Campbell Hall Rehabilitation Center Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during the Abbreviated Survey (NY00377106) the facility did not ensure for 1 (Residents #1) of 3 residents reviewed for abuse, that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, 1) the facility investigation did not include a review of the facility camera footage, 2)The facility did not provide documented evidence that a report was made to law enforcement regarding the incident of alleged abuse by staff that occurred on 4/6/25, 3)The Medical Director was not notified of the alleged abuse of Resident #1 that occurred on 4/6/25 until 4/17/25. Physician #1 was notified of the incident on 4/16/25 and the investigative report was missing signatures from the Administrator, the Physician, and the Nurse Manager. The findings are: The Facility policy titled Abuse Identification last reviewed on 4/16/25 documented that the Abuse Investigation Coordinator (Director of Nursing) will coordinate, follow 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 record review, and interviews conducted during the Abbreviated Survey (NY00377106 and NY00370944) the facility did not ensure that the Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status at the time of the assessments for 1(Resident #1) of 3 residents reviewed. Specifically, the Minimum Data Set assessment inaccurately documented that Resident #1 was assessed to have no behaviors. The Certified Nurse Aide Documentation dated 2/27/25, 3/2/25, and 3/3/35 and the Nursing Progress notes dated 3/2/25 documented Resident #1 had multiple physically aggressive behaviors. The findings are: Resident #1 was admitted on [DATE] with diagnoses including but not limited to Dementia, Encephalopathy, and Parkinson's Disease. The 3/3/25 admission Minimum Data Set documented that Resident #1 had severely impaired cognition, and no behaviors. The March 2025 Certified Nurse Aide Documentation documented that Resident #1 had a physically aggressive behavior on 2/27/25 involving kicking 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 during an abbreviated survey (NY00377106, NY00370944), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Resident # 1 and # 2) reviewed. Specifically, 1) Resident # 1 had a diagnosis of dementia with behavior disturbances and no care plan in place to address these behaviors; 2) Resident # 2 had diagnoses of Schizoaffective disorder and Alzheimer's disease with no care plan in place to address the resident's verbal and physically aggressive behaviors. The findings include: A review of the facility's Comprehensive Care Plan Policy dated 8/10/2022 and last modified/reviewed on 1/14/2025 documented the facility is dedicated to providing personalized, high-quality care for our residents using a comprehensive resident assessment and care planning process. This process is designed to maximize and maintain each resident's functional…

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 an abbreviated survey (NY00377106, NY00370944), the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 2 (Residents # 1, and # 2) of 3 residents reviewed. Specifically, 1) Resident # 1 had a diagnosis of Dementia with behavioral disturbances and did not have an individualized care plan with interventions in place to address the resident's verbal and physically aggressive behaviors to enhance their well-being and guide staff in managing the resident's care; 2) Resident # 2 had a diagnosis of Alzheimer's Disease with no behavioral care plan to address Resident # 2's verbal and physically aggressive behaviors. The findings are: Review of a behavior health policy dated 7/19/2024 and last revised on 8/13/2024 documented it is the policy of our nursing home to provide thorough and ongoing behavioral health training to equip our…

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

Based on record review, and interviews conducted during the Abbreviated Survey (NY00377106) the facility did not ensure that the Certified Nurse Aide training included dementia management and resident abuse prevention training for 1(Certified Nurse Aide#1) of 2 to ensure delivery of safe care. Specifically, the facility was unable to provide documented evidence that Certified Nurse Aide #1 was provided with abuse and/or dementia training. The Findings are: The facility policy titled Abuse Identification documented that All Staff are trained to identify physical abuse, psychological/ emotional abuse, sexual abuse, financial/material abuse, mistreatment, neglect, and self-neglect. All employees will be in-serviced on this policy initially, at the time of hire and annually thereafter by the Staff Development Coordinator On 4/15/25, Certified Nurse Aide #1's employee file to include in services and trainings were requested from the Human Resource Director, and they were unable to provide the requested information. The surveyor was only provided with a behavioral health training that…

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 and extended survey conducted 12/15/2024-12/22/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical, nursing mental and psychosocial needs for 4 of 8 residents (Resident #15, #84, #29, and #75) reviewed. Specifically, Resident #15's comprehensive care plans did not include Dementia Care, Psychotropic Drug Use, or a Diabetic care plan; 2) Resident #84's comprehensive care plans did not include an at risk for pressure ulcer care plan; 3) Resident #29's comprehensive care plans did not include a smoking care plan; 4) Resident #75's comprehensive care plans did not include respiratory/oxygen use care plan. Findings include: Review of the facility policy titled Comprehensive Care Plans last reviewed 9/23/24, documented that [NAME] Hall Rehabilitation Center is dedicated to providing personalized, high-quality care for our residents using a comprehensive resident assessment…

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

FACILITY Extended Survey Based on observation, record review and interview conducted during a recertification, abbreviated, and extended survey from 12/15/24-12/22/24 (complaint # NY00359302), the facility did not ensure that operative oversight for an effective system was in place to maintain health, safety, and the highest practicable well-being of residents. reviewed for accidents. Specifically, 1) the facility failed to provide adequate supervision to prevent accidents from smoking for 1 out of 3 residents reviewed for accidents. The facility Administrator did not ensure that smoking was not allowed in the facility grounds. 2) The facility Administrator did not ensure that employees were periodically instructed and followed the general fire procedures in accordance with the facility's Fire Emergency Plan, or that it conducted the required number of fire drills per quarter. 3) The Administrator did not ensure that its emergency preparedness plans were updated and that staff were trained annually. 4) In addition the facility did not ensure that staff were offered the updated…

