Orchard Park Rehab & Living Center

Based on employee record reviews, interviews, and the Facility Assessment, the facility failed to develop, implement, and maintain an effective in-service training program by failing to ensure that a Certified Nursing Assistant (CNA) received the required dementia management training for 5 out of 5 randomly sampled CNA files (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5).Findings:A review of the Comprehensive Facility Assessment, updated August 2025, indicates the facility is licensed for 38 beds and under Section 2.4, that the facility commonly provides care to individuals with Alzheimer's Disease and Non-Alzheimer's Dementia and that the Number/Average or Range of Residents with Dementia is 12. Section 3.1 Resident support/care needs states, Specific Care or Practices.care of someone with cognitive impairment.On 1/22/26, five randomly sampled employee files were reviewed and revealed the following:1. CNA #1 was hired on 1/7/25. The employee file lacked evidence of dementia training.2. CNA #2 was hired on 1/14/25. The employee file lacked evidence of dementia training.3. CNA #3 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 14 residents reviewed for care planning (Resident #28).Finding:Review of Resident #28's clinical record revealed an MDS Quarterly Assessment was completed on 12/17/25. Further review of Resident #28's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment.On 1/22/26 at 12:04 p.m., the above finding was discussed during an interview with the Social Services Director (LSW). At this time, the LSW stated that Resident #28's IDT meeting was held on 12/19/25. The surveyor requested evidence of the meeting, and the LSW stated she was off at the time and would request the meeting notes from the Director of Nursing (DNS). On 1/22/26 at 12:35 p.m. during a follow-up interview in the presence of 4 surveyors, the LSW confirmed that the facility did not have the meeting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and review of the facility's internal investigation, the facility failed to ensure that 1 of 1 resident reviewed for dignity was provided care in a manner that maintained and respected his/her dignity. (Resident #1) The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. On 8/27/25 at approximately 2:18 p.m., during a telephone interview with a surveyor, Certified Nurse's Assistant #6, (CNA) confirmed these actions, stating that he had tied a sheet around Resident #1's waist and secured it in a double knot as he/she was sitting in his/her wheelchair and applied johnny pants backwards,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews and review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy, the facility failed to ensure that 1 of 1 resident reviewed was free from abuse when the resident was found with a sheet double knotted in front of her waist and a pair of johnny pants applied backwards with the ties double knotted behind him/her. (Resident #1) The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.The facilities policy, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property indicates: It is the policy of this facility that each resident will be free from abuse. Abused can include verbal, mental, sexual or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, facility's internal investigation and Restraint Policy, the facility failed to ensure that 1 of 1 resident was free from the use of restraints. (Resident #1 The Division of Licensing and Certification received the facility reported incident regarding Resident #1 related to mistreatment on 8/4/25.Review of the facilities 5-day follow-up investigation dated 8/7/25 indicated that 8/4/25, Resident #1 was observed seated in a wheelchair wearing johnny pants that had been applied backwards, with the ties positioned in the back and secured in a double knot. The resident was also seated on a sheet that had been tied in front of him/her around the waist and secured in a double knot. The facilities restraint use policy indicates: The facility must ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the residents' medical symptoms. II. Procedure Examples of facility practices and meeting the definition of a physical restraint include but are not limited to: C. Tucking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility's Infection Control Immunizations - Influenza, Pneumococcal, COVID and Employee Immunization/Vaccination Requirements policy and procedures and interviews the facility failed to develop and implement policy and procedure to ensure all staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine or information on obtaining COVID-19 vaccine. This has the potential to effect all employees. Findings: Review of the Infection Control Immunizations - Influenza, Pneumococcal, COVID policy, last revised on 12/24, and the Employee Immunization/Vaccination Requirements policy, last revised on 9/5/23 failed to include procedures relating to staff education regarding the benefits and potential risks associated with COVID-19 vaccine or information on obtaining COVID-19 vaccine. 