Absolut Center for Nursing and Rehabilitation at G

Based on interviews and record reviews during a survey the facility failed to ensure the Director of Nursing served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Specifically, both the Director of Nursing #1 and the Director of Nursing #2 worked as a charge nurse when the facility had a daily average census of greater than 60. The findings include: An undated document titled Director of Nursing Job Summary provided by the facility documented duties to include but were not limited to organize documented plans, organizes and directs the overall operations of the Nursing Service Department in accordance with all state, federal and local guideline/regulations to ensure that the highest degree of quality care was always maintained. The Director of Nursing shall maintain and adhere to a master staffing plan, provide adequate and professional nursing and paraprofessional personnel sufficient and commensurate with the type and amount of nursing needs of individual residents. The facility policy and procedure tilted Daily Staffing revised…

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

Based on observations, interviews and record review conducted during a survey, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three (3) (Heritage unit (C/D), Main Dining Room, and Woodland Heights unit (A/B)) of three (3) test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, were not palatable, and were not attractive looking. Residents #1, #2, #3, #7, #11, #21, #42, #56, #61, and #85 were involved. The findings include:The policy titled Food Preparation, Service and Distribution dated 10/2022 documented the facility would assure safe and sanitary food preparation, holding, transport and distribution to prevent food borne illness. Tray line and/or alternate meal preparation and service areas may include steam tables, where hot prepared foods are held and served, and chilled areas where cold foods are held and served. The facility will avoid the following potential risks to reduce food borne illness: not holding food in the danger zone (temperatures above 41 degrees…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the survey, the facility failed to ensure a Pre-admission Screening and Resident Review (PASSAR), Level I identification screen, was completed prior to admission for two (2) (Residents #5 and #32) of two (2) residents reviewed. Specifically, there was no evidence that the screen was completed prior to admission for Residents #5 and #32. The findings are:The policy titled Pre-admission Screening and Resident Review, revised 11/2023, documented a screen is required for every resident prior to admission regardless of length of stay. A copy of the resident's most recent screen accompanies the resident upon transfer to a hospital or another Residential Health Care Facility.The policy titled Pre-admission Process, revised 12/16/2021, documented that all residents will have a completed screen which shows the minimum qualifications for admission to a Residential Health Care Facility are met.1. Resident #5 had diagnoses including bipolar disorder (a mental health…

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

Based on observation, interview, and record review conducted during survey the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for one (Resident #3) of two residents reviewed. Specifically, Resident #3's air/foam mattress pressure pump was disconnected from pump, and the pump was unplugged preventing air flow use with mattress.The findings include: The facility policy and procedure titled Documentation of Pressure Ulcer and Chronic Wounds) revised 6/23, documented that pressure ulcers and chronic wounds were monitored closely to monitor effectiveness of treatment and change in risk factors. Risk factors were identified and suggested interventions may be implemented or modified on an as needed basis. Review of undated Self-Adjusting Air/Foam Mattress with Optional Alternating Pressure Pump operation manual, documented the mattress was indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive…

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

Based on observation, interview and record review conducted during the survey, the facility failed to ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #2 ) of four (4) residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and one (1) of one (1) facility legionella program. Specifically, staff did not wear appropriate personal protective equipment during wound care for Resident #2 and the facility's Legionella Water Management Plan was not reviewed or revised annually. The findings include:The policy titled Policy on Disease-Specific Isolation/Precautions last revised 12/19/24 documented enhanced barrier precautions referred to an infection control intervention designed to reduce the transmission of multidrug resistant…

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 a Standard survey completed on 7/19/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases/infections or implement a system of surveillance designed to identify possible communicable diseases/infection before they can spread to other persons in the facility for three (Residents #3,22, and 37) of six residents reviewed. Specifically, the issues involved; staff did not wear a gown during peripherally inserted central catheter (a catheter that is inserted through a vein and advanced until the tip enters the central venous system) care; staff did not wear a gown and gloves during medication administration for a resident on contact and enhanced barrier precautions (infection control interventions including gown and glove use for high contact resident care activities designed to reduce transmission of multidrug-resistant organisms) (Resident #22).…

