Saints Joachim & Anne Nursing and Rehabilitation C

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification survey from 04/15/2025 to 04/22/2025, the facility did not ensure that resident or resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and/or resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 1 (Resident #116) of 2 residents reviewed for Care Plan out of 37 sampled residents. The findings are: The facility policy and procedure titled Care Planning Process with effective date 06/24 stated resident and/or designated representative will be informed of scheduled care plan meetings, including the suggested date and time by the Social Service Department. The policy and procedure also stated that the resident and/or designated representative will be invited to the meeting by phone call, in-person or written invitation. The policy and procedure further stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification Survey from 04/15/2025 to 04/22/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 2 (Resident #67 and Resident #482) of 3 residents reviewed for Beneficiary Notification out of 37 total sampled residents. Specifically, 1). the facility did not ensure that assistive devices were used to make appropriate notification, and 2). the Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage were not mailed to a resident's representative on the same day the telephone notification was made. The findings are: The facility policy titled Care and Treatment of Residents Medicare Determination for SNF (Skilled Nursing Facility) with an effective date of 01/21 stated that documentation on the Notice of Medicare Non-Coverage letter must include that the resident or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 04/17/2023 to 04/24/2023, the facility did not ensure that menus were followed. This was evident for 2 of 3 residents reviewed for Food out of 39 sampled residents (Resident #91 and Resident #288) and 182 residents present on 4/17/23. Specifically, 1) Resident # 91 received food items that did not match items on the tray ticket, and 2) Resident #288 reported they were served pork, fried foods and not their preferred foods. In addition, 3) on 4/17/23, the vegetable listed on the posted menu was changed, and residents were not informed. The findings are: The facility policy for Nutrition- Provision of Diet revised 1/10/2018 documented to provide each resident with a nourishing palatable, well balanced regular or therapeutic diet as per primary care provider order. The diet will meet the daily nutritional and specialty die needs of each resident, taking into consideration the cultural, social, religious ethnic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 4 of 5 resident floors (Floors 3, 5, 6, and 7). Specifically, resident rooms were observed with broken window blinds (Floors 3 and 5), torn window screens (6th Floor), and missing blinds and privacy curtains (7th floor). Resident wheelchairs had stained cushions (3rd and 6th Floor) and wheel noted with worn tires on both sides with decreased tread chipped paint on oxygen canister holder with a missing screw, wheelchair tires were noted to have multiple decreased rubber tread on bilateral wheels (6th floor). The findings are: The policy titled Maintenance and Cleaning of Rehab Equipment/Devices dated 08/01/2022 documented the facility will provide clean equipment or devices for each resident. To provide appropriate equipment/device necessary to needs of patients that are clean to prevent and control spread of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the Recertification and Complaint survey (NY00313269) from [DATE] and [DATE], the facility did not ensure that residents' comprehensive care plans (CCPs) were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident for 3 out of 39 sampled residents (Residents #19, #16 and #134). Specifically, (1) Resident #19's Advance Directive CCP was not reviewed and revised when their code status was changed to Do Not Resuscitate (DNR) and after the quarterly assessment; (2) Resident #16's CCP related to Anemia and gastrointestinal (GI) bleeding was not reviewed and revised to reflect a change in the resident's status after hospitalization; and (3) Resident #134's elopement risk CCP was not reviewed and revised for 6 months. The findings are: The facility policy titled Care Plan Process and Development last revised 07/2022 documented the CCP process is reviewed at least quarterly, upon significant change in condition,…

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 [DATE] to [DATE], the facility did not ensure biologicals were stored in accordance with professional principles. This was evident for 1 (6th Floor medication room) of 5 medication storage areas reviewed. Specifically, 1) emergency medications were stored in a plastic emergency box missing the tamper proof seal. The findings are: The undated pharmacy policy titled Emergency Boxes (EBOX) documented each E-box will be locked with a tamper resistant lock indicating if the box has been opened. Each box that is opened is sent to the Nursing office for return to the pharmacy for replenishment. Each box sent to the nursing office will be replaced immediately with a current in date box (swing box). On [DATE] at 12:47 PM - 01:00 PM, the medication room on the 6th floor was observed with Licensed Practical Nurse (LPN) # 1. The red emergency medication box was unlocked and did not have a tamper proof seal. When the box 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 during the Recertification survey from 04/17/23 and 04/24/23, the facility did not ensure that laboratory services were provided timely to meet resident needs for 1 (Resident #19) of 5 residents reviewed for Unnecessary medications. Specifically, laboratory (lab) blood work [Complete Metabolic Profile (CMP) and Complete Blood Count (CBC) with differentials, Lipids, B12, Folate, Thyroid -stimulating hormone (TSH), and Hemoglobin A1c] ordered for Resident #19 on 3/30/2023 and 04/19/23 was not done. The finding is: The facility's policy titled Laboratory- Specimen Collection, last reviewed 07/2022, documented that the facility will be responsible to contract with a laboratory to provide diagnostic laboratory services. The referrals for laboratory tests will be made by the Attending physician/Nurse Practitioner, or on the recommendation of a consulting physician. The policy also documented that the resident care manager/charge nurse on each floor will put the tests request into…

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, during the Recertification survey the facility did not ensure each resident received food that accommodated resident's allergies, intolerances, and preferences. This was evident for 2 of 39 residents sampled for dining observations. (Resident #91 and Resident #288). Specifically, (1). Resident #91's menu did not follow the resident's preferences, and (2). the food preferences of Resident #288 were not honored when the resident expressed a preference for cottage cheese, oatmeal and whose meal ticket specified food dislikes gravy, sauces, fried foods, beef, beef stew. The findings include: The facility policy for Nutrition- Provision of Diet revised 1/10/2018 documented to provide each resident with a nourishing palatable, well balanced regular or therapeutic diet as per primary care provider order. The diet will meet the daily nutritional and specialty die needs of each resident, taking into consideration the cultural, social, religious ethnic needs preferences…

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 staff interview and record review conducted during the recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that the comprehensive care plan included measurable goals, objectives and interventions to address a resident with behavior that included verbal abuse and rejection of care. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of a sample of 29 residents. (Resident # 57). The findings are: The facility policy and procedure titled Care Plans Process and Development reviewed 12/2019 documented under the section policy to provide care necessary for each resident to reach his/her highest practicable physical, mental and psychosocial well-being. The policy further stated based on a discipline-specific clinical assessment, a care plan will be developed for each resident in order to have a systematic…

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.