Ontario Center for Rehabilitation and Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the Extended Recertification Survey from 01/21/2025-01/31/2025, the facility did not ensure an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections was maintained for 3 (Residents' #65, #350 and #351) of 24 residents reviewed. Specifically, appropriate Personal Protective Equipment (PPE) was not worn by nursing staff in residents' room that were identified by the facility as requiring Enhanced Barrier Precautions while preforming high contact care to residents. Additionally, observations of multiple facility staff who had declined the influenza vaccine were not wearing face masks while in resident care areas during the current influenza season as determined by the Department of Health. The facility policy Enhanced Barrier Precautions dated 05/30/2024, documented Enhanced Barrier Precautions would be initiated 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 observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025 for one (Resident #65) of four residents reviewed, the facility did not ensure residents received the necessary care, treatment and services consistent with professional standards of practice to promote the healing of a pressure ulcer, prevent infection, and prevent new ulcers from developing (unless the individual's clinical condition demonstrates they were unavoidable). Specifically, Resident #65 who preferred to spend most of their time in bed, was not assisted with toileting, and was left incontinent of urine for multiple hours. Resident #65 developed a pressure ulcer to their right buttock and had not received treatments to the area for several days. This is evidenced by the following: The facility policy, Skin and Pressure Injury Prevention, dated 06/27/2024 included staff are to inspect the skin when performing or assisting with personal care or activities of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, for two (Residents #20 and #351) of two residents reviewed, the facility did not provide appropriate treatment and care, based upon current standards of practice and the residents' comprehensive assessment and care plan to prevent urinary tract infections to the extent possible. Specifically, Resident #20 had a history of urinary tract infections and was observed with their indwelling urinary catheter drainage bag (including the drainage port and catheter tubing) lying uncovered (no barrier) on a soiled chair and above the level of the bladder. Resident #351's indwelling urinary catheter drainage bag was observed on the ground without a barrier and above the level of the bladder on multiple occasions. Additionally Resident #20 had a physician order for a urinalysis that was not obtained timely. This is evidenced by the following: The facility policy Catheter Guidelines;…

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

Based on observations, interviews, and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, the facility did not ensure all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (second-floor north medication cart) of two medication carts and one (third-floor medication room) of two medication rooms reviewed. Specifically, the second-floor north medication cart contained controlled medications (medications such as narcotics and opioids that have the potential for abuse and addiction) that were not in a permanently affixed compartment per the regulations and the third-floor medication room contained multiple undated/unlabeled medications. This is evidenced by the following: The facility policy Controlled Substance Management dated August 2022, included the proper storage of controlled drugs was in a double door, double locked, double keyed, steel, wall mounted drug cabinet during non-med pass times and in locked controlled drug compartment of medication cart during med pass times. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Extended Recertification Survey from 01/21/2025 to 01/31/2025, the facility did not ensure each resident was educated and offered the influenza and/or the pneumococcal immunizations (vaccine) for three (Resident #12, #53, #351) of five residents reviewed. Specifically, the facility was unable to provide evidence the residents or their representatives had been provided educational material and offered, received or declined the pneumococcal and/or influenza immunizations. The facility policies Infection Control-Influenza Vaccine dated 08/22/2024 and the Pneumococcal Vaccine dated 11/27/2024 included all residents and/or their resident representative will be offered and provided the influenza and pneumococcal vaccines. Residents have the opportunity to refuse the vaccine(s). A resident's refusal of the vaccine(s) shall be documented on the informed consent for influenza vaccine and pneumococcal vaccine and placed in the resident's medical record and will…

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 an Abbreviated Survey (NY00342658), for one (Resident #12) of two residents reviewed for drugs and medication, the facility did not provide services to meet professional standards of quality. Specifically, nursing staff did not ensure medications were consumed by the resident and were left unattended with the resident in a common area. This was evidenced by the following. Review of the facility policy Medication Administration Review, dated August 2019, documented that Licensed Nurses must ensure that all medications are administered and documented. Resident #12 had diagnoses that included multiple sclerosis (a disease that affects the central nervous system), epilepsy (a brain condition that causes seizures), and hypertension (high blood pressure). The Minimum Data Set Resident Assessment, dated 10/13/2024, documented the resident had moderately impaired cognition and had impaired vision and trouble concentrating. Review of Resident #12 current Comprehensive Care Plan did not include that the resident's had been…

