Putnam Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2). Resident #12 had diagnoses Alzheimer's disease, dementia and depression. An Annual Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition and was dependent on staff with all activities of daily living. A physician order dated 11/26/24 documented to administer Baclofen 5 milligrams give 0.5 tablet (2.5 milligrams) 2 times per day, every day at 10 AM and 6 PM. Nurse's Progress Notes dated 12/4/24 documented the resident's family member was concerned that Baclofen might be making the resident lethargic. Registered Nurse Unit Manager #1 spoke with Nurse Practitioner #1 and Baclofen 2.5 milligrams was changed to once daily from twice daily. A physician order dated 12/4/24 documented to administer Baclofen 5 milligrams, give 0.5 tablet (2.5 milligrams) once daily. A physician order dated 12/5/24 documented to administer Baclofen 5 milligrams, give 0.5 tablet (2.5 milligrams) once daily. The December 2024 Medication Administration Record documented the physician's orders dated…

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 conducted during the Recertification Survey and Abbreviated Surveys (NY00354632, NY00357873, NY00337630, NY00372738, NY00372568, NY00373759, NY00364043, NY00339079) 4/21/25 to 4/23/25, the facility did not ensure one of five residents (Resident #11) were fed by staff members who completed a State-approved training course to assist residents in eating or drinking as required by regulations. Specifically, the facility was not able to provide documentation that Unit Assistants successfully completed a State approved training course for one Resident Assistants (Unit Assistant #26) observed feeding Resident #11 during a lunch meal. The findings are: Resident #11 diagnoses included Alzheimer's disease, Dementia and abnormal weight loss. The 4/21/25 Physician Order documented regular diet, blenderized texture, thin liquids consistency, aspiration precautions. The 3/19/25 Minimum Data Set documented Resident # 11 had severe cognitive impairment, was dependent on staff for all activities of daily living including eating and on a mechanically…

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 the abbreviated survey (NY00339079, NY00357873, NY00372568, NY00373759, NY00337630, NY00354632, NY00364043, NY00372738) conducted 4/21/25 to 4/23/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection and did not ensure there was a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease for all residents. Specifically, 1) facility staff were observed entering and exiting a contact and droplet isolation room (Resident #14) without donning and doffing personal protective equipment or performing hand hygiene. 2) Licensed Practical Nurse #3 was observed with their thumb entering the milk carton for Resident # 9 and Activities Leader #4 was observed with their thumb entering the top of milk carton for Resident #17. 3) Resident #18 was positive for respiratory syncytial virus and was observed walking up and down hallways of Apple unit without a mask during lunch 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.

Based on record review and interviews during an abbreviated survey (NY00345900, NY00332503), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 12 out of 39 residents reviewed for identification bands. Specifically, during an observation on 11/12/2024 there were 12 residents on the Apple unit observed without identification bands in place. The findings are: The facility Medication Administration policy dated 12/2016 and last revised 10/2023 documented that prior to administration of medication, the nurse must verify the resident's identification by checking the resident's identification band with the patient's name and medical record number. During observation conducted on 11/12/2024 at 3 PM on the Apple unit, there were 12 out of 39 residents noted without identification bands in place. During an interview on 11/12/2024 at 11:10 AM, Licensed Practical Nurse #1 stated most of the residents they administered medications to today on the apple unit did not have an identification band in place. Licensed…

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 an abbreviated survey (NY00345900, NY00332503), the facility did not ensure sufficient nursing staffing to attain or maintain the well-being of each resident for 39 residents on Unit A as determined by the facility nursing coverage plan as necessary to meet the needs of the residents. The findings are: The Facility Nursing Coverage Plan policy dated 8/3/2021 documented the purpose was to outline a staffing plan that shall be used to determine the personnel recommended for each shift as defined for each unit's core coverage and as necessary to provide the scope of services required to meet resident care. The Facility Assessment provided by the facility was last revised on 8/16/2024. The last review by the Quality Assurance and Improvement Committee was on 9/18/2023. The staffing plan documented a table describing the number of staff available to meet residents' needs, which listed the position of staff by title, as well as the number of full-time employees that hold…

