Hudson Valley Rehabilitation & Extended Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification and abbreviate survey (#2677034) the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for three (3) of seven (7) residents (Resident #15, Resident #115, and Resident #18) reviewed for activities of daily living. Specifically, 1) Resident #15's resident representative stated they observed Resident #15 double briefed on 02/08/2026 2), Resident #115 was observed double briefed on 02/19/2026, and 3) Resident #18 was observed on multiple occasions with poor oral hygiene. The findings include: A policy titled Activities of Daily Living last reviewed 09/04/2025 documented the purpose to ensure that all residents receive safe, appropriate, and consistent assistance with Activities of Daily Living (ADLs) while preserving dignity, promoting independence, and following individualized care plans. Certified nurse aides shall provide assistance,…

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 staff interview conducted during recertification and abbreviated survey (NY00622225) from 2/19/26 to 2/27/26, it was determined the facility did not ensure that they provided an ongoing program to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences of each resident, for one (1) of one (1) resident (#90) reviewed for activities. Specifically, Resident #90 was not provided with the opportunity to consistently attend activities of their choice or attend activities specified for residents with dementia. The findings includeResident #90 had diagnoses including Alzheimer's Disease, Anxiety, and Depression.The Care Plan for activity dated 02/10/2022 documented Resident #90 was able to make most needs known and make their own decisions on activity participation. Resident #90 was frequently confused and needed help to get from place to place. Identify previous activities and interests as possible, coordinate treatment…

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 staff interview during the recertification survey conducted from 02/19/2026 to 02/27/2026, the facility did not ensure that necessary services, and/or equipment were provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one (1) of four (4) residents (Resident #44) reviewed for position and mobility. Specifically, Resident #44 was observed on three (3) occasions without the use of a right ankle-foot orthosis as per physician order.The policy and procedure titled Splinting/Bracing, reviewed on 05/01/2025, documented a valid physician order was required before the application of splints or braces. Therapy staff were responsible for evaluating fit, and position, and for establishing a schedule of wear. Residents were to receive care and monitoring to prevent avoidable harm. Resident #44 had diagnoses of muscle weakness, hemiplegia of the right dominant side (paralysis 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.

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure each resident receives adequate supervision and or assistance devices consistent with resident needs to prevent accidents for one (1) of two (2) residents (Resident #103) reviewed for accidents. Specifically, after Resident #103 had a documented 05/19/2025 intact blister on the left hand second digit related to smoking, care plan interventions were not updated to reflect Resident #103 smoking cigarettes down to the butt and/or the use of a cigarette extender as per a 05/21/2025 hand-written note. Subsequently, Resident #103 was observed on 02/25/2026 smoking without the use of a cigarette extender. The findings includeThe policy titled Residents Smoking last reviewed 01/10/2025 documented the smoking plan of care is evaluated quarterly and revised as needed.Resident #103's diagnoses included unspecified psychosis, left femur fracture and post-traumatic stress disorder.A Care Plan for smoking dated 04/03/2025 documented Resident #103 was a dependent smoker 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 observation, interview, and record review conducted during the recertification survey from 2/19/2026 to 2/27/2026, the facility did not ensure care consistent with professional standards of practice, was provided for one (1) of one (Resident #5) reviewed for respiratory care. Specifically, Resident #5 was administered oxygen without a valid medical order from 01/29/2026 to 02/19/2026.The findings include:The policy titled Oxygen, last reviewed on 10/29/2025, documented oxygen is a medication and a specific physician's order is necessary to administer the same. Resident #5's diagnoses included lung cancer, pulmonary embolism, and acute respiratory failure. The significant Change Minimum Data Set (a resident assessment tool) dated 12/19/2025 documented Resident #5 had moderate cognitive impairment and had shortness of breath when lying flat.A nursing progress note dated 01/29/2026 documented Resident #5 returned from the hospital and was admitted back into the facility while receiving oxygen at two (2)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during a recertification survey conducted from 02/19/2026 to 02/27/2026, the facility did not ensure that medical supervision was provided for one (1) resident of five (5) residents reviewed for drug regimen review. Specifically, the pharmacy consultant recommended discontinuation of the drug Megace, an appetite stimulant, due to the resident's weight of 415 pounds. The physician agreed to discontinue the medication; however, the nurse practitioner reordered the medication, and the resident continued to receive the medication. The findings include The policy and procedure titled Medication Administration, revised 08/11/2025, documented the consultant pharmacist provided drug information and conducted monthly drug regimen reviews. The consultant pharmacist flagged or addressed unnecessary medications with the medical director. The facility established standards for physician countersignatures on orders and ensured they were completed promptly.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility did not ensure that residents with dementia were receiving the appropriate treatment and services to attain and maintain their highest practicable physical, mental, and psychosocial well-being for one (1) of two (2) residents reviewed for dignity. Specifically, Resident #28 was observed soiled and in the same clothing on consecutive days. The resident had a history of refusals of care and poor hygiene. The activities of daily living and behavior care plans both contained interventions including a referral to social services as needed for evaluation and follow-up but that was never completed. The findings included:Resident #28 had diagnoses that included bipolar disorder, dementia, and major depressive disorder. The Activities of Daily Living Care Plan effective 12/13/2025 documented that Resident #28 has compromised status and at risk for decline and/or lack of improvement related to congestive heart failure with edema, difficulty walking, mood…

