Grand Manor Nursing & Rehabilitation Center

Based on observations, record review, and interviews, the facility failed to maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program and plan with governance and leadership oversight. Specifically, the facility had widespread deficiencies in the areas of Food and Nutrition Services, Administration, Infection Control, Physical Environment, and Training Requirements. In addition, the facility had deficiencies (F656, F711, F801, F812, F835, F865, F880) from previous Recertification surveys that were repeatedly cited in the current survey whereby plans of correction were previously accepted by the New York State Department of Health, but the facility had no documented evidence of implementation or maintenance of outcomes.The findings are:The facility policy and procedure titled Quality Assurance and Performance Improvement Plan last updated on 01/2025 stated that the Quality Assurance and Performance Improvement Committee meets at least monthly and consists of the Administrator, Director of Nursing, Medical Director, department heads, and residents and/or…

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

Based on observation, record review, and interviews, the facility failed to develop an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was evident during the Infection Control Task. Specifically, the facility had no system to monitor antibiotic use. There was no system of reports related to antibiotic usage and resistance data. The findings are: The policy and procedure titled Antibiotic Stewardship Program with a reviewed date of 06/2024 documented the facility maintains an active Antibiotic Stewardship Program as part of its Infection Prevention and Control Program. The Infection Preventionist, under the oversight of the Director of Nursing, coordinates the Antibiotic Stewardship Program. The Medical Director and Consultant Pharmacist support the program through clinical guidance and oversight of antibiotic use. The policy documented that the facility monitors antibiotic prescribing patterns and outcomes. A review of Resident #1's medical record showed that Resident #1 had a diagnosis of urinary tract infection. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey from 12/01/2025 to 12/09/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, during the observation of the dishwashing task and review of the associated daily temperature logs the mechanical dishwasher was below 150 degrees Fahrenheit on more than one (1) occasion. Review of the Kitchen Equipment invoice dated 11/06/2025 indicated that the mechanical dishwasher has been malfunctioning, and the facility had failed to pay the vendor to have it repaired. The findings are:The facility policy titled Dishwasher and Manual Sanitizing Policy, with revision date 03/2025, documented that the facility will ensure all dishware, utensils, and food-service equipment are safely washed and sanitized at the required temperatures, and that an approved chemical sanitizing method is used whenever the dishwasher or booster heater is not fully operational.…

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, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents. This was evident for one (1) of 11 residents (Resident #88) reviewed for accidents out of 35 total sampled residents. Specifically, Resident #88 who was identified as at risk for falls, was observed without floor mats and their bed not in the lowest position as stated in their care plan. The findings are:The facility's policy and procedure titled Falls Prevention with a revision date of 05/14/2023 documented that it is the policy of the facility to assess all residents for their fall risk potential and institute an appropriate plan of care designed to prevent/reduce falls. A Fall Risk Assessment Score totaling 21 or more places the resident at risk for falls and therefore a prevention protocol should be initiated immediately. The protocol plan of care is entered onto the resident's care plan. The licensed Nurse will use the established protocols for fall risk prevention as a basis for the resident's plan of care. 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 observations, interviews, and record review, the facility failed to ensure the physician reviewed the resident's total program of care. This was evident for one (1) of 12 residents reviewed (Resident #8). Specifically, there was no documented evidence that a physician evaluated Resident #8 after a fall incident on 07/30/2025. The findings are: There was no documented evidence the facility has a policy related to physician services. Resident #8 was admitted to the facility with diagnoses that included diabetes mellitus (a condition that affects blood sugar levels), hypertension (high blood pressure), and depression. The Minimum Data Set (a resident assessment tool) dated 10/23/2025 documented Resident #8's cognition as intact and was independent in bed mobility, transfers, and toilet use. A nurse's progress note by Registered Nurse #7 dated 07/30/2025 at 10:39 AM documented that Resident #8 was sitting in the day room, asleep on the chair, and fell to the floor. A scant amount of blood was noted on the left nostril which was cleaned; there was no further bleeding was noted.…

