SCHAFFER EXTENDED CARE CENTER
Non profit - Corporation
150 Beds
Independent
Data: November 2025
Trust Grade
38/100
#559 of 594 in NY
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Schaffer Extended Care Center has received a Trust Grade of F, indicating poor performance with significant concerns. Ranking #559 out of 594 facilities in New York places it in the bottom half overall, and #41 out of 42 in Westchester County means only one local option is better. The facility is worsening, with issues doubling from 6 in 2023 to 12 in 2025. While staffing is a strength with a 4 out of 5-star rating and an 18% turnover rate well below the state average, the facility has concerning fines of $15,935, higher than 79% of New York facilities. Specific incidents include a resident developing a severe pressure ulcer due to lack of proper care, staff failing to conduct annual performance reviews for Certified Nurse Aides, and unsafe food handling practices, highlighting significant areas for improvement alongside some strengths.
- Trust Score
- F
- In New York
- #559/594
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 18% annual turnover. Excellent stability, 30 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $15,935 in fines. Lower than most New York facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for New York. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Bottom 6%
Needs review
6 → 12 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 6 issues
2025: 12 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Low Staff Turnover (18%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (18%)
30 points below New York average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
1-Star Overall Rating
Below New York average (3.0)
Significant quality concerns identified by CMS
Federal Fines: $15,935
Below median ($33,413)
Minor penalties assessed
The Ugly 24 deficiencies on record
1 actual harm
May 2025
12 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
Based on interview, observation and record review during the Recertification Survey conducted from 4/29/2025 to 5/6/2025, the facility failed to ensure residents received care consistent with professi...
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Based on interview, observation and record review during the Recertification Survey conducted from 4/29/2025 to 5/6/2025, the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and to prevent worsening of pressure ulcers. This was evident for one (1) of five (5) residents (Resident #32). Specifically, Resident #32 was assessed at risk for pressure ulcers, developed a sacral wound and there was no documented evidence that interventions were implemented to address off loading/incontinence schedule/incontinence care to prevent further deterioration of a sacral wound. Subsequently, when assessed by the physician on 3/4/2025 the wound was documented as Stage 3 (full thickness skin loss) and on 4/2/2025 the wound had progressed to an unstageable (damage to skin caused by constant pressure on an area for a long-time) pressure ulcer. This resulted in actual harm to Resident #32 that was not Immediate Jeopardy .
The findings include:
The policy titled Pressure Ulcer Prevention Protocol with a February 2025 revision date documented residents at risk for pressure ulcers could expect to receive appropriate care. Maximize mobility activity and provide pressure relief: float heels placing pillows/positioning devices under the lower extremities, use pressure relief devices such as pillows/positioning devices between bony prominence's behind the back and under the lower extremities, limit chair sitting: use a pressure relieving chair cushion, assist with toileting and monitor for incontinence at least every two (2) hours or more frequently as needed, manage incontinence-assure residents are clean, dry, moisturized and protected.
Resident #32 had diagnoses which included Schizophrenia (disorder that affects the ability to think, feel, and behave clearly), Depression and Morbid Severe Obesity.
The 8/12/2024 Care Plan titled Potential for Pressure Injury related to Dehydration, Immobility, documented bed to be as flat as possible to reduce shear, the resident preferred to be repositioned by one (1) person and inform the resident/family/caregiver of any new area of skin breakdown.
The 10/29/2024 Annual Minimum Data Set documented Resident #32 was cognitively intact, received substantial to maximum staff assistance for toileting, supervision for rolling left to right, was incontinent of bladder, frequently incontinent of bowel, was at risk for pressure ulcers and had a pressure relieving device in bed.
The 1/28/2025 Braden Scale (tool used to assess risk for developing pressure ulcers) documented a score of 17 (at mild risk).
The 1/29/2025 Quarterly Minimum Data Set (assessment tool) documented Resident #32 had intact cognition, no pressure ulcers, no impairments to upper or lower extremities, received substantial/maximal assistance with toileting, partial/moderate assist with sit to lying in bed and transfers, supervision with rolling in bed, was incontinent of bladder and frequently incontinent of bowel.
There was no documented evidence in the Care Plans to address Resident #32's incontinence schedule/incontinence care.
The 2/13/2025 Nurse Care Plan Note documented sacral wound measurement 1 cm X 1 cm, treat with hydrogel.
The 2/13/2025 Care Plan titled Potential Skin Integrity Issue related to being chairfast: Intra buttock opening 1 cm X 1 cm: daily hydrogel (water-based moisture) plus Allevyn (foam) dressing, daily Balmex (skin protectant) to the sacrum/buttocks, use a draw sheet or lifting device to move the resident, keep body parts from excessive moisture, and follow facility protocols for treatment of the injury.
The 2/20/2025 Physician Wound Assessment Progress Report documented coccyx (small bone at the bottom of the spine) open deep tissue injury wound, measurements 1 cm, 0.7 cm X 0.1 cm. The wound bed was a pink-purple color. There was no necrotic (injury to cells) tissue. Offloading discussed with the patient.
The 2/25/2025 Physician Wound Assessment Progress Report documented coccyx wound stage 2 (open skin), measurements 1.2 cm X 0.5 cm, wound bed color pink, no necrotic tissue, no exudate (fluid),100% granulation (new) tissue. May worsen due to obesity and decreased mobility and edema. Pressure off loading. Continue present treatment and discuss offloading with the patient.
The 3/4/2025 Physician Wound Assessment Progress Report documented coccyx wound stage 3, measurements 1.5 cm x 0.7 cm, wound bed color pink/yellow, no necrotic tissue, 100% granulation tissue. Recommendation: guarded healing prognosis due to incontinence, if no improvement, consider change to moisture barrier.
The 3/10/2025 Physician Wound Assessment Progress Report documented coccyx wound stage 3, measurements 2.0 cm X 1.2 cm, wound bed color yellow-pink, granulation tissue 100%. Pressure relief, pressure off loading, likely to worsen due to incontinence and mobility.
The 3/18/2025 Physician Wound Assessment Progress Report documented sacral wound stage 3, measurements 2.5 cm x 2.3 cm X 0.2 cm. Wound bed color pink/yellow and fibrinous (protein fibers), necrotic tissue 50%. Wound is larger and moist. The patient was very incontinent. Will change the treatment to daily Balmex with zinc and skin protectant. Will reassess at next rounds.
There was no documented evidence interventions were implemented to address the resident's incontinence.
The 3/25/2025 Physician Wound Assessment Progress Report documented sacral wound stage 3, measurements 2.4 cm x 1.5 cm x 0.2 cm. Wound bed color pink/yellow, necrotic tissue 20%, granulation tissue 80%. Treatment daily, Balmex to continue. Healing well. Continue the present treatment. Pressure off loading and mobilize.
The Care Plan titled Potential Skin Integrity Issues updated 3/28/2025, documented apply Balmex to the sacrum every shift.
The 4/2/2025 Physician Wound Assessment Progress Report documented unstageable coccyx wound (a wound caused by pressure on the area for a long time, that's distance from top to bottom can't be accurately determined).Measurements 2.7 cm x 1.5 cm x 0.5 cm. Wound bed color yellow. Necrotic tissue 100%. Change back to collagenase ointment (ointment that aides healthy tissue growth) and Allevyn lite dressing (thin, foam dressing designed for sensitive skin). Poor offloading compliance. No infection.
The Care Plan titled Potential Skin Integrity Issues updated 4/2/2025 documented apply collagenase plus Allevyn lite dressing daily and 4/3/2025 weekly wound rounds by the wound team.
The 4/8/2025 Physician Wound Assessment Progress Report documented coccyx wound unstageable, measurements 2.0 cm x 2.0 cm X 0.5 cm. wound bed yellow/gray, 100% necrotic tissue. Pressure offloading. Questionable stage 3 versus unstageable with necrotic tissue in the center. Continue collagenase. Non-compliance discussed with nursing. Out of bed to chair.
The Care Plan titled Potential Skin Integrity Issues updated 4/8/2025 documented Stage 3 coccyx wound 2.6 X 2.0 cm with yellow color, 100 % necrotic tissue 100% positive serous drainage. Continue daily collagenase plus Allevyn.
There was no documented evidence in the Care Plans to address Resident #32 non noncompliance related to offloading.
The 4/14/2025 Assessment Progress Report documented coccyx wound unstageable. Measurement 3.0 cm X 3.0 cm x 1.0 cm. Wound bed color eschar/black, necrotic tissue 100%. Treatment collagenase and Allevyn lite. Resident with decreased mobility and decreased oral intake. The wound is likely to worsen or have delayed healing. Continue collagenase and cover with Allevyn. Pressure offloading.
The 4/1/2025-4/16/2025 Documentation Survey Report documented Resident #32 was coded one (1) incontinent of bladder 15 days during the 7 AM-3 PM shift, 15 evenings during the 3:00 PM -11:00 PM shift and 15 nights during the 11:00 PM -7:00 AM shift.
The Care Plan titled Potential Skin Integrity Issues updated 4/14/2025 documented weekly wound rounds for coccyx Unstageable 3.0 X 3.0 X 1.0 cm eschar (dead skin) negative for drainage, apply Santyl (ointment to remove damaged tissue) and Allevyn daily.
There was no documented evidence that Resident #32 was placed on a turn and position and toileting schedule prior to 4/16/2025.
There was no documented evidence that Resident #32 was provided an appropriate pressure relieving wheelchair cushion prior to 4/16/2025.
During interview 5/1/2025 at 1:25 PM the Wound Physician/Medical Director stated when they documented pressure offloading in the Wound Notes, it was their expectation that nurses would implement off-loading, out of bed to the chair, and a pressure relieving cushion to the wheelchair. The Wound Physician/Medical Director stated nurses should be aware of the protocol and should have implemented at least some of them. The Wound Physician/Medical Director stated there was no documentation in the nurse's notes, that indicated interventions were in place and implemented as per wound protocol.
During an interview on 5/1/2025 at 12:29 PM the Director of Rehabilitation stated they were not aware of Resident #32's sacral wound until 4/30/2025 when they received a phone call from the 4th floor Registered Nurse Unit Manager #1. They stated if the nurse determined the resident needed a pressure relieving device, they were supposed to call the Rehabilitation Department to request what was needed or explain what the concern was. They stated if they had been made aware of Resident #32's pressure ulcer, someone in the Rehabilitation Department would have evaluated Resident #32.
During an interview on 5/1/2025 at 1:40 PM the Director of Nursing was unable to provide documentation of any interventions implementation to address Resident #32's incontinence schedule/incontinence care, and use of a pressure relieving wheelchair cushion.
During Wound Care observation on 5/2/2025 at 11:07 AM during wound care, Resident #32's Sacral wound measured approximately 4.0 cm x 2.0 cm, and the wound bed was dark brown colored eschar tissue.
