Northern Riverview Health Care, Inc

Based on observation, record review, and interviews conducted during the Abbreviated Survey (2695368), the facility did not ensure adequate supervision and implementation of an identified intervention for one (Resident #1) of three residents reviewed for injury of unknown origin. Specifically, Resident #1, who resided on a secure unit, required supervision with ambulation and had a history of wandering and falls, was found on 12/10/2025 with a hematoma to the forehead of unknown origin. Following the incident, enhanced monitoring for safety was initiated on 12/10/2025, however, the facility was unable to demonstrate consistent implementation of the enhanced monitoring intervention. The facility provided incomplete enhanced monitoring documentation from 12/15/2025 through 01/10/2026 which contained missing staff signatures and lacked supervisory review.The findings are:The facility policy titled Safety and Supervision of Residents, revised on 02/01/2024, documented that facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach 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 record review and interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that the resident's family representative was notified of a change in condition for one (Resident #1) of three residents reviewed for notification of changes. Specifically, on 08/29/2025, Resident #1's family representative observed redness to Resident #1's right eye. The Family representative reported the observation to facility staff and was informed that the redness was due to an allergic reaction to medication the issue had already been addressed by the physician. There was no documented evidence that nursing staff identified or assessed the redness prior to the family representative' observation. There was no documented evidence that the resident's representatives were notified of the change in condition prior to the report from the family representative.The findings include: The facility policy titled Notification of Change, revised 07/07/2025, stated that the nurse will notify the resident, resident representative, and the resident's physician promptly of…

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

Based on record review and interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that all alleged violations involving abuse and neglect are reported not immediately but not later than 2 hours after the allegation is made if the events that caused the allegation involve abuse or results in serious bodily injury, or not later than 24hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency for one (1) resident (Resident #1) of three (3) reviewed for abuse. Specifically, on 09/12/2025, Resident #1's family representative informed the facility that Resident #1 had been punched in the face by another resident. The facility's investigation form and progress notes revealed that a report was received on 09/12/2025 from the family representative and an investigation was initiated on 09/13/2025. There was no documented evidence that the allegation was reported to the New York State Department of Health or local law enforcement. 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 conducted during an abbreviated survey (2622688), the facility did not report to the State Agency an alleged violation of abuse against a resident who is receiving care from the facility no later than 24hours if the events that cause the suspicion did not result in serious bodily injury for one(1) Resident #1 of three (3) residents reviewed for abuse. Specifically, on 09/12/2025, Resident #1's family representative informed the facility that Resident #1 was punched in the face by a peer. The facility's investigation form and progress notes revealed the report from the family representative was received on 09/12/2025 receiving the information from the family representative. The Facility provided documentation of an investigation initiated on 9/17/2025. There was no documented evidence that the allegation was reported to the New York State Department of Health or local law enforcement. The Facility did not report the results of the investigation within 5 working days of the incident.The findings include: The Facility's Abuse Policy revised 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during the Abbreviated Survey (2622688), the facility did not ensure that Resident #1's Comprehensive Care Plan was revised to include measurable, resident-specific interventions specifically reflecting a change in condition involving right-eye redness that resulted in the initiation of antibiotic eye drops. Specifically, Ciprofloxacin(antibiotic) ophthalmic drops were ordered on 08/29/2025 and initiated on 08/30/2025 for the resident's right-eye redness. The Comprehensive Care Plan was not revised to include interventions related to the new treatment and the change in condition. Resident #1's comprehensive care plan interventions was last update 01/23/2025 which addressed a prior influenza related infection. There was no documented evidence of the current condition reported on 08/29/2025. The findings are: The facility's policy titled Care Plans - Comprehensive (revised 10/2019 and reviewed 08/02/2024) documented, Assessments of residents are ongoing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the Abbreviated Survey (# 2622688), the facility did not ensure that necessary care and services were provided to maintain the resident's highest practicable physical well-being for one (Resident #1) of three (3) residents reviewed for abuse. Specifically, on 08/29/2025, Resident #1's family representative reported redness to Resident #1's right eye to nursing staff. The family representative stated that nursing staff told them the condition was already addressed. Record review revealed was no documented nursing assessment, a change-in-condition evaluation or a physician notification. There was no documentation that staff identified the redness prior to the family representative report. Ciprofloxacin ophthalmic (antibiotic) eye drop was ordered on 08/29/2025 and initiated on 08/30/2025 with no documented clinical rationale for the treatment. There was no registered nurse assessment or a physician evaluation at the time the order was placed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an Abbreviated Survey (2622688), the facility did not ensure physician supervision oversight of medical care for one (Resident #1) of (3) three residents reviewed for physician services. Specifically, an order for ciprofloxacin(antibiotic) eye drops was ordered for Resident #1's right eye on 08/29/2025 after redness was reported by family representative. There was no documented physician assessment or nursing assessment at the time the order was entered. The treatment began 08/30/2025, and Resident #1 was not evaluated by a medical provider until 09/04/2025 six days after the change in condition was identified and after treatment had already been initiated.The findings include:The facility policy titled Physician Services, revised 05/2019 documented that a physician shall review and document orders for the care and treatment of residents and shall evaluate residents as clinically indicated. The policy also stated that all verbal orders must be authenticated…

