Emerald North Nursing and Rehabilitation Center

Emerald North Nursing and Rehabilitation Center

1205 Delaware Avenue

Buffalo, NY 14209

(716) 885-3838

www.pscwny.org/harbour-hawthorn-home.html

Services: Baseline Services

Beds

Behavioral Intervention:
Pediatric:
Pediatric Ventilator Dependent:
Residential Health Care:95
Transitional Care Unit:
Ventilator Dependent:
Total Number of Beds:95

Administrative

Ownership: Proprietary--LLC

Operated by: Ruby Care LLC
1205 Delaware Avenue
Buffalo, NY 14209

Permanent Facility Identifier: 633

Operating Certificate: 1401339N

Medicaid Certified

Medicare Certified

Medicare Number: 335640

Statistics

Employee Flu Vaccination Rate: 30%

Occupancy Rate: 71%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain12.56/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened4.39476/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine856/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine62.837836/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication3.614456/1/2017
471Percentage of short-stay residents who made improvements in function67.01796/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased22.177419006/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain2.824407006/1/2017
403Percentage of high risk long-stay residents with pressure ulcers10.169492006/1/2017
404Percentage of long-stay residents who lose too much weight9.055117006/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder26.724137006/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder4.847477006/1/2017
407Percentage of long-stay residents with a urinary tract infection0.346020006/1/2017
408Percentage of long-stay residents who have depressive symptoms10.236222006/1/2017
409Percentage of long-stay residents who were physically restrained0.000000006/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury7.191782006/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine96.470589006/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine69.520548006/1/2017
419Percentage of long-stay residents who received an antipsychotic medication12.053569006/1/2017
451Percentage of long-stay residents whose ability to move independently worsened17.250055006/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication15.172415006/1/2017

Complaints

Number of Standard Health Deficiencies:88
Number of Live Safety Code Deficiencies:72
Number of Total Deficiencies:160
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:4
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :3
Total intakes received (last three years):86
Intakes received per 100 occupied beds (last three years):99.2
Percent of total intakes received that were facility self reported incidents (last three years):42
On-site complaint investigations (last three years):28
Complaint investigations resulting in citations (last three years):14
Complaint investigations resulting in citations per 100 occupied beds (last three years):16.2
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:7
Complaint Citations in deficiency category: Resident Rights:3
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:0
Complaint Citations in deficiency category: Other Services:2
Complaint Citations across all deficiency categories (last three years):14

