The Eleanor Nursing Care Center

Based on observation and interviews conducted during the survey, the facility did not ensure residents were provided with food and drink that was palatable, and at an appetizing temperature. Specifically, 1) during a lunch observation on Unit 1, temperatures take at the time the last resident tray was served, revealed the chicken parmesan had a temperature of 107.6 degrees Fahrenheit, the pasta was 95.5 degrees Fahrenheit, the green beans were 105 degrees Fahrenheit and milk was 63 degrees Fahrenheit; and 2) for the lunch meal on 04/20/2026, hotdogs and french fries were served with no condiments (ketchup and/or mustard) available. The findings include: The facility policy, Dietary Department Policy and Procedure, documented that hot food should be held at 140 degrees Fahrenheit above and cold food at 46 degrees Fahrenheit or below. 1) During an observation on 04/23/2026 at 11:59 AM, with the Food Service Director, temperatures of the lunch tray line were tested before being served. Temperatures of the hot food were tested, and all were above 140 degrees Fahrenheit. During an…

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 survey, the facility did not store food or maintain equipment with food contact surfaces in accordance with professional standards for food service safety. Specifically, 1) unlabeled and undated food were stored in the kitchen freezer, and dry storage; 2) insufficient supply of emergency food; 3) food, water and supplies were not stored six (6) inches off the floor; and 4) food preparation and service equipment was not maintained. The findings are: The undated facility policy titled Dietary Department documented No boxes of food shall be stored on the floor. Food must be covered when stored. Cutting boards should be inspected frequently for wear and replaced as needed.During the initial tour of the kitchen on 04/20/2026 at 10:25 AM with the Food Service Director an observation of frozen hashbrowns, box of farina, pan of thickener, pan of instant potato and pan of sugar all unlabeled and undated; an opened box of cornstarch undated; and an open box of salt unsealed. The emergency food supply was short cans of tuna, beef stew,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the survey, the facility did not ensure the residents right to participate in care planning meeting for 1 of 3 residents (Resident #68) reviewed for Activities. Specifically, Resident #68's quarterly care plan meeting was cancelled due to snow in January 2026 and not rescheduled.Findings include:Resident #68 had diagnoses that included, but not limited to Non-Alzheimer's Dementia, Multiple Sclerosis, and depression.The Minimum Data Set assessment dated [DATE] documented Resident #68 had moderately impaired cognition, and required set-up assist for eating, and was dependent on staff for rolling, sit to lying and transfers.During an interview on 04/21/2026 at 11:26 AM, Resident #68 stated they were supposed to have had a care plan meeting, and it was canceled due to snow, and not rescheduled. Resident #68 stated care plan meetings were important to them for communication with their family members.During a record review of social work progress notes, there…

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 during the survey, the facility did not ensure residents needs and preferences were considered to create an individualized home-like environment for one (1) of two (2) residents (Resident #6) reviewed for choices. Specifically, Resident #6 purchased a shelf for their room and asked about purchasing a recliner for their room. The were waiting for approval to install the shelf and purchase a recliner; there was no documented evidence the facility responded to their request. The Personal Items in Resident Rooms policy dated 03/31/2026 documented that the Facility will accommodate, within reason, items of resident choice within the room environment that will enhance the homelike atmosphere. Items that may be considered for screening and approval may include: floor standing shelving unit (1) that does not extend outward from the wall at a distance that impedes safe passage, does not extend upward at a height that is at risk for tipping forward and does not extend along the wall at 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 interview and record review the facility failed to ensure a grievance process that was clear and consistent, and prompt efforts were made to resolve grievances for one (1) of nine (9) residents (Resident #114) reviewed for activities of daily living, and 3 of 12 residents (Resident #61, Resident #107, and Resident #121) at a Resident Council meeting. Specifically, 1) Resident #114's resident representative reported a grievance on 06/16/2025 and there was no documented evidence that a thorough investigation was conducted, and the complainant was notified of the resolution. 2) Resident #7 filed a grievance on 04/07/2026 and did not receive a response. 3) Resident #61, Resident #107, and Resident #121stated at the Resident Council meeting that the grievance process was unclear and inconsistent.The findings included: An undated facility policy titled Grievance/Complaint Procedure documented that the Administrator was the Grievance Officer and that the Nursing and Social Service Departments participate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility did not ensure that residents remained free from abuse from one (1) of four (4) residents (Resident #23) reviewed for behavioral-emotional concerns. Specifically, Resident #37 was not kept free from abuse when Resident #23 was observed by staff touching Resident #37's breast on 08/23/2025. Additionally, Resident #23 had psychiatric diagnoses that included sexual disorders there were no interventions in place prior to the incident that would ensure Resident #37 and other residents were free from being abused by Resident #23.The findings include:Resident #37 had diagnoses including dementia, anxiety and bipolar disorder. The Minimum Data Set (resident assessment tool) dated 06/10/2025 documented Resident #37's cognition was severely impaired, had no behavior symptoms and mobility devices included a walker and wheelchair.Resident #23 had diagnoses that included dementia, hydrocephalus (chronic condition of accumulation of fluid within the brain),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the survey, the facility did not ensure that alleged violations involving abuse were reported no later than two hours after the incident for one (1) of four (4) residents reviewed for behavioral emotional. Specifically, Resident #23 was witnessed touching another resident inappropriately on 08/23/2025 and the incident was not reported to the State Agency.Findings include:The facility policy titled Resident Abuse Prevention and Reporting, last revised 05/2025, documented upon suspicion of abuse of any kind, all employees are required to stop the abuse, protect the residents, immediately notify immediate supervisor or person in charge of the building (if during off-hours), make immediate statement of observations or cause for suspicion and provide to above-identified person. If deemed a reportable incident, reporting of the incident is to be made in accordance with the requirements stated in manual for specific incident. Resident #23 had diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the survey, the facility did not ensure that they initiated and completed a thorough investigation to determine if alleged abuse could have been prevented and to prevent further abuse while the investigation was in progress for one (1) of four (4) residents (Resident #23) reviewed for behavioral-emotional concerns. Specifically, Resident #23 was observed touching another resident inappropriately on 08/23/2025. The Accident/Incident report dated 08/23/2025 did not document a thorough investigation to prevent reoccurrence of the situation and protect other residents during the investigation. Additionally, the Medical Director was not aware of the nature of the incident, and the report was signed by the supervising nurse and only reviewed and signed by the Administrator. Findings included: Resident #23 had diagnoses that included dementia, hydrocephalus, and anxiety. The Quarterly Minimum Data Set, dated [DATE] documented severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the survey, the facility did not ensure notification to the resident representative or ombudsman regarding transfer or discharge, including the reason for the transfer/discharge, in writing and in a language and manner understood, for three (3) of three (3) residents (Resident #111, Resident #3, and Resident #5) reviewed for hospitalization. Specifically, 1) Resident #111 was hospitalized on [DATE] and the facility did not complete a discharge notice or bed-hold notification, and the ombudsman did not receive notification; 2) Resident #3 was hospitalized [DATE] and the facility did not provide a discharge notice or bed-hold notification to Resident #3's representative and did not notify the ombudsman; and 3) Resident #5 was hospitalized [DATE] and the facility did not provide a discharge notice or bed-hold notification and did not notify the ombudsman. Findings include: The Policy and Procedure titled Notice of Transfer/Discharge, last revised 05/2024, documented that…