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, abbreviated (NY00359302), and extended survey from 12/15/24 to 12/22/24 it was determined the facility did not ensure a process or frequency for the reporting by the Administrator to the governing body. The method of communication was not documented, and the governing body failed to establish and implement procedures for a clear line of communication regarding the management and operation of the facility. Specifically, the facility failed to provide adequate supervision to prevent accidents from smoking for six residents who were known smokers. Several observations documented residents smoking on the patio and gazebo, despite the facility being a nonsmoking facility. A fire occurred on 11/1/24, on the patio due to a discarded cigarette butt. Findings include: The facility was cited under Tag F 689 at Immediate Jeopardy scope and severity J. The facility did not provide documented evidence of a Quality Assurance Performance Improvement plan or action to address identified issues related to…

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

Based on interview and record review during the recertification survey conducted 12/15/24-12/22/24, the facility did not ensure each staff member was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 10 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence of immunization records for COVID-19 vaccine for Registered Nurse Supervisor #2, Receptionist #3, Licensed Practical Nurse # 21 Certified Nurse Aid #9#22, #23,#24, Physical Therapist #25, [NAME] #26 and Maintenance staff #27. Findings include: The facility policy titled COVID-19 Vaccination for Residents and Staff dated 5/15/2021 documented the purpose of COVID-19 vaccination is to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by offering residents and staff members immunization to COVID-19. Before offering COVID-19 vaccine all staff members are provided education regarding the benefits and risks and potential side effects associated with the vaccine.…

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 the Recertification, Abbreviated (NY00359302) and Extended Survey from 12/15/24 - 12/22/24, the facility did not ensure residents had a right to make choices regarding aspects of their life for 5 of 6 residents reviewed for smoking. Specifically, the facility did not offer a designated smoking area and did not offer a smoking cessation program prior to and after the facility changed its policy to prohibit smoking for Resident # 6, #9, #29, #41, and #54 who were known smokers at the time of admission. The findings are: The Policy and Procedure titled Smoking revised on 1/21/22 documented the facility aimed to maintain the highest quality of life for each resident who smoked, and smoking was permitted only in designated areas and at scheduled times. The Policy and Procedure titled Smoking created 6/23/22 documented the facility was to maintain the highest quality of life for each resident, and smoking will not be permitted by residents. During…

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 from 12/15/24-12/22/24, the facility did not ensure that the building was maintained in good repair to provide a safe, healthy, functional, sanitary, and comfortable environment for residents, personnel, and the public. The findings are: On December 17, 2024, during the recertification survey, between 11:30 AM - 5:45 PM, the following was observed: -The soiled room on the second floor, was observed with a dusty fan. - Resident's room [ROOM NUMBER], the tub was observed with a brown stain around the drain, and a green colored substance around the sink faucet. -Stained ceiling tiles on the second floor corridor. -The toilets in the nurse stations on the first and second floor observed with nonfunctional fans. - Resident's room [ROOM NUMBER], the toilet was observed with a dusty fan. - In the service corridor, on the second floor, the janitor's room door did not close properly. The Director of Maintenance, who was present at 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 reviews conducted during the Recertification and Abbreviated (NY00361230) Surveys conducted from 12/15-12/22/24, the facility did not ensure that the Comprehensive Care Plans were revised for 4 of 14 residents (#41, #89, #48, and #34) reviewed for Care Planning. Specifically, 1) The Smoking Care Plan for Resident #41 was not revised to include interventions for safe smoking after resident caused a fire when they extinguished a cigarette in the leaves behind the gazebo on the facility patio; 2. The Respiratory Care Plan for Resident # 89 was not revised to reflect the intervention of the physician order for oxygen as needed. Furthermore, the Psychotropic Medication Care Plan for Resident #89 was not revised to include interventions or goals. 3. The Discharge Care Plan for Resident #48 was not updated to reflect the planned discharge of resident or the related goals or interventions; 4. The Psychotropic Medication Care Plan for Resident # 34 was not updated to reflect…

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 a Recertification Survey from 12/15/24-12/22/24, the facility did not ensure sufficient nursing staff to provide nursing and related services to attain or maintain the well-being of each resident in accordance with the facility assessment. This was evident for 17 of 90 shifts from 11/20/2024-12/20/2024 during the staffing review. Specifically, the facility triggered a 1-star rating in the payroll-based journal report. A review of the Facility Assessment documented minimal staffing levels required to provide residents quality of care and services. The facility's actual staffing reports revealed that they did not meet those staffing levels the facility did not provide actual staffing as documented in their Facility Assessment. The findings are: A review of the Facility assessment dated [DATE], documented the minimum staffing levels for the building are: 1 Registered Nurse per shift: 7AM-3PM, 3PM-11PM, 11PM-7AM 5 Licensed Practical Nurses per…

