Bishop Charles Waldo Maclean Episcopal N H

Bishop Charles Waldo Maclean Episcopal N H was recognized and ceritified in 1985 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Bishop Charles Waldo Maclean Episcopal N H which is located in 17 11 Brookhaven Avenue Far Rockaway, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Bishop Charles Waldo Maclean Episcopal N H is being offered ceritified services and products in New York.
Address:   17 11 Brookhaven Avenue
       Far Rockaway, NY 11691

Phone:   (718) 869-8037

County: Queens
Federal Provider Number: 335682
Participates in: Medicare And Medicaid
Certified Date: Wednesday, July 24, 1985 (39 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Episcopal Health Services Inc
Ownership Type: Non Profit - Church Related
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
PersonJonathan ImmordinoDirector/officer
PersonKathleen GarciaW-2 Managing Employee
PersonKathleen GarciaDirector/officer
PersonJohn MorahanDirector/officer

Provider Resides in Hospital: No
Number of Federally Certified Beds: 163
Number of Residents in Federally Certified Beds: 149 (92% occupied)
Continuing Care Retirement Community: No
Special Focus Facility: No
With a Resident and Family Council: Both
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0412 (Provide or obtain dental services for each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0325 (Ensure residents maintain acceptable nutritional status.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Fire Safety
Deficiency: K0033 (Protected exits that allow the resident to escape the building.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 8, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 8, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0250 (Provide medically-related social services to help each resident achieve the highest possible quality)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 8, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Health
Deficiency: F0313 (Ensure that residents receive proper treatment and assistive devices to maintain their vision and he)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 31, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 10, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 8, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Monday, August 12, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0248 (Provide activities to meet the interests and needs of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0353 (Have enough nurses to care for every resident in a way that maximizes the resident's well being.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0498 (Make sure that nurse aides show they have the skills and techniques to be able to care for residents)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0281 (Ensure services provided by the nursing facility meet professional standards of quality.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0246 (Reasonably accommodate the needs and preferences of each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, June 3, 2013
Survey Type: Fire Safety
Deficiency: K0033 (Protected exits that allow the resident to escape the building.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, July 26, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0248 (Provide activities to meet the interests and needs of each resident.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Fire Safety
Deficiency: K0146 (A separate and independent backup electrical power source.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0159 (Properly hold, secure, and manage each resident's personal money which is deposited with the nursing)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0325 (Ensure residents maintain acceptable nutritional status.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0252 (Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal be)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 9, 2012
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, October 8, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 16, 2012
Survey Type: Health
Deficiency: F0490 (Make sure that the facility is administered in an acceptable way that maintains the well-being of ea)
Scope Severity Code: K
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 20, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, March 16, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: K
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, April 20, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Number of Facility Reported Incidents: 3
Number of Substantiated Complaints: 1
Number of Fines: 0
Number of Payment Denials: 0
Total Number of Penalties: 0
Total Amount of Fines in Dollars: USD 0
This data allows consumers to compare information about nursing homes. Information here is not an endorsement or advertisement for any nursing home and should be considered carefully. Use it with other information you gather about nursing homes facilities. Talk to your doctor or other health care provider about this.



This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (1 out of 5 stars)
Quality Rating (5 out of 5 stars)
Staffing Rating (1 out of 5 stars)
RN Staffing Rating (1 out of 5 stars)
Overall Rating (2 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
8%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
3%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
6%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
2%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
14%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
3%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
6%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
14%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
97%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
97%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
12%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
6%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
18%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
44%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
85%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
2%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
86%
84%

N/A
Data not available.

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Bishop Charles Waldo Maclean Episcopal N H [Federal No:335682] near 17 11 Brookhaven Avenue, Far Rockaway NY

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