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 pain15.053764/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened3.558484/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine85.628744/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine74.999994/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication3.571424/1/2017
471Percentage of short-stay residents who made improvements in function71.878814/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased22.568093004/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain3.463129004/1/2017
403Percentage of high risk long-stay residents with pressure ulcers11.640212004/1/2017
404Percentage of long-stay residents who lose too much weight8.679245004/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder26.785713004/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder4.330831004/1/2017
407Percentage of long-stay residents with a urinary tract infection0.000000004/1/2017
408Percentage of long-stay residents who have depressive symptoms16.666669004/1/2017
409Percentage of long-stay residents who were physically restrained0.000000004/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury8.196723004/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine95.977012004/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine76.065574004/1/2017
419Percentage of long-stay residents who received an antipsychotic medication10.212766004/1/2017
451Percentage of long-stay residents whose ability to move independently worsened17.687076004/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication12.949641004/1/2017

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 0:00:00Quality of Care8/9/201710000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
1/24/2017Certification1
12/5/2014Complaint1
3/8/2016Certification2
4/24/2015Certification2
4/4/2013Complaint2
5/15/2015Complaint2
5/7/2014Certification3
6/17/2013Certification3
9/10/2015Complaint2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS11
HealthFACILITY MAINTAINS QA COMMITTEE42
LSCESCALATOR/DUMBWAITER/MOVING WALK REQUIREMENTS22
LSCALCOHOL BASED HAND RUBS21
LSC22
LSC21
LSC22
LSC21
LSC22
LSC22
LSC22
LSC22
LSC21
LSC21
LSC21
LSC22
HealthREQUIREMENTS FOR MAINTAINING CLINICAL RECORDS12
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS21
HealthFACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING42
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES42
HealthINFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.11
HealthDIGNITY21
HealthFACILITY MUST LISTEN/RESPOND TO RESIDENT/FAMILY GROUP22
HealthACCOMMODATION OF NEEDS AND PREFERENCES21
HealthMEDICALLY RELATED SOCIAL SERVICES22
HealthHOUSEKEEPING AND MAINTENANCE SERVICES12
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE21
HealthRESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE22
HealthDRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS21
HealthSUFFICIENT SUPPORT PERSONNEL FOR DIETARY SERVICES22
HealthPROVIDES SPECIAL EATING EQUIPMENT/UTENSILS21
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS22
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS21
HealthMAINTAINS EFFECTIVE PEST CONTROL PROGRAM22
LSC22
LSC22
LSC22
HealthPHYSICAL ENVIRONMENT22
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING21
LSC21
LSC22
HealthHOUSEKEEPING AND MAINTENANCE SERVICES11
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME22
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2110/29/2015
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE214/20/2016
HealthSERVICES PROVIDED MEET PROFESSIONAL STANDARDS214/20/2016
HealthRESIDENT ASSESSMENT AUTOMATED DATA PROCESSING214/20/2016
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES214/20/2016
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS214/20/2016
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE224/20/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS214/20/2016
HealthQUARTERLY REVIEW OF ASSESSMENTS224/20/2016
HealthASSESSMENT CONDUCTED AT LEAST EVERY 12 MONTHS224/20/2016
HealthFREQUENCY OF ASSESSMENTS - NO LATER THAN 14 DAYS224/20/2016
HealthASSESSMENT AFTER A SIGNIFICANT CHANGE224/20/2016
HealthDEPARTMENT CRIMINAL HISTORY REVIEW FELONY CHARGES/DIRECT CARE & SUPERVISION PROHIBITED214/20/2016
HealthHOUSEKEEPING AND MAINTENANCE SERVICES224/20/2016
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES224/20/2016
HealthAPPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES224/20/2016
HealthFACILITY IS FREE OF ACCIDENT HAZARDS214/20/2016
LSCEMERGENCY PLAN224/20/2016
LSCEXISTING ELEVATOR REQUIREMENTS224/20/2016
HealthPHYSICAL ENVIRONMENT224/20/2016
LSCMEDICAL GAS SYSTEM214/20/2016
LSCCOMBUSTIBLE CURTAINS224/20/2016
LSCPORTABLE FIRE EXTINGUISHERS224/20/2016