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

Based on record review and interviews conducted during survey, the facility did not electronically transmit encoded and completed Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of the final MDS completion date, as required for payment information and quality measure purposes. This was evident for one (1) resident (Resident #101).The findings are: The facility policy titled Minimum Data Set, last revised 07/2025, required each resident to have a comprehensive functional capacity assessment recorded on a designated Minimum Data Set (MDS) form and electronically submitted to the State Department of Health in accordance with federal and state regulations. Review of facility Minimum Data Set assessment data completion and submission activities conducted on 04/27/2026 revealed the following. The Minimum Data Set record exceeded fourteen (14) days from the date of completion. It was not electronically transmitted to the Centers for Medicare and Medicaid Services system within the required timeframe. The 12/22/2026 Discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during the survey, the facility did not ensure a comprehensive person-centered care plan was developed and/or implemented, to meet a resident's needs for two (2) of three (3) residents (Resident #46 and #106) reviewed for Respiratory, one (1) of three (3) residents (Resident #29) reviewed for Urinary Catheters and Urinary Tract Infections, and one (1) of three (3) resident reviewed for Dental. Specifically, 1) Residents #46 and #106 received oxygen and did not have a respiratory care plan; 2) Resident #29 had an indwelling catheter placed on 04/01/2026 and did not have a care plan in place for catheter care; and 3) Resident #98 did not have a comprehensive care plan to address dental issues.The findings include: The facility policy, Comprehensive Care Plans, last reviewed 05/2025, documented that it is to ensure that each resident is provided with individual goal directed care that was reasonable, measurable and based upon a resident's needs. A resident's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review during the survey, the facility did not ensure that activities were provided based on the comprehensive assessment, care plan, and preferences of each resident that met the interests of and support the physical, mental, and psychosocial well-being for two (2) of three (3) residents (Resident #3 and Resident #68) reviewed for activities. Specifically, 1) Resident #3 was observed in their room on 04/20/2026 and 04/21/2026 and there was no documented evidence of attendance to group or in room visits on those days. 2) Resident #68 was observed in bed on 04/21/2026 and 04/24/2026 and there was no documented evidence of in-room activities on those days. Furthermore, there was no documented evidence of consistent activity attendance on any days.Findings include:A policy titled Activity Programs reviewed 05/2024 documented Activity programs designed to meet the needs of each resident are available on a daily basis; individual [NAME] group activities are included 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during the survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 2 (Resident # 117) residents reviewed for antibiotics. Specifically, the resident was to receive 18 doses of Amoxicillin for a urinary tract infection, but three doses were omitted, resulting in receiving 15 of 18 doses.The findings include: The policy titled Administering Medications dated 5/2025 documented a licensed nurse will be responsible for passing medications to residents in accordance with techniques approved for use in the Facility, in compliance with New York State Codes, rules and regulations and with other applicable Federal and State LawsResident #117 was admitted to the facility on [DATE] with diagnoses Acute Urinary Tract Infection, Parkinson's Disease, Lewy Body Dementia.The admission Minimum Data Set, dated [DATE] documented the resident 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 observation, interview, and record review the facility did not ensure care consistent with professional standards of practice was provided for two (2) of three (3) residents (Resident #46, #106) reviewed for Respiratory Care. Specifically, Residents #46 and #106 were administered oxygen at a liter flow greater than the physician order.The findings included: The facility policy, Oxygen Administration, last updated 5/2025, documented oxygen is administered by licensed nursing staff to patients requiring oxygen therapy in the presence of a physician order with a pertinent diagnosis relating to blood oxygenation. 1) Resident #46's diagnoses included chronic kidney disease-stage 4, cirrhosis of liver and acute respiratory failure with hypercapnia. The Annual Minimum Data Set (an assessment tool) dated 02/20/2026 documented Resident #46 had intact cognition and was short of breath when lying flat. A physician order dated 03/11/2026 documented three (3) liters/minute of oxygen via nasal cannula as needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the survey, the facility did not ensure that they had sufficient staff to provide nursing related services for residents with mental and psychosocial disorders to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents for one (1) of four (4) residents (Resident #23) reviewed for behavioral emotional concerns. Specifically, the facility determined that Resident #23 required one-to-one supervision during the day and evening shifts after an incident involving another resident and inappropriate touch on 08/23/2025. However, the need for one-to-one supervision was not documented clearly or consistently and the staffing sheets from 04/01/2026 to 04/27/2026 documented insufficient numbers of staff to cover the one (1) to one (1) supervision. The findings include:Resident #23 had diagnoses that included dementia, hydrocephalus (chronic condition of accumulation of fluid within 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 interviews, the facility did not ensure infection control practices and procedures were maintained when handling linens on two of three units (Unit 1 and 2). Specifically, 1) On Unit 2, room [ROOM NUMBER] had bagged soiled linens on the floor that had been there for a prolonged period; Certified Nurse Aide #14 was observed with soiled linens unbagged directly on the floor while changing the bed in room [ROOM NUMBER]; and carts holding clean linen were observed uncovered in the clean linen room. 2) On Unit 1, Certified Nurse Aide #15 was observed drinking and placing their personal drink cup into the clean linen and supply cart in hallway and then leaving the immediate area with the clean supply cart flaps open. The findings include: The facility Linen Management policy, last reviewed 05/2025, documented that clean linens are to be kept covered and protected from dust and other contaminants prior to use. Soiled linen is to be placed in a bag at the point of care, within the resident room…

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, observations, and interviews during an abbreviated survey (2596130) the facility did not ensure that sufficient nursing staff were available to meet the needs of residents as determined by the facility's own assessment. Specifically, the facility assessment date reviewed 03/25/2025 by Quality Assurance and Performance Improvement documented that the day shift would have a Charge Licensed Practical Nurse and a Med nurse per unit, this was not reflected in the staffing assignments. This staffing pattern contributed to medications being administered late for residents on the units with only 1(one) nurse providing care. The facility's documented assessment dated [DATE] indicated that on day shift each unit would be staffed with a medical nurse and a Charge Licensed Practical unit manager. However, on multiple dates including the observed date of 09/18/2025, units were staffed for the day shift with only one nurse responsible for approximately 30 residents. This staffing pattern did not align…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, during an abbreviated survey (2596130) the facility did not ensure that residents received care in a safe, clean, and comfortable environment. Specifically, multiple ceiling tiles in multiple rooms had visible dark water stains: on Unit 1 (one) room [ROOM NUMBER],109, & 110; on Unit 2 (two) in 218 the community room, the bathroom in 220, and room [ROOM NUMBER] & 227; on Unit 3 (three) room [ROOM NUMBER], 325 and 326. There were also multiple rooms with window curtains that were torn as well as tiles missing from under the bathroom sinks. The undated policy titled Policy and Procedure Manual Work Orders documents that maintenance work orders shall be completed in order to establish a priority of maintenance. The policy further documents that in order to establish a priority of maintenance service, items of concern to be addressed by the Maintenance Department are to be entered into the Maintenance Binder on each floor. Items that must be addressed immediately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during an abbreviated survey (2596130) the facility did not ensure that the facility assessment accurately reflected the resources and staff needed to care for residents. Specifically, the facility assessment dated [DATE] reviewed by Quality Assurance and Performance Improvement documented that the day shift would have a Charge Licensed Practical Nurse and a Med nurse per unit, but this was not reflected in the staffing assignments. This staffing pattern contributed to medications being administered late for residents on the units with only 1 (one) nurse providing care. Review of the facility's assessment dated [DATE] reviewed by Quality Assurance and Performance Improvement indicated that each unit would be staffed with a medical nurse and a Charge Licensed Practical Nurse unit manager for the day shift. Review of the staffing assignment sheet for 09/18/2025 the 3rd floor and 2nd floor units were observed to be operating with only one nurse assigned to work…

