Glengariff Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey, initiated on 09/11/2025 and completed on 09/18/2025, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for two (2) (Resident #99 and #238) of four (4) residents observed during Medication Administration. Specifically, during the medication administration observation, Licensed Practical Nurse #5 did not perform hand hygiene after administering medications for Resident #238 and before preparing the medications to administer to Resident #99.The finding is:Resident #238 was admitted to the facility with diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Diabetes. The Quarterly Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition.Resident #9 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review during an abbreviated survey conducted on 3/19/2025 through 04/21/2025 for case number NY00375018 the facility failed to protect each resident's right to be free from physical abuse. This was identified for one (Resident #1) of three residents reviewed for physical abuse. Specifically, video surveillance showed Licensed Practical Nurse #1 pointing their right finger at Resident #1's face. Licensed Practical Nurse #1 reaches forward with both hands, places them at Resident #1's neck, and pushes them backwards in their wheelchair. The incident was discovered when a staff member was reported as injured by Resident #1. The findings are: The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating created on 3/2022 and revised on 6/21/24 documented that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately 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 observation, interviews and record review during an abbreviated survey conducted on 9/3/24 through 9/27/24, the facility did not ensure that the alleged violations involving abuse, including injuries of unknown source, neglect, or mistreatment were reported within 24 hours to the New York State Department of Health. This was identified for two (Resident #1 and Resident #2) of three resident records reviewed for Abuse. 1) Specifically, Resident #1 was observed with areas of bruises to their forehead and area above their right eye. The cause of this injury was unknown. 2) Resident #2 was pushed by another resident and fell to the ground hitting their head on 08/06/2024 and neither (Resident #1 and Resident #2) incidents were not reported to the New York State Department of Health as required. The findings are: 1) The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating created on 3/2022 and revised on 6/21/24 documented that if resident abuse, neglect,…

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, interviews and record review during an abbreviated survey conducted on 9/3/24 through 9/18/24, the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment, including an injury of unknown origin were thoroughly investigated. This was identified for 2 of 3 residents reviewed for abuse. Specifically, 1) Resident # 1 was observed with an injury of unknown origin to the right side of their face and eyebrow area on 9/1/24. 2) Resident #2 was pushed by another resident and fell to the ground hitting their head on 08/06/2024.There is no documented evidence that the facility did a thorough investigation of the incidents to identify the root cause of the injury and to rule out Abuse, Neglect, and Mistreatment. This is a repeat deficiency. The findings are: 1) The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating created on 3/2022 and revised on 6/21/24 documented that all allegations are…

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, interviews and record review during an abbreviated survey conducted on 9/25/24 through 9/27/24, the facility did not ensure that care was provided in accordance with professional standards and by individuals qualified to do so. Specifically, the facility had a Licensed Practical Nurse serving in the capacity of Unit Manager completing assessments for 17 out of 17 reviewed records following accidents and falls on their unit. This Licensed Practical Nurse placed their name on the form in the space titled Registered Nurse Supervisor and signed their name and title on the completed document which is out of the scope of practice for a Licensed Practical Nurse. The findings are: An undated job description for Registered Nurse or Licensed Practical Nurse Unit Manager was reviewed and documented Prepare incident/accident reports events and observations using the Electronic Medical Record system. There was no documented evidence of who should complete the assessment in the Unit Manager Job…

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 and Abbreviated Survey (NY 00337626) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that all incidents including the injury of unknown origin were thoroughly investigated. This was identified for two (Resident #530 and Resident #140) of six residents reviewed for Accidents and for one (Resident #133) of three residents reviewed for Abuse. Specifically, 1) on 2/16/2024 Resident #530 was found on the floor and sustained a hematoma (bruising) to the forehead and skin tears on both arms. The facility did not thoroughly investigate the incident to identify the root cause and to rule out Abuse, Neglect, and Mistreatment. Additionally, the facility did not ensure that the investigation summary of the incident was completed within 5 days as required. 2) Resident #140 had multiple injuries of unknown origin from 9/22/2023 to 5/6/2024 and the facility did not thoroughly investigate the injuries of unknown origin…