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 during the recertification survey conducted 02/19/2026 through 02/27/2026, the facility did not ensure proper disposal of garbage and refuse. Specifically, 1) the recycle dumpster lid was broken, unable to be completely closed and left open which allowed cardboard boxes to spill over the top, 2) the compactor had food debris puddled in front of the compactor door, and litter on the ground between the compactor and the dumpster.The findings are:The policy titled Waste Handling issued 3/2024 documented, the facility will maintain a clean, safe, and sanitary environment by ensuring that all garbage, recyclable materials are properly disposed of in compliance with regulatory requirements. During an observation of the garbage area on 02/19/2026 at 10:03 AM with the Food Service Director, the recycle dumpster was open with cardboard boxes spilling over the top. There were boxes and other litter on the ground surrounding the dumpster and trapped under it. The waste management company arrived during this time to empty the dumpster. Once completed it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated surveys on 02/19/2026 to 02/27/2026, the facility did not ensure that rehabilitative services were provided for two (2) of two (Resident #79 and Resident #10) reviewed for Rehabilitation. 1) Specifically, an occupational therapy screen was not completed for Resident #79 as per physician order and 2) an occupational screen was not completed to evaluate and treat leaning to the right side for Resident #10 as per physician order. The findings included The facility policy titled Rehab Evaluation revised 04/02/2022 documented the evaluation must occur following admission with physician orders for evaluation. The evaluation should be performed within 48 hours following the physician order. 1)Resident #79 was admitted to the facility on [DATE] with diagnoses including unspecified dementia. The admission Minimum Data Set (a resident assessment tool) dated 12/30/2025 documented Resident #79 had moderate cognitive…

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 (NY00369540, NY00369602), the facility did not ensure residents right to be free from abuse for 2 of 7 residents (Resident #2, Resident #5) reviewed for abuse. Specifically, (1) on 1/19/2025 Resident #2 was involuntarily secluded in their room by Certified Nurse Aide #7 for approximately three hours. Certified Nurse Aide #7 placed wash cloth wipes wedged in the corner of the resident's door preventing them from exiting the room. During a rounding of resident rooms Resident #2 was found by Housekeeper #2 and House Keeping Lead in their room with a puddle of urine on the floor and feces all over the room. Resident #2 was unclothed and had a pair of pants in their which they pulled up over their chest. Resident #2 was cleaned up by Certified Nurse Aide #6 and brought to the day room after the incident. (2) On 1/18/2025 Resident #5 was video recorded by Certified Nurse Aide #3 and Certified Nurse Aide #4 while washing their incontinence brief 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 interviews during an abbreviated survey (NY00369540, NY00369602), the facility did not ensure a reasonable suspicion of a crime against a resident was reported to law enforcement or an allegation involving abuse was reported immediately, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse for 2 out of 6 residents (Resident #2, Resident #5) reviewed for abuse. Specifically, (1) on 1/19/2025 Resident #2 was barricaded in their room by Certified Nurse Aide #7 by placing wash cloth wipes in their door frame preventing the resident from exiting. Resident #2 was found by the Housekeeping Lead and Housekeeper #2 after getting the door opened. The facility Administrator was not informed of the incident until 1/20/2025, the incident was reported to the New York State Department of Health on 1/27/2025, and the incident was never reported to local law enforcement; (2) Resident #5 was video recorded by Certified Nurse Aide #3 and Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00318055, NY00383624) the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 2 out of 3 residents (Resident #3, Resident #6) reviewed for quality of care. Specifically, (1) Resident #3 had a wound care treatment ordered for their left below the knee area to be completed daily. Review of Resident #3's treatment administration record for March 2025 revealed their treatment was not signed as completed by the Licensed Practical Nurse on 3/9/2025, 3/11/2025, 3/16/2025. (2) Resident #6 had a known history of constipation and a history of small bowel obstruction in 2020. Review of Resident #6's certified nurse aide accountability revealed direct care staff did not consistently document the resident's bowel movement activity, the February 2025 documentation had certified nurse aide signature omissions on 25 occasions and March 2025 on 19 occasions. The findings are:The facility…

