Hope Center for HIV and Nursing Care

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that drugs and biologicals were stored in accordance with professional standards. This was evident in 2 (3rd and 4th Floor) of 3 units observed for medication storage. Specifically, 1.) The 4th floor medication storage room refrigerator was unlocked and contained controlled medications that were not stored in the affixed lock box. 2.) The 3rd Floor medication storage room contained food, and multiple prescribed medications were stored in unlocked cabinets. 3.) A previously administered 50 milliliter bag of intravenous solution was stored inside the 3rd Floor medication cart. The findings include: The facility policy titled Medication - Narcotic Management with a last revision date of 04/2019 documented that all narcotics and scheduled II medications will be maintained in the medication cart in a locked drawer. The facility policy titled Medication Storage with last revision date of 01/2019 documented that to provide guidelines for…

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

Based on record review and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that the Infection Preventionist participated on quality assessment and assurance committee. Specifically, the Infection Preventionist had not participated in any of the Quality Assurance and Performance Improvement meetings held from June 2024 through April 2025. The findings are: The facility's Infection Preventionist job description stated that the Infection Preventionist attends and reports monthly at the quality assurance meeting. The facility's Quality Assurance & Performance Improvement Plan - 2025 did not include the Infection Preventionist in the list of committee members. A review of the Quality Assurance and Performance Improvement attendance sheets dated June 2024 through April 2025 had no documented evidence that the Infection Preventionist attended the meetings. On 05/16/2025 at 8:45 AM, the Infection Preventionist was interviewed and stated they do not attend the quality assurance meeting and does not know they are supposed to 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 observation, record review, and interview during the Recertification Survey conducted from [DATE] to [DATE], the facility did not ensure that infection control practices and procedures were maintained. This was evident in 1 (3rd Floor) of 3 units observed for medication storage. Specifically, a bag of previously administered antibiotic intravenous solution was observed inside the medication cart. The findings are: The facility policy titled Medication Storage with a last revision date of 01/2019 documented that with the exception of emergency drug kits, expired, discontinued, and or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy. The facility policy and procedure titled Infection Prevention and Control with a last revision date of [DATE] documented that the facility adheres to an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development 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 an abbreviated survey (NY00332540), the facility did not ensure that a resident was able to exercise their rights as a resident in the facility and as a citizen or resident of the United States. This was evident in one out of four residents sampled (Resident #1). Specially, on 01/25/2024 at 11:00 AM, Recreational Aide #1 reported to Recreational Supervisor #1 that Resident #1 refused to have their hair cut and become agitated and combative. The Director of Social Work instructed License Practical Nurse #1, and Home Health Aide #1 to hold Resident #1's arms and legs against Resident #1's will and cut Resident #1's hair. The findings are: The facility's Policy titled Resident Rights dated 05/28/2024, documented Healthcare Personnel shall treat all residents with kindness, respect, and dignity. The policy further documented resident has the right to exercise his or her rights as a resident of the facility and as a resident or citizen of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during an abbreviated survey (NY00332540), the facility failed to ensure a resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was evident for one out of four residents sampled (Resident #1). Specifically, on 01/25/2024, Recreational Aide #1 reported to their Recreation Supervisor that Resident #1 was refusing their hair cut and become agitated and combative. The Director of Social Work instructed License Practical Nurse #1, and Home Health Aide #1 to hold Resident #1's arms and legs against Resident #1's will and cut Resident #1's hair. There was no documented evidence that restraints were medically necessary, nor that alternatives were attempted prior to holding down Resident #1's arms and legs for a haircut. Findings are: The Facility's Policy titled Use of Restraints, dated 12/2022, documented the nursing center will promote 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.

