Deficiencies (last 4 years)
Deficiencies (over 4 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
239% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Census: 170
Capacity: 190
Deficiencies: 2
Date: Apr 3, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements including resident care and staffing levels.
Findings
The facility was found deficient in ensuring residents were free from neglect, specifically failing to provide timely toileting care to four residents on the evening and night shift of 10/27/2024. Additionally, the facility did not maintain sufficient nursing staff from 1/19/2025 through 3/22/2025, resulting in delayed care and unmet resident needs.
Deficiencies (2)
Failure to ensure residents were free from neglect, with four residents not provided toileting care on evening and night shift of 10/27/2024, resulting in residents left in soiled clothes and bedding.
Failure to provide enough nursing staff every day to meet the needs of every resident, with staffing below minimum levels on multiple occasions from 3/25/2025 through 4/02/2025, causing delayed response to call bells and long wait times for care.
Report Facts
Residents present: 170
Total licensed capacity: 190
Staffing levels: 2.5
Staffing levels: 1.5
Residents affected by neglect: 4
Residents in group meeting: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shahbaz #11 | Certified Nurse Aide | Admitted to not changing Residents #16, 25, and 99 during overnight shift; terminated for neglect |
| Shahbaz #12 | Certified Nurse Aide | Admitted to putting extra incontinence pads on Resident #25 against care plan; terminated for neglect |
| Director of Nursing #1 | Director of Nursing | Confirmed staffing requirements and termination of Shahbaz #11 and #12; stated not involved in investigation |
| Scheduler #1 | Scheduler | Provided details on staffing schedules and challenges filling shifts |
| Nurse Educator #1 | Nurse Educator | Agreed with staffing issues and noted discrepancy in facility assessment staffing numbers |
| Administrator #2 | Administrator | Updated facility assessment on 7/31/2024 |
Inspection Report
Annual Inspection
Census: 170
Capacity: 190
Deficiencies: 14
Date: Apr 3, 2025
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Eddy Village Green nursing home.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, medication administration, grievance resolution, bed hold notification, PASARR assessments, activity programming, accident hazard prevention, respiratory care, staffing levels, medication labeling and storage, food safety, and medical record documentation.
Deficiencies (14)
Residents were not always treated with dignity and respect, including medication administration in common areas without permission and improper feeding practices.
Residents were allowed to self-administer medications without proper assessment or physician orders.
Facility did not promptly resolve a grievance regarding missing hearing aids and failed to keep the resident appropriately informed.
Resident was not given written notice of bed hold policy within 24 hours of hospital transfer.
Assessments were not coordinated with PASARR program for residents with mental illness or intellectual disability.
Facility did not ensure ongoing provision of activities to meet residents' physical, mental, and psychosocial needs.
Resident environment was not free from accident hazards; electronic monitoring device alarm was not functioning properly; alcoholic beverages were accessible and not tracked.
Residents needing respiratory care did not consistently receive oxygen as ordered.
Facility did not provide sufficient nursing staff to meet residents' needs; staffing was below minimum levels on multiple occasions.
Nurse staffing information was not posted in areas accessible to all residents and visitors.
Drugs and biologicals were not labeled or stored according to professional standards; medication rooms were left open and unlicensed staff had access.
Food was not stored in accordance with professional standards; bulk food items were unlabeled, appliances were dirty, and chicken was improperly thawed.
Medical records were not maintained in accordance with accepted professional standards; alcoholic beverage administration was not documented.
Psychotropic medication orders as needed did not include end dates as required.
