Williamsbridge Center For Rehabilitation And Nrsg

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) Infection prevention and control practices were not maintained during medication administration. This was evident in 1 of 3 nurses observed for medication administration. 2.) Staff failed to assist residents with hand washing or hand hygiene before meals. This was evident in 2 of 2 units observed during meals. 3.) A resident's urinary drainage bag was observed touching the floor. This was evident in 1 (Resident #4) of 3 residents reviewed for Urinary Catheter out of 22 sampled residents. The findings are: 1.) The facility's policy titled Infection Prevention and Control Program with a last revision date of 05/30/2024 documented that the facility adheres…

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 01/02/2025 to 01/08/2025, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, 1.) The walk-in refrigerator contained undated items. 2.) A unit refrigerator contained spilled liquids and undated fruit cups and open drinks items. The findings are: The facility's policy titled Food Storage with a revision date of 05/10/2024 documented that food will be stored in an area that is clean, dry, and free from contaminants, stored at appropriate temperatures, and by methods designed to prevent contamination or cross contamination. All refrigerator units will be kept clean and in good working condition at all times. Perishable foods such as meat, poultry, fish, dairy products, fruits, and vegetables must be stored in the refrigerator immediately after receipt to assure nutritive value and quality. All food should be covered, labeled,…

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 from 01/02/2025 to 01/08/2025, the facility did not ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident in 2 of 22 sampled residents (Residents #35, #18). Specifically, 1.) Resident #35's care plan related to Smoking was not reviewed and revised quarterly after each assessment, and 2.) Resident #18's care plan was not reviewed and revised after a fall occurrence. The findings are: The facility policy and procedure titled Care Plans Comprehensive with a last revised date of 08/02/2024 documented that a comprehensive person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, 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 conducted during the Recertification Survey from 6/13/23 to 6/21/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident 1 (South Unit) of 2 resident units. Specifically, the make resident bathroom was observed to be dirty. The findings are: On 6/15/2023 at 12:39 PM and on 6/16 /2023 at 11: 40 AM, Male Resident's Bathroom on the South Unit was observed dirty and stained, with rust colored stains throughout the entire inside of the bathroom. On 6/21/2023 at 3:26 PM, the Director of Maintenance and Housekeeping (DOMH) was interviewed and stated they visit the resident's rooms twice daily. The resident bathrooms are cleaned every shift. The DOMH stated the bathrooms will be inspected more often to make sure they stay clean. 415.29(j)(1)

Based on observations, record review, and interviews conducted during the Recertification survey from 06/13/2023 to 06/21/2023, the facility did not ensure that a safe food storage was practiced. This was evident during the Kitchen Observation. Specifically, expired water was observed in the kitchen's Emergency Food Storage Room (EMSR). The findings are: The facility policy titled Disaster/Plan dated 01/2023 documented in an emergency, the facility will have emergency food, water, and supplies for 3 days. This should include adequate water for additional people like staff, family members, rescue workers, and evacuees. On 06/20/2023 at 10:56 AM during the tour of the EMSR observation, there was an unopened box of 6 gallons of water with a use by date of 5/13/2022. On 06/21/2023 at 2:47 PM, an interview was conducted with the Food Service Director who stated they always look at the expiration date every time an order comes to the facility. They usually rotate all boxes in the central storage and the EMSR. These expired bottles of water were given to the facility from another facility…