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 an abbreviated survey (NY00345900, NY00332503) the facility did not ensure medications were administered in accordance with the prescriber's order or in accordance with professional standards for 3 out of 3 residents (Resident #1, Resident #2, Resident #3) reviewed for medication administration. Specifically, (1) Resident #1 had an order for the medication Depakote sprinkles, for their seizure disorder, and was administered their medication outside of the regulated time of an hour before or an hour after the scheduled time on 10/30/2024, 11/7/2024, 11/11/2024 and 11/12/2024. There was no documented evidence that the physician was made aware of the medication being administered late. (2) Resident #2 had an order for the medication Carbidopa-Levodopa, for their Parkinson's disease, and was administered their medication outside of the regulated time of an hour before or an hour after the scheduled time on 8/30/2024, 9/4/2024, 9/6/2024 and 9/17/2024. There was no…

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 an abbreviated survey (NY00345900, NY00332503), the facility did not ensure the residents environment remained free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 2 out of 3 (Residents #2, #3) residents reviewed for accidents. Specifically, (1) Resident #2 who had history of falls and required moderate assistance for transfers had falls from their wheelchair on 8/3/2024, 8/8/2024, 8/30/2024, 9/14/2024, 9/29/2024 with no injuries; (2) Resident #3 had unwitnessed falls on 8/7/2023, 11/14/2023, 1/5/2024 and 1/10/2024 with minor injuries. There was no documented evidence that new interventions were implemented to prevent further falls and care plans were not updated on each occurrence for both Residents #2 and #3. The findings are: The Facility Fall Risk Assessment and Fall Prevention policy dated January 2003 and last revised November 30, 2017, documented all residents will be free of falls and free 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 record review and interviews during an abbreviated survey (NY00345900), the facility did not ensure that a resident with urinary and bowel incontinence received appropriate treatment and services to prevent urinary tract infections. This was evident for 1 out of 3 residents (Resident #1) reviewed for incontinence. Specifically, Resident #1 who was always incontinent of bladder and bowel functions and dependent on direct care staff for cares was diagnosed with a urinary tract Infection on 5/7/2024 and 9/9/2024. Review of Resident #1's certified nurse accountability reports for May 2024, June 2024, July 2024, August 2024, and September 2024 revealed numerous occasions where there was no documented evidence of direct care staff providing bladder and bowel incontinence care. The Findings are: The undated Facility Incontinence policy documented residents who are incontinent of urine, feces, or both are kept dry, clean and comfortable while maintaining their dignity. Disposable diapers and pads are used…

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 (NY00345900, NY00332530) the facility did not ensure a facility-wide assessment documented what resources are necessary to care for its residents competently during day-to-day operations including nights and weekends. The assessment did not include a review of individual staff assignments and systems for coordination and continuity of care for residents within and across the staff assignments. Findings include: The Facility Assessment provided was last completed on 8/16/2024 and last reviewed by the quality assurance and improvement committee on 9/18/2023. The staffing plan documented a table describing the number of staff available to meet residents' needs, which listed the position of staff by title, as well as the number of full time employees that hold these positions. On 11/12/2024 the facility wide assessment was reviewed and revealed the assessment did not include the staffing plan, the requirements of number of staff allotted for each unit or per shift. During an interview on 11/14/2024 at 5:45 PM 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 review of facility records, observation and interview during the recertification and abbreviated surveys (#NY00311199), from [DATE] through [DATE], it was determined the facility did not ensure any individual working in the facility as a nurse aide for more than 4 months was competent to provide nursing and nursing related services, for 7 of 7 staff (Training Nurse Aide (TNA) #1-#7) reviewed for training. Specifically, TNAs were employed by the facility and functioned in the role of a nurse aide for greater than 4 months without receiving nurse aide certification. Findings include: The Centers for Medicare and Medicaid Services (CMS) published a quality, safety and oversight memorandum (QSO-22-15-NH-TLTC-LSC), originally dated [DATE], which documented that previous staffing waivers allowing nurse aides to work for greater than 4 months without completing a state-approved nurse aide competency evaluation program or passing an oral or written exam expired on [DATE], which required facilities to ensure…

