About Nursing Home Inspections

Inspections

The New York State Department of Health, Division of Quality and Surveillance for Nursing Homes and ICFs/MR, licenses nursing homes and conducts investigations (also known as surveys) of the quality of care and life for the approximately 117,000 people residing in nursing homes in the State. Nursing home residents include the frail elderly with chronic disabilities; infants with multiple impairments; young adults suffering from traumatic brain injury or other physical disabilities; and individuals with short-term rehabilitation or subacute treatment needs.

The Department conducts investigations every 9 to 15 months at each nursing home for purposes of certification, as well as follow-up visits to ensure that any previously cited deficiencies have been corrected. Investigations are also conducted as a result of complaints and incident reports received by the Department.

Survey teams conduct unannounced investigations on weekdays, nights, weekend, and holidays. The survey teams comprise trained health care professionals in nursing, nutrition, social work, pharmacy and sanitation. A report is sent to the facility after each investigation. Survey results include Standard Health Inspection and Life Safety Code Inspection (see below).

Standard Health Inspections

During a Standard Health Inspection the survey team will review the quality of the care provided by the facility. The survey team will observe resident care, staff/resident interaction, and environment; they also review medical records and other documentation during the survey process. Using established protocols, the team interviews a sample of residents and family members about their life within the nursing home, and interviews caregivers and administrative staff. Trained inspectors will determine whether the wide range of regulatory standards is met.

Life Safety Code Inspections

During a Life Safety Code (LSC) Inspection the inspection team will review whether the life safety code requirements as established by the National Fire Protection Agency (NFPA) are met. The LSC inspection covers a wide range of aspects of fire protection, including construction, protection and operational features designed to provide safety from fire, smoke, and panic.

When regulatory requirements have not been met, the nursing facility must submit a plan of correction to the Department. The Department must find the plan acceptable before the facility is found to be back in compliance. The providers may be fined for each violation cited. Survey results must be made available to residents, families, and other interested parties.

Since actual survey results can be technically or medically complex and sometimes difficult to interpret, the Department has created Inspection Reports to present this information in a manner that is more understandable to the general public. These reports will help consumers compare, evaluate, and choose a nursing home. For each nursing home, information is presented in a Summary and Detail section. All information is updated on a monthly basis to reflect the three most recent Certification Surveys, and the last three years of Complaint Surveys.

Requesting Copies of Nursing Home Surveys

To obtain copies of the Statement of Deficiencies that is the specific citation results from survey, send an e-mail to nhinfo@health.state.ny.us, or submit a written request to the address provided below. Questions can also be submitted using either method.

To facilitate the processing of your request, please follow these guidelines:

  • Submit one request for all of the surveys needed.
  • Include your name, postal address and daytime phone number.
  • For each survey, specify the nursing home name, Permanent Facility Identifier, and survey date as they appear on the report.
New York State Department of Health
Division of Residential Services
875 Central Ave.
Albany, NY 12206

Understanding Inspection Reports

The Inspection Report provides a snapshot of the compliance status of a nursing home at a particular point in time. Its status may have improved or declined since this posting. The nursing home is required to post the results of its most recent Certification Survey in a location within the facility that is readily accessible to residents and their families. When visiting the home the actual survey results will be available for review.

Summary

This section of the Inspection Report summarizes the number of citations issued for both Certification Surveys and Complaint Surveys, and compares this information against the statewide average for the following categories:

Standard Health Deficiencies
The total number deficiencies cited on Standard Health Inspections.
Life Safety Code Deficiencies
The total number deficiencies cited on Life Safety Code Inspections.
Total Deficiencies
The total number deficiencies cited on Standard Health Inspections and Life Safety Code Inspections.
Deficiencies Related to Resident Harm or Immediate Jeopardy
The total number deficiencies cited, which were as a result of resident harm or immediate jeopardy.
% of Deficiencies Related to Resident Harm or Immediate Jeopardy
The number of deficiencies related to resident harm or immediate jeopardy, divided by the total number of deficiencies.

Detail of Certification and Complaint Survey

This section of the Inspection Report lists all citations issued in the reporting period for both Certification Surveys and Complaint Surveys. The citation details are displayed by severity, number of resident affected, and when the citation was corrected. The related Standard Health Inspection and Life Safety Code Inspection results are shown for each survey.

