Brooklyn United Methodist Church Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and complaint (NY00310185), the facility did not ensure the residents' right to a safe, clean, comfortable environment. This was evident for the outdoor patio and 3 of 3 resident floors (2nd, 3rd, and 4th). Specifically, 1) the outdoor patio was observed with paper cups, gloves, and cigarette butts on the ground and overgrown shrubs, trees, and grass; 2) the 2nd floor was observed with sticky dirty furniture, sticky floors stained black at the baseboards, broken dressers, peeling paint, sagging unhooked privacy curtains, a bed frame in disrepair, missing mirror, urine odor, and a stained faucet with a loose handle in resident rooms and dirty air conditioning (AC) units in the dayroom; 3) the 3rd floor was observed with a broken AC unit, dirty windowsills, broken floor and wall tiles, a leaking rust colored sink, urine odor, and a hole in the wall of resident rooms; and 4) the 4th floor was observed with mismatched peeling…

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 and abbreviated survey (NY00302016 and NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations involving abuse were reported within 2 hours, or events not involving abuse were reported within 24 hours to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #92) of 3 residents reviewed for abuse and 1 (Resident #79) of 2 residents reviewed for accidents out of 27 total sampled residents. Specifically, 1) Resident #92 reported a Certified Nursing Assistant (CNA) pushed them in the chin and the facility did not report the allegation to the NYSDOH within 2 hours, and 2) the facility did not report Resident #79 was found on the floor in their room with left arm redness and sheering within 24 hours. The findings are: The facility's policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 4/20/23 documented the resident will be free…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and staff interviews during the recertification and abbreviated (NY00318546 and NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations of abuse were thoroughly investigated. This was evident for 2 (Resident #171 and #79) of 27 total sampled residents. Specifically, 1) Resident #171 was observed with a bump and redness to their forehead that was not thoroughly investigated, and 2) staff statements were not obtained to rule out abuse when Resident #79 was found on the floor. The findings are: The facility policy titled Accident/Incident (AI) Report dated 3/9/2023 documented promptly submit completed statements from all Certified Nursing Assistants (CNA) related to the AI to the Nursing Supervisor within the tour of duty. 1) Resident #171 had diagnoses of Psychotic Disturbance, Mood Disturbance and Anxiety. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #171 had severely impaired cognition. On 9/14/2023 at 5:28 PM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. This was evident for 5 of 27 sampled residents (Resident #s 60, 109, 110, 66, and 27). Specifically, Resident #60 had no CCP for Glaucoma. Resident #66 and #109 had no CCP developed to address dental issues. Resident #110 had no CCP developed to address the care needs of Latent Syphilis. Resident #27 had no CCP to address pain. The findings include but are not limited to: The facility policy and procedure title Comprehensive Care Plan last updated on 4/20/23 stated that an individualized comprehensive care plan will be developed and implemented for each resident. The policy further stated that the care plan will be maintained within the medical record of each resident in the facility. The care plan will be developed by an interdisciplinary team of health care professional as appropriate to the need of each resident. 1)…

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 survey from 9/10/23 to 9/18/23, the facility did not ensure resident's Comprehensive Care Plan (CCP) were reviewed, revised, and implemented after each assessment. This was evident for 1 of 2 residents reviewed for Pain Management (Resident #87) and 1 (Resident #79) of 2 residents reviewed for Accidents out of 27 total sampled residents. Specifically, 1) CCPs related to Pain Management/Therapy were not reviewed and revised quarterly to reflect current pain management regimen for Resident #87, and 2) the CCP related to Resident #79's risk for falls was not reviewed and revised to reflect updated interventions after the resident had an incident on 6/19/2023. The findings are: The facility policy titled CCP dated 4/20/2023 documented CCPs are reviewed and revised quarterly and as needed. 1) Resident #87 was admitted to the facility with diagnosis of Schizophrenia, Osteoarthritis and Diabetes Mellitus. The Minimum Data Set 3.0…