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 an Abbreviated Survey (NY00320939), for three (Residents #1, #2 and #3) of three residents reviewed the facility did not ensure a written notice of the facility's bed hold policy was provided to the residents or their representatives at the time of transfer to the hospital, or for emergency transfers, within 24 hours. Specifically, the facility could not provide evidence that any of the residents or their representatives were given written information regarding their bed hold policy in allowing the residents to return to the facility following a hospital discharge at the time of their transfer. This was evidenced by the following: 1. Resident #2 had diagnoses that included bacteremia, major depressive disorder, and anemia. The Minimum Data Set Resident Assessment, dated 5/21/24, revealed the resident was cognitively intact. Review of Resident #2's electronic medical record revealed the resident was transferred to the hospital several few weeks ago. 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 an Abbreviated Survey (Complaint #NY00314833), for two (Resident #11 and Resident #12) of three residents reviewed for Activities of Daily Living, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #11 did not receive assistance with shaving and washing their hair. Resident #12 did not receive assistance with shaving and nail care. This is evidenced by the following: Review of the facility policy Activities of Daily Living Care and Support, dated 3/13/24, documented that the facility would provide residents with activities of daily living care and support in accordance with current standards of practice, State and Federal regulations, and were based on the resident's assessed needs, personal preferences, and goals of care. Additionally, nail care should be provided as needed, and facial hair…

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 an Abbreviated Survey (Complaint # NY00314833) it was determined that for one (Resident #12), of three residents reviewed for accidents the facility did not ensure that each resident received the appropriate assistance devices to prevent accidents. Specifically, Resident #12 required the use of a Hoyer lift ( a mechanical lift device) for safe transfers. During an observation two staff members transferred the resident without using a mechanical lift. This is evidenced by the following: The facility policy Activities of Daily Living Care and Support revised on 3/13/24, documented that the facility shall provide residents with Activity of Daily Living care and support in accordance with current standards of practice, State and Federal regulations, and are based on the resident's assessed needs, personal preference, and goals of care. Review of the facility policy Care Plans - Comprehensive, dated October 2019 revealed the care plans are used 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 observations, record review, and interview conducted during the Recertification Survey completed 1/11/23, it was determined that for three (first, second and third floors) of three resident use floors, the facility did not provide a safe, functional, and sanitary environment for residents, staff, and the public. Specifically, unapproved chemical treatment of the domestic hot water system was occurring without approval of the New York State Department of Health. The findings are: Record review on 1/5/23 at 11:50 a.m. revealed a facility document titled 'environmental assessment of water systems in health care settings' dated 1/25/22 included supplemental disinfection using a 50/50 chlorine sodium hypochlorite solution in the domestic hot water supply. Observations during the initial tour of the facility on 1/4/23 included hot water was provided throughout the facility on all three floors including the main kitchen, at sinks, and in shower rooms. Observations on 1/6/23 at 9:35 a.m. included a 15-gallon container with a label that read: Stainex laundry brightener. Further…

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

Based on observations, interviews and record review conducted during the Recertification Survey completed on 1/11/23, it was determined that for two (2nd floor and 3rd floor) of two units reviewed for medication storage, the facility did not have a consistent system to account for the receipt, usage, disposition, and reconciliation of all controlled medications (narcotics). Specifically, the controlled medications count sheets and the signatures of staff members for each shift-to-shift count were not consistently completed to validate the correct controlled substance count was done and was accurate. This is evidenced by the following: The facility policy Narcotic Count, dated August 2018, documented that the oncoming and outgoing nurses assigned to the medication cart are responsible for ensuring the accuracy of the controlled drug count. The policy also included that two nurses would count the number of individual controlled drugs by looking at each medication and verify that the number of individual controlled drugs matched the number on inventory. The policy also included 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.

Based on observations, record review, and interviews conducted during the Recertification Survey and complaint investigations (#NY00297231 and #NY00307562), completed on 1/11/23, it was determined that the facility did not follow the meal menus to ensure the nutritional needs of the residents. Specifically, residents did not receive menu items as listed on their meal tickets. The findings are: During an interview on 1/5/23 at 9:17 a.m., Resident #15 stated that when they received their meals, the food on their plate did not always match the food ticket. Resident #15 had a copy of the facility's meal menu and stated this was the first time they had gotten one since they were admitted (11/10/22) to the facility. While reviewing the menu, Resident #15 stated that for breakfast, they received boiled eggs instead of scrambled eggs and a donut instead of a muffin. Resident #15 stated that when they told staff that they did not have everything on their plate, the staff member said they will get something but did not come back. Observation of tray line for the lunch meal on 1/6/23 from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification Survey completed on 1/11/23, it was determined for one (Resident #54) of five residents reviewed for unnecessary medications, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs. Specifically, a CCP was not developed for use of psychotropic medications that included targeted symptoms, measurable goals, and person-centered nonpharmacological interventions. The finding is: Resident #54 had diagnoses that included anxiety disorder, depression and recent hip fracture. The Minimum Data Set (MDS)assessment dated [DATE] documented the resident was moderately impaired of cognitive function and had received anti-anxiety and anti-depressant medications on 6-7 days respectfully in the look back period. The PHQ-9 test (a screening done by health care staff to assess for…