During an interview on 5/2/2025 at 11:18 AM, Licensed Practical Nurse #2 stated Resident #32 had a regular foam cushion in their wheelchair when the wound was classified as a Stage 3 wound and when the wound was classified as an unstageable wound.
During observation and interview on 5/2/2025 at 11:25 AM, Certified Nurse Aide #3 stated they were frequently responsible for Resident #32. They stated Resident #32's wheelchair did not have a ROHO (pressure relief designed to reduce the risk of pressure sores) cushion until 4/30/2025.
During an interview on 5/2/2025 at 11:30 AM, the Director of Rehabilitation stated the standard foam wheelchair cushion that was used in Resident #32's wheelchair was not appropriate for a Stage 3 Pressure Ulcer or Unstageable Pressure Ulcer. They stated when Resident #32's wound worsened to a Stage 3 Pressure Ulcer they should have been given a gel wheelchair cushion or a ROHO wheelchair cushion.
During an interview on 5/2/2025 at 3:50 PM, the Director of Nursing stated the Per Diem Registered Nurse Supervisor #4 who initiated the care plan for the newly identified wound on 2/13/2025, should have notified the Rehabilitation Department and should have initiated interventions to promote wound healing. They stated routine wound protocol included to offload the affected area when in bed and when in the wheelchair to reduce pressure and address incontinence schedule/incontinence care if applicable.
During interview on 5/2/2025 at 4:00 PM the Per Diem Registered Nurse Supervisor #4 stated they started the care plan for the newly identified wound on 2/13/2025 and should have entered interventions to promote wound healing. They stated they should have requested a referral from the Rehabilitation Department for a pressure relieving wheelchair cushion, but they got distracted by something else.
During a follow up Interview on 5/5/2025 at 10:33 AM the Wound Physician/Medical Director stated Resident #32's wound may not have deteriorated if interventions had been implemented to address the resident's incontinence schedule/incontinence care, the use of an appropriate pressure relieving wheelchair cushion.
During interview on 5/6/2025 at 10:15 AM the Director of Nursing stated when the wound stage was changed from Stage 2 to Stage 3, and from Stage 3 to unstageable, interventions should have been discussed with the team and should have been documented on the care plan by the Nurse Manager or the per diem Supervisor. The Director of Nursing stated they routinely accompanied the wound doctor on wound rounds and either the Nurse Manager or per diem Supervisor also accompanied the wound doctor on wound rounds so they could document nurse's wound notes. They stated that at that time they should have discussed any new interventions to promote wound healing, and they should have updated the care plan timely.
10 NYCRR 415.12(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview during the recertification survey from 4/29/25 to 5/6/25 the facility did not ensure the right to receive services with reasonable accommodation of ne...
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Based on observation, record review and interview during the recertification survey from 4/29/25 to 5/6/25 the facility did not ensure the right to receive services with reasonable accommodation of needs and preferences for 1 of 3 residents (Resident #19) reviewed for positioning and mobility. Specifically, Resident #19 stated they informed the Director of Social Work their wheelchair needed to be repaired 3 months ago and the wheelchair was observed in disrepair on 4/30/25.
The findings include:
The policy titled Physical Medicine and Rehabilitation Wheelchair Repairs last revised 7/2023 documented any wheelchair that is found to be in need of repair must be immediately taken out of service and inform Physical Medicine and Rehabilitation department notified. The Physical Medicine and Rehabilitation department will provide a replacement wheelchair while repairs are made.
Resident #19 had diagnoses including Cancer, Peripheral Vascular Disease, and Asthma.
The 1/25/25 Quarterly Minimum Data Set assessment documented Resident #19 was cognitively intact, used a manual wheelchair and was dependent upon staff to be wheeled in the wheelchair.
There was no documented evidence in the electronic medical record that Resident #19 was assessed by the rehabilitation department and/or nursing to determine if Resident #19 could safely use the wheelchair.
There was no documented evidence in the social work notes that the resident had informed the social worker of the broken wheelchair.
There was no documented evidence of work orders that the wheelchair needed to be repaired.
During an interview on 4/29/25 at 10:10 AM, Resident #19 stated they informed the Director of Social Work at least 3 months ago the chair was small and needed repair and nothing was done. Resident #19 stated if they did not put a towel on the left side of wheelchair it would dig and cut into their skin.
During an observation on 4/30/25 at 12:23 PM the wheelchair had a left wheel that was shredded, the left wheel lock did not touch the wheel and did not lock.
During an interview on 4/30/25 at 12:23 PM the Director of Rehabilitation stated they were informed the previous night the resident's wheelchair needed repair. The Director of Rehabilitation stated the condition of the wheelchair looked like it was in need of repair for some time. The Director of Rehabilitation stated they relied on nursing staff to report concerns when wheelchairs needed to be repaired.
During an interview on 5/5/25 at 10:27 AM, Certified Nurse Aide #25 stated they reported the condition of the wheelchair several times to the nursing supervisor while Registered Nurse #1 was not working. Certified Nurse Aide #25 stated the wheels on the wheelchair were falling apart and made it hard to push the resident. Certified Nurse Aide #25 stated the resident also reported the wheelchair needed repair to the nurses. Certified Nurse Aide #25 stated they were not sure when they reported it but they knew it was this year.
During an interview on 5/06/25 at 10:48 AM, Registered Nurse #1 stated they were on leave and returned to work sometime in March 2025. Registered Nurse #1 stated they were informed the wheelchair needed to be repaired in March of 2025. Registered Nurse #1 stated they did not know why there was a delay in the repair of the wheelchair. Registered Nurse #1 stated it was also reported to nursing supervisors while they were on leave and they did not know why it had not been repaired during that time.
During an interview on 5/06/25 at 2:10 PM, the Director of Social Work stated the resident did inform them their wheelchair needed to be repaired. The Director of Social Work stated they informed Registered Nurse #1 Resident #19's wheelchair needed to be repaired. The Director of Social Work stated they did not remember when they reported it but thought it was sometime in March 2025. The Director of Social Work stated they did not have progress notes or grievances from March 2025 about the resident's request to repair the wheelchair.
10NYCRR 415.5(e)(1)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00336728), the facility did not ensure all alleged violations of abuse were reported ...
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Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00336728), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 1 resident reviewed for Abuse (Resident #77). Specifically, Resident #77 was observed with a swollen right arm which was warm to touch and of unknown origin on 3/20/24 at 10:15 AM, and it was not reported to the state agency until 3/21/2024.
Findings included:
The policy titled Abuse, Neglect, Mistreatment and Exploitation last revised February 2025, documented an injury of unknown origin will be investigated with the assistance of the appropriate personnel. If the event which caused the allegation results in serious bodily injury they are reported immediately or no later than two hours.
Resident #77 had diagnoses including dementia, hemiplegia and hemiparesis, and dysphagia.
The 2/27/24 Quarterly Minimum Data Set (assessment tool) documented Resident #77 had severely impaired cognition, no behavioral symptoms, impairments to upper and lower extremities on both sides and was dependent on staff with all activities of daily living.
The 3/20/24 Incident Investigation completed by Registered Nurse Unit Manager #1 documented they were informed on 3/20/24 around 10:30 AM the Certified Nurse Aide doing cares, observed the right upper arm swollen and tender, warm to touch, with limited range of motion, and facial grimace when moved.
The 3/20/24 statement written by Licensed Practical Nurse #2 documented on 3/20/24 at 10:15 AM, the assigned Certified Nurse Aide reported Resident #77's right arm had swelling, was warm to touch, had limited range of motion, and the resident had facial grimace on movement.
The 3/20/24 statement written by Certified Nurse Aide #5 documented on 3/20/24 at 10:15 AM during morning care while taking off Resident #77's gown, they observed the right hand was swollen and they called the nurse.
The 3/20/24 at 12:54 PM X-Ray results documented fracture of the right humeral shaft.
The Incident Investigation Report Summary, signed by Registered Nurse Unit Manager #1 documented the date of the incident 3/20/2024 at 10:15 AM, and the State Agency was notified by the former Assistant Director of Nursing.
The 3/20/24 at 2:38 PM email from the former Director of Risk Management addressed to the facility Administrator, Director of Quality, former Director of Nursing, former Assistant Director of Nursing, and the Assistant Administrator among other facility staff, documented that although the resident's prior history was predisposed to fractures, the Medical Director reviewed the chart and advised that the cause of fracture could not be said to be pathological. Accordingly, this fracture is of unknown origin and must be reported to the State Agency.
The Submission Nursing Home Facility Incident Report documented it was submitted 3/21/24 at 11:52 AM. It documented the facility staff was first made aware on 3/20/24 at 12:39 PM and the administrator was first made aware on 3/20/24 at 12:50 PM.
During an interview on 05/06/25 at 10:59 AM, the Director of Nursing stated the former Director of Nursing was responsible to report the injury of unknown origin to the State Agency. They stated they were now aware that injuries of unknown origin should be reported within 2 hours if abuse cannot be ruled out within 2 hours.
During an interview on 05/06/25 at 11:59 AM, Registered Nurse Unit Manager #1 stated
the injury of unknown origin should have been reported to the State Agency within 2 hours, and they thought it had been reported timely by the former Director of Nursing.
During an interview on 05/05/25 at 1:53 PM, the facility Administrator stated the right arm swelling was identified 3/20/24 in the morning and it was reported to the State Agency on 3/21/24. They stated the incident should be reported within 2 hours if serious bodily injury was suspected to be abuse. The Administrator stated they did not know the resident had a fracture until the x-ray results came in. They stated swelling and warmth to touch might have been caused by cellulitis.
During an interview on 05/05/25 at 05:34 PM, the Medical Director stated the cause of fracture could not be assumed to be pathological (caused by an underlying disease that weakens the bone structure). They stated the fracture was likely caused by a fall or trauma. They stated the fracture was of unknown origin and should have been reported to the State Agency.
During an interview on 05/06/25 at 10:59 AM, the Director of Nursing stated the report was completed when it was submitted to the State Agency on 03/21/2024 at 11:52 AM. They stated the former Director of Nursing was responsible for reporting to the State Agency.
10 NYCRR 415.4(b)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey 4/29/25 to 5/6/25, the facility di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey 4/29/25 to 5/6/25, the facility did not ensure a significant change Minimum Data Set (MDS) Assessment (tool to assess resident care needs) was completed within the 14-day requirement for 1 of 5 residents (Resident #48) reviewed for pressure ulcer/injury. Specifically, a Significant Change Minimum Data Set was not initiated within 14 days for Resident #48 with a decline in swallowing ability who required a 1/28/25 diet downgrade to nothing by mouth.
The findings include:
Resident #48 was admitted to the facility with a diagnosis of Dementia.
The 12/3/24 Quarterly Minimum Data Set assessment documented no swallowing disorders present.
The 12/6/24 Clinical Nutrition assessment dated [DATE] documented puree diet with nectar thick liquids, tolerating the modified texture and no swallowing issues.
