Springvale Nursing & Rehabilitation Center

Based on observations, record review and interviews conducted during the recertification survey from 8/11/2024 to 8/15/2024, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. This was observed during dining observation for 1 of 6 residents reviewed for nutrition (Resident #17). Specifically, Resident #17 was observed on three occasions eating without the use of the proper assistive devices as indicated in the meal tray ticket, recommended by occupation therapy and ordered by the medical doctor.Findings include:Resident # 17 was admitted with diagnoses that included cerebral infarction, peripheral vascular diseases, and Type 2 diabetes.The Quarterly Minimum Data Set (an assessment tool) dated 08/02/2025 documented the resident had intact cognition, impairment on bilateral upper/lower extremities and required supervision assistance with eating.The Rehabilitation: Contractures Care Plan effective 7/28/2025 documented the resident had a left and right upper extremity contracture which interfere with the ability to use…

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 from August 11, 2025, through August 15, 2025, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically,1) Licensed Practical Nurse #13, did not don a gown while providing wound care to Resident #165, who was on enhanced barrier precautions; 2) Home Health Aide #4 did not perform proper hand hygiene during meal service and assistance with feeding Resident #183; and 3) Home Health Aide #8 did not perform hand hygiene after feeding Resident #157 and then fed another resident during a breakfast meal. Findings include: 1) The policy and procedure titled Enhanced Barrier Precautions, last revised April 2025, directed staff to maintain enhanced barrier precautions, requiring the use of personal protective equipment, including gowns and gloves, during high-contact resident care activities such 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the recertification and abbreviated surveys (NY00382686) from 8/11/2025-8/15/2025, the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for 1 (Unit 2 East) of 5 residential units. Specifically, on Unit 2 East, the call bell system was not functioning correctly on 8/13/2025, 8/07/2025, 8/01/2025, 5/07/2025, 3/16/2025, 1/11/2025, 1/08/2025, 10/16/2024, 6/19/2024, and 2/22/2024. The findings include:During an interview and observation on 08/13/2025 at 10:44 AM, Certified Nurse Aide #16 stated the audible portion of the Unit 2 East call bell system was not working. Certified Nurse Aide #16 was observed to activate the call bell system from room [ROOM NUMBER]. It was observed that the light illuminated outside the door, but no sound was heard on the unit floor or at the centralized nurse station.During an interview on 08/13/25…

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 on 8/11/2025 to 8/15/2025 the facility did not maintain an effective pest control program so that the facility was free of flies. Specifically, Resident #8's room was observed with several flies.Findings are:The facility policy and procedure titled Pest Control last reviewed 5/2025 documented it is the responsibility of the Maintenance Department to coordinate the control of pests with a company engaged in business of providing Pest Control Services. Pest control Company will provide the control of other insects that may be harmful to humans, equipment, supplies through direct and/or indirect contact or contamination.During an observation on 8/12/2025 at 8:50AM, flies were observed on Resident #8's room.During a subsequent observation on 8/13/2025 at 9:27AM, Resident #8's room was observed with several flies on the pillow, at the bedside chair, on the call bell cord, on the bedside table napkin, on the bed sheets, on the closet door and on the Resident #8's big toe and on the urinal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during the recertification survey 8/11/25-8/15/25, the facility did not ensure individuals working in the facility under the title Home Health Aides, had successfully completed a State-approved training program for feeding residents for 12 of 12 employees reviewed (Home Health Aides #4, #8, #32, #33, #34, #35, #36, #37, #38, #39, #40 and #41.) Specifically, there was no documentation the Home Health Aides received the required training to feed residents and Home Health Aide # 4 was observed feeding Residents on more than one occasion and Home Health Aide#38 and #36 were observed feeding residents on the Dementia Unit.Findings include:The facility policy titled Home Health Aide Utilization and Scope of Duties dated 9/8/22 documented Home Health Aides are to be utilized within the scope of duties outlined in their job description. Home Health Aides provide non-clinical support services that contribute to the comfort, safety and wellbeing of residents and work…

