River Ridge Living Center

Based on record review and interview during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, time frames for the different steps in the process. Specifically, the facility policy titled, Long Term Care Solutions, Drug Regimen Review did not identify time frames for when the Pharmacist would notify the facility and Physician of irregularities, how long the Physician had to respond to the report or how long the nursing staff have to address identified issues requiring nursing intervention. This is evidenced by: An undated policy titled, Long Term Care Solutions, Drug Regimen Review documented, Upon completion of a drug regimen review by the consultant pharmacist the following steps are taken: If an irregularity is identified, the consultant pharmacist documents the relevant drug and summary of recommendation in the resident's medical record. A separate drug regimen review document is completed by the consultant pharmacist whenever an irregularity is identified. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for two (2) (Resident #s 41 and 80) of 13 residents observed during a medication pass for a total of 27 observations. This resulted in a medication error rate of 7.41%. This is evidenced by: The Facility's Policy and Procedure titled Administering Medications revised February 2024, documented . only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: (a) the date and time the medication was administered. (b) the dosage. (c) the route of administration. (d) the injection site (if applicable); (e) any complaints or symptoms for which the drug was administered. (f) any results achieved and when those results were observed; and (g) the signature and…

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 conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for three (3) ( A, B, and C Wings) of three (3) medication carts, and 1 (C Wing) of 2 medication rooms reviewed. Specifically, (a.) 1 Novolog Kwik insulin pen was in a bag labeled Degludec insulin; (b.) 8 insulin kwik pens and 3 vials of insulin had no open and or expiration dates; (C.) 2 bottles of Megace liquid were discontinued; (d.) 3 inhalers had no open and or expiration dates; (e.); 3 bottles of eye drops had no open and or expiration dates; (f.) 1 bottle of eye drops opened [DATE], expired as of [DATE]; (g.) 1 opened bottle of Jevity Tube feed with 200 milliliters remaining was found in the medication room refrigerator; (h.) 1 black extra-large ice pack belonging to a discharged resident was found in the medication room refrigerator. 1 crate overflowing with discontinued medications…

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 during a recertification and abbreviated survey (Case #'s NY00349575 and NY00370532), the facility did not ensure that food and drink were palatable and attractive for two (2) (Residents #19 and 32) of 11 residents reviewed for palatable and appealing food and drink. Specifically, (a.) residents complained that the food was cold, unattractive, and generally unpalatable during the resident council meeting; (b.) Resident #19's lunch tickets did not match what the resident received during their lunch service on 3/17/2025; (c.) Resident #32 complained of cold, unattractive, and not palatable food, and during lunch service on 3/13/2025, the resident's food tray did not match their ticket This is evidenced by: A facility policy titled Food and Nutrition Services, dated 1/2024, documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering each…

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 that special eating equipment and utensils were provided for one (1) (Resident #38) of seven (7) residents reviewed for dining. Specifically, for Resident #38, adaptive eating equipment was not provided to maintain or improve the resident's ability to eat independently. This is evidenced by: Resident #38 was admitted to the facility with unspecified dementia (a decline in mental ability severe enough to interfere with daily life), essential (primary) hypertension (persistent high blood pressure), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels). The Minimum Data Set (an assessment tool) dated 2/15/2025 documented the resident had moderate impairment in cognition, was able to make themselves understood, and was usually able to understand others. During an observation on 3/11/2025 at 1:02 PM, Resident #38 was eating lunch in the common area. 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, record review, and interview during the recertification survey, the facility did not ensure food was stored, prepared, distributed, or served food in accordance with professional standards for food service safety in the main kitchen and two (2) of three (3) kitchenettes. Specifically, equipment, floors, and walls were not clean and/or were in good repair, and the facility did not have the correct equipment to test the chemical sanitizing solution. This is evidenced by: During observations of the main kitchen on 3/11/2025 at 10:18 AM, the following was noted: 1. Test papers to check the sanitizing solution did not have a graduation of 150 parts per million of quaternary ammonium compound graduation and another above 400 parts per million of quaternary ammonium compound. The efficacy range as stated on the sanitizer concentrate label was between 150 and 400 parts per million of quaternary ammonium compound. 2. The following items were soiled with food particles: Bulk food containers. Shelving. Sheet pan rack. Stoves. Floor under cooking line equipment. Shelving…