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 (NY00369540, NY00369602), the facility did not ensure the Quality Assurance and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality of care deficiencies. Specifically, there was no documented evidence of the Quality Assurance and Performance Improvement committee convening to discuss, develop and prioritize actionable plans for the reportable incidents that occurred on 1/18/2025 and 1/19/2025. On 1/18/2025 Resident #5 was videorecorded by staff; the recording was posted on social media by Certified Nurse Aide #3. On 1/19/2025 Resident #2 was barricaded in their room by Certified Nurse Aide #7, the resident was found in their room by Housekeeper #2 and the Housekeeper lead approximately three hours later.The findings are:The facility Quality Assurance and Performance Improvement policy last revised 10/7/2024 documented the purpose is to promote high-quality care and ensure compliance with federal and state regulations through continuous quality…

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 (NY00369602), the facility did not ensure the residents right to a dignified existence or to be treated with respect and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 out of 7 residents (Resident #5) reviewed for dignity. Specifically, (1) Resident #5 was video recorded by Certified Nurse Aide #3 and Certified Nurse Aide #4 while cleaning their briefs in the sink. Certified Nurse Aide #3 then posted the video on social media (Tik Tok). Certified Nurse Aide #3 was terminated by the facility for violating abuse policy.The findings are:The facilities undated Resident Dignity policy documented the purpose is to ensure that all residents in the facility are treated with dignity and respect in every aspect of their care. All staff must recognize and uphold each resident's right to dignity, regardless of physical or cognitive ability. This includes respecting privacy during personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00369540) the facility did not ensure in response to allegations of abuse that all alleged violations are thoroughly investigated for 1 out of 7 residents (Resident #2) reviewed for abuse. Specifically, on 1/19/2025 Resident #2 was barricaded in their room by Certified Nurse Aide #7 by stuffing wash cloth wipes in the door of their room preventing the door from opening. There was no documented evidence of Resident #2 being assessed for injury after the incident and statements were not obtained from all staff on duty at the time of the incident. There was also no available video footage to review for the incident that occurred on 1/19/2025. The findings are:The facility Abuse policy last revised 1/20/2025 1) Resident #2 admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease, Parkinsonism and Bipolar disorder.A Quarterly Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive…

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 (NY00383624) the facility did not ensure assessments accurately reflected the resident's status for 2 out of 3 residents (Resident #2, Resident #4) reviewed for assessments. Specifically, Resident #2 was a known wanderer and always has a wander guard in place. The quarterly Minimum Data Set assessment dated [DATE] (under section E) did not document the resident had wandering behavior. (2) Resident #4's was care planned as having a known behavior of rejecting medications and cares. Known to the facility staff as rejecting medication and cares. The Comprehensive Minimum Data Set, dated [DATE] did not accurately reflect the resident's behavior.The Findings are:The facility Completion of the RAI/MDS Process policy last revised 5/25 documented it is the policy of the facility to assure that all residents achieve their highest level of functioning possible and maintain their sense of individuality. Assessments will be completed within the guidelines…

