Taconic Rehabilitation And Nursing At Ulster

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey from 3/5/2025 to 3/12/2025, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 1 residents (Resident #65) reviewed for Dignity. Specifically, Resident # 65 was observed ambulating wearing socks that were labeled with the resident's name on the top of the foot clearly visible to other residents, visitors and staff. The findings are: Resident #65 with diagnoses that included, but not limited to, Dementia, Anemia, and Hypertension. The Facility Policy titled Dignity, Respect, and Privacy in Treatment and Care revised 10/2023 documented that the Resident is treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his personal needs. The Annual Minimum Data Set, dated [DATE] documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for Resident #30 reviewed for Call Systems/Environment. Specifically, the call system unit at the bedside for Resident #30 was not accessible. Findings include: The facility's policy titled Call Light revised 10/24/22 documented all residents will be provided with a method to communicate requests and needs directly to a staff or a centralized work area from the bedside, bathroom, and bathing areas, and to always place the call light within the resident's reach. The facility policy titled Fall Prevention revised July 2023 documented that all reasonable steps will be taken to keep the residents safe from falls and related injuries. Resident #30 was admitted with diagnoses…

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

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00346725) from 3/5/25 to 3/12/25, the facility did not ensure residents and/or representatives were provided written notification in a manner they understood for 5 of 5 residents reviewed for discharge (Resident #50, #202, #203, #68, and #69) who were transferred/discharged to the hospital. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand was provided to the resident and the resident's representative(s). The findings are: The facility policy titled Discharge Notice and dated 3/25 documented; Nursing homes must provide residents with a detailed, written discharge/transfer notice which must include specific information regarding the resident's rights in this process. 1.Resident #50 was admitted with diagnoses including anxiety, acute respiratory failure and dependence on…

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

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00346725) from 3/5/25 to 3/12/25, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 5 of 5 residents (Resident #50, #202, #203, #68,#69) reviewed for discharge. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the resident or their representatives. The findings are: The facility policy titled Bed Hold and Notice dated 8/24 documented the facility will notify the designated representative and/or the resident of the facility's bed reservation policies, verbally and in writing at the time of admission and at the time of transfer. 1.Resident #50 was admitted with diagnoses including anxiety, acute respiratory failure and dependence on mechanical ventilation. The Minimum Data Set, an assessment tool dated 1/4/24 documented the resident had intact cognition and 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, record review, and interview during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 (Resident #68) of 4 residents reviewed for pressure ulcers. Specifically, Resident #68's Skin Integrity at Risk Care Plan dated 11/15/24 and updated 2/12/25 documented to float Resident #68's heels, however it was not updated to include a new intervention when staff observed the resident moving their legs frequently when in bed. The findings are: The facility policy titled Interdisciplinary Care Planning revised 4/15/2024 documented a comprehensive resident centered care plan is developed by the interdisciplinary team upon admission and reviewed/ updated on a regular basis throughout the residence length of stay. The comprehensive care plan is reviewed and updated with changes and minimally on a quarterly basis. Resident #68 had diagnoses including protein calorie malnutrition, failure to thrive,…

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 reviews and interviews during the recertification survey from 3/5/25 through 3/12/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 1 resident (Resident #29) reviewed for activities of daily living. Specifically, Resident #29 required staff assistance with personal hygiene was observed on three (3) occasions with long, stained fingernails. Findings include: The facility policy titled nail care revised October 2011 documented that routine nail care is to be done following baths and showers whenever possible. The facility policy titled activities of daily living revised October 2023 documented that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including hygiene bathing dressing grooming and oral care. Resident #29 was admitted with diagnoses including heart failure,…

