Deficiencies (last 6 years)
Deficiencies (over 6 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
267% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 21, 2025
Visit Reason
The abbreviated survey was conducted to review compliance related to resident abuse and notification policies following an incident involving Resident #1 on 09/27/2025.
Findings
The facility failed to ensure timely notification of the resident's representative regarding an incident involving Resident #1, who had an aggressive altercation requiring psychiatric evaluation. The family was only informed by the resident during a visit, leading to a grievance and subsequent counseling and reeducation of the nursing supervisor.
Complaint Details
The investigation was complaint-related, triggered by the resident's family grievance that they were not notified timely about the incident on 09/27/2025. The complaint was substantiated, resulting in counseling and reeducation of the nursing supervisor.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely notify the resident's representative of an incident involving Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Incident date: Sep 27, 2025
Survey dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #7 | Registered Nurse Supervisor | Informed family about Resident #1 swinging a chair and hitting the wall |
| Certified Nurse #1 | Certified Nurse | Asked by Resident #1 to keep the door open during the incident |
| Certified Nurse Aide #1 | Certified Nurse Aide | Denied Resident #1's request to keep the door open and was sitting outside Resident #1's room during the incident |
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Observed the incident aftermath and reported on family notification attempts |
| Registered Nurse #3 | Medication Nurse | Asked Registered Nurse Supervisor #2 to come to unit 2 during the incident |
| Assistant Director of Nursing | Assistant Director of Nursing | Attended family meeting and addressed concerns about notification |
| Social Worker #6 | Social Worker | Aware of family meeting and grievance regarding the incident |
| Administrator | Administrator | Attended interdisciplinary meeting and initiated grievance regarding family notification |
Inspection Report
Annual Inspection
Deficiencies: 8
Jan 29, 2025
Visit Reason
The inspection was conducted as part of the Recertification and Abbreviated surveys from 01/22/2025 to 01/29/2025 to assess compliance with regulatory requirements and resident care standards at Westchester Center for Rehabilitation & Nursing.
Findings
The facility was found deficient in multiple areas including failure to ensure resident rights regarding medication administration and room changes, improper management of resident financial affairs, inadequate respiratory care for residents on oxygen therapy, insufficient nursing staff to meet resident needs, and improper disposal of garbage and refuse.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure a resident's designated representative was informed and able to choose treatment options, resulting in administration of Donepezil against representative's wishes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written notice to a resident's Health Care Agent prior to a room change. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a resident's right to manage financial affairs; facility diverted income to a personal needs account without informing the resident's Legal Guardian. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain written authorization from resident's Legal Guardian prior to depositing income and opening a personal needs account. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide quarterly financial statements to a resident and inability to prove resident received statements. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care; oxygen flow rates not consistent with physician orders, tubing disconnected, and delayed provision of humidified oxygen as recommended. | Level of Harm - Minimal harm or potential for actual harm |
| Insufficient nursing staff on multiple shifts and units, not meeting facility assessment minimums, resulting in resident concerns about care delays and inadequate assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly contain and dispose of garbage and refuse; trash compactor had food spilling out and recycled boxes were scattered around the dumpster. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for resident rights: 2
Residents reviewed for Choices: 7
Residents reviewed for Personal Funds: 4
Residents reviewed for Respiratory Care: 3
Residents reviewed for staffing concerns: 11
Certified Nurse Aides scheduled: 2
Certified Nurse Aides scheduled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Interviewed regarding oxygen administration and tubing connection for Resident #226 |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen administration protocols and staffing adequacy |
| Registered Nurse #4 | Registered Nurse | Interviewed regarding oxygen flow rate for Resident #333 |
| Licensed Practical Nurse Unit Manager #3 | Licensed Practical Nurse Unit Manager | Interviewed regarding oxygen administration and nursing responsibilities |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Interviewed regarding ENT recommendations and humidifier provision for Resident #333 |
| Medical Doctor #1 | Medical Doctor | Interviewed regarding notification and orders related to Resident #333's ENT recommendations |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding staffing shortages and workload |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing levels and facility assessment discrepancies |
| Administrator | Administrator | Interviewed regarding facility assessment and staffing levels |
| Food Service Director | Food Service Director | Interviewed regarding garbage disposal and trash compactor conditions |
Inspection Report
Annual Inspection
Deficiencies: 16
Jan 29, 2025
Visit Reason
