Delhi Rehabilitation And Nursing Center

Based on observation, record review, and interviews during the recertification, the facility did not maintain a pest-free environment and an effective pest control program on 2 of 2 resident unit serveries and the main kitchen. Specifically, evidence of insect infestation was found in the main kitchen and resident unit serveries, and the facility did not implement the remediation recommendations of the pest control vendor. This is evidenced by: During observations of the main kitchen on 7/24/2024 at 1:21 PM and again on 7/30/2024 at 9:37 AM: • A swarm of small flies were found around the drink preparation area floor drain. • A swarm of small flies were found around the drain in and in the corridor just outside of the cart-wash room. • 7 of 7 floor drains in the main kitchen were soiled with food debris and/or a black residue. • The floor drain in the cart-wash room was heavily soiled with a black build-up. • The floor and drain below and behind the dishwashing machine were heavily soiled with a black build-up. • Dead cockroaches were found above the suspended ceiling and in ceiling…

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 (Case #s NY00321796, NY00320120, NY00320846, and #NY00322090), the facility did not ensure each resident received adequate supervision to prevent accidents for 3 (Resident #s 2, 5 and #3) of 5 residents reviewed. Specifically, for Resident #2, who had severe cognitive impairment, the facility did not ensure adequate supervision was provided when the resident left the Aspen Unit where they resided to visit a friend on the Fir Unit on 7/1/2023. Resident #2 entered Resident #1's room on the Fir Unit and Resident #1 alleged they were sexually abused by Resident #2, and when on 7/14/2023, Resident #2 entered Resident #6's room on the Fir Unit and the resident alleged that Resident #2 stole their wallet; For Resident #5 who had severe cognitive impairment and was assessed as high risk for elopement, the facility did not ensure the resident was provided with adequate supervision on 7/26/2023, when the resident left the facility undetected by staff at…

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 (Case #s NY00321796 and NY00322090) the facility did not ensure the resident's right to be free from abuse for 2 (Resident #s 1 and #3) of 5 residents reviewed. Specifically, for Resident #1, the facility did not ensure Resident #1 was free from non-consensual sexual contact by Resident #2 on 7/1/2023. Resident #2, who was cognitively impaired and care planned for the potential to become physically aggressive and for going into other residents' rooms, entered Resident #1's room and slipped their hand inside Resident #1's shirt and grabbed their right breast. For Resident #3,the facility did not ensure Resident #3, who was cognitively impaired, was free from non-consensual sexual contact on 8/12/2023, when Resident #3 wandered into Resident #2's room and was observed by CNA #1 laying in Resident #2's bed and Resident #2 was standing over Resident #3 and was touching the resident's breast. This is evidenced by: Refer to F689 The facility's Abuse…

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 the facility did not ensure to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for 2 (Resident #'s 29, and 143) of 2 residents reviewed for right to privacy. Specifically, the facility did not ensure that Resident #29 and #143's, mail was delivered unopened. This was a repeat deficiency from the recertification survey dated 11/13/2019. This was evidenced by: The Policy & Procedure (P&P) titled Resident Mail dated 1/2021, documented mail will be delivered to the residents within 24 hours of receipt into the facility unopened/untampered. Resident #29: Resident #29 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (COPD), hypertension (HTN) and diabetes mellitus (DM). The Minimum Data Set (MDS-an assessment tool) 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.

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure walls and floors were clean on 5 of 6 resident units. This is evidenced as follows: During observations on 02/01/2022 at 9:30 AM, the walls or floors had scuff marks or floors were soiled in resident rooms A106, A109, A-118, B108, B109, B110, B112 (including cobwebs), B118, C201, C203, C205, C206, E101, E132, E133, E139, F151, F159, F163, F167, and F168. The corridor floors were soiled in corners and next to walls on the A-unit, B-unit, C-unit, E-unit, and F-unit; the floors were soiled in the A-unit activity area and F-unit common area. The nurse station floors were soiled on the A-unit and B-unit. Additionally, the service area corridor and cart-wash room required cleaning. During an interview on 02/01/22 at 1:49 PM, the Administrator stated that the floors and walls will be cleaned 483.10(i)(3); 10 NYCRR 415.5(h)(4)