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

Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY00360576) from 04/29/25 to 05/06/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1. Upon review of the nursing staffing schedule from 3/29/25-5/29/25, for multiple days, on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents and as per their Facility Assessment and, 2. Resident Council meeting attendees expressed concerns the facility did not staff enough nurse aides to provide them with necessary activity of daily living care. The findings included:The facility Staffing Policy reviewed 9/2024 documented the facility shall have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility shall further assure that staffing levels enable each…

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

Based on record review and interviews during the recertification survey conducted 4/29/25-5/6/25, the facility did not ensure certified nurse aides had the specific competencies and skills necessary to care for residents' needs as identified through resident assessments and described in the plan of care for 5 of 5 recently hired certified nurse aides reviewed. Specifically, Certified Nurse Aides #6, #7, #8, #9, and #10) did not receive a facility orientation upon hire and did not receive documented skills competency training that covered key skill-set areas as outlined in the facility assessment. The findings included: The 2/25/25 Facility Assessment Tool documented an orientation package is given to all new hires after they have been hired. The orientation package details all the education topics that are presented to newly hired employees. This general orientation is scheduled for the first Wednesday of every month for all new hires. Day two is with the department for specific coverage of department information. Education is provided to staff mostly through the Assistant Director…

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 conducted during the recertification survey from 4/29/25 to 5/06/25, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) there were multiple containers of unknown food observed in the walk-in refrigerator, 2) the dishwasher did not achieve proper temperatures for the wash and rinse cycles and 3) the stovetop controls and large portable exhaust fan were dirty and covered in dirt and dust. The findings include: The facility policy Food Receiving and Storage which was last revised on 09/2024 documented all opened items would be labeled and dated and discarded after three days once opened. An undated facility policy titled Cleaning Dishes, Dish Machine documented dishes and cookware will be washed and sanitized after each meal. The policy further notes to check the dish machine gauges throughout the cycle to assure proper temperatures. The facility dishwasher installation and operating manual for the EcoLab model ES-4000…

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 4/29/2025 to 5/6/2025, the facility did not ensure the views, grievances, and recommendations of the resident group were considered and promptly acted upon. This was evident for 10 of 10 (Residents #103, 48, 46, 90, 86, 66, 29, 31, 10, and 28) residents who attended the resident council meeting. Specifically, the attendees of the resident council meeting expressed concerns during consecutive monthly meetings without receiving a facility response. The findings are: The facility policy titled Grievance/Complaint Procedure dated 6/2024 documented the facility must consider the views of a resident group. The policy was implemented by the Social Services Department and the Administrator was listed as the Grievance Officer. The Resident Council Meeting Minutes dated 2/27/2025 documented attendees reported that nurse aides refused to take them out of bed in the morning saying they were short of staff. The attendees also requested for more mechanical lifts on the 1st Floor. There was no…

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 (NY00370712) from 4/29/25 to 5/6/25, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 3 of 3 (1st, 2nd, and 3rd Floors) resident units during environmental observation. Specifically, 1) Resident #93 had a broken closet bar preventing clothing from being hung on top of closet unit, 2) Resident #35 was not provided with a lock box resulting in the loss of funds, 3) each resident unit contained heat/air conditioning radiators were dusty, rusty, and had exposed conductor fins that were damaged and bent, 4) room [ROOM NUMBER] had missing closet doors, 5) the 3rd Floor dayroom had inadequate lighting, and 6) the 3rd floor was noisy due to a defective beeping call bell system. The findings are: The facility policy titled Resident Right - Safe/Clean/Comfortable/Homelike Environment, revised 5/2024, documented: It is the policy 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 record review and interview conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not ensure certified nurse aides were provided the required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides (#1, #2, #3, #4, #5) reviewed for nurse aide in-service training were provided 12 hours of mandatory annual in-service training or an in-service on dementia. The findings included: The facility policy titled 12 hours Certified Nurse Aide Training documented certified nurse aides required to receive 12 hours a year of in-services.During an interview on 05/01/25 at 12:53 PM, the Infection Control/Staff Educator stated today was their first day in the position. They stated they were not aware of status or location of annual in-service training documentation for certified nurse aide staff. During an interview and observation of annual in-service documentation on 05/01/25 at 3:32 PM, the Interim Director of Nursing stated they were unable to provide 12 hours 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 4/29/2025 to 5/6/2025, the facility did not ensure the attending physician, the medical director, and the director of nursing received and acted upon pharmacy irregularity reports. This was evident for and 4 (Resident #s 38, 83, 81, and 80) of 5 residents reviewed for unnecessary medication and 1 (Resident #3) of 2 residents reviewed for psych/opioid medication side effects. Specifically, pharmacy recommendations for Resident #38, #83, #81, #80 and #3 were not addressed by the attending physician.The findings are:The facility policy titled Pharmacy Services - Drug Regimen Review dated 1/2024 documented the licensed pharmacist will report and drug regimen review irregularities to the attending physician/nurse practitioner and these reports will be acted upon. The irregularities will be sent to the director of nursing for the attending physician/nurse practitioner. The policy did not document a timeline for 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 and interviews conducted during the recertification survey from 4/29/25-5/6/2025, the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage, labeling, and the expiration date. Specifically, expired medications and incorrectly labeled eyedrops were found in the medication cart on one of three units (Third Floor Unit), the medication storage refrigerator was observed unlocked and not affixed on two of two units (Second and Third Floor Units), and the medication rooms on two of two units (Second and Third Floor Units) were observed unlocked on two occasions. The findings are: The facility policy, Storage of Drugs, reviewed 8/2024 documented that all drugs requiring refrigeration are stored in the refrigerator locked in the medication room, drugs shall be accessible only to personnel designated by the facility, drugs shall not be kept on hand after the expiration date, and drug storage areas in the medication cart should not contain nondrug items. During an observation on 04/29/25 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.

Based on observation, interview, and record review conducted during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure menus were followed. This was evident for 10 of 10 (Residents #103, 48, 46, 90, 86, 66, 29, 31, 10, and 28) during Resident Council Meeting and 2 (Floor 1 and 3) of 3 resident units during Dining Observation. Specifically, 1) the Resident Council consistently reported concerns related to meal tray item accuracy in accordance with the posted menu and meal ticket, 2) multiple residents were observed at mealtime with meal tickets that did not match the items served on their meal tray. The findings are: The undated facility policy titled Dining Services documented if an incorrect meal was served to a resident nursing staff will report it to the Food Service Director/Cook Supervisors that a new food tray can be issued. The undated facility policy titled Menus documented if a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting nutritional needs. The undated facility policy titled Dining…

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, from 4/29/2025 - 5/6/2025, the facility did not adequately establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) the facility did not provide a site-specific water management plan for legionella; (2) During wound care the Licensed Practical Nurse and the Certified Nurse Aide did not wear a gown; and (3) During medication administration the nurse did not practice hand hygiene prior to administering eye drops.Findings include:The policy and procedure titled Enhanced barrier Precaution, dated 4/2024, documents this facility's policy is to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. The Policy and Procedure titled Legionella undated documents it is the policy of the facility to remain in compliance with ASHRAE 188, Section 7 to reduce Legionella growth and spread;…