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 the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, 1) the facility did not ensure that 1) medications were administered within one hour of the ordered administration time on two (Unit 2 [NAME] and Unit 1 West) of four units during unit observations, and 2) the drug records were in order and accounted for all controlled drugs on one (Unit [NAME] 1) of six units observed during the medication storage task. Specifically, 1) on 4/29/2024 on Unit 2 [NAME] in the Glengariff building, three residents (Resident #126, #131, and #32) did not get their 9:00 AM medications within one hour of the physician-ordered administration time; and on 4/30/2024 on Unit 1 [NAME] in the Glengariff building eleven residents (Resident #134, #151, #331, #82, #34, #92, #95, #8, #46, #157, #178) did not get their 9:00 AM medications within one hour of the physician-ordered administration time; and 2) During the medication storage task observation 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 interviews during the Recertification Survey and Extended Survey (NY 00321997) initiated on 4/29/2024 and completed on 5/7/2024 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, were 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. This was identified for two (Resident #151 and Resident #82) of three residents reviewed for Abuse. Specifically, Resident #151 and Resident #82 were involved in a resident-to-resident altercation on 8/11/2023, in which Resident #151 was allegedly pushed by Resident #82 and fell to the floor. The incident of resident to resident altercation was not reported to the New York State Department of Health until three days after the incident, on 8/14/2023. The finding is: The facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that preadmission screening for individuals with a mental disorder and individuals with intellectual disability was conducted prior to their admission to the facility. This was identified for one (Resident #18) of 40 residents reviewed for Pre-admission Screening and Resident Review (a federal requirement to ensure that residents were not inappropriately placed in a skilled nursing facility). Specifically, Resident # 18 was admitted [DATE], the Level 1 Pre-admission Screening and Resident Review (PASARR) screening was not completed by the facility staff until 7/16/2023, two days after the resident's admission to the facility. The finding is: The facility's policy and procedure titled, Pre-admission Screening and Resident Review (PASARR) last revised in December 2023 documented all residents to have the required pre-admission screen prior to admission 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 observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Resident #531) of six residents reviewed for Accidents. Specifically, Resident #531 was not assessed to safely self-administer their medications. On [DATE] an inhaler (handheld devices that allow you to breathe medicine in through your mouth, directly to your lungs) was observed in Resident #531's room with no staff member present. The inhaler did not have a label that indicated the resident's name or direction for the administration. Additionally, Resident #531 did not have a Physician's order for the use of the inhaler. The finding is: The facility policy and procedure titled, Medication Administration last revised in 12/2023 documented only people licensed or permitted by the state to prepare, administer, and document the administration 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 during the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024 the facility did not ensure that the medication regimen review recommendations that were approved by the physician were implemented. This was identified for one (Resident #24) of five residents reviewed for unnecessary medications. Specifically, on 3/12/2024 the consultant Pharmacist recommended the addition of a calcium supplement to Resident #24's medication regimen. The resident's Physician approved the recommendation made by the consultant Pharmacist; however, there was no physician's order written for the calcium supplement and the resident did not receive the recommended supplement. The finding is: The facility's policy titled Drug Regimen Review, dated 12/2023, documented the consultant Pharmacist shall identify, document, and report possible medication irregularities for review and action by the attending Physician. The attending Physician or licensed designee shall respond to the drug regimen review within 7-14 days or more promptly, whenever possible.…

