Elm Manor Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure food and drink were provided that was at a safe and appetizing temperature for one (1) of one (1) test tray and for one (1) (Resident #9) interviewed. Specifically, food and beverages during the meal were served at suboptimal temperatures and were not palatable.The findings include:During an interview on 04/28/2026 at 12:43 PM, Resident #9 stated that the food was typically cold, did not taste good and that the buns would be soggy from the vegetables being put on the same plate.During observations and interview on 04/29/2026 at 11:53 AM, the lunch meal tray line started. Meal trays were placed and covered on the tray cart which included the test tray. The tray cart was open and had no insulating doors. Cold food and drink items were held pre-portioned and pre-poured on the meal trays. The last cart left the kitchen at 12:41 PM and residents were served their lunch at 12:50 PM. A test tray was completed with the Regional Food Service Director and Dietary Aide #1 for temperatures and palpability. The…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a liquid substance drained from the kitchen sink plumbing onto the floor during tray line (lunch meals were being prepared for the residents) and staff did not wash their hands in-between glove use or prior to touching ready to eat food after cleaning up the liquid on the floor. Additionally, the dumbwaiter (a small freight elevator used for moving items, such as food) was dirty, dried white debris was seen around the ice machine grate, and an ice scoop was observed resting inside a cooler of ice. The findings include:The facility's undated Handwashing/Hand Hygiene policy included all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Staff should use an alcohol-based hand rub containing at least 62 percent alcohol; or alternatively, soap and water after, but not limited to, the following…

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, the facility failed to maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three (3) other members of the facility's staff, one (1) of who must be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide documented evidence that the Infection Preventionist attended the Quality Assurance and Performance Improvement meetings on a regular basis (quarterly).The findings include:The facility's Quality Assurance and Performance Improvement Program policy revised April 2014, included the primary purpose of the Quality Assurance and Performance Improvement Program was to establish data-driven, facility-wide processes that improved the quality of care, quality of life and clinical outcomes of the residents. Steps that would be employed to support and enhance the facility's Quality Assurance and Performance…

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, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for one (1) (Resident #10) of seven (7) residents reviewed for activities of daily living. Specifically, facility staff did not perform hand hygiene after assisting Resident #10 with incontinence care and prior to touching multiple surfaces and equipment. In addition, the facility did not appropriately implement the use of Enhanced Barrier Precautions (EBP, an infection control strategy that uses gloves and gowns during high contact resident care to reduce the spread of infection) for Resident #10, who had a wound, and staff were observed not using personal protective equipment (PPE; equipment, such as gown and gloves, worn to protect individuals and reduce the risk of exposure to and spread of infections) as required during high-contact care. Lastly, staff did not wash their hands in between…

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

Based on interviews and record review conducted during the Recertification Survey from 08/21/2024 to 08/27/2024, for six (Residents #11, #24, #27, #29, #33, and #38) of six residents reviewed for Baseline Care Plans, the facility did not ensure that a Baseline Care Plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents, that they were able to understand) was created in a timely manner or that a summary was provided to the residents and/or resident representatives. Specifically, for Residents #11, #24, #29, #33, and #38 there was no evidence the facility completed a Baseline Care Plan upon admission. For Resident #27, the facility was able to show that a Baseline Care Plan had been completed, but there was no evidence that a copy of the summary was provided to the resident and/or their representative. This is evidenced by, but not limited to the following: The facility's policy Care Plans - Baseline, revised December 2016, documented a baseline plan of care to meet the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the Recertification Survey from 08/21/2024 to 08/27/2024, for three of three observations of suction machines, the facility did not ensure the resident environment remained as free of accident hazards as possible. Specifically, suction machines were not prepared to be used in case of an aspiration emergency on units with residents at risk for aspiration. The findings are: Observations on 08/22/2024 at 11:05 AM included a Medline Vac-Assist and an Invacare suction machine (a compact medical suctioning device which is used to remove fluids from the airway) on the crash cart next to the nurse's station. Neither device was fully assembled and there was no tubing or reservoir attached to catch fluids. Observations on 08/23/2024 at 1:35 PM included a Medline Vac-Assist and an Invacare suction machine on the crash cart next to the nurse's station. The Medline device was observed to have the reservoir to catch fluids in place, but the Invacare did not, and neither…