Date
The date displayed for each survey reflects the initial survey exit date of the survey.
Certification or Complaint Survey
Each survey will either be listed as a Certification Survey or Complaint Survey.
  • A Certification Survey is conducted onsite approximately on a yearly basis to determine whether the facility meets the Medicare and Medicaid quality and performance standards. The last three Certification Surveys will be displayed on the report, even in instances when the facility was not cited.
  • Complaint Surveys are conducted on-site, due to complaints reported to the Department, or incidents reported by the facility. Complaint Surveys focus on specifics of the complaint or incident, which may in turn result in citations issued to the facility. Only Complaint Surveys with citations will be reflected on the Inspection Report. The last three years of Complaint Surveys will be displayed on the report.
Standard Health Inspection or Standard Life Safety Code Inspection
Each survey Certification survey has a Standard Health Inspection and Standard Life Safety Code Inspection component. Any related citations are listed underneath each respective inspection type.
Citation
Citations are listed on the report as a result of the survey team finding that the facility is not in compliance with federal or state regulatory requirements.
Severity
The overall impact related to the citation, and the associated level of harm. Severity is defined by the following four dimensions:
  • Level 1 – No Actual Harm with the Potential for Minimal Harm – The deficiency has the potential for causing no more than minimal harm and will have only a minor negative impact on the residents.
  • Level 2 – No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy – The deficiency has resulted in noncompliance of the requirement and has caused the residents minimal discomfort and/or has the potential to comprise the ability of residents to reach their highest practicable level of functioning.
  • Level 3 – Actual Harm that is Not Immediate Jeopardy – The deficiency has resulted in noncompliance of the requirements and has resulted in a negative outcome that has compromised the resident's ability to each the highest practicable level of functioning.
  • Level 4 – Immediate Jeopardy to Resident Health or Safety – The deficiency has resulted in noncompliance and immediate action is necessary. An event has caused or is likely to cause serious injury, harm, impairment or death to the residents.
Residents Affected
The overall scope related to the citation, and how many residents are affected. Scope is defined by the following three dimensions:
  • Isolated – Only one or a very limited number of residents were affected and/or a very limited number of staff is involved, and/or the situation has occurred only occasionally or in a very limited number of locations. The facility has a system in place to prevent the recurrence of the deficiency.
  • Pattern – More than a limited number of residents are affected, and/or more than a very limited number of staff is involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice.
  • Widespread – Problems causing the deficiency are pervasive throughout the facility and have affected or have the potential to affect all or a large portion of the facility's residents. The facility does not have an adequate system or policies in place to prevent the deficiency from recurring.
Substandard Quality of Care
Substandard Quality of Care indicates a systemic deficiency in quality of care within a facility. Only citations related to the quality of residents' care can have this designation. A citation pertaining to skin wound care is one example. In addition, for a citation to receive this designation, the deficiency must be severe and/or impact several residents.
Correction Date
The correction date identifies when the citation has been corrected, as recognized by the Department of Health. Nursing Home Administrators are required to send in a Plan of Correction, which includes an anticipated correction date. The Department of Health verifies the date when the citation was indeed corrected by the facility. If the citation(s) is more severe, then a Post Certification Survey occurs to verify the actual date when the citation was corrected. Correction dates in some instances may not be available for more recent surveys that have not fully concluded.

A Plan of Correction is required by the Nursing Home Administrator to demonstrate how the facility will correct any deficiencies cited within the facility. Each nursing home is required to post their plan of correction, statement of deficiencies, and any enforcement actions taken against their facility in a place readily accessible to residents and designated representatives without staffing assistance.

Please note that an indicator of n/a is defined as not available. This identifies that an acceptable Plan of Correction (POC) hasn't yet been received, or alternatively, fully processed by the Department of Health. In some instances, for lower severity levels or when the citation was corrected before the investigation (Past Non-compliance), it is possible that a correction date will not be entered, and there will be an n/a indicator.

Statement of Deficiencies
Statement of Deficiencies (SOD) is a report that identifies more in-depth survey results for each survey, and is available in Portable Document Format (PDF). Any citations displayed within the Summary Report will be elaborated on within the SOD. There are some exceptions to this including Life Safety Code (LSC) citations that are waived. While waived citations are not shown on the Summary Report, they will be displayed on the SOD with a notation that the LSC citation was waived. In addition, citations that are in dispute by the provider will not be displayed within the Summary Report, since they are not finalized. Statement of Deficiencies in some instances may not yet be available in a PDF format, since the survey has not fully concluded, or may be in dispute by the provider. If an SOD is unavailable in a PDF format, then a form will be displayed that allows you to send an e-mail request for the Statement of Deficiencies to the Department of Health.

Complaints

All complaints and incident reports received about nursing homes are reviewed by the Department through the Centralized Complaint Intake Unit with appropriate action taken. The most serious complaints and incidents require Department investigators to conduct interviews, review medical records and other facility documentation, and perform other activities onsite at the nursing home.