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

Based on observation, record review, and interviews the facility failed to maintain medical records on each resident in accordance with professional standards and practices that are systematically organized and readily accessible. This was evident for five (5) of five (5) residents (Resident #'s 4, 7, 56, 68, and 88) reviewed for unnecessary medications out of 35 total sampled residents. Specifically, the residents' drug regimen review reports were not readily available for review upon request. The findings include:The facility's policy and procedure titled Drug Regimen Review dated 06/2025 documented that Consultant Pharmacist shall perform Medication Regimen Review for each resident at least monthly; upon completion, shall provide written documentation of all recommendations and submit monthly to the facility for attending prescriber or designees to respond. The Facility shall maintain copies of all Drug Regimen Review recommendations along with prescriber responses in an easily retrievable location for presentation to surveyors upon request.On 12/03/2025 between 10:00 AM 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 record review and interviews conducted during the Recertification Survey, the facility failed to ensure that each resident was offered the pneumococcal and influenza immunizations. This was observed in five (5) of nine (9) residents (Residents #25, #88, #99, #153, #202) sampled for immunizations out of a total of 38 sampled residents. Specifically, there was no documented evidence that Residents #25, #88, and #202 were offered, educated, received or declined the influenza immunization, and there was no documented evidence that Residents #25, #88, #99, #153, and #202 were offered, educated, or received or declined the pneumococcal immunization.The findings include:The undated facility policy titled Influenza Vaccine, documented that all residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.The undated facility policy titled Pneumococcal Vaccines, documented that all…

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 conducted during the Recertification Survey, the facility failed to ensure that each resident was offered the COVID-19 immunization. This was observed in four (4) of nine (9) residents (Residents #25, #99, #153, #202) sampled for immunizations out of a total of 38 sampled residents. Specifically, there was no documented evidence related to the screening, administration or declination, and education on the COVID-19 immunizations for Residents #25, #99, #153, and #202.The findings include:The facility policy titled Infection Prevention and Control last reviewed 06/2025 documented the COVID-19 vaccine will be offered to all residents upon admission as part of the facility's routine immunization program. Each resident will be screened to determine their vaccination status and clinical eligibility. All screening results, vaccine offerings, consent/refusals, and vaccination administration will be documented.Resident #25 was admitted to the facility on [DATE] and had diagnoses…

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, the facility failed to ensure there was adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This was evident for 25 out of 25 rooms on the second floor. Specifically, call bell systems did not function as designed and residents were given hand bells. The findings are: The facility's policy and procedure titled Preventative Maintenance Program with a last reviewed date of 01/2025 stated that the Maintenance Director will be responsible for developing and maintaining a schedule of maintenance services to ensure that the building, grounds and equipment are maintained in a safe and operable manner. On 12/02/2025 at 10:16 AM, the call bell system was tested on the second floor. room [ROOM NUMBER]'s call light went on when the bell was pressed but there was no bell sound either in the unit's north corridor or at the nursing station.…

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 conducted during the Recertification Survey, the facility failed to ensure that certified nurse aides were provided the required 12 hours of in-service training per year. This was evident for five (5) of five (5) Certified Nursing Assistants reviewed for nurse' aide training requirements. Specifically, the facility was unable to provide documented evidence that Certified Nursing Assistants #14, 15, 16, 17, and 18 were provided 12 hours of annual in-service training. The findings are:A facility document titled Employee Education Inservice Policy with a last reviewed date of 06/2025 stated that the facility will maintain an ongoing in-service education program to support staff competency.The Facility-wide Assessment with a last reviewed date of 09/2025 documented nurse aide in-service training must include no less than 12 hours per year.During a record review of personnel files for Certified Nursing Assistants #14, 15, 16, 17, and 18, who were all currently employed by the facility, there was no documented evidence that the above…

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 the facility failed to ensure that the resident was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for one (1) of four (4) residents (Resident #153) reviewed for hospitalization out of a total sample of 35 residents. Specifically, the facility did not complete a notice of discharge or transfer when Resident #153 was transferred to the hospital on [DATE]. The findings are:The policy and procedure titled Transfer and Discharge (including Against Medical Advice) last revised 01/2025, documented that when the facility initiates a transfer or discharge, notice will be provided to the resident and representative in a manner they can understand.Resident #153 was admitted to the facility on [DATE] with diagnoses that include anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, and anxiety that interfere with daily activities), bipolar disorder(a chronic mental…