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
Quality of Care2/13/200810000
6/17/2013 0:00Quality of Care8/9/201710000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/24/2017Certification3
12/5/2014Complaint1
3/8/2016Certification2
4/24/2015Certification2
5/15/2015Complaint2
5/7/2014Certification3
6/17/2013Certification3
9/10/2015Complaint2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS11
HealthHOUSEKEEPING AND MAINTENANCE SERVICES11
HealthINFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.11
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2110/29/2015
LSC213/23/2017
HealthPROVIDES SPECIAL EATING EQUIPMENT/UTENSILS213/24/2017
LSC223/24/2017
HealthDIGNITY213/24/2017
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING213/24/2017
HealthFACILITY MUST LISTEN/RESPOND TO RESIDENT/FAMILY GROUP223/24/2017
HealthACCOMMODATION OF NEEDS AND PREFERENCES213/24/2017
HealthHOUSEKEEPING AND MAINTENANCE SERVICES123/24/2017
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE213/24/2017
HealthRESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE223/24/2017
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS213/24/2017
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS213/24/2017
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS213/24/2017
HealthREQUIREMENTS FOR MAINTAINING CLINICAL RECORDS123/24/2017
HealthMAINTAINS EFFECTIVE PEST CONTROL PROGRAM223/24/2017
LSC213/24/2017
HealthMEDICALLY RELATED SOCIAL SERVICES223/24/2017
LSCALCOHOL BASED HAND RUBS213/24/2017
LSC223/24/2017
LSC213/24/2017
LSC223/24/2017
LSC223/24/2017
HealthSUFFICIENT SUPPORT PERSONNEL FOR DIETARY SERVICES223/24/2017
LSC223/24/2017
LSC223/24/2017
LSC213/24/2017
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME223/24/2017
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES423/24/2017
LSCHAZARDOUS AREAS - SEPARATION224/20/2016
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES224/20/2016
HealthFACILITY PROVIDES SPECIALIZED REHABILITATION SERVICES224/20/2016
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS214/20/2016
HealthFACILITY IS FREE OF ACCIDENT HAZARDS214/20/2016
HealthAPPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES224/20/2016
LSCEXISTING ELEVATOR REQUIREMENTS224/20/2016
LSCEMERGENCY PLAN224/20/2016
LSCGENERATORS INSPECTED/TESTED224/20/2016
LSCCOMBUSTIBLE CURTAINS224/20/2016
LSCFIRE DRILLS224/20/2016
LSCTESTING OF FIRE ALARM214/20/2016
LSCSTAIRS AND SMOKE PROOF TOWERS214/20/2016
LSCSMOKE PARTITION CONSTRUCTION224/20/2016
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS224/20/2016
LSCCORRIDOR DOORS224/20/2016
LSCMEDICAL GAS SYSTEM214/20/2016
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE214/20/2016
HealthPHYSICAL ENVIRONMENT224/20/2016
LSCPORTABLE FIRE EXTINGUISHERS224/20/2016
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE224/20/2016
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES214/20/2016
HealthDEPARTMENT CRIMINAL HISTORY REVIEW FELONY CHARGES/DIRECT CARE & SUPERVISION PROHIBITED214/20/2016
HealthRESIDENT ASSESSMENT AUTOMATED DATA PROCESSING214/20/2016
HealthSERVICES PROVIDED MEET PROFESSIONAL STANDARDS214/20/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS214/20/2016
HealthQUARTERLY REVIEW OF ASSESSMENTS224/20/2016
HealthASSESSMENT CONDUCTED AT LEAST EVERY 12 MONTHS224/20/2016
HealthASSESSMENT AFTER A SIGNIFICANT CHANGE224/20/2016
HealthFREQUENCY OF ASSESSMENTS - NO LATER THAN 14 DAYS224/20/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS214/20/2016
HealthHOUSEKEEPING AND MAINTENANCE SERVICES224/20/2016
LSCCONSTRUCTION TYPE225/16/2016
LSCSPRINKLER SYSTEM MAINTENANCE225/16/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME225/16/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW NURSING HOME225/16/2016
LSCEMERGENCY LIGHTING215/6/2016
LSC215/8/2017
LSC225/8/2017
LSC225/8/2017
LSCESCALATOR/DUMBWAITER/MOVING WALK REQUIREMENTS225/8/2017
HealthPHYSICAL ENVIRONMENT225/8/2017
LSC225/8/2017
LSC225/8/2017
LSC225/8/2017
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION225/8/2017
LSC215/8/2017
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS225/8/2017
HealthFACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING425/8/2017
HealthFACILITY MAINTAINS QA COMMITTEE425/8/2017
LSCSPRINKLER SYSTEM MAINTENANCE236/24/2015
LSCTESTING OF FIRE ALARM226/24/2015
HealthAPPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES216/24/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS216/24/2015
LSCGENERATORS INSPECTED/TESTED226/24/2015
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES216/24/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS216/24/2015
LSCCOOKING EQUIPMENT226/24/2015
LSCCORRIDOR DOORS226/24/2015
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT216/24/2015
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES216/24/2015
HealthRESIDENT RECEIVE TREATMENT TO MAINTAIN HEARING/VISION216/24/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS216/24/2015
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN216/24/2015
HealthMEDICALLY RELATED SOCIAL SERVICES216/24/2015
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE216/24/2015
HealthRESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE216/24/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING216/24/2015
LSCCONSTRUCTION TYPE216/24/2015
LSCFIRE DRILLS226/24/2015
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME226/24/2015
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES226/24/2015
LSCSPRINKLER SYSTEM MAINTENANCE227/17/2013
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION227/17/2013
LSCSTAIRS AND SMOKE PROOF TOWERS227/17/2013
LSCALCOHOL BASED HAND RUBS227/17/2013
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES217/17/2013
HealthCORRIDORS HAVE FIRMLY SECURED HANDRAILS227/17/2013
LSCFURNISHING AND DECORATIONS227/17/2013
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/17/2013
LSCCOOKING EQUIPMENT227/17/2013
HealthRESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS217/17/2013
LSCHAZARDOUS AREAS - SEPARATION227/17/2013
HealthFACILITY PROVIDES DRUGS AND BIOLOGICALS227/17/2013
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN217/17/2013
LSCEXIT SIGNS227/17/2013
HealthDEVELOP COMPREHENSIVE CARE PLANS217/17/2013
HealthEMERGENCY PHYSICIAN SERVICES 24 HR./DAY217/17/2013
LSCPORTABLE FIRE EXTINGUISHERS227/17/2013
HealthCOMPREHENSIVE ASSESSMENTS127/17/2013
LSCCONSTRUCTION TYPE227/23/2013
LSCCONSTRUCTION TYPE227/24/2014
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.217/24/2015
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/24/2015
HealthFACILITY PROVIDES SPECIALIZED REHABILITATION SERVICES217/3/2014
LSCDOORS IN SMOKE PARTITIONS227/3/2014
HealthDEVELOP COMPREHENSIVE CARE PLANS217/3/2014
LSCCORRIDOR DOORS227/3/2014
HealthPOLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT227/3/2014
LSCALCOHOL BASED HAND RUBS227/3/2014
HealthCRIMINAL HISTORY RECORD CHECK PROCESS SUBMIT APPROVED FORM & FINGERPRINTS WITHIN TEN DAYS127/3/2014
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES227/3/2014
LSCGENERATORS INSPECTED/TESTED227/3/2014
LSCEMERGENCY PLAN227/3/2014
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS227/3/2014
LSCOTHER227/3/2014
LSCFURNISHING AND DECORATIONS227/3/2014
LSCTESTING OF FIRE ALARM227/3/2014
LSCEXIT PARTITIONS227/3/2014
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS217/3/2014
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/3/2014
LSCHAZARDOUS AREAS - SEPARATION227/3/2014
LSCPORTABLE FIRE EXTINGUISHERS227/3/2014
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS227/3/2014
LSCCORRIDOR WALLS227/3/2014
LSCCOMMON WALL227/3/2014
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION227/3/2014
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM227/3/2014
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS227/3/2014
HealthPROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS217/3/2014
HealthNURSE STAFFING127/3/2014
HealthSUFFICIENT NURSING STAFF ON A 24-HOUR BASIS228/14/2013
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS318/14/2013
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING228/14/2013
LSCMEDICAL GAS SYSTEM228/3/2014
LSCSPRINKLER SYSTEM MAINTENANCE228/3/2014
LSCAUTOMATIC SPRINKLER SYSTEM238/3/2014
LSCSMOKE PARTITION CONSTRUCTION228/3/2014
LSCEMERGENCY LIGHTING228/3/2014
LSCCOOKING EQUIPMENT228/3/2014