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 conducted during the recertification and complaint (NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents remained free of accidents and hazards. This was evident for 1 (Resident #79) of 2 residents reviewed for Accidents and the 1 (2nd Floor) of 3 resident units. Specifically, 1) Resident #79 was not adequately assessed for fall risk following each fall, did not have a CCP related to fall risk with adequate interventions that was reviewed upon each fall, and did not receive supervision to prevent further falls; and 2) there were observations of a 2nd floor window in the floor dayroom that can fully open, an eyewash station without an eyewash device in place, a dental office with an x-ray machine and drill that remained unlocked, and a wet shower room floor without a wet floor sign. The findings are: 1) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews conducted during the recertification and complaints (NY00307070, NY00318546, survey from 9/10/23 through 9/18/23, the facility did not ensure there was sufficient staff available to meet residents' needs considering the number, acuity and diagnose of the facility's resident population as determined by the Facility Assessment. Specifically, 1) the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report, 2) Resident #171 was discovered with an injury of unknown origin on a day when the unit was short of Certified Nursing Assistants (CNA), and 3) Resident #121 reported not receiving care on a day when the facility was short of CNAs on their unit. The findings include but are not limited to: The Facility Staffing policy reviewed 4/20/23 documented that each nursing unit will have adequate staff to safely and effectively complete resident care on a daily basis. 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, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure the facility 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 7 of 7 Licensed Practical Nurse (LPN) Permittees and 1 of 1 Registered Nurse (RN) Permittees employed by the facility. Specifically, the facility employed 7 LPN Permittees and 1 RN Permittee to work in the capacity as a licensed nurse without the required application approval and documented RN supervision. The findings are: The facility policy titled Limited Permit dated 5/12/2023 documented the facility employs nurses who do not hold a New York State (NYS) license by accepting a permit from the NYS Education Department (NYSED). Permits to practice a RN or LPN are issued by the NYSED after filing an application. No Permittee will be allowed to begin employment without form N5 of the NYSED. Upon…

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 9/10/2023 to 9/18/2023,the facility did not ensure a quality assurance and performance improvement (QAPI) program that use evidence to define and measure indicators of quality and facility goals, include resident choice, and address all systems of care and management practices. This was evidenced Specifically, the facility's QAPI topics were not reflective of previous State Survey Inspection results and the method of gathering measurable data was not accurate or adequate to identify quality improvement. The findings are: The facility policy titled QAPI Plan dated 1/23/23 documented Governing Body is responsible for: 1) Identifying and prioritizing problems based on performance indicator data. 2) Incorporating resident and staff input that reflects organizational process, functions and services provided to residents. 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4) Setting clear expectations for safety, quality, rights, choice 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, interviews, and record review conducted during the recertification and complaint (NY00310185) from 9/10/2023 to 9/18/2023, the facility did not ensure a safe, functional, and comfortable environment for residents, staff, and the public. This was evident for the outside area of the facility and 1 (2nd floor) of 3 Units. Specifically, the outside surrounding area of the nursing home had overgrown grass and shrubs and garbage on the sidewalks and in the parking lot, and insects hovering around standing water in a cart near the entrance to the facility; and, the 2nd Floor had a nursing station that had chipped and missing veneer and broken filing cabinets. The findings are: The facility policy titled Terminal/Environmental Room Cleaning dated 4/20/2023 documented the facility will maintain a clean environment for resident care that meets professional standards. 1) On 9/10/2023 at 8:30 AM, 9/11/2023 at 9:00 AM and 10:00 AM, and 9/12/2023 at 11:36 AM, the grass and shrubs surrounding the facility in the parking lot and along the perimeter fence and sidewalk were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure a resident's right to formulate an advance directive (AD). This was evident for 1 (Resident #371) of 33 total sampled residents. Specifically, Resident #371's AD status was not determined with their Legal Guardian (LG) upon readmission to the facility. The findings are: The facility's policy titled AD dated 4/21/2023 documented in the event residents cannot make their own decisions the Medical Orders for Life-Sustaining Treatment (MOLST) process will be followed. Resident #371 was readmitted to the facility on [DATE] with diagnoses of schizophrenia and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #371 was severely cognitively impaired. The Comprehensive Care Plan (CCP) related to AD and initiated 5/26/2022 documented Resident documented maintain communication with Resident #371's LG regarding all needs and…

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

Based on record review and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were completed in a timely manner. This was evident for 2 (Resident #103, #105) of 2 residents reviewed for Resident Assessment. Specifically, 1) Resident #103's Discharge MDS was not completed within 14 calendar days from the Assessment Reference Date (ARD), and 2) Resident #105's Discharge MDS was not completed within 14 calendar days from the Assessment Reference Date (ARD). The findings are: 1. Resident #103 was admitted to the facility with diagnoses including Dementia, Hypertension, and Obstructive Uropathy. The physician note dated 5/5/23 documented resident noted AMS/hypotension/hypoxia, possible severe sepsis vs shock. Oxygen started and 911 was activated. Resident was discharged to the hospital on 5/5/23. There was no documented evidence a Discharge MDS was completed upon Resident #103's discharge to the hospital on 5/5/2023. 2. Resident #105 was admitted to the facility with diagnoses including…