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 reviews and interviews during an abbreviated survey (NY00355946, NY00334577, NY00336626), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility also did not report the results of all investigations to the New York State Department of Health in accordance with State law, within 5 working days of the incident for 3 out of 3 residents (Resident #1, Resident #3, Resident #5) reviewed for abuse. Specifically, (1) on 9/27/2024 Resident #1 reported to their representative that staff had beat them up while in the dining room the day before. The Administrator was not made aware of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews during an abbreviated survey (NY00355946, NY00334577), the facility did not ensure the comprehensive care plan was updated and revised for 3 out of 3 residents (Resident #1, Resident #3, Resident #4) reviewed for care planning. Specifically, (1) On 9/27/2024 Resident #1 reported to their representative that they were beaten on 9/26/2024 by staff in the dining room. Review of Resident #1's abuse care plan revealed it was not updated to reflect the allegation of abuse (2) On 3/26/2024 Resident #4 exposed themself to Resident #3. Resident #3's abuse care plan was not updated to reflect this allegation and Resident #4's behavior care plan was not updated to reflect their behavior. The findings are: The facility Comprehensive Care Plan policy last reviewed 8/2/2024 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00373143, NY00352914), the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal care for 2 out of 3 residents (Resident #2, Resident #7) reviewed for activities of daily living. Specifically, (1) Resident #2 had a known history of bladder and bowel incontinence and was dependent for toileting. Review of Resident #2's Certified Nurse Assistant documentation for June 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff was not provided on 5 occasions. Review of Resident #2's Certified Nurse Assistant documentation for July 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff,on 7 occasions; (2) Resident #7 had a known history of bladder and bowel incontinence and was dependent for toileting. Review of Resident #7's Certified Nurse Assistant documentation for July 2024…

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

Based on record review and interview during an abbreviated survey (NY00373143) the facility did not ensure that sufficient nursing staff was consistent for residents according to the daily staffing needs. Certified nurse aide staff levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the facility daily staffing sheets for July 2024 and August 2024 revealed staffing was not adequate across various shifts, on the first floor, based on the unit needs and provider average ratio levels documented in the facility assessment. The findings are: The facility Staffing Hours policy last revised 4/2025 documented the facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Certified nurseing assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00334577) the facility did not ensure the residents right to a dignified existence inside the facility for 1 out of 3 residents (Resident #3) reviewed for dignity. Specifically, on 2/26/2024 Resident #4 who was Resident #3's neighbor, went to Resident #3's room unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and crying about Resident #4's behavior. The Findings are: The facility Residents Rights policy last revised 5/28/2024 documented Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, to be treated with respect, kindness, and dignity and be free from abuse, neglect, misappropriation of property, and exploitation. Resident #3 was admitted with diagnoses including but not limited to Dementia, Major Depressive Disorder and Personal History of COVID-19. Review of an admission Minimum Data Set, dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00334577), the facility did not ensure the residents right to be free from abuse for 1 out of 3 residents (Resident #3) reviewed for abuse. Specifically, on 2/26/2024 Resident #4, who was Resident #3's neighbor, went to Resident #3's room unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and was crying about Resident #4's behavior and verbalized a fear of being raped. Subsequently, Resident #3's room was changed to another unit. The findings are: The facility Abuse policy last reviewed 6/1/2024 documented the facility prohibits the mistreatment, neglect and abuse of residents/patients by anyone but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient…