The 1/28/25 Physician Order documented Aspiration Precautions as necessary and nothing by mouth diet, texture and consistency.
The 1/29/25 Speech Therapy Evaluation and Plan of Treatment documented resident seen with puree consistency x 1 teaspoon at this evaluation. Bolus dumped in oral cavity with bolus holding and no attempts at manipulation or transfer evidenced. Bolus removed from resident's oral cavity. No further by mouth was presented secondary to the above findings putting the resident at high risk for aspiration.
The 1/29/25 Speech Therapy Treatment Encounter Notes documented precautions nothing by mouth (npo). Recommend continue nothing by mouth status as resident with a recent aspiration pneumonia and remains at high risk for aspiration.
The 3/5/25 Significant Change Minimum Data Set assessment documented swallowing disorder, the resident was holding food in mouth/cheeks or had residual food in mouth after meals.
During interview on 5/5/25 at 3:24 PM the Speech Therapist stated the resident was on aspiration precaution and stated the resident received comfort/pleasure feeds via teaspoon as tolerated.
During interview on 5/6/25 at 9:20 AM the acting Minimum Data Set Coordinator stated the Significant Change Minimum Data Set Assessment was initiated because the resident had worsening dysphagia and inability to take oral feedings. They stated the facility waited to do the Assessment when the Quarterly Assessment was due instead of following the 14-day requirement.
10 NY CRR 415.11(a)(3)(ii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review conducted during the Recertification Survey from 04/29/2025 to 05/06/2025, the facility did not ensure residents received treatment and care in accor...
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Based on observation, interview, and record review conducted during the Recertification Survey from 04/29/2025 to 05/06/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one of one resident (Resident #67) reviewed for edema. Specifically, for Resident #67 a left foot ace bandage wrap was not consistently applied in the morning to allow 12 hours of use daily and legs were not elevated when out of bed as per physician order.
The findings include:
Resident #67 had diagnoses including but not limited to Hemiplegia following a Cerebral Infarction, Morbid Obesity, and Heart Failure.
The Care Plan titled Hypertension dated 10/26/24 documented monitor for edema.
The Quarterly Minimum Data Set (an assessment tool) dated 1/31/25 documented Resident #67 was cognitively intact and independent with all activities of daily living.
The 2/14/25 Care Plan Note documented blood pressure stable, lower extremities remain with swelling. Continue same plan of care.
The 3/7/25 Physician Order documented wrap the left foot for 12 hours every day with an ace wrap, put on in the morning and take off at bedtime. Elevate leg/s as much as possible during the day.
There was no documented evidence in the Certified Nurse Aide Tasks to address directions related to elevation of Resident #67's legs.
The April 2025 Treatment Administration Record documented the left foot ace wrap was applied on 4/30/25.
During observation on 4/30/25 at 11:03 AM, 5/1/2025 at 11:26 AM, and 5/02/2025 at 8:56 AM, Resident #67 was sitting in a chair. Both lower legs had 2-3 plus edema. Both legs were not elevated and the left foot ace wrap was not in place as per physician order.
During an interview on 04/30/25 at 11:03 AM Resident #67 stated they had swelling in their leg. They stated they would like to elevate their leg/s but had nothing to elevate them on. They stated when they began to walk, their wheelchair was taken away which left them without the ability to elevate their legs when not in bed. They stated they had asked the staff on several occasions about elevating their legs
During an interview on 05/01/2025 at 11:26 AM Resident #67 stated their left foot should be wrapped every day. They stated the staff told them they would come back and wrap it, but no one came back. They stated they should have the left foot wrapped before they get out of bed, but they had to wait for the day nurse to wrap the foot. They stated the nurses were busy in the morning so most days it did not get done until the afternoon.
During an interview on 05/05/25 at 9:58 AM Licensed Practical Nurse #24 stated the resident was encouraged to elevate their legs. They stated when they came to work the resident's left leg was usually not wrapped. They stated they usually did not get to wrapping the leg until around 10:30 AM. They stated they were aware the resident's legs should be elevated but were unaware the resident had nothing to elevate their legs on.
During an interview on 05/05/25 at 10:03 AM Registered Nurse Manager #23 stated they were not aware the residents' legs should be elevated when out of bed or that the resident had not been provided with a means to elevate their legs.
10 NYCRR 415.12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not ensure irregularities identified by the pharmacist and forwarded to the facility were acted upon for 1 of 5 residents (Resident #121) reviewed for unnecessary medications. Specifically, for Resident #121 laboratory requests were not ordered and obtained as per consultant pharmacist and physician agreement.
The findings include:
Resident #121 was admitted to the facility on [DATE] with the diagnosis of dementia with psychotic disturbance, anxiety, and falls.
The 1/21/25 Quarterly Minimum Date Set (assessment tool) documented the resident had severely impaired cognition and was taking an antipsychotic medication.
The 4/4/25 Medication Regimen Review documented laboratory monitoring as a requirement for Seroquel use and there were no recent labs on file. Physician signature documented reviewed and will order.
There was no documented evidence in the physician orders that the requested laboratory tests were ordered.
During an interview on 5/5/25 at 10:52 AM Licensed Practical Nurse #27 stated the medication regimen review recommendation was signed by the physician but labs were not ordered and results were not available for review.
During an interview on 5/5/25 at 12:15 PM Unit Manager Registered Nurse #23 stated they did not know what the medication regimen review paper was and had never seen it before. They stated there was no order for labs and no documented physician note regarding requested labs.
During an interview on 5/5/25 at 3:42 PM the Director of Nursing stated they called the physician regarding the requested labs. The physician stated Resident #121 must have refused. The Director of Nursing stated there was no documentation of refusal.
10NYCRR 415.18 (c)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the recertification survey conducted 4/29/2025-5/6/2025, the facility did not ensure each resident received and the facility provided food pre...
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Based on observation, record review, and interview during the recertification survey conducted 4/29/2025-5/6/2025, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 3 residents (Residents #113, #86) reviewed for food. Specifically, 1) Resident #113 had a physician order for mince and moist diet and was served a fruit cup and 2) Resident #86 had a physician order for nectar thick liquids and was provided a pitcher of water by the Certified Nurse Aide.
The findings include:
The policy titled Diet Orders, revised 4/2025 documented the purpose of the policy is to ensure the resident/patient receives meals that are consistent with clinical needs.
1)Resident #113 with diagnosis that include Hypertension, Heart Failure and Chronic Kidney Disease.
The 9/14/24 Quarterly Minimum Data Set (an assessment tool) documented the resident's cognition was moderately impaired and they received set up assistance for eating.
The 11/5/24 Physician Order documented minced and moist texture diet and thin liquids.
The current Care Plan titled Potential for Aspiration- mechanical soft diet documented mince and moist texture, encourage to chew thoroughly and eat slowly.
The current Care Plan titled Nutrition, documented minced and moist texture with aspiration precautions.
During observation on 4/29/25 at 1:09 PM of the 5th floor dining room the lunch ticket on the meal tray listed minced fruit cup. Resident #113 received a regular tropical fruit cup.
During an interview on 5/01/25 at 11:30 AM Registered Dietitian #7 stated the minced and moist texture was comparable to a ground texture and the tropical fruit cup that was served was not a ground texture.
During a follow up interview on 5/02/25 at 9:50 AM Registered Dietitian #7 stated the facility changed to a new food system menu program on 8/1/24. The diet textures were changed from mechanical soft to minced and moist. They felt this diet was safest for residents. They stated the regular tropical fruit cup was still on the menu in error.
During an interview on 5/02/25 at 10:00 AM the Food Service Director stated there was no in-service documentation for dietary staff on the new diet, minced and moist texture. They stated a huddle was held to provide education for staff. They stated there was no policy regarding diet textures and consistencies.
2) Resident # 86 with diagnoses to include Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, and Heart Disease.
The 1/13/25 Quarterly Minimum Data Set (an assessment tool) documented Resident #86's cognition was intact, and they were independent with eating.
The 8/1/25 Physician Order documented Regular Diet with Nectar mildly thick consistency for liquids
The current Certified Nurse Aide Kardex documented eating and nutrition, regular diet, regular texture, nectar/mildly thick liquids with aspiration precautions.
The current Care Plan titled Nutritional Problem related to swallowing difficulty documented Regular Diet with Nectar mildly thick consistency for liquids.
During observation on 05/02/25 at 01:20 PM Resident # 86 had a lunch tray at the bedside. The tray had soft food, and thickened liquids. Additionally, the resident had 2 large cans of iced tea and a pitcher of non-thickened ice water on the over bed table.
During an interview on 05/02/25 at 01:20 PM Certified Nurse Aides #20 stated they did not think, the resident had special diet needs, the resident received thickened milk but they thought it was their preference. They stated the resident requested water, so they provided them with a pitcher of ice water. They stated if the resident was on a special diet, the nurse would let them know. They stated they did not know if the resident's diet was available for a Certified Nurse Aide to review.
During an interview on 05/02/25 at 01:34 PM Licensed Practical Nurse #2 stated they were unsure if the Certified Nurse Aides could see the residents diet order. They stated Certified Nurse Aides received report at the start of shift and would be told if the resident had a special diets. They stated they were unaware the resident was given ice water.
During an interview on 05/02/25 at 01:48 PM the Director of Nursing stated the Certified Nurse Aides should know what diet residents were to receive. They stated residents who were supposed to receive nectar thick liquid should not have been given a pitcher of regular water.
During an interview on 05/05/25 at 02:08 PM the Dietician stated the resident should not have received regular water.
10NYCRR 415.14 (d-e)
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview during the recertification survey and abbreviated survey (NY00374695) from 4/29/25 to 5/6/25 the facility did not ensure the development and implement...
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Based on observation, record review and interview during the recertification survey and abbreviated survey (NY00374695) from 4/29/25 to 5/6/25 the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with resident rights that included measurable objectives and time frames to meet a resident's needs for 1 of 5 residents (Resident #32) reviewed for pressure ulcers, 1 of 3 residents (Resident #19 ) reviewed for positioning and mobility and for 1 of 2 residents (Resident #8) reviewed for tube feeding. Specifically, 1) Resident #32 was incontinent of bladder and there was no documented evidence that a care plan to address an incontinence schedule/incontinence care was developed and/or implemented, 2) Resident #19 did not have an activities of daily living care plan prior to 5/5/25 and 3) the care plan to address Resident #8's feeding tube was incomplete and did not have measurable objectives, goals and interventions.
The findings include:
The Comprehensive Care Plan Policy last revised 1/2025 documented each resident will have a comprehensive care plan developed and updated by all members of the comprehensive care plan team as appropriate.
1) Resident #32 had diagnoses which included Schizophrenia (disorder that affects the ability to think, feel, and behave clearly), Depression and Morbid Severe Obesity.
The 10/29/2024 Annual Minimum Data Set documented Resident #32 was cognitively intact, received substantial to maximum staff assistance for toileting, was incontinent of bladder, frequently incontinent of bowel, and was at risk for pressure ulcers.
