Hudson Park Rehabilitation And Nursing Center

Based on observation, interview, and record review conducted during a Recertification survey, the facility did not ensure that residents received proper treatment and assistive device to maintain hearing abilities for 1 (Resident #58) of 4 residents reviewed. Specifically, Resident #58 did not receive assistance with replacement of broken hearing aids and did not receive follow up Audiologist (a healthcare professional that manages hearing loss and balance disorders) visits for maintenance of hearing aids as recommended. This is evidenced by: Resident #58 was admitted with diagnosis of Unspecified osteoarthritis (degeneration of bone causing pain and stiffness), Impacted cerumen (ear wax), bilateral; Chronic obstructive pulmonary disease, unspecified (a condition involving constriction of the airways and difficulty or discomfort in breathing). The Minimum Data Set of 3/28/2024, documented resident was cognitively intact, could be understood, and understand others. During an observation and interview on 6/04/2024 at 1:50 PM, Resident #58 was noted to be very hard of hearing. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey, the facility did not ensure that residents who required respiratory care were provided such care in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences for 2 (Resident #20 and 98) of 3 residents reviewed. Specifically, Resident #s 20 and 98 oxygen therapy were not administered as ordered by the physician. This is evidenced by: The Policy and Procedure titled Oxygen Administration, last revised on 4/09/2024, documented the purpose of the procedure was to provide guidelines for safe oxygen administration. The procedure included that nursing staff should first verify the physician order for oxygen and then adjust the flow of oxygen as prescribed. Resident #20 Resident # 20 was admitted with diagnoses of Parkinson ' s Disease (disorder that affects the nervous system and the parts of the body controlled by the nerves); diabetes mellitus…

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, record review, and interviews during an Abbreviated survey (Case # NY00323479), the facility did not ensure residents were free from misappropriation of residents' property and free of exploitation for 3 (Resident #s 1, 2, and 3) of 3 residents reviewed. Specifically, for Resident #1 and #3, the facility failed to prevent forgery of the stolen checks which lead to the theft of the residents' personal funds. Specifically, for Resident #2, the facility did not ensure the resident had a secure location for their personal check book to prevent forgery of the resident's checks. Subsequently, leading to theft of the resident's personal funds, requiring Resident #2 to close their account to prevent further attempts of their funds being stolen from their checking account. This is evidenced by: The facility's policy and procedure titled, Misappropriation of Resident Property, last revised on 02/16/2024, was reviewed and indicated all reports of theft, unauthorized use or removal, embezzlement, or…

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, interviews, and record review conducted during the abbreviated survey (NY00337430), the facility did not provide effective housekeeping and maintenance services on five (5) of 5 resident units. Specifically, the facility did not ensure that resident room, resident bathroom, common areas, and closets were clean; and furniture and walls were in good repair. This is evidenced by: The following observations were noted on 01/10/2024 from 9:50 AM through 3:30 PM and again on 04/03/2024 from 11:35 AM through 12:06 PM: Finding #1: Soiled Floors • Floors were soiled in corners and next to walls in resident room #s 201, 203, 213, 217, 221, 227 bathroom, 304, 316, 317, 317 bathroom, 401, 402, 427, 523, and 525 (behind loose coving baseboard). • Floors were soiled around wardrobes in resident room #s 407, 408, 409, 412, 418, 420, 421, and 422. • The bathroom shower floor drains were soiled with a black buildup in resident room #s 505, 513, and 522. • The bathroom floor in resident room [ROOM NUMBER]…

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 during an abbreviated survey (NY00336807), the facility did not ensure each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used without adequate indications for its use for 1 (Resident #3) of 5 residents reviewed for unnecessary drugs. Specifically, Resident #3 was administered Resident #9's medication in error when the nurse became distracted. This is evidenced by: The Policy and Procedure titled, Medication Administration, revised 3/8/2024, documented medications shall be administered in a safe and timely manner, and in a way that ensured the resident's safety. Medications must be administered in accordance with the orders. Resident #3 The resident was admitted to the facility with diagnoses of diabetes, peripheral vascular disease (narrowed blood vessels reduce blood flow to the legs), and heart disease with heart failure. The Minimum Data Set (an assessment tool) dated 2/15/2024, documented the resident was cognitively intact, could be understood, and could understand others. The Medication…