Report Facts
Residents present: 170
Total licensed capacity: 190
Staffing levels: 2.5
Medication cart count: 8
Medication room count: 8
Resident records reviewed: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shahbaz | Certified Nurse Aide | Mentioned in relation to feeding practices, medication room access, and electronic monitoring device |
| Licensed Practical Nurse #4 | Mentioned in relation to medication administration and feeding practices | |
| Director of Nursing #1 | Director of Nursing | Provided statements regarding feeding practices, grievance follow-up, electronic monitoring device, oxygen administration, medication room access, and staffing |
| Registered Nurse #4 | Registered Nurse | Provided statements regarding feeding practices, grievance follow-up, electronic monitoring device, oxygen administration |
| Licensed Practical Nurse #5 | Mentioned in relation to medication self-administration and knowledge of missing hearing aids | |
| Social Worker #2 | Social Worker | Responsible for grievance follow-up |
| Administrator #1 | Administrator | Provided statements regarding grievance follow-up, bed hold policy, medication room access, staffing, and activities |
| Recreational Therapy Manager #1 | Recreational Therapy Manager | Provided statements regarding activities programming |
| Medical Director #1 | Medical Director | Provided statements regarding psychotropic medication orders |
| Director of Maintenance #1 | Director of Maintenance | Checked and replaced electronic monitoring device battery |
| Scheduler #1 | Scheduler | Provided statements regarding staffing schedules |
| Nurse Educator #1 | Nurse Educator | Provided statements regarding staffing and scheduling |
| Registered Nurse #1 | Registered Nurse | Provided statements regarding food safety and alcoholic beverage administration |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 26
Date: Apr 3, 2025
Visit Reason
Multiple standard health and life safety code citations issued, mostly level 2 severity, covering quality of care and safety issues, all corrected by May 15, 2025.
Findings
Multiple standard health and life safety code citations issued, mostly level 2 severity, covering quality of care and safety issues, all corrected by May 15, 2025.
Deficiencies (26)
Activities meet interest/needs each resident
Coordination of pasarr and assessments
Definitions
Food procurement,store/prepare/serve-sanitary
Free from abuse and neglect
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Grievances
Label/store drugs and biologicals
Notice of bed hold policy before/upon trnsfr
Posted nurse staffing information
Resident records - identifiable information
Resident rights/exercise of rights
Resident self-admin meds-clinically approp
Respiratory/tracheostomy care and suctioning
Responsibilities of providers; required notif
Sufficient nursing staff
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Ep training program
Fire alarm system - testing and maintenance
Illumination of means of egress
Means of egress - general
Names and contact information
Plan based on all hazards risk assessment
Sprinkler system - maintenance and testing
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The abbreviated survey was conducted to review the facility's compliance with safety regulations following an incident where a resident sustained a second degree burn from contact with a heating unit.
Findings
The facility failed to ensure the resident's bed was positioned away from a heating unit, resulting in a second degree burn to the resident's arm. Corrective actions included medical treatment, staff education, bed repositioning, and inspection and repair of heating units. At the time of the survey, the facility was found to be in substantial compliance with the safety requirement.
Deficiencies (1)
Facility did not ensure the resident's bed was positioned away from the heating unit resulting in a second degree burn to the resident's arm.
Report Facts
Residents Affected: 1
Heating unit temperature: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Documented finding of resident lying with arm on heater | |
| Certified Nurse Aide #2 | Reported resident moves in bed and was told to keep beds away from heaters | |
| Certified Nurse Aide #3 | Aware of incident and instructed to keep beds away from heaters | |
| Senior Maintenance Manager #1 | Reported heating company found faulty valve in resident's heater and others; valves replaced | |
| Maintenance Manager #1 | Checked heating unit temperatures and reported all at or below 160 degrees |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
One level 2 standard health citation for accident hazards, corrected by March 6, 2025.
Findings
One level 2 standard health citation for accident hazards, corrected by March 6, 2025.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Feb 24, 2025
Visit Reason
The facility was surveyed due to allegations of abuse and neglect involving multiple residents, including physical abuse, neglect, and verbal abuse, which resulted in immediate jeopardy to resident health and safety.
Findings
The facility failed to protect residents from abuse and neglect, including physical abuse resulting in injury, neglect leading to falls and injuries, and verbal abuse. Investigations and reporting of these incidents were delayed or incomplete, and corrective actions were insufficient for involved staff. Immediate jeopardy was identified and later lifted.
Deficiencies (3)
Failure to protect residents from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect.
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to respond appropriately to all alleged violations and thoroughly investigate allegations of abuse.
