Resort Nursing Home

Based on record review and interviews conducted during an abbreviated survey (Incident # 2581915), the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress. This was evident for one (1) out of three (3) residents (Resident #1) sampled for abuse. Specifically, on 08/05/2025 at 1:59 PM Certified Nursing Assistant #1 reported to Registered Nurse #1 that Resident #1 slapped Clinical Transportation Aide #1, who was providing 1:1 supervision to Resident #1, and Clinical Transportation Aide #1 in return slapped Resident #1 while they were assisting them with repositioning the resident in their wheelchair. Registered Nurse #1 did not protect Resident #1 from further potential abuse; Clinical Transportation Aide #1 was left by themself in the room with Resident #1 until Registered Nurse Supervisor #1 came to the unit at 2:00 PM and removed Clinical Transportation Aide #1 from the unit and schedule. Resident #1 was assessed by both Registered Nurse #1 and Registered Nurse Supervisor #1 and there were no visible signs…

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 reviews and interviews, during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 to 05/29/2024, the facility did not ensure that all alleged violations involving abuse and neglect, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency. Additionally, the facility did not ensure the results of all investigations were reported to the State Survey Agency within 5 working days of the incident. This was evident for 3 (Resident #126, #136, and #195) of 7 residents reviewed for Abuse out of 36 sampled residents. Specifically, 1.) On 01/13/2024 at approximately 2:30 PM, the facility was made aware that Registered Nurse #3 administered the wrong medication to Resident #126. An initial report was made to the New York State Department of Health on 01/14/2024 at 9:01 AM. A Follow-up Investigation Report was not submitted by the facility within 5 working days of the incident. 2.) On 05/06/2024, Resident #136 had a physical altercation…

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 interview and record review during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 through 05/29/2024, the facility failed to ensure that residents were free of significant medication errors. This was evident for 1 (Resident #126) of 1 resident reviewed for medication administration. Specifically, Resident #126 had a physician's order for 12 tablets of Methadone 10 milligram by oral route once daily. On 01/13/2024, the Resident was administered 12 tablets of Percocet 10-325 milligrams instead of Methadone. Cross Reference: F658 - Services Meet Professional Standards The findings include: The facility policy titled Medication Administration with a revision date of 10/2023 documented the purpose of the policy was to ensure safe administration of medication for residents. The policy stated that medication and strength are verified with physician's order as transcribed on the medication administration record. Controlled substance record is signed immediately after a narcotic has been administered. During an interview on 05/29/2024 at 1:00 PM, Registered…

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 conducted during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 to 05/29/2024 the facility did not ensure that services provided by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for 1 (Resident #126) of 1 resident reviewed for medication administration. Specifically, Resident #126 had a physician's order for 12 tablets of Methadone 10 milligram by oral route once daily. On 01/13/2024, Registered Nurse #3 administered 12 tablets of Percocet 10-325 milligrams instead of Methadone. The findings include: The facility policy titled Medication Administration with a revision date of 10/2023 documented the purpose of the policy was to ensure safe administration of medication for residents. The policy stated that medication and strength are verified with physician's order as transcribed on the medication administration record. Controlled substance record is signed immediately after a narcotic…

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, record review, and interviews conducted during the recertification survey, the facility did not ensure the garbage and refuse were disposed of properly. This was evident during observation of the Kitchen. Specifically, the garbage compactor (GC) was observed open on more than one occasion. The findings are: The facility policy titled GC Area revised 4/2022 documented the garbage compactor door will be closed after each use to prevent pests, cross contamination and to maintain a clean environment. On 04/26/22 at 09:28 AM, the GC used by the Kitchen was observed with its door open. The Food Services Director (FSD) was present during the observation and stated the GC door is functional and able to close. On 04/29/22 at 09:23 AM, a Food Service Worker (FSW) was observed removing an uncovered garbage can from the kitchen by wheeling the can to the GC. FSW threw garbage bags in the GC, turned the GC on, and left the GC door open. On 04/29/22 at 03:24 PM the FSD was interviewed and stated the GC door is not closed after each use because staff use the GC often to…