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 and complaint investigation (NY00351141) from 08/21/2024 to 08/27/2024, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all residents in the facility. Specifically, there was not sufficient staff to meet all resident needs in activities of daily living, including timely showers, long waits for addressing call lights, assistance with activities of daily living (eating, toileting, personal hygiene), and complete necessary documentation for resident transfers and discharges. This is evidenced by, but not limited to, the following: For additional information see Centers for Medicare/Medicaid Services Form 2567: F677- Activities of Daily Living Care for Dependent Residents. The Facility Assessment, dated 02/20/2024, included the facility was licensed to provide care for 46 residents and had an average daily…

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

Based on observations, interviews, and record review conducted during a Recertification Survey completed 08/21/2024 through 08/27/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a potentially hazardous food item was not properly thawed, and potentially hazardous foods were not held cold at or below 45 degrees Fahrenheit (°F). The findings are: Review of the facility policy, Elm Manor Nursing and Rehabilitation Center Dietary Policy and Procedure Food Preparation, dated 11/03/2022, included the following: It is the policy of Elm Manor Nursing and Rehabilitation Center that all foods are prepared by acceptable methods to maintain optimal nutritional value, flavor, and appearance. Meals are to be attractively served at the proper temperature and to meet the individual resident's needs. Observations on 08/22/2024 at 2:29 PM included a chest freezer holding approximately six square crates of pint sized 2% milk located in the kitchen dry storage room. 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 reviews conducted during the Recertification Survey and complaint investigation (NY00351141) from 08/21/2024 to 08/27/2024, for one (Resident #191) of one resident reviewed for a discharge to the hospital, the facility did not ensure the transfer or discharge was appropriately documented in the resident's medical record to include the basis and necessity for the transfer, the receiving heath care institution, physician notification, and documentation of the discharge. Specifically, there was no documentation of a discharge summary, nursing assessment, change in condition to explain why the resident was transferred or discharged , or to where they were discharged . This is evidenced by the following: The facility's policy for transfers/discharges documented that the facility should provide a brief statement of facts that clearly supports the determination to discharge or transfer the resident and to document all discharge planning and notice activity in the social service notes.…

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 a Recertification Survey and complaint investigation (NY00342410) from 08/21/2024 to 08/27/2024, for two (Residents #5 and #26) of five residents, the facility did not ensure that residents who were dependent on staff for assistance received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #5 did not receive assistance with showering and washing their hair. Resident #26 did not receive assistance with showering, shaving, or obtaining a haircut. This is evidenced by the following: Review of the facility's Daily Staffing Sheets instructed that all staff are responsible for completing resident care tasks to include cleaning and cutting nails, shaving, and hair combing. 1. Resident #5 had diagnoses that included Alzheimer's dementia, hypertension, and chronic pain syndrome. The Minimum Data Set Resident Assessment, dated 06/10/2024, documented the resident had severely impaired cognition, required assistance…

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 interviews conducted during the Recertification Survey from 08/21/2024 to 08/27/2024, for one (cart two) of two medication carts reviewed, the facility did not ensure all medications were stored and labeled in accordance with acceptable professional standards. Specifically, four medication cups that contained medications that had been pre-poured (medications that are prepared in advance and stored until the time of adminstration), were in the medication cart drawer uncovered and only labeled with room numbers. This is evidenced by the following: During observations on 08/26/2024 at 3:50 PM, Licensed Practical Nurse #2 was at medication cart two. The top drawer was open and contained four medication cups each containing multiple pills. The medication cups were labeled with room numbers only. During an immediate interview, Licensed Practical Nurse #2 said they had pre-poured their medications and were not aware that it was not good nursing practice to prepare medications and leave them in the medication cart. Licensed Practical Nurse #2 said they had seen…

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 completed on 10/24/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were food and non-food contact surfaces not maintained in clean and sanitary condition, sections of flooring in disrepair, improper thawing of a potentially hazardous food, pests were present, a thermometer in use was not accurate, equipment was not properly air dried, a food preparation sink lacked an indirect drain, food was stored directly underneath an unprotected sewer line, and there was lack of sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service as evidenced by test tray food temperatures (see F804) and arrival of trays over one hour past scheduled meal delivery times on various occasions. This is evidenced by the following: 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 observations, interviews, and record review conducted during the Standard Recertification Survey and complaint investigation (#NY00292292) completed on 10/24/22, it was determined that for three (Canandaigua, Honeoye, and [NAME] Lanes) of three resident units and one of one basement the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, boxes of medical supplies were stored on the floor, walls, ceilings and floors were dirty and in disrepair, pooling water was present, privacy curtains were inadequate, handwash sinks were in disrepair or not present in soiled holding locations, an electrical breaker was damaged, and a door was damaged. The findings are: 1. Observations on 10/17/22 from 10:17 a.m. to 3:25 p.m. included: a) A cardboard box of medical supplies was stored directly on the floor in the storage room across from room EM200. b) A cardboard box of incontinence supplies was stored directly on the floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey completed on 10/24/22, it was determined that for one (Canandaigua) of three resident units, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees (°) Fahrenheit (F) were accessible to residents at point of use. The findings are: Observations, interviews, and record review from 9:34 a.m. to 12:26 p.m. on 10/17/22 included: 1. The following water temperatures were observed from handwash sinks using a ThermoWorks Thermapen One digital thermometer: 129°F in the shared bathroom between resident rooms #4 and# 2, 121°F in the shared bathroom between resident rooms #6 and #8, 134°F in the shared bathroom between resident rooms #5 and #7, and 133°F in the shared bathroom between resident rooms #1 and #3. The water temperatures in the shower room across from room [ROOM NUMBER] were measured using a [NAME] model 9842 digital…

