Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Gouverneur Hospital S N F during CMS and state inspections, most recent first.
The facility did not maintain corridor doors to resist smoke passage, as observed during a Life Safety Recertification Survey. All eight resident floors had doors with openings that compromised their smoke resistance. The Director of Maintenance confirmed the issue and planned to install astragals to address it.
The facility did not ensure smoke barrier walls met the required fire resistance rating, with openings found on two resident floors. Observations included a 1/8 inch gap around a pipe on the 13th Floor and a 4x4 inch penetration on the 11th Floor, compromising smoke restriction.
A survey found multiple unmounted power strips in various rooms and offices, including a power strip on the floor powering a microwave, indicating non-compliance with NFPA 70 standards for electrical safety.
A survey found that the facility did not ensure proper illumination of the means of egress as required by NFPA 101. Emergency exit discharges on the basement level, including those by the Dry Storage Room and leading to the loading dock, lacked light fixtures above the doors. Additionally, the path leading to a public way was not illuminated, compromising egress continuity. The CEO and Director of Maintenance acknowledged these findings.
A survey found that sprinkler heads in the corridor to the Loading Dock were improperly installed 56 inches below the ceiling, exceeding the maximum allowable distance of 12 inches. The Director of Maintenance noted the ceiling had been removed and would be replaced.
A facility failed to create a comprehensive care plan for a resident with Major Depressive Disorder, omitting the diagnosis and use of Sertraline in the care plan. Despite the facility's policy requiring timely development and updates of care plans, the oversight was attributed to multiple staff members, including nursing and social services, who missed updating the care plan during assessments and readmission.
A resident's care plan was not updated to reflect their current transfer needs, requiring partial/moderate assistance with a sliding board, instead of a Hoyer lift with two-person assistance. The oversight occurred despite acknowledgment from the RN responsible for updating the care plan, leading to inaccurate documentation and instructions for CNAs.
A resident with a high risk for falls and a history of numerous falls was not adequately supervised, resulting in a fall from their wheelchair in the dining room. The assigned Patient Care Technician was not in close proximity to the residents, as required by the facility's policy, and was completing a monitoring sheet elsewhere. Video surveillance confirmed the lack of staff presence near the residents during the incident.
The facility failed to include the total number of nursing staff in the daily nurse staffing information, as required by policy. Observations during a survey revealed that the posted information only included the facility name, current date, actual hours worked, and resident census. Interviews with the Deputy Director of Nursing, Director of Nursing, and Administrator indicated a lack of awareness and oversight regarding the requirement to post the total number of staff.
Corridor Doors Fail to Resist Smoke Passage
Penalty
Summary
The facility failed to ensure that the corridor doors to resident rooms were maintained to resist the passage of smoke, as required by NFPA 101 standards. During a Life Safety Recertification Survey conducted on two consecutive days, it was observed that the corridor doors on all eight resident floors had openings between the two doors, which compromised their ability to resist smoke passage. This deficiency was confirmed through staff interviews, where the Director of Maintenance acknowledged the issue and indicated that astragals would be installed to address the problem.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K363 Corridor Doors 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Astragals will be installed on the corridor doors to the resident suites to ensure they resist the passage of smoke. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Astragals will be installed throughout the skilled nursing facility building on all the corridor doors to ensure they resist the passage of smoke. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: A follow-up inspection will be conducted by the Director of Maintenance to verify that the astragals have been installed and are functioning properly. The facility’s compliance will be monitored utilizing the following quality assurance system: Weekly rounds will be conducted to ensure the astragals have been installed and are functioning properly, and that all corridor doors are maintained to resist the passage of smoke in accordance with NFPA 101. The Maintenance and Fire Safety Staff were in-serviced on corridor doors installed to resist the passage of smoke, in accordance with NFPA 101. The Fire Safety Staff and Maintenance Staff will conduct weekly rounds confirming the corridor doors resist the passage of smoke. The Maintenance Staff will address any doors that are not compliant with the standard. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Maintenance will gather information from the maintenance checks performed and report the findings to the QAPI committee for a period of 3 months or until compliance is achieved. 5. Responsible Individual: Director of Maintenance
Deficiency in Smoke Barrier Wall Construction
Penalty
Summary