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 interview during an abbreviated survey (NY00355663) the facility did not ensure the resident representative was immediately informed of a significant change in the resident's physical status or a need to alter treatment significantly for 1 of 3 residents (Resident #1) reviewed for notification of changes. Specifically, Resident #1's representative was not notified when the resident had a Midline Catheter (Intravenous Catheter) inserted. Findings include: The facility notifications policy dated 1/2017 last reviewed 1/2025 documented the clinical nurse will recognize and appropriately intervene in the event of change in resident's condition. The facility will notify the resident, attending physician and representative of changes in the resident's condition and or status. Resident #1 had diagnoses including dementia, end stage renal disease, and coronary artery disease. The Quarterly Minimum Data Set (MDS) (assessment tool) dated 8/14/24 documented the resident had severely impaired cognition. The resident required moderate to maximal assistance for 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 record review, and interview conducted during the abbreviated survey (NY00352849) the facility did not ensure that residents remained free from abuse for one of three (Resident #7) reviewed for Abuse. Specifically, for Resident #7 with documented ongoing aggressive behaviors and refusal of medication/s, there was no documented evidence that care plan interventions were evaluated to determine effectiveness to ensure resident safety. Subsequently, on 8/28/2024 Resident #7 propelled their wheelchair hitting another resident as staff assisted the other resident up off the floor and on 9/4/2024 Resident #7 struck Resident #10 in the stomach which caused a fall and resulted in Resident #10 sustaining a left side hematoma of the head, right wrist fracture, left femoral intertrochanteric (hip) fracture. The findings include: Resident # 7 had diagnoses including dementia, anxiety disorder, and psychotic disorder. The 9/20/2023 Care Plan tited At Risk for Abuse documented identify pattern of behaviors and redirect negative behaviors. The care plan was updated on 8/29/2024 to include…

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 an abbreviated survey (NY00331614) the facility did not ensure that all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 3 residents reviewed for Abuse (Resident #5). Specifically, Resident #5 made an accusation of abuse on 1/15/2024 and that was not reported to the state agency until 1/17/2024. In addition, there was no documented evidence of the 5-day investigation report submission to the Department of Health either. Findings included: Resident # 4 had diagnoses including bipolar disorder, paranoid schizophrenia, and schizoaffective disorder. The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition, with behaviors, and required moderate-maximum assistance with activities of daily living. The Investigation Report documented that Resident #5 called 911 on 1/15/2024 at 6:00AM and made an allegation of being beaten and raped. Law enforcement 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 during an abbreviated survey (NY00332451), the facility did not ensure that 1 of 3 residents (Resident #4) investigated for abuse received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident preferences to promote mental, and psychosocial well-being. Specifically, on 1/29/24, Resident #4 made an allegation of abuse. The Accident and Incident report, nursing notes and care plans documented a referral to psychiatry was made. There was no documented evidence that the referral was completed. The findings included: Resident # 4 had diagnoses that included, but were not limited to status post fall and right elbow injury triad, alcoholic cirrhosis, and hypertension. The Comprehensive Care Plan titled At Risk for Abuse dated 9/21/23 documented the resident will show no signs or symptoms of abuse. The Physician Order dated 9/21/23 documented Psychiatric Consult as needed. The admission Minimum Data Set,…

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 (NY00355610, NY00353621, NY00356241) the facility did not ensure residents' right to be free from abuse for 4 of 4 residents (Resident #1,#2, #3, #4) reviewed for abuse. Specifically, (1) on 9/7/2024 Resident #1 who was assessed as having aggressive behavior walked up to Resident #2 in the dining room and pushed them from behind. Resident #2 complained of back pain, was given Tylenol, and sent to the emergency room for evaluation. On 9/26/2024 Resident #1 struck Resident #2 on the right ear, and they sustained an abrasion. First aid was administered to Resident #2, and Resident #2 was transferred to the emergency room for further evaluation. The corrective action for both incidents with Resident #1 and Resident #2 documented to keep the residents separated. There were no specific interventions on the care plan to address the behaviors and the investigation concluded that there was no cause to believe any alleged resident abuse or mistreatment…

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 (NY00355610, NY00353621, NY00356241), the facility did not ensure submission of the report of the results of an investigation to the New York State Department of Health within 5 working days of the incident. This was evident for 4 of 4 residents (Resident #1, #2, #3, #4) reviewed for abuse. Specifically, (1) on 9/7/2024 Resident #2 reported that they were pushed by Resident #1. The 5-day investigative conclusion report was not submitted to the New York State Department of Health until 10/3/2024; (2) On 9/26/2024 Resident #2 reported they were struck on the right ear by Resident #1 and sustained an abrasion to their right ear. The 5-day investigative conclusion report was not submitted to the New York State Department of Health until 10/25/2024; (3) On 10/3/2024 Resident #3 and Resident #4 were found lying naked in Resident #4's bed during staff rounds. The 5-day investigative conclusion report was not submitted to the New York State…