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

Based on observation, record review and interview conducted during a Recertification survey from 12/15/24-12/20/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection and did not ensure there was a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease for all residents. Specifically,1) there was no evidence that a Water Management Plan was in place to prevent and control Legionella, a Facility Risk Assessment was completed, or that Legionella testing was performed within the last year, 2) the facility did not effectively implement accurate tracking and monitoring of infection and outbreak among residents to prevent further spread of infection and early identification of outbreaks and 3) the facility did not provide documentation of screening, administration or declination and education provided for 3 of 10 staff (Certified Nurse Aide #9, Registered Nurse Supervisor #2 and Receptionist #3) reviewed for influenza…

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 during the recertification survey from 12/15/24-12/22/24, the facility did not ensure residents or resident's representatives were notified in writing of the facility policy for bed hold for 2 of 2 residents reviewed (Resident #49 and Resident #93) for hospitalization. Specifically, Residents #49 and #93 were transferred to the hospital, and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the resident or the resident's representative. The findings are: The facility policy titled Bed Hold Reservation revised 6/2019 and documented that it is the policy of the facility to notify private insurance carrier that resident has been transferred to the hospital or is out on therapeutic leave. 1. Resident #49 was admitted to the facility with diagnoses including Sepsis, Dementia, and Bipolar Disorder. The Minimum Data Set (assessment tool) discharge assessment dated [DATE] documented Resident #49 was discharged to hospital…

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

Based on observation, record review and interview conducted during the Recertification Survey from 12/15/24 to 12/22/24, the facility did not ensure a Preadmission Screen was completed for 1 of 22 residents reviewed. Specifically, for Resident #55, the facility did not ensure the Screen form (DOH-695) was completed. The findings are: The Facility Screen/Preadmission Screening and Resident Review Policy dated 5/26/2022 documents that the Social Worker is designated as the facility's Qualified Screener and is responsible for the completion of the Screen/Preadmission Screening and Resident Review as identified in the New York State Department of Health Regulations. Section 4 documents that no resident will be admitted to the Facility without a completed Preadmission Screening and Resident Review. The document must be done to determine whether or not the resident requires the level of services provided by the Facility, or if the resident requires the level of services of an inpatient psychiatric hospital or institution for mental disease or requires an intermediate care facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the standard survey from 12/15/24-12/22/24, the facility did not ensure that residents who had an indwelling/ suprapubic (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #86) of three residents reviewed for bowel and bladder. Specifically, Resident #86 had a size 16 French suprapubic catheter surgically inserted, the facility did not develop a care plan, obtain a doctor's order with diagnosis to include the catheter size or directions on care of the suprapubic tube or when the catheter should be changed. The finding is: Resident #86 had diagnoses of Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Hypertension. The Quarterly Minimum Data Set (an assessment tool) dated 9/27/24 documented the resident's cognition was intact. The resident required supervision to moderate assistance for activities of daily living. The resident has an…

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 during the recertification survey conducted from 12/15/24-12/22/24, the facility did not ensure that acceptable parameters of nutritional status for 1 of 2 residents (Residents #93) reviewed for Nutrition were maintained. Specifically, Resident #93 had a significant weight loss of 28.12% in four months (8/28/24-12/18/24) and that weight loss was not communicated to the physician effectively resulting in no assessment by the physician for weight loss. Findings included: The Facility Policy titled Weight Monitoring last reviewed 9/20/24 documents that Residents experiencing unplanned weight gains or losses will have such changes monitored and care plans revised, as necessary, by the Interdisciplinary Team. Furthermore, it documents that the Registered Dietician/Dietician Technician is responsible for documentation regarding significant weight changes as well as notification to the attending physician. Dietary is also responsible for documenting a progress note and reviewing and revising the Comprehensive Care Plan, as necessary. 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 12/15-12/22/24, the facility did not ensure residents who need respiratory care are provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2/2 residents reviewed for Respiratory Care (Resident #75 and Resident #89). Specifically, 1) Resident #75 was provided oxygen 2.5 liters via nasal cannula without a physician order and 2) Resident #89 with a physician order for oxygen 2 liters as needed via nasal cannula for saturation below 90% was observed with oxygen being administered at 3 liters via nasal cannula. The Findings include: Review of the facility policy titled Oxygen Therapy, last reviewed 5/26/22, documented that a physician's order is required to institute oxygen therapy. In an emergency situation, a licensed nurse may start oxygen therapy and obtain a physician's order as soon as possible. Furthermore it documents that when charting use 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.

Based on observations, interviews and record review during the recertification survey conducted 12/15/24-12/22/24, the facility did not ensure that the Physician provided supervision of medical care for 1 of 1 resident (Resident #93) reviewed for Physician Services. Specifically, Resident #93 had a significant weight loss of 41 pounds, 145.8 pounds to 104.8 pounds or a 28.12% weight loss, in sixteen weeks (8/28/24-12/18/24), and there was no assessment specific to the recorded weight loss by the Physician. Findings include: Review of the Facility Policy titled Weight Monitoring last reviewed 9/20/24 documented that residents experiencing unplanned weight gains or losses will have such changes monitored and care plans revised, as necessary, by the Interdisciplinary Team. Furthermore, it documents that the Registered Dietician/ Dietary Technician is responsible for documentation regarding significant weight changes as well as notification to the attending physician. Dietary is also responsible for documenting a progress note and reviewing and revising the Comprehensive Care Plan, as…