The facility failed to ensure that smoke barrier walls were constructed to provide at least a one-half-hour fire resistance rating as required by NFPA 101. During a Life Safety Code recertification survey, surveyors observed deficiencies in the smoke barrier walls on two of the eight resident floors. Specifically, on the 13th Floor adjacent to resident room 1314, there was an opening of approximately 1/8 inch around a 1-inch metal pipe. Additionally, on the 11th Floor adjacent to resident room 1126, a penetration of approximately 4 inches by 4 inches was found. These observations indicate that the smoke barrier walls were not adequately sealed to restrict the transfer of smoke, as required by the relevant fire safety codes. The Director of Maintenance acknowledged the issue during an interview at the time of the observation, noting that the pipe would be sealed with fire stop material. However, the report does not provide details on any corrective actions taken at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 K372 Smoke Barrier Walls 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The opening observed in the smoke barrier wall of approximately 1/8 inch around a 1-inch metal pipe on the 13th Floor adjacent to resident room 1314 was sealed with a fire stop material. The opening observed in the smoke barrier wall of approximately 4 inches x 4 inches on the 11th Floor adjacent to resident room 1126 was sealed with a fire stop material. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: An audit of all smoke barrier walls throughout the facility was conducted to ensure all openings are correctly sealed with fire stop material. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: A system for a regular review of the smoke barrier walls was developed. The Director of Maintenance will oversee the sealing of the openings and the audit of the smoke barrier walls. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Maintenance/Designee will gather the data from the audit of the smoke barrier walls and report findings to the QAPI Committee for a period of 3 months to ensure the smoke barrier walls are compliant. 5. Responsible Individual: Director of Maintenance
Non-compliance with NFPA 70 Standards for Power Strips
Penalty
Summary
During the Life Safety Recertification survey conducted on two consecutive days, the facility was found to be non-compliant with NFPA 70 standards regarding the use of extension cords and power strips. Specifically, surveyors observed multiple instances of unmounted power strips in various rooms and offices throughout the facility. These included four unmounted power strips in room 132, one in room 125, one in the Dietary office, two in the Staff Work Room on the 12th Floor, one in the Office of the Assistant Director of Nursing, and a power strip on the floor powering a microwave in the Office of Community Outreach & Marketing. The Director of Maintenance acknowledged the findings and indicated that the extension cords would be mounted, and the microwave was immediately plugged directly into an outlet. However, the report focuses on the deficiency observed during the survey, which highlights the facility's failure to ensure that power strips and extension cords were used in accordance with the National Electrical Code, potentially compromising electrical safety standards.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K920 Power Strips 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice The following was addressed for the identified areas: Four unmounted power strips in room [ROOM NUMBER].132 were mounted, one unmounted power strip in room [ROOM NUMBER].125 was mounted, one unmounted power strip in the Dietary office was mounted, two unmounted power strips in the Staff Work Room on the 12th Floor were mounted, one unmounted power strip in the Office of the Assistant Director of Nursing was mounted and the power strip on the floor, powering a microwave in the Office of Community Outreach & Marketing, was mounted, and the microwave was plugged directly into an outlet. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: all skilled nursing facility rooms were checked to ensure that any power strips in use were mounted or that electrical items were plugged directly into an outlet. The Director of Maintenance/Designee will provide education to all staff regarding the policies and procedures related to electrical safety highlighting the proper use and installation of power strips. An educational summary will be provided to all staff highlighting the proper use and installation of power strips. Information on the proper use and installation of power strips will be shared at a Resident Council Meeting. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Maintenance/Designee will conduct regular maintenance checks to ensure that all power strips are properly mounted and used in accordance with NFPA 101. Findings will be collected on a monthly basis and additional corrective action will be implemented as needed. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Director of Maintenance will gather information from the maintenance checks performed and report the findings to the QAPI committee for a period of 3 months or until compliance is achieved. 5. Responsible Individual: Director of Maintenance
Deficiency in Egress Illumination
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility failed to ensure proper illumination of the means of egress in accordance with NFPA 101 standards. Specifically, on the basement level, the emergency exit discharge located by the Dry Storage Room and the exit leading to the loading dock were both found to be without light fixtures above the doors. Additionally, there were no light fixtures along the path leading to a public way, compromising the continuity of the egress path. These observations were made between 9:30 AM and 2:00 PM, and the findings were acknowledged by the Chief Executive Officer and the Director of Maintenance present during the survey.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K281 Illumination of Means of Egress 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice Light fixtures were installed above the emergency exit discharge. Light fixtures were installed above the emergency exit discharge located by the Dry Storage Room on the basement level. Light fixtures were installed above the emergency exit discharge leading to the loading dock on the basement level. Additional light fixtures were installed along the path leading to a public way to ensure continuity in the path of egress. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: all areas of egress were assessed to ensure proper illumination is in place. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Hospital Police will add inspection of proper illumination of the means of egress to daily building rounds. Hospital Police has been educated on this new responsibility, on confirming illumination of egress. Regular maintenance checks will be conducted to ensure that all light fixtures are functioning properly and that the means of egress remain illuminated in accordance with NFPA 101. All maintenance staff were in-serviced regarding illumination of means of egress. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice All egress areas will be monitored for proper illumination and functionality of the light fixtures monthly for a period of 3 months or until compliance is achieved. The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance
Improper Sprinkler Installation in Loading Dock Corridor
Penalty
Summary
During a Life Safety Recertification Survey conducted on two consecutive days, it was observed that the facility did not comply with the 2010 NFPA 13 standards for sprinkler installation. Specifically, in the corridor leading to the secondary access of the Loading Dock, pendent-style sprinkler heads were installed approximately 56 inches below the ceiling, which exceeds the maximum allowable distance of 12 inches. This installation was at the same level as the lighting fixture. The Director of Maintenance acknowledged that the ceiling had been removed and stated it would be replaced, indicating a temporary alteration that led to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K 351 Sprinkler System - Installation 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The ceiling, in the corridor of the secondary access to the loading dock, was reinstalled where the sprinkler heads were found to be greater than 12 in. from the ceiling. The ceiling in the corridor of the secondary access to the Loading Dock was reinstalled to its original position. The pendent-style sprinkler heads were adjusted to ensure the installation is in accordance with 2010 NFPA 13. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Maintenance or Designee will conduct a thorough inspection of all sprinkler heads to confirm that installation is not greater than 12 in. from the ceiling. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Fire Safety Team and the Maintenance team were in-serviced on NFPA Standard for the installation of Sprinkler Systems and highlighted their role in ensuring that pendant style sprinkler heads are not greater than 12 in. from the ceiling in accordance with NFPA 13. The Fire Safety Staff and Maintenance Staff will conduct weekly rounds confirming that Sprinkler Heads are not greater than 12 in from the ceiling. The Maintenance Staff will address any sprinkler heads that are not compliant with the standard. Regular maintenance checks will be conducted to ensure that all sprinkler heads are installed and maintained in accordance with 2010 NFPA 13. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Director of Maintenance/Designee will review 10% of all sprinkler heads to confirm that they are installed no greater than 12 in from the ceiling for a period of 3 months or until improvement is sustained that all sprinkler heads are no more than 12 in from the ceiling. The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance
Failure to Develop Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with Major Depressive Disorder, which included the use of antidepressant medication. This deficiency was identified during a recertification survey, where it was found that the care plan for the resident did not address the diagnosis of Major Depressive Disorder or the administration of Sertraline, an antidepressant medication prescribed to the resident. The facility's policy requires that a comprehensive care plan be developed within seven days of the completion of the Minimum Data Set Assessment, and that it should be updated upon the resident's readmission or during quarterly assessments. Interviews with facility staff revealed that the responsibility for creating and updating care plans was shared among various disciplines, including nursing and social services. However, the care plan for the resident's depression was overlooked by all involved parties. The Director of Nursing acknowledged that the care plan should have been updated during the resident's quarterly assessment and upon readmission, but it was not. This oversight resulted in the absence of a documented care plan addressing the resident's Major Depressive Disorder and the use of antidepressant medication.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Care Plan for the identified resident was reviewed and updated. Resident #20- A depression care plan was developed and implemented by the charge nurse after review of the medical record and physician orders [REDACTED]. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Assistant Directors of Nursing/designee will review the medical record of all residents to ensure that residents’ comprehensive care plans are reviewed and revised to reflect accurate plans. Additional corrective actions will be implemented as needed. The Educator/designee will provide additional education to all licensed nursing staff regarding policies and procedures related to reviewing and revising comprehensive care plans to reflect accurate plans. The Director of Nursing/designee will monitor compliance with care plan development and implementation and will: A. Create a report of all [MEDICAL CONDITION] medications to ensure that each resident maintained on a [MEDICAL CONDITION] medication has an active care plan for the medication and its use. B. All affected residents care plans will be reviewed by the Interdisciplinary Team at the Comprehensive Care Plan meetings. C. All care plans for readmitted residents will be reactivated in the EMR, reviewed and revised as needed for the use of [MEDICAL CONDITION] medications. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility’s compliance will be monitored utilizing the following quality assurance system: The Assistant Directors of Nursing/designee will audit 10% of all residents to ensure that residents’ comprehensive care plans are reviewed and revised to reflect accurate plans. Findings will be reported to the Director of Nursing on a monthly basis. Additional corrective action will be implemented as needed. The Administrator, Director of Nursing and Medical Director will review and revise, as needed, policies and procedures related to Comprehensive Care Plans. The Educator/designee will provide education to all staff involved in the care planning process regarding the above protocol so that upon readmission, residents’ care plans are reactivated and care plans are reviewed and revised as necessary to reflect accurate care needs. Interdisciplinary Care Planning meeting will be utilized to review that all appropriate care plans are implemented based on residents’ needs. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit all care plans of residents who are on [MEDICAL CONDITION] medications monthly for 3 months or until improvement is sustained to ensure that care plans are implemented and resident centered for [MEDICAL CONDITION] medications. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing
Failure to Update Resident's Care Plan for Transfer Assistance
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was accurately reviewed and revised to reflect the resident's current status. Specifically, the care plan for a resident with diagnoses of Paraplegia, Human Immunodeficiency Virus, and Bipolar Disorder was not updated to reflect the resident's need for partial/moderate assistance with one-person physical assist and a sliding board for transfers. Instead, the care plan inaccurately documented the requirement of a Hoyer lift with two-person assistance for chair/bed-to-chair transfers. The discrepancy arose when the Functional Status Endorsement from Rehab to Nursing indicated the need for a one-person assist with a sliding board, which was acknowledged by Registered Nurse #5. However, the care plan and Certified Nursing Assistant Task instructions were not updated to reflect this change. Interviews with the Director of Rehabilitative Therapy and Registered Nurse #5 confirmed the oversight, with the latter acknowledging responsibility for updating the care plan but failing to do so. The Director of Nursing also confirmed that Registered Nurse #5 was responsible for the update.
Plan Of Correction
Plan of Correction: Approved January 22, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Care Plan for the identified resident was reviewed and updated. Resident #217 - The ADL care plan and C.N.A. instructions/tasks were updated by the charge nurse to reflect the resident’s need for partial/moderate assistance with 1-person physical assist and a use of a sliding board. The Educator issued an educational counseling to all staff involved on the policy of care planning to ensure that care plans are reviewed and revised at least quarterly, with a change in condition and as needed. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Assistant Directors of Nursing/designee conducted a facility-wide audit of all residents to ensure that all endorsements to Nursing from Rehabilitation were accurately reflected on the comprehensive care plan and C.N.A. instructions/tasks, at least quarterly, annually, and as needed. The Educator/designee will provide additional education to all licensed nursing staff on the “Comprehensive Care Planning” policy, and updating of C.N.A. instructions/tasks, with emphasis on the review and revision of rehabilitation endorsements to nursing in a timely manner after each assessment, at least quarterly, annually, and as needed. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Administrator, Director of Nursing, and Medical Director will review and revise, as needed, policies and procedures related to the review and revision of Comprehensive Care Plans after each assessment, at least quarterly, annually, and as needed. The Educator/designee will provide additional education to all staff involved in the care planning process regarding the above protocol so that residents’ care plans are reviewed and revised to reflect accurate plans with emphasis on updating the care plans and C.N.A. instructions/tasks after each Rehabilitation assessment and endorsement to Nursing. Licensed Nursing Staff will audit the care plans at the Comprehensive Care Plan meetings to ensure that care plans of residents are reviewed and updated based on the resident’s current condition and needs. Any findings will be reported to the Director of Nursing/designee for correction. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit 10% of all residents weekly for 3 months or until improvement is sustained to ensure that care plans and C.N.A. instructions/tasks are implemented and revised timely in regards to Rehabilitation endorsements to Nursing. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow-up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of numerous falls and was diagnosed with dementia, reduced mobility, and osteoarthritis, was not provided with the necessary monitoring or supervision. On the day of the incident, the resident stood up from their wheelchair in the dining room and fell, despite being on a care plan that included half-hourly monitoring and positioning close to staff. The incident occurred when the assigned Patient Care Technician was not in close proximity to the residents in the dining room, as required by the facility's policy. The technician was reportedly completing a monitoring sheet in the back of the kitchen at the time of the fall. Video surveillance confirmed that no staff was near the residents during the incident, and the technician admitted to not being attentive to the residents. Interviews with staff revealed a lack of awareness and adherence to the monitoring duties. The technician responsible for monitoring was not present, and other staff members were not aware of the resident's fall history or interventions in place. The Deputy Director of Nursing confirmed that the technician was not in close proximity to the residents, which was a requirement for their monitoring duty. Despite the incident, the investigation concluded that there was no cause to believe neglect occurred.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The Interdisciplinary team met, reviewed, and updated the Care Plan for Resident #22 to ensure all interventions related to falls are in place. After physical therapy assessment and team discussion, a geri chair was provided to resident #22. Resident #22 is non-ambulatory and has no ability to transfer independently. This seating provided a stable and secure seating surface. Resident #22 continues to be placed in the Dining room for close monitoring when awake, and staff are reminded to be in close proximity when monitoring. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/Designee will ensure that staff assigned to the Dining Room for monitoring are attentive to all residents in the Dining area and positioned in the dining room within close proximity to the majority of the residents. The Educator/Designee will provide additional education to all staff on the "Fall Reduction and Injury Prevention Program" and protocols on how to adequately monitor the Dining Room to prevent falls and injury. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Administrator, Director of Nursing, and Medical Director will review and revise, as needed, policies and procedures related to fall reduction and injury prevention. The Educator/Designee will provide additional education to all staff on the "Fall Reduction and Injury Prevention Program" and protocols on how to adequately monitor the Dining Room to prevent falls and injury. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit 10% of the Dining rooms on all 3 shifts to ensure assigned staff are attentive and within proximity of residents in the dining room on a weekly basis for 3 months or until improvement is sustained to ensure that staff are appropriately monitoring residents to prevent falls and accidents. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow-up to ensure 100% compliance. Additional corrective actions will be implemented as needed. 5. Responsible Individual: Director of Nursing
Deficiency in Daily Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information included all required details, specifically the total number of licensed and unlicensed nursing staff directly responsible for resident care. During the Recertification Survey conducted from December 12 to December 19, 2024, it was observed that the posted nurse staffing information, located next to the elevators and nursing units, included the facility name, current date, actual hours worked, and resident census, but omitted the total number of nursing staff. This omission was contrary to the facility's policy, which mandates that the posted information should include the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Nurses, and Certified Nurse Aides. Interviews conducted during the survey revealed a lack of awareness and oversight regarding the requirement to post the total number of staff. The Deputy Director of Nursing stated that the Assistant Director of Nursing from each shift is responsible for posting the nurse staffing information, and the current practice was based on hours worked rather than the number of staff. The Director of Nursing admitted that the omission of the total number of staff was an oversight, and the Administrator was unaware of the requirement to include this information. This deficiency was identified under 10 NYCRR 415.13.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: The daily nurse staffing form was revised to include all required elements of posting, specifically, a column for the total number of licensed and unlicensed nursing staff directly responsible for resident care was added to the form that is posted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/designee will monitor compliance with the daily posting of nurse staffing to include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Educator/designee will provide additional education to all licensed nursing staff on the "Minimum Staffing" policy. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Administrator and Director of Nursing will review and revise as needed policies and procedures related to the posting of staffing. The Educator/designee will provide additional education to all staff involved in the posting of daily nurse staffing to include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: The Assistant Directors of Nursing/designee will audit 10% of all Daily Nurse Staffing Forms on a weekly basis for 3 months to ensure that the posted staffing includes the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Director of Nursing/designee will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New York
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New East Side Nursing Home | 0.3 mi | ★★★★★ | 0 | 0 |
| West Village Rehabilitation And Nursing Center | 1.4 mi | ★★★★★ | 0 | 0 |
| The Phoenix Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Cobble Hill Health Center Inc | 1.7 mi | ★★★★★ | 2 | 0 |
| Bedford Center For Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
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