The inspection was a Recertification and Abbreviated survey conducted from 01/22/2025 to 01/29/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, resident rights regarding treatment and room changes, financial management, care planning, medication administration, respiratory care, staffing adequacy, nurse aide training and performance reviews, medication storage, food safety, infection control, and waste disposal.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility staff were observed standing over residents while assisting with meals, not ensuring a dignified dining experience. | Level of Harm - Minimal harm or potential for actual harm |
| Facility administered Donepezil to a resident despite the representative's request to withhold the medication. | Level of Harm - Minimal harm or potential for actual harm |
| Resident's wheelchair unable to maneuver around bed preventing access to bathroom; no reasonable accommodation provided. | Level of Harm - Minimal harm or potential for actual harm |
| Resident's Health Care Agent did not receive written notice or explanation for room change. | Level of Harm - Minimal harm or potential for actual harm |
| Facility diverted resident's income to personal needs account without informing court-appointed Legal Guardian. | Level of Harm - Minimal harm or potential for actual harm |
| Facility's surety bond was less than the total amount of resident personal needs accounts managed by the facility. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not post survey results in a place readily accessible to residents and families. | Level of Harm - Minimal harm or potential for actual harm |
| Resident receiving continuous oxygen therapy without a documented respiratory/oxygen care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Resident's insulin order had a discrepancy and was not followed as written; sliding scale used without additional unit of insulin. | Level of Harm - Minimal harm or potential for actual harm |
| Multiple residents on oxygen observed with oxygen flow rates inconsistent with physician orders; delayed implementation of humidified oxygen as recommended by ENT. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not provide sufficient nursing staff per facility assessment; residents reported staffing shortages affecting care. | Level of Harm - Minimal harm or potential for actual harm |
| Certified nurse aide performance reviews were incomplete or not conducted annually for several aides. | Level of Harm - Minimal harm or potential for actual harm |
| Expired medical supplies found in medication storage rooms; undated open supplement bottle found on medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Food items in kitchen and unit pantries were not properly sealed, dated, or stored; expired food was not discarded; food served at inappropriate temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Trash compactor had food spilling out and recycled boxes were littered around dumpster area. | Level of Harm - Minimal harm or potential for actual harm |
| Staff failed to maintain infection prevention and control practices including improper use of personal protective equipment for residents on enhanced barrier precautions and failure of some staff to receive influenza vaccination or wear masks. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity while dining: 35
Residents reviewed for resident rights: 2
Residents reviewed for environment: 7
Residents reviewed for choices: 7
Residents reviewed for personal funds: 3
Resident personal needs accounts: 106
Sum total of resident personal needs accounts: 278452.49
Certified Nurse Aides reviewed for performance: 5
Residents reviewed for respiratory care: 3
Residents reviewed for insulin treatment: 4
Residents reviewed for infection control: 3
Staff reviewed for influenza vaccination: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #21 | Certified Nurse Aide | Observed standing while feeding Resident #168 and interviewed about feeding practice |
| Registered Nurse #27 | Registered Nurse | Observed standing while feeding Resident #14 and interviewed about feeding protocol |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and facility protocols |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding medication discontinuation for Resident #233 |
| Administrator | Administrator | Interviewed regarding resident room access issues and survey posting |
| Fiscal Manager | Fiscal Manager | Interviewed regarding resident funds management and representative payee status |
| Staffing Educator | Staffing Educator | Interviewed regarding nurse aide performance reviews and training |
| Certified Nurse Aide #36 | Certified Nurse Aide | Observed providing care without proper PPE for resident on enhanced barrier precautions |
| Licensed Practical Nurse #17 | Licensed Practical Nurse | Observed not wearing mask and not vaccinated for influenza |
| Certified Nurse Aide #15 | Certified Nurse Aide | Observed not wearing mask and not vaccinated for influenza |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Interviewed regarding oxygen care plan and insulin order discrepancy |
| Licensed Practical Nurse Unit Manager #3 | Licensed Practical Nurse Unit Manager | Interviewed regarding oxygen administration and flow rate |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding oxygen administration and tubing connection |
| Medical Doctor #1 | Medical Doctor | Interviewed regarding delayed notification of ENT recommendations |
| Nurse Educator | Nurse Educator | Interviewed regarding staff immunization records |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing levels and facility assessment |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding staffing shortages |
| Human Resource Director | Human Resource Director | Interviewed regarding performance review documentation and influenza vaccination policy |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 23
Jan 29, 2025
Visit Reason
Multiple Level 2 deficiencies in standard health and life safety code citations related to quality of care, resident rights, and physical environment; all corrected by March 28, 2025.