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 and abbreviated surveys (NY00328066) from 2/12/24 to 2/27/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during confidential interviews and the group meeting that the facility was short staffed at times especially at night and on the weekends, there was a lack of timely staff response to call bells, and some stated that they smelled urine odors, 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions from January 13, 2024 through February 15, 2024, the facility was below the minimum levels documented on the Facility Assessment. Findings include: On 2/12/24 at 10:36 AM, Resident #92 stated they got a shower today after a month, and that the facility needed more help/needed to hire people. On 2/12/2024 at 10:21 AM, Resident #475 stated they have waited too long to be…

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

Based on observation, record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID). This was evident for 5 of 35 residents reviewed. Specially, Residents #34, #151, #105, #79, and #117 did not have the required pre-admission screening and resident review assessment completed prior to their admission to the facility. The findings are: The facility policy and procedure entitled PASARR/Screens last revised 12/2019 documented that prior to every resident's admission to the facility, they would have completed a level 1 pre-admission screening and resident review screen to ensure the residents are appropriate for the facility. In addition, residents that are identified with serious mental illness or intellectual disability would have a completed level 2 pre-admission screening and resident review screen. The facility will protect the rights of the residents with mental illness and/or intellectual disabilities by ensuring the delivery…

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 reviews and interviews during the Recertification Survey from 2/12/24 to 2/27/24, the facility did not ensure that Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, performance evaluations were not conducted every 12 months for 9 of 10 Certified Nurse Aides (Staff #13, 14, 15,16,16, 38, 39, 40, and 41) records reviewed. The findings are: Facility documentation revealed the most recent performance evaluation for: - Staff #13 was dated 10/12/15. - Staff #14 was dated 1/14/15. - Staff #15 was dated 1/14/15. - Staff #16 was dated 10/12/15. - Staff #17 was dated 2/22/18. There was no documented evidence of any performance evaluations for Staff #38, 39, 40, and 41. On 2/15/2024 at 3:45 PM, the Human Resources Director stated they could not locate any current performance evaluations, and that perhaps the Certified Nurse Aide performance evaluations were located in the Director of Nursing office. On 2/15/2024 at 3:56 PM, the Director of Nursing stated they did the performance reviews annually in February. The Director 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 observation, interview and record review during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that they store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were baking sheets on the floor in the kitchen, garbage was placed on top of a cart next to a pan storage rack with a whisk touching the garbage bags, thermometers used for food thermometers were not sanitized properly, sanitizer logs were not completed, a dining room resident refrigerator, freezer thermometer, was not working and resident's personal food items were not dated and labeled appropriately. Findings include: During a walk-through observation and interview with the Food Service Director on 02/12/24 at 09:56 AM, there were 4 baking pans on the floor in between equipment in the kitchen. The Food Service Director picked the baking pans up and stated they did not know why they were there. A cart with clear bags filled with garbage on top of it was observed in the middle of kitchen, near the red meat pans. 