The 1/29/2025 Quarterly Minimum Data Set (assessment tool) documented Resident #32 had intact cognition, received substantial/maximal assistance with toileting, and was incontinent of bladder and frequently incontinent of bowel.
There was no documented evidence in the Care Plans to address Resident #32's incontinence schedule/incontinence care.
There was no documented evidence interventions were implemented to address Resident #32's incontinence.
The 4/1/2025-4/16/2025 Documentation Survey Report documented Resident #32 was coded one (1) incontinent of bladder 15 days during the 7 AM-3 PM shift, 15 evenings during the 3:00 PM -11:00 PM shift and 15 nights during the 11:00 PM -7:00 AM shift.
During an interview on 5/1/2025 at 1:40 PM the Director of Nursing was unable to provide documentation of a care plan with interventions to address Resident #32's incontinence schedule/incontinence care.
2)Resident #19 had diagnoses including Cancer, Peripheral Vascular Disease, and Asthma.
The 1/25/25 Quarterly Minimum Data Set Assessment documented Resident #19 was cognitively intact, had upper and lower extremity impairment on both sides required substantial to maximal assist for toileting and was dependent in bed mobility/transfer/wheelchair mobility and was able to eat independently.
There was no documented evidence in the Comprehensive Care Plan to address Activities of Daily Living prior to 5/5/25.
During an interview on 5/06/25 at 2:00 PM, the Director of Nursing stated while Registered Nurse #1 was on leave they assigned three (3) Registered Nurse Per Diem Supervisors the role of initiating and updating care plans for the 4th floor unit.
During an interview on 5/06/25 at 3:05 PM, the Director of Nursing stated they provided education to the nurse managers and supervisors and they offered classes twice a year. The Director of Nursing stated they had no documented in-services for the past year. The Director of Nursing stated the nurse managers were supposed to review the care plans and make updates during family care plan meetings.
During an interview on 5/06/25 at 3:31 PM, Registered Nurse #1 stated they could not explain why the Activities of Daily Living Care Plan was not created until 5/5/25. Registered Nurse #1 stated they did know how to initiate a care plan in the system. Registered Nurse #1 stated they started using the new system in August of 2024 and were still learning how to use it.
3) Resident #8 had diagnoses including Stiff-Man Syndrome, Type 1 Diabetes, Dysphagia with G-tube feedings and Stomach Cancer.
The 3/2/25 Quarterly Minimum Data Set (assessment tool) documented Resident #8 had impaired cognition,was dependent on staff for all activities of daily living and received all nutrition and hydration via G- tube.
There was no documented evidence in the Comprehensive Care Plan to address goals and interventions related to G-tube feedings.
During an interview on 5/6/25 at 11:21 AM Registered Nurse Unit Manager #23 stated the care plan was started but never completed and needed goals and interventions.
During an interview on 5/6/25 at 3:05 PM the Director of Nursing stated the medical team developed/updated care plans and the Nurse Managers were to review care plans for completion.
10 NYCRR 415.11 (c)(1)
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, during the recertification survey and abbreviated survey (NY00376185) and (N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, during the recertification survey and abbreviated survey (NY00376185) and (NY00342713), the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, 1) the 5th floor call bell was not audible and did not have a centralized location to alert staff when residents needed assistance for twenty nine of twenty nine rooms and the light above the door did not light up for five of the twenty nine rooms (Rooms #104A, 105B, 111P, 115A, 115B, bathroom in room [ROOM NUMBER]). Additionally, tap or hand bells were not provided/readily available as per facility plan for ten of the twenty nine rooms (Rooms #104B, 105B, 111P, 115B, 117A, 121A, 121B, 126B, 127A, 127B, 128A, 128B, 129A, and 129B).
The findings include:
The Policy and Procedure titled Call Bell System last revised 2/2025 documented the promptness of the call bell is key priority for patients. Addressing and responding to the patient call bell improves patient satisfaction, decreases the patients anxiety and increases their trust and provides the patient with information.
The 5/23/24 In-service documented training on 15 minute monitoring initiated related to call bells not working on the 5th floor.
The 8/7/24 In-service documented training on the tap bell or hand bells being used in replace of original call bell system on the 5th floor.
The 11/16/24 Work Order documented the 5th floor call bell system was broken and unable to be repaired.
The emails reviewed included but were not limited to the following:
The email dated 1/9/24 from the Bioengineer Manager to the Director of Quality documented an apology for the delay and explained the repair had been a challenge and the vendor was coming out on that date to look at the system.
The email dated 1/10/24 from the Bioengineer Manager to the Director of Quality documented the repair of the 5th floor call system and to remind staff to continue to do their rounding's.
The email dated 2/22/24 to the Administrator documented the call bell system on the 5th floor was still not functioning as of 1/17/24. The Bioengineer Manager outsourced repair 1/17/24 and was still seeking parts. Continue to use tap bells and 15 minute monitoring. It also documented families had complained about nonfunctioning call bells.
The email dated 2/23/24 to the Administrator documented they were collaborating with distributors to explore all avenues. Despite engaging several vendors, regrettably, they had not been successful in repairing the unit. The master stations were phased out as early as 2003. Finding a suitable replacement has been challenging and they would like to review the option of replacing the existing system. Calls would be placed to obtain a new quote.
The 2/27/24 quote from a company provided an estimated cost for the replacement of the 5th floor call bell system.
The email dated 1/27/25 documented a delay in the production of equipment, equipment would be received the week of 2/13/25 and once the documentation needed to start the installation was received, they could begin corridor installation the week of 2/17/25.
The email dated 2/24/25 sent from the Senior Financial Analyst to the company documented the facility requested an update on the call system being installed, as they had passed the 2/17/25 install date.
The email dated 3/14/25 from the company to the Engineer Manager documented availability to start working on the call bell system replacement.
The email dated 3/20/25 from the company to the Engineer Manager documented a request to reschedule for 3/21/25 at 11 AM.
During an observation with a team of surveyors on 4/29/25 between 11:15 AM and 11:54 AM the 5th floor call bell was not audible and did not have a centralized location in twenty nine rooms, the light above the door did not light up for five of twenty nine rooms (Rooms #104A, 105B, 111P, 115A, 115B, bathroom in room [ROOM NUMBER]). Tap or hand bells were not provided/readily available as per facility plan for ten of twenty nine rooms (Rooms #104B, 105B, 111P, 115B, 117A, 121A, 121B, 126B, 127A, 127B, 128A, 128B, 129A, and 129B).
During an interview on 4/29/25 at 11:53 AM, Resident #93 stated when they used the hand bell at times they waited 2-3 hours.
During an interview on 4/29/25 at 11:54 AM, Resident #67 stated when they used the hand bell, they were concerned about it actually working.
During an interview on 4/29/25 at 11:54 AM, Resident #60 stated when they used the hand bell, the staff could not hear them. They further stated at times they waited 1-2 hours and would go and get the staff themselves.
During an interview on 5/01/25 at 4:40 PM, Certified Nurse Aide #29 stated they worked the 3:00 PM to 11:00 PM shift and all residents were to have a hotel or tap bell while the call bell system remained broken. Certified Nurse Aide #29 stated they did frequent rounding every 15 minutes and signed off on a sheet to monitor the residents.
During an interview on 5/02/25 at 1:31 PM, the Biomedical Manager stated they were informed about 1 year ago the call bells were not functioning on the 5th floor. They stated the plan was to try to fix and rebuild it initially. The Biomedical Manager stated they contacted vendors but were unsuccessful. They stated they were not able to provide details on how long it took to get approval for the system to be fixed. The Biomedical Manager stated the vendor provided a quote to replace it. The Biomedical Manager stated it took some time to get the plan to replace it approved, but they were scheduled to start replacement of the call bell system next week.
During an interview on 5/02/25 at 1:55 PM, the Senior Director of Bioengineering stated the call bell system was a capital purchase that needed to be approved by a lot of people. The Senior Director of Bioengineering stated somebody had to initiate the requisition in their system, which then pinged to the next person, and so on and then the final decision needed to go through finance. The Senior Director of Bioengineering stated there were about 7 people involved in the process. The Senior Director of Bioengineering stated they felt it was urgent but needed to go through the system for it to be processed. The Senior Director of Bioengineering stated they made provisions with the malfunctioning of the call bell system which was to provide manual bells to every room. The Senior Director of Bioengineering stated they had paperwork that was needed prior to the start of construction and the process took some time to come up with plans. The Senior Director of Bioengineering stated when equipment breaks they were responsible for repair, but not responsible to replace broken capital equipment. The Senior Director of Bioengineering stated the layers added to the time it took to get the repair started. The Senior Director of Bioengineering stated it was a critical piece of equipment for the resident's safety and should have been escalated. The Senior Director of Bioengineering stated in retrospect everybody should have really tried to influence the replacement sooner.
During an interview on 5/06/25 at 4:03 PM, the Administrator stated they had been following the call bell issue in Quality Assurance and Resident Council. The Administrator stated the plan was to initially repair it, but they found out it was not repairable around January 2024. The Administrator stated they immediately started the process to get the call bell replacement approved. They stated they received quotes immediately and purchasing addressed the quotes. The Administrator stated it went through the system to get approved and it took that long to get all the approvals. The Administrator stated they had to go through this process to get approval and the residents understood the process was lengthy and were comfortable with the 15 minute monitoring that was implemented.
10 NYCRR 415.29
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review during the recertification survey from 04/29/25 through 05/06/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once...
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Based on interview and record review during the recertification survey from 04/29/25 through 05/06/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#13, #14, #15, #16, #17) did not have a performance review documented at least once every 12 months.
The findings include:
The Policy & Procedure titled Competency Based Performance Evaluation Program with a 4/2023 revision date documented it was the responsibility of administrative, managerial, and or supervisory staff to review the performance of all employees under their supervision and to complete and forward completion information to the human resource department. The individual departments will maintain a file of the actual performance appraisals. Performance Appraisals are to be completed annually.
There was no documented evidence that performance reviews were completed in the last 12 months for Certified Nurse Aide #13 with a hire date of 11/6/13, Certified Nurse Aide #14 with a hire date of 11/6/13, Certified Nurse Aide #15 with a hire date of 11/6/13, Certified Nurse Aide #16 with hire date of 6/7/21 and Certified Nurse Aide #17 with hire date of 11/6/13.
During an interview on 05/06/25 at 01:48 PM the Director of Nursing stated they were behind in completing Performance Appraisals.
During an interview on 05/06/25 at 02:24 PM the Director of Human Resources stated they were involved in the process to complete Performance Appraisals. They stated they were aware the Performance Appraisals needed to be completed every 12 months and were aware they were not being completed timely.
During an interview on 05/06/25 at 02:45 PM the Assistant Administrator stated they thought Performance Appraisals needed to be done every two years. They stated it was the responsibility of the department head to ensure the performance approvals were completed. They were unaware the performance appraisals were not being completed as required by regulation.