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

Based on observations, record review, and interviews conducted during the Recertification survey from 6/13/23 to 6/21/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 2 (Resident #70 and #26) of 21 total sampled residents. Specifically, blood pressure (BP) cuffs were not cleaned and disinfected between use with Resident #70 and Resident #26. The findings are: The facility policy titled COVID-19 Environmental Management dated 2/1/2023 documented equipment/device that cannot be dedicated should be cleaned disinfected between each patient use. On 06/15/23 at 09:26 AM, Licensed Practical Nurse (LPN) #3 was observed on the resident unit using the BP cuff and machine to take Resident #26's in the resident's room. LPN #3 placed the BP cuff on Resident #26's left arm without sanitizing the BP cuff prior to placement. LPN #3 then rolled the BP machine into the hallway next to the cart without sanitizing the cuff. At 09:39 AM, LPN #3 did not sanitize the BP machine and placed the BP cuff onto Resident #70 to take their BP. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification Survey from 6/1/23 to 6/21/23, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident # 6) out of 5 residents reviewed for Accidents of 21 total sampled residents. Specifically, the facility did not report an unwitnessed incident resulting in bilateral eye ecchymosis and frontal hematoma to Resident #6. The findings are: The facility policy titled Abuse last revised 01/2023 documented the Administrator/Director of Nursing (DNS) is responsible for investigation and reporting all allegations of suspected abuse, neglect, mistreatment, distortion, injury of unknown origin, misappropriation shall be promptly and thoroughly investigated by facility management. The Administrator shall report to the local police department, the ombudsman, 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 from 06/13/23 to 06/21/23, the facility did not ensure a person-centered Comprehensive Care Plans (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #24) of 21 total sampled residents. Specifically, a CCP related to Resident #24's behavior of emptying their urine and feces into the garbage bin in their room. The findings are: The facility policy titled Care Plans Comprehensive last revised 1/2019, 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 facility policy titled Behavior Management dated last revised 1/2023, documented behavioral symptoms and approaches shall be planned in the resident-specific plan of care and communicated to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification from 6/13/23 to 6/21/23, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #27) of 2 residents reviewed for Edema out of 21 total sampled residents. Specifically, Resident #27 was observed on multiple occasions without Thrombo-Embolic Deterrent (TED)/compression stockings in place according to Medical Doctor Order (MDO). The findings are: Resident #27 had diagnoses of localized edema, diabetic peripheral angiopathy, and venous insufficiency. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #27 had moderately impaired cognition and required extensive assistance from 1 person to dress. On 6/14/2023 at 12:45 PM, 6/15/2023 at 2:43 PM, 6/16/2023 AT 9:55 AM, Resident #27 was observed sitting in their room, alert, watching TV, and without bilateral TED stockings on their legs. The MDO 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 survey from 6/13/23 to 6/21/23, the facility did not ensure a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and public. This was evident in stairwell of facility that is used by staff and visitors to access the basement. Specifically, the stairwell used to enter and exit the resident unit was soiled and dirty with debris. The findings are: Between 06/13/23 12:43 PM and 06/16/23 at 09:57 AM, multiple observations of the facility stairwell used to travel from the resident unit to the staff locker room and conference room were made. The stairs had black dirt ground into the floor and stuck on each step. There were multiple steps with two-tone patches of flooring. Dust buildup was present on each step of the stairs. There were 2 dark mats at the foot of stairs, stuck to the floor and built up with dirt. On 06/21/23 at 03:26 PM, an interview was conducted with Director of Maintenance/Housekeeper who stated they are aware the stairs have mismatched floor…

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 06/13/23 through 06/21/23, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident for 1 (South Unit) of 2 resident units. Specifically, multiple gnats were observed room [ROOM NUMBER] and #20 on the South Unit. The findings are: The facility policy titled Pest Control dated 11/2021 documented the facility shall maintain an effective and ongoing pest control program to ensure the building is kept free form pests and rodents. On 06/13/23 at 10:00 AM, multiple gnats were observed on an uncovered sandwich in room [ROOM NUMBER]B on the South Unit. On 06/13/23 03:12 PM, 06/14/23 at 09:48 AM, 06/15/23 09:07 AM, and 06/21/23 09:35 AM multiple gnats and flies were observed resting on an empty urinal on the side of bed in 20 C on the South Unit. The facility document titled Pest Management dated 6/2/2023, 6/6/2023 documented the facility 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 record review and interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident with chronic pain reported continued pain to the staff despite pain management. The nursing staff did not assess the resident's reported pain, complete pain assessments as ordered, or report the pain to the physician for follow-up. This was evident for 1 of 3 residents reviewed for pain management (Residents #273). The finding is: The facility policy, titled Pain Management dated 07/2019 documented the following: The facility is committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. The Pain management policy also documented that the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey, conducted on 5/28/2021, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) contracted vendors were not wearing the proper personal protective equipment (PPE) while working in the room of a resident on contact and droplet precautions; and 2) a resident's indwelling catheter drainage bag was on the floor on multiple occasions. This was evident for random observations of 2 residents (Resident #71 and Resident #222) on 1 of 2 units (1 South Unit). The findings are: The Centers for Disease Control and Prevention (CDC) Guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may…

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.