BRIARCLIFF MANOR CENTER FOR REHAB AND NURSING CARE

Nursing Home Inspector

620 SLEEPY HOLLOW ROAD
BRIARCLIFF MANOR, NY 10510
Westchester County
Phone: 914-941-5100
Provider Number: 335005
Last Inspection: 08/02/2017

About the Nursing Home

Number of Beds: 131
Number of Residents: 112
Beds Available: 19
Percent Occupancy: 85%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

21

Facility
7

County
14

NY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

21

2017
12

2016
29

2016

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/2/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide proof that residents' personal money that is deposited with the nursing home is secure. Pattern : Minimal 4 9/21/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 9/21/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/21/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 9/21/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 9/21/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 9/21/2017
 

10/24/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 12/15/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 12/15/2016
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 12/15/2016
 

2/1/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 3/28/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 3/28/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 3/28/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/28/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 3/28/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/28/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 3/28/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 3/28/2016
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Isolated : Minimal 3 3/28/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/6/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Widespread : Immediate 7 9/9/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Widespread : Immediate 7 9/9/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Immediate 7 9/9/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Immediate 7 9/9/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 112 137.88 167.28
Registered Nurses 0.34 1.09 0.74
Licensed Practical / Vocational Nurses 1.04 0.70 0.84
Certified Nursing Assistants 2.54 2.44 2.30
Total Staff Hours 3.92 4.24 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of high risk long-stay residents with pressure ulcers 5 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 84 96 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 88 96 96
of long-stay residents experiencing one or more falls with major injury 2 2 2
of long-stay residents who have depressive symptoms 8 8 8
of long-stay residents who lose too much weight 4 5 6
of long-stay residents who received an antianxiety or hypnotic medication 22 16 15
of long-stay residents who received an antipsychotic medication 11 11 13
of long-stay residents who self-report moderate to severe pain 0 1 3
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 7 12 16
of long-stay residents whose need for help with daily activities has increased 9 10 13
of long-stay residents with a catheter inserted and left in their bladder 0 1 1
of long-stay residents with a urinary tract infection 0 3 3
of low risk long-stay residents who lose control of their bowels or bladder 31 52 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 54 83 81
of short-stay residents who had an outpatient emergency department visit 14 9 9
of short-stay residents who made improvements in function 55 69 68
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 0 6 9
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 66 84 82
of short-stay residents who were rehospitalized after a nursing home admission 24 21 21
of short-stay residents who were successfully discharged to the community 37 50 48
of short-stay residents with pressure ulcers that are new or worsened 0 0 0