Emerald North Nursing and Rehabilitation Center

Emerald North Nursing and Rehabilitation Center

1205 Delaware Avenue

Buffalo , NY 14209

7168853838

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: 34%

Occupancy Rate: 76.8%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain12.37009/1/2018
425Percentage of short-stay residents with pressure ulcers that are new or worsened2.27009/1/2018
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine65.31009/1/2018
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine40.00009/1/2018
434Percentage of short-stay residents who newly received an antipsychotic medication1.82009/1/2018
471Percentage of short-stay residents who made improvements in function72.28009/1/2018

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased34.31009/1/2018
402Percentage of long-stay residents who self-report moderate to severe pain4.46009/1/2018
403Percentage of high risk long-stay residents with pressure ulcers11.11009/1/2018
404Percentage of long-stay residents who lose too much weight8.61009/1/2018
405Percentage of low risk long-stay residents who lose control of their bowels or bladder34.88009/1/2018
406Percentage of long-stay residents with a catheter inserted and left in their bladder3.58009/1/2018
407Percentage of long-stay residents with a urinary tract infection0.79009/1/2018
408Percentage of long-stay residents who have depressive symptoms1.41009/1/2018
409Percentage of long-stay residents who were physically restrained0.39009/1/2018
410Percentage of long-stay residents experiencing one or more falls with major injury5.86009/1/2018
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine77.27009/1/2018
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine71.88009/1/2018
419Percentage of long-stay residents who received an antipsychotic medication14.72009/1/2018
451Percentage of long-stay residents whose ability to move independently worsened36.62009/1/2018
452Percentage of long-stay residents who received an antianxiety or hypnotic medication19.37009/1/2018

Complaints

Number of Standard Health Deficiencies:81
Number of Live Safety Code Deficiencies:56
Number of Total Deficiencies:137
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:3
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :2
Total intakes received (last three years):82
Intakes received per 100 occupied beds (last three years):118.8
Percent of total intakes received that were facility self reported incidents (last three years):51
On-site complaint investigations (last three years):20
Complaint investigations resulting in citations (last three years):8
Complaint investigations resulting in citations per 100 occupied beds (last three years):11.6
Complaint Citations in deficiency category: Administration:3
Complaint Citations in deficiency category: Quality of Care:2
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:0
Complaint Citations across all deficiency categories (last three years):8