Based on record review and interviews during a recertification survey and abbreviated surveys (Case #'s NY00277014 and NY00289938), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for three (Resident #'s 17, #125 and #111) of three residents reviewed for abuse. Specifically, for Resident #17, the facility did not ensure a resident's allegations that a facility staff member was rough…

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 a recertification survey and abbreviated survey (Case #NY00289117), the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 8 (Resident #'s 8, 17, 49, 60, 74, 99, 116, and 125) of 35 residents reviewed. Specifically, for Resident #8, the facility did not ensure the care plan for actual skin impairment addressed moisture associated skin damage (MASD) on the resident's right buttock, did not ensure a care plan was developed for edema, and tdid not ensure the care plan documenting the resident was a picky eater included interventions; for Resident #17 the facility did not ensure a care plan was developed for the diagnoses of cellulitis (bacterial infection underneath the skin surface characterized by redness, warmth, swelling, and pain); 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 observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure the desired staffing levels for Licensed Practical Nurses (LPNs), as documented in the Facility Assessment, were met 5 of 6 calendar days from 1/25/2022 to 1/30/2022 and Registered Nurses (RNs), as documented in the Facility Assessment, were met 6 out of 6 calendar days from 1/25/2022 to 1/30/2022. As a result of the insufficient staffing, nursing staff reported that indirect resident care activities were unable to be completed. This included the inability to develop comprehensive care plans and the inability to supervise the implementation of resident-specific care plans.…

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, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, and equipment and surfaces required cleaning in the kitchen and 6 of 6 unit nourishment kitchens. This is evidenced as follows. The kitchen and unit nourishment kitchens were inspected on 01/26/2022 at 10:33 AM. During the inspection of the kitchen, the concentration of QAC used to sanitize food contact equipment at the 3-bay sink was found to be less than 200 parts per million (ppm) when measured at 72 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The can opener and holder, floor mixer, stove drip pans, servery area reach-in refrigerator, dry storage area ceiling lights, 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 a recertification survey the facility did not ensure the resident's medical record contained required documentation on the basis for the transfer and appropriate information was communicated with the receiving medical provider for one (Resident #17) of three residents reviewed for hospitalizations. Specifically for Resident #17, the resident's medical record did not include documentation regardng the basis for the transfer, the specific resident's needs that could not be met at the facility, or communication with the physician regarding the need for transfer to the hospital. Additionally, Resident #17's transfer paperwork was not completed and sent to the hospital with the resident. Resident #17: The resident was re-admitted to the facility with diagnoses of cellulitis of the bilateral lower extremities (infection of the skin and the soft tissues underneath), diabetes and chronic kidney disease. The Minimum Data Set (MDS- an assessment tool) dated 1/17/2022,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey the facility did not ensure they developed and implemented an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #85) of 2 residents reviewed for discharged planning. Specifically, for Resident #85, the facility did not ensure the discharge planning process was developed, implemented, and evaluated based on the resident's request to return home. Additionally, the facility did not discuss a discharge plan with the resident following the exhaustion of Medicare Part A benefits and the resident's discharge from Rehabilitation Services. This was evidenced by: The Policy & Procedure (P&P) titled Discharge Planning and dated 9/2017 documented, Discharge planning is an on-going process. Regular reevaluation to identify…

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 a recertification and an abbreviated survey (Case #NY00277014), the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #'s 49 and #125) of 7 residents reviewed for ADL's. Specifically, for Resident #49, who was dependent on staff for ADL care, the facility did not ensure showers were provided in accordance with the resident's care plan and did not ensure Resident #49 was assisted out of bed per the resident's preference and for Resident #125, the facility did not ensure the resident received denture care or assistance with oral hygiene. This is evidenced by: The Policy and Procedure (P&P) titled Activities of Daily Living- Range of Motion and Mobility dated 9/2017, documented it was the facility's policy that based on the comprehensive assessment of a resident and consistent with the resident's needs 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.