Based on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was evident during observation of the kitchen. Specifically, 1) the dish washing machine did not maintain appropriate temperatures for washing and rinsing dishes, and 2) Dietary Worker #1 did not follow proper sanitation procedure during the pot washing process. The findings are: The facility policy titled Dish Washing and Storage dated 5/17/2019 documented dishes, pots, and pans will be washed and dried using procedures, chemicals, and equipment that result in clean, sanitized dishes, pans, flatware, and utensils. The facility policy titled Cleaning Dishes - Manual Wash dated 1/2023 documented dishes and cookware will be cleaned and sanitized by immersion in quaternary ammonium with a strength of 200-400 Parts Per Million (PPM) at 75 degrees Fahrenheit (F) for 60 seconds of contact. On 12/18/2023 at 9:44 AM, the kitchen…

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 12/18/2023 to 12/22/2023, the facility did not ensure garbage and refuse were disposed of properly. This was evident during observation of the kitchen. Specifically, garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests. The findings are: The facility policy titled Garbage and Rubbish Disposal dated 1/2023 documented outside dumpsters provided by the garbage pick-up service will be kept closed and free of surrounding litter. On 12/22/2023 at 8:30 AM and 9:43 AM, the outside garbage compactor was observed without a door or cover, exposing garbage contained inside of the compactor. On 12/22/2023 at 1:04 PM, the Director of Food Service was interviewed and stated the compactor did not close after being filled with garbage. On 12/22/2023 at 3:44 PM, the Director of Facilities was interviewed and stated the compactor was not equipped with a lid, door, or cover; therefore, the compactor was always left open with garbage exposed. 10 NYCRR…

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 F584 The resident has a right to a safe, clean, comfortable and homelike environment. Based on observations and interviews conducted during a standard recertification survey, the facility did not ensure that residents had a homelike environment due to multiple issues with paint chips and scratches, broken bathroom equipment and shabby furnishings in communal areas. The findings are: The facility's policy and procedure entitled Maintenance Services, last reviewed 08/2019, states that functions of Maintenance Department personnel include but are not limited to providing routinely scheduled maintenance service to all areas. The survey team made multiple observations on all units throughout the days of the survey. The following were noted: Unit 2: scuffed lower doors throughout the unit, chipped doorways, broken railing next to shared bathroom, doorframes chipped and scuffed, paint bubbling next to room [ROOM NUMBER] bathroom, missing paint below Exit sign which is above the bulletin board, wall-mounted hand…

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, interviews, and record review conducted during the recertification and abbreviated (NY00327468 and NY00321011) survey from 12/18/2023 to 12/22/2023, the facility did not ensure adequate supervision to prevent accidents or hazards. This was evident for 2 of 16 total sampled residents. Specifically, 1) Resident #264 was at high risk for elopement and was able to climb the fence bordering the facility's back patio and elope, and 2) Resident #33 had incidents of being verbally abusive towards others and was unsupervised while in the Main Dining Room with other residents, placing them at risk for an altercation with Resident #214. The findings are: The facility's policy titled Smoking Program dated 06/2019 documented residents with a history of substance abuse disorder may be at increased risk for leaving the facility without notification. Facilities are responsible for identifying and assessing a resident's risk of leaving the facility without notification to staff and developing interventions…

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, interview, and record review during the recertification survey conducted from 12/18/2023 to 12/22/2023, the facility did not ensure a discharge planning process was in place which addressed each resident's discharge goals and needs. This was evident for 1 (Resident #33) of 16 total sampled residents. Specifically, Resident #33's discharge care plan was not reviewed and revised to reflect the resident's desires and goals for discharge from the facility. The findings are: The facility policy titled Discharge Planning dated 12/2019 documented the Social Worker was responsible for developing a discharge plan including input from the resident and resident representative and will initiate all necessary referrals. Resident #33 had diagnoses of schizophrenia and psychoactive substance abuse. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #33 was moderately cognitively impaired and did not have an active discharge plan. On 12/18/2023 at 2:34 PM, Resident #33 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure that foods were served at a safe and appetizing temperature. This was evident for 2 (Unit 3 and 4) of 3 resident units during dining observation. Specifically, hot and cold food items were not held at safe and appetizing temperatures during meal service on Unit 3 and Unit 4. The findings are: The United States Department of Agriculture (USDA) Food Safety and Inspection Service (FSIS) Safe Minimum Internal Temperature Chart dated 5/11/2020 documented poultry be held at 165 F and casseroles be held at 165 F. The facility policy titled Dining Room Service dated 1/2023 documented meals will be served promptly to maintain adequate temperature and appearance. The effective equipment shall be provided, and guidelines established to maintain food at appropriate and palatable temperatures during meal service. Resident #49 had diagnoses of hypertension and depression.…