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, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for one (1) (Resident #142) of one (1) resident reviewed for transmission-based precautions in the Infection Control task out of 38 total sampled residents. Specifically, Resident #142 who had diagnoses of Osteomyelitis (infection in a bone) and Methicillin-Resistant Staphylococcus Aureus (a type of infection resistant to several antibiotics) had no care plan to address infection and contact precaution. The findings are: The facility policy and procedure titled Comprehensive Care Plans with a reviewed date of 09/2022 documented it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, 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 observations, record review, and staff interviews, the facility failed to ensure that residents are provided food that accommodates their allergies, intolerances, and preferences. This was evident for one (1) out of 38 residents (Resident #35) reviewed for food preferences. Specifically, during observation on 12/01/2025, Resident #35 who preferred chicken and fish during meals, and disliked beef and pork, was noted with pork in their lunch tray. The findings are: The facility policy and procedure titled Food Preference dated 07/2022, last revised 06/2025, documented: The facility recognizes each resident's right to reasonable food choices and preferences, including cultural, religious, and personal preferences. Resident preferences should be honored to the extent possible while following physician and diet orders, allergy restrictions, and safety requirements. Resident #35 was admitted with diagnoses that included bipolar disorder (a mental health condition that causes extreme mood swings), asthma (a condition that causes your airways to swell, narrow and fill with mucus),…

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, the facility failed to ensure infection control practices and procedures were maintained. This was evident for one (1) unit (six (6) of five (5) resident units. Specifically, Certified Nursing Assistant #5 picked up Resident #152's pillow from the floor and placed it under Resident #152's head without changing the pillowcase.The findings are:The facility policy titled Linen Handling and Infection Control reviewed 12/2024 documented the purpose is to establish safe and sanitary procedures for handling clean and soiled linens and resident clothing in order to prevent the spread of infection within the facility, including residents on contact precautions and those with blood, body fluids, or wound drainage on linens.In an observation on 12/01/2025 at 10:07 AM, Resident #152 was in their reclining wheelchair in the hallway with a pillow on the floor adjacent to them. Certified Nursing Assistant #5 picked up the pillow from the floor and placed it under Resident #152's head without changing the pillowcase.During an interview 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.

Based on observation, record review, and interview the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control that include infection preventionists role, infection surveillance, outbreak, antibiotic stewardship, and other recommended Infection prevention and control (IPC) training that must be sufficient to perform the role of an Infection Preventionist. Evidence includes: Pursuant to regulation, the facility must designate one or more individual(s) as the infection preventionist, who, among other requirements, must have completed specialized training in infection prevention and control. The facility's policy titled Infection Prevention and Control Program dated 02/2022 documented the facility has established and maintains an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. There was no documented evidence the Infection Preventionist received specialized training on facility infection prevention and control. On 05/27/2025 at 10:04…

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 the facility failed to ensure that a resident's right to privacy during medical treatment and confidentiality of medical records was maintained for one (1) (Resident #183) of 38 total sampled residents. Specifically, Registered Nurse #4 performed Resident #183's blood glucose testing (measures the level of sugar in blood), administered an insulin injection, and administered enoxaparin (an injectable that prevents blood clot) while in the hallway. Additionally, Registered Nurse #4 walked away from the medication cart without locking the computer monitor, exposing Resident #183's medical information. The findings are: The facility policy and procedure titled Resident Dignity with a revised date of 01/2025 documented the facility will promote and protect resident's rights and ensure each resident is cared for in a manner that maintains or enhances their dignity, individuality, and quality of life. The policy documented residents have the right to privacy during care, communication, and personal interactions. Resident #183 had…