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 staff interview and review of facility records during the recertification and abbreviated surveys (NY311199) form 10/17 to 10/25/23, it was determined the facility did not ensure each certified nurse aide received twelve hours of in-service education per year, based on their individual performance review for 4 of 8 CNAs (CNA #8, #9, #10 and #11) reviewed for inservices. Specifically, CNA #8 lacked 6 hours of training; CNA #9 lacked 10 hours of training; CNA #10 lacked 8.5 hours of training, and CNA #11 lacked 7 hours of training; and all 4 CNAs lacked an annual performance evaluation. Finding Include: Review of the facility records for in-service education, provided by the Infection Control Nurse/Educator (IP) #1, revealed: - CNA #8 received 6 hours of in-service in 2023, and the last performance evaluation was completed 12/12/20. - CNA #9 received 2 hours of in-service in 2023, and the last performance evaluation was completed 9/7/22. - CNA #10 received 3.5 hours of in-service in 2023, and the last performance evaluation was completed 2/12/20. - CNA #11 received 5 hours 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.

Based on observation, interview, and record review during the recertification survey conducted 10/17/23 through 10/25/23, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication carts (Cedar and Apple). Specifically, medications were not stored in a clean environment on medication carts located on the Cedar and Apple units and undated/expired drugs and biologicals were discovered on medication carts of the Cedar and Apple unit. Findings include: A facility policy titled, Medication Storage, last revised 4/2014 documented medications should be stored in an orderly, organized manner in a clean area and that expired/discontinued/contaminated medications will be removed from the medication storage areas and disposed. During a medication storage observation on 10/24/23 at 5:30 PM, with Registered Nurse (RN) #2, the following was observed on the Cedar Unit medication cart: -1 undated, opened tobramycin eye drops -1 undated, opened bottle of olopatadine eye drops -1 undated, opened bottle 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.

Based on observation and interview conducted during a recertification survey conducted 10/17/23 through 10/25/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food safety. Specifically, food items in the walk in refrigerator and the cook's refrigerator were unlabeled and undated. The rack designated for dry pans was wet. The findings are: The policy and procedure titled storage of food in the facility refrigerator dated 4/8/22 documented,all items must have received dates written. Stored items must be labeled with a name and open date. All items opened and prepared over 72 hours ago must be discarded. The initial tour of the kitchen was conducted on 10/17/23 from 9:10 AM to 9:50 AM and the following were identified: - A rack of bread with ten loaves of bread in a plastic bag had no receive date. - The walk-in refrigerator had a package of approximately ten slices of cheese that were not labeled or dated; a small pan of applesauce was not labeled; and a small pan of yogurt was dated 10/15 but not…

