The Valley View Center For Nursing Care And Rehab

Based on observation, interview and record review conducted during a recertification survey, from 7/15/2025-7/22/2025 the facility did not ensure that comprehensive person-centered care plans were developed and/or implemented for each resident to meet the resident's medical and/or nursing needs for 1 of 4 residents (#214) reviewed for range of motion. Specifically, for Resident #214 with muscle weakness a care plan was not developed to address left-hand contracture and/or the use of a left-hand roll as per occupational therapy recommendation The findings includeResident # 214 had diagnoses which included Dementia. A Quarterly Minimum Data Set (assessment tool) dated 6/15/25 documented Resident #214 had severely impaired cognition, no functional limitation in range of motion, and received substantial/maximal assistance with all other activities of daily livingThe Occupational Therapy Discharge Note dated 6/20/2025, documented staff/caregivers were educated and instructed on the use of a left upper extremity handroll schedule, range of motion, hygiene, and skin checks for irritation.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the Recertification Survey from 7/15/2025-7/22/2025, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of three residents (#6) reviewed for mood and behavior and one of four residents (#171) reviewed for positioning. Specifically, 1) Resident #6 did not receive follow up psychiatric services as ordered and recommended by the physician and 2) Resident #171 was observed seated in their wheelchair with their legs/feet unsupported and dangling above the footrests.The findings include: 1) Resident #6 had diagnoses including but not limited to unspecified dementia, psychotic disorder, and anxiety disorder. The physician order dated 10/16/2024 documented psychiatric consultation in house follow up in one-month last visit 10/16/2024. There was no documented evidence of a psychiatric follow up after the 10/16/2024 consultation. The care…

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 the recertification survey conducted 7/15/2025 to 7/22/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for one of three residents (Residents #171) reviewed for pressure ulcers. Specifically, heel booties were not applied as per physician order and care plan for Resident #171 who was assessed at risk for pressure ulcers. The findings include:The policy & procedure titled Pressure Ulcers Prevention dated 11/2010 documented staff were to identify risk factors for pressure ulcer development and take measures to prevent the formation of pressure ulcers.Resident #171 had diagnoses including Dementia, Stroke, and Hemiplegia.The Quarterly Minimum Data Set (an assessment tool) dated 6/8/25 documented Resident #171 had severely impaired cognition, functional impairment on both sides of the upper and lower body, was dependent with all activities of daily living and was at risk for developing pressure ulcers.The Physician order dated 6/23/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification Survey from 07/15/2025 to 07/22/2025, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 4 residents (Resident #10) reviewed for Position/Mobility. Specifically, Resident #10 with functional limitation in range of motion was observed on multiple occasions without the use of a left-hand splint as per Occupational Therapy recommendation. The findings included:The policy and procedure titled Care Planning, Orthotic Device, Splints Skin Integrity Monitoring dated last revised 10/10 documented the orthotist/designee will evaluate appropriateness and proper fit of the brace and splint. They will work in collaboration with the referring physician, unit manager and the therapist are to assess the effectiveness and fit of the brace or splint.Resident #10 had diagnoses including Cerebral Infarction and Dementia.The…

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

Based on observation, record review, and interview during the Recertification Survey conducted from 07/15/2025- 07/22/2025, the facility did not ensure that residents were free of medication error rates less than 5% for 1 of 4 residents (Resident #114) reviewed for Medication Administration. Specifically, Licensed Practical Nurse #11 crushed 3 medications and administered them all at once via gastrostomy tube, then combined 3 liquid medications and administered them all at once to for Resident #114 via gastrostomy tube.The findings included:The policy titled Medication Treatment Administration, which was last reviewed on 10/17, documented medications are to be crushed and administered separately, whether administered via oral or gastrostomy route.Resident #114 had diagnoses including Major Depressive Disorder, Epilepsy (seizure disorder), and Gastrostomy status.The care Plan titled Tube Feed last updated on 09/28/19, documented administer medication as ordered.The physician orders dated 7/7/2025 documented Famotidine 20mg tablet give one tablet by gastrostomy tube daily. Lamotrigine…