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 conducted during the Abbreviated Survey (NY00377759, NY00377846), the facility did not ensure that all alleged violations involving misappropriation of resident property were reported within 24 hours after the allegation was made to the State Survey Agency. Additionally, the facility did not ensure that the results of all investigations were reported to the State Survey Agency within five (5) working days of the incident. This was evident in three (3) of three (3) residents (Residents #4, #5, and #6) sampled for abuse. Specifically, 1.) On 4/07/2025 at 2:30 PM, Resident #4 reported that Patient Care Assistant #1 borrowed money from them to repay a loan from Resident #5. Resident #4 alleged that Patient Care Assistant #1 did not pay them back. The facility initially reported the misappropriation allegation to the New York State Department of Health on 04/11/2025 at 4:59 PM. In addition, the facility did not submit a Follow-Up Investigation Report within five (5) working 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, the facility failed to thoroughly investigate all alleged violations involving abuse for one (1) (Resident #158) of five (5) sampled residents. Specifically, the Director of Recreation received a report from Resident #158 alleging they were threatened by an unidentified Certified Nursing Assistant. An investigation was not immediately initiated, and measures were not put in place to ensure further potential abuse did not occur. The findings are: The facility policy titled Abuse Prohibition & Prevention with a last revised date of 12/2024 documented all allegations or reasonable suspicions must be reported to a staff member's immediate supervisor, and to the Director of Nursing and/or the Administrator immediately upon discovery. The facility initiates internal investigations immediately, to be completed within five (5) business days. Resident #158 had diagnoses of Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves), Hemiplegia (paralysis that affects only one side of your body), and Adjustment…

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, the facility failed to develop a comprehensive care plan to address a resident's full code status for 1 (Resident #171) of 38 sampled residents. The findings are: The facility's policy titled Comprehensive Care Plan with a revised date of 08/2024 documented the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's policy titled Resident's Rights Regarding Treatment and Advance Directives with a revised date of 01/2025 documented advance directives will be reviewed during care plan meetings to determine whether updates are needed Resident #171 had diagnoses which included Paranoid Schizophrenia (a mental disorder characterized by paranoia, delusion, and hallucination), Anxiety Disorder, and Bipolar Disorder (a mental health condition characterized by extreme mood swings). The quarterly Minimum Data Set (an assessment tool) dated 04/25/2025 documented Resident #171 had intact cognition and had…

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, the facility failed to ensure that infection control prevention and practices were followed during wound care treatment for 1 of 38 sampled residents. Specifically, Registered Nurse #6 and Licensed Practical Nurse #2 failed to follow infection prevention and control practices while performing wound care treatment. The findings include: The facility policy titled Pressure Ulcer Prevention and Management Policy, with a revised date of 12/2024, documented that the facility is committed to prevention and effective management of pressure ulcers to ensure optimal resident care and quality of life, thus providing appropriate interventions. An Infection Prevention and Control Policy titled Clinical Operations, with a revised date of 12/2024, documented that staff will be trained on infection control procedures and practices including pertinent procedures, supplies, and equipment related to infection prevention and control. Resident #33 was admitted to the facility with diagnoses that included Vascular Dementia (a group of symptoms…

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, the facility failed to address the recommendations made by the Pharmacy Consultant during medication regimen review for one (1) (Resident # 162) of five (5) residents reviewed for unnecessary medications. The medication regimen review report for Resident #162 dated 12/09/2024 documented that the pharmacy consultant was unable to locate the recent documentation of current need/effect, absence/presence of side effects, ability or lack of ability to taper current dose in chart for trazodone. The attending physician agreed to the recommendation and documented that a psychiatry consult will be ordered. However, no psychiatry consult was completed for Resident #162 to address the pharmacist's recommendation. The findings include: The facility policy titled Monthly Drug Regimen Review with a last revised date of 07/2024 stated the Consultant Pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending…

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 the facility failed to administer all physician ordered medications for 1 of 35 sampled residents. Specifically, Resident #164 was not administered two consecutive doses of sertraline (an antidepressant) as ordered by a physician. The findings include: The facility policy titled Medication Administration and Documentation with a last reviewed date of 07/2024 established that medication administration and documentation shall occur in a timely and accurate manner, within one hour before or after prescribed time. Staff uses prudent, professional judgment by informing the physician in a timely manner when medications are held, refused, or otherwise unavailable for administration. On 05/22/2025 at 10:52 AM, Resident #164 was interviewed and stated they did not receive their medication for depression this morning or yesterday morning. Resident #164 further stated that the nurse informed them the medication was ordered but was not delivered to the facility yet.…