LSCGENERATORS INSPECTED/TESTED224/20/2016
LSCFIRE DRILLS224/20/2016
LSCTESTING OF FIRE ALARM214/20/2016
HealthFACILITY PROVIDES SPECIALIZED REHABILITATION SERVICES224/20/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS214/20/2016
LSCCORRIDOR DOORS224/20/2016
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS224/20/2016
LSCSMOKE PARTITION CONSTRUCTION224/20/2016
LSCHAZARDOUS AREAS - SEPARATION224/20/2016
LSCSTAIRS AND SMOKE PROOF TOWERS214/20/2016
HealthPASARR REQUIREMENTS FOR MI AND MR215/14/2013
HealthFACILITY PROVIDES SUFFICIENT FLUID INTAKE215/14/2013
HealthSTANDARDS OF CONSTRUCTION FOR NEW NURSING HOME225/16/2016
LSCCONSTRUCTION TYPE225/16/2016
LSCSPRINKLER SYSTEM MAINTENANCE225/16/2016
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME225/16/2016
LSCEMERGENCY LIGHTING215/6/2016
LSCGENERATORS INSPECTED/TESTED226/24/2015
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
HealthDEVELOP COMPREHENSIVE CARE PLANS216/24/2015
HealthSAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT216/24/2015
HealthMEDICALLY RELATED SOCIAL SERVICES216/24/2015
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE216/24/2015
HealthAPPROPRIATE TREATMENT FOR MENTAL/PSYCHOSOCIAL DIFFICULTIES216/24/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS216/24/2015
HealthRESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE216/24/2015
LSCCONSTRUCTION TYPE216/24/2015
LSCCORRIDOR DOORS226/24/2015
LSCFIRE DRILLS226/24/2015
LSCTESTING OF FIRE ALARM226/24/2015
LSCCOOKING EQUIPMENT226/24/2015
LSCSPRINKLER SYSTEM MAINTENANCE236/24/2015
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES216/24/2015
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES226/24/2015
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING216/24/2015
HealthSTANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME226/24/2015
HealthRESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS217/17/2013
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN217/17/2013
HealthDEVELOP COMPREHENSIVE CARE PLANS217/17/2013
HealthCOMPREHENSIVE ASSESSMENTS127/17/2013
LSCSPRINKLER SYSTEM MAINTENANCE227/17/2013
LSCCOOKING EQUIPMENT227/17/2013
LSCFURNISHING AND DECORATIONS227/17/2013
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES217/17/2013
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/17/2013
LSCEXIT SIGNS227/17/2013
LSCSTAIRS AND SMOKE PROOF TOWERS227/17/2013
LSCHAZARDOUS AREAS - SEPARATION227/17/2013
LSCPORTABLE FIRE EXTINGUISHERS227/17/2013
LSCALCOHOL BASED HAND RUBS227/17/2013
HealthCORRIDORS HAVE FIRMLY SECURED HANDRAILS227/17/2013
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION227/17/2013
HealthFACILITY PROVIDES DRUGS AND BIOLOGICALS227/17/2013
HealthEMERGENCY PHYSICIAN SERVICES 24 HR./DAY217/17/2013
LSCCONSTRUCTION TYPE227/23/2013
LSCCONSTRUCTION TYPE227/24/2014
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/24/2015
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.217/24/2015
LSCGENERATORS INSPECTED/TESTED227/3/2014
LSCOTHER227/3/2014
LSCFURNISHING AND DECORATIONS227/3/2014
LSCPORTABLE FIRE EXTINGUISHERS227/3/2014
LSCTESTING OF FIRE ALARM227/3/2014
HealthFACILITY PROVIDES SPECIALIZED REHABILITATION SERVICES217/3/2014
LSCEXIT PARTITIONS227/3/2014
LSCHAZARDOUS AREAS - SEPARATION227/3/2014
LSCDOORS IN SMOKE PARTITIONS227/3/2014
LSCSTAIRWAY ENCLOSURES AND VERTICAL SHAFTS227/3/2014
LSCCOMMON WALL227/3/2014
LSCCORRIDOR WALLS227/3/2014
LSCEMERGENCY PLAN227/3/2014
LSCALCOHOL BASED HAND RUBS227/3/2014
HealthPOLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT227/3/2014
HealthDEVELOP COMPREHENSIVE CARE PLANS217/3/2014
HealthCRIMINAL HISTORY RECORD CHECK PROCESS SUBMIT APPROVED FORM & FINGERPRINTS WITHIN TEN DAYS127/3/2014
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS217/3/2014
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES217/3/2014
HealthPROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS217/3/2014
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS227/3/2014
HealthNURSE STAFFING127/3/2014
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM227/3/2014
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS227/3/2014
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION227/3/2014
LSCCORRIDOR DOORS227/3/2014
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES227/3/2014
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING228/14/2013
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS318/14/2013
HealthSUFFICIENT NURSING STAFF ON A 24-HOUR BASIS228/14/2013
LSCEMERGENCY LIGHTING228/3/2014
LSCSPRINKLER SYSTEM MAINTENANCE228/3/2014
LSCSMOKE PARTITION CONSTRUCTION228/3/2014
LSCCOOKING EQUIPMENT228/3/2014
LSCMEDICAL GAS SYSTEM228/3/2014
LSCAUTOMATIC SPRINKLER SYSTEM238/3/2014