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

Based on observation, record review, and interview conducted during the recertification survey from 12/15/24-12/22/24, the facility did not ensure that drugs and biological's in 1 of 2 medication storage areas were labeled and stored in accordance with professional standards. Specifically, antibiotics and intravenous fluids were found expired in the medication storage room. The findings include: The policy and procedure titled Storage of Drugs revised 9/17 documented, discontinued drug containers shall be removed from the medication cart, and marked to indicate that the drug has been discontinued. Discontinued drugs shall be disposed. During an observation on 12/19/24 at 9:32 AM in the medication storage room on the first floor, Piperacillin and Tazobactam 3.375 (an antibiotic to treat bacterial infections) with an expiration date of October 2024 and 1000 milliliters of intravenous fluids with an expirations date of October 2024 were identified. During an interview on 12/19/24 at 9:32 AM, Staff #14 stated that medications were checked for expiration dates, and the night nurse 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 interview during the recertification survey conducted 12/16/24 to 12/22/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #79) reviewed. Specifically, there was no documented evidence Resident #79 was offered, declined, or educated about the pneumococcal immunization. Findings include: The undated facility policy titled Pneumococcal Vaccination documented the Pneumovax vaccine will be available to all residents at [NAME] Hall Rehabilitation Center to aid in the control and spread of pneumonia between residents and staff. Residents at any age who have long term health problems are at high risk of contracting pneumonia. All residents who have no documentation of previous pneumococcal vaccine shall receive the vaccine upon admission. Pneumococcal vaccination will be recorded on the immunization record. Before offering the vaccine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Recertification Survey completed on [DATE]-[DATE], the facility did not develop and maintain policies and procedures for the monthly drug regimen review. The facility did not ensure that the attending physician, the facility's medical director and the Director of Nursing received and acted upon the Pharmacy Consultant's recommendations within a timely manner and documented in the medical record that the identified irregularities had been reviewed and what action should be taken for 3 of 5 residents reviewed for unnecessary medications (#9, #79, and #89 ). Specifically, 1) Resident # 9 had no documented follow up for drug regimen reviews from [DATE]. 2) Resident # 79 had no documented follow up for drug regimen reviews from [DATE] and [DATE] and 3) Resident #89 had irregularities documented by the Pharmacy Consultant for reviews performed on [DATE] and [DATE] with no evidence of physician review and response. The findings are: The facility did not provide…

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 abbreviated and partial extended survey (NY00340632, NY00340457), the facility did not ensure all violations were thoroughly investigated and that results of all investigations were reported to the administrator and other designated representative and to other officials in accordance with State law, including the State Agency, within 5 working days of the incident and appropriate corrective action taken for 4 (Resident #1, #2, #3, #4) of 5 residents reviewed. Specifically, (1) Review of video surveillance dated 4/28/2024 revealed, Resident #1 was trying to exit the facility through the front door and a facility staff member was rushing from outside the facility through the outermost door and pushed the inside door against Resident #1, causing the resident to fall to the floor. The facility did not initiate an investigation into abuse until 4/29/2024, and the Director of Nursing was not notified of the incident until 4/29/2024. (2) The facility did not conduct 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 record review and interviews during an abbreviated and partial extended survey (NY00340632, NY00340457) the facility did not complete a performance review once every 12months for Certified Nurse Assistant reviewed. Of every nurse aide at least once every 12 months. Specifically, Certified Nurse Assistant #1's performance evaluation was last completed 2018. Certified Nurse Assistant #2's performance evaluation was last completed 2019. Findings include: Review of a sample of 2 certified nurse assistant (certified nurse assistant #1 and certified nurse assistant #2) employees files during onsite visit on 7/22/2024 revealed their performance evaluation was last completed in 2018 and 2019 respectively. There was no documented evidence that performance evaluations were completed from May 2022 to 7/22/2024. During an interview on 7/22/2024 at 1:50 PM the Human Resources Director/Scheduling Coordinator stated performance reviews are kept in employee personnel files. Staff education/competencies are kept in a separate file in the educator's office and staff mandatory trainings 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 record reviews and interviews during an abbreviated survey (NY00340632, NY00340457), the facility did not to ensure that the resident was provided with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 (Residents #1 & #2) of 3 Residents reviewed for behavioral health. Specifically, (1) on 4/28/2024 at 5:45 AM, Resident #1 was seen on surveillance walking with unsteady gait and trying to exit the facility through the front door unsupervised; Resident # 1 was identified as an elopement risk, and a wanderer. The Behavioral Symptom Care Plan initiated on 2/29/2024 and updated on 3/25/2024 and 4/20/2024 had no identified goals and interventions to address the elopement and wandering behaviors and prevent reoccurrence, and to ensure the safety of the resident, other residents, and staff; (2)Resident # 2 who had a history of throwing food 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 record review and interviews conducted during an abbreviated survey and extended survey (NY00340632, NY00340457), the facility did not ensure that all staff were in serviced in the behavioral health needs of the residents. Specifically, the facility was unable to provide documented evidence that they provided staff education on behavioral health between 1/1/2024 and 7/2024. The findings are: A request was made for a Facility Behavioral Health Policy and procedure and was not provided prior to the exit date of 7/22/2024. A request was made for a Facility Behavioral Health in-services and staff education but was not provided until 7/22/2024. A Facility assessment dated [DATE] documented that the facility had a total bed capacity of 134 residents. The Facility Assessment documented common diagnosis of residents which include but not limited to Psychiatric/Mood Disorders, Neurological Systems and provides person-centered/direct care: psycho/social/spiritual support and mental and behavioral health services…