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 conducted during a recertification survey, the facility did not ensure for 1 of 5 residents (Resident #62), reviewed for activities of daily living, that care was provided in a manner to maintain dignity. Specifically, the urinary (Foley) catheter bag for Resident #62 was not concealed to prevent direct observation by other residents and their families. Findings include: A facility policy titled, Urinary Catheter Care, last revised 9/21, documented that privacy must be provided when a resident has the presence of an indwelling urethral catheter. Resident # 62 was admitted with diagnoses including but not limited to cerebral infarction, chronic kidney disease, and atrial fibrillation. The Significant Change Minimum Data Set (MDS - an assessment tool) dated 7/30/2023, documented that Resident #105 had moderately impaired cognition and was totally dependent of 2 or more staff for toilet use, and required the extensive assistance of 1 staff member for assistance with personal hygiene. A physician order dated 10/15/23 documented 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 reviews and interviews during the recertification survey from 10/17/23-10/25/23, the facility did not ensure that the call bell system was accessible for 7 (Residents #115, #60, #105, #109, #132, #72 and #12) of 12 residents reviewed for Environment. Specifically, multiple observations revealed that call bells designated for Residents #115, #60, #105, #109, #132, #72 and #12, were not within the resident's reach. The findings are: 1.) Resident #115 was admitted to the facility with diagnoses including anxiety disorder, senile degeneration of the brain, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented Resident #115 had severely impaired cognition and required supervision with bed mobility and transfers, and extensive assist of one staff with toileting. The fall care plan dated 4/11/22, documented for the call bell to be within reach. On 10/17/23 at 09:48 AM, Resident #115 was observed in bed awake, the call bell was hanging on…

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 interview conducted during the recertification and abbreviated surveys (# NY00317914) from 10/17 to 10/25/23, the facility did not ensure all injuries of unknown origin were thoroughly investigated and reported to the New York State Department of Health (NYSDOH) for 1 of 2 residents reviewed for abuse. Specifically, Resident #449 reported an unwittnessed fall and broken arm that was not thoroughly investigated to rule out abuse. Findings include: Resident # 449 was admitted on [DATE] with diagnoses including stroke, non-traumatic brain dysfunction, Parkinson's, and dementia. The Fall Risk assessment dated [DATE] documented the resident had intermittent confusion, required use of an assistive device for gait and balance, had a history of falls and was at high risk for falls. The Skilled Nursing Progress note dated 9/20/22 at 10:05 PM, documented Resident #449 was alert with periods of confusion and required contact guard and limited assistance with transfers and toileting. 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, interview and record review conducted during the recertification survey from 10/17/23 to 10/25/23, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene for one (Residents #64) of five residents reviewed for ADL's. Specifically, Resident #64 was observed on multiple occasions with urine-soaked pants and on one occassion was observed not out of bed as planned. Findings include: Resident #64 was admitted with diagnoses including but not limited to vascular dementia, hypothyroidism, muscle weakness, and orthostatic hypotension. The Comprehensive Minimum Data Set (MDS - an assessment tool) dated 7/26/23, documented Resident #64 had severely impaired cognition, and required extensive assist of two with toileting and transfers. The 11/25/2020 urinary/bowel incontinence/UTI prevention care plan documented the resident was incontinent of bladder and was to be toileted. Interventions included incontinent cares every two hours and as needed,…

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 and abbreviated (NY00312435, NY00323395) surveys conducted 10/17/232023 - 10/25/2023, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 3 of 8 residents (Resident #23, #299, and #105) reviewed for quality of care. Specifically, 1) Resident #23, had a physician order for Clonazepam (anxiety medication) and received an incorrect dose. 2) Resident #299 was sent to a medical appointment without an aide and the consultant physician refused to see the resident without an aide. 3) Resident #105 was administered crushed medications without a physician's order. Findings include: 1.) Resident #23 had diagnoses including Alzheimer's disease, hyperlipidemia, and major depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance of one for bed mobility and transfers,…

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 interview conducted during a recertification survey, the facility did not ensure that adequate supervision was provided to prevent accidents for 1 of 9 residents (Resident #302) reviewed for accidents. Specifically, Resident #302 who was assessed at high risk for falls on admission and was observed attempting to stand up from their wheelchair without staff assistance or redirection. The findings are: Resident #302 was admitted on [DATE] with diagnoses including lack of coordination, non-displaced fracture of seventh cervical vertebra, and dementia without behavioral disturbance. The fall assessment dated [DATE] documented the resident was at high risk for falls with score of 17. The occupational therapy (OT) evaluation dated 10/14/23 documented the resident assessment identified 3-5 deficits in areas of physical, cognitive, psychosocial skills resulting in activity limitation or participation restrictions. The resident presented with impairments in balance, mobility and strength…