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 the recertification survey and abbreviated surveys (NY00347643) from 3/5/25-3/12/25, the facility did not ensure residents at risk for pressure ulcers and residents who had pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for 2 of 4 residents (Residents #68 and #352) reviewed for Pressure Ulcers. Specifically, 1) Resident #68's feet were not floated in bed as ordered and there was no documented evidence that wound care treatments were administered 10 of 48 times in February and 4 of 18 times in March, and 2) for Resident #352, there was no documented evidence that wound care treatments were administered five (5) times in May and June 2024 for their Stage 3 pressure ulcers to their coccyx, and left lateral ankle, and Stage 4 pressure ulcer to their left dorsal foot. The findings are: The 6/23 facility policy titled Documentation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from [DATE]-[DATE], the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for expiration dates and storage. Specifically, 1) one (1) of two (2) medication rooms examined for medication storage, had a box of expired Jevity 1.5 feeding that was stored and being used; and expired nicotine patches were stored in 1 of 3 medication carts examined for medication storage. 2) Resident #60 was found with physician ordered Isosorbide, Amlodipine, Carvedilol (blood pressure pills), Sertraline (anti-depressant), Aspirin, Apixaban (blood thinner), Folic Acid (supplement), Levetiracetam (seizure medicine), Docusate (stool softener), and Omeprazole (anti-acid) in their room on their bedside table. The findings are: The facility policy titled Medication/Treatment Labeling and Storage revised 7/2013, documented medications/treatments are stored under proper…

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

Based on observation and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, nursing staff did not perform proper hand hygiene while serving beverages at lunch meal. The findings are: The facility policy last revised 11/2019, Dining Room Service documented dining room meal service is provided in a clean, comfortable and orderly atmosphere. On 3/5/25 at 12:28 PM in the main dining room, the Assistant Director of Nursing was observed serving beverages to multiple residents wearing disposable gloves and not changing gloves between service. The Assistant Director of Nursing touched the beverage cart handle, proceeded to pick up a resident's glass, touched the carafe/pitcher handle and replaced the glass for resident use. The Assistant Director of Nursing did not change their disposable gloves before moving to serve the next resident. This was observed multiple times until the Regional Director of Nursing was observed…

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 a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, 1) the facility did not provide documentation of screening, administration, or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16) reviewed for pneumococcal vaccination; 2) there was no evidence that a Water Management Plan was reviewed and updated, if needed, annually to prevent and control Legionella; and 3) a Licensed Practical Nurse was observed putting an unsanitized blood pressure cuff into the medication cart before properly cleaning it. The findings are: The facility policy titled Pneumococcal Vaccination Program for employees dated 10/24 documented control of pneumococcal disease is increasingly important due to high morbidity rates. The pneumococcal vaccine will be offered to all employees. During 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 from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16), reviewed for COVID-19 vaccinations. The findings are: The facility COVID-19 policy dated 10/30/24 documented the facility will ensure that all employees and contracted staff will be screened prior to offering the vaccination and prior to immunization, medical precautions and contraindications necessary for determining whether they are appropriate candidates for vaccination at any given time. Documentation will be maintained to reflect that the required education was provided and whether the resident and staff member received the vaccine. During the recertification survey, the facility was asked to…

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

Based on observation and interview conducted during a recertification survey, the facility did not ensure food was prepared, stored, and served in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1. cooling logs were not completed for TCS (time and temperature controlled for safety) foods, 2. defrosting foods were not dated, 3. cooked TCS foods were not dated, 4. Unlabeled, undated, improperly wrapped, and/or expired foods were stored in two (2) refrigerated units; 5. TCS foods were not maintained at 41 degrees Fahrenheit (F) or less; and 6. thermometers used to monitor food temperatures were not calibrated. Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause…

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

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that staff followed proper hand hygiene to prevent cross contamination and the spread of infection. Specifically, 1) hand hygiene was not observed during wound treatment for 1 of 4 residents (# 16). 2) for multiple residents # 34, # 72 and # 78 during a lunch meal observation on the first-floor unit. Additionally, hand hygiene was not observed following disposal of soiled items and prior to transporting a resident (#82) off the unit. The findings are: A lunch meal observation was conducted on 1/17/19 at 12:25 PM on the first-floor unit and the following was observed: The Certified Nursing Assistant (CNA # 1) was observed delivering lunch meal trays to multiple residents in their rooms. CNA # 1 delivered a lunch meal tray to resident # 78. During the process, her ungloved hands contacted the resident's over bed table. Without performing hand hygiene, CNA # 1 exited the room and began to add additional liquids/beverages and other condiment items from a cart 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.