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 interview conducted during the recertification survey from 7/15/25 to 722/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of infection for 1 of 4 residents reviewed for nutrition. Specifically, Licensed Practical Nurse #12 was observed without the use of a gown when they administered medications via gastrostomy tube to Resident #14 who was on enhanced barrier precautions.The findings included:The policy titled Infection Control Practices Precaution Guidelines, revised 11/2023, documented residents suspected or known to have an infection, and/or transmissible disease will be clinically managed to prevent and control outbreaks and cross contamination. Enhanced barrier precautions guidelines include the use of a gown for high contact resident care Resident #14's diagnoses included dysphagia, and encounter for attention to gastrostomy. A significant change Minimum Data Set (assessment tool) dated 6/20/25 documented Resident #14 had severe cognitive impairment.During an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review conducted during the recertification and abbreviated survey (813417) from 7/15/25 - 7/22/25, the facility did not ensure Comprehensive Care Plans were revised to reflect the resident's current condition for 1 of 6 residents (Resident #227) reviewed for Accidents. Specifically, for Resident #227, there was no documented evidence that comprehensive care plans were reviewed and/or revised to include safety interventions recommended by occupational therapy after a 1/18/2024 fall.The findings include:The policy titled Falls Standard of Care and Comprehensive Planning, reviewed 3/2019 documented care plans will be updated in the Electronic Medical Record as soon as the fall investigation is complete.Resident #227's diagnoses included Alzheimer's disease, dependence on renal dialysis, and history of falling.The quarterly Minimum Data Set, dated [DATE] documented Resident #227 was cognitively intact, required a wheelchair for ambulation and was dependent for toileting and transfers.…

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

Based on observations, record review and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) The facility did not provide adequate staffing to meet the needs of the residents, and as per their Facility assessment dated 6/2018 and revised on 4/9/2025; 2) Upon review of the nursing staffing schedule on 6/2/2024 (3pm-11pm), there were a total of 27 Certified Nurse Aides and a total of 5 Licensed Practical Nurses in the facility and the Facility Assessment documented that there must be 29-32 Certified Nurse Aides and 6-9 Licensed Practical Nurses in the building on the evening shift,; 3) On 12/8/2024(11pm-7am), there were a total of 21 Certified Nurses' Aides, and one nurse covered 2 units in which the Facility Assessment does not indicate that one nurse should cover more than one unit; 4) On 2/9/2025(3pm-11pm shift), there were a total of 24 Certified Nurse Aides…

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

Based on observations, record review and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that residents had the right to a dignified existence by promoting resident independence and dignity while dining for 1(Resident #6) of 3 residents observed for residents' rights. Specifically, Licensed Practical Nurse #7 was observed standing over Resident #6 while assisting them to eat their dinner. The findings are. The facility's policy titled residents rights dated 2//5/2021 documented resident have a right to dignified experience and be treated with respect, kindness, and dignity. Resident #7 was admitted with diagnoses including but not limited to Alzheimer's disease with late onset hemiplegia and hemiparesis, and dysphagia. The 3/23/25 Quarterly Minimum Data Set(MDS-an assessment tool) documented that Resident #6 had severely impaired cognition, and dependent with eating. On 5/14/25 at 6:01 pm, Licensed Practical Nurse #6 was observed standing over Resident #6 while assisting them to eat their dinner. During an interview on…