Findings
Multiple Level 2 deficiencies in standard health and life safety code citations related to quality of care, resident rights, and physical environment; all corrected by March 28, 2025.
Deficiencies (23)
| Description |
|---|
| R9-10-803.J — Accounting and records of personal funds |
| Choose/be notified of room/roommate change |
| Develop/implement comprehensive care plan |
| Dispose garbage and refuse properly |
| Food procurement,store/prepare/serve-sanitary |
| Infection prevention & control |
| Label/store drugs and biologicals |
| Nurse aide peform review-12 hr/yr in-service |
| Protection/management of personal funds |
| Quality of care |
| Reasonable accommodations needs/preferences |
| Required in-service training for nurse aides |
| Resident rights/exercise of rights |
| Respiratory/tracheostomy care and suctioning |
| Right to be informed/make treatment decisions |
| Right to survey results/advocate agency info |
| Sufficient nursing staff |
| Surety bond-security of personal funds |
| Electrical systems - essential electric syste |
| Fire alarm system - testing and maintenance |
| Fire drills |
| Hazardous areas - enclosure |
| Sprinkler system - maintenance and testing |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Jan 21, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with regulations regarding resident safety and supervision, specifically focusing on accident prevention and monitoring of residents at risk for harm.
Findings
The facility failed to provide adequate supervision and monitoring to prevent accidents for two residents, including lack of documented 1:1 monitoring for a resident with suicidal behavior and insufficient care plan interventions and therapy evaluations for a resident with multiple falls and severe cognitive impairment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide documented 1:1 monitoring for Resident #3 with suicidal history after a self-inflicted wrist laceration. | Level of Harm - Minimal harm or potential for actual harm |
| Lack of appropriate care plan interventions and therapy evaluations following multiple falls for Resident #10 with severe cognitive impairment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Falls without injury: 6
Falls with injury: 1
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 4
Barthel Index Score: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Interviewed regarding lack of knowledge of monitoring for Resident #3 | |
| Certified Nurse Aide #2 | Interviewed about incident and monitoring for Resident #3 | |
| Certified Nurse Aide #3 | Reported blood on floor and interaction with Resident #3 | |
| Nursing Supervisor #1 | Nursing Supervisor | Provided information on monitoring and assessment of Resident #3 |
| Director of Nursing | Director of Nursing | Interviewed about monitoring expectations and documentation |
| Administrator | Administrator | Interviewed about expectations for monitoring documentation |
| Director of Social Services | Director of Social Services | Interviewed about room assignment and family interactions for Resident #10 |
| Physical Therapist | Physical Therapist | Interviewed about therapy evaluations for Resident #10 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Jan 21, 2025
Visit Reason
One Level 2 standard health citation for free of accident hazards/supervision/devices; corrected by March 20, 2025.
Findings
One Level 2 standard health citation for free of accident hazards/supervision/devices; corrected by March 20, 2025.
Deficiencies (1)
| Description |
|---|
| Free of accident hazards/supervision/devices |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Aug 21, 2024
Visit Reason
The abbreviated survey was conducted from 8/19/24 to 8/20/24 to evaluate compliance with care planning and pain management standards, specifically focusing on Resident #1's care after being placed on Comfort Care.