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 4/29/25 to 5/6/25, the facility did not ensure annual performance reviews for nursing staff were completed at least once every 12 months. Specifically, the facility was unable to provide annual performance reviews for 5 of 5 Certified Nurse Aides (#1, #2, #3, #4, and 5) reviewed. The findings included: A facility policy titled Annual Performance Review, last revised March 2025, documented: the facility is committed to ensuring that all employees have a clear understanding of performance expectations and are provided with the necessary support to achieve their goals. Managers/supervisors will perform the review on at least an annual basis. During an interview on 05/01/25 at 12:53 PM, the Infection Control/Staff Educator stated it was their first day in the Staff Educator position. They were not aware of status or location of annual performance appraisals for staff. During an interview on 05/01/25 at 3:32 PM, the Interim Director of Nursing stated they were unable to provide annual performance…

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 4/29/2025 to 5/6/2025, the facility did not ensure reasonable accommodation of resident needs for 1 (Resident #6) of 27 sampled residents. Specifically, the door to Resident #6's bathroom was nailed shut and Resident #6 had to ambulate down the unit hallway to the bathroom located in a shower room to toilet themselves. The findings are: The facility policy titled Resident Rights dated 8/2024 documented residents had the right to dignity, respect, and a comfortable living environment. Resident #6 had diagnoses of paranoid schizophrenia, bipolar disorder, and psychosis. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 was severely cognitively impaired, did not display inappropriate behavior, was continent of bladder and bowel, and was able to toilet and dress themselves without staff assistance. On 5/1/2025 at 6:56 PM and 5/02/2025 at 2:30 PM, the bathroom door in Resident #6's room 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 interviews and record review conducted during the recertification and abbreviated surveys (NY00376085 and NY00370712) from 4/29-5/6/2025 , the facility did not ensure the resident representative/emergency contact was notified for 2 of 2 residents (Resident #8 and Resident #201) reviewed for notification of change. Specifically, Residents #8 and #201 were transferred to the hospital and their resident representative was not notified. Findings include:1) Resident #8 had diagnoses that included end stage renal disease, respiratory failure, and atrial fibrillation.Resident #8's family member was listed as the emergency contact on the contact page of the medical record.The Five Day Minimum Data Set assessment dated [DATE] documented Resident #8 had intact cognition and required maximum assistance, or dependent on staff, for most activities of daily living except eating and oral hygiene. The Facility Policy titled Notice of Transfer or Discharge, last revised October 2024, documented the facility must notify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews during a recertification survey from 4/29/25-5/6/25 the facility did not ensure a resident's right to be free from misappropriation of resident property for 1 out of 1 resident (Resident #35) reviewed for personal property. Specifically, Resident #35 was missing money which was reported to facility staff and the facility did not complete a timely and thorough investigation of the missing money. Findings include: Resident #35 diagnoses included parkinsonism, left leg above knee amputation, and peripheral vascular disease. An annual Minimum Data Set, dated [DATE] documented Resident #35 was cognitively intact. During an interview on 04/30/25 at 9:48 AM, Resident #35 stated approximately $45 which they kept in wallet on bedside table was missing. They stated they kept a bag on bedside table which contained cash and credit/debit cards. They stated they checked the bag at end of last week and noticed that cash was missing. Resident #35 stated they reported the missing cash to 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 interview and record review during the recertification survey from 4/29/25 to 5/06/25, the facility did not ensure that a resident-to-resident physical altercation with injuries was reported to the State Survey Agency for one of three residents (Resident #13) reviewed for abuse. Specifically, Resident #81 entered Resident #13's room and struck Resident #13 causing injuries to their nose and eye. The facility did not report this incident to the State Survey Agency. Findings include: The undated facility Abuse, Neglect, Exploitation Policy and Procedure Manual documents that reporting of all allege violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified times and the administrator will follow up with government agencies, during business hours, to confirm the initial report was received and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Resident #13 had diagnoses including dementia, bipolar…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the recertification and abbreviated surveys (NY00376085 and NY00370712) from 4/29-5/6/2025, the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for 2 of 4 residents (Resident #8 and Resident #201) reviewed for hospitalization. Specifically, 1) the facility did not complete a discharge notice or notification of bed hold for Resident #8 when they were hospitalized on [DATE], 3/3/2025, and 3/17/2025. The ombudsman was not notified of Resident #8's 2/2/2025 hospitalization. 2) The facility did not complete a discharge notice or notification of bed hold for Resident #201 when they were discharged to the hospital on 1/21/2025. Findings include:Resident #8 had diagnoses that included end stage renal disease, respiratory failure, and atrial fibrillation.The Five Day Minimum Data Set assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure the Resident Assessment was accurate for 2 of 8 residents reviewed for Activities of Daily Living (Resident #1, Resident #8). Specifically, for Resident # 1 and #8, the toileting hygiene coding was incorrectly, coded as not applicable. Findings include: 1) Resident #1 had diagnoses that included heart failure, dementia, and schizophrenia. The Annual Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition, toileting hygiene not applicable, and always incontinent of urine. The Activities of Daily Living Care Plan last updated 3/4/2025 documented resident dependent for cares. Interventions included maintaining optimal hygenic cleanliness as evidenced by freedom from odor, soil, and wetness. The Bowel and Bladder Continence Care Plan updated 3/4/2025 documented resident incontinent of bowel and bladder. Interventions included providing routine toileting and prompt incontinence care. 2) Resident #8 had diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the recertification survey from 4/29-5/6/2025 the facility did not ensure a comprehensive care plan was developed and implemented for 1 of 2 residents (Resident #38) reviewed for Activities. Specifically, there was no documented evidence that a care plan was developed for Resident #38's activity preferences or involvement. Findings include: The facility policy, Comprehensive Resident Centered Care Plans last reviewed 1/2025 documented that the care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. Resident #38 with diagnoses that included, but not limited to, Anxiety Disorder, Depression, and Psychotic Disorder. During an interview on 04/29/25 at 01:40 PM, Resident #38 stated the activities offered at the facility are not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the recertification and abbreviated surveys (NY00376085) conducted from 4/29-5/6/2025, the facility did not ensure that the Comprehensive Care Plan was revised to reflect the resident's current condition for 3 of 8 residents reviewed for accidents (Resident #8, Resident #9, and Resident #38). Specifically, Resident #8, Resident #9, and Resident #38's Comprehensive Care Plan was not updated to reflect falls that occurred, and the effectiveness of interventions or new interventions implemented after the falls. Findings include: The facility policy, Comprehensive Resident Centered Care Plans, reviewed 1/2025 documented it is the policy of the facility to promote interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. Care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. The…

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

Based on observations, record review, and interviews during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #53) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #53 who received hemodialysis treatments at a community-based dialysis center. The findings included: An undated facility policy titled Care of Resident Receiving Hemodialysis documented: Prompt attention must be given to the resident when they return to unit. Nursing responsibilities after hemodialysis include obtain vital signs, observe shunt site for bleeding or redness. Observe site for erythema, local warmth, swelling, exudate and unusual tenderness at graft, fistula or shunt site. Notify physician to report drainage and obtain…