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

Based on record review and interviews during an abbreviated and partial extended survey (NY00340632, NY00340457), the facility was not 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. Specifically, (1) Specifically, there was no documented evidence that the facility Assessment was reviewed and/or updated from 7/31/2021 to 7/18/2024; (2) The Facility experienced an Electronic System Outage during the extended survey on 7/19/2024, and the Administrator was not aware of the emergency plan or process for mitigating the occurrence; (3) the Facility Administrator did not report the results of all investigations to the New York State Departemnt of Health in accordance with State law for allegation of abuse that occurred on 4/19/2024 and an injury of unknown origin that occurred on 6/22/2024. Findings include: The Facility Assessment was requested for review on 7/17/2024. The Facility Assessment was provided to the surveyors on 7/19/2024. 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 record review and interviews during an abbreviated and partial extended survey (NY00340632, NY00340457), the facility did not ensure a facility-wide assessment was conducted and documented to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, there was no Facility Assessment readily available for review upon request during the survey on 7/17/2024. There was no documented evidence that the Facility Assessment was reviewed/or updated from 7/31/2021 to 7/18/2024. Findings include: The Facility assessment dated [DATE] documented under requirement the Nursing facility will conduct, document and annually review a facility-wide assessment, which includes bith their resident population and the facility needs to care for their residents. the purpose was to use this assessment to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility. On 7/17/2024 at 8:30…

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 an abbreviated survey (NY00335594), the facility did not ensure the Minimum Data Set (an assessment tool) accurately reflected the resident's status for 1 (Resident#1) out of 3 residents reviewed. Specifically, Resident #1's Quarterly Minimum Data Set, dated [DATE] had no documented evidence of the resident's rejection of care, having a pressure ulcer, and complaints of occasional mild pain. Findings include: Resident #1 had diagnoses that included non-pressure ulcer other part of the right foot with fat layer exposed, cellulitis, other chronic pain, lymphedema, depression, opioid dependence in remission, muscle weakness and osteomyelitis. Review of the Quarterly Minimum Data Set, dated [DATE] documented in Section E0800 (titled Rejection of care presence and frequency) revealed that the resident did not exhibit the behavior of rejection of care that is necessary to achieve goals for health and wellbeing, such as assistance with activities of daily living. Staff…

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

Based on record review and interviews conducted during an abbreviated survey (NY0035594), the facility did not ensure comprehensive care plans were reviewed/updated quarterly and as needed in a timely manner. This was evident for 1 (Resident #1) out of 3 residents reviewed for care planning. Specifically, Resident # 1's Care Plans for Pain, Osteomyelitis, Lymphedema, Pressure Ulcer, and Behavior were not updated quarterly and after a comprehensive assessment. Findings include: The facility care plan policy last reviewed on 3/4/24 documented comprehensive care plans (CCP) must be updated quarterly, annually and upon readmission, and with a significant change of condition. Resident #1 had diagnoses that included non-pressure ulcer other part right foot with fat layer exposed, cellulitis, other chronic pain, lymphedema, depression, opioid dependence in remission, muscle weakness and osteomyelitis. Review of the quarterly Minimum Data Set (an assessment tool) dated 12/22/2023 documented a score of 13/15 denoting intact cognition, impairment on both side of upper and lower extremities.…

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 F689 Based on record review and interviews conducted during an abbreviated survey (NY00316488), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible. This was evident for 1 out of 6 residents (Resident #6) reviewed for accidents. Specifically, Resident #6 who required supervision with locomotion on and off the unit was able to disarm the 15 second hold on the unit exit door and fell down a flight of stairs in their wheelchair on 5/13/2023. Resident #6 was found with wheelchair lying on top of them. The facility did not ensure adequate supervision and monitoring for 1 of 6 residents reviewed for adequate supervision and accidents. The findings are: The Policy and Procedure titled, Resident Accident/Incident Report, dated 4/2022 documented that facility will promote and maintain a safe environment and maintain reports and surveillance of all resident's accidents. The facility must investigate and document all…

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

Based on observation and interview conducted during a recertification survey from 4/18/2022 to 4/29/2022, the facility did not ensure that food was stored and prepared in a manner to prevent contamination. Specifically, undated rice and pastrami and a platter of cooked turkey were observed in the kitchen walk- in refrigerator and uncooked shrimp was observed being thawed in the sink in an unapproved manner. The findings are: The Facility policy and procedure titled Food Preparation, which is undated documents that foods are stored and properly labeled, and food removed from the freezer for thawing should be thawed under cold running water. During a kitchen tour on 4/18/22 at 10:00 am, undated rice, pastrami, and a platter of cooked turkey were observed in the walk- in refrigerator in the kitchen, and uncooked shrimp was observed being thawed in an unapproved manner. During a follow-up kitchen tour on 4/21/22 at 12:00 pm, a metal container with cooked rice was undated, a metal container with pastrami was undated, a platter of turkey was in the walk-in refrigerator and had no date,…