10NYCRR 415.26 (c) (2) (iii)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and interview conducted during the recertification survey from 4/25/25 to 5/6/25, the facility did not ensure food was distributed and served in accordance with professional stand...
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Based on observation and interview conducted during the recertification survey from 4/25/25 to 5/6/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, unlabeled and undated food items in kitchen and unit pantry, expired food in kitchen storage pantry and unit pantry, and dietary staff did not perform proper hand hygiene before preparing a sandwich.
The findings include:
The policy titled Handwashing with a 1/2022 revision date documented food service associates are expected to perform proper hand hygiene while on duty; specifically, before and after wearing gloves.
The policy titled Use and Storage of Food/Beverages brought from off-site with a 4/2025 revision date documented food may be stored in the unit pantry refrigerator for up to 48 hours, labeled with current date and discarded after 48 hours of date on the label.
During the initial tour of the kitchen conducted on 4/29/25 at 9:25 AM, there was a bag of unlabeled sundried tomatoes in the salad refrigerator and two containers of mayonnaise not dated in the refrigerator. At that time Staff #6 stated all food items should be labeled and dated.
During the tour of the emergency food supply on 4/29/25 9:52 AM, there were protein meal bars with a 4/8/25 expiration date, canned tuna fish with a 4/6/25 expiration date, apple juice with a 3/28/25 expiration date, ensure clear supplements with a 3/1/25 and 4/1/25 expiration date and glucerna supplement with a 3/1/25 expiration date.
During a tour of Unit 3 pantry on 5/1/25 at 4:35 PM there was a plastic container of blueberries not dated, a disposable plastic container of fruit salad not dated and a plastic bag of cake dated 4/23/25.
During interview on 5/1/25 at 4:35 PM Licensed Practical Nurse #12 stated the items should have been thrown out after 48 hours from the recorded date. They stated it was nursing staffs responsibility to label food items for the residents with their name and current date.
During an interview on 5/6/25 at 10:37 AM the Food Service Director stated the storeroom staff should have noticed the expiration dates one month prior to expiration.
During an interview with the Director of Nursing on 5/6/25 at 10:47 AM, they stated nursing staff was to make sure food was labeled with name and current date and then discarded after 48 hours. The environmental department was responsible for completing general pantry cleaning.
During a follow up tour of the kitchen on 5/1/15 at 11:41 AM Dietary Staff #10 was observed making a peanut butter and jelly sandwich. Staff #10 was wearing a surgical mask and coughed while holding a bare hand about 2 inches from the mask. They proceeded to put on gloves without washing hands as per policy.
During an interview with the Food Service Director on 5/6/25 at 10:41 AM regarding hand hygiene they stated it was the policy to wash hands before applying gloves and staff education had been provided.
10 NYCRR 415.14(h)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on record review and interview during a Recertification Survey on 4/29/2025 - 5/6/2025, the facility did not maintain an infection prevention and control program designed to prevent the developm...
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Based on record review and interview during a Recertification Survey on 4/29/2025 - 5/6/2025, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure an infection surveillance plan based on facility assessment was implemented for the identification, containment and prevention of infections.
Findings include:
The policy titled Infection Control Program last reviewed on 12/24 documented the Infection Control Committee shall investigate, control and prevent infections, decide which procedures shall be applied, such as isolation when control of infection or communicable disease is required: perform surveillance and investigation of prevention, to the extent possible, the onset and spread of infection, prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions.
The Antibiotic list for March 2025 and April 2025 documented residents on antibiotic therapy for wound infection, respiratory infection, urinary tract infection, pressure ulcer, bacteremia, and local infection of the skin. The antibiotic list had no documentation that could be reviewed for infection onset dates, signs and symptoms, results of laboratory tests, isolation, and outbreak potential.
During an interview on 05/01/25 at 3:40 P M the Director of Nursing/Infection Preventionist stated they were responsible for tracking and surveillance of infections. They further stated the Antibiotic list for March 2025 and Aril 2025 was the surveillance report of residents that were placed on antibiotic therapy.
During a subsequent interview on 5/6/2025 at 12:55 PM and review of the Antibiotic list for March 2025 and April 2025 the Director of Nursing/Infection Control Preventionist stated the Antibiotic list which was also the surveillance list lacked documentation of infection onset date, signs and symptoms, laboratory results, radiology results, type of precaution and outbreak potential.
10 NYCRR 415.19(a)(1-3)
Dec 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during a recertification survey from 12/12/23 through 12/20/23, the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during a recertification survey from 12/12/23 through 12/20/23, the facility did not review and revise the comprehensive care plan with appropriate interventions for 2 out of 2 residents (Residents #89 and #98) reviewed for Activities. Specifically, Residents # 89 and #98's recreation care plans were not updated quarterly and did not reflect the residents' preferred activities.
Findings include:
The facility comprehensive care plan policy, revised April 2023, documented the frequency of care plan updates was after any significant changes in the resident's condition, after family/team meetings, quarterly and annually.
1) Resident #89 was admitted with diagnoses including dementia, hypertension (high blood pressure), and asthma.
The quarterly Minimum Data Set (an assessment tool) dated 8/29/23 and 11/26/23 documented Resident #89's cognition was intact for daily decision making. The Activity Preferences section (section F) of the MDS was not completed for either review.
Review of Resident #89's current comprehensive care plan (CCP) for Recreation was last reviewed 3/2/23 and only noted music as activity of interest.
The Recreation quarterly note dated 5/31/23 documented Resident #89 attended 3-5 activities weekly including coffee social, special events, music programs and attends religious services.
Further review of the record revealed no updates or evaluation to the resident's Recreational care plan after 5/31/23.
During an observation conducted on 12/12/23 at 10:23 AM resident #89 was in bed, fully dressed, facing window.
During an observation on 12/14/23 at 10:46 AM resident #89 came to dayroom to enjoy warm beverage during coffee social.
2. Resident #98 was admitted with diagnoses and conditions including vascular dementia, Hypertension, and Mood Disorder.
The quarterly Minimum Data Set, dated [DATE], documented Resident #98's cognition was severely impaired; the resident had unclear speech, was unable to be understood, and could not understand others. The Activity Preferences section documented the resident could not participate in the assessment. The 'Staff Assessment of Daily and Activity Preferences' documented the resident preferences included reading books, newspapers, or magazines, listening to music, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices.
Review of the current comprehensive care plan (CCP) for recreation, last reviewed 3/22/23, documented music, exercise, and trivia as resident interests and to escort resident to musical programs.
The Recreation quarterly note dated 6/2/23 documented the resident attended 0-1 activities per week and spent most of the time in their room. The note documented the resident received tactile stimulation 1-2 times per week during 1:1 room visit.
There had been no update to the care plan since 3/22/34 and no recreational notes since 6/2/23 to reflect a change in the resident's activities.
During an observation conducted 12/12/23 at 10:28 AM, Resident #98 was in bed resting; the feeding tube was running and there were fall mats by bed.
During an interview conducted on 12/20/23 at 11:07 AM, Licensed Social Worker #2 stated the Activities Department was responsible for the quarterly assessment notes and recreation care plans. When reviewed with Licensed Social Worker #2, they stated the care plan should have been updated in November.
During an interview on 12/20/23 at 12:28 PM, the Recreation Supervisor stated that for bed bound residents the facility provided sensory and tactile stimulation. They stated care plans and assessment notes were supposed to be done quarterly and annually but the person that helped with the documentation was no longer at the facility. They stated they were trying to catch up with documentation.
10 NYCRR 415.11(c)(2)(i-iii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that they evaluated, updated, and implemented an effective discharge plan for...
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Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that they evaluated, updated, and implemented an effective discharge plan for one of four residents reviewed for discharge (Resident #127). Specifically, Resident #127 who expressed a desire to be discharged to the community was not re-evaluated and a new discharge plan developed based on the resident's choice when the initial community discharge plan could not be implemented, and planned community support were no longer available.
Findings include:
Review of the facility policy entitled Discharge/Transfer, dated 7/03, last reviewed 9/23, stated the facility will discharge a resident when the interdisciplinary team, in consultation with the resident, determines that the discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, and is being made in compliance with the resident's request. Further, for discharges to the community, the Social Worker confirms that the resident has a suitable place to live, if not, she/he assists the resident in obtaining a suitable living arrangement and arranges supportive community services.
Resident #127 was admitted with diagnoses including syncope, hypertension, and asthma.
The 9/28/2022 Baseline Care Plan documented the discharge plan was for the resident to return to the community.
On 11/14/2022, Social Worker #1 documented that prior to the 10/11/22 care plan meeting, the resident's family member made them aware that the resident's dischare plan was to return to the community with family support via the Consumer Directed Personal Assistance Program when the resident's Medicaid was approved and to move to a new apartment. The social work informed the family that the last day of projected rehabilitation was 10/27/2022.
The comprehensive care plan updated 1/2/2023 documented the resident's overall expectation was to be discharged to the community and to discuss discharge planning on all assessments, including interventions to assess home situation and environment and arrange for community agency, to engage resident/family in development of a discharge plan, and if the resident verbalized an interest in residing in an assisted living or adult home, provide information and assist as needed with completing applications.
The 2/6/2023 and 11/01/2023 Minimum Data Set (an assessment tool) documented Resident #127 was cognitively intact, had no mood or behavioral deficits, did not have functional limitations in range of motion and received supervision assistance or independence with activities of daily living, was not receiving occupational or physical therapy and their discharge plan was to return to the community and no referral to local contact agency (community agency) for discharge planning was made.
The comprehensive care plan for discharge date d 2/6/2023 documented the resident's overall expectation was to remain in the facility and to assist the resident in adjusting to the facility and need for continued placement.
The social worker notes documented by Licensed Social Worker #1 dated 5/16/2023 and 8/15/2023 documented the residents' family was no longer available to participate in long-term care planning for resident, and plan was for resident to remain in facility for long term care.
The physician's progress note dated 8/29/2023, documented the resident requested that Medical Doctor #2 speak with the social worker regarding their wish to return to their apartment in the community and informed the medical doctor that a daughter was ill and unable to assist them the Medical Doctor agreed to speak to social work.
The physician's progress note dated 10/23/2023, documented the resident expressed to Medical Doctor #2 a desire to be discharged from the facility and requested assistance obtaining a new apartment and that their family was no longer able to assist them with discharge.
The physician's progress note dated 11/7/2023, documented Medical Doctor #2 received a telephone call from the residents' granddaughter and discussed Senior Housing and Assisted Living as alternative housing for resident upon discharge.
The social worker notes documented by Licensed Social Worker #1 dated 11/15/2023 documented residents' family was no longer available to participate in long-term care planning for resident, and plan was for resident to remain in facility for long term care
During interviews on 12/13/2023, and 12/19/2023 at 10:49 AM and 3:32 PM, Resident #127 stated they would like to be discharged to the community and into their own apartment and did not wish to be in this facility any longer and did not have any medical problems.