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 and interviews conducted during the Abbreviated Surveys (NY00342238 and NY00364422), the facility did not ensure that a facility-wide assessment was conducted to thoroughly assess the needs of its residents and to determine the required resources to provide the care and services to its residents during its day-to-day operations, did not address what is considered sufficient, particularly on the weekends, how the care required on a weekend shift is different than the care required on other shifts, and did not include behavioral health services necessary to meet resident needs. Additionally, the facility assessment did not have the date that it was reviewed with Quality Assurance and Performance Improvement (QAPI). Specifically, the Facility assessment dated 6/2018 and last revised on 5/12/2025 did not include the minimum staffing requirements for Certified Nurses' Aides and Licensed Practical Nurses and did not include the number of staff needed for behavioral healthcare and services, and the Facility assessment dated 6/2018 and last revised on 4/9/2025 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during an abbreviated survey (NY00318168), the facility did not ensure adequate supervision was provided and residents environment remained free of accidents hazards as possible for 1 of 3 residents reviewed for accidents. Specifically, on 6/10/2023, Resident #1 who had a wander guard in place exited the facility through the north hall exit undetected by staff. Resident #1 was found by staff outside the facility up the hill by the roadway and was returned to the facility by Nurse Care Supervisor. The north hall exit sensor did not alarm/sound when Resident #1 exited. The findings are: The Facility Electromagnetic System Policy created 6/1/2002 and last revised 3/2019 documented that the purpose is to prevent identified at risk residents from wandering into unsafe environments. Upon identification of high risk for elopement, an electronic wandering device anklet will be obtained and placed on the resident. Placement and function of transmitter(device) is monitored on…

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, staff and resident interviews conducted during the recertification survey from 6/1/2023 to 6/8/2023, the facility did not ensure the rights of citizenship, including the right to receive mail, were maintained for all residents. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. The findings are: During a group interview with the resident council held on 6/06/23 at 10:49 AM, 8 of 8 residents in attendance stated mail and packages were not delivered to them on Saturdays. During an observation of the Glenmere unit on 6/07/23 at 4:48 PM, there was a clear plastic file folder holder affixed to the wall outside the nurse care managers office with a few pieces of residents' mail still in it. During an interview on 6/06/23 at 11:54 AM, the Administrator stated residents did not get the mail on Saturdays, and mail was delivered Monday through Friday. The Administrator stated when packages arrived at the facility on the weekend, they were put in 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 interview conducted during the 6/1/2023 - 6/8/2023 recertification and abbreviated surveys (NY00301182, NY00298858), the facility did not ensure that all alleged violations involving an injury of unknown origin or allegations of abuse were reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence for 4 out of 5 residents (Resident #39, #55, #173 #175) reviewed for abuse. Specifically, 1)Resident #173 had left shin swelling and left ankle swelling identified on 3/15/23, an X-ray was completed on 3/16/23 and revealed an acute spiral fracture of the distal tibia, the incident was not reported to the NYSDOH. 2) Resident #175 sustained a fracture of unknown origin and the incident was not reported to the NYSDOH. 3) Resident #39 was observed with new bruising to right upper arm and complaints of pain, x-ray results revealed right acute spiral fracture proximal shaft of the humerus (arm), and the facility did not report this injury of unknown origin 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.

Based on record review and interview during the 6/1/2023 to 6/8/2023 recertification and abbreviated surveys (#NY00301182), the facility did not promptly notify the resident's representative of a need to alter treatment for 1 of 1 resident (Resident #39) reviewed for notification. Specifically, on 8/22/2022 Resident #39 was found to have new bruising and pain to their right upper right arm, x-rays were ordered, and there was no documented evidence that the resident's Health Care Proxy (HCP) was notified until 8/23/2022. Findings include: The facility policy on Injuries of Unknown Origin dated 4/2019, did not specify who was responsible to notify the resident representative when there was a change in condition or treatment. Resident #39 was admitted to the facility with diagnoses including hypertension, paraplegia, and non-Alzheimer's dementia. A Quarterly Minimum Data Set (MDS: an assessment tool) dated 6/1/2022, documented Resident #39 had moderately impaired cognition for decision making, was totally dependent with assist of 2 persons for bed mobility, transfer, dressing, toilet…

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 conducted during the recertification survey from 6/1/23 to 6/8/23, the facility did not ensure residents were free from physical restraints for 2 of 2 residents (#91 and #190) reviewed for physical restraints. Specifically, Resident #190 did not have a thorough restraint assessment and re-assessments were not completed to address the continued use of a lap tray while in the wheelchair, and for Resident # 91 the lap tray was not removed every 2 hours and with meals as ordered. Findings include: The facility policy and procedure titled Resident Restraints, revised on 03/2023, documented that residents maintain their highest practicable wellbeing while in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has a medical symptom that warrants the use of the restraints. The policy and procedure further documented the rehab therapist in conjunction with the nurse care…