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, the facility failed to ensure that drugs and biologicals were stored in accordance with professional standards. The facility failed to store schedule II medications in locked compartments, failed to keep medication cart locked or under direct observation, and failed to dispose of expired supplement in 1 (3rd Floor) of 3 units observed. The findings include: The facility's policy titled Medication Storage with a last reviewed date of 06/2024 stated outdated medications will be destroyed and that Schedule II controlled drugs are stored under double lock and key. During observation on 05/28/2025 at 11:56 AM, the medication cart on the 3rd Floor was unlocked with Registered Nurse #1 not in close proximity of the medication cart. A bottle of ProStat (a supplement for increased protein needs) with an expiration date of 03/27/2025 was stored in the 3rd Floor medication cart. It was also noted that the narcotic box inside the medication cart was not locked. On 05/18/2025 at 2:53 PM, Registered Nurse #1 was interviewed and stated that 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 an abbreviated survey (NY00373346), the facility did not ensure the designated resident's representative was notified of changes in the resident's condition. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, on 02/01/2025, Certified Nursing Assistant #1 informed License Practical Nurse #1 Resident #1's had a stuffy nose. On 02/01/2025, License Practical Nurse #1 documented Resident #1 had a low grade fever of 100.5-degree Fahrenheit, and was restlessness. The medical doctor and the family were not notified. The findings are: The Facility's Policy on Designated Representative Notifications reviewed 12/2024, documented the facility will notify the resident's approved representative as designated in their records. Resident #1 was admitted to the facility with diagnoses of Epilepsy, Non-Alzheimer's Dementia, Depression with Schizophrenia, Traumatic Brain Injury and Urinary/Fecal incontinence and Constipation. The Minimum Data Set (a resident assessment tool) dated11/23/2024, 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.

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated Survey (NY00347302, NY00351629, and NY00351064) conducted from 11/13/2024 to 11/21/2024, the facility did not ensure that sufficient nursing staff was consistently provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1) Several residents reported the facility was short staffed of Certified Nursing Assistants, especially during the evenings, and weekends, which resulted in lack of timely staff response to residents who needed assistance with toileting, bathing, and personal care. 2.) A review of the actual staffing schedules dated from 07/01/2024 to 11/21/2024 revealed staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment and on the daily staffing schedules for Certified Nursing Assistants. The findings include but are not limited to: The Facility Assessment…

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 staff interviews conducted during the Recertification Survey from 11/13/2024- 11/21/2024, the facility did not ensure performance reviews of every nurse aide was conducted at least once every 12 months, and that regular in-service education was provided based on the outcome of these reviews. This was evident for 5 (Certified Nursing Assistants #8, #15, #16, #17, and #18) of 5 Certified Nursing Assistants reviewed for nurse aides' training requirements. The findings are: The facility policy titled In-Service Training: Nurse Aide dated 06/2024 documented that performance reviews must be completed for nurse aides at least every 12 months. The Facility Assessment Tool dated 10/2024 documented that performance reviews will be conducted, and that the reviews will provide structured feedback and that the process will highlight individual strengths and identifies areas needing improvement. The facility assessment did not specify the frequency of performance reviews. A review of personnel files for Certified Nursing Assistants #8, #15, #16, #17, and #18 showed 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.