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 a recertification survey 4/18/2022-4/29/2022, the facility did not ensure that it maintained an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, two (2) Certified Nursing Assistants (CNAs #1 and #10) were observed, not performing hand hygiene during the resident's lunch. The finding is: The facility policy and procedure titled Hand washing revised 2/2022 documented the facility objective is to protect and prevent cross infection to the residents through the removal of dirty and transient flora by becoming aware of and developing the skill needed to wash hands before and after feeding residents, and if hands are not visibly soiled to use an alcohol based rub, decontaminate hands before direct contact with patients and after contact with inanimate objects in the immediate vicinity of the patient. The facility policy and procedure titled Dining Room revised 2/2022 documented the…

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

Based on record review and interviews conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not maintain an Infection Prevention and Control Program (IPCP) to ensure residents' health and safety and to prevent the transmission of COVID-19 infection. Specifically, the facility did not obtain and maintain vaccination medical records of a newly hired staff prior to starting on 4/13/22. In addition, this staff was present in the facility on 4/14/22, 4/15/22, and 4/16/22 and worked in areas where residents were at high risk for exposure to COVID-19. The findings are: Review of the facility policy and procedure, titled, COVID-19 Vaccination-Residents and Personnel, dated 5/1521, documented the facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum the following: Staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine, staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine, The facility policy and procedure, titled, COVID-19…

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 and staff interviews conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not ensure that each resident was provided with a dignified dining experience, specifically, staff did not provide lunch meal trays in a timely manner for five residents (Residents # 32, #59, #44, #31, and #91). Specifically, the residents were not provided their lunch meal trays at the same time as their tablemates. The findings are: The facility policy and procedure titled Meals-Food Service updated 8/21 documents that unit managers will provide seating chart to dietary to ensure meals are served orderly and grouped together by room and/or dining room if resident eats in dining room by table. Staff to serve all residents seated in a group before moving to another table. The facility policy and procedure titled Dining Room revised 2/2022 documents that residents will be seated according to the seating plan in the dining area. Observations were made on 4/19/2022 and on 4/21/2022 during lunchtime in the second-floor dining room: On 4/19/2021 at 12:00 PM,…

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, observation, and interviews conducted during Recertification Survey and Abbreviated Survey (NY00288478) and (NY00292194) from 4/18/2022-4/29/2022, it cannot be ensured that the facility thoroughly conducted and completed an investigation to rule out abuse, neglect, and mistreatment for 1 of 5 residents (#275) reviewed for abuse and 1 of 5 residents (#112) reviewed for accidents Specifically, 1.a thorough Accident/Incident Investigation was not conducted for Resident #275 with a reported allegation of abuse and 2. a thorough Accident/Incident Investigation was not conducted for Resident # 112 with a Left Femur Fracture. The findings are: The facility Accident and Incident Reporting Policy dated 4/7/2021 is the policy of [NAME] Hall Rehabilitation Center to promote and maintain a safe environment, and to maintain reports and surveillance of all resident's accidents and incidents. The purpose of the policy is to investigate all accidents and incidents and develop corrective measures to…

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

Based on observation, record review and interview conducted during a recertification survey 4/18/2022-4/29/2022, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services/ equipment for 1 of 6 residents (Resident #90) reviewed for ADLs. Specifically, for Resident #90, who was dependent on staff for Activities of Living (ADL) care (transfer) the facility did not ensure the resident was transferred out of bed in a timely manner with the use of a Hoyer lift in accordance with the resident's preference. The Findings Are: The Policy and Procedure titled AM and PM Care dated 6/2021, documented unless restricted by doctor's orders, all residents must be up and out of bed each day as much as allowed by medical condition. All necessary equipment needed to care for each resident should be readily available on the nursing unit. Resident #90 was admitted to facility on 3/10/20 with a diagnosis of Chronic Pain, Lymphedema, Muscle Weakness. The Quarterly 3/23/22 Minimum Data Set (MDS) documented the Resident had a Brief…

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 a recertification survey and abbreviated survey (NY00289709), conducted 4/18/2022-4/29/2022, the facility did not ensure that the necessary care and services were provided to promote the highest practicable well-being for 1 of 6 residents (resident #109) reviewed for non pressure related skin ulcer/wound and 1 of 5 residents (Resident #112) reviewed for accidents. Specifically, 1. heel booties were not applied as per physician order for a resident at high risk for skin breakdown (#109) 2. the facility did not ensure ongoing monitoring was provided for ( R#112) to ensure timely medical intervention and or hospitalization following a fall. The findings are: Resident # 109 was admitted to facility 6/4/2021 with diagnoses including of Diabetes Mellitus II, Osteoarthritis, and Dementia, required extensive assist of 2 for bed mobility, bathing and dressing and an extensive assist of 2 with Hoyer for transfers The 2/26/22 Quarterly Minimum Data Set (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, interview and record review conducted during a Recertification Survey and Abbreviated Survey (NY00268466) completed on 6/24/21, the facility did not make information on how to file a grievance available to the residents. This was evident for 11 of the 11 residents who attended the Resident Council Meeting. Additionally, the facility did not ensure that a grievance was resolved in a timely manner for one (Resident #90) of three residents reviewed for personal property. Specifically, the lack of a thorough investigation and resolution into a resident's report of missing property. The findings are: The policy and procedure titled Grievances, revised on 3/2021, documents that at the time of admission the Social Worker (SW) or designee will review the admission Packet with the resident/concerned party, which is inclusive of the Grievance Policy and Procedure and that the initiated Resident Grievance Form must be submitted to the Director of Social Work/Designee, who will log the complaint in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP) to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not ensure a person-centered care plan was developed (1) for 2 of 5 residents (#56, #83) reviewed for Activities; (2) for 1 of 8 residents (#76) reviewed for Activities of Daily Living (ADL); (3) for 2 of 6 residents (#14, #76) reviewed for Dementia Care; and (4) 1 of 5 residents (#14) reviewed for Unnecessary Medications Review. The findings are but not limited to: The Facility Policy & Procedure on CCP updated on 03/2017 documented that the CCP will be periodically reviewed and revised by a team of qualified persons after each assessment or reassessment but at least quarterly, every ninety (90) days. Dates on the care plan will reflect the date reviewed or the date that changes are made…