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 conducted during the recertification survey from 4/29/25-5/6/2025, the facility did not ensure a medication error rate of no more than 5% during a medication administration observation when 4 of 28 opportunities of error were observed (14%) for 4 of 9 residents (Resident #1, Resident #45, Resident #74, Resident #80). Specifically, Resident #1 was administered latanoprost eye drops instead of timolol eye drops. Resident #45 was administered chewable aspirin instead of delayed release aspirin. Resident #74 was going to be administered 10 milliters of Potassium instead of 7.5 milliters until they were asked to confirm the correct amount of liquid in the cup just prior to administration. Resident #80 was going to be administered two 500 milligram tablets of Tylenol instead of two 325 milligram tablets of Tylenol until asked to confirm the dose was correct just prior to administration. Findings include: The facility policy, Administration of Medications, last reviewed 5/2024 documented that a licensed nurse will be responsible 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 interview during the recertification survey from 4/29/2025 to 5/6/2025, the facility did not ensure that an ongoing review of antibiotic use protocols and a system to monitor antibiotic use was completed for 2 of 2 residents reviewed for antibiotic use. Specifically, (Residents #95 and #205), the facility could not provide an infection/antibiotic tracking report as requested on 5/5/2025 at 4:00 PM, ensuring that their antibiotic program was implemented to monitor antibiotic use protocols when prescribed to residents. The findings are: The policy and Procedure titled Antibiotic Stewardship Program, undated, documents that it is the facility's policy to maintain an Antibiotic Stewardship Program to promote the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotics. 1. Resident #95 had diagnoses of Urinary Tract Infection, Pressure Ulcer of the Sacral Region, and Dysuria (pain when urinating). The physician's order dated 4/12/2025 documented Ciprofloxacin (antibiotic) 250 milligrams give one tablet…

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

Based on record review and interview during the recertification survey conducted 04/29/2025 to 05/06/2025, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 3 of 5 residents (Residents #14, #57, #204) reviewed. Specifically, there was no documented evidence that residents were offered, declined, or educated on the pneumococcal immunization. Findings include: The undated facility policy titled Infection Control Immunizations for Residents documents that the facility's policy ensures that the residents are offered COVID-19, Influenza, and Pneumococcal immunizations by state and federal regulations and national guidelines. 1. Resident #14 had diagnoses of Dysphagia, Acute respiratory failure with hypoxia, and Depression. The Quarterly Minimum Data Set, an assessment tool dated 2/26/2025, documented that the resident had severe cognitive impairment and needed Partial Moderate assistance with activities of daily living. The pneumococcal vaccine was not up 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 interview and record review during the recertification survey conducted 4/29/2025 to 5/6/2025, the facility did not ensure each resident was offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 2 of 5 residents (Resident #57, #204) reviewed for infection control. Specifically, there was no documented evidence they were offered, declined, or educated about the COVID-19 vaccination. Findings include: The Policy and Procedure titled COVID-19 vaccination, revised 2/26/2025, documents that the Facility's Policy supports and facilitates compliance with Infection Control best practice regarding routine vaccinations, including the COVID-19 vaccine. Resident #57 with diagnoses of Cognitive communication deficit, Depression, and Basal cell Carcinoma of the skin (Skin Cancer). The Quarterly Minimum Data Set, an assessment tool, dated 3/2/2025, documented the resident had moderate cognitive impairment. Resident #204 with diagnoses of fracture of the right femur, Depression, and Type 2 Diabetes. 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 the recertification survey from 9/5//2024 to 9/17/24, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment for 2 of 3 units. Specifically, during environmental observations on Unit 2, room [ROOM NUMBER] D had missing/broken floor molding, room [ROOM NUMBER] had a rusted/ scratched heater, and the walls had damaged sheet rock/ large gouges. The Unit 3 heater (outside the elevator) was rusty and holes were noted in the wall. The Unit 3 floor tiles near the elevator were dirty and dusty with particles. There was a strong odor of urine noted on the Unit 3 hallway on 9/11/24 and Resident #3, #27, #13 had dusty wheelchairs with ripped arm rests and caked on food. Additionally, One of two passenger elevators on the first floor was out of service and not accessible to residents and staff. The findings are: During observation on 9/05/24 at approximately 9:20 AM and through out the duration of the onsite survey, there 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 staff interviews conducted during the recertification and abbreviated surveys (NY00324750) from 9/5/24-9/17/24, the facility did not protect 5 of 6 residents reviewed for abuse from resident-to-resident abuse/mistreatment. Specifically, the facility did not implement interventions for Resident #84 after escalating behaviors were documented starting on 9/16/23 and Resident#84 punched a Staff in the face and punched Resident #73 in the face on 9/22/23. Resident #84 was sent to the hospital for evaluation. Upon return, there were no new interventions to address Resident #84's unprovoked combative behaviors and on 10/7/23 Resident#84 became combative and hit Resident #70 while being transported in a wheelchair from a shower (no injury), hit Resident #49 on the head while they were sleeping, jumped on Resident #65's bed and scratched them on the chest ripping shirt, jumped on Resident #103's bed and repeatedly punched them in the face and arms opening an abscess on 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.

Based on observation, record review and interview conducted during the Recertification and Abbreviated Surveys (NY 00327092, NY 00324750 and NY 00333010) from 9/5/24-9/17/24, the facility did not ensure for 3 (Residents #104, #45, and #73) of 9 residents reviewed for abuse, that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Agency in accordance with State law through established procedures. Specifically, 1) For Resident #104 there was no documented evidence that an injury of unknown origin was reported by the facility to the state agency after the family representative reported bruises to the resident's hands; 2) For Resident #45 the facility did not report a 2/4/24 resident reported allegation of staff to resident abuse to the State Agency until 2/7/2024; and 3) For Resident #73 the facility did not report an allegation of resident to resident abuse to the State Agency within the two hour timeframe for 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 and Abbreviated Surveys (NY 00327092,), the facility did not ensure for 1 (Residents #104) of 9 residents reviewed for abuse, that all alleged violations involving abuse, mistreatment, or neglect, were thoroughly investigated. Specifically, Resident #104's family member reported to nursing on multiple occasions that they observed bruises to Resident 104's hands which resulted in x rays being done, and the injuries of unknown origin were never investigated by the facility. The findings are: The facility policy titled Resident Accident/Incident Report Policy that was undated documented that if a cause of injury is unknown, the Nursing supervisor is responsible for initiating the investigation into the possible cause. Resident #104 was admitted with diagnoses including but not limited to Anxiety Disorder, Dementia, and Hypokalemia. The 8/2/23 Significant Change Minimum Data Set, dated [DATE] documented that resident had…

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 and Abbreviated Surveys (NY 00324324) from 9/05/24 to 9/17/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 1(Residents #10) of 10 residents reviewed for accidents. Specifically, Resident #102 who had a history of exit seeking behaviors, eloped on 9/18/23 during the night shift, and was found in the early morning hours by the police department at an address away from the facility's property. The findings are: The facility policy titled Elopement/Missing Resident dated 04/2017 and updated on 8/2022 documented that immediately the resident unit is to be searched thoroughly, including bathrooms, closets, behind and under beds, behind privacy curtains, and in any room that is accessible. The facility policy titled Elopement Screening Policy and Procedure dated 04/2017 and updated 8/2022 documented the Individualized Care Plan will include the following interventions at minimum: identification 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 during a recertification survey from 9/5/24 to 9/17/24, the facility did not ensure residents had the right to a dignified experience for 3 of 6 residents. (Residents #80, #401 and # 97) reviewed for dignity. Specifically, 1.) A Registered Nurse was observed standing over Resident #80 and Resident #97 while assisting the residents with their meals. 2.) Resident #401 was observed in the dining room with other residents while wearing a hospital gown and/or sweatshirt with no pants. and 3.) On 9/12/24 on the first floor hallway outside room [ROOM NUMBER] (a resident's room on unit one) Certified Nurse Aide #11 verbally labelled the residents who needed to be fed as Feeders. The findings include: The Facility policy titled Residents' Rights dated 8/22 documented protect the dignity and well-being of the residents by providing a dignified, respectable and a comfortable living environment. 1. Resident # 80 was admitted to the facility with diagnoses including…