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 conducted during the recertification and complaint (NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure services met professional standards of practice. This was evidenced for 1 (Resident #79) of 27 total sampled residents. Specifically, Resident #79 was found on the floor in their room and was placed back in bed by the Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) prior to receiving an assessment by a Registered Nurse (RN). The findings are: Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was severely cognitively impaired and had a fall since their prior assessment that did not result in injury. Resident #79 required extensive assistance of 2 people for walking in their room and for transfers. On 09/14/2023 at 12:30 PM, an interview was conducted with the complainant who stated they came to visit Resident #79 on 6/19/2023 after 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, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure a resident received quality care. This was evident for 1 (Resident #24) of 27 total sampled residents. Specifically, Resident #24 was observed on multiple occasions without compression stockings in place as ordered to address left lower extremity (LLE) edema. The findings are: The untitled facility policy related to anti-embolic stocking use dated 1/2023 documented report and document application of compression stockings, any skin issues, or other changes noted with the resident. Resident #24 had diagnoses of schizophrenia and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #24 was severely cognitively impaired and required the extensive assistance of 1 person for dressing. On 09/10/23 at 09:59 AM, Resident #24 was observed wheeling themselves in wheelchair in the hallway towards their room. Resident #24 had LLE swelling and 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 9/10/23 to 9/18/23, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for Resident #371 reviewed for Position/Mobility out of 27 total sampled residents. Specifically, Resident #371 had bilateral upper and lower extremity contractures and was observed without an abduction/contraction cushion (ACC) as per Medical Doctor Order (MDO). The findings are: The facility policy titled Assistive/Adaptive and Positioning Devices dated 4/2023 documented the assigned Certified Nursing Assistant (CNA) will be responsible for the application of devices according to the Plan of Care and signs the CNA Accountability record every shift daily. Resident #371 had diagnoses of diabetes mellitus and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #371 was severely…

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 interview conducted during the Recertification and abbreviated survey, the facility did not ensure policies and procedures to prevent loss of controlled drugs were implemented. This was evident on 1 of 3 units reviewed for Medication Storage (Unit 3). Specifically, a bag containing a pair of glasses and dentures (top and bottom) were stored in the Unit 3 narcotic cabinet. The findings are: The policy and procedure titled Medication Storage last reviewed on 4/20/2023 documented that the facility stores all drugs and biologicals in a safe, secure and orderly manner. Only person authorized (Licensed Nurses) to prepare and administer medications have access to locked medications. On 9/12/2023 at 3:35 PM, an observation of the medication storage room on the 3rd floor was conducted with the Licensed Practical Nurse (LPN #4). A small plastic bag containing a pair of glasses and full dentures (top and bottom) was observed in the narcotic cabinet. On 9/18/2023 at 12:34 PM, the Licensed Practical Nurse on the unit (LPN#4) was interviewed 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, interview, and record review conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 2 (2nd Floor and 4th Floor) of 3 units. Specifically, 1) medications were not kept in locked compartment and were on the 2nd Floor Nursing Station, and 2) the 4th Floor medication cart contained unopened eye drops labeled with directions to refrigerate until opened. The findings are: The policy titled Medication Storage dated 4/20/2023 documented the facility stores all drugs and biologicals in a safe, secure and orderly manner. Only Licensed Nurses are authorized to prepare and administer medications and have access to locked medications. 1) On 09/10/23 at 12:07 PM, medication blister packs containing 3 pills of Seroquel 50mg, 3 pills of Finasteride 5mg, 3 pills of Lexapro 20mg, and 3 pills of Eliquis 5mg were observed on the 2nd Floor Nursing Station desk, open to the public and accessible to anyone walking in the hallway.…