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 from 10/17/23 to 10/25/23, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 3 of 25 opportunities (12%) resulted in error and impacted 2 of 6 residents (Resident #132 and #136). Specifically, 1) Resident # 132 was administered Metoprolol Extended Release Tablet crushed instead of whole, and 2) Resident #136 was administered medication through a feeding tube without flushing between 2 medications. The findings are: The facility's policy titled Medication Administration dated 12/16 documented that nurses should double check and ensure all medications were administered to patient/resident as per MD order. 1. Resident #132 was admitted to the facility with diagnoses including but not limited to diabetes, chronic kidney disease, and heart failure. The current physician order as of 10/23/23, documented to administer metoprolol succinate ER 50 milligram tablet extended-release 24 hr, by mouth once daily for ventricular…

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 the Recertification Survey and abbreviated survey (NY00323395) the facility did not ensure that each resident's representative was informed about appointments for 1 of 2 (Resident # 299) residents reviewed for notification. Specifically, Resident #299 was not seen at an orthopedic appointment due to not having an escort, and family was not contacted to accompany resident. Findings include: Resident #299 was admitted to the facility on [DATE] with diagnoses including a fracture of T9-T10 vertebra (thoracic spine), subsequent encounter for fracture with routine healing, diabetes, and congestive heart failure. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #299's cognition was intact and the resident had a fall with fracture in the last 2-6 months. The physician order dated 8/9/23 documented resident may go out on pass with family or outside appointment. The Out of House Appointment and Transportation Worksheet dated 8/9/23, documented…

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 (NY00323392) survey, the facility did not implement a person-centered care plan with measurable objectives, time frames and appropriate interventions based on comprehensive assessments for 1 of 5 residents (Resident #299) reviewed for activities of daily living. Specifically, for Resident #299 there was a non-compliant care plan for the TLSO back brace, which had no documented goals or interventions. The findings are: Resident #299 was admitted to the facility on [DATE] with diagnoses including fracture of T9-T10 vertebra, subsequent encounter for fracture with routine healing, diabetes, and congestive heart failure. The admission Minimum Data Set (MDS) assessment 9/5/23 documented the resident's cognition was intact and the resident had a fall with fracture in the last 2-6 months. The physician order dated 8/10/23 documented wear TLSO Brace when out of bed. The Non-compliant with TLSO Brace Care Plan dated…

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 interview conducted during an abbreviated survey (NY00316737, NY00319286), the facility did not ensure that all alleged violations involving abuse was reported immediately to the New York State Department of Health (NYS DOH). This was evident for 2 of 4 (Resident # 1 and #2) Residents reviewed for Abuse. Specifically, (1) the facility was notified of an abuse allegation on 5/12/2023 by Resident#1's family. The facility did not report the incident to NYS DOH until 5/16/2023; (2)The Facility was notified of an alleged abuse incident involving Resident #2. The incident was reported to the Director of Nursing (DON) on 6/28/2023. The facility did not report the incident to NYS DOH until 6/30/23. The findings are: The Facility Policy on Abuse Prevention and Reporting dated 1/9/2017, last revised 12/30/2019 documented residents must not be subjected to abuse by anyone including but not limited to facility staff. All staff will notify their supervisor who will notify their RN Supervisor. 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 interview conducted during an abbreviated survey (NY00319286), the facility did not ensure that each resident was free from abuse for 1 of 3 Residents (Resident #2) reviewed for Abuse. Specifically, on 6/27/2023, Certified Nursing Aide (CNA #1) was witnessed rough handling and calling Resident#2 demented and saying they did not have the patience to deal with the resident, when CNA#1 was getting the resident ready for a shower and during a transfer from the shower bed back to bed. The Findings are: The Facility Policy on Abuse Prevention and Reporting dated 1/09/2017, last revised 12/30/2019 documented residents must not be subjected to abuse by anyone including but not limited to facility staff. Verbal abuse is defined as oral or gestured language that willfully includes disparaging and/or derogatory terms to residents within hearing distance or ability to comprehend. Examples of verbal abuse include but are not limited to threats of harm or saying things to frighten the resident. Resident #2 was admitted to the facility with 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.