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

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00298858) from 6/1/2023 to 6/8/2023, the facility did not ensure all alleged violations involving physical abuse including injuries of unknown source were thoroughly investigated and did not prevent the potential for further abuse while an investigation was in progress . This was evident for 2 out of 5 residents (Residents #55 and #173) reviewed for abuse. Specifically, 1) Certified Nurse Aide (CNA) #14 was accused of slapping Resident #55 and was not immediately removed from resident care while the investigation was in progress. 2) When an injury of unknown origin was identified for Resident #173, and then diagnosed as a spiral fracture of the distal tibia, there was no documented evidence that the incident was investigated. Findings include: The policy and procedure titled Accident incident revised 2/2014 documented it is the policy of the facility that an accident/ incident report will be initiated and completed for all accidents and incidents / purpose to perform a systemic…

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 recertification survey of 6/1/2023 - 6/8/23 the facility did not ensure that a Baseline Care Plan was developed and implemented within 48 hours for a resident admitted with an indwelling catheter. This was evident for 1 (Resident #211) of 3 residents reviewed for urinary catheter/urinary tract infection. Specifically, Resident #211's baseline care plan did not include the instructions needed and the physician orders for care of the resident's urinary indwelling catheter. The findings are: Resident #211 was admitted with diagnoses including Parkinson's disease, urinary tract infection, and benign prostatic hypertrophy. The admission Minimum Data Set (MDS, an assessment tool) dated 4/30/23 documented the resident had moderately impaired cognition and had an indwelling catheter. Physician's orders dated 4/26/23 included a Foley (Indwelling) Catheter to straight drainage, change every 4 weeks, irrigate the Foley as needed for obstruction, and Foley care every shift. Review of the record revealed no baseline care plan was found…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification survey from 06/01/23-06/08/23, the facility did not develop and implement a comprehensive person-centered care plan for 1 of 2 residents (Resident #54) reviewed for pressure ulcers. Specifically, Resident #54 did not have a care plan developed to address a Stage 4 pressure ulcer. The Findings are: The policy and procedure titled Comprehensive Care Plan Process, revised 7/2015, documented the interdisciplinary team was responsible for the development of resident care plans. Resident #54 was admitted with diagnoses of Alzheimer's Disease functional Quadriplegia and hypertension. The quarterly Minimum Data Sheet (MDS, an assessment tool) dated 10/30/2022 did not document any pressure ulcers. The annual MDS assessment dated [DATE] documented there was one unhealed Stage 4 pressure ulcer. The resident had severe cognitive impairment and needed total assistance of 2 persons for bed mobility, transfers, dressing and was incontinent of bowel 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 observations, record reviews, and interviews conducted during the recertification survey 6/1/23-6/8/23, the facility did not ensure 1 (Resident #54) of 2 residents reviewed for pressure ulcers received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #54 had a Stage 4 pressure ulcer and interventions were not implemented as ordered. The findings are: Resident #54 was admitted with diagnoses including Alzheimer's Disease, Functional Quadriplegia, and a pressure ulcer on sacrum. The Minimum Data Set (MDS, an assessment tool) quarterly assessment, dated 10/30/22, did not document any pressure ulcers. The MDS annual assessment, dated 1/29/2023, documented there was one unhealed pressure ulcer, Stage 4. The resident had severe cognitive impairment and needed total assistance of 2 persons for bed mobility, transfers, dressing and incontinent of bowel and bladder. The physician order dated 3/9/2023 included a bed cradle to the foot of bed at all times when in bed and the nurse was to check for placement. The 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.