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, completed on 1/11/23, it was determined that for one (Resident #1) of five residents reviewed for Unnecessary Medications, the facility did not ensure the services provided or arranged by the facility as outlined in the resident's Comprehensive Care Plan (CCP) met professional standards of quality. Specifically, Resident #1 had two orders for the same medication, dosage, and frequency both active at the same time. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE], with diagnoses of left tibia fracture, fibromyalgia (widespread muscle pain), and anxiety. The Minimum Data Set Assessment, dated 11/1/22, included that Resident #1 was cognitively intact, and had received an antianxiety medication in the previous seven days. Review of the Comprehensive Care Plan revealed that Resident #1 was on psychotropic medications (a group of medications used to treat a person's mental state) for diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey completed on 1/11/23, it was determined that for one (Resident #15) of nine residents reviewed for activities of daily living (ADLs), the facility did not ensure that ADL care was provided for dependent residents. Specifically, Resident #15's facial hair was not shaved. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE], with diagnoses of end-stage renal disease (requiring hemodialysis), gout, and diabetes. The Minimum Data Set Assessment, dated 11/27/22, included that the resident was cognitively intact and required set-up help and supervision of one-staff member with bathing. Review of the Comprehensive Care Plan (CCP) initiated 12/28/22, and the current [NAME] (care plan used by the Certified Nursing Assistant (CNA) for daily care) revealed that Resident #15 required set-up help and/or supervision with bathing, and staff assistance with providing cleaning products, towels 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 observations, interviews and record reviews conducting during the Recertification Survey, completed on 1/11/23, it was determined that for one (Resident #15) of six residents reviewed for nutrition, the facility did not ensure that the resident's daily fluid intake was monitored to ensure their needs as ordered by the physician were met. Specifically, the physician ordered fluid restriction was not being consistently documented or monitored. This is evidenced by the following: The facility policy, Fluid Restrictions, dated last revised in December 2019, included that the physician order should include the number of milliliters (mLs) of fluids permitted for each day, and nursing fluids are divided into medications passes and the individual's daily routine. The policy stated that nursing is responsible for recording the intake and output of fluids for each shift. The policy included that the Registered Dietician (RD) would calculate and distribute the fluid pattern for the total fluid allowance to be…

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 completed on 1/11/23, it was determined that for one (2 North hallway) 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, multiple medications were found pre-poured, unlabeled and undated for future medication administration. Additionally, a large bottle of Tylenol was on top of a medication cart and unsupervised for an extended length of time. This is evidenced by the following: The facility policy Medication Administration, dated December 2019, documented that medications may not be prepared in advance and must be administered within one hour their prescribed time, unless otherwise specified. The facility policy Medication Storage, dated January 2019, documented that medication should be stored in their original, labeled containers as received from the pharmacy. 1. During an observation on 1/9/23 at 2:41 p.m., on 2nd floor resident unit there were multiple pre-poured…

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 interview conducted during the Recertification Survey completed on 1/11/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: 1. Observations on 1/5/23 at 1:42 p.m. included three natural gas-powered dryers located in the first-floor laundry room, and there were no carbon monoxide detectors within or in the vicinity of the laundry area. 2. In an interview on 1/5/23 at 2:06 p.m. the Director of Maintenance stated there was a carbon monoxide detector in the laundry room behind the washers but that it was taken out about a week ago as the batteries needed to be replaced. 3. On 1/5/23 at 2:34 p.m. it was observed that a carbon monoxide detector was plugged into an outlet next to the meat slicer in the kitchen and was marked with an install date of 11/3/20.…

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 a Recertification Survey, completed on 6/9/21, it was determined that for nine (Residents #7, #14, #27, #63, #67, #70, #76, #82 and Resident A) of ten residents reviewed, the facility did not provide food and drink that was palatable, attractive and at a safe and appetizing temperature. Specifically, the issues involved food that was unpalatable, not served at preferable temperatures and was unattractive related to frequently being served meals in Styrofoam (disposable dishware). This is evidenced by, but not limited to, the following: 1.Resident A has diagnoses including hypertension, diabetes mellitus and arthritis. The Minimum Data Set (MDS) Assessment, dated 3/20/21, revealed the resident was cognitively intact. During an interview on 6/3/21 at 12:25 p.m., Resident A said they hate the Styrofoam plates that are used all the time and the food is always cold. 2.Resident #82 has diagnoses including anemia, heart failure and hypertension. 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 Survey, completed on 6/9/21, for one (Resident #56) of two residents reviewed, the facility did not allow the resident to make choices about aspects of their life that were significant to them. Specifically, the resident did not receive showers as per their stated preferences. This is evidenced by the following: Resident #56 was readmitted to the facility on [DATE] with diagnoses including amputation of the left leg, morbid obesity, and a recent urinary tract infection. The Minimum Data Set Assessment, dated 5/4/21, revealed that the resident had moderately impaired cognition, required extensive assistance to total dependence of two staff members for personal hygiene and bathing and had stated that being able to choose their bathing routine was very important to them. The February 2020 facility policy, Resident Rights, directs staff to ensure that residents are guaranteed basic rights that include self-determination. The…