Based on observation, record review and interview conducted during an Extended Survey (#NY000264371), the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the administrator failed to have a system in place for monitoring/inspecting the condition of hoyer pads and indicating which staff would be responsible for monitoring/inspecting the hoyer pads. The Findings Are: Facility Policy and Procedure titled Mechanical Lift revised August 2018 indicates all staff must assure that all hoyer slings are in good repair. If sling is noted to be in disrepair it must be taken out of service. Facility Accident/Incident Report indicated that the Director of Nursing (DON) completed the investigation on 09/17/2020 and removed the equipment from the unit. The investigation indicates Resident #1 was being assisted from the wheelchair to the bed via the hoyer lift with assist of 2 staff. When Resident # 1 was lifted via…

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 provide and maintain an infection control program to help prevent the transmission of communicable diseases and infections. Specifically, (1) the staff did not consistently apply personal protective equipment (PPE) upon entry to a room where a resident on contact-based precautions resided and (2) equipment used for transferring residents was observed being dragged on the floor. This was evident for 1 of 1 residents reviewed for infection control (Resident #31) and during a facility observation on 1 of 4 units (Apple). The findings are: 1. Resident #31 was re-admitted to the facility on [DATE] following a hospital stay for treatment of pneumonia. Review of laboratory tests from the hospital revealed the resident was infected with Clostridium Difficile (C. diff. - a bacterial infection of the colon). The resident was placed on Contact Precautions (used to prevent the spread of infection from touching…

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 conducted during a recertification survey, the facility did not ensure that the nurse aides were provided the required hours of training and annual in-service training on dementia care management and resident abuse prevention to ensure safe delivery of care. This was evident for 10 of 10 Certified Nursing Aides (CNAs # 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) reviewed for nurse aide training. The findings are: The CNA annual in-service training records were reviewed with the In-service Coordinator in the afternoon of 7/24/18 and on 7/25/18 at 4:20 PM. This review revealed that none of the following CNAs were provided 12 hours of training annually (based on their date of hire) and that the mandatory training on abuse prevention and dementia care was not being done annually. Specific findings include: - CNA #3 was hired on 4/18/08. Documented evidence revealed 1/30/17 as the last date of abuse in-service training. There was no evidence that dementia care management training was provided since at least 4/2017. The total hours of training received since…

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 interview conducted during a recertification survey, the facility did not ensure that care and services were provided in accordance with the residents' care plan for 1 of 1 resident (Resident #95) reviewed for physical restraints; for 1 of 3 residents reviewed for hospitalization/quality of care (Resident #24); and for 1 of 1 resident reviewed for dialysis (Resident #140). Specifically, the facility did not: (1) ensure that an assistive device (Velcro seatbelt) used to prevent the resident from falling off a chair was released in accordance to the physician's order. (2) address Resident #24's ongoing weight gain; (3) consistently maintain ongoing communication with the dialysis center regarding the care of Resident #140 who was undergoing dialysis treatment; and The findings are: 1. The facility Restraint Policy dated [DATE] stated that if a restraint is utilized it must be released every 2 hours for at least 10 minutes for prescribed activities as per physician orders, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not re-evaluate the person-centered care plan and develop appropriate interventions for 1 of to address changes in the resident's current health status. Specifically, a care plan for constipation was not revised to address issues related to a resident's recent hospitalization. This was evident for 1 of 1 resident (#140) reviewed for constipation /quality of life. The finding is: Resident #140 was admitted to the facility on [DATE]. The current diagnoses included End Stage Renal Disease, Dehydration and Constipation. The Significant Change Minimum Data Set (a resident assessment and screening tool) dated 6/28/18 indicated the resident's bowel pattern did not include constipation, cognitively intact, and required extensive assistance of one person for most aspects activities of daily living. The nursing progress note dated 6/18/18 indicated the resident complained of stomach discomfort and stomach was very bloated,…

