Hollis Park Manor Nursing Home

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that all drugs and biological were stored in accordance with currently accepted professional principles. This was evident in 1 (Unit C) of 2 units observed. Specifically, expired medications were stored in Unit C medication cabinet. The findings are: The facility policy and procedure titled Medication Administration with a revision date of 09/2024 stated over the counter drugs should be labeled clearly and monitored regularly. The labels should include expiration dates and any specific storage instructions. During observation on 05/13/2025 at 2:23 PM, Unit C medication cabinet was observed with 2 bottles (100 tablets in each bottle) of Zinc Sulfate - 220 milligram per tablet, with expiration date of 09/2024, 1 bottle (200 tablets in a bottle) of Iron tablet - 325 milligrams per tablet, with expiration date of 09/2024, and a bottle of liquid Vitamin C - 473 cubic centimeter with an expiration date of 03/2025. On 05/13/2025 at 2:59…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure a resident's right to receive services with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #15) of 21 total sampled residents. Specifically, Resident #15 was prevented from using their room's bathroom due to the door being locked. The findings are: Resident #15 was admitted on [DATE] with diagnoses of cerebral vascular accident with left hemiplegia and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #15 was cognitively intact, required substantial to maximal assistance with toileting, and had episodes of bladder incontinence. On 01/16/2024 at 10:20 AM and 01/17/24 at 10:17 AM, Resident #15 was interviewed and stated they were unable to use the bathroom in their room. The bathroom was shared between Resident #15's room and the room next to theirs. The resident in the adjoining…

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

Based on observation, interviews, and record review conducted during the Recertification Survey from 01/16/2024 to 01/23/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment. This was evident for 1 (Unit C) of 3 units. Specifically, resident rooms had loose wires and dusty, dirty equipment, and the floor dining room had dirty window shades. The findings are: 1) Unit C was observed multiple times from 01/16/2024 at 8:00 AM to 01/23/2024 at 12:00 PM with the following: 1- Room C05 had a wheelchair and seat cushion with crusty brown stains, food particles, and dust and dirt on the metal frame and wheel spokes. 2- Room C06 had a dusty wheelchair with brown stains and a tube feeding pump and pole with crusty brown stain. The dusty, dirty clothing hamper had brown stains. 3- Room C10 had a recliner chair and stained cushion with food particles and layers of dirt and dust. 4- Room C11 had a dirty and dusty wheelchair and a dusty, dirty clothing hamper with brown stains. 5- Room C12 had a tube feeding pump pole and power cord with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident in 1 (Resident #30) of 18 total sampled residents. Specifically, Resident #30 fall resulting in spinal fracture was not reported to the New York State Department of Health. The findings are: The facility policy titled Accidents and Incidents Investigation and Reporting dated 12/2023 documented all accidents and incidents shall be investigated and reported to the Administrator and Director of Nursing. Resident #30 had diagnoses of dementia and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #30 was severely cognitively impaired. Nursing Note dated 12/17/2023 documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not services provided met professional standards of quality. This was evident for 1 (Resident #16) 18 total sampled residents. Specifically, the nurse did not inform Physician #1 of Resident #16's high fingerstick blood sugar readings in accordance with Physician's Orders. The findings are: The facility policy titled Long-term Diabetic Care dated 07/2017 documented the Physician will confirm factors that may influence glucose tolerance. Resident #16 had diagnoses of diabetes mellitus and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #16 was moderately cognitively impaired. The Comprehensive Care Plan related to diabetes mellitus dated 11/10/2023 documented Resident #16 was at risk for abnormal glucose levels and blood glucose levels were monitored according to physician's order. Physician's Orders dated 12/18/2023 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 observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #16) 18 total sampled residents. Specifically, Physician #1 did not address Resident #16's consistently high blood glucose levels. The findings are: The facility policy titled Long-term Diabetic Care dated 07/2017 documented the Physician will confirm factors that may influence glucose tolerance. Resident #16 had diagnoses of diabetes mellitus and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #16 was moderately cognitively impaired. The Comprehensive Care Plan related to diabetes mellitus dated 11/10/2023 documented Resident #16 was at risk for abnormal glucose levels and blood glucose levels were monitored according to physician's order. Hemoglobin A1c laboratory results for Resident #16 dated 10/3/2023 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 observation, record review and interview conducted during the Recertification/Complaint Survey, the facility did not ensure that a Significant Change (MDS) Minimum Data Set assessment was completed for a resident within 14 days of determining the status change was significant. Specifically, a resident who had a change in Activity of Daily Living (ADL), in more than 2 care areas did not have a significant change assessment initiated within 14 days. This was evident for 1 of 1 resident reviewed for ADL decline, out of a sample of 23 residents. (Resident #14). The findings are: The Centers for Medicare and Medicaid Services (CMS) Long Term Care Resident Assessment Instrument (RAI) Manual 3.0 documented: A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. 2. Impacts more than one area 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 the Recertification/Complaint Survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a resident's Discharge Assessments were not submitted and transmitted within 14 calendar days after the assessments were completed. This was evident for 1 of the 2 residents reviewed for Resident Assessment, out of a sample of 23 residents. (Resident #2). The CMS RAI Version 3.0 Manual (Dated October 2017) was referenced. Chapter 5 titled Submission and Correction of the MDS Assessments was reviewed. The MDS completion date must be no later than 14 days after the ARD for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the recertification survey , the facility did not ensure that each resident's drug regimen must be free from unnecessary drugs when used in the presence of adverse consequences which indicate the dose should be reduced or discontinued. This was evident in 1 of 1 resident reviewed for change in condition in a sample of 16. (Resident #39) The finding is : The facility policy titled, Laboratory (LAB) and Diagnostic Test Results with effective date of 1/2016 documents, Assessment and Recognition: The physician will identify and order diagnostic test and lab testing based on diagnostic and monitoring needs. The staff will process test requisition and arrange for tests. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. It further documents on Identifying Situations that Warrant Immediate Notification step #4-- High or toxic drug levels. If a test was obtained to monitor the blood level of 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 and interviews conducted during the recertification and abbreviated survey, the facility did not ensure that drugs and biological's were stored under proper temperature. Specifically an eye drop that was supposed to be kept refrigerated before opening was found sitting in the cart top drawer unopened. This was evident during the facility Medication Storage Task on 1 of 3 units. (Unit A-first floor) The findings are The facility policy Storage of medication effective in January 2017 documented medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications must be stored and labeled accordingly. On 2/11/2022 at 11:21 AM, during the medication storage task, an unopened bottle of Rhopressa 0.02%, eye drop was observed in a bag labeled refrigerate. The medication was sitting in the top drawer of the medication cart on unit A, the first floor. A label affixed to the Rhopressa bottle documented the medication has been dispensed from the pharmacy on 1/31/2022 The Drug insert…

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.