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 a recertification survey, the facility did not ensure that the Comprehensive Care Plan (CCP) were reviewed and revised in a timely manner. Specifically, (1) the CCP was not reviewed and revised for 2 of 7 (#36, #44) residents investigated for Accidents; (2) The CCP was not reviewed and revised for 2 of 5 (#4, #28) residents investigated for Activities; (3) the CCP was not reviewed and revised for 4 of 8 (#4, #28, #56, #83) residents investigated for Activities of Daily Living (ADL) Functional / Rehabilitation Potential; (4) the CCP was not reviewed and revised for 3 of 6 (#28, #69 #83) residents investigated for Dementia Care; and (5) the CCP was not reviewed and revised for 1 of 3 (#4) residents investigated for Urinary Catheter or UTI. The findings are but not limited to: The Facility Policy & Procedure on CCP updated on 03/2017 documented that the CCP will be periodically reviewed and revised by a team of qualified persons after each assessment 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 observation, interviews and record review conducted during a Recertification Survey and Abbreviated Survey (NY00274235), the facility did not ensure that sufficient staff was available to meet the needs of all residents. Specifically, the Certified Nursing Assistant (CNA) actual staffing levels were below the facility assessed minimum levels 24.3% of shifts for the months of April 2021, May 2021 and June 2021. The findings include: A review of the Facility Assessment Tool dated 04/01/2021 indicated that the facility had a 134-bed capacity, with an average daily census of 115-122, and a current census of 90. The Assessment documented that the following minimum staffing per shift: 1) Day Shift (7:00AM to 3:00PM): Director of Nursing (DON) = 1, Registered Nurse (RN)/Licensed Practical Nurse (LPN)Unit Manager =2, LPN Medication and Treatment Nurses = 5,Certified Nursing Assistants(CNAs) 9 2) Evening Shift (3:00PM to 11:00PM):RN Supervisor = 1, LPN Medication and Treatment Nurses = 5, CNAs = 9 3) Night…

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 interview, the facility did not ensure that carbon monoxide detectors in buildings with fuel-fired appliances were installed in compliance with Section 915 of the 2015 edition of the International Fire Code as adopted by New York State. Specifically, a carbon monoxide detector was not installed in the generator room. The generator is located in the basement of the building and is fuel operated. The findings are: During the Life Safety recertification survey on 6/17/21 at 11:30 AM, a tour of the generator room located in the basement revealed that a carbon monoxide detector was not installed in the room. In an interview at the time of the finding, a maintenance staff member stated that a battery operated carbon monoxide detector was installed in the room and must have fallen off the wall. In a subsequent interview with the Director of Facilities at 11:35 AM, the Director of Facilities stated that that carbon monoxide detectors will be installed. 483.70 (b)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review on a recent recertification survey, the facility did not ensure residents have a right to a dignified existence for two of three residents screened for dignity. Specifically, several observations were made of Resident #85 and #5 with his/her Foley bag uncovered so that passing by staff and residents can see his/her urine in the tubing and bag and for Resident #85, staff were observed performing a dressing change exposing him/her to passing by staff. The findings are: The facility policy for Resident Care and Quality of Life/Dignity dated 10/02/20 documents in the policy statement each resident shall be care for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Staff are to assist with bodily privacy helping the resident to keep urinary catheter bags covered. Resident #85 was admitted with diagnoses including Type II Diabetes Mellitus, Hypertension, Atrial Fibrillation 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.

FACILITY Based on observations, interviews and record reviews on a recent recertification survey, the facility did not ensure that the Office of the Long Term Ombudsman was made aware of transfers and discharges for the months of April, May and June 2021. Specifically there were 68 discharges/transfers made from 4/1/2021-6/22/2021 without notification to the Ombudsman. The findings are: An interview was conducted with the Ombudsman on 6/15/2021 who reported that she has not received discharge/transfer lists or copy of the letters since the end of April 2021. An interview was conducted with the Facility Administrator on 6/18/2021 at 11:53PM who reportd there was no Social Worker currently working at the facility. The last Social Worker left the faciity on April 30, 2021 and a new one was set to start on 7/1/2021. The facility Administrator indicated they have been using the Director of Activities in place of the Social Worker and does not think the Ombudsman notification was being done by the Social Worker. An interview was conducted with the Director of Activities 6/18/2021 12:47PM…