Based on observations, record review, and interviews conducted during the Recertification and Complaint Survey from 11/13/2024 to 11/21/2024, the facility did not ensure it was 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. This was evident during review of Activities of Daily Living, Staffing, Infection Control, Medication Storage, and Quality Assurance. Specifically, 1.) The Administration did not ensure the facility was sufficiently staffed to meet the residents' needs. In addition, the Administration did not monitor and enhance the quality of care and services as indicated by repetition of deficiencies that were cited on previous recertification surveys (F641, F657, F725, and F761) 2.) Nursing Services were not administered adequately to ensure that assistance with activities of daily living were consistently provided to the residents, that drugs were stored in a sanitary manner, infection control practices were maintained, 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 observations, record reviews, and interviews conducted during the Recertification and Complaint Survey from 11/13/2024 to 11/21/2024, the facility did not ensure it has an active governing body that is responsible for establishing and implementing policies regarding the management of the facility. Specifically, based on the multiple deficient practices that were identified during the Recertification Survey, there was inconsistent communication between the facility Administrator and the Governing Body to ensure management of the facility and regulatory compliance. The findings are: The facility policy titled Quality Assurance and Performance Improvement with a reviewed date of 04/2024 documented the Governing Body and/or executive leadership is responsible and accountable for the Quality Assurance and Performance Improvement program. Governing oversight responsibilities include ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indictor data, 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 observations, record review, and interviews conducted during the Recertification and Complaint Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that the quality assurance and performance improvement program identified and prioritized problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, resident and staff input, and other information. Specifically, the facility had widespread deficiencies in the areas of Nursing Services, Administration, and Infection Control. In addition, the facility had deficiencies from previous Recertification surveys that were repeatedly cited in the current survey (F641, F657, F725, F761, and F865). Also, the facility failed to ensure the Governing Body's oversight of the facility's quality assurance and performance improvement program and activities. The findings are: The facility's Quality Assurance and Performance Improvement Plan with a revision date of 05/04/2023 documented the plan was designed to provide guidance in assessing 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 observation, record review, and interviews conducted during the Recertification Survey from 11/13/2024 -11/21/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident for 7 (Residents #69, #47, #92, #412, #87, #7, #74) of 10 residents, from 3 different units, observed for medication administration. Specifically, 1.) Licensed Practical Nurse #4 failed to sanitize the blood pressure machine and cuff after each resident use. 2.) Registered Nurse #5 failed to sanitize the glucometer (a medical device used to measure the amount of sugar in the blood) after each resident use. 3.) Licensed Practical Nurse #1 failed to sanitize the blood pressure machine and cuff after each resident use. The findings are: The facility's policy titled Equipment Cleaning last reviewed 06/2024 documented that any equipment shared between residents must be cleaned and disinfected between uses to prevent cross contamination. The policy also documented that all resident care equipment, including example blood pressure monitors, must be cleaned 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 observations, record review, and interviews conducted during the Recertification and Complaint Survey (NY00351064) from 11/13/2024 to 11/21/2024, the facility did not ensure that residents who are unable to carry out activities of daily living receive the necessary services and assistance to maintain grooming, and personal hygiene. This was evident for 2 (Residents #48 and #169) of 7 residents reviewed for Activities of Daily Living. Specifically, Residents #48 and #169 were not provided regular showers according to their plan of care. The findings are: The facility's policy titled Activities of Daily Living with a reviewed date of 05/2023 documented a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. The facility's policy titled Nursing Home Activities of Daily Living Policy and Procedure for Showering with a revised date of 10/2023 documented residents will be offered a shower as specified…

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 conducted during the Recertification Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that a resident at risk for developing pressure ulcers, receives care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1 (Resident #123) of 3 residents reviewed for Pressure Ulcers. Specifically, Resident #123, who had history of healed pressure ulcers and had a care plan for use of a pressure ulcer relieving device when in bed, was observed with deflated air mattress on 3 occasions. The findings are: The facility's policy titled Mattress Management and Maintenance with a revision date of 06/2024 documented all mattresses will be regularly inspected, cleaned, and maintained to meet safety, hygiene, and comfort standards. Specialized mattresses, such as pressure relief mattresses, will be used as needed to support residents' clinical needs including prevention and management of pressure ulcers. Resident #123 was admitted to the facility with diagnoses that included Schizophrenia,…

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 the Recertification and Complaint (NY00350179) Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This was evident in 1 (Resident #118) of 6 residents reviewed for abuse. Specifically, Resident #118 exhibited multiple incidents of behavior symptoms such as stealing from other residents and had been involved in resident-to-resident altercations. The facility did not evaluate the effectiveness of the interventions to address Resident #118's behavior, lacked individual approach in the care plan to address Resident #118's behavior, and lacked monitoring and supervision of Resident #118's behavior that may provoke reaction from other residents. The findings are: The facility's policy titled Behavioral Health Policy with a reviewed date of 06/2024 documented the facility provides…

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 conducted during the Recertification Survey from 11/13/2024 through 11/21/2024, the facility did not ensure that all medications and biologicals used in the facility were safely stored. Specifically, insulin pens were not stored in a sanitary manner to prevent cross-contamination. This was evident during observations (Unit 5) conducted for the Medication Storage Task. The findings are: The facility policy and procedure titled Medication Storage with a revision date of 09/07/2023 documented that medication must be stored in accordance with manufacturer's specifications, sufficient to ensure proper sanitation, and secured in locked areas in compliance with State and Federal requirements and accepted professional standards of practice. On 11/19/2024 at 10:52 AM, an observation was conducted of the medication cart on the 5th floor. Four different resident insulin pens were observed stored together in a compartment in the top drawer of the medication cart. On 11/19/2024 at 10:53 AM, Registered Nurse #1 who was administering 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.