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 (NY00383624), the facility did not ensure residents were free from medication errors and accepted professional standards and principles which apply to professionals providing services for 1 out of 3 residents (Resident #3) reviewed for medications. Specifically, Resident #3 was prescribed some narcotic pain medication (Morphine-medication used to help relieve severe pain) to be administered (while on comfort care) at the following scheduled times: 12 AM, 9 AM and 7 PM. Review of Resident #3's administration record for April 2025 and May 2025 revealed the standing doses were not administered within regulated times of one hour before or one hour after scheduled time. There was also no documented evidence of Resident #3 receiving three standing doses of their narcotic pain medication on 5/4/2025 and 5/9/2025 when they were on comfort care. There was pain assessment documented and there was no documentation that the physician was notified 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 (NY00383624), the facility did not ensure enhanced barrier precautions were followed by staff for 2 out of 3 residents (Resident #4, Resident #15) reviewed for infection control. Specifically, (1) on 6/17/2025 Certified Nurse Aide #1 and Certified Nurse Aide #2 provided care to Resident #4, who was on enhanced barrier precautions and did not don gowns; (2) On 6/18/2025 Resident #15 was observed walking down the hallway from their room to the nurse's station with their Foley catheter drainage bag in their hand and used the telephone at the nurse's desk. Resident #15 was noted to be on enhanced barrier precautions.The findings are:The facility Infection Control: Enhanced Barrier Precautions policy last revised 4/8/2024 documented it is the policy that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk 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 observations, interviews, and record reviews during an abbreviated survey (NY00349142), the facility did not ensure the services provided adhered to accepted standards of practice for medication administration (including right time) for 24 (Residents #26 and #18) of 40 residents reviewed. Specifically, 1) on 08/12/2024 at 12:30 PM Licensed Practical Nurse #1 was observed attempting to administer 13 medications to Resident #26, where the physician ordered these medications to be given at 9:00 AM. Licensed Practical Nurse #1 did not notify the physician prior to changing the medication administration time; 2) on 08/13/2024 from 10:05 AM to 10:12 AM Licensed Practical Nurse #4 was observed passing 10 medications for Resident #18 where the physician ordered them to be given at 9:00 AM. Licensed Practical Nurse # 4 did not notify the physician prior to changing the medication administration time. During interviews both nurses stated that they did not have the time to notify the attending physician that they are administering the medication late. The findings are: The facility…

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

Based on observations, interviews, and record reviews during an abbreviated survey (NY00349142), it was determined that the facility did not ensure residents were free from significant medication errors for 23 (Residents #18, #4, #14, #19, #24) of 40 residents reviewed for late medication administration. Specifically, the Residents on the Second Floor Dementia Unit did not receive medications including but not limited to Antianxiety, Antidiabetic (Insulin), Anticoagulant, Antihypertensive, Antipsychotic, Anti-Parkinson's, and Antiseizure timely from 07/01/2024 to 08/13/2024 in accordance with prescriber's order and accepted health standards established by national boards and councils. The findings include but are not limited to: The facility policy titled Medication Administration dated 08/06/2024 documented that the purpose of the policy was to establish guidelines to promote the health and safety of residents by ensuring the safe assistance and administration of medication and treatments. Medications will be administered to residents as prescribed and by persons lawfully…

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 an abbreviated survey (NY00349142), the facility did not ensure Resident Primary Care Physicians (Attending Physician) comprehensively reviewed the resident's total program of care, including the Residents' medications and treatments for 24 of 40 residents reviewed. Specifically, a review of the medication administration detailed report from 07/01/2024 to 08/13/2024 revealed residents received their medications late including 19 Residents with significant medications (Antianxiety, Antidiabetic (Insulin), Anticoagulant, Antihypertensive, Antipsychotic, Anti-Parkinson's, and Antiseizure). During an interview with the Medical Director, they stated they were unaware of the consistent late medication administration in the facility. There was no documented evidence that facility staff communicated to the Resident' Primary Care Physician and/or the Medical Director that significant medications were not administered as prescribed by the physician. The Findings are: The facility policy titled By-Laws, Rules and Regulations of the Medical Staff…

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.