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 interview during the recertification survey, the facility did not ensure food brought for residents by family or visitors was stored safely and in a way that is either separate or easily distinguishable from facility food on one (1) (A-Wing Unit) of three (3) resident units. Specifically, resident food stored in the resident unit kitchenette refrigerators was not properly labeled. This is evidenced by: The document titled, Food Brought by Family/Visitors and dated 11/2024, documented that food brought to residents are to be labeled with the resident name, date, and use-by date. During observations on the A-Wing Kitchenette on 3/11/2025 at 11:16 AM, two restaurant entrees were not labeled and dated. During an interview on 3/11/2025 at 2:51 PM, Administrator #1 stated that the staff should label food brought to residents with the resident name, date received, and the date to discard the food. They further stated that staff would be re-educated on labeling food brought to residents. 10 New York Codes, Rules, and Regulations 415.14(h)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during a recertification and abbreviated survey (Case #NY00349575), the facility did not ensure it established and maintained an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and did not maintain infection control prevention during dressing changes for two (2) (Resident #s 32 and 47) of four (4) residents reviewed for pressure sores. Specifically: (a.) for Resident #32, Licensed Practical Nurse #1 did not set up and maintain a clean field and proper infection control that included proper hand hygiene was performed, during a dressing change to prevent contamination of a resident's wound; (b.) for Resident #47, Licensed Practical Nurse #5 did not change gloves and hand sanitize during the dressing change; (c.) Staff did not maintain isolation precautions by closing doors to isolation rooms with residents who were positive for Covid 19 and on droplet precautions; (d.) the facility…

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 maintain a pest-free environment and an effective pest control program on one (1) of six (6) resident units. Specifically, small fly infestation was found. This is evidenced by: During observations on 3/11/2025 from 10:15 AM through 12:35 PM, Little black flies were found in the corridors by Room #s 54, 57, 62, and 73. Little black flies were found flying around a resident with a feeding tube on the C-Wing. During observations on 3/12/2025 at 9:45 AM, little black flies were found flying around staff serving meal trays. During an interview on 3/11/2025 at 11:30 AM, Family Member #10 stated that the fly infestation was so bad they covered the television in the resident room and that it helped when the trash was removed from the room. During an interview on 3/12/2025 at 12:15 PM, Certified Nurse Aide #3 stated there have been black flying bugs since they were hired, and that though the facility had a pest control vendor, the problem was worse on some days more than other days.…