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

Based on interview, and record review conducted during the recertification survey from 9/05/2024 to 9/17/2024, the facility did not ensure residents had a right to organize and participate in resident groups in the facility. Specifically, during a Resident Council meeting on 9/9/2024 at 11:32 AM, Residents #96, #66, #88, #70, #30, #4, #33 and #10 stated it had been a couple of months since they last attended a resident council meeting, because they did not know who should be assisting them. There were no documented resident council minutes for April-July 2024. The findings are: Policy and Procedure dated 10/2020 documented per the regulation found at §483.10(f)(5), residents of a skilled nursing/long term care facility have a right to organize and participate in resident groups in the facility. The Facility promotes the residents' participation in the Resident Council meeting. During a survey scheduled Resident Counsel meeting on 09/09/24 at 11:32 AM attending residents stated it had been a couple of months since the last Resident Council meeting. The residents stated the activities…

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 conducted during the Recertification survey from 9/05/24 to 9/17/24, the facility did not ensure resident Comprehensive Care Plan was reviewed and revised upon each assessment. This was evident for 2 of 10 residents reviewed for care planning (Resident #31, Resident #88). Specifically, 1) Resident #31 at risk for falls did not have their comprehensive care plan related to falls updated to reflect current interventions in place to prevent falls. 2) Resident #88 did not have documented evidence of quarterly care plan meetings or updates since 2/27/24. Findings include: The facility policy and procedure Comprehensive Care Plan dated 2/2024 documented the care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate. The Interim Interdisciplinary Care Plan will be located in the care plan section of the Medical Record. It is our purpose to ensure that each resident is…

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 interviews and record review conducted during the Recertification and Abbreviated Survey (#NY 00345570) from 9/5/24-9/17/24 the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) Several residents reported in a group meeting (Resident Council) that the facility was short staffed especially on various shifts and weekends which resulted in a lack of timely staff response to call bells 2) several nursing staff reported a lack of sufficient staff. 3) resident family members reported staff were not visible during their visits to the facility and 4). an analysis of the actual staffing schedule showed that on multiple occasions from the month of June 2024, and August 5 2024 through September 5 2024, the facility was below their minimum staffing levels. The Facility Assessment documentation for nursing staff was below the minimum requirement to care for a capacity of 120 residents. The findings are: The 8/12/24 Facility Assessment Tool reviewed and approved by the Administrator 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.

Based on observation, record review, and interviews conducted during the recertification survey on 9/5/2024 - 9/17/2024, it was determined that the facility did not have a process and frequency by which the administrator reported to the governing body, the method of communication was not recorded, and the governing body did not establish and implement procedures for a clear line of communication regarding the management and operation of the facility. Furthermore, due to this lack of communication to the governing body, they did not ensure that the call bells on unit 300 (3rd floor) were in working order and in regulatory compliance. Specifically, it was revealed during the survey that the call bell system had been non-functional since April of 2024 and there were no plans in place to correct the issue, as well as no documentation to show that this issue was brought up or addressed in any Quality Assurance Performance Improvement meetings. The facility did not provide documented evidence of a Quality Assurance Performance Improvement plan/action to address identified issues related…

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, observation and interviews conducted during the recertification survey from 9/5/24 to 9/17/24, the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues that impacted resident safety or ensured corrective actions addressed gaps in systems, and were evaluated for effectiveness; and that clear expectations were set around safety, quality, rights, choice, and respect. Specifically, the centralized call bell system had not been working since April of 2024. The facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the central call bell system being out of service. On the 3rd Floor Unit residents were unable to call for assistance when necessary while in their rooms or when using their bathrooms. Family that were visiting were unable to call for staff assistance if…

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 and abbreviated survey (NY 00345570) from 9/5/24-9/17/24, the facility did not ensure that a copy of the Notice of Transfer and Discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman or that a resident's representative was immediately notified when the decision was made to transfer the resident from the facility to the hospital, for 2 of 3 residents (Residents #100 and # 34) reviewed for notification requirement before transfer/discharge. Specifically, 1. Resident #100 was discharged to another facility in July 2024 and there was no documented evidence the Ombudsman had been notified and 2. Resident # 34 was transferred to the hospital on 6/10/24 and there was no documented evidence in the electronic medical record to indicate the resident's Health Care Proxy was notified. The findings are: The facility policy titled Notice of Transfer or Discharge11/2023, revised 3/4/24 documented the facility would adhere to the office of the State Long Term Care Ombudsman practices…

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

Based on observation, interview, and record review during the Recertification Survey from 9/5/2024 to 9/17/2024, the facility did not ensure that each resident received an accurate assessment, reflective of the residents status for 1 of 6 residents reviewed for Activities of Daily Living and 1 of 1 resident reviewed for Respiratory Care (Resident #22). Specifically, the 8/8/24 Quarterly Minimum Data Set Assessment for Resident #22 did not accurately code/capture the residents impaired vision and use of oxygen. The Findings Are: Resident # 22 was admitted with diagnoses including but not limited to chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, and adult failure to thrive. The 3/12/24 admission Minimum Data Set documented Resident #22 was cognitively intact and had highly impaired vision. The 5/27/24 Physician Order documented continuous oxygen 2 liters continuous. The 8/24 Administration Record documented continuous oxygen 2 liters via nasal cannula was administered. The 8/8/24 Quarterly Minimum Data Set documented Resident #22 was cognitively intact,…

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

Based on observation, record review, and interview during the recertification survey conducted 9/05/2024 through 9/17/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Residents # 40) reviewed for pressure ulcers, and 1 of 5 residents (Resident #19) reviewed for unnecessary medications. Specifically, 1.) Resident #40 was not care planned for an actual Pressure Ulcer and 2.) Resident #19 did not have a plan of care in place to address the residents needs for Psychotropic drug use. Findings Include: Policy and Procedure: dated 2/2024 The care plan will contain information about the physical, emotional/psychological, psychosocial, spiritual, educational and environmental needs as appropriate. The Interim Interdisciplinary Care Plan will be located in the care plan section of the Medical Record. It is our purpose to ensure that each resident is provided with…