During an interview on 12/19/2023 at 3:50 PM Social Worker #3 stated if a resident no longer required skilled care a care plan meeting would be scheduled to determine the residents' goals and needs in the community, and they would assist resident with locating housing or placement if needed.
During an interview on 12/20/2023 at 10:00 AM Social Worker #1 stated they were involved in the ongoing discharge plans for this resident and that they were aware the resident's family was no longer available or able to assist the resident with discharge planning or homecare in the community and no plans for discharge to the community were made after March 2023.
During an interview on 12/20/2023 at 1:41 PM the Director of Nursing stated that they were part of the interdisciplinary team, and that all departments, to include social work were responsible for reading the physician notes regarding resident care and status. The Director of Nursing stated they were not aware Resident #127 wanted to be discharged from the facility and that there was no formal discharge planning within the interdisciplinary team for this resident.
During an interview on 12/20/2023 at 2:09 PM Medical Doctor #2 stated that they were a part of the interdisciplinary team and stated they communicated the resident's housing difficulties with the Social Worker.
10 NYCRR415.11(d)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure that residents with a Foley (indwelling) catheter (a tube inserted into the bladder via the urethra to drain urine into a drainage bag) received the treatment and services needed to prevent urinary tract infections to the extent possible for one (Resident #87) of 3 residents reviewed for indwelling catheters. Specifically, Resident #87's Foley catheter drainage bag was not changed as per physician orders, and there was a lack of Foley care provided per professional standards to prevent complications.
Findings include:
Resident #87 was admitted with diagnoses including hematuria (blood in the urine), neurogenic bladder (dysfunction of nerve pathways to the bladder), and sepsis (systemic infection) secondary to urinary tract infection.
The Minimum Data Set assessment, dated 9/8/2023, documented the resident had intact cognition, received extensive assist of one staff for bed mobility, toileting and transfers, and had an indwelling catheter.
The urinary incontinence and indwelling catheter care plan dated 6/15/2023, and updated on 9/8/2023, documented Resident #87 had an indwelling catheter related to atonic (loss of muscle tone) bladder. Interventions included changing the Foley catheter bag every Tuesday.
The hospital Discharge summary dated [DATE], documented Resident #87 had a diagnosis of recurrent sepsis secondary to urinary tract infection.
The physician order dated 12/8/2023, documented Foley catheter bag change every week on Tuesday.
The current resident care profile documented change the Foley catheter bag every week on Tuesdays.
During an interview on 12/12/2023 at 11:42 AM Resident #87 stated they were recently hospitalized for a urinary tract infection and have had recurrent urinary tract infections since admission into the facility.
During an observation on 12/19/2023 at 09:40 AM Resident #87's Foley catheter bag had a date of 12/5/2023 (2 weeks prior) written on the bag and was signed by the emergency room department.
During an interview on 12/19/2023 at 11:12 AM, Physician #1 stated there was an order in place to change Resident #87's catheter bag every Tuesday. Physician #1 was unaware the bag was not changed and expected to be notified if there were any issues changing it.
During an observation on 12/20/2023 at 1:45 PM, Resident #87's Foley catheter bag still had the date of 12/5/23.
During an interview on 12/20/2023 at 1:47 PM Licensed Practical Nurse #2 stated they were aware Resident #87's Foley catheter bag was supposed to be changed every week on Tuesdays and it should have been changed on 12/12/2023.
During an interview on 12/20/2023 at 1:50 PM, Registered Nurse Manager #1 stated that Resident # 87's Foley catheter bag must be changed weekly on Tuesday and that it should have been changed on 12/12/2023.
10 NYCRR 415.12(d)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey 12/12/2023-12/20/2023, the facility did not ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey 12/12/2023-12/20/2023, the facility did not ensure an infection prevention and control program designed to provide a safe and sanitary environment was maintained. Specifically, (1) The facility could not provide evidence that a facility risk assessment was conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system and 2)Foley catheter tubing was observed on the floor without a barrier for 1 of 3 residents reviewed for foley catheters (Resident #87).
The findings are:
The facility Legionella Water Management Program dated 1/1/2023 documented the purpose of the water management program is to identify areas in the water systems where Legionella bacteria can grow and spread and include an assessment of the infrastructure components in terms of their potential contact with patients/visitors and a sampling and maintenance schedule for demonstrating how the effects of Legionella will be addressed.
1) The facility did not provide any documented evidence that an Environmental Assessment of Water Systems in Healthcare Settings was performed and updated annually to minimize the risk of healthcare facility associated Legionella Species according to best practice standards and regulations.
During an interview on 12/15/2023 at 4:00 PM the Chief Engineer stated they oversaw the Legionella Management Program since January 2023 but was not familiar with the Environmental Risk Assessment. The Chief Engineer stated it was important to know what the risks are and an effective plan was needed.
During an interview on 12/19/2023 at 09:40 AM the Director of Engineering stated the Chief Engineer is new to the facility since 1/2023. The Director of Engineering could not explain why an assessment was not available for review.
2) The facility's policy titled urinary catheter management dated 1977, and last reviewed/revised on 4/2023 documented to anchor the catheter to tubing and to place excess coil of tubing on the bed and fasten to the bottom sheet with clip from drainage set.
Resident #87 was admitted with diagnoses including, hematuria, neurogenic bladder, and sepsis secondary to urinary tract infection.
The Minimum Data Set, dated [DATE] documented Resident #87 had intact cognition, received extensive assist of one staff for bed mobility, toileting and transfers, and had an indwelling catheter.
The urinary incontinence and indwelling catheter care plan dated 6/15/2023 and updated on 9/8/2023 documented Resident #87's foley catheter bag should not touch the floor and that the foley catheter was to be secured to facilitate the flow of urine.
The physicians orders dated 12/8/2023 documented that Resident #87's foley catheter tubing should not touch the floor.
On 12/12/2023 at 11:42 AM and 12/13/2023 at 10:25 AM Resident #87 was observed in bed. The foley catheter tubing was resting on the floor. The foley catheter tubing was not anchored to the bed or resident's thigh.
When interviewed on 12/12/2023 at 11:42, Resident #87 stated that they were recently hospitalized for a urinary tract infection and has had recurrent urinary tract infections since being admitted to the facility.
During interview on 12/13/2023 at 10:45 AM, Certified Nurse Aide #1 and Certified Nurse Aide #2 stated that Resident #87 foley catheter tubing should never be placed on the floor.
During interview on 12/15/2023 at 03:45 PM, Registered Nurse Manager #1 stated that it was not acceptable for Resident #87's foley catheter tubing to be on the floor.
During an interview on 12/19/2023 at 09:41 AM, Licensed Practical Nurse #2 stated that Resident #87's foley catheter tubing should not be on the floor.
During an interview on 12/19/2023 at 11:12 AM, Physician #1 stated it was not an acceptable standard of practice for Resident #87's foley catheter tubing to be touching the floor.
10 NYCRR 415.19
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure 4 of 5 residents (Residents #114, 57, 14, and 28) reviewed for pressure ulcers, received care and services to promote healing. Specifically, Resident #114 had a Stage 4 pressure ulcer and was not turned and positioned as planned; additionally, there was not a documented wound assessment, by a qualified professional over a 3-week period. Residents #57, #14 and #28 had Stage 4 pressure ulcers and no documented evidence that wound assessments were completed as planned.
Findings include:
1) Resident #114 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including right above the knee amputation, cerebral vascular accident (CVA, stroke), and Stage 4 pressure ulcer (skin impairment). The 11/25/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired. The resident required total assistance with bed mobility, eating, toileting and transfers, and had a Stage 4 pressure ulcer.
a) turning and positioning:
The pressure ulcer comprehensive care plan (CCP)dated 11/15/23 and updated on 11/25/23 documented Resident #114 has a Stage 4 pressure ulcer to the sacrum related to incontinence and impaired mobility. Interventions included turning and positioning every two hours and as needed.
The resident care profile dated 11/2023, documented turning and positioning every 2 hours.
During observations on 12/12/23 at 10:11 AM and 12/13/23 at 10:30 AM , Resident #114 was observed in bed asleep, lying on their back. A turn and position schedule was observed on the resident's wall and documented the resident was to be positioned on their back from 12 o'clock to 2 o'clock, left side from 2 o'clock to 4 o'clock, right side from 4 o'clock to 6 o'clock, back side from 6 o'clock to 8 o'clock, left side from 8 o'clock to 10 o'clock, and right side from 10 o'clock to 12 o'clock.
The Certified Nurse Aide accountability record for turning and positioning documented Resident #114 was lying on their right side in bed on 12/12/23 at 10 AM and supine in bed on 12/13/23 at 10 AM.
When interviewed on 12/13/23 at 10:35 AM, Certified Nurse Aide #2 stated that Resident #114 was laying on their back and not able to be turned and positioned on their right side due to staffing issues. Certified Nurse Aide #2 stated there were multiple residents on the floor that needed to be turned and positioned and there was not enough staff to accommodate each resident's needs.
When interviewed on 12/18/23 at 12:20 PM, the Registered Nurse Unit Manager #1 stated that the Certified Nurse Aide did not document properly on the turn and position section of the Certified Nurse Aide accountability record for Resident #114. Registered Nurse Unit Manager #1 stated Resident #114 should have been on their right side on 12/12/23 at 10:11 AM and 12/13/23 at 10:30 AM.
When interviewed on 12/19/23 at 11:14 AM, Physician #1 stated that Resident #114 must be turned and positioned every 2 hours and as needed, as a pressure relief intervention for the Stage 4 pressure ulcer.
b) wound assessments:
The facility Pressure Ulcer Protocol- Assessment and Management policy, revised April 2023, documented pressure ulcers would be tracked on a weekly basis on wound care rounds.
The Physician order for Resident #114, dated 10/03/23, documented wound rounds every two weeks.
The Wound Assessment Progress Report dated 11/14/23, documented Resident #114 had a Stage 4 pressure ulcer on their sacrum that measured 2 centimeters x 1.5 centimeters x 1 centimeter (length x width x depth) with 0.5 centimeters of undermining. The wound status was marked as decline; the treatment was Hydrogel daily with a plan to try the Wound VAC (negative pressure wound therapy) again.
A physician order dated 11/15/23 documented to continue Hydrogel until get wound VAC.
A physician order dated 11/28/23 documented to continue wound VAC to sacrum, every 3 days at 125 mmHg (negative pressure setting).
The Wound Assessment Progress Report dated 11/28/23 documented Resident #114's pressure ulcer measured 2.4 centimeters x 1.2 centimeters x 1 centimeter (length x width x depth) with 0.5 centimeters of undermining. The wound status was marked as same; the plan was to continue wound VAC for now and if no better, will call back plastic surgery for assessment.