Findings
The facility failed to ensure Resident #1's preferences and designated representative were included in pain management care planning. Pain management was inadequate, with no documented pain assessments or interventions after the family requested morphine. The primary physician did not order morphine due to medical concerns and did not communicate effectively with the family. The resident was found unresponsive and pronounced dead on 8/10/24.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to allow resident to participate in the development and implementation of his or her person-centered plan of care, specifically excluding the designated representative in pain management care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate pain management for a resident who requires such services, including lack of documented pain assessments and interventions despite family requests for pain medication. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for pain management: 3
Residents affected: 1
Physician's Orders date: Aug 1, 2024
Date resident placed on Comfort Care: Aug 9, 2024
Date resident pronounced dead: Aug 10, 2024
Number of facilities physician was on call for: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Documented family request for morphine and communicated with primary physician |
| Registered Nurse #2 | Registered Nurse | Provided care to Resident #1 and reported awareness of Comfort Care status |
| Assistant Medical Director | Assistant Medical Director | Informed about Resident #1's condition and ordered to hold medication |
| Primary Physician | Primary Physician | Made decisions regarding pain medication orders and communicated with family and staff |
| Director of Nursing | Director of Nursing | Provided statements regarding Comfort Care policies and communication responsibilities |
| Administrator | Administrator | Stated expectations for pain management for residents on Comfort Care |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Aug 21, 2024
Visit Reason
Two Level 2 standard health citations for pain management and right to participate in planning care; corrected by September 30, 2024.
Findings
Two Level 2 standard health citations for pain management and right to participate in planning care; corrected by September 30, 2024.
Deficiencies (2)
| Description |
|---|
| Pain management |
| Right to participate in planning care |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Aug 8, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and to assess compliance with care planning and accident prevention regulations.
Findings
The facility failed to ensure residents were free from abuse, did not thoroughly investigate and report abuse allegations timely, failed to update care plans to reflect abuse incidents, and did not provide adequate supervision or safety measures to prevent accidents for at least two residents.
Complaint Details
The complaint investigation involved allegations that a Certified Nurse Assistant shoved Resident #1 on 2/20/2023 and that Licensed Practical Nurse #2 pinched Resident #4 on 1/25/2024. The facility conducted investigations but did not substantiate the abuse due to lack of evidence, including no video footage. The facility delayed reporting the incidents to the State Department of Health and failed to complete required documentation timely. Resident #1's abuse care plan was not updated to reflect the incident. Licensed Practical Nurse #2 was suspended for not reporting the incident but later returned to work on the same unit.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to protect residents from physical abuse, specifically a Certified Nurse Assistant shoved a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to alleged violations of abuse, including incomplete investigations and delayed reporting to the State Department of Health. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and revise the comprehensive care plan to reflect an allegation of abuse for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and assistive devices to prevent accidents, resulting in a resident fall with injury. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 6
Brief Interview of Mental Status score: 15
Brief Interview for Mental Status score: 12
Fall risk score: 6
Date of fall resulting in injury: Oct 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Named in physical abuse allegation for shoving Resident #1 and subsequently terminated | |
| Licensed Practical Nurse #2 | Named in allegation of pinching Resident #4 and suspended for not reporting the incident | |
| Staff #2 | Registered Nurse Supervisor | Interviewed regarding abuse allegation investigation and reporting |
| Assistant Director of Nursing | Conducted investigation and interviews related to abuse allegations and care plan updates | |
| Director of Nursing | Provided statements regarding investigation, reporting, and care plan responsibilities |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Aug 8, 2024
Visit Reason
Multiple Level 2 standard health citations including care plan timing and revision, free from abuse and neglect, free of accident hazards, and investigate/prevent/correct alleged violation; all corrected by September 30, 2024.
Findings
Multiple Level 2 standard health citations including care plan timing and revision, free from abuse and neglect, free of accident hazards, and investigate/prevent/correct alleged violation; all corrected by September 30, 2024.
Deficiencies (4)
| Description |
|---|
| Care plan timing and revision |
| Free from abuse and neglect |
| Free of accident hazards/supervision/devices |
| Investigate/prevent/correct alleged violation |
Inspection Report
Capacity: 60
Deficiencies: 1
Feb 12, 2024
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Dec 26, 2023
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Oct 10, 2023
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Oct 2, 2023
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 23, 2023
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 17, 2023
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 3, 2023
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Sep 12, 2022
Visit Reason
Multiple Level 2 standard health citations including free from abuse and neglect, free of accident hazards, investigate/prevent/correct alleged violation, and others; all corrected by September 30, 2022.