1. On 12/10/24 at 2:38 p.m., during an interview, the Infection Preventionist confirmed that staff are not provided education regarding the benefits and potential risks associated with COVID-19 vaccine, stating, No, I haven't since last year, In…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 3 of 3 units (Northern Spy, Cortland and [NAME]) and the laundry room for 1 of 1 environmental tour (12/11/24). Findings: 1. On 11/19/24, from 10:05 a.m. to 10:30 a.m., an environmental tour was conducted with the Administrator, the Maintenance Director and the Housekeeping Account Manager, in which the following findings were observed: - The shower room across her nursing station had a missing ceiling tile and a broken shelf which was missing laminate on the edge exposing bare wood. - -The whirlpool room had ripped/torn flooring at the corners of the sink cabinet and had a large split-apart seam in the middle of the floor which was full of dirt. The bottom edge of the sink cabinet was broke and missing laminate. The walls had chipped/missing paint and holes in them. - Resident room [ROOM NUMBER] - On 12/09/24 at 9:54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #80 was admitted on [DATE] with diagnoses to include sleep apnea. Review of Resident #80's clinical record revealed active order dated 11/30/24 for CPAP (Continuous Positive Airway Pressure) 2 Times Daily 11/30/2024. If refuses CPAP, may use PRN order for oxygen at 2 LPM (Liters Per Minute) via nasal cannula. Oxygen - see notes PRN. If refuses CPAP use 2 LPM oxygen via nasal cannula during night time sleep hours. Review of Resident #80's baseline care plan, initiated 11/22/24, lacked evidence that goals and interventions were put into place for his/her respiratory needs. On 12/10/24 at 10:12 a.m., in an interview, the Quality Improvement Specialist confirmed that the baseline care plan lacked evidence that goals and interventions were put into place for his/her respiratory needs. 3. Resident #23 was admitted on [DATE] with diagnosis of dementia with behavioral disturbance. Physician History and physical states resident has diagnosis of dementia with behavioral disturbances. Review of Residents #23's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, record review and interviews, the facility failed to adequately monitor a resident after an unwitnessed fall for 1 of 2 residents reviewed for falls (#5). Findings: The facilities Fall Management Policy, last revised 7/19 subsection D states, A fall incident report will be completed after a resident has had a fall, whether it is a witnessed or not, subsection E states, Complete Post Fall Observation tool, following a fall, to help identify if the cause of the fall is related to mental status changes, physical limitations or environmental factors and subsection F states, Documentation must be completed in the nurse's note on each shift X3 following the fall. The 'Neurological Assessment Policy, last revised 1/2019 states, Residents with suspected neurological compromise will have a neurological sign monitored and recorded for a minimum of 12 hours. Subsection III Procedures states A neurological assessment following resident head injury will be completed for all residents sustaining head…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 2 of 3 days of survey (12/9/24 and 12/11/24). Findings: The Safety Data Sheet for Rapid Multi Surface Disinfectant Cleaner noted the following: 4. First Aid Measures In case of eye contact: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Get medical attention immediately. In case of skin contact: Wash off immediately with plenty of water for at least 15 minutes. Wash clothing before reuse. Thoroughly clean shoes before reuse. Get medical attention immediately. If swallowed: Rinse mouth with water. Do not induce vomiting. Never give anything by mouth to an unconscious person. Get medical attention immediately. If inhaled: Remove to fresh air. Treat symptomatically. Get medical attention. The Safety Data Sheet for Enzymatic Foul Odor Digester noted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care (Resident's #14, and #180). In addition, the facility failed to follow provider orders for 2 of 3 residents reviewed for respiratory care. (Resident 's #80 & #180) Findings: Review of facilty policy CPAP/BIPAP/AVAP Management dated 8/6/24 states .keep out of direct sunlight. Store in clean zip lock or string-tie plastic bag. The storage bag should be changed weekly . 1. Resident 180 was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, and shortness of breath. Observations of Resident #180 on 12/9/24 at 10:20 a.m., and 2:28 p.m., and 12/10/24 at 10:25 a.m., a nebulizer was observed on bedside table with tubing connected to mask lying on top of table not bagged. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the hood system, 2 wall air conditioning units, a floor fan, a grease trap cover and the ceiling grid hangers for 1 of 1 tour. On 12/9/24 from 9:05 a.m. to 9:35 a.m., an initial kitchen tour was completed with the Food Service Director in which the following findings were observed: - The hood system filers was dusty/dirty. - The wall air conditioning unit and the wall above it, by the 3-bay pot sink, were dusty/dirty. Also, the wall below the air conditioning unit was soiled with dried liquid residue. - The wall air conditioning unit and the wall above it, in the dish room, was dusty/dirty. - The ceiling grid hangers were rusty and stained a yellowish color throughout the kitchen. - The floor fan was dusty/dirty. -The grease trap lid had chipped/missing paint creating an uncleanable surface. On 12/9/24 at 9:35 a.m., in an interview, the Food Service Director confirmed the findings.