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 during an abbreviated survey (NY00336807), the facility did not ensure its residents were free of any significant medication errors for 1 resident (Resident #2) of 5 residents reviewed for significant medication errors. Specifically, Licensed Practical Nurse #6 applied a 50 microgram Fentanyl transdermal patch (a strong narcotic pain medication that could be absorbed through the skin by applying a patch on the skin) on the resident's arm. The resident was prescribed a Fentanyl 12.5 microgram transdermal patch. This is evidenced by: The Policy and Procedure titled, Medication Administration, revised 3/08/2024, documented medications should be administered in a safe and timely manner, and in a way that ensured the resident's safety. Medications must be administered in accordance with the orders. The individual administering the medication must check the label 3 times to verify the right medication, right dosage, right time, and right route of administration before giving the medication. Resident #2 Resident #2 was admitted to the facility with…

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 facility record review during an abbreviated survey (Case #NY00277162), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #2) of 3 residents reviewed for injuries of unknown origin. Specifically, for Resident #2, the facility staff did not ensure to report a serious bodily injury of unknown origin within 2 hours of an allegation when on 5/14/2023 at…

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, record review, and interviews during abbreviated survey (NY00308571)dated 08/08/23 through 08/31/23 the facility did not maintain a pest-free environment and an effective pest control program one (1) of 6 resident units and the main kitchen. Specifically, the floors in the main kitchen electrical closets were heavily soiled with dirt and food particles, and dead cockroaches were found in the insect glue traps found therein. Additionally, the pest control vendor report dated 08/08/23 documented that insect traps were placed in resident room #s 510, 511, 513, and #515, however insect traps were not found in resident room #s 510, 511, 513, and #515 on survey. This is evidenced as follows: The document titled Mohawk Valley Pest Control, Inc. Service Report documented that the facility had been treated for cockroach activity approximately every one to 2 weeks from 10/04/22 through 08/08/23. The document titled Pest Sighting Log dated 12/02/21 through 08/06/23, documented that within the past 9…

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 during a recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 8 (Resident #'s 37, 43, 54, 64, 98, 116, 143, and #293) of 17 residents reviewed for baseline care plans. Specifically, for Resident #'s 54, 64, 143, and # 293, the facility did not ensure a baseline care plan was developed or completed within 48 hours of the resident's admission and for Resident #'s 37, 43, 98, and #116, the facility did not ensure the baseline care plans included the minimum healthcare information necessary to properly care for the resident. This is evidenced by: The facility Policy and Procedure titled Comprehensive Care Plans last revised 6/20/2020, documented all residents admitted to HPRNC will have baseline care plans initiated within 48 hours of admission. The plan of care developed will be based on individual and specific assessed risks, medical diagnosis,…

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 interviews conducted during a recertification survey, the facility did not ensure each resident was treated in a dignified manner for one (1) (Resident #90) of two (2) residents reviewed. Specifically, for Resident #90, the facility did not ensure staff were able to access and enter the resident's bathroom to assist the resident with toileting. This is evidenced by: Resident #90: The resident was admitted to the facility with the diagnoses of chronic obstructive pulmonary disorder, depression and muscle weakness. The Minimum Data Set (MDS-an assessment tool) dated 10/15/2021, documented the resident was without cognitive impairment, was able to understand and be understood. The MDS documented the resident required extensive assistance for toileting, transferring and dressing and supervision for personal hygiene. The MDS documented the resident had no falls since admission or the prior assessment. The Policy and Procedure (P&P) titled Dignity revised on 4/2020, documented each resident would be cared for in a manner that promotes and enhances his or her sense…

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 during the recertification survey, the facility did not ensure to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #38) of 3 residents reviewed for hospitalizations. Specifically, for Resident #38, the facility did not ensure the physician was notified when two physician ordered medications, Pregabalin (used to treat nerve and muscle pain and can also treat seizures) and Modafinil (used to promote wakefulness), were not available for administration upon the resident's re-admission to the facility. This is evidenced by: The Policy and Procedure (P&P) titled Admission/readmission Medication Orders dated 12/18/2019, documented upon review and approval of the hospital discharge medication list and discharge summary by the facility provider, if a medication was not available for the next dose the physician needed to be made aware for new orders at their discretion and a corresponding note would be placed in the EMR (electronic medical record). Resident #38: Resident #38 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 observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean on 3 of 4 resident units and baseboards were missing on the 4th floor resident unit. This is evidenced as follows. The floors were spot checked on 11/03/2021 at 11:15 AM, revealing that the floors at the base of door frames and the areas by the corners of resident room #'s 203, 209, 211, 216, 220, 222, 225, 226, 400, 403, 404, 407, 410, 413, 415, 418, 420, 500, 506, 508, 513, and #516 were soiled with a brownish build-up, and baseboards were missing in the hallways and dining room of the 4th floor resident unit. The Corporate Clinical Consultant stated on 11/03/2021 at 2:50 PM, that the facility had a written plan to address the environmental concerns in the residents' rooms, but the Director of Maintenance resigned, and the issues were not addressed. The Administrator stated in an interview on 11/04/2021 at 9:30 AM, that the facility will audit the floors in resident rooms to ensure that they…