Findings
Multiple Level 2 standard health citations including free from abuse and neglect, free of accident hazards, investigate/prevent/correct alleged violation, and others; all corrected by September 30, 2022.
Deficiencies (3)
| Description |
|---|
| Free from abuse and neglect |
| Free of accident hazards/supervision/devices |
| Investigate/prevent/correct alleged violation |
Inspection Report
Annual Inspection
Deficiencies: 5
Mar 21, 2022
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 3/14/22 to 3/21/22 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity related to catheter bag privacy, failure to protect residents from abuse resulting in actual harm, failure to develop and implement comprehensive care plans for residents' needs including contractures and respiratory care, failure to provide appropriate care to maintain range of motion, and failure to implement infection prevention and control practices including proper sanitization of nebulizer tubing and glucometer.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Actual harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure resident dignity by not covering urine-filled catheter bag visible from hallway for resident #155. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect resident #119 from abuse by resident #58 resulting in a wrist fracture. | Level of Harm - Actual harm |
| Failure to develop and implement a comprehensive care plan for resident #82's contractures and for resident #102's nebulizer treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care to maintain or improve range of motion for resident #82 by not applying ordered splint device. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention and control program including improper protection and labeling of nebulizer tubing for resident #102 and failure to sanitize glucometer between residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity: 2
Residents reviewed for abuse: 5
Residents reviewed for positioning/mobility: 1
Residents reviewed for respiratory care: 1
Residents reviewed for limited ROM: 2
Residents reviewed for blood glucose check: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Mentioned in relation to catheter bag privacy and responsibility for CNA oversight |
| RN/Staff Educator | Inservice Coordinator | Provided information on catheter bag privacy practices |
| CNA #5 | Certified Nursing Assistant | Interviewed about catheter bag placement |
| LPN #12 | Licensed Practical Nurse | Documented escalating behaviors of Resident #58 |
| LPN #9 | Licensed Practical Nurse | Documented aggressive behavior and incident with Resident #58 |
| LPN #6 | Licensed Practical Nurse | Documented incidents involving Resident #58 and Resident #119 |
| RN #3 | Registered Nurse | Assessed aggressive behavior of Resident #58 and involved in hospital transfer |
| Administrator #1 | Administrator | Provided statements about Resident #58 placement and behavior management |
| CNA #1 | Certified Nursing Assistant | Interviewed about care and device application for Resident #82 |
| RNUM #3 | Registered Nurse/Unit Manager | Interviewed about care plan and device application for Resident #82 and glucometer sanitization |
| COTA | Certified Occupational Therapy Assistant | Provided information on splint device recommendation and rehab follow-up |
| RS | Rehab Supervisor | Discussed device replacement and nursing notification |
| LPN #7 | Licensed Practical Nurse | Interviewed about nebulizer treatment and tubing protection |
| RNUM #2 | Registered Nurse Unit Manager | Interviewed about Albuterol order and care plan initiation |
| LPN #1 | Licensed Practical Nurse | Observed not sanitizing glucometer between residents |
| DON | Director of Nursing Services | Commented on glucometer sanitization compliance and monitoring |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 23
Mar 21, 2022
Visit Reason
Multiple Level 2 and one Level 3 standard health citations including accuracy of assessments, behavioral health services, free from abuse and neglect (Level 3), and multiple life safety code citations; all corrected by May 16, 2022.
Findings
Multiple Level 2 and one Level 3 standard health citations including accuracy of assessments, behavioral health services, free from abuse and neglect (Level 3), and multiple life safety code citations; all corrected by May 16, 2022.