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

Based on interview and record review conducted during a Complaint investigation (#NY00319528) during the Standard survey completed on 7/19/24, the facility did not ensure that all alleged violations of abuse and neglect were thoroughly investigated for one (Resident #36) of five residents reviewed. Specifically, there was a lack of employee interviews and statements to rule out abuse regarding an injury of bruising below the resident's right eye. The finding is: The facility policy and procedure titled, Facility Incident/Abuse Investigation and Reporting, with a revision date of 6/7/23, documented the facility will conduct an immediate and thorough investigation, upon discovery of an incident including injury of unknown source. An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in 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 interview, observation, and record review conducted during a Complaint investigation (#NY00322578) conducted during a Standard survey, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #38) of two residents reviewed for accidents. Specifically, Resident #38 who was a risk for elopement, eloped from the facility without staff knowledge and was outside of the facility for 20 minutes. The finding is: The policy and procedure titled Risk of Elopement dated 1/26/22 documented that a safe environment is provided for patients/residents who are at risk to wander. The policy and procedure titled Loss of Resident/Missing Resident dated 11/09 documented that all staff will be able to follow an organized plan to enable us to locate a missing resident as quickly as possible. The policy and procedure titled Elopement Security System Alarms/Devices dated 5/08 documented that security alert devices are used to alert staff 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 observation, interview, and record review conducted during a Standard survey completed on 7/19/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #37) of one resident reviewed. Specifically, there was lack of voiding trial (removal of a urinary catheter to see if someone can pass urine normally) when the resident was readmitted to the facility from the hospital with a foley catheter and the lack of a urology (part of health care that focuses on diseases of the urinary system) consult. The finding is: The policy and procedure titled Catheter (urinary) Insertion and Removal dated 9/2/20, documented prior to insertion or upon continued use upon admission, the unit coordinator or designee will discuss and document the involvement of the resident/representative of the risk and benefits of the use of a catheter, removal of the catheter when…

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

Based on interview and record review conducted during the Standard survey completed on 7/19/24, the facility did not ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #65) of one resident reviewed. Specifically, Resident #65 received Augmentin (antibiotic, Amoxicillin-Potassium Clavulanate 875-125 milligram) for osteomyelitis (bone infection) since 7/25/23 and there was no ongoing monitoring by the Antibiotic Stewardship Program including communication, tracking of its use, appropriate indications for continued use, or follow up appointment with the Infectious Disease Physician as recommended. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Program effective 5/2017, documented the primary goal is to optimize the treatment of infections and clinical outcomes while minimizing unintended consequences of antibiotic use. The antibiotic stewardship program includes a system of monitoring antibiotic use. Actions to improve antibiotic prescribing/use include institute 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 interview and record review during an Abbreviated survey (Complaint #NY00322015) completed on 8/22/23, the facility did not ensure that they immediately informed the resident's representative and the physician when there was a significant change in the resident's health, mental, or psychosocial status for two (Residents #1 and #2) of three residents reviewed. Specifically, Resident #1 was observed to have a left heel blister and the facility did not notify their Health Care Proxy (HCP). Additionally, Resident #2 had a recent history of a gastrointestinal (GI) bleed and the facility did not ensure they immediately consulted with the resident's physician when the resident developed emesis that had a coffee ground (vomit that is brown or black with a lumpy texture that looks like coffee grounds and was a sign of internal bleeding) appearance. The findings are: The policy and procedure (P&P) titled Change in a Resident's Condition or Status revised 3/2020, documented that the resident, his or her attending…

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

Based on interview and record review during a Standard survey started 9/28/22 and completed 10/4/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made to the appropriate officials (including the State Survey Agency). Specifically, one (Resident #39) of one resident reviewed for allegation of physical abuse was not reported to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy titled Abuse Reporting and Facility Incident Reporting revised date 4/1/21 documented any alleged violations involving mistreatment or abuse will be reported to the appropriate involved parties and state agencies. The facility administrator, or designee, notifies the State Licensing and Certification Agency when there is an allegation that a resident has been abused. All alleged violations involving abuse against a resident are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse, to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Standard survey started on 9/28/22 and completed on 10/4/22, the facility did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care. Specifically, three (Residents #18, 25, and 49) of four residents reviewed for discharge planning lacked a referral to the local contact agency when a desire to return to the community was expressed. In addition, the facility did not develop a care plan that included the resident's discharge planning needs to address their desire to return to the community (Resident #25). The findings are: The facility policy and procedure (P&P) titled Discharge Plan dated 3/2020 documented an individualized interdisciplinary discharge care plan is developed with input from the patient and patient's representative to meet the patient's needs and goals. For patient's that…

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

Based on observation, interview, and record review conducted during a Standard survey started on 9/28/22 and completed on 10/4/22, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #10) of three residents reviewed for antipsychotic medication use. Specifically, there was a lack of a GDR for a resident receiving antipsychotic medication and a lack of supporting documentation for the continued use of the antipsychotic. The finding is: The facility policy and procedure (P&P) titled Psychotropic Med Use Initiation and Gradual Dose Reduction dated 3/1/2020 documented that each resident is evaluated for the continued need of psychotropic medications and the determination of whether they are being maintained on the lowest effective dose. The P&P documented a GDR is to occur with the first year after admission in two separate quarters, with at least one month between attempts unless clinically contraindicated. The P&P 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.