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 an abbreviated survey (NY003355610, NY00353621), the facility did not ensure the comprehensive care plan was reviewed, updated, and revised for 2 out of 4 residents (Resident #1, #2) reviewed for care planning. Specifically, (1) on 9/7/2024 Resident #2 reported Resident #1 pushed them from behind. Review of Resident #1's abuse care plan revealed it was not updated to reflect the incident; (2) On 9/7/2024 Resident #2 was reportedly pushed from behind by Resident #1. Review of Resident #2's risk for abuse care plan revealed no documented evidence of updating from the 9/7/2024 incident. Review of Resident #2's psychosocial care plan last revised 10/28/2024 revealed it was not updated with the incident that occurred on 9/26/2024. The findings are: The facility Care Plan policy last revised 8/2024 documented the facility will develop a comprehensive resident centered care plan for each resident. Care plan development, renewal and revision will be based upon the results 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 record review and interviews conducted during an Abbreviated survey (NY00339167 & NY00345633) completed on 12/30/24, the facility did not ensure that their facility assessment included an evaluation of the overall number of facility staff that are needed to ensure that each resident's needs are met. Findings include: The Facility Assessment last updated on 10/10/24 has a section on page six titled the staffing plan where it documents the facility nursing levels are based on an average daily census of 185. This section further states that continued efforts are being made to maintain adequate staffing levels while experiencing a state of emergency in the state of NY regarding the health care worker shortage. This is the only section that documents staffing plans and it does not indicate any actual staffing minimum numbers. During an interview on 12/27/24 at 11:45 am the Staffing Coordinator stated that the staffing requirements are as follows: Day time shift 7:00 am to 3:00 pm there should be 1 Nurse Manager for each unit, and a Licensed Practical Nurse and/or a Registered…

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 (NY00340395, NY00339018) the facility did not ensure comprehensive care plans included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment or discharge plans for 2 out of 3 (Resident #2, Resident #4) residents reviewed for discharge planning. Specifically, Resident #2 had no discharge care plan initiated for the resident on admission and they were discharged from the facility on 4/1/2024. Resident #4 was discharged from the facility on 4/15/2024 and there was no documented evidence of a discharge care plan initiated on admission for the resident. Findings include: The facility care planning/process and care conference dated 7/2017 and last revised 7/3/2023 documented an interdisciplinary baseline care plan will be initiated upon admission by the admitting nurse and competed within 48 hours. Social service, dietician, therapy 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 (NY00340395, NY00339018) the facility did not ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #3, Resident #4, Resident #5) out of 3 residents reviewed for accidents. Specifically, Resident #3 who had a history of falls had a total of 3 falls in a month (3/3/2024, 3/19/2024, 3/24/2024) and a 4th fall on 4/3/2024. Resident #3 sustained acute left femoral neck fracture with slight varus angulation. There was no documented evidence of timely updates/interventions after each fall to prevent reoccurrence. The resident's fall risk care plan was not updated after each fall and no new interventions were put in place. Findings include: The facility Falls Prevention and Management policy dated 3/1/2016 and last revised 1/12/2023 documented the interdisciplinary team identifies and implements appropriate interventions 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 interviews and record reviews conducted during the Abbreviated Survey, ( NY00333646) it was determined for 1 of 5 residents (Resident #1) reviewed for Quality of Care, the facility did not ensure a Baseline Care Plan was developed and implemented for each newly admitted resident that included the instructions needed to provide effective care within 48 hours of a resident's admission and that a summary of the Baseline Care Plan was provided to the resident and/or their representative. Specifically Resident #1's baseline care plan was not developed by nursing to provide direction for diabetic care and there was no documented evidence the plan was provided to the resident's representative. Findings include: The facility policy and procedure Admission dated 7/1/2023 documented a Baseline Care Plan would be developed within 48 hours of a resident's admission. Resident #1 was admitted on [DATE] with diagnoses of Diabetes, Cerebrovascular disease, and Alzheimer's disease. The Minimum Data Set (MDS, 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 record review and interview conducted during an Abbreviated survey (#NY00333646) the facility did not ensure 1 of 5 residents (Resident #1) received treatment and care in accordance with professional standards of practice. Specifically, Resident #1's hospital discharge orders for blood glucose monitoring and insulin were not reviewed or clarified. Findings include: The facility policy titled admission Process dated 07/2016 and last review 02/2024, documented residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to achieve the highest practicable level of function. The facility will obtain the appropriate physician orders from the discharge facility, if applicable. The Registered Nurse/Licensed Practical Nurse will verify the admission orders with the attending physician. The Registered Nurse/Licensed Practical Nurse will reconcile medications orders with the physician based on the discharge instructions from the transferring facility. 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 interview and record review conducted during an Abbreviated survey (NY 00333646), the facility did not ensure sufficient staff with the appropriate competencies and skill sets to provide nursing related services for the residents on 1 of 6 units (Unit 1 West) reviewed for staffing. Specifically, on 2/04/24 the facility did not have a licensed nurse on Unit 1 [NAME] from 3 PM to 6 PM when Resident #1 suffered a medical emergency requiring the resident's family to call 911 for assistance. Findings include: A review of the Policy and Procedure titled Staffing dated 11/29/22, and revised 7/1/23, documented the facility will provide sufficient staffing to meet needed care. Resident #1 was admitted on [DATE] with diagnoses of Diabetes, Cerebrovascular disease, and Alzheimer's disease. The Minimum Data Set (MDS, an assessment tool) dated 2/4/24 documented the resident had moderately impaired cognition, required moderate assistance with toileting and transfers, supervision with eating and bed mobility, 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 observation, interview, and record review during the recertification survey from 6/26/23-6/30/23, the facility did not ensure that residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, resident bathrooms were observed to have call bells without pull strings, making the call bell inaccessible if resident was on the floor. This was evident for 2 of 2 residential floors. The findings include but are not limited to: 1. On 6/26/23 at 11:35 AM, it was observed that the call bell located in the bathroom of resident room [ROOM NUMBER], was activated by pushing button in toward the wall, however no pull string was attached to be accessible from the floor. 2. On 6/26/23 at 12:25 PM, it was observed that the call bell located in the bathroom of resident room [ROOM NUMBER], was activated by pushing button in toward the wall, however no pull string was attached to be accessible 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.