The physician order dated 11/29/23, documented Hydrogel (wound healing gel) after cleansing with normal saline and apply Allevyn (adhesive foam dressing) to sacrum.
During a wound care observation on 12/15/23 at 12:04 PM, LPN #4 removed the old dressing and cleansed the wound with normal saline, applied Hydrogel using a Q-tip and covered the wound with an Allevyn dressing.
Further review of the resident's record on 12/19/23 revealed no further documentation in the Wound Assessment Progress Reports or anywhere else in the resident's medical record on the wounds progress since 11/28/23.
When interviewed on 12/19/23 at 11:05 AM, Physician #1 stated that wound rounds were done weekly on Tuesday mornings and Resident #114 was last seen on 11/28/23 due to the unavailability of the physician. The resident should have been seen bi-weekly as per physician orders. Physician #1 stated that the registered nurses should be assessing the wounds daily and reporting any changes to the physician.
When interviewed on 12/19/23 at 12:18 PM, Registered Nurse Unit Manager #1 stated that wound rounds and measurement were done every week by the wound care physician, and that nurses did not measure or document assessments unless there was a new finding. Registered Nurse Unit Manager #1 stated that Resident #114 was scheduled to be seen by wound rounds on 12/12/23 but the wound care physician was not available and therefore Resident #114 was not seen and was last seen on 11/28/23.
When interviewed on 12/19/23 at 12:31 PM, the Assistant Director of Nursing stated Resident #114 was last seen on 11/28/23 by the wound care team and was supposed to be seen every two weeks. The Assistant Director of Nursing stated that wound assessments and measurements were done on wound rounds by Physician #1 or the Medical Director. Nursing progress notes were reviewed with the Assistant Director of Nursing, and they were unable to find documentation of any wound assessments from 11/28/23-12/19/23.
2) Resident #57 was admitted with Hypertension, Spastic Quadriparesis, and a chronic Stage 4 pressure ulcer.
The quarterly Minimum Data Set ( MDS) dated [DATE] documented Resident # 57 cognition as intact, BIMS 13. Required minimal to maximum assistance with activities of daily living. Resident #57 was admitted with Stage 4 pressure ulcer on the sacrum.
Resident #57's wound care plan dated 9/23/2023 documented weekly wound assessments.
During a wound observation on 12/14/23 at 2:33 PM, the Licensed Practical Nurse #1 changed the resident's dressing using Maxorb AG (absorbent dressing with antimicrobial) and covered with Allevyn. The wound was not measured, the wound bed was pink with the surrounding area had healing scar tissue.
Review of Resident #57's record revealed the Wound Assessment Progress Report documented a Stage 4 sacral pressure ulcer on:
- 11/15/23 measured 0.7 centimeters x 0.3 centimeters x 0.5 centimeters (length x width x depth). The treatment was Hydrogel daily.
- 11/21/23 measured 1.3 centimeters x 0.3 centimeters x 0.5 centimeters. The treatment was to discontinue Hydrogel and use collagenase twice daily and cover with Allevyn.
- 11/28/23 measured 1.5 centimeters x 0.5 centimeters x 0.5 centimeters. The treatment was to discontinue collagenase and use Maxorb Ag twice a day and cover with Allevyn.
- 12/6/23 measured 1.8 centimeters x 0.7 centimeters x 0.5 centimeters. The treatment was Maxorb AG and to consider going back to Hydrogel soon.
Further review of the record on 12/19/23 revealed no weekly wound assessment after 12/6/23.
3) Resident # 14 was admitted to the facility with diagnoses including dementia, sacral decubitus (pressure ulcer) with sacral bone osteomyelitis (bone infection) and diabetes. The quarterly Minimum Data Set, dated [DATE] documented Resident #14's cognition was severely impaired, and they required a two person assist for bed mobility, transfers, toilet use, and bathing. Resident #14 had a Stage 4 pressure ulcer that was present on admission or reentry.
During an observation on 12/15/23 at 12:06 PM, the Licensed Practical Nurse #2 changed the dressing using Collagenase (used to break down dead tissue and promotes growth of healthy tissue) gauze, packing, and covered with dry gauze and Allevyn. The wound was deep with undermining noted and the outer edges were white.
Review of the Wound Assessment Progress Report dated:
-11/28/23 documented a Stage 4 pressure ulcer on the sacrum measured 2.0 centimeters (cm) x 2.5 cm x 1.5 cm (length x width x depth) and undermining little smaller and 2.5 cm of tunneling.
-12/6/23 documented a Stage 4 pressure ulcer on the sacrum measured 2.8 centimeters (cm) x 2.0 cm x 1.5 cm (length x width x depth) and had 1.7 cm of undermining and 3.5 cm of tunneling.
Further review of Resident #14's medical record and the Wound Assessment Progress Report on 12/20/23 at 12:21 PM revealed no assessment of the wound after 12/6/23.
When interviewed on 12/19/23 at 10:35 AM, the Director of Nursing stated that wound rounds were done weekly on Tuesdays by Physician #1 along with the wound care team.
When interviewed on 12/19/23 at 11:05 AM, Physician #1 stated that the registered nurses should be assessing the wounds daily and reporting any changes to the physicians.
When interviewed on 12/19/23 at 12:31 PM, the Assistant Director of Nursing stated that wound measurements were done on wound rounds by Physician #1 or the Medical Director, and that registered nurses could measure/assess wounds.
10 NYCRR 415.12(e)(1)
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
Minor procedural issue · This affected multiple residents
Based on record review and interview conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure the required quarterly Minimum Data Set ( a resident as...
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Based on record review and interview conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure the required quarterly Minimum Data Set ( a resident assessment and screening tool) was conducted within the regulatory time frame as per the Centers for Medicare and Medicaid Services resident assessment instrument process. Specifically, the Minimum Data Set records for Residents #27 and #38 revealed that the quarterly Minimum Data Sets were not completed within the assessment reference date plus 14 days.
The findings are:
Resident # 27's quarterly Minimum Data Set was completed with an assessment reference date of 11/02/2023. Per the validation report Resident #27's quarterly Minimum Data Set was completed late with a Minimum Data Set completion date of 12/14/23, more than 14 days after the assessment reference date.
Resident # 38's quarterly Minimum Data Set was completed with an assessment reference date of 11/07/2023. Per the validation report Resident #38's quarterly Minimum Data Set was completed late with a Minimum Data Set completion date more than 14 days after the assessment reference date.
During an interview on 12/19/2023 at 10:23 AM, the Minimum Data Set Consultant stated they were not aware of the late assessments. After reviewing the validation report they stated the Minimum Data Set for Resident # 27 and #38 were completed late and they were unsure why this had occurred.
10 NYCRR 415.11(a)(4)
Oct 2019
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
Resident #243 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Overactive Bladder...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
Resident #243 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Overactive Bladder. She was discharged to an assisted living facility (ALF) on 08/20/19.
The resident's Minimum Data Set (MDS; an assessment tool) dated 08/29/19 documented that Resident #243 had moderately impaired cognitive skills, required extensive to total assistance with activities of daily living and had an indwelling catheter.
Review of the resident's record showed that the catheter was removed on the day of admission [DATE]) and reinserted when she was unable to urinate on 7/25/19. Resident #243's Nursing Progress Notes and Medication Administration Records (MARs) dated 07/25/19 through 08/20/19 documented the presence of the catheter.
Review of the resident's record revealed that there were no care plans related to risk for urine retention, the presence of a catheter or goals to improve urinary continence before discharge. This was confirmed by the Director of Nurses (DON) in an interview on 10/23/19 at 04:00 PM.
415.11(c)(3)(ii)
Based on observations, interviews and record review during a recertification and abbreviated survey (Complaint #NY00244321), the facility failed to develop plans of care with measurable goals, time frames and interventions to address the residents assessed needs for one of two residents reviewed for respiratory therapy (Resident #102) and one of two residents reviewed with a urinary drainage bag (catheter, Resident #243). Specifically, Resident #102's plan of care failed to address strict aspiration precautions for a resident with a tracheostomy tube in place. Resident #243's Comprehensive Care Plan did not provide measurable goals and interventions to address her diagnosis of overactive bladder leading to the need for a urinary catheter.
The findings are:
1.
Resident #102 was admitted on [DATE] with diagnoses including Quadriplegia, Tracheotomy Dependence, Hypertension, Spasmodic Upper Extremity Weakness and Poor Dexterity in both Hands. The quarterly Minimum Data Set (MDS; an assessment tool) dated 9/23/2019 showed that the resident had no cognitive impairments and was dependent on staff for all cares. However, the resident can feed himself with tray set up. Physician orders from 10/1/2019 states strict aspiration precautions, and a honey-thickened liquids with regular solids diet.
On 10/23/2019 08:45am the resident was observed with a breakfast tray on bedside table while sleeping. At 10:15 am he was observed eating the last of scrambled eggs. The head of bed was set in a low position.
The resident was interviewed on 10/24/19 at 11:58am and was able to make his needs known; communicating by covering his tracheotomy with the back of his hand to occlude his airway making it possible for air to then pass over his vocal cords to produce sound. During interview, he stated that he raises the bed on his own using the remote control. He went on to state that he cannot tolerate sitting high up in bed, so he lowers the head of the bed to almost flat as soon as his meal is finished. He stated that staff do not accompany him when he eats. He explained that has been directed to eat small bites at a time but went on to say that he prefers to eat larger amounts of food at a time instead.
LPN #1, CNA #1 and the Unit Manager were interviewed on 10/23/2019 and explained that Resident #102 eats independently without supervision from facility staff. They also explained that Resident #102 prefers the head of his bed to be flat and will adjust it independently to a position of preference. The facility staff do not intervene and adjust the head of the bed to an upright position despite his need for aspiration precautions.
Resident #102's record was reviewed for a Nursing Care Plan that addresses potential choking hazards in accordance with aspiration precautions but was not present in the record. Interview with LPN #1 and the Unit Manager on 10/23/19 confirmed that no Nursing Care Plan was developed to address Resident #102's aspiration risk.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during recertification and abbreviated surveys (Complaint #N00244321), it cannot be ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during recertification and abbreviated surveys (Complaint #N00244321), it cannot be ensured that the facility completed a discharge summary that included a course of treatment, resident status and post-discharge plans for 1 of 4 residents reviewed for Admission, Transfer and Discharge (Resident #243). Specifically, Resident #243's discharge summary furnished to the receiving Assisted Living Facility (ALF) did not summarize the course of treatment for urinary continence, did not provide a final summary of urinary status and did not provide a post-discharge plan for urinary continence.
The findings are:
Resident #243 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Overactive Bladder. She was discharged to an Assisted Living Facility (ALF) on 08/20/19.
The resident's Minimum Data Set (MDS; an assessment tool) dated 08/29/19 documented that Resident #243 required extensive to total assistance with activities of daily living, had moderately impaired cognitive skills and had an indwelling catheter.