Report Facts
Residents affected: 4
Residents in facility: 177
Time resident left unattended: 80
Date of survey completion: Feb 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shahbaz #1 | Certified Nurse Aide | Pushed Resident #1 to the floor causing a broken hip; terminated after investigation. |
| Shahbaz #5 | Certified Nurse Aide | Left Resident #2 unattended leading to fall and injury; verbally abused Resident #3; terminated. |
| Shahbaz #6 | Certified Nurse Aide | Pushed Resident #4 down on bed and left without assistance; terminated. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Involved in transferring Resident #1 off the floor without proper assessment; did not assess resident. |
| Registered Nurse #1 | Registered Nurse | Called to respond to Resident #1 fall; did not perform assessment prior to transfer; documented inaccurately. |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Delayed investigation and reporting of abuse incidents; reviewed video after delay; reported abuse to state. |
| Guide #1 | Guide (Supervisor of Shahbaz) | Involved in reviewing video and interviewing staff; informed of terminations; did not intervene timely. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported abuse allegations to Guide; not interviewed by administration regarding allegations. |
| Director of Nursing #1 | Director of Nursing | Acknowledged delays in reporting and investigation; documented requests for termination of Shahbaz #5. |
| Administrator #1 | Administrator | Notified late of abuse incidents; not informed timely by Assistant Director of Nursing. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Feb 24, 2025
Visit Reason
Multiple citations including immediate jeopardy level 4 deficiencies for abuse and neglect and investigation, plus a level 2 citation for reporting violations, all corrected by April 8, 2025.
Findings
Multiple citations including immediate jeopardy level 4 deficiencies for abuse and neglect and investigation, plus a level 2 citation for reporting violations, all corrected by April 8, 2025.
Deficiencies (3)
Free from abuse and neglect
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Oct 17, 2023
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
The inspection was conducted as an abbreviated survey focusing on allegations of abuse and neglect involving five residents, specifically investigating incidents related to Resident #1 and Resident #2.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse and neglect involving Residents #1 and #2. The investigation found substantiated abuse of Resident #2 by CNA #8 and failure to timely report abuse allegations to the state authorities.
Findings
The facility failed to protect Resident #2 from physical abuse by a Certified Nurse Aide (CNA #8) who dragged the resident backward on the floor into their room without following the facility's Fall Standard of Care. Additionally, the facility did not timely report suspected abuse and neglect to the New York State Department of Health within the required 2-hour timeframe for Residents #1 and #2.
Deficiencies (2)
Failure to protect Resident #2 from physical abuse by CNA #8 who dragged the resident backward on the floor into their room without proper assessment or reporting.
Failure to timely report suspected abuse and neglect to the New York State Department of Health within 2 hours for Residents #1 and #2.
Report Facts
Residents reviewed for abuse: 5
Residents affected: 2
Date of incident: Apr 2, 2022
Date survey completed: Jun 22, 2023
Bruise size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #8 | Certified Nurse Aide | Named in the abuse finding for dragging Resident #2 backward on the floor |
| LPN #1 | Licensed Practical Nurse | Reported bruise on Resident #2 and involved in assessment and reporting |
| RNM #1 | Registered Nurse Manager | Interviewed regarding the abuse incident and reporting requirements |
| DON | Director of Nursing | Reviewed video evidence and stated reporting requirements |
| ADON | Assistant Director of Nursing | Notified of bruise and involved in investigation |
| CNA #11 | Certified Nurse Aide | Observed injuries on Resident #2 and called LPN #1 |
| RNS #3 | Registered Nurse Supervisor | Assessed Resident #2 after injury report |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 22, 2023
Visit Reason
Two level 2 standard health citations for abuse and neglect and reporting violations, both isolated and corrected by July 21, 2023.
Findings
Two level 2 standard health citations for abuse and neglect and reporting violations, both isolated and corrected by July 21, 2023.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 28, 2022
Visit Reason
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 28, 2022
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with professional standards related to food service safety and medical record documentation.
Findings
The facility was found deficient in food service safety, including improper operation of dishwashing machines, incorrect chemical sanitizer concentrations, and unclean kitchen areas. Additionally, medical records were incomplete and medication administration records did not accurately document medication administration for several residents.