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, interview and record review during the recertification survey, the facility did not ensure all alleged violations of abuse, neglect and mistreatment, including injuries of unknown source were thoroughly investigated for 1 (Resident #'s 56) of 3 resident's reviewed for skin conditions. Specifically, for Resident #56, the facility did not ensure bruises of unknown origin on the resident's bilateral (both) inner thighs were investigated to rule out abuse, mistreatment, or neglect. This is evidenced by: The Policy and Procedure (P&P) titled Abuse Prevention dated 5/21/2019, documented the facility identified events that may indicate abuse or neglect such as suspicious bruising, occurrences, patterns, or trends that may constitute as abuse and used this information to guide the investigation. The P&P documented the facility investigated different types of incidents as they occur. All incidents of potential abuse, neglect, misappropriation of resident property would be investigated. Resident #56: Resident #56 was admitted to the facility with the diagnoses of…

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, record review and interview during the recertification survey the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #'s 38, 41, 46, 56, 85, and #96) of 30 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #38, the facility did not ensure the CCP included care plans to address the resident's pain and diagnoses of heart disease, diabetes, and seizures; for Resident #41, the facility did not ensure a care plan was developed for the resident's risk of elopement, for Resident #46, the facility did not ensure a care plan was developed that addressed communication; for Resident #56, the facility did not ensure the CCP addressed the bruises on the residents bilateral inner thighs; for Resident #85, the facility did not ensure CCP's were…

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, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00285383), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #41) of 12 residents reviewed for accidents. Specifically, for Resident #41, the facility did not ensure appropriate interventions were implemented and care planned for after Resident #41 was identified as an elopement risk on 7/31/2021. Subsequently, Resident #41 successfully eloped from the facility on 10/24/2021. This is evidenced by: The facility policy titled Elopement Prevention and Safe Wandering last revised 1/1/2018 documented at admission/readmission, quarterly, annually, and with significant changes the Unit Manager/designee will assess each resident using the Elopement Risk/Leaving Against Medical Advice (AMA) assessment form. This form is designed to assess each resident's level for elopement/unsafe wandering and help in developing and documenting care plan interventions. Based on the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. Specifically, end caps were missing from the handrails in the hallways on 2 of 4 resident units. This is evidenced as follows. On 11/01/2021 at 1:15 PM, an inspection of facility hallways revealed that the endcaps were missing from the handrails exposing sharp metal edges in the hallway on the 2nd floor resident unit by resident room #'s 219, 220, and #225, and on the 5th floor resident unit by resident room [ROOM NUMBER]. The Regional Corporate Housekeeping Director stated in an interview on 11/01/2021 at 2:45 PM, that the facility will repair the handrails and order a spare supply of endcaps. The Administrator stated in an interview on 11/04/2021 9:20 AM, that the facility installed new end caps on 11/02/2021 and will monitor the hallways on resident units to ensure that the end caps are not removed. 10 NYCRR 415.12(h)(1)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed, maintained, and implemented for the monthly medication regimen review (MRR) process that addressed the time frames for the different steps in the process. Specifically, the facility did not ensure the MRR policy included time frames for the steps a pharmacist must follow when an identified irregularity requires immediate action to protect the resident and prevent the occurrence of an adverse drug event. This is evidenced by: The facility policy titled Pharmacy Consulting and Medication Regimen Reviews initiated 1/1/2011, and last revised 12/2017 documented, the expectation is for all pharmacy recommendations to be addressed on or prior to the physician visit following the recommendation but no later than 60 days from the date written. In the event a recommendation must be addressed by medical staff immediately (a potentially significant clinical concern) a call will be made to speak with staff directly. The staff will contact the medical provider who will be…