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 during the Recertification/Complaint Survey, the facility did not ensure a resident was cared for in a manner that maintained. This was evident for 1 of 1 resident out of a sample of (Resident # 46). Specifically, Resident #46's stomach and gastrostomy tube were left uncovered and exposed to public view. The findings are: The facility's policy titled Abuse Prohibition revised December 2021 documented the staff was respectful of individual dignity. Resident # 46 had diagnoses of Gastrostomy status, Aphasia, and Non-Alzheimer's Dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #46 was severely cognitively impaired and required extensive assistance for bed mobility and dressing. On 4/26/2022 at 10:08 AM, 4/26/2022 at 3:11 PM, 4/27/2022 at 10:26 AM, 4/27/2022 at 3:04 PM and 4/28/2022 at 12:54 PM, Resident # 46 was observed lying in bed in their room without the privacy curtain drawn. Resident #46's stomach was exposed with gastrostomy tube visible from 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 that a resident was invited to participate in comprehensive care planning (CCP). This was evident for 1 of 32 sampled residents (Resident #69). Specifically, Resident #69 was not invited to CCP meetings with the interdisciplinary team (IDT). The findings include: The facility policy titled IDT Care Plan Meetings dated 12/2021 documented that CCP meetings with the IDT will be held initially within 21 days of admission, quarterly, upon significant change and upon request. Residents are invited to attend the IDT meetings. Resident #69 had diagnoses of Neurogenic Bladder, Diabetes Mellitus, and Paraplegia. The Minimum Data Set 3.0 (MDS) 02/25/2022 documented Resident #69 was cognitively intact. On 04/26/22 at 11:06 AM, Resident #69 was interviewed and stated they could not recall the last time they were invited to a CCP meeting with the IDT team. CCP Meeting attendance records documented CCP meetings for Resident #69 were held on 10/12/2021, 12/28/2021, 3/8/2022, and 4/19/2022.…

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 conducted during the Recertification survey, the facility did not ensure infection prevention control practices were maintained. This was evident for 2 of 2 residents reviewed out of a sample of 32 residents (Resident #62 and #69). Specifically, respiratory equipment for Resident #62 and Resident #69 was observed on multiple occasions unprotected, unlabeled, and undated. The findings are: The facility policy titled Oxygen Therapy dated 12/2021 documented oxygen nasal cannulas (NC) and masks must be changed once a week and must be stored in plastic bags when left at bedside. 1) Resident #62 had diagnoses of congestive heart failure and chronic obstructive pulmonary disease (COPD). The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had moderate cognitive impairments and required extensive assistance of staff for activities of daily living. On 04/26/22 at 10:37 AM and 04/27/22 at 12:18 PM, Resident #62 was observed in bed with one end of an…

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, the facility did not ensure the dishwasher was functioning properly to sanitize dinnerware and that food was stored under the proper temperatures. Specifically, 1) The facility dishwashing machine was not operating at the proper temperature to ensure proper sanitization of serving plates and utensils; and 2) The walk-in Freezer was not operating at the proper temperature to ensure that frozen foods remain frozen. The findings are: 1) The initial inspection of the kitchen was conducted on 6/6/19 at 9:45 AM. The facility dishwashing machine was inspected while in operation. The final rinse temperature was observed to reach a maximum operating temperature of 162 degrees Fahrenheit. The Food Service Director (FSD) was interviewed on 6/6/19 at 9:45 AM. He stated that he was aware of a problem with the hot water booster since the previous day. He stated that the booster was not operating properly and would fluctuate in operation, at times reaching 180 degrees and at other times not reaching 180 degrees…

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 each resident who displays or is diagnosed with Dementia receives the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well being. This was identified for 7 (Resident #38, #72, #64, #154, #177, #111 and #454) of 7 residents reviewed for Dementia care. Specifically, the facility did not develop person-centered care plans to reflect individualized approaches to care with measurable goals, timetables, and specific interventions, nor identify effective non-pharmacologic interventions to maintain the highest psychosocial wellbeing for these residents. Additionally, an intervention to provide Russian speaking staff to interpret the needs and wants was in place for residents who did not speak Russian (Resident #38, #72, and #64). The findings include but are not limited to: 1) Resident #38 was admitted to the facility on [DATE] 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 observations, record review, and interviews during the recertification survey, the facility did not ensure that each resident receive reasonable accommodation of needs by ensuring each resident's call bell was within reach. This was identified for 9 (Residents #160, #20, #68, #108, #175, #40, #195, #155, and #165) of 38 sampled residents. Specifically, 1) The call bell for Residents #160, #20, #68, and #108 was observed with the wire of the call bell wound, tied, and hung on the wall near the head of bed (HOB). 2) Resident #175 was observed with his call bell placed on top of the overhead lighting fixture above the HOB. 3) The call bell for Residents #155, #195, #40, and #165 was observed on the floor. The findings include but are not limited to: The facility's policy and procedure dated 10/2018 titled Use of Call Bells documented . 1. Explain use of call bell and place within easy reach . 1) Resident #160 has diagnoses including Anxiety Disorder, Anemia, and Hypertension. The resident was admitted to…

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 implement a comprehensive person-centered care plan for each resident. This was identified for 1 (Resident # 64) of 1 resident reviewed for Range of Motion (ROM). Specifically, Resident # 64's Comprehensive Care Plan (CCP) developed for the Development of the Functional Limitation in ROM included an intervention to use an Abductor pillow. The Physician ordered Abductor pillow was not observed in place on two separate occasions. The finding is: The Facility's Comprehensive Care Plan (CCP) policy dated 2/2018 documented that the Care Plan guides the care and treatment provided to each resident. The CCP addresses the resident's medical, functional, and severity of the resident's condition. Resident #64 was admitted to the facility on [DATE] with the diagnoses including Non-Alzheimer's Dementia and Muscle Spasm. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #64 could not 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.