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

Based on observation ,interview and record review conducted the Recertification Survey and complaint investigations ( #NY00273585 and #NY00272080), completed on 6/9/21, it was determined that for two (Residents #56 and #58) of six residents reviewed, the facility did not thoroughly investigate alleged violations of potential abuse neglect or mistreatment. Specifically, bruises of unknown origin for Resident #56 and a grievance by Resident #58 regarding lack of care were not thoroughly investigated to rule out abuse, neglect, or mistreatment. This is evidenced by the following: The facility policy Abuse, dated February 2019, included allegations of suspected abuse, neglect, mistreatment, injury of unknown origin or misappropriation of property shall be promptly and thoroughly investigated by facility management. The summary must take into account an objective overview of the facts and a reason or basis for decision, to substantiate or not substantiate the allegation. The facility policy Resident Rights, dated February 2020 included employees shall treat all residents with kindness,…

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 during the Recertification Survey and complaint investigation (#NY200273585), completed on 6/9/21, the facility did not ensure that two of five residents reviewed received the necessary services to maintain good nutrition, grooming and personal hygiene. Specifically, Resident #58 was not provided a meal tray and was not given showers as requested and Resident #67 lacked nail care. This is evidenced by the following: 1.Resident # 58 was admitted on [DATE] with diagnoses including COVID-19, critical illness myopathy (muscle disease), and diabetes. Review of the Minimum Data Set (MDS) Assessment, dated 5/10/21, included the resident was cognitively intact, required extensive assistance of two staff for bathing, assist of one staff for eating and received the majority of their calories via a feeding tube. The admission MDS Assessment, dated 3/17/21, included that choice of bathing was very important to the resident. The Comprehensive Care Plan included that Resident…

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, completed on 6/9/21, it was determined that for two of three residents reviewed the facility did not ensure that each resident received adequate supervision and assistance to prevent accidents. Specifically, Resident #27 did not receive supervision at meals related to aspiration precautions and Resident #70 did not receive assistance with ambulation and transfers to minimize risk for falls. This was evidenced by: Review of the facility policy Aspiration Precautions, dated February 2019, revealed staff were to sit the resident upright or as close as possible for any intake and must be supervised for all intake of liquid and solids. 1.Resident #27 had diagnoses that included chronic obstructive pulmonary disease, diabetes, and Alzheimer's disease. The Minimum Data Set (MDS) Assessment, dated 3/24/21, revealed the resident was moderately impaired cognitively, and required supervision with eating. In a dietary note, dated…

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, completed on 6/9/21, it was determined that for one (Resident #49) of one resident reviewed for bowel and bladder incontinence, the facility did not ensure that the resident received the treatment and care in accordance with professional standards of practice, the resident's comprehensive person-centered care plan and the resident's choice in order to maintain continence and restore bowel function to the extent possible. Specifically, the facility did not develop and implement a person-centered care plan with measurable goals and interventions to effectively restore and manage the resident's bowel function. This is evidenced by the following: Resident #49 has diagnoses including a femur fracture, heart failure, and hypertension. The Minimum Data Set Assessment, dated 4/28/21, included that the resident is cognitively intact, was incontinent of bowls frequently and required total dependance on staff for toileting Review 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 reviews conducted during the Recertification Survey, completed on 6/9/21, it was determined for one (Resident #76) of two residents reviewed, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, facility staff did not notify the medical team to initiate new dialysis orders regarding a new medication and a fluid restriction. Additionally, there was no Comprehensive Care Plan (CCP), including person centered goals, interventions, and preferences, for the resident's dialysis needs. This is evidenced by the following: Resident #76 had diagnoses including end stage renal disease requiring hemodialysis three times a week and an arteriovenous fistula (connection between an artery and a vein used for the dialysis treatments). A Minimum Data Set Assessment, dated 5/18/21, included the resident was cognitively intact and was on a therapeutic diet. Current physician orders included 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.