F725 - Sufficient Nursing Staff Based on observation, interviews and record review conducted during an abbreviated survey (NY00349142), the facility did not provide sufficient numbers of personnel to meet the care needs of all residents on the Second Floor Dementia Unit. Specifically, an observation conducted on 08/13/2024 at 9:35 AM revealed that there was no additional medication nurse to pass medications on the north side of the unit. Consequently, 23 residents received their physician ordered 9 AM medications (see associated tag F760) late. Further review of the Medication Administration History Detailed Report from 07/01/2024 to 08/13/2024 revealed consistent pattern of late medication administration on the second floor. Facility daily shift schedule and Director of Nursing interview revealed one medication nurse assigned to pass meds to all forty residents on the second-floor dementia unit. The findings include but are not limited to: Review of the facility assessment last updated 08/01/2024 and last reviewed by the Quality Assurance and Performance committee on 08/06/2024 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 record review and interviews conducted during an abbreviated survey (NY00349142), the facility did not ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly review, analyzed, and act on available data to make improvements and to ensure improvements are sustained. Specifically, 1) On 06/28/2024 the facility received feedback from Bureau of Narcotics representative regarding facility staff not administering medications according to prescriber's order; 2) a complaint from the facility's Resident Council indicated residents received their medications late on 07/20/2024 and 07/21/2024, the facility did not conduct a thorough investigation, and/or audit the medication administration practice in the facility; 3) during an observation on 08/13/2024 on the Second Floor Dementia Unit and further record review from 07/01/2024 to 08/13/2024 revealed that 23 Residents did not receive significant medications including but not limited to Antianxiety, Antidiabetic…

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 from 1/19/23 to 1/26/23, it was determined for 1 of 3 resident (Resident #30) 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 resident's report of a missing shoe. The findings are: The facility Policy and Procedure titled Loss of Resident Clothing documented when an article of clothing is reported lost, a Missing Personnel Belongings Form is generated. The 1/2019 facility Grievance Policy and Procedure documented a specific procedure and a specific form to address missing items. The policy also documented all complaints and grievances were to be addressed promptly and in a timely manner. The 12/4/22 quarterly Minimum Data Set (MDS - a resident assessment tool) documented Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. During an interview on 1/19/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey and Abbreviated Survey #NY00263725 from 1/19/23 to 1/26/23, it was determined for 2 of 4 residents (Residents #6 and #15) reviewed for accidents, the facility did not ensure adequate supervision to maintain resident safety. Specifically, Resident #15 was not provided the planned assistance and rolled out of the bed and when Resident # 6 was assessed as unsafe to smoke, the facility did not implement consistent communication to ensure the resident's safety The findings are: The facility Policy and Procedure titled Accident/Incident/Occurrence/Wound Policy and Procedure dated 7/2013 documented it is the facility intention to provide an environment that is free from accident hazard's and provide supervision and assistive devices to each resident to prevent avoidable accidents. The facility Policy and Procedure titled CNA Assignment Sheet/Cares Policy and Procedure dated 2020, revised 7/15/22 documented the Resident 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 Survey from 1/19/23 to 1/26/23, the facility did not ensure the monthly medication review by the pharmacist was followed up by the attending physician/medical director for 1 of 5 residents (Resident #9) reviewed for Unnecessary Medications The finding is: During a review of facility policy titled The Pharmacy Drug Regimen Review revised 10/2/2018 documented the Consultant Pharmacist shall identify, document and report possible medication irregularities for review and action by the attending physician when appropriate. The attending physician or licensed designee shall respond to the drug regimen review within 7 days of receipt. Resident #9 was admitted with diagnoses including Heart Failure, Osteoporosis, and Asthma. The 8/10/22 admission MDS (Minimum Data Set; a resident assessment tool) documented the resident's BIMS score (Brief Interview for Mental Status) was 15 out of 15/cognitively intact. The 8/5/22 Physician's order documented Alendronate 70 mg to be given at 6:00 am every week on Monday 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 observations and interviews conducted during the Recertification Survey from 1/19/23-1/26/23, the facility did not ensure that food was stored in accordance with professional standards for food safety. Specifically, food was stored on the floor of the refrigerator, freezer, and non-perishable food storage area, and the unit refrigerator temperature logs were not completed. The findings are: During the initial kitchen observation on 01/19/23 at 9:22 AM, food was observed on the floor in the food storage area, freezer, and refrigerator #1. During an observation on 01/19/23 at 11:48 AM, unit 3E refrigerator temperature logs were not completed for 1/17/23, 1/18/23, and 1/19/23. During an observation on 01/19/23 at 2:15 PM, food was observed on the floor in the food storage area, freezer, and refrigerator #1. During an observation on 01/24/23 at 11:04 AM boxes of food were observed on the freezer floor. During observations on 01/24/23 at 12:16 PM, 12:20 PM and 12:33 PM, Unit 1E, 2E and 3E had refrigerator temperature logs that were not completed for 1/20/23, 1/21/23, 1/22/23,…