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 a recertification survey, the facility did not ensure an interdisciplinary team assessed residents to determine their ability to safely self-administer medication when clinically appropriate for one (1) (Resident #16) of one (1) resident reviewed for medication administration. Specifically, Resident #16 was observed sitting in the solarium (a room that permits abundant daylight and views of the landscape while sheltering from adverse weather) of the B Wing administering their nebulized medication without being assessed as to whether they could safely self-administer their medication. This is evidenced by: The facility policy titled, Administering Medications, updated February 2024, documented that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they have the decision-making capacity to do so safely. Resident #16 was admitted to the facility with diagnoses of chronic systolic congestive heart failure (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a recertification and abbreviated survey (Case #NY00370532), the facility did not ensure each resident's right to make choices about aspects of their life that were significant for them for two (2) (Resident #'s 32 and 34) of 25 residents reviewed. Specifically, (a.) Resident #32 did not have a choice of time for application of their C-PAP (continuous positive airway pressure) machine. (b) Resident #34 did not have a choice of time for returning to bed after dialysis (treatment for kidney disease) appointments. This is evidenced by: Resident #32: Resident #32 was admitted to the facility with diagnoses of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), obstructive sleep apnea (a sleep disorder where breathing stops during sleep due to a blockage in the airway causing a decrease in oxygen delivery to the body), and osteomyelitis of the spine (bone infection from an open wound that is infected). 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 record review and interviews conducted during the recertification survey, the facility did not ensure the resident's right to be free from abuse and neglect for one (1) (Resident #14) of seven (7) residents reviewed for abuse and neglect. Specifically, for Resident #14, a Certified Nurse Aide provided care to the resident by themselves when the resident was care planned to be a two person assist with care. This resulted in the resident falling out of bed, sustaining ecchymosis (bruising) to their right facial area and a laceration above their right eye. Floor mats that were care planned to be on both sides of the bed parallel to the bed due to Resident #14 being at risk for falls were not in place during care when Resident #14 fell out of bed. This is evidenced by: Resident #14 was admitted to the facility with diagnoses of vascular dementia (dementia caused by a series of strokes. Restricted blood flow due to strokes reduced oxygen and glucose delivery to the brain, causing cell injury and neurological deficits in the affected region), epilepsy (a brain disease where nerve…

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 and abbreviated survey (Case #NY00370532), the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made for two (2) (Residents #14 and #32) of seven (7) residents reviewed for abuse. Specifically, (a.) an allegation of a Certified Nurse Aide not following care plan recommendations while they provided care for Resident #14 on 3/08/2025 which resulted in the resident falling out of bed sustaining ecchymosis (bruising) to the facial area and a head laceration above their eye was not reported to the New York State Department of Health until 03/10/2025. Specifically, (b.) for Resident #32 an allegation of abuse that had been reported to staff resulting in a mark on the resident's face was not been reported to New York State Department of Health by the facility. This is evidenced by: Facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-…

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 staff interviews conducted during the recertification survey, the facility did not ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment, recognized, evaluated, and addressed the needs of every resident for two (2) (Resident #s 51, and 64) of five (5) residents reviewed for nutrition/hydration status maintenance. Specifically, (a.) Resident #51's weight was not monitored as indicated in their comprehensive person-centered plan of care despite being at risk for weight changes, and a quarterly dietary assessment was not completed to address the nutritional status of this resident. (b.) for Resident #64, nutritional care plan was not implemented, quarterly dietary nutrition status assessment was not completed, and weight were not done as scheduled despite Resident #61 being at risk for weight changes. This is evidenced by: Facility policy titled Nutritional…

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 interview during a recertification and abbreviated survey (Case # NY00370532), the facility did not ensure that all allegations of abuse were thoroughly investigated for one (1) (Resident #32) of seven (7) residents reviewed for abuse. Specifically, Resident #32 reported an allegation of abuse and rough treatment when a nurse put on their C-Pap (continuous positive airway pressure machine) mask on them during an overnight shift between 1/25/2025 and 1/26/2025. The facility did not initiate an investigation until 3/18/2025 after the resident was reviewed during the survey process between 3/11/2025 through 3/18/2025. This is evidenced by: The facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program - Reporting and Investigating, last updated October 2024, documented the residents have the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. All allegations of abuse are thoroughly investigated immediately. 1. All allegations are thoroughly investigated. 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 observation, record review, and interviews during the recertification survey dated 01/03/23 through 01/10/23, the facility did not prepare and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 kitchenettes. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications, equipment and floors required cleaning, and a refrigerator and a table required repair. This is evidenced as follows: During observations on 01/03/23 at 10:18 AM, in the main kitchen, the automatic dishwashing machine final rinse registered both zero degrees Fahrenheit (F) at 40 pounds per square inch (psi) and zero parts-per-million (ppm) of available chlorine while tableware was being washed; the operating instruction on the dishwashing machine state that the final rinse temperature is to be 180 F at between 15 psi and 25 psi. The slicer, floor mixer, table mixer, K-rated fire extinguisher, dry storage room door, and dietician office storage room were soiled with food particles, dirt, and/or grime.…