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 conducted during a recertification survey, the facility did not ensure for 1 of 1 resident (Resident #31) reviewed for tube feeding that the necessary care was provided to ensure sufficient fluid intake in accordance with the physician's order. Specifically, the facility did not ensure that additional water (automatic water flushes) for hydration was administered in accordance with the physician's order. The findings are: Resident #31 has diagnoses that include Cerebrovascular Accident (CVA) and Dementia. The Annual Minimum Data Set (MDS; a resident assessment and screening tool) of 7/6/18 revealed that the resident was fed via a feeding tube. The care plan for tube feeding and nutrition/hydration dated 3/22/17 revealed that the resident was fed via a tube due to dysphagia (difficulty swallowing) and CVA and that the resident's nutrition/hydration needs will be met by tube feeding. The most recent laboratory report dated 7/3/18 revealed that results were indicative of one's hydration status, electrolytes and blood urea nitrogen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure that there was adequate indication for initiating and continuing an antipsychotic medication used to treat the behavioral symptoms of 1 of 5 residents reviewed for unnecessary medications (Resident #31). Specifically, (1) the clinicians assigned to the care of the resident did not consider the diagnosis of a urinary tract infection as a possible cause for the change in the resident's behavior prior to initiating the use of Zyprexa to address this change; (2) specific behaviors were not documented quantitatively and qualitatively to assess the effectiveness and determine the need for ongoing use of the medication; and (3) evidence was lacking regarding ongoing documentation and evaluation of the utilization of non-pharmacological interventions in accordance with the antipsychotic plan of care. The findings are: Resident #31 is an [AGE] year old female admitted to the facility on [DATE]. The resident's…

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

Based on observation and interviews conducted during a recertification survey the facility did not ensure that medications were stored and labeled in accordance with currently accepted professional standards. Specifically, 1 of 4 medication carts (Birch Unit) reviewed for medication storage, one insulin pen and 2 insulin vials were observed to be opened and undated, and one insulin vial was observed to be opened, undated and unlabeled. The finding is: Observation of medication storage was conducted on 7/23/18 from 4:15 to 4:45 PM on the Birch Unit low side and the following were noted: - One opened, undated vial of Humalog insulin; - One opened, undated vial of Lantus vial; - One opened, undated Levemir FlexTouch insulin pen, and - One opened, unlabeled vial of Lantus. The manufacturer's recommendation stated that Humulin vials in use must be used within 28 days or be discarded; Lantus vials in use must be used in 28 days; and Levemir Flextouch insulin pen must be kept at room temperature once in use and discarded after 42 days. The expiration date of the insulin vial or pen is…

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

Based on observation and interview conducted during a recertification survey, the facility did not ensure that food items kept in resident refrigerators were stored to prevent potential for food borne illness on 2 out of 4 resident units Cedar and Dogwood) . Specifically, foods brought in from the outside were not properly labeled and dated. The findings are: The resident refrigerators were checked on all 4 units on 7/19/18 at 1:30 PM. The following was observed: A. Cedar unit: broccoli cheese soup from a local store was opened and half full, no name or date. The RN unit manager stated she would throw it away. B. Dogwood unit: four plastic containers of food were observed in the refrigerator: a pasta salad without a name or date; another kind a salad had no name and undated; another salad container without a date; and bow-tie pasta without a name and date. A Food Service Worker (FSW) who was present at the time of observation was interviewed on 7/19/18 at 2:05 PM and she stated that nursing was supposed to label and date the food items and keep track of how long they've been in 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.