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 Recertification Survey from 1/19/23 to 1/26/22, the facility did not ensure infection prevention and control standards were maintained. This was evident for the facility's Legionella Sampling and Management Policy and Procedure and Environmental Assessment of Water Systems reviewed during the Infection Prevention and Control Program (IPCP) review. Specifically, the facility did not complete the Legionella Risk Assessment and lacked a diagram of the facility water system to determine possible areas where Legionella could grow and spread in the water system. In addition, only one controlled location (water heater) for legionella was tested on [DATE] and 6/30/22. The Findings Are: Review of the facility Legionella Sampling Plan documented the sampling sites shall include, but not limited to the following locations: at least three samples should be collected from each floor. This is normally done as follows; tap closest to first delivery of hot water from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview conducted during a recertification survey, the facility did not ensure that housekeeping and maintenance services provided a comfortable home-like environment. Specifically, there were numerous instances of disrepair observed in multiple rooms. This was evident for 4 resident rooms including, but not limited to rooms #101, #113, #120, and #302. The findings are: Resident room observations were conducted on 2/22/2019 between 2:16 PM and 2:30PM on the first floor unit. The following was observed: - room [ROOM NUMBER] had chipped wall paint. The electrical heater/AC unit had a brownish substance on the outside. - room [ROOM NUMBER] had brownish water stains on the ceiling, cracked floor tiles, chipped wall paint, and cracked wall plaster near the heater/AC unit. - room [ROOM NUMBER] had scuff marks on the walls, cracked floor tiles, a soiled bathroom door, soiled, rusty bathroom door frame, and cracked floor tiles where the wardrobe was located. The Director of Maintenance (DOM)…

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 a recertification survey, the facility did not ensure that 4 out of 12 residents reviewed for Resident Assessment had the required Comprehensive Minimum Data Set (MDS; a resident assessment and screening tool) conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. The findings are: The MDS records of the following residents were reviewed and revealed that the following comprehensive assessments were not completed within the ARD (assessment reference date) +14 days or 366 days from the most recent comprehensive assessment. 1-Resident #06 -Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the last section was completed on 2/23/19. 2-Resident #16- Had an Annual MDS assessment with an ARD date of 1/10/19 indicated the last section was completed on 2/23/19. 3-Resident #25- Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the last section was completed on 2/17/19. 4-Resident #114-Had an Annual MDS…

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

F 638 Based on record review and interview conducted during the recertification survey, the facility did not ensure that the required Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) was conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. This was evident for 7 of 12 residents reviewed for Resident Assessment. The findings are: The MDS records of the following residents were reviewed and revealed that Quarterly assessments were not completed within the ARD (Assessment Reference Date) +14 days or 92 days from the last Quarterly Assessment. 1-Resident #02 -Had a Quarterly MDS assessment with an ARD date of 12/18/18 indicated the last section was completed on 2/16/19 2-Resident #03- Had a Quarterly MDS assessment with an ARD date of 12/23/18 indicated the last section was completed on 2/16/19. 3-Resident #04- Had a Quarterly MDS assessment with an ARD date of 12/24/18 indicated the last section was completed on 2/25/19. 4-Resident #08- Had a Quarterly MDS…

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

Based on record review and interview conducted during the recertification survey, the facility did not electronically transmit encoded and completed MDS (Minimum Data Set; a federally-mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) to the CMS (Centers for Medicare and Medicaid Services) system within 14 days of the final MDS completion date as indicated in section Z0500 ( date the Registered Nurse (RN) assessment coordinator signed assessment as complete). This was evident for 11 of 12 residents reviewed for resident assessment. The findings are: 1--Resident #03- Had a Quarterly MDS assessment with an ARD date of 12/23/18 indicated the assessment was complete on 1/2/19 and was submitted on 2/26/19. 2-Resident #04- Had a Quarterly MDS assessment with an ARD date of 12/24/18 indicated the assessment was complete on 12/31/18 and was submitted on 2/26/19. 3-Resident #06 -Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the assessment was complete on 1/28/19 and was submitted 2/26/19 4-Resident #08- 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.

