Inspection Reports for Williamsbridge Center for Rehabilitation and Nursing
NY
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 8, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 01/02/2025 to 01/08/2025 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to review and revise residents' comprehensive care plans as required, incomplete daily nurse staffing information postings, improper food storage and labeling practices, lapses in infection prevention and control practices during medication administration and meal assistance, and improper positioning of a resident's urinary catheter drainage bag touching the floor.
Deficiencies (4)
Failure to ensure residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed.
Daily nurse staffing information did not include the actual number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care.
Food was not stored, prepared, distributed, and served in accordance with professional standards; undated items and spilled liquids were observed in refrigerators.
Infection prevention and control practices were not maintained during medication administration, hand hygiene before meals was not assisted or reminded, and a resident's urinary catheter drainage bag was touching the floor.
Report Facts
Residents sampled: 22
Residents affected: 2
Dates of quarterly review assessments missing care plan revision: 4
Date of care plan for fall: 1
Date of survey completion: Jan 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Unit Manager | Interviewed regarding care plan updates and infection control issues |
| Recreation Director | Interviewed about responsibility for initiating and updating smoking care plan | |
| Director of Nursing | Interviewed about care plan update responsibilities and infection control breaches | |
| Licensed Practical Nurse #1 | Interviewed about fall documentation and medication administration observation | |
| Minimum Data Set Coordinator | Interviewed about care plan review and update process | |
| Staffing Coordinator #1 | Interviewed about nurse staffing posting responsibilities | |
| Dietary Director | Interviewed about food storage and labeling requirements | |
| Certified Nursing Assistants #2, #3, #4, #5 | Certified Nursing Assistants | Interviewed about failure to assist residents with hand hygiene before meals |
| Licensed Practical Nurse #3 | Interviewed about urinary catheter drainage bag touching floor infection risk | |
| Registered Nurse #1 | Unit Manager | Interviewed about urinary catheter infection control issue |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 21, 2023
Visit Reason
The inspection was conducted as a recertification and complaint investigation to assess compliance with care standards, specifically related to pressure ulcer care and medication management.
Complaint Details
The complaint investigation was triggered by allegations regarding inadequate pressure ulcer care for Resident #18 and missing narcotics medication found in possession of Resident #40. The investigation included interviews, record reviews, and observations from 6/13/23 to 6/21/23.
Findings
The facility failed to provide appropriate pressure ulcer care for Resident #18, resulting in new pressure ulcers and inadequate repositioning. Additionally, the facility did not ensure adequate supervision and secure storage of controlled medications, as Resident #40 was found in possession of narcotics without proper authorization.
Deficiencies (3)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #18.
Failure to ensure adequate supervision to prevent accidents, evidenced by Resident #40 possessing blister packs and narcotics medication.
Failure to ensure drugs and biologicals were stored properly and only accessible to authorized personnel, as Resident #40 was found with controlled substance pills.
Report Facts
Sampled residents: 38
Sampled residents: 21
Pressure ulcers: 2
Klonopin tablets: 5
Klonopin tablets missing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Interviewed regarding Resident #18's pressure ulcer care and Resident #40's narcotics possession |
| CNA #2 | Certified Nursing Assistant | Interviewed about care provided to Resident #18 |
| RN #3 | Registered Nurse | Interviewed about pressure ulcer prevention protocols for Resident #18 |
| Director of Nursing | Director of Nursing (DNS) | Interviewed about Resident #18's care and narcotics incident involving Resident #40 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding narcotics incident involving Resident #40 |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jun 21, 2023
Visit Reason
The inspection was conducted as a Recertification Survey from 6/13/2023 to 6/21/2023 to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found deficient in multiple areas including maintaining a safe, clean, and homelike environment; timely reporting of suspected abuse; development and implementation of comprehensive care plans; adherence to treatment orders; safe food storage; infection control practices; environmental cleanliness; and pest control.
Deficiencies (8)
Resident bathroom on the South Unit was observed dirty and stained with rust colored stains throughout.
Facility did not timely report an unwitnessed injury of unknown origin to the New York State Department of Health for Resident #6.
A person-centered Comprehensive Care Plan was not developed and implemented for Resident #24 to address behavior of emptying urine and feces into garbage bin.
Resident #27 was observed without TED/compression stockings as ordered by Medical Doctor Order.
Expired water was observed in the kitchen's Emergency Food Storage Room.
Blood pressure cuffs were not cleaned and disinfected between use with different residents.
Facility stairwell used by staff and visitors was soiled and dirty with debris and dust buildup.
Facility did not maintain an effective pest control program; multiple gnats and flies were observed in resident rooms on the South Unit.
Report Facts
Residents reviewed: 21
Residents reviewed for Accidents: 5
Residents reviewed for Edema: 2
Gallons of expired water: 6
Pest control visits: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse Manager and former Director of Nursing Services | Interviewed regarding failure to report injury of unknown origin for Resident #6 |
| Administrator | Facility Administrator | Interviewed regarding abuse reporting policies and stairwell cleanliness |
| Director of Maintenance and Housekeeping | Director of Maintenance/Housekeeper (DOMH/DMH) | Interviewed regarding bathroom cleanliness, stairwell condition, and pest control |
| LPN #3 | Licensed Practical Nurse | Observed and interviewed regarding failure to clean blood pressure cuffs between residents |
| RN #1 | Registered Nurse | Interviewed regarding infection control practices and pest control awareness |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Interviewed regarding pest sightings and resident behavior |
| Housekeeper #1 | Housekeeper | Interviewed regarding pest control and cleaning practices in resident rooms |
| Food Service Director | Food Service Director | Interviewed regarding expired water in Emergency Food Storage Room |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding TED stocking orders and compliance |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Interviewed regarding Resident #27's refusal to wear TED stockings |
| Director of Nursing | Director of Nursing | Interviewed regarding TED stocking orders and infection control practices |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 28, 2021
Visit Reason
The inspection was conducted as a Recertification and Abbreviated survey to assess compliance with regulatory requirements related to pain management, infection prevention and control, and catheter care.
Findings
The facility failed to provide appropriate pain management for a resident with chronic pain, did not ensure contracted vendors wore proper PPE in isolation rooms, and allowed a resident's catheter drainage bag to touch the floor on multiple occasions, posing infection control risks.
Deficiencies (2)
Failure to provide safe, appropriate pain management for a resident requiring such services, including lack of pain assessment and failure to report pain to the physician.
Failure to provide and implement an infection prevention and control program, including contracted vendors not wearing proper PPE and catheter drainage bag on the floor.
Report Facts
Residents Affected: 1
Residents Affected: 2
Gabapentin dosage: 600
Gabapentin dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Named in pain management deficiency for failing to assess and document pain properly | |
| Registered Nurse (RN) Supervisor | Interviewed regarding resident pain complaints | |
| Physical Therapist (PT) | Interviewed regarding resident pain complaints | |
| Maintenance Vendor #1 and #2 | Observed not wearing proper PPE in isolation room | |
| Maintenance Director (DOM) | Interviewed regarding PPE policies for vendors | |
| Director of Nursing/Infection Preventionist (DON/IP) | Interviewed regarding infection control and monitoring | |
| Certified Nursing Assistant (CNA #4) | Interviewed regarding catheter bag care | |
| Registered Nurse (RN #1) | Interviewed regarding catheter bag monitoring |
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