Based on record review and interviews during a recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #138) of 3 residents reviewed. Specifically, for Resident #138, the facility did not ensure the resident received care and treatment in accordance with professional standards to promote healing and minimize infection after it was reported that the tip of a Q-tip (cotton swab) had broken off inside the tunnel of a Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the resident's left lateral gluteal (left buttock away from the midline of the body) on 1/24/2022. This is evidenced by: Resident #138: Resident #138 was admitted to the facility with the diagnoses of stage 4 pressure ulcers, chronic respiratory failure, and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 1/6/2022 documented the resident was cognitively intact, could understand…

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 and abbreviated survey (NY00289117 & NY00277014), the facility did not ensure acceptable parameters of nutritional status were maintained for 5 (Resident #'s 8, 60, 71, 125 and 127) of 7 residents reviewed for nutritional status. Specifically, for Resident #8, the facility did not ensure weekly weights were obtained in accordance with the physician order and did not ensure the facility's procedure to re-weigh a resident with an increase or decrease of 5 pounds or more from the previous documented weight entry was followed and did not ensure meal intakes were consistently obtained and monitored in accordance with professional standards, and that nutritional care plan interventions were consistently implemented and monitored; for Resident #60, the facility did not ensure the resident was weighed weekly times 4 weeks, and every month as ordered by the physician, and did not have a reweigh done immediately after a weight showing a…

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

Based on observation, record review and interview during a recertification survey, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for 1 (Resident #346) of 3 residents reviewed for pain management. Specifically, Resident #346 had requested pain medication and did not receive it for 24 hours after being admitted to the facility. This was evidenced by: A facility policy and procedure titled Pain Management dated 2/02/2022 documented, as a person with pain you have the right to have your pain thoroughly assessed and promptly treated. A facility policy and procedure titled Medication Administration dated 4/2017 documented, if a medication is unavailable from the primary pharmacy, the medication can be ordered through the facilities contracted back-up pharmacy or Cubex (an automated medication dispensing system). Resident #346: Resident #346 was admitted to the facility with the diagnoses of intervertebral disc degeneration lumbar region, acute kidney failure and acute cystitis with…

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 a recertification survey, the facility did not ensure it had sufficient staff, who provided direct services to residents, with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3 (Elm, Dogwood, and Fir) of 6 units. Specifically, the facility did not ensure staff received education, training, and guidance to effectively care for residents with dementia. This is evidenced by: Refer to F-744 Treatment/Services for Dementia The Facility assessment dated [DATE], documented the care offered based on resident needs included person centered/directed care; psychosocial and spiritual care. This included building relationships and engaging residents in covnersations, incorporating resident preferences and routines, supporting emotional and mental well-being, meeting spiritual, cultural, and ethical needs, 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 the recertification survey, the facility did not ensure residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 (Resident # 74) of 3 residents reviewed for dementia care. Specifically, for Resident #74, the facility did not ensure person-centered care plans with individualized interventions that included and supported the residents' dementia care needs were developed. This is evidenced by: Resident #74: Resident #74 was admitted to the facility with the diagnoses of cerebrovascular disease, vascular dementia without behavioral disturbance, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 12/21/2021, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Policy and Procedure (P&P) titled Dementia Care dated 1/5/2022, documented the…

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

Based on record review and interview during the recertification survey the facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when an irregularity is identified that requires urgent action to protect the resident. Specifically, the facility did not ensure the facility policy and procedure developed for the monthly Medication Regimen Review (MRR) included time frames for the different steps in the process. This is evidenced by: A facility policy and procedure titled Medication Regimen Reviews dated 7/08/2021 did not include documentation of the time frames for the steps in the MRR process. During an interview on 2/2/2022 at 2:15 PM the Director of Nursing (DON) stated they were not aware the MRR policy did not document specific time frames for the steps of the process, and the MRR policy should include the necessary time frames for the steps of the process. 10NYCRR415.18(c)(2)

