive necessary care to maintain hearing; hearing aid care was not documented and hearing loss interventions were lacking.
F 0685: Resident #16 did not receive ordered eye drops for 11 days after an eye doctor consultation due to delayed processing of consult paperwork.
F 0692: Residents #44 and #51 experienced significant weight loss without timely interventions; supervision during meals was inadequate.
F 0730: Two CNAs lacked performance evaluations and documented in-service education, with no evidence of training based on individual needs.
F 0801: The Food Service Director did not receive frequent scheduled consultations from the dietitian as required.
F 0812: Food safety violations included improper food storage, malfunctioning dishwashing machine, uncalibrated thermometers, and unclean equipment and floors.
F 0842: Medical records for Residents #16 and #48 were incomplete and not systematically organized, resulting in delayed treatment and missing audiology consult documentation.
F 0908: Essential kitchen equipment including dishwashing machine booster heater and unit refrigerators were not functioning; maintenance work orders were not submitted timely.
Report Facts
Residents reviewed: 21
Residents reviewed for Beneficiary Protection Notification: 3
Residents reviewed for hospitalization notification: 3
Residents reviewed for baseline care plans: 12
Weight loss: 14.3
Weight loss percentage: 8.6
Weight loss: 26.8
Weight loss percentage: 17.4
Eye drops delay: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported delay in eye drop administration for Resident #16 |
| Director of Nursing | Acting Director of Nursing | Responded to bed size issue for Resident #33 and care planning deficiencies |
| Registered Nurse #2 | Registered Nurse | Reported missing audiology paperwork for Resident #48 |
| Food Service Director | Food Service Director | Reported lack of frequent dietitian consultations and kitchen equipment issues |
| Staff Educator | Facility Staff Educator | Reported lack of CNA performance evaluations and training documentation |
| Director of Social Work | Director of Social Work | Reported nursing responsibility for transfer/discharge notices and care plan discussions |
| Registered Dietitian | Registered Dietitian | Discussed nutrition assessments and interventions for residents with weight loss |
Viewing
Loading inspection reports...