Deficiencies (23)
| Description |
|---|
| Accuracy of assessments |
| Behavioral health services |
| Develop/implement comprehensive care plan |
| Free from abuse and neglect |
| Increase/prevent decrease in rom/mobility |
| Infection prevention & control |
| Resident rights/exercise of rights |
| Residents are free of significant med errors |
| Right to participate in planning care |
| Services provided meet professional standards |
| Treatment/svcs to prevent/heal pressure ulcer |
| Corridor - doors |
| Corridors - construction of walls |
| Electrical equipment - power cords and extens |
| Electrical systems - essential electric syste |
| Electrical systems - maintenance and testing |
| Fire drills |
| Horizontal sliding doors |
| Maintenance, inspection & testing - doors |
| Physical environment |
| Sprinkler system - installation |
| Sprinkler system - maintenance and testing |
| Standards of construction for new existing nh |
Inspection Report
Capacity: 60
Deficiencies: 1
Jan 3, 2022
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Capacity: 60
Deficiencies: 1
Dec 27, 2021
Visit Reason
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Findings
One Level 2 standard health citation for reporting - national health safety network; not corrected as of report.
Deficiencies (1)
| Description |
|---|
| Reporting - national health safety network |
Inspection Report
Annual Inspection
Deficiencies: 9
Jul 17, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations for nursing homes.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification to resident representatives upon hospital transfers, incomplete care plans and inadequate implementation of pain management and nutrition interventions, failure to provide appropriate treatment and care according to physician orders, unsafe equipment monitoring, inadequate catheter care, medication availability issues, failure to monitor antipsychotic medication effects, unsecured medications, and improper food storage and sanitation procedures.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to provide timely written notification to resident representatives upon hospital transfers for 3 residents. | Level of Harm - Potential for minimal harm |
| Incomplete care plans and failure to implement pain management and nutrition interventions for 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to physician orders for 3 residents, including delayed treatment after a fall, wound care omissions, and failure to administer critical medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement effective monitoring procedures to ensure resident assistive equipment (Hoyer lift pads) remain free from repeat accident hazards. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate catheter care and urine output monitoring for a resident with an indwelling catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Medications were not available when needed, resulting in delayed administration of Kayexalate for a resident with elevated potassium levels. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure diagnostic monitoring results (EKGs) for a resident on antipsychotic medication were available and reviewed by the physician, with no evidence of medication discontinuation after abnormal EKG findings. | Level of Harm - Minimal harm or potential for actual harm |
| Medications, including prescription eye drops, were not secured in a locked storage area and were found in a resident's bedside table without physician orders or care plan authorization for self-administration. | Level of Harm - Minimal harm or potential for actual harm |
| Improper food handling and sanitation practices including delayed storage of potentially hazardous food, freezer packed to the door with ice buildup, and dishwasher not sanitizing dishes due to malfunction and inadequate sanitizer concentration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for hospitalization: 3
Residents sampled for care plan review: 40
Residents reviewed for pain management: 3
Residents reviewed for skin impairment: 6
Residents reviewed for medication administration: 5
EKG reports uploaded: 8
Freezer temperature: 45
Freezer temperature: -10
Dishwasher final rinse temperature: 160
Dishwasher final rinse temperature: 170
Potassium level: 7.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse Manager | Interviewed about written notices to families regarding hospital transfers and catheter care documentation |
| RN #4 | Registered Nurse/Unit Manager | Interviewed about pain monitoring and hospital transfer notifications |
| LPN #2 | Medication Nurse | Interviewed about pain assessment and medication administration |
| LPN #5 | Medication Nurse | Interviewed about nutrition plan implementation |
| RD | Registered Dietitian | Interviewed about nutrition plan implementation |
| RN #1 | Unit Manager | Interviewed about medication availability and medication security |
| LPN #1 | Medication Nurse | Interviewed about medication availability |
| RN #2 | Night Nurse | Interviewed about medication availability |
| RN #5 | Registered Nurse Supervisor | Interviewed about wound care orders |
| LPN #3 | Licensed Practical Nurse | Interviewed about laundry inspection of Hoyer lift pads |
| Physician | Primary Care Physician | Interviewed about medication and EKG monitoring for Resident #179 and Resident #66 |
| Food Service Manager | Interviewed about freezer operation and food delivery | |
| Regional Food Service Manager | Interviewed about dishwasher sanitizing process | |
| Technician | Interviewed about dishwasher malfunction and repair | |
| CNA #1 | Certified Nursing Assistant | Interviewed about catheter care for Resident #205 |
Loading inspection reports...