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 staff interview during the recertification survey dated 01/03/23 through 01/10/23, the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations in three (3) of 3 kitchenettes. Specifically, food brought to residents was not labeled and discarded per the facility policy. This is evidenced is as follows: The document titled Food Brought in from Outside Facility and dated 09/25/2020 documented that food brought in from the outside will be labeled by staff with the resident name, the date the item(s) was brought to the facility, resident room number, and will be discarded on the third day. During observations on 01/03/23 at 10:18 AM, in the C-Unit Kitchenette refrigerator, a homemade entre was labeled with the name of Resident #38; the label did not include a date; a homemade entre was labeled with the name of Resident #58 and the date 12/25/22; and a restaurant breaded cheese sticks and pizza did not have a label. In the A-Unit Kitchenette refrigerator, an entre was labeled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the Recertification Survey conducted 1/3/23 through 11/10/23, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative for 2 (Residents #81 and #100) of 2 residents reviewed. Specifically, the facility did not ensure that the medical record included documentation that a written notice of the facility's bed hold policy was provided to the resident or/or their representative upon discharge to hospital. This is evidenced by: The facility policy titled Bed Reservation/Retention dated 9/26/16, documented all residents will be informed verbally and in writing at the time of admission and again at the time of transfer of the (Facility name) bed retention/reservation policy. Resident #81: Resident #81 was admitted to the facility with diagnoses of multiple sclerosis, anxiety disorder, and pressure ulcer of sacral region. The Minimum Data Set (MDS - a resident assessment tool) dated 11/7/22…

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 a recertification survey on 1/3/2023 through 1/10/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #62) of 3 residents reviewed. Specifically, for Resident #62, the facility did not ensure wound care treatments to the resident's Stage 4 sacral wounds were provided in accordance with the physician order. This is evidenced by: Resident #62: Resident #62 was admitted to the facility with diagnoses of pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of sacral region; stage 4 (full-thickness skin and tissue loss), hypertension, and anemia. The Minimum Data Set (MDS- an assessment tool) dated 9/28/2022, documented the resident was cognitively intact, could understand others and could make self-understood. The Policy and Procedure titled Skin Care Protocol…

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 food that accommodates resident allergies, intolerances, and preferences was provided for 1 (Resident #78) of 3 residents reviewed for food. Specifically, for Resident #78, the facility did not ensure the resident was consistently provided with food preferences as documented on their meal tickets on 1/6/2023 and 1/9/2023. This was evidenced by: Resident #78 Resident #78 was admitted to the facility with diagnoses of diabetes, hyperkalemia, and acute kidney failure. The Minimum Data Set (MDS - an assessment tool) dated 11/21/2022, documented the resident was able to make themselves understood, understand others, and was cognitively intact. The undated Policy and Procedure (P&P) titled Resident Food Preferences, documented food preferences would be identified by the Dietician or nursing staff. Whenever possible, staff would attempt to accommodate resident food preferences. The undated P&P titled Resident Nutrition Services, documented prior to serving food trays, 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.

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 special eating equipment and utensils were provided for a resident who needed them for 1 (Resident #47) of 9 residents reviewed for dining. Specifically, for Resident #47, the facility did not ensure adaptive eating equipment was provided as documented on the resident's meal ticket for breakfast, lunch, and dinner on 01/06/2023. This was evidenced by: Resident #47 Resident #47 was admitted to the facility with dysphagia (difficulty swallowing), diagnoses of chronic respiratory failure, and osteoarthritis. The Minimum Data Set (MDS - an assessment tool) dated 11/12/2022, documented the resident was able to make themselves understood, usually able to understand others, and severely cognitively impaired. The undated Policy and Procedure (P&P) titled Eating Environment, documented adaptive self-help devices were provided as needed, as per the resident's plan of care, and as identified on meal tray…