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 12/18/2023 to 12/22/2023, the facility did not ensure a resident was provided with required rehabilitative services. This was evident for 1 (Resident #55) of 16 total sampled residents. Specifically, Resident #55 was not evaluated for Physical Therapy (PT) services after a referral to PT was ordered by the Attending Physician. The findings are: The facility policy and procedure titled PT Screen dated 10/12/2021 documented the rehabilitation department (Rehab) screened residents upon referral from the interdisciplinary team (IDT). During an interview on 12/18/2023 at 2:46 PM, Resident #55 stated they were supposed to be screened by Rehab but haven't received PT services. Resident #55 had diagnoses of post-traumatic stress disorder and cerebral infarct. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #55 was cognitively intact. The Attending Physician Note dated 7/18/2023 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, interview, and record review conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure a safe and comfortable environment for residents, staff, and public. This was evident for 1 (Unit 2) of 3 units. Specifically, the Unit 2 nursing station had mismatched paint and a damaged desk. The findings are: During multiple observations on Unit #2 between 12/18/2023 at 10:30 AM to 12/22/2023 at 9:53 AM, the nursing station desk had chipped and missing veneer, was stained with black and brown scuff marks, and had mismatched paint near the supply closet. On 12/20/2023 at 10:31 AM, Registered Nurse #3 was interviewed and stated they tried to fill out a work order form for Maintenance to fix repair issues. On 12/20/2023 at 11:59 AM, Maintenance Worker #1 was interviewed and stated they reviewed the work order requests in the Maintenance box and made rounds on the units to identify repair issues. They looked for paint and broken furniture and addressed issues immediately. On 12/22/2023 at 3:38 PM, the Facilities Director was…

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

Based on observation, interview, and record review conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure handrails were firmly secured to the wall. This was evident for 1 (Unit #2) of 3 resident units during environmental observation. Specifically, 2 sections of handrail were not fully connected in the Unit 2 hallway. The findings are: During multiple observations on Unit #2 between 12/18/2023 at 10:30 AM to 12/22/2023 at 9:53 AM, a handrail in the hallway near the elevator had 2 sections that were loose and not fully linked at a joint connection. There was no documented evidence the loose handrail was reported in the Maintenance Log Book from 10/26/2023 to 12/16/2023 On 12/22/2023 at 9:45 AM, Certified Nursing Assistant #1 was interviewed and stated they call housekeeping when something needs to be fixed and was not aware of a Maintenance Logbook used to report repair concerns. On 12/20/2023 at 11:59 AM, Maintenance Worker #1 was interviewed and stated they addressed repair concerns left in the Maintenance mailbox and performed unit…

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 an Abbreviated Survey (NY00324241), the facility did not ensure that an alleged violation involving abuse was reported immediately but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury to New York State Department of Health (NYSDOH). This was evident for one out of three residents (Resident #1) sampled for abuse. Specifically, on 09/12/23 at approximately 12:00 PM, Recreational Aide (RA) #1 reported that they observed Certified Nurse Assistant (CNA) #1 hitting Resident #1 in the face with a towel and cursed at Resident #1while providing personal care. The facility did not report the alleged violation of abuse to NYSDOH. The findings are: The facility Policy and Procedure entitled, Abuse, last updated on 12/22, documented notify the local law enforcement and appropriate State Agency immediately no later than 2 hours after the allegation/identification…

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.

F 842 Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00324241). In accordance with accepted professional standards and practices, the facility did not maintain clinical records that were completed and accurately documented. This was evident in one of three residents (Resident #1) reviewed for Abuse. Specifically, on 09/12/2023, Recreation Aide (RA)#1 reported to the Administrator that they observed Certified Nurse Assistant (CNA) #1 hit Resident #1 with a towel and cursed Resident #1 while providing care. Registered Nurse Supervisor (RNS) #1 assessed Resident #1 and did not document the assessment in Resident #1's medical record. The findings are: The Facility's Policy and Procedure entitled, Charting and Documentation revised date 01/2020, documented all services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All incidents, accidents, or changes in the resident condition must be recorded. A review of the facility's investigation 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 observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that necessary housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, resident rooms were not maintained in good repair and in a homelike manner. This was observed during Environmental Observations on 1 of 3 resident units. (Unit #2) The Findings Include: The policy titled Physical Plan last revised date 11/2017- documented that environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Blood Borne Pathogens Standard. The housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled. Walls, blinds and window…