Based on observations, record review and interviews during the recertification survey from 6/1/23-6/8/23, the facility did not ensure the resident environment remained free of accident hazards and each resident received adequate supervision to prevent accidents for 1 (Resident #182) of 3 residents reviewed for accidents. Specifically, Resident #182, with a history of wandering, was not provided supervision to prevent the ingestion of medicated cream and the resident's level of supervision was not reassessed for ongoing unsafe wandering. The findings are: Resident #182 had diagnoses including Alzheimer's disease, anxiety, depression and wandering. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 5/28/23 documented the resident had severe cognitive impairment and received supervision for ambulation. The facility policy Resident Safety dated 3/19 documents residents who are assessed to need close supervision related to dementia or other related neurological conditions or history of wandering will wear light weight ankle bracelet which contains a radio transmitter. 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 interview during the 6/1/2023 to 6/8/2023 recertification survey, the facility did not ensure for 1 of 3 residents (Resident #211) reviewed for urinary catheter or urinary tract infection (UTI) that a urinary indwelling (Foley) catheter was discontinued as soon as it was clinically possible. Specifically, Resident #211 was admitted to the facility with a Foley catheter for a diagnosis of other retention of urine and no services were provided to the resident in order to restore or improve as much bladder function to the extent possible. The findings are: Resident #211 was admitted on [DATE] with diagnoses Parkinson's Disease, urinary tract infection, and benign prostatic hypertrophy. The admission Minimum Data Set (MDS, an assessment tool) dated 4/30/23 documented the resident had moderately impaired cognition and had an indwelling catheter. The resident's care plan, dated 5/2/23, documented the resident had an indwelling catheter and UTI with interventions to handle catheter with care,…

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 reviews and interviews during a recertification survey, the facility did not ensure drugs and biologicals were stored in locked compartments for 2 of 3 residents (Residents #72 and #128) reviewed for medication storage. Specifically, 1) medicated creams and ointments for Resident #72 were found in a dresser drawer and 2) medicated powder was observed on a dresser top in Resident #128 room. Both residents were on units with other resident who had known wandering behaviors. The findings are: 1)Resident # 72 had diagnoses including dementia, psychosis, and candidiasis (yeast infection). The physician order dated 5/30/23 documented orders for Nystatin topical ointment and Triamcinolone acetonide topical ointment to be applied three times a day for 14 days to penis and scrotum after washing/drying. An observation was made on tour with the Registered Nurse Unit Manager (RNUM) #2 on 6/8/23 at 9:40 AM and Nystatin ointment and Triamcinolone ointment were found in Resident #72's bedside table. When interviewed during the observation, RNUM#2 stated it was not…

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 recertification survey, the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 8 out of 8 residents from that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack, they were not provided with an evening snack. The findings are: The policy and procedure titled Resident Nourishments revised 8/2020 documented nourishments will be made available to those residents requiring additional calories, protein and other nutrients to promote weight maintenance/gain, nutritional status and skin integrity. Nourishments will be delivered to the unit by the food service helper and placed directly into the unit refrigerator/freezer. During flu season or other contagious outbreaks, the nourishments will be delivered on the top of the breakfast and lunch meal carts. Nursing staff will take the snack trays and place them in the unit refrigerators.…

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 a recertification survey from 6/1/23-6/8/23, the facility did not ensure that Infection Control practices and procedures were maintained. Specifically, 1) Staff did not practice proper hand hygiene during a pressure ulcer dressing change for Resident #54 and contaminated the clean dressing field with dirty gloves, 2) A dirty linen cart was positioned next to a clean linen cart on the Echo unit, and 3) Resident #211's Foley catheter was observed on the floor without the use of a barrier. Findings include: 1) Resident #54 had diagnoses including Alzheimer's dementia and a Stage 4 pressure ulcer to sacrum. The physician orders dated 3/31/23 documented the treatment for the sacrococcygeal wound and new partial thickness wound on the left buttocks was to cleanse with sterile water and pat dry, apply skin prep to peri-wound skin, loosely pack wound bed only with fibracol, cover both wounds with large gentle border Allevyn dressing. The facility policy 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.