Based on observation and interviews during the recertification survey, the facility did not ensure residents received food prepared by methods that conserved flavor and that were palatable. Specifically, for Resident #138, the facility did not ensure food was served at appetizing temperatures. This is evidenced by: Resident #138: Resident #138 was admitted to the facility with the diagnoses of stage 4 pressure ulcers, chronic respiratory failure and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 1/6/2022, documented the resident was cognitively intact, could understand others and could make self understood. During an interview on 1/26/2022 at 12:29 PM, the resident stated they received cold food a lot. During an observation and interview on 1/27/2022 at 9:34 AM, the resident was eating pancakes. The resident stated they were eating cold pancakes and did not like cold pancakes. During an observation and interview on 1/31/2022 at 10:18 AM, the resident was eating scrambled eggs. The resident stated they just received cold scrambled eggs from the kitchen. The 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 record review and interviews during a recertification survey, the facility did not ensure the facility conducted initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity and completed within 14 calendar days after admission for 8 (Resident #'s 9, 32, 35, 46, 109, 309, 358, and #359) 19 residents reviewed for Comprehensive Resident Assessments. Specifically, for Resident #'s 9, 32, 35, 46, 109, 309, 358, and #359, the facility did not ensure Comprehensive Resident Assessments were completed within 14 calendar days after admission. This is evidenced by: Resident #32: The resident was admitted to the facility on [DATE], with diagnoses of vascular dementia, cerebral infarction, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 12/27/19, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. During a record review, the Comprehensive MDS…

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 a recertification survey, the facility did not ensure residents were assessed using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 12 (Resident #'s 1, 2, 3, 5, 8, 9, 16, 17, 18, 36, 39, and #50) of 14 residents system selected for Resident Assessments. Specifically, for Resident #'s 1, 2, 3, 5, 8, 9, 16, 17, 18, 36, 39, and #50 the facility did not ensure each resident was assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments. This is evidenced by: Resident #1: The resident was admitted to the facility on [DATE] with the diagnoses of hypertension, dementia, and seizures. The Minimum Data Set (MDS- an assessment tool) dated 4/15/19. documented the resident had severely impaired cognition, could usually understand others, and could make self understood. The medical record…

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

Based on record review and interviews during a recertification survey, the facility did not ensure within 14 days after the facility completed resident assessments that the assessments were electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) System, including the following: (i)admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that did not have an admission assessment. Specifically, the facility did not ensure required Minimum Data Sets (MDS's), which included admissions, annuals, quarterly, and significant change assessments, were transmitted as required to CMS. This is evidenced by: The Policy and Procedure titled, MDS- Resident Assessments 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 observation, record review and interviews during the recertification survey the facility did not ensure they developed and implemented a comprehensive person-centered care plan (CCP) for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 10 (Resident #'s 11, 29, 35, 46, 48, 109, 309, 311, 358, and #359) of 19 residents reviewed. Specifically, for Resident #11, the facility did not ensure that a CCP(s) was developed to address the diagnoses of depression and anxiety and did not ensure the psychotropic medication related to behavior care plan included resident specific interventions; for Resident #29, the facility did not ensure that a CCP was developed for constipation; for Resident #35, the facility did not ensure a CCP was developed for urinary incontinence; for Resident #46, the facility did not ensure a CCP was developed for an upper body rash; for 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.