Based on facility policy, record reviews, and interviews, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all residents receiving an antibiotic. Findings: Review of the facility policy Antibiotic Stewardship Program last revised on 8/24 states .To improve antibiotic use are expected to reduce adverse events, prevent emergence of resistance and lead to better outcomes for residents . Infection Preventionist: Monitors and supports antibiotic activities through rounds, review of providers orders, documentation, and available reports. Tracks antibiotic therapy through use of line listings and pharmacy report. Reviews antibiotic resistance patterns: Monitors HAI (Heath care Acquired Infections) and MDRO's (multi-drug resistant organisms) on Monthly Line listings and Infection Control Report looking for increased rates or trends and under Tracking/Reporting: Monitoring measures of antibiotics use by auditing available reports and resident medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure that a medical provider and the resident's representative were notified timely of a significant change and/or incident for 1 of 3 residents reviewed for falls (Resident #1). Findings: Resident #1 has a history of lumbar vertebra fracture and a bone density disorder with a most recent Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Review of the facilities incident report stated Resident #1 had fallen on 2/2/25 at 5:00 p.m. and the medical provider was notified of the fall on 2/3/25 at 1 p.m. (20 hours after the fall), the incident report lacked any further description, resident assessment or resident representative notification after the fall. Review of the nursing documentation shows a Post Fall Observation completed on 2/3/25 at 4:06 p.m., stating the resident obtained a fall in the dining room while ambulating using a walker and there were no abnormalities in his/her neurological status. The report lacked resident representative notification of the fall. In addition,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and family interview, the facility failed to provide dental care and dress a resident in clean clothes for 2 of 2 residents sampled for activities of daily living (ADL) (Resident's #7 & # 10). Findings: 1. Resident 10 was admitted on [DATE] and has diagnoses to include dementia. Review of Minimum Data Set (MDS) dated revealed Resident #10 had a Brief Interview for Mental Status (BIMS) of 0 of 10 indicating he/she is not cognitively intact. During an initial tour of facility on 12/9/24 at 10:15 a.m., Resident #10 was observed walking down the hall with a family member, passing 4 other residents with an excessive amount of what appeared to be food/tartar build up on his/her teeth. At this time the family member indicated that he was bringing his mother/father to the dentist to have his/her teeth cleaned because they were really bad. Resident #10 returned to facility at approximately 12:25 p.m. Review of Resident 10 care plan updated 8/23/24 states: Problem: [Resident 10] requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview the facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by administering doses of Insulin outside of the physician order parameters and failed to follow the care plan in the area of nutrition for 1 of 5 reviewed for unnecessary medications (#5). Finding: Resident #5's current Physician orders contained an order, dated 9/7/23 for Novolog Insulin 100 unit/mL (milliliter) give 6 units subcutaneous three times daily for type 2 Diabetes Mellitus with Diabetic Polyneuropathy with Instructions to Hold for Blood sugar less than 110. Review of the Electronic Medication Administration Record (EMAR) for October 2024 states, nursing administered Novolog insulin, 6 units on 10/13/24 with a documented blood sugar of 100 and on 10/16/24 with a blood sugar of 98. The EMAR for November 2024 states, nursing administered Novolog insulin, 6 units on 11/9/24 with documented blood sugar of 109. In December 2024, nursing administered Novolog insulin, 6 units on 12/1/24 with a blood sugar of 108 and on 12/7/24 with a blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 12/11/24, were effective. The Federal citations F684, and F757 were cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 2/5/25. Finding: 1. During the follow-up survey on 2/5/25, it was determined that F684 and F757 would be recited for the same reasons: F684 for failure to document and adequately monitor a resident after an unwitnessed fall and F757 for failure to ensure that a resident's drug regimen was free from unnecessary medications (see F684 and F747). On 2/5/25 at 3:20 p.m., during and interview, the above was confirmed with the [NAME] President of Quality Improvement and Nursing Services and the Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure food was served under sanitary conditions during 1 of 3 units observed during lunch meal (Cortland Unit). Findings: Review of Infection Control: Standard Transmission Based Precautions Policy dated 9/18 states: Hand washing is the single most important seep in infection control. Hands must be washed before and after all resident contact . On 12/9/24 at 12:00 p.m., Licensed Practical Nurse (LPN) was observed coming out of room [ROOM NUMBER] holding a lunch tray. LPN was observed walking down the hall to kitchen utility cart located outside of room [ROOM NUMBER]. LPN then removed trash from the top of the lunch tray with bare hands and placed it in trash can. LPN then