Some complaints and incidents contain more than one allegation. If an investigation determines that any of the allegations did occur, then the allegation is sustained. Further, the investigation will determine whether a facility has failed to meet federal and/or state requirements. In cases where the Department determines the nursing home violates regulation, the Department will issue a citation to the nursing home. The facility then must submit a plan of correction that is acceptable to the Department and correct the deficient practice.

Understanding the Complaint and Incident Summary Report

The Complaint and Incident Summary Report presents information about complaints and incidents.

Complaints and Incidents Received

Information is presented at the Facility and Statewide level for the following information:

Received
The number of complaints and incidents, which were received by the Department during the reporting period.
Received per 100 Occupied Beds
This rate demonstrates the number of complaints and incidents received per 100 occupied beds. Occupied beds are approximated by taking the daily occupancy rate data from the most recent year's audited Nursing Home Cost Report. This rate allows the user to compare a specific facility's complaint experience with that of other homes or a statewide average.

Complaints and Incidents On-site Inspections

Information is presented at the Facility, and Statewide level for the following information:

On-site Inspections
The number of inspections at the Nursing Home completed by the Department of Health during the reporting period, as a result of complaints and incidents.
Citations
The total number of citations issued during the reporting period, as a result of the complaint and incident on-site inspections.
Citations per 100 Occupied Beds
This rate demonstrates the number of citations issued per 100 occupied beds. Occupied beds are approximated by taking the daily occupancy rate data from the most recent year's audited Nursing Home Cost Report. This rate allows the user to compare a specific facility's complaint experience with that of other homes or a statewide average.

Citations by Deficiency Category:

A single complaint or incident may result in multiple citations, which are included within the Statement of Deficiencies. The Citations by Deficiency Category presents information about the citations issued as a result of the Department's inspections. The information includes:

Deficiency Category
This is the area of nursing home service delivery for which a deficiency has been found. The categories are described in the Deficiency Categories section of this site.
Number of Citations
The number of citations issued during the reporting period, as a result of the complaint and incident on-site inspections.

Enforcement Summary Report (Enforcement Tab)

State Fines

Section 12 of the Public Health Law allows the Department of Health to assess fines against nursing homes that have been cited for noncompliance with federal or state regulations that resulted in harm to residents, represents substandard quality of care, or place residents at immediate risk for harm.

The maximum fine allowed under law is $2,000 per violation. The Enforcement Summary Report presents a history, starting on January 1, 2002, of fines assessed against each nursing home. The information includes:

Survey Date
The date of the survey conducted by the Department related to the citation that led to the fine.
Deficiency Category
The area of service delivery in which the Department determined the facility to be noncompliant. The categories are described in the Deficiency Categories section of this site.
Stipulation and Order
The agreement signed by the Department and the nursing home which identifies the deficiency and the amount of the fine for the violation. The full text of the order can be viewed by clicking on the Stipulation and Order number.
Stipulation and Order Date
The date the Stipulation and Order was signed.
Fine
The total amount of the fine assessed against the facility.

Deficiency Categories

Deficiency categories are found on the Survey Summary Report, the Complaint Summary Report, and the Enforcement Summary Report. There are six categories, as listed below. "Other Services" includes dental, pharmacy and specialized rehabilitation.

Administration
A facility must be run in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable level of well being for each resident. The administration category addresses how well the overall administration and management of a nursing home are carried out. Examples of the types of requirements that are measured when evaluating this category are outlined below:
  • The facility ensures that staff employed at the facility are appropriately trained, properly licensed and skilled to perform the tasks assigned.
  • The facility must maintain the clinical records of each resident in accordance with professional standards. The facility must ensure that it has written plans and procedures for potential emergencies and disasters and that staff have been trained to implement these procedures in the event of an emergency.
  • The facility must have an agreement with at least one hospital that assures residents can be sent to a hospital when medically appropriate.
  • The facility must have established a quality process to identify and improve the care and life of residents residing in the home.
  • The facility has a medical director.
Quality of Care
The quality of care category addresses how well the facility renders services provided and supervised by nursing staff. It includes the assessment of the resident, development of plan for care, following plan of care, and evaluating the results of care. This category evaluates issues such as nutrition, hydration, pressure sores, activities of daily living, infection control practices, range of motion, vision, hearing, urinary incontinence, medications, psychosocial functioning, and ability to care for residents with specialized conditions or treatments such as tube feedings, ostomy care and respiratory care.