Based on record review and interviews conducted during the recertification and abbreviated surveys (#NY00304291) from 6/26/23-6/30/23, the facility did not ensure all alleged incidents involving injuries of unknown origin were reported to the New York State Department of Health (NYSDOH) immediately, but no later than two hours after the time of the incident occurrence. This was evident for 1 of 1 resident (Resident #94) reviewed for abuse. Specifically, Resident #94 sustained an injury of unknown origin resulting in a fracture to their left humorous (upper arm) bone, and there was no evidence the incident was reported to the NYSDOH in the required time frame. The findings include: A facility policy last revised 9/8/2022 titled Abuse Policy- Prevention and Management, documented after a resident sustains an injury of unknown source, the facility Administrator, Director of Nursing (DON), or designee shall notify the appropriate Agency/State office according to State specific guidelines for timeliness of reporting as applicable. Resident #94 was admitted to the facility with diagnoses…

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 during the recertification survey from 6/26/23-6/30/23, the facility did not ensure that a resident's comprehensive person-centered care plan was implemented. This was evident for 1 of 4 residents (Resident #84) reviewed for Nutrition. Specifically, Resident #84's care plan documented the need for a weighted mug, and on three observations the weighted mug was not provided on Resident #84's meal tray. Findings include: Resident #84 had diagnoses including Parkinson's disease, encephalopathy and Alzheimer's disease. The Policy and Procedure titled Care Plan, dated 7/2017, documented resident care and interventions must be carried out per the care plan. The Annual Minimum Data Set (MDS, an assessment tool) dated 4/24/23 documented the resident was severely cognitively impaired and required extensive assistance with eating. Physician orders dated June 2023 documented an order for dietary adaptive assistive device including a weighted mug. The Nutrition care plan dated June 2023 documented interventions included assistance with eating…

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 interview conducted during the recertification survey from 6/26/23-6/30/23, it was determined for 1 of 4 residents (Resident # 76) reviewed for Nutrition, the facility did not ensure the resident was provided the necessary care to maintain, to the extent possible, acceptable body weight. Specifically, Resident #75 had a weight loss of 8.5% in 3 months, the physician was not notified and new interventions were not initiated. Findings include: The Policy and Procedure titled Weight Policy, dated 12/2022, documented the Registered Dietitian (RD) will review the medical record of residents with significant weight changes (i.e. 7.5% loss in 3 months), dietary interventions will be recommended as needed, and all weight changes will be reported to the physician. Resident #76 was admitted to facility with diagnoses including multiple sclerosis, dementia, and anxiety disorder. The 5/9/2023 Minimum Data Set (MDS, a resident assessment tool) annual assessment, documented Resident #76 had intact cognition and received extensive assist of 1 person with eating. 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 during the recertification survey from 6/26/23-6/30/23, the facility did not ensure that Infection Control practices and procedures were maintained. Specifically, Resident #90's Foley (indwelling) catheter bag was observed on the floor without the use of a barrier, and was observed on a soiled floor mat covered with a towel. Findings include: Resident #90 had diagnoses including obstructive and reflux uropathy, other urinary incontinence, and malignant neoplasm of the brain. The facility policy for Foley Catheter, dated 4/25/22, documented infection control considerations including do not allow catheter bag or tubing to lay on floor, and if resident in low bed place catheter bag and tubing in dignity bag and or wash basin to avoid lying on floor. During observation on 6/27/23 at 9:18 AM Resident #90 was in bed, and the indwelling catheter bag was observed uncovered on the floor. During observation on 6/29/23 at 9:21 AM Resident #90 was in bed, and the indwelling catheter bag was observed on a soiled floor mat covered with a cloth…