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 staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure adequate dental services were provided for a resident with tooth pain. This was evident for 1 (Resident #66) of 2 reviewed for Dental out of 27 sampled residents. Specifically, Resident #66 had tooth pain that was not evaluated by the dentist in a timely manner. The findings are: The facility policy and procedure titled Dental Services - Hygiene Program, reviewed 4/20/23, documented the program will meet residents' specific oral hygiene and dental care needs. Resident #66 was admitted to the facility with diagnoses of Dementia, Glaucoma and Depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident #66 had severely impaired cognition for decision making and daily life tasks. During an interview on 9/10/23 at 11:43 AM, Resident #66's family member stated that the resident's toothache was reported to the nurse about three months ago, but the family…

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 did not ensure that each Resident or resident representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, residents were not invited to quarterly care plan meetings. This was evident for 1 of 2 residents reviewed for Care Plan and 1 of 1 resident reviewed for Dental out of a sample of 24 residents. (Resident #42 & Resident #1) The findings are: 1. The facility's policy titled Comprehensive Care Plan last reviewed 09/21/21, documented that the resident and his or her legal representative, are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The policy also documented that care plans be reviewed at least quarterly by the Interdisciplinary team (IDT) and revised as necessary. Resident #42 was admitted on [DATE] with diagnoses that include Anxiety Disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that a safe, clean, comfortable, and homelike environment was maintained. Specifically, a resident's room was observed on multiple occasions to be cluttered with food items, plastic utensils and clothing strewn on the window sills, overbed table, closet, and floor. This was observed during environmental observations on 1 of 3 units. (Unit 2) The findings are: The facility policy and procedure Maintenance of Facility corridors and other floor areas dated 4/22/15 and revised on 8/3/21 documented that the policy is to maintain the corridors and all other floor areas clean, orderly, neat, and free of obstructions. The purpose is to maintain good infection control practices. Resident's rooms are cleaned daily on the 7-3 shift by the housekeeper on the assigned floor. The housekeeper on each unit will clean 3 rooms thoroughly. During observations of the environment conducted on Unit 2 on 1/18/2022 at 11:37 AM,…

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 interviews and record review conducted during a Recertification survey and Complaint investigation (NY 00264258) the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report the self-inflicted injury of a resident to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 1 of 4 residents reviewed for Accidents out of a sample of 24 residents. (Resident #323). The findings are: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's property, effective 11/28/16 and reviewed on 11/01/21, documented that the facility will ensure that that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown…

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 staff interview during the recertification and abbreviated survey, the facility did not ensure that a person centered comprehensive care plan was developed and implemented to address the resident's medical needs. Specifically, there was no care plan developed to address the use of psychotropic medications. This was evident for 1 of 5 residents reviewed for Unnecessary Medication out of a sample of 24 residents. (Resident #40) The finding is: The facility policy and procedure Comprehensive Care Plan revised on 9/21/21 documented that a written comprehensive care plan will be developed and implemented for each resident in conjunction with the resident and the resident's representative. An individual comprehensive care plan will be maintained within the medical record of each resident at the facility. The physical, mental, and psychosocial condition of the resident will determine the composition of the interdisciplinary team. The care plan will be developed as appropriate to the need of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during a Recertification survey and Complaint investigation (NY00264258) the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a resident was observed sitting in their wheelchair in the back courtyard of the facility, unsupervised at night, with injury to wrists, abdomen, and inner thigh. This was evident for 1 out of 4 residents reviewed for Accidents out of a sample of 24. (Resident #323) The findings are: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident's property, effective 11/28/16 and reviewed on 11/01/21, documented that it is the policy of BUMCH ([NAME] United Methodist Church Home) that each resident will be free from Abuse. The policy also documented that resident will be protected from abuse, neglect, and harm while they are residing at the facility. Resident #323 was admitted to the facility with diagnoses that included Depression and Psychotic Disorder. 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, and staff interviews conducted during the Recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1) oxygen tubing was observed touching the floor on multiple occasions, and 2) residents were observed on the unit sitting in less than 6 feet apart from each other and were not wearing face masks. This was evident on 1 out of 3 units observed for infection control. (Unit 4) The findings are: 1. Resident # 99 was admitted to the facility with diagnoses that included Viral Hepatitis and Legionnaire disease. The Quarterly Minimum Data Set, dated [DATE] documented the resident cognitive level is severely impaired and required dependent assistance for most Activities of Daily Living. The MDS also documented that the resident is receiving oxygen therapy, trach care and suctioning. On 01/18/22 at 10:46 AM, 01/18/22 at 12:22 PM, 01/19/22 at 10:29 AM and on 01/20/22 at 12:30 PM, Resident #99 was observed seating in geriatric…

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.