Examples of the types of requirements measured when evaluating this category are outlined below:

  • Each resident receives the necessary care and services to maintain or, when possible, improve his or her functional ability.
  • Each resident is appropriately assisted to retain or, when possible, improve in ability to bathe, dress, eat, walk, communicate, transfer and toilet oneself.
  • Nursing staff adhere to acceptable infection control practices while rendering care to residents in the facility.
  • Residents will not develop unavoidable pressure sores. A resident at high risk for pressure sores receives appropriate preventative care. Residents with pressure sores receive the proper treatment, including nutrition, turning, positioning, etc., to facilitate healing.
  • Residents that are incontinent of urine receive the appropriate care and services to prevent infection and, when possible, restore normal bladder functioning.
  • Each resident receives sufficient fluid intake to maintain proper hydration.
  • Each resident receives sufficient calories and appropriate nutrients to maintain health unless the resident's clinical condition prevents it.
  • Each resident's medications are carefully administered to prevent the occurrence of medication errors.
  • Residents receive adequate supervision and assistance to prevent accidents.
Resident Rights
The resident rights category addresses how well the facility succeeds in ensuring the rights of residents are respected, recognized and upheld. Requirements evaluated in this section include, but are not limited to, the following: dignity and respect and a comfortable living environment; quality care and treatment without discrimination; freedom of choice to make independent decisions; safeguarding your property and money; safeguards associated with admission, discharge and transfer; privacy in communication; participation in organizations and activities of your choice; an easy to use and responsive complaint procedure; freedom from physical, verbal, sexual and mental abuse, corporal punishment and involuntary seclusion; reasonable accommodation of individual needs; and freedom from restraints.

Examples of the types of requirements measured when evaluating this category are outlined below:

  • The facility provides written information to residents about their rights.
  • The facility, when authorized by the resident, must safeguard and manage resident personal funds deposited with the facility.
  • The facility must ensure each resident's personal privacy and confidentiality, as related to the telephone, mail, visitation, and clinical records.
  • The facility must establish a mechanism for residents to voice complaints or grievances and have a responsive system through which it can respond promptly.
  • The facility must ensure that particular protocols are followed prior to transferring or discharging a resident. The facility must ensure its admission practices are in accordance with the regulations.
  • The facility must not restrain residents for purposes of discipline or convenience unless required to treat the residents' medical symptoms.
  • The facility must ensure it has actively worked to prevent abuse, mistreatment, neglect, and misappropriation of resident property; this includes requiring alleged violations be immediately reported to other officials in accordance with state and federal laws and regulations; and, ensure individuals found guilty of abusing, neglecting or mistreating a resident are not employed by the facility.
  • The facility must care for residents in a manner and an environment that promote maintenance or enhancement of each resident's quality of life.
  • The facility must ensure that residents are permitted to choose activities, schedules and make other choices consistent with their interests, and plan of care.
  • The facility must provide for an ongoing program of activities to meet the needs of the residents.
  • The facility provides a safe, clean, comfortable and homelike environment for the residents.
Dietary Services
This category addresses how well resident meals are prepared and served. It is concerned with the storage, preparation and serving of food under sanitary conditions. It is also concerned with residents being served meals that meet nutritional needs and are appetizing for residents. Examples of the requirements measured to evaluate this category are outlined below:
  • Each resident must be provided with a nourishing, tasty, well balanced diet that meets the daily nutritional and special dietary needs of each resident.
  • The facility must employ a dietitian and sufficient support personnel competent to carry out the functions of the dietary service.
  • Each resident's food must be tasty, palatable, attractive, and at the appropriate temperature.
Physical Environment
This category addresses how well the facility maintains the resident environment to protect the health and safety of its residents, personnel and the public. Examples of the requirements measured when evaluating this category are outlined below:
  • The facility must be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public.
  • The facility must meet the applicable provisions of theLife Safety Code of the National Fire Protection Association.
  • The facility must provide sufficient space and equipment in dining, health services, recreations, and program areas to enable staff to provide residents with privacy as well as needed services.
  • Facility equipment must be safe and functioning.
  • Resident rooms must provide residents with appropriate private space for clothes and other personal belongings.
Other Services
Specialized Rehabilitative Services
This category includes services such as physical therapy, occupational therapy, speech-language and mental health rehabilitative services for mental illness and mental retardation.
Dental Services
This category addresses how well the facility assists residents in obtaining needed dental services.
Pharmacy Services
This category addresses how well the pharmaceutical services are delivered to assure appropriate acquisition, receipt, dispensation, and administration of all drugs and biologicals to meet the needs of each resident