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

Based on observation, interview and record review conducted during a recertification and abbreviated surveys (NY 00327092 and NY 00337480) from 9/5/24 to 9/17/24, the facility did not ensure residents received the necessary assistance for bathing to maintain personal hygiene for 2 of 6 residents (Resident #104, and #105), reviewed for activities of daily living. Specifically, 1. Resident #104 did not receive 41 scheduled showers between May 2023 and September 2023 and 2. Resident #105 did not receive 12 scheduled showers between December 2023 and January 2024. Additionally, there was no documented evidence that skin checks were consistently done as per physician order for Resident #105. Findings include: The facility policy for showering dated 2015 and updated 6/23 documented each resident will be offered a shower minimally twice a week, with consideration of personal preferences and facility care routine (i.e. appointment) when scheduling. The purpose of weekly showering is to promote good hygiene, cleanliness, freedom from odor, stimulation of skin and protection of 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 interview conducted during the recertification survey from 9/5/2024 to 9/17/2024, the facility did not ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 7 residents (Resident #401) reviewed for pressure ulcers. Specifically, For Resident #401 with a left foot wound, treatments and weekly skin checks were not consistently documented as per physician order and/or care plan, a physician order was not obtained as per wound round recommendations for the implementation of heel booties and an air mattress, and Resident #401 was observed wearing a left air heel boot with velcro straps without a physician order. The Findings Are: Resident #401 was admitted on [DATE] with diagnoses including but not limited to Repeated Falls, Unspecified Dementia, and Pressure Ulcer of Left Heel. The 8/21/24 Care Plan titled Skin Integrity related 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, record review, and interview during a recertification survey conducted (9/5/2024-9/17/2024), the facility did not ensure the provision of nutrition and hydration care and services for 1 of 5 residents reviewed for Nutrition (Residents # 22). Specifically, the facility did not ensure that For Resident #22 with a 9.79 % weight loss over 6 months, that meal intake was consistently monitored as per care plan. Additionally, Resident #22 with impaired vision was not reassessed to determine the level of assistance needed during meal intake. This is evidenced by: Resident # 22 was admitted with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Neuromuscular Dysfunction of Bladder, and Adult Failure to Thrive. The 3/5/24 Activities of Daily Living Care Plan documented eating supervision set up. The 3/6/24 Dietary Nutrition Risk Care Plan documented at risk for altered nutrition related to advanced age, variable by intake 25-75% and Body Mass Index of 17.2 indicative of underweight status interventions continue ensure plus three times daily,…

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, observation and interview during the Recertification Survey the facility did not ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 of 1 resident reviewed for Respiratory Care (Resident #22). Specifically, Resident #22 with a physician order to receive continuous oxygen 2 liters/min was administered oxygen 3 liters/min via nasal cannula. The findings are: Resident #22 was admitted with diagnoses including Coronary Artery Disease, Congestive Heart Failure and Asthma. The 3/5/24 Care Plan titled Cardiovascular Disease documented provide oxygen as ordered, encourage resident to elevate head as needed. The 5/27/24 Physician Order documented continuous oxygen 2 liters/min The 8/08/24 Quarterly Minimum Data Set documented Resident #22 was cognitively intact, and did not receive oxygen therapy. The September 2024 Medication Administration Record documented continuous oxygen 2 liters/min was administered every shift. There was no documented evidence in the Medication Administration…

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 and Abbreviated Surveys (NY 00324324 and NY 00327092) from 9/05/24 to 9/17/24, the facility did not ensure that the Physician reviewed the resident's total program of care, including medications, and treatments, at each visit for 1 of 10 residents reviewed for Accidents (Residents #102) and 1 of 1 residents reviewed for Change of Condition (Resident #104). Specifically, 1.) Resident #102 who was assessed at high risk for elopement during the 8/12/23 admission, had no physician order in place for placement and checking the function of a wander guard 2.) Resident #104 who was admitted to the facility on [DATE] from the hospital, had no physician order for Oncologist follow up within 1-2 weeks and repeat Computed Tomography Scan within 3-6 months as per Hospital Discharge Instructions. The findings are: The facility policy titled Physicians Visits and Responsibilities dated 10/2023 documented that the intent of these visits is…

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

Based on interview, and record review conducted during the Recertification Survey from 9/5/24-9/17/24, the facility did not ensure each Certified Nurse Aide received twelve hours in-service education per year based on their individual performance review for 8 of 8 Certified Nurse Aides (#6, #11, #22, #31, #32, #33, #34, and #35) randomly selected for review of 12-hour yearly mandatory in-services and yearly performance reviews The findings include: The 8/12/24 Facility Assessment documented education was provided to staff mostly done by the Director of Nursing/Staff Educator. Several sessions were scheduled to allow the staff to attend on all shifts. The sessions were held regularly to include mandatory education per regulation, as well as new topics or topics needing re-education. There was no documented evidence that Certified Nurse Aides #6, #11, #22, #31, #32, #33, #34, and #35 had performance reviews completed at least once every 12 months. During an interview on 9/13/24 at 10:00 AM, the Director of Nursing stated the Certified Nurse Aide education was done by the cooperate…

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

Based on interview and record review conducted during the Recertification Survey completed on 9/5/24-9/17/24, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing or that the attending physician documented in the medical record that the identified irregularities had been reviewed and what action should be taken for 3 of 5 residents reviewed for unnecessary medications (# 89, #83, and #19 ). Specifically, 1) Resident # 89 had no documented follow up for drug regimen reviews from 3/24-8/24. 2) Resident # 83 had no documented follow up for drug regimen reviews from 3/24-8/24 and 3)Resident #19 had no documented follow up for drug regimen reviews dated 3/21/24 and 4/15/24. The findings are: 1)Resident # 89 had diagnoses including but not limited to Metabolic Encephalopathy, Type 2 Diabetes, and Dysphagia The 1/29/24 Care Plan titled Psychiatric Drug Use documented assess behavior daily, and psychiatric management. The 7/16/24 Quarterly Minimum Data Set (an assessment tool)…

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 and Abbreviated Surveys(NY 00337480) from 9/05/24 to 9/17/24, the facility did not ensure residents were free of significant medication errors for 2 of 8 residents reviewed for medications (Residents #105 and #19). Specifically, 1.) Resident #105 had multiple medication omissions on the Medication Administration Record including antihypertensive's, antibiotics, antidepressants, antianxiety, and thyroid hormones and 2.) Resident #19 had multiple missed does of Insulin (medication used to lower blood sugar levels in people with Type 2 diabetes mellitus). The findings are: The facility policy titled Administrations of Medications last reviewed on 10/23 documented that Medications administration must be charted in the Medication Administration Record immediately before going on to the next resident. If a medication is not given for any reason, the nurse must document appropriately; the reason medication was not given…

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

Based on observation, record review and interview during the recertification survey conducted from 09/5/24-09/17/24, the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards. Specifically, 1) a cupful of morning medications was left for Resident #45 on their bedside table while the resident was in the bathroom and 2) Dakins' solution and a tube of Silver Sulfadiazine were left on Resident # 90s bedside table. The findings are: 1. Resident #45 had diagnoses of hepatic encephalopathy, hypothyroid and neoplasm of breast. The 9/5/24 Physician Order documented Resident #45 received Aldactone 25 mg, Vitamin E 268 mg, Ursodiol 300mg capsule, Tramadol 250mg, Propranolol 10 mg, Amlodipine 5mg, Gabapentin 100 mg and Acidophilus at 09:00 AM. During an observation on 9/05/24 at 10:35 AM Resident #45 was in the bathroom and a cup with approximately ten pills were observed on the resident's bedside table. The nurse was not in the resident room. During an interview on 9/5/24 at 10:40 AM Resident #45 poured 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, record review and interview conducted during a recertification survey 09/05/24-09/17/24, the facility did not ensure that the necessary dental services were provided in a timely manner for 1 of 1 resident (Resident #70) reviewed for dental services. The findings are: Resident #70 was admitted to the facility on [DATE] with diagnoses and conditions including Dementia, Major Depressive Disorder, and Cerebrovascular Accident. The 6/22/24 Annual Minimum Data Set (a resident assessment tool) of 6/22/24 documented Resident #70 had intact cognition, performed oral care independently and had no natural teeth. During interview on 9/6/24 in the late morning Resident #70 stated that they did not have teeth and had not seen a dentist. During an interview on 09/17/24 at 10:30 AM Licensed Practical Nurse #27 stated when a resident is admitted to the unit they will be seen by the dentist on their next routine visit. When the in-house dentist arrives, they will ask the nurses for a list of new residents.…