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 the Recertification Survey initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that each resident's drug regimen was free from unnecessary medication. This was identified for one (Resident #166) of five residents reviewed for Unnecessary Medications. Specifically, on 2/20/2024 and again on 3/12/2024, Resident #166's Physician agreed to discontinue Oxybutynin (medication to treat bladder overactivity) and Benadryl (anti-allergy medication) as per the recommendations made by the consultant Pharmacist because the medications were no longer medically required. Resident #166 continued to receive Oxybutynin Extended Release 5 milligrams from 2/20/2024 to 5/5/2024 and received Benadryl Allergy oral tablet 25 milligrams on 3/22/2024, 3/29/2024, 5/4/2024 and 5/5/2024. The finding is: Resident #166 was admitted to the facility with diagnoses that included an Overactive Bladder, Hyperuricemia (high uric acid level), and Seizures. 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 during the Recertification and Abbreviated (NY 00331067) Survey initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure each resident received routine dental services to meet the needs of each resident. This was identified for one (Resident #127) of one resident reviewed for Dental Services. Specifically, Resident #127 had a dental consult completed on 3/18/2024. The dental consult documented recommendations for a dental follow-up visit in one week with medical clearance for tooth extraction. There was no documented evidence that the recommendations made by the Dentist were addressed until 5/7/2024. The finding is: The facility's Dental Services policy last revised in December 2023, documented to provide residents with routine and emergency dental services. Residents have the right to select Dentists of their choice when dental care or services are needed. A social services representative will assist residents with appointments and transportation…

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 staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00337626) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not immediately notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for one (Resident #140) of one resident reviewed for Notification of Change. Specifically, on 3/17/2024 Resident #140 fell and hit their head on a radiator and was identified to have sustained a scalp laceration. Subsequently, the resident was transferred to the hospital for evaluation on 3/17/2024. There was no documented evidence that the resident's designated representative was notified of the resident's fall and the resident's transfer to the hospital until 3/19/2024. The finding is: The facility's policy titled, Notification of Change created in 12/2021 and revised in 12/2023 documented to notify the resident, their attending physician, and 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.

Based on record review and interviews during the Recertification Survey and Extended Survey (NY 00337759) initiated on 4/29/2024 and completed on 5/7/2024, the facility did not ensure that a physician wrote, signed, and dated a progress note at each visit. This was identified for one (Resident #126) of two residents reviewed for Hospitalization. Specifically, on 3/17/2024 Resident #126 reported experiencing stroke-like symptoms. Physician #1 examined the resident but did not document the examination findings in the resident's medical record. Subsequently, the resident was transferred to the hospital after the resident's family activated emergency medical services and was diagnosed with a possible acute Cerebral Vascular Insufficiency. The finding is: The facility's policy titled, Physician Services last revised 5/3/2024, documented an alternate physician supervises the care of residents when the attending physician is not available. Physician orders and progress notes are maintained in accordance with Omnibus Budget Reconciliation Act regulations and facility policy. Physician…