Review of the resident's record showed that the catheter was removed on the day of admission [DATE]) and reinserted when she was unable to urinate on 7/25/19. Resident #243's Nursing Progress Notes and Medication Administration Records (MARs) dated 07/25/19 through 08/20/19 documented the presence of the catheter.
Resident #243's Discharge Summary form dated 08/20/19 provided an area to document her elimination pattern. There was no recorded information about the resident's history of urinary retention or that she had a catheter that was discontinued just before discharge. There were no post-discharge instructions regarding monitoring the resident for urinary output. Furthermore, there was no documentation in the resident's record that the discharging nurse passed the resident's prior or current urinary status to the ALF.
In a telephone interview on 10/23/19 at 11:50 AM the Director of Nurses (DON) at the receiving ALF stated the facility did not send documentation to let them know that the resident experienced urinary retention, had a catheter that was removed just prior to discharge and that she was discharged prior to demonstrating the ability urinate.
415.11(d)(1)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recerfication survey, it could not be ensured that facility residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recerfication survey, it could not be ensured that facility residents (Residents #51 and # 85) who are unable to carry out activities of daily living (ADL's) receive the necessary services to maintain personal hygiene and bathing.
The findings are:
1.
The Minimum Data Set (MDS; an assessment tool) dated 2/6/19 was reviewed and revealed that Resident #85 had diagnoses including Diabetes Mellitus (DM) and Depression. Resident #85 also required physical support of one person to assist with bathing. Furthermore, Resident #85's Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment.
A review of the Comprehensive Care Plan for Activities of Daily Living/ Functional Rehab for resident #85 dated 8/31/19 documented that Resident #85 required extensive assistance with the support of one person assist to include personal hygiene and bathing.
A review of the CNA (Certified Nursing Assistant) Accountability Sheets for Resident #85 for the months of September and October 2019 revealed that the resident #85 received 1 documented shower for September and 3 documented showers for October 2019.
2.
Resident #51 had diagnoses including CVA (Cerebral Vascular Accident), Paraplegia and DM. The MDS dated [DATE] revealed that the resident required physical assistance with the support of a one person assist. Furthermore, Resident #51's Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment.
A review of the CNA (Certified Nursing Assistant) Accountability Sheets for Resident #51 for September and October 2019 revealed that the resident #51 received 0 documented showers for September and 3 documented showers for October 2019.
During the resident council meeting on 10/21/19 at 11AM, 2 of the 7 residents #51 and #85 confirmed that they were not provided with weekly showers.
415.12(a)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review on a recent recertification survey, the facility did not ensure proper care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review on a recent recertification survey, the facility did not ensure proper care and treatment of a resident receiving oxygen therapy.
Specifically, a resident with a tracheostomy received 4 liters of humified oxygen via tracheostomy collar without a physician order for twelve weeks. Additionally, there was no documentation of pulse oximetry measurements and a self-inflating bag resuscitator was not provided in the resident room.
The findings are:
Review of Resident #102's record showed that #102 was admitted to the facility on [DATE] with diagnoses including Spinal Cord Injury, Quadriplegia, Tracheostomy Dependence and Hypertension. Physician orders dated 10/01/2019 indicated that Resident #102 was on strict aspiration precautions with a regular consistency solid diet, no hard items to chew, no beef with honey-thickened liquids. The MDS quarterly assessment done on 9/23/2019 indicates the resident is cognitively intact. Resident #102 has spontaneous respirations and breathes through a well healed tracheostomy.
1.
On 10/21/2019, Resident #102 was observed in bed with a tracheostomy collar delivering 4 liters of humidified oxygen. Review of the physician's orders dated 10/01/2019 failed to include oxygen therapy. The most recent physician's order that contained oxygen therapy via tracheostomy collar was dated 6/28/2019.
2.
During interview on 10/21/19, LPN #1 was asked how often pulse oximetry readings were performed for Resident #102 and she stated that they were done occasionally but not on a schedule. Review of Resident #102's record showed that there was no documentation of pulse oximetry readings in progress notes, vital sign records or medication records. The Nurse Educator was interviewed on 10/24/2019 and stated that the facility standard of care is that pulse oximetry should be completed every shift and documented on the MAR. She confirmed that this had not been done but should have been.
3.
On 10/24/2019, respiratory equipment in resident #102's room was checked in the presence of LPN #1 and found to be lacking a self-inflating bag resuscitator (a hand-held device that provides positive pressure ventilation to residents who are not breathing). The Nurse Educator was interviewed on 10/24/2019 and confirmed that a self-inflating bag resuscitator was essential and needed for a resident with a tracheostomy. During interview with LPN #1, she explained that she did not know it was needed.
Of note, on 10/21/2019 LPN #1 was interviewed about the lack of and need for an oxygen order for Resident #102. In the presence of the surveyor and without contacting the physician, LPN #1 then turned to the physician order page and wrote v/o, 4 liters O2 indicating a verbal order from the physician. Follow-up interview with LPN #1 confirmed that she had not communicated with the physician to obtain the verbal order. The incident was reviewed with the Unit Manager who confirmed this was not in adherence with facility policy and procedure.
415.12(k)(5)(4)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the most recent re-certification survey, it could not be ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the most recent re-certification survey, it could not be ensured that the facility provided services consistent with standards of practice and in accordance with the written plan of care for 1 of 2 residents (Resident #193) reviewed for dialysis. Specifically, the resident's pre and post dialysis weights were not consistently obtained from the dialysis center in accordance with the resident's plan of care.
The findings are:
Resident #193 was admitted to the facility on [DATE] with the diagnosis of End Stage Renal Disease that required hemodialysis three times weekly.
The resident's Plan of Care for dialysis dated 10/9/19 noted that the goals for the resident included no volume deficit/overload and the interventions to achieve this goal included pre and post dialysis weights and a dialysis diet. The current physician's orders included a renal diet with a 1000cc daily fluid restriction.
A review of the Dialysis Communication Book revealed that the pre and post dialysis weights were to be included. There was no documentation for the month of October 2019 reflecting pre dialysis weights for 10/18, 21, and 23 and post dialysis weights for 10/11, 14, 16, 18 and 21.
The Registered Dietitian at the hemodialysis Center (RD #2) stated via telephone on 10/24/19 at 11:05 AM that the resident's pre dialysis weights should be done by the nursing home and that the post dialysis weights should be recorded by the dialysis center. This was confirmed by the Unit Manger on 10/24/19 following the interview with the renal dietitian.
415.12(k)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the most recent re-certification survey, the facility did not ensure that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 4 residents (Resident #125) reviewed for dementia care was provided appropriate care to maintain the highest psychosocial well-being and to avoid the use of antipsychotic medication for behavior management. Specifically, there was no documented evidence that 1) underlying causes for behavioral symptoms were determined during the onset of these behaviors; and 2) person-centered behavioral interventions were attempted prior to initiating the use of Haldol, an antipsychotic medication.
The findings are:
Resident #125, a 77- year-old male with diagnoses including Dementia, was admitted to the facility on [DATE].
The comprehensive care plan revealed that on 6/12/19 goals and intervention were developed to address the resident's cognitive status related to Dementia. The plan noted that the goal was to maintain/minimize decline in cognitive capacity. The interventions to achieve this goal included explaining all procedures prior to cares, help to locate room, and encourage participation in cares and socialization with other residents. A Mood care plan dated 6/12/19 noted that the resident's primary language was Spanish and that he did understand some English.
Four days after the Dementia related care plan was developed, nursing notes showed the following behavioral symptoms and the implementation of the use of Haldol:
6/16/19 at 11:37 PM - Attempted to come out of chair and bed. Wants to go home. Gets agitated and MD aware. Haldol (an antipsychotic medication) 2 mg given.
6/17/19 at 11:01 PM - Coming out of chair. Don't want to stay in bed. Wants to go home. Sitting in nurse's station. Gets agitated. Haldol 2 mg given as per order with some effect.
6/17/19 at 7:42 PM - At 11:00 PM rounds resident in front of station. In a wheelchair and awake until 1:30 AM. Still trying to get out of wheelchair; calm down at 2:00 AM and slept until 5:00 AM. Started on Haldol 2 mg twice daily for 2 days.
6/18/19 - Attempted to come out of bed and chair and wants to go home. Wants to walk around. Gets agitated. MD made aware; order Haldol 1 mg and one dose given.
The Medication Administration Record showed that for the month of June 2019 Haldol was administered one time on 6/16, two times on 6/17 and two times on 6/18.
The initial Minimum Data Set, dated [DATE] noted that the resident had had no behavioral problems, which was not consistent with the nurse's notes mentioned above. This assessment also noted that the resident had severe cognitive impairment, was non-ambulatory, and had limitations in his receptive and expressive communication abilities. He was able to understand simple directives and only able to respond to simple, direct communication.
The Dementia care plan referenced above was not revised to address the onset of the resident's behavior. Also, the documentation on the resident's behavior did not give any details on the intensity of the resident's agitated behaviors. It was not until 8/18/19, 2 months after the onset of behavioral symptoms, that a Behavior care plan was developed to address the resident's aggressive behavior.
Additionally, there was no documented evidence that attempts were made to determine the underlying cause(s) for the resident's behaviors noted above and that non-pharmacological/behavioral interventions were implemented and determined to be ineffective before the administration of Haldol. There was no documented evidence that attempts were made to involve the family in the care of the resident (to include obtaining historical information on what triggered the resident's behavior and what he responded to best) while the resident was adjusting to the facility.
415.12
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 18% annual turnover. Excellent stability, 30 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • 24 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $15,935 in fines. Above average for New York. Some compliance problems on record.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Schaffer Extended's CMS Rating?
CMS assigns SCHAFFER EXTENDED CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Schaffer Extended Staffed?
CMS rates SCHAFFER EXTENDED CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 18%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Schaffer Extended?
State health inspectors documented 24 deficiencies at SCHAFFER EXTENDED CARE CENTER during 2019 to 2025. These included: 1 that caused actual resident harm, 22 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Schaffer Extended?
SCHAFFER EXTENDED CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 150 certified beds and approximately 133 residents (about 89% occupancy), it is a mid-sized facility located in NEW ROCHELLE, New York.
How Does Schaffer Extended Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, SCHAFFER EXTENDED CARE CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (18%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Schaffer Extended?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Schaffer Extended Safe?
Based on CMS inspection data, SCHAFFER EXTENDED CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Schaffer Extended Stick Around?
Staff at SCHAFFER EXTENDED CARE CENTER tend to stick around. With a turnover rate of 18%, the facility is 28 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 18%, meaning experienced RNs are available to handle complex medical needs.
Was Schaffer Extended Ever Fined?
SCHAFFER EXTENDED CARE CENTER has been fined $15,935 across 1 penalty action. This is below the New York average of $33,238. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Schaffer Extended on Any Federal Watch List?
SCHAFFER EXTENDED CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.