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 reviews, conducted during the Recertification Survey, completed on 10/24/22, it was determined that for one of one main kitchen, the facility did not provide food and drink that was palatable, attractive and at a safe and appetizing temperature. Specifically, the food was not served at safe and appetizing temperatures. This is evidenced by the following: When requested, the facility was unable to provide Food Service policies related to safe and appetizing temperatures for food and drinks. Review of the facility's resident scheduled mealtimes directed that breakfast was at 8:00 a.m., lunch was at 12:00 p.m., and dinner was at 5:00 p.m. During observations on 10/19/22 of the lunch meal, the meal cart arrived on the resident unit at 1:35 p.m. At 1:45 p.m., staff were observed bringing the last meal tray on the cart to a resident's room. At 1:46 p.m., the following food temperatures of a test tray were measured using both the Surveyor's Aqua Tuff 351 Thermocouple and a facility standard bimetallic thermometer (unknown brand). Both…

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 Survey completed on 10/24/22, it was determined that for one of four residents reviewed for medication administration, the facility did not ensure that residents were appropriate for self-administration of medications. Specifically, Resident #22 had medications left at the bedside without a nurse present to supervise and without the resident being assessed and care planned for safe self-administration. This is evidenced by the following: The facility policy, Self-Administration of Drugs at the Bedside, dated 7/26/22, included: 1. The care planning team will assess each resident's mental, physical, and visual ability to determine if the resident is capable of safe self-administration. Until the care planning team makes a decision, drugs will continue to be administered in accordance with Center policies governing the administration of medications. Residents will not be permitted to self-administer or retain medications in…

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 reviews, conducted during a Recertification Survey, completed on 10/24/22, it was determined that the facility did not ensure for two (Residents #24 and #29) of 42 residents reviewed, that the residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive that would be honored. Specifically, Resident #24's Medical Orders for Life-Sustaining Treatment (MOLST) form and Resident #29's medical orders for code status in the electronic medical record (EMR) were not updated to reflect each resident's current wishes for code status. The facility policy Advanced Directives, dated revised on 7/15/21, included that the social worker (SW) or licensed designee would review or initiate a MOLST form upon admission. In addition, once the advanced directive is current and verified, the SW or verified designee would notify nursing and medical and place the originally signed MOLST 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 interviews and record review conducted during the Recertification Survey completed on 10/24/22, it was determined that for one (Resident #24) of one resident reviewed for hospitalizations, the facility did not ensure a written notification, which specifies the duration of the bed-hold policy, was provided to the resident and/or the resident representative at the time of transfer to the hospital or as soon after as possible. Specifically, Resident #24 was transferred to the hospital and the facility could not provide evidence that a written notice of information regarding the facility's bed-hold policy was provided to the resident or the resident's representatives at the time of transfer or soon after per the regulation. This was evidenced by the following: The facility policy, 'Bed Hold Policy', reviewed/revised 7/11/22, included that at the time of each transfer for hospitalization or therapeutic leave, the facility would inform the resident of the bed-hold policy. 1. Resident #24 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the Recertification Survey completed on 10/24/22, it was determined that for two (Canandaigua Hall and Honeoye Hall) of two medication carts reviewed, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. Specifically, both medication carts were observed to be unlocked and unsupervised, and contained multiple medications that were easily accessible to residents, visitors, and facility staff. This is evidenced by the following: The facility policy Medication Storage Of, dated 3/22/22, included that all compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. 1.In an observation on 10/18/22 at 1:30 p.m., a medication cart in the Canandaigua Lane Unit main hallway was unlocked, unsupervised and filled with multiple medications. Residents were observed ambulating in the hallway near the…