Based on interview and record review conducted during the recertification survey, the facility did not ensure that staff received proper training to provide competent care for 1 resident (Resident #314) reviewed for safe transfer using a sliding Board. Specifically, the facility did not provide evidence to show that 2 Certified Nursing Assistants (CNAs) were trained effectively on how to transfer a resident out of bed with a sliding board. The findings are: Resident #314 was admitted with diagnoses that included; nondisplaced bicondylar fracture of the left tibia and hemiplegia. The admission Minimum Data Set (MDS- an assessment tool) dated 6/6/19 documented that the resident required extensive physical assistance of two persons for transfer. Review of the Accident/ Incident report dated 7/14/19 indicated that Resident #314 was being transferred from bed to wheel chair with a sliding board by two CNAs. The resident sustained a laceration to her left lower leg and was transferred to the emergency room for evaluation. On 8/7/19 at 11:45 AM CNA #6 was interviewed regarding the…

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

Based on observation, interviews and record review, the facility did not ensure that an effective pest control program was in place. Specifically, gnats were found in the kitchen dry storage room. Chapter 1 of the State Sanitary Code, subpart 14-1, states the premises are to be free from insects, rodents, harborage, and insect or rodent breeding conditions. The findings are: A follow up tour of the kitchen conducted on 8/05/19 at 2:25 PM revealed: The kitchen dry storage room contained a tray rack holding 6 trays of bananas which were surrounded by a multitude of gnats. The FSD (food service director) was interviewed at that time and reported she had not had a recent problem with gnats; she would speak to the exterminator about it and she was going to discard the bananas. An interview with the Director of Housekeeping (DH) conducted on 8/06/19 at 11:20 AM revealed he was not aware there were gnats in the kitchen dry storage room. Then, without observing the dry storage room, the DH further stated they are not gnats, they are drain flies, and the facility has been using fly lights to…

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

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff documented specific instructions or implemented interventions on the use of seat belts for safety and prevention of falls. This was evident for 1 resident (Residents # 172) reviewed for restraints. Specifically, 1. Residents # 172 - no specific instructions were provided in the care guide on the use of a Velcro seat belt. The findings are: 1. Resident # 172 had diagnoses and conditions including Alzheimer's Disease, Generalized Anxiety, and History of Falls. According to the 6/16/19 Quarterly Minimum Data Set ( MDS; an assessment tool) the resident had severely impaired cognition and required extensive assistance for activities of daily living (ADLs). A medical note dated 3/29/19 documented the resident was evaluated following a fall from his wheelchair. Recommendations included foot pedals and a seat belt to prevent falling forward. An occupational therapy progress note dated 3/29/19 documented that the resident was assessed and provided with 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 record review and interview conducted during the recertification survey, the facility did not ensure that the care plan was updated and did not develop appropriate interventions to address changes in the resident's current health status. Specifically , a care plan for constipation was not revised to address issues related to a resident's hospitalization. This was evident for 1 resident reviewed for quality of care. (Resident #269). The findings are: Resident #269 was admitted with diagnoses including fecal impaction and slow transit constipation. The Minimum Data Set ( MDS- a resident assessment and screening tool) dated 4/27/19 documented that the resident had mild cognitive impairment but was capable of making decisions and was frequently incontinent of bowel. The physician's orders dated 9/8/18 included fleet enema pr (per rectum) q 3 days prn(as needed) and the following medications were prescribed for the treatment of constipation; Miralax 17 grams daily, Senna 8.6 mg 2 tabs daily and MOM (milk of magnesia) 30 ml daily prn. The Medication Administration Records (MARs)…

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

Based on record review and interview conducted during the recertification survey the facility did not ensure that care was provided in accordance with professional standards of practice. Specifically , the physician's orders for the treatment of constipation were not consistently implemented. This was evident for 1 resident reviewed for hospitalization. (Resident #269). The findings are: Resident #269 was admitted with diagnoses including; fecal impaction, slow transit constipation and congestive heart failure. The Minimum Data Set ( MDS- a resident assessment and screening tool) dated 4/27/19 documented the resident had cognitive impairment but was capable of making decisions. It further documented that he was frequently incontinent of bowel. The physician's orders dated 9/8/18 included fleet enema pr (per rectum) q 3 prn (as needed) and the following medications were prescribed for the treatment of constipation, Miralax 17 grams daily, Senna 8.6 mg 2 tabs daily, and MOM (milk of magnesia) 30 ml daily prn. The Medication Administration Records (MARs) for April 2019 and May 2019…