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 during the recertification survey 2/12/24 to 2/27/24, the facility did not ensure each resident was offered influenza and/or pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 4 (Residents #63, #96, #165 and #168) of 5 residents reviewed. Specifically, the facility did not ensure, Resident #63 was screened properly for influenza immunization, and/or Residents #96, #165, and #168 were screened for eligibility, offered and educated about pneumococcal immunizations. This was evidenced by: The facility policy titled Resident Immunizations dated 9/1/23 documented the facility will offer immunizations to residents who consent to aid in the prevention of infectious diseases/conditions in accordance with the Centers for Disease Control and Prevention (CDC) and the Advisory Committee for Immunization Practices. The facility policy for Pneumococcal Vaccination dated 5/23/23 documented prior to or within 5 working days after admission residents will be assessed for eligibility 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 record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, it was determined for 1 of 7 residents (Resident #151) reviewed for dignity, the facility did not ensure all residents had the right to a dignified existence. Specifically, Resident #151 reported Staff #35 (Certified Nurse Aide) spoke to her in a derogatory manner on more than one occasion and Staff #35 was observed stating please to Resident #151 after Resident #151 made two requests for ice. Findings include: Resident #151 was admitted with diagnoses including Heart Failure, Non-Alzheimer's Dementia, and Adjustment Disorder. The 8/1/23 comprehensive care plan titled 'At Risk for Abuse' documented the resident was at risk for misappropriation, neglect, abuse and or exploitation. Interventions included monitor the resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to the facility's abuse officer and medical provider; refer for psychiatric evaluation and follow-up if indicated; and refer for psychology evaluation and ongoing services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure residents rights to a safe, comfortable, home-like environment for 1 of 4 residents (Resident #114) observed during dining. Specifically, Resident #114 was not provided an overbed table and was observed eating their lunch meal which was placed on a chair in their room. On another occasion, the resident was observed lying in bed and staff placed the resident's food tray on their bed by their feet. Findings include: Resident #114 was admitted to the facility with a diagnosis and conditions of but not limited to Encephalopathy, Dementia and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe cognitive impairment and required substantial/maximal assistance with eating. During an observation on 02/14/24 at 12:37 PM Resident #114 was eating their lunch meal from a tray that had been placed on a chair next to the bed. During an observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview during the recertification and abbreviated surveys (NY00330459) from 2/12/24 to 2/27/24, the facility did not ensure that all alleged violations involving abuse and neglect were reported and/or reported timely to The New York State Department of Health for 2 of 3 residents reviewed for abuse and/or misappropriation (Residents #129 and #156). Specifically, 1) the facility did notify the New York State Dept of Health when Resident #80 pushed Resident #129 to the floor resulting in Resident #129 hitting their head requiring medical evaluation; and (2) the facility did not notify the New York State Department of Health timely when Resident #156's wallet and cell phone were stolen. Findings include: 1) 1) Resident #129 admitted with diagnoses that included dementia, muscle weakness, and difficulty walking. The Annual Minimum Data Set (an assessment tool) dated 11/7/23 documented Resident #129's cognition was severely impaired and no documented behavioral symptoms.…

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 recertification survey from 2/12/24 to 2/27/24, the facility did not notify the ombudsman for 1 of 2 residents (Resident # 105) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility could not provide evidence that notification was sent to the ombudsman. The findings are: Resident #105 was admitted with diagnoses which included Diabetes Mellitus, Alzheimer's Disease, Dementia. The discharge Minimum Data Set assessment dated [DATE] documented the resident had an unplanned discharge, return anticipated. On 2/23/24 at 4:20 PM during an interview with the Director of Social Work, they stated they were not responsible for notifying the ombudsman of resident's transfers. On 2/27/24 at 8:37 AM during an interview the Ombudsman stated they did not receive notification that Resident #105 was transferred to the hospital on [DATE]. On 2/27/24 at 1:16 PM during an interview with the Administrator, they stated the…