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 from 6/26/23 - 6/30/23, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for one resident (Resident #90) on the 1 [NAME] unit. Specifically, Resident #90 was not provided a long enough bed and the control unit for the resident's alternating mattress was soiled and on the floor. An undated policy and procedure titled Resident Room Cleaning documented Daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. Steps in the daily cleaning included to clean and dust all vertical and horizontal surfaces using a clean cloth soaked in or sprayed with disinfectant cleaner. Findings include: On 6/27/23 at 9:07 AM, Resident #90 was observed sitting up in a bed without a footboard, and their heels and feet extended past the end of their mattress without support. The control unit for 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 F550 Based on observation, interviews and record review conducted during a recertification survey, it could not be ensured that the facility residents were treated with respect and dignity. Specifically, for 3 of 3 residents (Residents #41, #72 and #108) reviewed for dignity, 1) Resident #41 was interviewed in a common area in proximity of other residents and staff, 2) staff did not respond in a timely manner to a meal request for Resident #72, and 3) staff did not assist Resident #108 with her meal at the same time as her tablemates. The findings are: 1. Resident #41 is [AGE] year-old who was initially admitted to the facility on [DATE] with diagnoses including but not limited to Non-Traumatic Intra-Cerebral Hemorrhage, Anxiety and Depression. The Quarterly Minimum Data Set (MDS; an assessment tool) dated 7/24/2020 documented Resident #41 had intact cognition and requires physical assistance of one person for activities of daily living. During an observation on 10/13/2020 at 9:10 AM, Resident #41 was observed…

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 it could not be ensured that the facility properly stored perishable foods and maintain food storage equipment in accordance with standards for food service safety. Specifically, several items of perishable foods were not properly dated and 3 of 3 refrigerators used to store items brought in by residents' families were not maintained in sanitary condition. The findings are: 1. The facility Policy and Procedure dated 5/14/2018 and titled, Labeling and Dating stated that all foods must be labeled with either a manufacturers label or handwritten label, all food items must be dated with a received date preceded by an R or the word Received, all pulled/defrosting bulk products will be labeled with a pull date preceded by a P and utilized within the number of days noted on the package or on the Quick Reference Shelf Life List provided by the food service vendor. Furthermore, the dining services manager on duty will check perishables for proper labeling and dating twice per day. The initial tour…

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.

F880 Based on observation and staff interview during the recertification survey, it cannot be ensured that the facility practiced proper infection control. Specifically, an observation of 5 of 5 residents (# 6, #20, #35, #103 and #108) revealed did not clean the pulse oximeter before and after each use, did not place a barrier between the pulse oximeter and table and staff did not perform hand hygiene after each use of the pulse oximeter. Furthermore, one staff did not perform hand hygiene after each resident contact for 3 of 3 residents (#4, #6, and #103) observed during dining . Findings include: The 4/14/2004 and last revised 9/10/2019 Policy and Procedure titled, Hand Hygiene indicated that a pathogen can contaminate the hands of staff during contact with residents or contact with contaminated equipment. Review of October 2020 Physician's Orders showed that Residents #6, #20, #35, #103 and #108 are to have pulse oximeter checks every shift. During observation on 10/6/2020 at 11:05AM, a facility Home Health Aide (HHA #1) was performing pulse oximeter checks in the 2 North…

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, it cannot be ensured that the facility provided Advanced Directives services. Specifically, no evidence was available to verify that staff periodically reassessed residents' desires regarding Advanced Directives or that facility staff communicated residents' wishes to the physician. This was evident for 1 of 3 residents (Resident #30) reviewed for Advanced Directives. The facility Policy and Procedure titled, Advance Directives/Advance Care Planning dated 11/5/2005 and revised 5/2015 revealed the facility's Social Work Department leads ongoing education to all residents regarding their right to execute advance directives during care planning. Furthermore, on an individual basis, advance directives include a Health Care Proxy. Any advanced directives obtained or executed during a residents' stay will be placed in the advance directive section of the medical record, and existing advance directives will be reviewed as part of 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.