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

Based on observation, staff interview and record review conducted during the Recertification/Complaint Survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Specifically, there was no CCP developed and implemented for resident's Self-Care Administration of Tube Feeding and Self-Performance of respiratory care. This was evident for 1 of 1 resident reviewed for Tube Feeding and for 1 of 2 residents reviewed for respiratory care respectively, out of 18 sampled residents (Resident #48). The findings included but were not limited to: The facility policy and procedure titled Care Plans-Comprehensive last revised on 10/2019 documented, A Comprehensive, person-centered Care Plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT) in conjunction with 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 staff interviews during the Recertification/Complaint survey, the facility did not ensure that care and services are provided according to accepted standards of clinical practice to meet professional standards of quality. Specifically, the facility did not ensure that a resident with Intravenous Peripherally Inserted Central Catheter (IV PICC) line for an antibiotic is provided with care and services to prevent further infection. This was evident for 1 of 5 residents observed for Medication Administrations out of a sample of 18 residents. (Resident #110). The findings are: The facility policy on Insertion and Maintenance of Intravenous Catheter last revised date: 05/2021 documented: - To minimize the risk of infection and other complications associated with the insertion and maintenance of intravenous catheters, IV site dressing will be replaced in accordance with MD orders or when damp, loosened or visibly soiled or when IV site is changed. The date and time of IV insertion will be written on the dressing. On 10/07/21 at 8:33AM, a Registered…

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

Based on observation, staff interview and record review conducted during the Recertification/Complaint Survey, the facility did not ensure that needed care and services that are resident centered, in accordance with the professional standards of practice that will meet resident's physical, mental, and psychosocial needs are provided to a resident. Specifically, a resident that required Self-Administration of Tube Feeding and Self-Performance of respiratory care were not properly monitored and supervised. This was evident for 1 of 1 resident reviewed for Tube Feeding and for 1 of 2 residents reviewed for respiratory care respectively, out of 18 sampled residents (Resident #48). The findings included but were not limited to: The facility policy and procedure titled Care Plans - Comprehensive last revised on 10/2019 documented A Comprehensive, person-centered Care Plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT) in conjunction with…

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

Based on observation, interviews and record review conducted during the Recertification Survey the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, two residents (Resident #15 and #42) did not receive doses of intravenous antibiotics ordered for the overnight hours on 10/04-08/2021. The findings are: On 10/04/2021 at 11:20AM, the Nursing Supervisor (RN #1) was observed giving medications on the 3rd floor and stated to be filling in due to a shortage in staffing. RN #1 stated that on the day shift there is usually one nurse per floor (1:20 residents). There are supposed to be two nurses in the building (1:30 residents) during the evening and night shifts…

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

Based on observation and staff interviews conducted during the Recertification survey, the facility did not ensure that all equipment was being maintained in a clean, sanitary manner. Specifically, the meat slicer was observed uncovered and electric wire coiled (wrap around) the meat slicer for three days. This was evident during the kitchen inspection. The Findings Include: The policy titled Sanitization policy last revised 02/2021 documented that equipment near preparation areas shall remain covered once cleaned and air dried to prevent cross contamination. The instruction manual for the Globe G12 slicer documented to prevent illness caused by the spread of food borne pathogens, it is important to properly clean and sanitized the entire slicer as any surface of the slicer can become contaminated. It is the responsibility of the slicer owner / operator to follow all guidelines, instructions and laws as established by your local and state health department and the manufacturers of chemical sanitizer. There is no specific facility Meat Slicer cleaning policy. On 10/06/2021 at…

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

Based on observation, record review, and staff interviews during the Recertification/Complaint survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, The residents on oxygen/nebulizer/suction treatment were observed with the tubing not properly labelled and dated to indicate the time the tubing was replaced. This was evident in 2 of 2 residents reviewed for respiratory care area (Residents #6 and #48). The findings are: The facility policy and procedure titled Oxygen Therapy Administration dated 01/2020 documented: Oxygen tubing will be changed at least weekly, or as needed based on soiling/breaches in infection control. Date initial tubing when changed. Resident #6 is admitted to the facility with diagnoses that included Viral hepatitis (includes type A, B, C, D, and E), Asthma (COPD) or chronic lung disease. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 06/28/2021 documented that the resident has Intact…

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.