placed the lunch tray on the kitchen utility cart, walked past hand sanitizer located outside room [ROOM NUMBER], and proceeded to walk across the hall and into room [ROOM NUMBER] where she was observed to place her right bare hand on a resident's shoulder, and her left bare hand on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, and record review, the facility failed to assess and have measures in place to monitor and prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility resulting in the potential for harm to all residents in the facility. Finding: On 10/12/23, the facility's Legionella Prevention Program policy developed July 2019 was reviewed. Under procedure - The following employees will be on the Water Management Team: The Administrator, the Infection Control Specialist, the Maintenance Director and the Corporate Plant Manager. The policy indicates to 1. Describe your building water systems. 2. Describe your building water systems using a flow diagram. 3. Identify areas where Legionella could grow & spread on the flow diagram. 4. Decide where Control Measures should be applied & how to monitor them. 5. The elements of the program will be reviewed at least once per year. There was no evidence of a description and diagram of the water management system that identified areas of potential growth and spread of Legionella or other opportunistic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure that a call bell was accessible to 3 of 26 sampled residents observed for 1 of 3 days of survey (Residents #8, 5, and 18). Findings: On 10/10/23 at 10:18 a.m., a surveyor observed Resident #8 sitting in his/her wheelchair. Resident #8's call bell was wrapped around the siderails of his/her bed. The resident was not able to reach the call bell. On 10/10/23 at 10:42 a.m., a surveyor observed Resident #5 lying in bed and his/her call bell was laying on the floor. The Resident was not able to reach the call bell. On 10/10/23 at 10:42 a.m. a surveyor observed Resident #18 sitting in his/her wheelchair. Resident #18's bed was pushed against the wall and the call bell was wrapped around the side rail closest to the wall. The resident was not able to reach the call bell. On 10/10/23 at 11:32 a.m. the above findings were confirmed with Registered Nurse #1. At this time Registered Nurse #1 placed the call bells within reach of these three residents. On 10/10/23 at 11:44 a.m. the above findings were discussed with the Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable interior for the laundry rooms, the basement floors, the ice machine, doors and door frames, ceiling tiles, privacy curtains and patient lifts for 1 of 1 environmental tours. Findings: On 10/12/23 from 8:15 a.m. to 8:50 a.m., an environmental our was conducted with the Maintenance Director, in which the following findings were observed: > The laundry room had a washing machine base that had chipped/missing paint and wash rusty creating an uncleanable surface. The cement floor behind the washing machines had chipped/missing paint creating an uncleanable surface. > The dryer room had two wall vents that were rusty and dusty/dirty. The floor mat was ripped open in many places creating an uncleanable surface. The wall mounted air conditioning unit was dirty/dusty. > The basement ramp, the basement floor, the basement nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of Safety Data Sheets (SDS), the facility failed to ensure that the residents environment was free from the potential risk of accident relating to a patient lift and missing safety clips. In addition, the facility failed to ensure that a chemical was properly secured for 3 of 3 observations for 1 of 3 days of survey (10/10/23) Findings: 1. On 10/10/23 at 11:10 a.m., a surveyor observed the unlocked linen closet which had a bottle of 100% Acetone Nail Polish Remover Onyx Brand on a shelf inside the closet. Safety Data Sheet for 100% Acetone Nail Polish Remover Onyx Brand noted: Section 2: Hazard Identification. 2.1. Hazard Classification - Flammable Liquid and Vapor Irritating to eyes Vapors may be irritating to eyes, nose, throat, and lungs May cause central nervous system depression. Section 4: First aid measures Eye contact: In case of contact with substance, immediately flush skin or eyes with running water for at least 20 minutes. If symptoms persist, call a physician. Skin contact: Wash skin with soap and water. Remove and wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling lights, ceiling tiles, ceiling vents, the hood exhaust system, wall mounted air conditioning units, the food mixer, shelving, the walk-in cooling unit, the walk-in freezer and the ice machine for 1 of 3 days of survey. (10/10/23) Findings: On 10/10/23 from 9:00 a.m. to 9:45 a.m., an initial kitchen tour was conducted with the Food Service Director in which the following findings were observed: > The cart storage area had three ceiling tiles with dried liquid spatter on them. The exhaust vent was dusty/dirty. > The utility closet had a dusty/dirty ceiling exhaust vent. The ceiling light lens cover had large amount of dust/debris in it. > The kitchen office ceiling light lens cover was heavily soiled with dust/dirt. > The exhaust hood filters were dusty/dirty. > There were eleven(11) ceiling tiles above a food preparation area that had dried liquid spatter and dust on them. > There were two(2) wall mounted air conditioners, one(1) over a clean dish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.