Based on record review and interviews conducted during the Recertification and Complaint (NY00351064) Survey from 11/13/2024 to 11/21/2024, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident for 1 (Resident #48) of 7 residents reviewed for Activities of Daily Living. Specifically, Resident #48's bathing preference was not honored. The findings are: The facility's policy titled Nursing Home Resident Rights with a reviewed date of 06/2022 documented the resident has a right to choose activities, schedules, health care and providers of health care services consistent with their interests, assessments, and plan of care. The facility's policy titled Activities of Daily Living with a reviewed date of 05/2023 documented the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in activities of daily living do not deteriorate unless unavoidable. The policy documented a resident who is unable 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, staff interviews, and record review conducted during the Complaint Survey (NY00339166, NY00332772), the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and the residents' choices. This was evident for 2 of 3 residents reviewed for medication administration. Specifically, 1.) On 04/02/2024, Resident #6, who had a diagnosis of Diabetes Mellitus, had not been given the prescribed Lantus Insulin (a long-acting insulin used in adults with type 2 diabetes) at 9:00 PM. 2.) On 10/24/2023, Resident #4 was admitted to the facility with hospital discharge orders for an antibiotic intravenous infusion for bacteremia (a medical condition characterized by bacteria in the bloodstream). A review of medical record revealed the antibiotic had not been ordered or administered to Resident #4. The findings are: 1.) Resident #6 was admitted to the facility with diagnoses that include Diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review conducted during the Recertification Survey from 06/03/2024 to 06/11/2024, the facility did not ensure that a resident received foot care and treatment in accordance with professional standards of practice. This was evident for 1 (Resident #191) of 4 residents reviewed for pressure ulcer/injury. Specifically, Resident #191 did not receive the recommended wound treatment made by the Infectious Disease consultant and podiatrist for the care and treatment of diabetic foot ulcer. The findings are: The facility policy titled Foot Care, with an effective date of 06/2023, documented that residents receive appropriate care and treatment to maintain mobility and foot health. Residents are provided foot care and treatment in accordance with professional standards of practice. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions (Diabetes, Peripheral Vascular disease, and immobility, etc.). 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 interview and record review conducted during the Recertification Survey from 06/03/2024 to 06/11/2024, the facility failed to ensure that the physician reviewed the resident's total program of care. This was evident for 1 (Resident #191) of 4 residents reviewed for pressure ulcer/injury. Specifically, there was no documented evidence the treatment recommendations from the Infectious Disease consultant and podiatrist for Resident #191's diabetic ulcer on the left foot were reviewed by the attending physician. Additionally, there was no documented evidence that Resident #191's diabetic ulcer on the left foot was evaluated by the attending physician and/or the nurse practitioner. The findings are: The facility policy titled Physician Visits and Physician Delegation, last reviewed on 01/2024 documented it is the policy of the facility to ensure the physician takes an active role in supervising the care of residents. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must…

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 an abbreviated survey (Case #NY 00320443, Case #NY 00320343), the facility did not ensure each resident was free from physical abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, on 07/18/2023 at 7:22 PM, the facility's surveillance video recording showed Security Guard (SG) #1 pushed Resident #1 to the wall to prevent them from leaving the back exit of the facility and then pushed Resident #1 towards the elevator. The findings are: The facility's Policy on Abuse Prevention and Reporting which was last revised on 10/10/2022, documented it is the policy of the Facility to ensure that all residents are treated with consideration, respect and full recognition of dignity and individuality including privacy in treatment and care for personal needs. The Policy documented that the Facility has zero tolerance for abuse. Resident #1 was admitted to the facility with diagnoses of Schizoaffective Disorder, Anxiety, and Depression with Anoxic Brain Injury. The Minimum Data Set (MDS - an assessment tool) dated 05/26/2023…

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.