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 interview during the recertification survey the facility did not ensure that each resident received an accurate assessment reflective of the resident's current status. This was evident for one (Resident #62) resident reviewed for Minimum Data Set (MDS) accuracy. Specifically, Annual Assessment of the MDS dated [DATE] and Quarterly assessment 05/05/21 did not document the Resident's Brief Interview for Mental Status (BIMS) score. The finding is: Resident #62 was admitted to the facility on [DATE] and had diagnoses including Psychotic Disorder, Schizophrenia and Major Depressive Disorder. An admission MDS assessment dated [DATE] documented the resident was cognitively intact with some mood and behavior issues. The Quarterly MDS assessment dated [DATE] did not have a BIMS score documented. Further record review revealed the resident did not a BIMS score for the following assessments: Annual assessment 11/02/20, Quarterly assessment 02/02/21 and 05/05/21. The MDS did not…

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 a recent recertification survey, the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming and personal hygiene for 2 (Resident #85, and #42) of 3 residents reviewed for ADL's staff provided incomplete AM (morning) care. Specifically, staff did not give Resident #85 a shower for more than ten days, shave and provide oral and nail care and Resident # 42 did not receive showers. The findings are: 1. Resident #85 was readmitted to the facility on [DATE] and had diagnoses of Type II Diabetes Mellitus, Hypertension, Atrial Fibrillation, Peripheral Vascular Disease. Minimum Data Set (MDS-a resident assessment tool) dated 2/13/21 documented the resident was cognitively intact and required extensive assistance for all Activities of Daily Living (ADLs.) An undated facility policy and procedure titled Showers documented residents requiring or requesting…

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 the recertification and abbreviated surveys the facility did not ensure that 2 of 5 residents (Resident #66 and Resident # 53) reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, 1. 2. The findings are: 1.Resident #66 was admitted to the facility on 5.13.21 with diagnoses of: Type II Diabetes with Neuropathy, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease and Schizophrenia. Review of the resident's medical record reveals the resident is cognitively intact as indicated by the Brief Interview for Mental Status (BIMS) with a score of 15:15. Review of the physicians admitting orders were evaluate skin weekly: document findings in administrator note and document findings in weekly Activities of Daily Living ( ADL) note, notify shift supervisor and obtain treatment order for MD if indicated. Review of the resident electronic medical record (EMR) revealed 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 record reviews and interviews during a recertification survey, for 2 of three residents reviewed for medication administration (#85) (#64), the facility did not ensure residents were free from significant medication errors. Specifically, Resident #85 had three omissions of Intravenous antibiotics and Resident (64) Insulin amounts were not documented on the Medication Administration Record (MAR) for a resident receiving sliding scale insulin. The findings are: The facility policy for Medication Administration last revised 10/13/21 stated the doctor will notified with any omissions/refusals in medications immediately. The DNS will be notified following the physician. Documentation of omissions in resident Electronic Medical record (EMR) as well as progress note will be done at the time of the omission/refusal. Resident #85 has diagnoses of Type II Diabetes Mellitus, Osteomyelitis, Atrial Fibrillation, Peripheral Vascular Disease. Minimum Data Set (MDS-a resident assessment tool) dated 2/13/21 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 staff interview conducted during a recertification survey, the facility did not ensure that juice thickeners in the nourishment refrigerators located on the nursing units (2 of 2 resident floors), on the refreshment cart and in the kitchen storage room, were stored in accordance with acceptable standards of food safety practice. The finding is: On 6/16/21 at 8:50 AM an examination of the first floor unit refrigerator was conducted and it was noted that there were two containers of Ready Care thickener cranberry cocktail in the refrigerators and the containers had a use by date of 12/24/20 and 6/8/21. In an interview with the Licensed Practical Nurse (LPN) # 1 at the time of the findings, LPN #1 stated that dietary staff is responsible for removing the outdated foods in the refrigerator. On the second floor at 9:00 AM, outdated Nectar consistency thickener was noted with a use by date 4/9/21. This container was noted on the morning juice cart brought from the kitchen. A review of the the directions on the container of Ready Care Thickener are…

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 a Recertification Survey completed on 6/24/21, the facility with a licensed bed capacity of 134 was operating without a Social Worker (SW) from 4/30/21 to present. The findings are: The Facility Survey Report (FSR) dated 6/16/21 included the question: Has your facility ensured that employees and other persons providing resident services in your facility are licensed, registered or certified in accordance with applicable laws? The answer was checked Yes. Under the heading of Director of Social Work in the FSR, the facility checked off consultant. Independent Contractor Agreement with the (Social Worker) SW Consultant, dated 1/1/2021, documents the following: The facility has engaged the services of this contractor sufficient consultation to maintain compliance with the state and federal standards for providing counseling services to its Social Work staff. In an interview conducted on 06/18/21 at 11:53 AM with the Administrator he/she stated the facility's previous SW left on 4/30/21 and that the Director of Activities…

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, the facility did not ensure that a Legionella Risk Assessment and Water Management Plan was provided in accordance with Section 483.80. Specifically, the facility policy and procedures did not contain the required elements; a risk assessment, control measures to maintain the physical, chemical, and temporal conditions of the system, and a system description analysis of hazardous conditions or corrective actions. The findings are: During the Life Safety recertification survey conducted on 6/17/21 at 1:15 PM, documentation review of the facility's Legionella folder revealed a water sample lab report for legionella with a collection date 6/17/2020 and a process date 6/25/2020 reported that Legionella was not detected. A review of the facility Policy and Procedures for legionella updated on 6/2020 did not include a risk assessment for Legionella, control location, control measures, control limits, a system for monitoring hazardous conditions or a corrective action plan. In an interview at 1:50 PM with the Director of Facilities,…

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.