Deficiencies (2)
Automatic dishwashing machines in 6 of 13 Houses were not operating within manufacturer's specifications; chemical sanitizing rinse concentration was incorrect in 1 House; cabinetry and floors required repair and cleaning in multiple Houses.
Medical records were incomplete and did not accurately document medication administration for 5 of 28 residents reviewed.
Report Facts
Houses with dishwashing machine issues: 6
Houses inspected: 13
Residents reviewed: 28
Residents with medication record deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Dining Services | Interviewed regarding dishwashing machine repairs and cleaning protocols | |
| Manager of Plant Operations | Interviewed regarding dishwashing machine repairs and cleaning protocols | |
| Administrator | Interviewed regarding addressing kitchen deficiencies | |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration and documentation practices |
| RNM #3 | Registered Nurse Manager | Interviewed regarding medication pass protocol and documentation |
| Director of Nursing (DON) | Interviewed regarding medication administration policies and review processes | |
| Assistant Director of Nursing (ADON) | Mentioned as involved in reviewing medication administration records |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 5
Date: Apr 28, 2022
Visit Reason
Multiple level 2 standard health and life safety code citations including food sanitation, resident records, cooking facilities, electrical systems, and hazardous areas, all corrected by June 2022.
Findings
Multiple level 2 standard health and life safety code citations including food sanitation, resident records, cooking facilities, electrical systems, and hazardous areas, all corrected by June 2022.
Deficiencies (5)
Food procurement,store/prepare/serve-sanitary
Resident records - identifiable information
Cooking facilities
Electrical systems - essential electric syste
Hazardous areas - enclosure
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 2, 2022
Visit Reason
One level 3 standard health citation for developing and implementing comprehensive care plan, corrected by March 4, 2022.
Findings
One level 3 standard health citation for developing and implementing comprehensive care plan, corrected by March 4, 2022.
Deficiencies (1)
Develop/implement comprehensive care plan
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 9, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Eddy Village Green nursing home.
Findings
The facility was found deficient in multiple areas including incomplete comprehensive care plans for residents, unsecured wardrobes posing accident hazards, improper use and documentation of psychotropic medications, lack of policy for food brought by visitors, incomplete and inaccurate medical record documentation, and missing physician orders for indwelling catheters.
Deficiencies (5)
Incomplete comprehensive care plans for 6 residents, lacking measurable objectives and time frames to meet medical, nursing, and psychosocial needs.
Wardrobes in resident rooms were unsecured and toppled over when tested, posing accident hazards.
PRN orders for psychotropic medication (Ativan) were not limited to 14 days without documented rationale from the physician.
Facility lacked a policy regarding use and storage of foods brought to residents by visitors, specifically lacking process for assisting residents unable to access or consume food on their own.
Medical records for 5 residents were incomplete, inaccurately documented, and not systematically organized, including backdated activity participation records and missing physician orders for indwelling catheters.
Report Facts
Residents reviewed for comprehensive care plans: 35
Residents with deficient comprehensive care plans: 6
Residents reviewed for unnecessary medications: 5
Residents affected by medical record deficiencies: 5
Days resident declined ace wrap: 6
Days resident declined ace wrap: 5
PRN Ativan order duration: 70
Activity documentation entries with time 14:59: 11
Activity documentation entries with time 14:59: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Stated care plan should document resident refusal of treatment and PRN Ativan order rationale | |
| Registered Nurse #2 | Stated care plan should document resident refusal of treatment and at risk for victimization care plan | |
| Director of Nursing | Stated care plans should include refusal of treatment, at risk for victimization, wound healing goals, and PRN medication tracking improvements | |
| Facilities Manager | Acknowledged unsecured wardrobes could cause accidents and planned to secure them | |
| Nurse Practitioner | Acknowledged regulation on PRN psychotropic medications and described provider practices | |
| Activities Aide #3 | Explained backdating of activity documentation for residents | |
| Activity Director | Discussed activity documentation practices and backdating | |
| Registered Nurse #1 | Acknowledged missing physician order for indwelling catheter and size |
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