Based on observation, record review and interview conducted during the recertification survey, the facility did not implement interventions for 1 of 5 residents reviewed for pressure ulcers. Specifically, a pressure relieving device was not implemented according to the physician's order. (Resident #71). The findings are: Resident #71 was admitted with diagnoses including multiple sclerosis, neuropathy and quadriplegia. Review of the 12/14/18 significant change MDS (Minimum Data Set: an assessment tool) indicated the resident had a BIMS (Brief Interview of Mental Status: a tool to assess cognition) score of 5/15 (severe cognitive impairment), received extensive assist of 2 for bed mobility, had impairment to both lower extremities,had a stage 2 pressure ulcer that was not present on admission, had pressure relieving devices for the bed and chair, was on a turning and positioning schedule, and received pressure ulcer care. Physician's orders dated 6/7/18 included heel lift ongoing at all times, ongoing positioning while out of bed and in the geri recliner. Review of the comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey, the facility did not ensure that residents or their representatives and the Office of the State Long Term Care Ombudsman were given written notification of the resident's transfer to the hospital. This was evident for 1 of 4 residents reviewed for hospitalization. (Resident #152). Findings are: Resident #152 was admitted to the facility on [DATE] with diagnoses including hypertension and unspecified dementia without behavioral disturbance. On 1/10/19 the resident notified nursing of right leg pain. Upon completion of the nursing assessment, the physician and the family were notified and the resident was transferred to the hospital. Resident #152 returned from the hospital on 1/21/19 with a diagnosis of status post right hip open reduction internal fixation. Interviews were conducted with two Licensed Practical Nurses (LPN #1 and LPN #2) on 2/28/19 at 2:00 PM. When asked how family members or resident representatives are notified…

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 implement interventions to prevent the development of pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. Specifically, pressure relieving interventions were not implemented per the physician's order. ( Resident #71). The findings are: Resident #71 was admitted with diagnoses including Non Alzheimer's Dementia, Quadriplegia and Multiple Sclerosis. Review of the 12/14/18 significant change MDS (Minimum Data Set: a resident assessment tool) indicated Resident #71 had a BIMS (Brief Interview for Mental Status) score of 5/15 (severe cognitive impairment), received extensive assist of 2 staff support for bed mobility, had impairment to bilateral lower extremities, had a stage 2 pressure ulcer that was not present on admission, had pressure relieving devices for the bed and chair, was on a turning and positioning schedule, and received pressure ulcer care. Review of the Physician's Orders dated 6/7/18 included; Heel Lift ongoing at all times, ongoing positioning while out…

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 conducted during the re-certification survey, it was determined that treatment and care was not provided to meet a resident's physical needs. Specifically, the facility did not ensure that a resident was provided proper leg rests for positioning. This was evident for 1 of 6 residents reviewed for positioning and mobility. (Resident #178). The findings are: Resident #178 was admitted with diagnoses including acute respiratory failure, toxic encephalopathy and heart failure. The admission MDS (Minimum Data Set: an assessment tool) dated 8/1/18 indicated Resident #178 had a BIMS (Brief Interview for Mental Status) score of 3/15 (indicating severe cognitive impairment), received extensive assist of one for bed mobility, extensive assist of 2 for transfers, had functional limitation ROM (range of motion) to both upper extremities and had no limitation to lower extremities. The physician's orders dated 8/6/18 revealed an order for Dermasavers to be worn at all times to both lower extremities; may remove during cares. (Dermasavers are worn…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that the call bell was in reach for one of two residents (Resident #81) reviewed for accidents. Resident #81 had diagnoses including dementia. The Minimum Data Set (MDS, an assessment tool), dated 12/28/18 indicated the resident had severely impaired cognitive status, required extenisive assistance for transferring and toilet use, was occasionally incontinent of urine and had no history of falls. A Fall assessment dated [DATE] and noted to be signed on 1/24/19 identified the following interventions: bilateral side rails, call bell within reach and bed at proper height. Environmental rounds were conducted on 2 [NAME] on 2/21/19 at 9:30 AM. Resident #81, assigned to the A bed in room [ROOM NUMBER], was seated between the bathroom door and the head of the resident's bed. The resident's call bell was on the floor on the other side of the bed. During rounds on 2/22/19 at 9:45 AM, the resident was…

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

483.70 (b) Compliance with Federal, State, and Local laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Based on observation and interview, the facility was not in compliance with Section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. A carbon monoxide monitor was not installed in the room housing the facility's diesel-powered emergency generator. The findings are: On 2/26/19 at approximately 12:10 PM, a tour of the generator room was conducted, and a carbon monoxide detector was not observed in the room. The emergency generator housed in this room is diesel-powered. In an interview with the Director of Facilities on 2/27/19 at approximately 12:30 PM, he confirmed that a carbon monoxide detector was not in…

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.