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 the recertification survey, it cannot be ensured that the facility's environment remained as free of accidents as possible, Specifically 2 of 2 residents (Residents #159 and #314) reviewed for accidents. The findings are: 1. Resident #159 is a 63year old male was admitted to the facility on [DATE] from an acute hospital stay. Resident #159 has diagnoses that include cerebral infarction due to embolism of right cerebral artery, Hemiplegia, Type 2 Diabetes Mellitus. Based on admission Minimum Data Set (MDS - a resident assessment tool) completed on 6/11/2019, Resident #159 requires extensive assistance of 2 persons for Bed mobility, Toilet use, Bathing, and Transfer. He also requires extensive assistance of 1 person for Locomotion on unit, personal hygiene and dressing. He requires total dependence of 1 person for Locomotion off unit. Resident #159 also has frequent incontinence of Bowel and bladder functions. The Fall care plan dated 5/29/2019…

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 observation conducted during the recertification survey, the facility did not ensure adequate holding temperatures for cold foods in accordance with professional standards of food safety practice. According to the Food Safety and Inspection Service of the US Department of Agriculture (www.fsis.usda.gov), cold foods should be held at or below 40 degrees Fahrenheit (F) and placed in containers on ice. The findings are: Temperatures of cold foods held for service on the serving line were checked by the Food Service Supervisor (FSS) on 8/06/19 at about 12:20 PM and the following was observed: - individual yogurt 54 degrees F - 4-ounce Lactaid Milk 55.5 degrees F - 8-ounce low fat chocolate milk 53 degrees F - 4-ounce nectar chocolate milk 56.2 degrees - chicken salad sandwich 54 degrees F - ham salad sandwich 54 degrees F At that time, the FSS was interviewed and reported she will be making changes to ensure cold foods are maintained at acceptable temperatures. 415.14

Based on observation and interview conducted during the recertification survey, the facility did not ensure proper storage, preparation, distribution and service of food in accordance with professional standards for food safety. Specifically, 1. the facility did not ensure food contact equipment and kitchenware were maintained in sanitary condition, and 2. the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than required by the manufacturer. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated. The findings are: A follow up tour of the kitchen conducted on 8/05/19 at 2:25 PM revealed: 1. In the dry storage room the following were observed: -22 bins ranging in size from 22-42 gallons were in use for dry storage. -14 of 22 bins had sliding lids which were soiled with an accumulation of dried debris. -5 of 22 bins were soiled on the exterior surface with sticky-to-touch brown-ish and black-ish colored residue. -2 of 22 bins were soiled 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.

Based on observation, interview, and record review conducted during the recertification survey, the facility did not provide a safe, sanitary environment to help prevent the transmission and development of communicable diseases and infections. Specifically, 1) the facility did not ensure that the potable water system was tested as required by public health laws and regulations, to determine the presence of Legionella and/or other opportunistic waterborne pathogens and 2) the facility did not ensure that staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 3 residents (Residents #24, #46, and #196) observed during the lunch meal observation. The findings are: 1. Review of the facility's water management plan revealed no documented evidence that its potable water system was tested, as required by public health laws and regulations to determine the presence of Legionella and/or other opportunistic waterborne pathogens. The Director of Plant Operation (DPO) was interviewed on 8/9/19 at 1:45PM, in the presence of the Administrator, and stated…

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 observations conducted during the recertification survey, the facility did not ensure that residents consistently had a means of directly contacting staff for assistance. The findings are: - 08/08/19 at 10:42 AM during random observations, resident room [ROOM NUMBER] bed A call bell was tested and found to be non-functioning and the wall cover plate was missing. - 08/08/19 at 12:01 PM room [ROOM NUMBER] bed A call bell was tested and the call light soft pad was found to be non-functioning. The registered nurse manager (RNM) was interviewed on that date at 11:52 AM regarding the procedure for reporting environmental /equipment issues and she stated that staff are required to enter a work order when there are problems with equipment. 415.29