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
Quality of Care2/13/200810000
1/24/2017Multiple Deficiencies6/19/20176000
6/17/2013Quality of Care8/9/201710000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/18/2018Complaint2
1/24/2017Certification3
12/5/2014Complaint1
3/8/2016Certification2
4/24/2015Certification2
4/25/2018Certification1
5/15/2015Complaint2
9/10/2015Complaint2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate of Initial SurveyDate Citation Corrected
HealthHOUSEKEEPING & MAINTENANCE SERVICES1112/5/2014
LSCEP Program Patient Population134/25/2018
LSCEP Training Program134/25/2018
HealthReasonable Accommodations Needs/Preferences214/25/2018
HealthProtection/Management of Personal Funds214/25/2018
HealthAccounting and Records of Personal Funds124/25/2018
HealthSafe/Clean/Comfortable/Homelike Environment124/25/2018
HealthComprehensive Assessments & Timing214/25/2018
HealthQrtly Assessment at Least Every 3 Months214/25/2018
HealthBaseline Care Plan214/25/2018
HealthDevelop/Implement Comprehensive Care Plan214/25/2018
HealthADL Care Provided for Dependent Residents214/25/2018
HealthQuality of Care214/25/2018
HealthFree of Accident Hazards/Supervision/Devices224/25/2018
HealthDialysis214/25/2018
HealthPharmacy Srvcs/Procedures/Pharmacist/Records224/25/2018
HealthDrug Regimen Review, Report Irregular, Act On224/25/2018
HealthFree from Unnec Psychotropic Meds/PRN Use214/25/2018
HealthInfection Prevention & Control224/25/2018
HealthInfluenza and Pneumococcal Immunizations214/25/2018
LSCBuilding Construction Type and Height224/25/2018
LSCCooking Facilities224/25/2018
LSCFire Alarm System - Testing and Maintenance224/25/2018
LSCSprinkler System - Maintenance and Testing224/25/2018
LSCPortable Fire Extinguishers224/25/2018
LSCHVAC224/25/2018
LSCElevators224/25/2018
LSCFire Drills224/25/2018
LSCElectrical Systems - Essential Electric Syste224/25/2018
LSCElectrical Equipment - Power Cords and Extens224/25/2018
LSCElectrical Equipment - Testing and Maintenanc224/25/2018
LSCGas Equipment - Cylinder and Container Storag224/25/2018
HealthInfection Control224/25/2018
HealthStandards of Construction for New NH224/25/2018
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE114/24/2015
HealthNOTICE OF RIGHTS, RULES, SERVICES, CHARGES111/24/2017
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS219/10/201510/29/2015
HealthFree of Accident Hazards/Supervision/Devices211/18/20182/28/2018
LSCSprinkler System - Installation211/24/20173/23/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES421/24/20173/24/2017
HealthDIGNITY AND RESPECT OF INDIVIDUALITY211/24/20173/24/2017
HealthLISTEN/ACT ON GROUP GRIEVANCE/RECOMMENDATION221/24/20173/24/2017
HealthREASONABLE ACCOMMODATION OF NEEDS/PREFERENCES211/24/20173/24/2017
HealthPROVISION OF MEDICALLY RELATED SOCIAL SERVICE221/24/20173/24/2017
HealthHOUSEKEEPING & MAINTENANCE SERVICES121/24/20173/24/2017
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING211/24/20173/24/2017
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER211/24/20173/24/2017
HealthMAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE221/24/20173/24/2017
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS211/24/20173/24/2017
HealthSUFFICIENT DIETARY SUPPORT PERSONNEL221/24/20173/24/2017
HealthASSISTIVE DEVICES - EATING EQUIPMENT/UTENSILS211/24/20173/24/2017
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS211/24/20173/24/2017
HealthMAINTAINS EFFECTIVE PEST CONTROL PROGRAM221/24/20173/24/2017
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE211/24/20173/24/2017
HealthRETENTION OF RESIDENT CLINICAL RECORDS121/24/20173/24/2017
LSCGeneral Requirements - Other221/24/20173/24/2017
LSCMeans of Egress - General211/24/20173/24/2017
LSCDoors with Self-Closing Devices221/24/20173/24/2017
LSCVertical Openings - Enclosure211/24/20173/24/2017
LSCPortable Fire Extinguishers221/24/20173/24/2017
LSCSubdivision of Building Spaces - Smoke Barrie221/24/20173/24/2017
LSCPortable Space Heaters211/24/20173/24/2017
LSCElectrical Systems - Essential Electric Syste221/24/20173/24/2017
LSCGas Equipment - Cylinder and Container Storag221/24/20173/24/2017
LSCGas Equipment - Precautions for Handling Oxyg211/24/20173/24/2017
HealthStandards of Construction for New Existing NH221/24/20173/24/2017
HealthDepartment Criminal History Review213/8/20164/20/2016
HealthINVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS213/8/20164/20/2016
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES223/8/20164/20/2016
HealthHOUSEKEEPING & MAINTENANCE SERVICES223/8/20164/20/2016
HealthCOMPREHENSIVE ASSESSMENT 14 DAYS AFTER ADMIT223/8/20164/20/2016
HealthCOMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE223/8/20164/20/2016
HealthCOMPREHENSIVE ASSESS AT LEAST EVERY 12 MONTHS223/8/20164/20/2016
HealthQUARTERLY ASSESSMENT AT LEAST EVERY 3 MONTHS223/8/20164/20/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS213/8/20164/20/2016
HealthSERVICES PROVIDED MEET PROFESSIONAL STANDARDS213/8/20164/20/2016
HealthENCODING/TRANSMITTING RESIDENT ASSESSMENT213/8/20164/20/2016
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES213/8/20164/20/2016
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER223/8/20164/20/2016
HealthTX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES223/8/20164/20/2016
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES213/8/20164/20/2016
HealthPROVIDE/OBTAIN SPECIALIZED REHAB SERVICES223/8/20164/20/2016
HealthDRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS213/8/20164/20/2016
HealthRES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD213/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20164/20/2016
HealthPhysical Environment223/8/20164/20/2016
LSCLIFE SAFETY CODE STANDARD223/8/20165/16/2016
LSCLIFE SAFETY CODE STANDARD223/8/20165/16/2016
HealthStandards of Construction for New Existing NH223/8/20165/16/2016
HealthStandards of Construction for New NH223/8/20165/16/2016
LSCLIFE SAFETY CODE STANDARD213/8/20165/6/2016
HealthFOOD PROCURE, STORE/PREPARE/SERVE - SANITARY221/24/20175/8/2017
HealthESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION221/24/20175/8/2017
HealthEFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING421/24/20175/8/2017
HealthQAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS421/24/20175/8/2017
LSCBuilding Construction Type and Height221/24/20175/8/2017
LSCHazardous Areas - Enclosure221/24/20175/8/2017
LSCSprinkler System - Maintenance and Testing221/24/20175/8/2017
LSCCorridor - Doors221/24/20175/8/2017
LSCHVAC221/24/20175/8/2017
LSCElectrical Systems - Other211/24/20175/8/2017
LSCElectrical Systems - Essential Electric Syste211/24/20175/8/2017
LSCElectrical Equipment - Power Cords and Extens221/24/20175/8/2017
HealthPhysical Environment221/24/20175/8/2017
HealthRIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES224/24/20156/24/2015
HealthSELF-DETERMINATION - RIGHT TO MAKE CHOICES214/24/20156/24/2015
HealthRIGHT TO NOTICE BEFORE ROOM/ROOMMATE CHANGE214/24/20156/24/2015
HealthPROVISION OF MEDICALLY RELATED SOCIAL SERVICE214/24/20156/24/2015
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT214/24/20156/24/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS214/24/20156/24/2015
HealthRIGHT TO PARTICIPATE PLANNING CARE-REVISE CP214/24/20156/24/2015
HealthPROVIDE CARE/SERVICES FOR HIGHEST WELL BEING214/24/20156/24/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS214/24/20156/24/2015
HealthTREATMENT/DEVICES TO MAINTAIN HEARING/VISION214/24/20156/24/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES214/24/20156/24/2015
HealthNO CATHETER, PREVENT UTI, RESTORE BLADDER214/24/20156/24/2015
HealthTX/SVC FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES214/24/20156/24/2015
HealthFREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES214/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD214/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD234/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
LSCLIFE SAFETY CODE STANDARD224/24/20156/24/2015
HealthStandards of Construction for New Existing NH224/24/20156/24/2015
HealthNOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)215/15/20157/24/2015
HealthTREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES215/15/20157/24/2015