| General |
| City |
| Briarcliff Manor |
Williamsville |
| State attribute explanation |
| Ny |
Ny |
| Street |
| 620 Sleepy Hollow Road |
147 Reist Street |
| Zip Code |
| 10,510 |
14,221 |
| Phone |
| 9,149,415,100 |
7,166,335,400 |
|
Overall Star Rating |
| 1 |
2 |
|
Health Inspections Star Rating |
| 2 |
1 |
|
Nurse Staffing Star Rating |
| 1 |
4 |
|
Quality Measures Star Rating |
| 3 |
3 |
|
RN Only Star Rating |
| 1 |
4 |
|
Number of Certified Beds |
| 131 |
142 |
|
Total Number of Residents |
| 110 |
117 |
|
Percent of Occupied Beds |
| 84 % |
82 % |
| Health Survey Date |
| 4/6/2012 |
3/9/2012 |
| Fire Survey Date |
| 4/6/2012 |
3/9/2012 |
| Sprinkler Status |
| Fully Sprinklered |
Partially Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| Non Profit - Corporation |
Non Profit - Church Related |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Resident |
Both |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
Yes |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 2 |
75.2 |
| Total Enforcement Actions Count |
| 2 |
75.2 |
| # of deficiencies |
| 3 |
10 |
|
| Staff Information |
| Number of Residents |
| 110 |
117 |
| Number of RN Hours Per Resident Per Day |
| 0.32 |
0.88 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.93 |
1.2 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.25 |
2.08 |
| Number of CNA Hours Per Resident Per Day |
| 0.05 |
0.15 |
| Number Therapy Hours Per Resident Per Day |
| 0.05 |
0.15 |
| Environmental Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 4deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 09/02/2009date Of Correction: 09/30/2009 |
|
| Mistreatment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.survey Date: 05/05/2010date Of Correction: 06/10/2010 |
|
| Resident Rights Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.survey Date: 03/09/2012date Of Correction: 05/01/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.survey Date: 10/28/2010date Of Correction: 12/01/2010 |
| Quality Care Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That Each Resident Gets A Nutritional And Well Balanced Diet, Unless It Is Not Possible To Do So.survey Date: 03/09/2012date Of Correction: 05/01/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 01/24/2011date Of Correction: Not Available |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 10/28/2010date Of Correction: 12/01/2010 |
| Deficiency #4 |
|
Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 05/13/2010date Of Correction: 07/05/2010 |
| Deficiency #5 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 05/13/2010date Of Correction: 07/05/2010 |
| Deficiency #6 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 03/30/2010date Of Correction: Not Available |
| Resident Assessment Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.survey Date: 03/09/2012date Of Correction: 05/01/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That Doctors See A Resident's Plan Of Care At Every Visit And Make Notes About Progress And Orders In Writing.survey Date: 03/30/2010date Of Correction: Not Available |
| Administration Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 4deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 09/02/2009date Of Correction: 09/30/2009 |
|
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 37.6 % |
8.2 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 6.8 % |
2.6 / 3 |
| Percent of long-stay residents who self-report moderate to severe pain |
| 4.4 % |
9.5 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 12.1:1 |
15.1 % |
| Percent of long-stay residents who lose too much weight |
| 8.5 % |
6.9 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 28.3 % |
68.4 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 2 % |
3.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 11.3 % |
9.8 % |
| Percent of long-stay residents who have depressive symptoms |
| 0.9 % |
10.9 % |
| Percent of long-stay residents who were physically restrained |
| 13.8 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 8.3 % |
21.1 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 87.5 % |
87.4 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 67.9 % |
88.5 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 |
75.2 |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 0.9 % |
2 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 33.3 % |
8 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 3 % |
3.3 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 5.5 % |
9.1 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 11.2-20 |
16.3:1 |
| Percent of long-stay residents who lose too much weight |
| 7.1 % |
11 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 28 % |
67 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 1.6 % |
2.7 % |
| Percent of long-stay residents with a urinary tract infection |
| 9.5 % |
7.2 % |
| Percent of long-stay residents who have depressive symptoms |
| 0.6 % |
13.3 % |
| Percent of long-stay residents who were physically restrained |
| 9.3 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 1.8 % |
2.7 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 14.5 % |
22.2:1 |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 66.7 % |
83.9 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 52 % |
85.8 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 12.7 % |
23.1 % |