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

Based on observations record review and interviews, during the recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 of 4 residents reviewed for accidents. Specifically, Resident #129 was involeved in a resident-to-resident altercation on 1/25/24 and the Behavior and Abuse Care Plans were not revised and/or updated to reflect new interventions to prevent reoccurrences. The findings are: Resident #129 was admitted with diagnoses that included non-Alzheimer's dementia, muscle weakness, and difficulty walking. The Annual Minimum Data Set (an assessment tool) dated 11/7/23 documented Resident #129's cognition was severely impaired and the resident exhibited no documented behavioral symptoms. Facility Accident/Incident investigation for Resident #129 dated 1/25/24 documented that a Certified Nurse Aide observed Resident #129 being pushed to the floor by their roommate, Resident #80. Resident was transferred to emergency room for evaluation. There was no documented evidence 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, record review, and interviews conducted during the Recertification and Abbreviated surveys (NY00320687) from 2/12/24 to 2/27/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #64) reviewed for antibiotic use. Specifically, Resident #64 did not receive intravenous antibiotic medication Meropenem as ordered by the medical provider at 12 AM, 6 AM, 12 PM and 6 PM on 7/22/2023 and the medical provider was not notified. Findings include: Policy and Procedure Admission, readmission revised 9/2022 documented it is the philosophy of the Facility to admit residents 24 hours per day, 7 days a week, based upon a clinical decision that considers the resident's needs, the Facility's ability to meet those needs. Policy and Procedure medication Administration revised 12/2019 documented medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that each resident received adequate supervision and that the environment remained as free from accidents as possible for 1 out of 4 residents (Resident #114) observed during dining. Specifically, supervision during meal intake was not provided as per care plan and staff did not ensure the resindent remained upright for 30 minutes after meals as per speech pathologist recommendation for Resident #114 with aspiration precautions. Findings include: Resident #114 was admitted to the facility with a diagnoses including dysphagia, dementia and depression. The care plan dated 10/1/21, documented the resident had potential for aspiration related to dysphagia. Interventions included to encourage resident to be out of bed for meals, keep/maintain upright sitting position when assisting resident with meals and at least 30 min after meal. Resident must be supervised for all intake solid or…

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 conducted 2/12/24 to 2/27/24, the facility did not ensure each resident was offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 2 of 5 residents (Resident #165, #168) reviewed for infection control. Specifically, there was no documented evidence Resident #165, #168 was offered, declined, and/or were educated about the COVID-19 vaccination. Findings include: The facility policy titled COVID Vaccine: Residents and Healthcare Personnel, dated 12/4/23, documented upon admission/readmission, the facility shall obtain COVID 19 vaccine history to all extent possible and COVID 19 vaccine will be offered, promoted and encouraged to eligible residents and Healthcare Personnel. Prior to offering the vaccine Healthcare Personnel, residents or their representatives should be provided education regarding the vaccine. The Healthcare Personnel, residents, or their…

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 and abbreviated surveys (NY00324940 and NY00295143) from 2/12/24 to 2/27/24, it was determined for 2 of 5 residents (Residents # 274 and 224) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation of the completion of a thorough investigation and timely resolution of the residents' reports of missing chains with pendants. The findings are: The facility Policy and Procedure titled Grievances reviewed 2/1/23 documented that the facility would assist residents, representatives, family members, or resident advocates in filing a grievance/concern form when concerns are expressed, and the facility will investigate and resolve resident grievances in a timely manner to ensure resident's safety and protection of residents' rights. 1. Resident #274 was admitted with diagnoses including Diabetes Mellitus and a mental disorder. The Concern/Grievance-Resident Notification Summary dated 4/15/2022 documented 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 reviews and interview during recertification and abbreviated surveys (NY00321475) from 2/12/24 to 2/27/24, the facility did not ensure a resident who was unable to carry out activities of daily living received services and assistance to maintain good personal hygiene for 1 out of 9 residents (Resident #234) reviewed for activities of daily living. Specifically, there was no documented evidence that colostomy care, bed baths, hoyer lift transfer and bladder incontinence care were consistently provided for Resident #234 as per physician order and/or the comprehensive care plan. Findings include: Resident #234 was admitted to the facility with diagnoses including intellectual disabilities, schizoaffective disorder and obstructive uropathy. The quarterly Minimum Data Set (an assessment tool) dated 7/3/2023, documented a Brief Interview for Mental Status score of 10 (moderate cognitive impairment), inattentive and disorganized thinking at times. The resident had a colostomy and was totally dependent…