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 and Abbreviated Survey (Complaint # NY 00339556) initiated on [DATE] completed on [DATE], the facility did not ensure that all residents were provided medically-related social services to attain or maintain the highest practicable well-being. This was identified for one (Resident #380) of one Resident reviewed for Hospice and End of Life. Specifically, Resident #380 was admitted to the facility with a deteriorating health condition due to a diagnosis of Cancer. On [DATE] (Saturday) upon request of Resident #380's designated representative the Physician wrote an order to obtain a Hospice service referral. The facility's Social Worker or designee was not available to request the physician-ordered Hospice service referral until Monday ([DATE]). Resident #380 expired on [DATE] shortly after the referral to the Hospice services was made. The finding is: The facility Social Services policy and procedure revised on 12/2023 documented that 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 during the Recertification Survey and Abbreviated Survey (NY 00339556) initiated on [DATE] and completed on [DATE], the facility did not ensure that all residents were assisted with the provision of Hospice services when a resident requested a transfer. This was identified for one (Resident #380) of one Resident reviewed for Hospice and End of Life. Specifically, Resident #380's designated representative requested Hospice services on [DATE] and a referral was not provided until [DATE]. Resident #380 expired on [DATE] shortly after the referral to the Hospice services was made. The finding is: The facility Comfort Care and Palliative Care policy and procedure revised on 12/2023 documented it is the policy of the facility to respect the wishes of the residents and their designated representatives regarding end-of-life decisions. The policy documented that the interdisciplinary team explores Hospice where appropriate. The facility does not provide in-house Hospice service. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, conducted during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022, the facility did not ensure that the facility's medication error rates are not five percent or greater. This was identified for 15 of 25 opportunities during a medication pass observation resulting in a 60% medication error rate. Specifically, 1) Resident #109 did not receive the Physician ordered 9 AM medications until 12:20 PM. 2) Resident #433 did not receive the Physician ordered 9 AM medications until 12:50 PM. 3) Resident # 150 did not receive the Physician ordered 9 AM medications until 1 PM. The findings are: The Facility's Policy for Administering Medications dated 2/1/2021, documented medications are administered in a safe and timely manner, and as prescribed. The Policy documented medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). 1) Resident #109 was admitted 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 staff interviews during the Recertification Survey and abbreviated survey (NY 00297469 and NY 00290555) initiated on 8/02/2022 completed on 8/9/2022 the facility did not ensure that for each resident the resident's representative or physician were notified immediately when there was a change in condition. This was identified for 1 (Resident #432) of 3 residents reviewed for change of condition and one (Resident #483) of 2 residents reviewed for hospitalization. Specifically, 1) Resident #432 developed an infection and required Intravenous (IV) antibiotics; however, the resident's representative was not notified of initiation of the IV antibiotic therapy for the resident. 2) Resident #483 had a Physician order to contact the Physician if Resident # 483's finger stick (FS) blood sugar (BS) results were less than 70 milligram/deciliter (mg/dL) or greater than 250 mg/dL. There was no documented evidence that Resident # 483's Physician was notified when the resident's Blood Sugar level was…

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 staff interviews during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #83) of 6 residents reviewed for Pressure Ulcers; and 2 of 10 Resident Council attendees (Resident #127 and Resident #118) who complained of not receiving wound care treatments consistently. Specifically, 1) Resident #83 was identified with an open area to the left lateral Malleolus (outer ankle) on 7/15/2022. There was no assessment or treatment provided until six days later on 7/21/2022; however, the assessment did not include the size, depth, or type of wound until 7/27/2022 when the resident was seen by the wound care Physician. Additionally, the Physician's order for bilateral heel booties to be worn while in bed was not implemented on two separate observations. Furthermore,…

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 initiated on 8/2/2022 and completed on 8/9/2022, the facility did not ensure that all residents received adequate supervision to prevent Accidents. This was identified for one (Resident #7) of five residents reviewed for Accidents. Specifically, Resident #7, who required extensive assistance of one person for personal hygiene, was observed shaving themselves with a razor without supervision. The finding is: The Facility's Hazardous Area, Devices and Equipment Policy dated 4/24/2022, documented all hazardous devices in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to sharp objects that are accessible to vulnerable residents. The Facility Safety and Supervision of Residents Policy dated 4/24/2022,…

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.

Based on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY00280683) initiated on 8/2/2022 and completed on 8/9/2022 the facility did not promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's order. This was identified for 1 (Resident #582) of 3 residents reviewed for change in condition. Specifically, Resident #582 had Urine Analysis and Culture and Sensitivity (UA and CS) report results that were outside of clinical reference ranges; however, there was no documented evidence that these results were reviewed either by the physician or the nursing staff prior to the resident being sent to the hospital. The resident was diagnosed in the hospital with a Urinary Tract Infection (UTI) diagnosis. The finding is: The facility's policy titled Laboratory and Diagnostic Test Results-Clinical Protocol, dated 2/1/2021, documented when test results are reported to the facility, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the Recertification Survey initiated on 8/2/2022 and completed on 8/9/2022, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure that a sufficient number of qualified nursing staff are available to meet each resident's needs. The finding is: The facility assessment dated [DATE] documented that the staffing plan was based on the resident population and their needs for care/support. The staffing plan portion of the facility assessment documented that the number of hours in a two-week period for licensed nurses providing direct care was 4,040 and 8,184 hours for nurse aides. The Administrator was interviewed on 8/9/22 at 11:31 AM. The administrator stated that the facility assessment documented only the number of working hours 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.