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition and shall protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. Food temperature thermometers shall be calibrated, and sanitizer solution must be maintained at proper concentrations. Specifically, cans of food were dented, a food temperature thermometer was not in calibration, and a sanitizer bucket did not have the proper chemical residual. This is evidenced as follows. The main kitchen was inspected on 09/16/2019 at 10:35 PM. One can of sweet potatoes and one can of beets were found in the dry stock area with V-shaped dents in the hermetic seal. One of 2 in-use thermometers were found out of calibration when checked by the standard ice-bath method measuring 40 degrees Fahrenheit (F). Chemical residual of the sanitizer bucket solution on the main kitchen food preparation counter…

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 the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his/her own and the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced by: A Policy and Procedure (P&P) titled Food From Outside Sources dated 12/2017, did not include documentation on safe food handling and storage practices, and did not include information regarding residents that are unable to access and consume foods on their own. During an interview on 9/18/19 at 12:41 PM, the Nutrition Services Director stated the policy did not include how dependent residents would access food, and does not include any information on food safety practices. 10 NYCRR 415.14(h)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during a recertification survey, the facility did not ensure the residents and/or resident representatives were provided with specific notification when the facility determined that the residents no longer qualified for Medicare Part A services and Medicare benefit days remained for 1 of 3 (Resident #'s 1, 15, and #258) residents reviewed for Beneficiary Protection Notification. Specifically, for Resident #1, the facility did not ensure the resident or resident representative was informed of the beneficiary's potential liability for payment and related standard claim appeal rights using the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form CMS-10055 and did not issue the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123, to convey to the beneficiary his or her right to an expedited review of a service termination. This is evidenced by: Resident #1: The resident was admitted to the facility on [DATE], with the diagnoses of hypertension,…

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 the facility did not ensure the right to privacy in his or her oral, written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident. Specifically, the facility did not ensure Resident #17, and all resident's mail was delivered unopened. This was evidenced by: The Policy & Procedure (P&P) titled Resident Mail dated 9/2017, documented the facility would ensure that all residents have privacy in written communications, including the right to send and receive mail promptly, that is unopened. Resident #17: The resident was admitted to the facility on [DATE], with the diagnosis of hypertension, cerebral vascular accident (CVA), and depression. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact and was able to make himself understood and understand others. During 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, record review, and interviews during a recertification survey the facility did not ensure each resident was free from physical restraints imposed not required to treat the resident's medical symptoms for one Resident (#109) of one reviewed for restraints. Specifically, the facility did not ensure that the resident's freedom of movement was not inhibited when seated in his geri chair with the wheels locked, and pushed up to table and counter. This is evidenced by: Resident #109: The resident was admitted to the nursing home on 5/3/19 with diagnoses of dementia, constipation, and pain. The Minimum Data Set (MDS-an assessment tool) dated 5/10/19, assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. Section F for preferences was not assessed. A Policy titled Restraints, dated 9/2017, documented that an example of a restraint was using devices in conjunction with a chair such as a table, that the resident could not remove 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 interview and record review during the recertification survey, the facility did not ensure written notice was provided to the resident and/or the resident's representative of the bed hold policy for 1 (Resident #12) of 1 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence the resident and/or the resident's representative received written notice of the bed hold policy when the resident was transfered and admitted to the hospital. This evidenced by: Resident #12: The resident was admitted to the facility on [DATE], with a diagnosis of Parkinson disease (a progressive nervous system disorder that affects movement), heart failure and pneumonia. The MDS dated [DATE], documented the resident could understand and make self-understood. The policy and procedure titled Reserved Bed Days Policy dated 2/2019, documented that written notice must be provided to the resident/resident representative regarding bed-hold upon transfer to the hospital. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure a Significant Change (a major decline or improvement in a resident's status that will not normally resolve itself ) Minimum Data Set (MDS - an assessment tool) assessment was completed for 1 (Resident #12) of 1 residents reviewed for significant changes in health status. Specifically, for Resident #12, the facility did not ensure that a significant change MDS was completed upon the resident's admission to Hospice services. This is evidenced by: Resident #12: The resident was admitted to the facility on [DATE], with a diagnosis of Parkinson disease (a progressive nervous system disorder that affects movement), heart failure and pneumonia. The MDS dated [DATE], documented the resident could understand and make self-understood. A physician's order dated 8/26/18, documented a Hospice consult/services and diagnosis for acceptance in the program. A Social Services note dated 8/27/19, documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure it had an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one (Resident #109) of one reviewed for activities. Specifically, the facility did not ensure that the resident was provided activities based on his mental and physical abilities. This is evidenced by: Resident #109: The resident was admitted to the nursing home on 5/3/19, with diagnoses of dementia, constipation, and pain. The Minimum Data Set (MDS-an assessment tool) dated 5/10/19, assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. Section F for preferences was not assessed. An Activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews during a recertification survey and abbreviated survey (Case #NY00243367) the facility did not ensure that each resident received care, consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for one (Resident #309) of two residents reviewed for pressure ulcers. Specifically, the facility did not ensure that an initial nursing and skin assessment were completed upon the resident's admission, and did not develop a Comprehensive Care Plan (CCP) that addressed the resident's risk for pressure ulcer development, when facility's risk scale (Braden Scale - an algorithm to show risk for pressure sore development) done on admission, assessed the resident as being at moderate risk for skin breakdown. This is evidenced by: Resident #309: The resident was admitted to the nursing home on 7/25/19, with diagnoses of heart failure, chronic obstructive pulmonary disease, and atrial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey the facility did not ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; for one (Resident #48) of three reviewed for nutrition. Specifically, for Resident #48. the facility did not ensure that a dental consult was done to address the resident's difficulty with chewing related to dentures, that a Comprehensive Care Plan (CCP) was developed to address potential nutritional problems, and that intakes were monitored when the care plan was developed on 8/12/19, that the resident's weight was monitored weekly per the Medical Doctor (MD) Order, and the facility did not ensure the medical provider was notified when the resident refused meals. This is evidenced by: Resident #48: The resident was admitted…