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, record review and interviews during the recertification survey, the facility did not ensure medical records were maintained in accordance with accepted professional standards and practices that were accurately documented for 2 (Resident #'s 56 and 64) of 3 residents reviewed for skin conditions. Specifically, for Resident #'s 56 and 64, the facility did not ensure the residents' weekly skin checks accurately documented bruises observed on the residents. This was evidenced by: The Policy and Procedure (P&P) titled Skin Checks Policy last revised 1/5/2018, documented it was the responsibility of the Licensed Practical Nurse (LPN) to observe skin integrity every shower/bath day and to report any new skin breakdown to the Nurse Manager/Nursing Supervisor. The P&P titled Documentation last revised 2/1/2019, documented all observations must be documented in the resident's clinical records, all incidents, accidents, or changes in the resident's condition must be recorded, and staff were to chart any other information that was pertinent to the resident's condition.…

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, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 4 (Resident #'s 18, 54, 95 and #104) of 4 residents reviewed for nutrition. Specifically, for Resident #'s 54 and 104, the facility did not ensure nutritional assessments were completed timely, did not ensure the physician was notified of weight changes in a timely manner, and did not ensure nutrition care plans included person-centered approaches to maintain acceptable parameters of residents' nutritional status. Specifically, Resident #18 the facility did not ensure that it identified that the resident was not taking in an adequate amount of fluids. Specifically, for Resident #95, the facility did not ensure the resident's weight and intake was consistently monitored. This is evidenced by: The Policy and Procedure (P&P) titled Nutritional Assessment dated 1/18, documented the Dietician would assess all residents' nutritional needs upon…

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 staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Toxic chemicals are to be labeled, ready-to-eat foods may only be handled with sanitary food service gloves (gloves) or utensils and food preparation equipment preparation areas are to be kept clean. Specifically, food contact and non-food contact equipment and floors in the main kitchen and resident unit satellite kitchenettes were not clean, and toxic chemicals were not labeled. This is evidenced as follows. The main kitchen and the unit nourishment kitchens were inspected on 06/24/2019 at 8:42 AM. In the main kitchen, the table mixer, worktables, shelving, refrigerator door gaskets, and the floor fan were soiled with food particles. One spray bottle located on the shelf below the chemical worktable was not labeled. On the unit nourishment kitchens, the floors below refrigerators, refrigerator door handles, and drawer handles were soiled or sticky to the touch. During…

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 staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean. This is evidenced as follows. The trash compactor area was inspected on 06/24/2019 at 10:05 AM. Litter and a brown, white, and yellow liquid were found below and on the ground down grade of the trash compactor. The Director of Maintenance stated in an interview conducted on 06/24/2019 at 10:05 AM, that the seal around the bottom of the compactor may be leaking. The compactor company was contacted about 3 months ago, but have not yet made repairs. 10 NYCRR 415.14(h)

Based on observation record review, and staff interview during the recertification survey, the facility did not maintain a pest-free environment and an effective pest control program. Specifically, the facility has not maintained an adequate pest control program as evidenced by multiple sightings of drain flies. This is evidenced as follows. The main kitchen was inspected on 06/24/2019 at 8:42 AM. Small drain flies were noted amongst and around the dishwashing machine area. The pest control vendor monthly service reports and the main kitchen pest-control sighting logs dating from January 2019 were reviewed on 06/24/2019. These documents revealed that kitchen staff noted they themselves, not a professional pest control vendor, treated for drain flies dating from 01/11/2019. The Director of Maintenance state in an interview on 06/24/2019 at 3:10 PM, that though dietary treats the kitchen drains themselves, he had shown the vendor the kitchen pest-control sighting logs. He will follow-up with the vendor to treat for drain flies in the main kitchen. 10 NYCRR 415.29(j)(5)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it treated each resident with respect and dignity and cared for each resident in a manner and in an environment that promoted, maintained or enhanced his or her quality of life, recognizing each resident's individuality for one (1) of five (5) dining rooms. Specifically, the facility did not ensure residents were treated with dignity during dining. This is evidenced by: The following observations were made in the 5th floor dining room: -06/24/19 at 9:42 AM, the last 2 residents served breakfast were served on Styrofoam plates and plastic ware. -06/25/19 at 1:24 PM, 7 residents were eating off Styrofoam plates, and 8 residents were drinking from using Styrofoam cups. -06/26/19 at 8:19 AM, Resident #179 was sitting at a table in the dining room with an 8-ounce glass of a chocolate drink spilled on the table in front of her. On 2 occasions, 2 different Dietary Aids (DAs) approached the resident to give her other items, but neither cleaned up the spill. A DA opened a…