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. Food preparation and serving areas and equipment are to be kept clean. Specifically, equipment, floors, and walls were not clean. This is evidenced as follows. The main kitchen and the unit kitchenettes were inspected on 09/22/2020 at 9:34 AM. The slicer, steamtable insert pans, table mixer, microwave oven, bulk food containers, butcherblock island drawers, stove, shelving, wall fan, floor fan, floor under cooking equipment in the main kitchen; walls and carts in the dishwashing machine room; and floors and walls in the kitchenettes were soiled with food particles, dirt, or grime. The Director of Food Service stated in an interview on 09/22/2020 at 10:34 AM, that she will review the daily routine cleaning list, update it, check every morning to verify all cleaning has been completed; and will contact the housekeeping department to have the kitchenettes cleaned. 10 NYCRR 415.14(h);…

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 a recertification survey 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, were reported immediately, but not later than 2 hours after the allegation was 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 caused the allegation did not involve abuse and did 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 #71) of 1 resident reviewed for abuse. Specifically, for Resident #71, the facility did not ensure an alleged incident involving the resident being restrained to a wheelchair with a gown was reported to the Administrator within 2 hours of 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.

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 that residents received treatment and care in accordance with standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #'s 18 and 19) of 18 residents reviewed. Specifically, for Resident #18, the facility did not provide monitoring for effectiveness of medication administered on an as needed basis and for Resident #19, the facility did not assist the resident with a range of motion or a home exercise plan as recommended by a physical therapist to prevent decline in functional ability to bilateral lower extremities. This is evidenced by: Resident #18: Resident #18 was admitted to the facility with diagnosis of Parkinson's disease, ulcerative colitis, and stage 4 colorectal cancer. The Minimum Data Set (MDS - an assessment tool) dated 7/14/20, documented the resident had no cognitive impairment could understand others, and could be understood. 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 record review and interview during the recertification survey, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it and if there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 3 (Resident #'s 49, 53, and #64) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #'s 49 and #64, the facility did not ensure irregularities noted by the pharmacist during medication regimen reviews were reviewed by the physician; and for Resident #53, the facility did not ensure the physician documented a rationale in the resident's medical record when the consultant pharmacist identified an irregularity during a medication regimen review. This is evidenced by: The Policy and Procedure (P&P) titled Drug Regimen Review last reviewed 7/2020, documented a separate Drug Regimen Review (DRR) document was completed by the consultant…

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 leaking waste and the compactor area was heavily soiled. This is evidenced as follows. The trash compactor area was inspected on 09/22/2020 at 10:19 AM. The trash compactor was leaking a black-brownish liquid onto the ground, and the trash compactor portal area was heavily soiled with a black greasy buildup on the standing area and in front of, above, below, and around the compactor door. The Food Service Director stated in an interview 09/22/2020 at 10:35 AM, that he first noticed the compactor leaking last Friday, July 27, 2018. The Environmental Services Manager stated in an interview on 07/30/2018 at 1:30 PM, that she will contact the vendor to replace the trash compactor and will have the entire compactor area thoroughly cleaned. 10 NYCRR 415.14(h)

Based on observation, record review and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that are accurately documented and complete for 2 (Resident #'s 19 and 42) of 18 residents. Specifically, for Resident #19, the facility did not ensure accurate documentation was reflected for a resident's transfer out of bed; for Resident #19, the facility did not ensure documentation was completed for physician ordered treatments for wound and skin care; for Resident #42, the facility did not ensure the resident's medical record included accurate documentation of the resident's physician ordered oxygen tubing change. This was evidenced by: The Policy and Procedure (P&P) titled Charting and Documentation Policy last reviewed 2/2020, documented that treatments or services performed are to be recorded in the medical record; documentation in the medical record will be objective, complete and accurate; and documentation of procedures and treatments will include care-specific details,…

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.