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 during the recertification survey, the facility did not ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (Resident #358) of 2 residents reviewed for mood and behavior. Specifically, the facility did not ensure the resident was provided with a physician ordered psychological consultation to address her behavioral health care and needs. This is evidenced by: Resident #358: The resident was admitted to the facility on [DATE], with the diagnoses od dementia, anxiety, and traumatic brain injury (TBI). The medical record did not include documentation of a Minimum Data Set (MDS - an assessment tool). A Brief Interview for Mental Status (BIMS) dated 6/21/19, documented the resident had severely impaired cognition. A Comprehensive Care Plan (CCP) for Risk for Unwanted Affection, last updated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (Case #NY00235924) and recertification survey the facility did not ensure the residents were free from significant medication errors for 1 (Resident #308) of 6 residents reviewed. Specifically, the facility did not ensure the resident received significant medications in a timely manner upon admission. This was evidenced by: Resident #308: The resident was admitted to the facility on [DATE], with the diagnosis of right ankle fusion, diabetes mellitus and arthritis. The Minimum Data Set (MDS) dated [DATE], documented the resident was cognitively intact and was able to make herself understood and could understand others. The physician orders dated 2/12/19, documented the following medications to be administered: Xarelto (a prescription blood thinner) 10 milligrams (MG) once per day; Basaglar Insulin ( long-acting insulin used to control high blood sugar) 28 units once per evening; Baclofen (used to treat muscle spasms) 10 MG two times per day;…

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, the facility did not ensure foods were served to accommodate resident allergies. Specifically, the facility did not ensure the gluten free menu was free from foods containing gluten, an appropriate alternative was served to a resident on a gluten free diet, and gluten free toast was prepared without being cross contaminated. This is evidenced by: Finding #1: The facility did not ensure the gluten free menu was free from foods containing gluten. A review of the facility menu dated 9/15/19, documented the residents on a gluten free diet were to receive the following gluten containing foods; corn muffin, vegetable lasagna, strawberry ice box cake, lemon cake, carrot spice muffin. The diet manual dated 2013 documented residents on a gluten free diet were not to receive foods that contained wheat, and cross contamination with gluten containing grains during food handling should be avoided. The undated gluten free guidelines documented no cake and no lasagna were to be served. During an interview on 9/17/19 at 1:45 PM, the Nutrition…

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.