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 record review and interviews during a recertification survey, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience for 1 (Resident #54) of 1 resident reviewed for restraints. Specifically, for Resident #54, the facility did not ensure a physician order was obtained for the use of a zip-back jumpsuit as a physical restraint and did not ensure a physical restraint care plan was developed. This is evidenced by: Resident #54: The resident was admitted to the facility on [DATE], with vascular dementia with behavioral disturbance, lattice degeneration of retina, and periodic headache syndrome. The Minimum Data Set (MDS) dated [DATE], documented the resident had severely impaired cognition, could understand others and could make himself understood. The Policy and Procedure (P&P) titled Restraint Use dated 08/18, documented the physician had to be contacted to report the application of the device with the reason, the Registered Nurse (RN)…

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 review, and interviews during a recertification survey the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (Resident #95) of three residents reviewed for pressure sores. Specifically, for Resident #95, the facility did not ensure infection control practices were maintained during a dressing change. This is evidenced by: Resident #95: The resident was admitted to the nursing home on [DATE], with diagnoses of cerebrovascular accident with hemiplegia (one sided paralysis), aphasia (inability to speak) and heart failure. The Minimum Data Set (MDS- an assessment tool) dated 5/2/19, assessed the resident as having intact cognitive skills for daily decision making and that the resident understood and was usually understood by others. It documented the resident had an unstageable pressure ulcer, required extensive assistance of two…

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 during a recertification and abbreviated survey (Case # NY000231379) the facility did not ensure that each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was palatable, attractive, and at a safe and appetizing temperature, for one of four units. Specifically, the facility did not ensure that the pancakes served on the fifth floor were palatable. This is evidenced by: Dining Room observations on 6/24/19 on the 5th floor were as follows: - 9:10 AM, the server picked up pancakes with gloved hands and placed them on plates. Some of the pancakes were curled up at the edges and none of them bent over when picked up from one side. Two residents put syrup on the pancakes and ate them like a slice of toast. The pancakes did not fold in their hands. - 9:14 AM, another container of pancakes came up from the kitchen, and the server continued to serve the pancakes onto plates with her hands. The pancakes did not fold over when picked up. - 9:20 AM, a nurse 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 during the recertification survey, the facility did not have a policy regarding the use of foods brought to residents by family and other visitors to ensure safe and sanitary handling from 11/2017 through 06/21/2019. Specifically, the facility did not ensure a policy was developed and information on safe food handling was provided to families and visitors that bring food to residents. This is evidenced is as follows. The Director of Admissions and Concierge Services stated in an interview on 06/24/2019 at 10:40 AM, during the review of the facility policy for foods brought in by visitors, that the policy was developed last Friday. No families other than the new admissions from today, have been provided information to help them understand safe food handling practices.

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2017 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in buildings utilizing gas operated equipment. Section 915.3(g)(1) requires that carbon monoxide alarms in existing buildings receive their primary power form building wiring served from a commercial source except in existing buildings, the use of a 10-year battery is permitted. Specifically, the carbon monoxide detection alarms were not hardwired to a commercial power source or were not powered by a 10-year battery. This is evidenced as follows. Observations on 06/25/2019 at 2:15 PM, revealed that the carbon monoxide detection in the kitchen and boiler rooms was not hard wired or powered with a 10-year battery. The Director of Maintenance stated in an interview on 06/25/2019 at 2:22 PM, that he was unaware of the requirement to provide carbon monoxide detection alarms with a 10-year battery. 483.70 (b); 2017…

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, staff interview, and record review during the recertification survey, essential equipment was not maintained in safe operating condition. Specifically, plumbing fixtures and walls in the main kitchen were not in good repair. This is evidenced as follows. The main kitchen was inspected on 06/24/2019 at 8:42 AM. The floor/wall base coving tiles left of the dishwashing machine and the garbage disposal unit were in disrepair. A Maintenance Department work order record review on 06/24/2019, revealed work order submissions by the Dietary Department, dating from November 2018, for repairs needed to the garbage disposal unit and from January 2019, for repairs needed to the floor/wall base coving tiles by the dishwashing machine. The Director of Maintenance stated in an interview on 06/24/2019 at 3:10 PM, that the garbage disposal should be removed, but it will involve fabricating a new stainless-steel attachment to the dishwashing machine and coordination with the Dietary Department while the dishwashing machine is down. Additionally, he stated that he was not aware…

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.