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

Based on observations, interviews, and record reviews conducted during a Recertification Survey completed on 10/24/22, it was determined that for one (Resident #7) of one observation of wound care, the facility did not maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections. Specifically, the nurse did not ensure that appropriate and sanitary equipment was used when providing wound care. This was evidenced by the following: The facility policy, Infection Control Prevention policy, dated 5/31/22, included standard precautions are the practices used to prevent transmission of infectious disease and protect health care workers and residents from the exposure to infectious material. Resident #7 had diagnoses including a stage 4 (full thickness tissue loss with extensive destruction) pressure ulcer of the sacral area, morbid obesity, and bacteremia (infection in the bloodstream). The Minimum Data Set (MDS) Assessment included that the resident was cognitively intact. Physician orders for 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 during the Recertification Survey, it was determined for one (Resident #11) of one resident reviewed for care planning, the facility did not ensure that each resident was given the right, along with their representative, to participate in the care planning process with their interdisciplinary team members. Specifically, there was no evidence that the resident or their representative had an interdisciplinary care plan meeting following admission to the facility. This is evidenced by the following: Resident #11 was admitted to the facility on [DATE] with diagnoses including Stage IV lung cancer, dementia, uncontrolled diabetes and anxiety. The Minimum Data Set Assessment, dated 7/29/20, revealed the resident had moderately impaired cognition. In a random family interview on 10/27/20 at 2:06 p.m., the resident's representative stated that they had not been invited to any meetings (in person or remotely) with the resident's care team or spoken with anyone from 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 during the Recertification Survey, it was determined that the facility did not provide the residents who were unable to carry out activities of daily living the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one of five residents reviewed. Specifically, Resident #5 was observed for four days with nails that were uncut, jagged and filled with brown debris. This is evidenced by the following: Resident #5 had diagnoses including, malignant neoplasm of the bladder with chronic indwelling urinary catheter, chronic obstructive lung disease and sepsis. The Minimum Data Set Assessment, dated 7/20/20, included that the resident was cognitively intact and had moderately impaired vision. The current Comprehensive Care Plan and Certified Nursing Assistant (CNA) [NAME] included that the resident had a self-care deficit in activities of daily living and required limited assistance of staff for personal hygiene, extensive assistance…

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 reviews during the Recertification Survey and complaint investigation (#NY00246752), it was determined that the facility did not provide necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers from developing for one of two residents reviewed. Specifically, Resident #15 did not have dressing changes done according to wound clinic recommendations. This is evidenced by the following: Resident #15 had diagnoses including diabetes, peripheral vascular disease and an unstageable pressure ulcer of the right heel. The Minimum Data Set Assessment, dated 9/2/20, included that the resident was cognitively intact. In an interview on 10/27/20 at 9:26 a.m., the resident stated that they had a sore on their right heel for months and it was starting to heal. The resident said they are being seen at the wound clinic. The resident said they used to get a dressing change daily but not anymore. On 10/28/20 at 2:17 p.m., the resident stated that they 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 observations, interviews and record reviews during the Recertification Survey, it was determined that for one of three residents reviewed, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, Resident #15 was being transferred with a stand-up lift despite a previous fall with one and contrary to therapy recommendations. This is evidenced by the following: Resident #15 had diagnoses including heart failure, morbid obesity and a history of a leg fracture following a fall from a stand-up lift approximately five months ago (May 2020). The Minimum Data Set Assessment, dated 9/2/20, included that the resident was cognitively intact and required total dependence on staff for transfers. Review of the current Comprehensive Care Plan and the Certified Nursing Assistant (CNA) [NAME] revealed that the resident was transferred via a full mechanical lift with the assistance of two staff members. Review of the Fall Report, dated 8/16/20, revealed…

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 reviews during the Recertification Survey, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice, the comprehensive person-centered-care plan, and the resident's goals and preferences for one of three residents reviewed. Specifically, Resident #18 was receiving continuous oxygen with no physician order, and oxygen use was not addressed in the person-centered-care plan. This is evidenced by the following: Resident #18 has diagnoses including chronic obstructive pulmonary disease, congestive heart failure, a history of COVID-19, and was dependent on oxygen. The Minimum Data Set Assessments, dated 9/20/20 and 10/22/20, revealed the resident was cognitively intact and received oxygen therapy while a resident. Review of August 2020 facility policy, Oxygen Administration, directs staff to verify there is a medical order for oxygen that includes the amount of oxygen to be administered, the route (mask or nasal cannula) and if a humidifier bottle is…

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.