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 a recertification and an abbreviated survey (NY00259391) conducted from 10/19/2020 through 10/26/2020 it could not be ensured that the facility reported timely or thoroughly investigated all alleged violations involving abuse, neglect or mistreatment for 1 of 2 residents (Resident #118) reviewed. Specifically, Resident #118 sustained a laceration on his right hand after an interaction with a staff member. Supporting evidence to rule out abuse/neglect or evidence confirming that the incident was reported timely to the New York State Department of Health (NYSDOH) was not available for review despite several requests. The findings are: Resident #118 was admitted to the facility on [DATE] with diagnoses including Alcohol Dependence with Withdrawal, Cellulitis of Limb, and Major Depressive Disorder. According to the 6/25/2020 Annual Minimum Data Set (MDS; an assessment tool), the resident had a Brief Interview Mental Status (BIMS) score of 15/15 indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during a recertification survey it could not be ensured that the facility notified all residents or the residents' representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This was evident for 1 of 2 (Resident #140) residents reviewed for Hospitalization. The findings are: The facility policy and procedure titled, Discharge-Summary dated 9/2017 and revised 8/2019, describes the policy for anticipated discharges which includes writing a discharge summary and a post discharge plan. No policy or procedure was available for review regarding notification of unanticipated transfers and discharges. The facility Notice of Transfer/Discharge form was reviewed, which is completed by the nursing department at the time of an unanticipated transfer/discharge. Resident #140 was originally admitted to the facility on [DATE], was discharged to the hospital on [DATE] and readmitted on [DATE] with diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during a recertification survey, it cannot be ensured that the facility provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s). This was evident for 1 of 2 residents (Resident #140) reviewed for Hospitalization. The facility policy and procedure titled Bed Hold dated 3/2018 and revised 7/2019, documents the facility will provide written information regarding the bed-hold and return policy upon admission and prior to/at the time of hospitalizations or therapeutic leaves as soon as practicable following an emergency transfer. The findings are: Resident #140 was originally admitted to the facility on [DATE], was discharged to the hospital on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia, Hemiparesis, Dysphagia, Dependence on Renal Dialysis, and Diabetes. The Minimum Data Set (MDS; an assessment tool) dated 10/8/2020 documented that the resident has moderately impaired cognition and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility provided the appropriate treatment and services to improve and /or prevent further decline in range of motion (ROM). Specifically, 1 of 4 residents (Resident # 29) reviewed for limited Range of Motion (ROM) did not have bilateral hand rolls in place to prevent further joint contracture as ordered by the physician. The findings are: Resident # 29 was admitted to the facility on [DATE]. Diagnoses included, but not limited to Quadriplegia, Generalized Muscle Weakness, Non-Traumatic Subarachnoid Hemorrhage, and Disorder of the Autonomic Nervous System. The 8/4/2020 Annual Minimum Data Set (MDS; an assessment tool) showed the resident's Brief Interview Mental Status (BIMS) could not be conducted and the resident required total dependence on staff with activities of daily living (ADLs). On surveyor observation, the resident was not responsive to verbal stimuli. Physician orders dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a recertification survey it could not be ensured that the facility staff followed proper hand hygiene and gloving techniques to prevent cross contamination and the spread of infection for 2 of 3 residents (Residents #113 and #115) reviewed for pressure ulcers. Specifically, 1) cross contamination of wound/wound supplies was observed during dressing change and 2) hand hygiene after removal of used gloves was not observed during wound care. The findings are: 1. Resident #113 was admitted to the facility on [DATE] with diagnoses including Major Depression, Generalized Muscle Weakness and Pressure Ulcer. The 7/1/2020 Annual Minimum Data Set (MDS; an assessment tool) showed the resident as experiencing moderately impaired cognition, requiring extensive assistance of staff support with Activities of Daily Living (ADLs) and at risk for Pressure Ulcers (PUs). Alteration in Skin Integrity Care Plan updated 10/1/2020, documented that the resident had 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.