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 9/05/24 to 9/17/24, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, there was open and undated food located in the walk-in refrigerator, there were two metal trays with chicken and tuna salad that passed length of storage and expired half pint boxes of low-fat milk. There were two opened and expired orange juice boxes. In the walk-in freezer there were two boxes of frozen chicken thighs without expiration dates. One of these two boxes was opened to air without the date of opening. In the dry food storage there were Mac orzo and egg noodle pastas' loose in plastic bags without expiration dates. Finding include: The facility policy Food Receiving and Storage which was last revised on 09/2024 documented expired items will be discarded, refrigerator storage of potentially hazardous foods or time/temperature control for safety foods, required time/temperature control for safety to limit the growth of pathogens or toxin…

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

Based on observation, record review, and interview during the recertification survey conducted 9/05/2024-9/17/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #3 and # 63) reviewed for pressure ulcers. Specifically, 1) Signs identifying resident needs for enhanced barrier precautions or any personal protective equipment were not placed outside the room of Resident #3 with a pressure ulcer and 2) staff were observed not wearing the required personal protective equipment while completing a dressing change for Resident #63 with a stage 4 pressure ulcer. Findings include: A Policy and Procedure titled Enhanced Barrier Precautions date 4/2024 documented; it is the policy of this facility to implement enhanced barrier precautions. Enhanced Barrier Precautions require the use of gowns and gloves for certain residents for high contact resident care activities.…

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 F656-Care Plan Based on observation, record review, and interviews conducted during an abbreviated survey (NY00315819), the facility did not ensure that a Comprehensive Care Plan (CCP) were followed for 3((Residents #4, #5 & #6) of 11 residents reviewed. Specifically, during observation on 4/4/2024 from 12:09 PM to 12:27 PM Residents #4, #5 and #6 who were care planned as needing supervision and/or limited assistance when eating lunch without staff present for supervision. The findings are: Review of facility Quality of Care Policy and Procedures revision date 4/2024, documented the intent to ensure each resident receive the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with the comprehensive assessment plan of care, in accordance with state and federal regulations. (7.) The facility will ensure the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision 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, record review, and interviews conducted during an abbreviated survey (NY00315819), the facility did not ensure residents received adequate supervision to prevent an avoidable accident from occurring. This was evident for three (Residents # 4, #_5, & #_6) of eleven residents reviewed for accidents. Specifically during an observation on 4/4/2024 from 12:09 PM to 12:27 PM Residents #4, #5 and #6 was eating lunch with no staff supervision in the dinning rom during lunch. The findings are: Review of facility Activities of Daily Living Policy and Procedures revision date 9/2023, documented the intent of policy to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and department understand the principles of quality of life and honor and support these principles for each resident: and that the care and services provided are person-centered, and honor support each resident's…

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 an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), it cannot be ensured that the facility disclosed the service limitations to residents and potential residents. This was evident for 7 (Resident #1, #2, #3, #4, #5, #6, #7) out of 10 residents reviewed for notification. Specifically, on 11/28/2023 a water restriction was issued due to the presence of legionella bacteria in the facility's water system. There was no evidence of consistent notification to residents and their families regarding water restriction implementation, the potential risk for legionnaires disease, and the steps being taken by the facility to resolve the issue. The findings are: Review of the Resident Council Minutes dated 11/28/2023, and 12/28/2023 revealed that the issues legionella contamination in the facility water system was not discussed, the water restriction implementation, steps taken by the facility to resolve the issue or guidelines on 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, record review and interview during an Abbreviated survey(NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure that sanitary conditions were being maintained in the kitchen. Specifically, on a tour of the kitchen, the single rinse water temperature gauge on the dishwashing machine was not reaching appropriate temperature, specifically the wash cycle was not meeting temperatures of 165 degrees Fahrenheit (°F). The findings are: On 1/26/24 at 2:05 PM, observed use of the dishwashing machine twice with maximum wash cycle temperatures of 142 °F. The facility did not provide a policy and procedure on kitchen sanitary procedures or dishwashing procedures. A manual with manufacturer's instructions for the dishwasher was not provided during the survey. Without the manual, it could not be determined if the machine was a high temperature machine or if the sanitizing solution was at the appropriate levels. Documentation of the dishwasher temperature logs were not located during the survey. Documentation of the sanitizing solution logs were not…

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

Based on observation, record review and interview conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility was not administered in a manner that enables the use of its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 11/28/2023 a water restriction was issued due to positive legionella bacteria in the facility's water system: (1) the Facility Assessment (FA) was not reviewed or updated to address how the facility can meet the needs of the residents and facility staff; and (2) the facility did not ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified issues with the facility's water system; The findings are: (1) Review of the Facility Assessment submitted by the facility revealed an assessment/update date on 11/30/2020 and 08/15/2023. There was no documented evidence that the Facility Assessment was reviewed/revised after 08/15/2023.…

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 (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure that it updated and reviewed their facility assessment (FA) annually, or updated any changes in the facility resources and services necessary to provide for the needs of residents. Specifically, (1) the Facility Assessment was not reviewed or updated from 11/31/2020 to 08/14/2023; and (2) the Facility Assessment was not reviewed or updated to address how the facility will meet the needs of the residents and facility staff after they determined on 11/28/2023 that the potable water system was contaminated due to the presence of legionella and were directed by the state and local health departments to implement water restrictions throughout the building. There was no documented evidence that the Facility Assessment was reviewed/revised after 08/15/2023. The findings are: Review of the Facility Assessment submitted by the facility revealed an assessment/update date on 11/30/2020 and 08/15/2023. There was no documented evidence that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified issues with the facility's water system. Specifically, a water restriction was implemented due to water system contamination with legionella bacteria on 11/28/2023, and members of the Quality Assurance Performance Improvement committee were made aware that the water system was not functional. No quality assurance measures were put in place to identify or address the water issue and to ensure clinical staff and residents were educated on interventions/plans to address the problem during their meeting on 12/19/2023. The facility did not provide documentation for any meetings held to address the ongoing water problem. The findings are: The facility undated Quality Assurance Performance Improvement Plan documented that 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, record review and interviews conducted during an abbreviated survey (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not ensure infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, on 11/28/2023 the facility detected Legionella in their water system. As a result, the facility was directed by state and local health departments to implement water restrictions throughout the building. 1) On 01/26/2024 the kitchen staff were observed using unfiltered tap water for hand washing. There was no signage instructing staff not to use unfiltered tap water to prevent the spread of legionella; 2) During an observation on 01/29/2024 at 1:20 PM of medication administration performed by Licensed Practical Nurse #1 (Staff #10), water bottles were not readily accessible in resident rooms in case hand washing became necessary; 3)…

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 (NY00331049, NY00330977, NY00330997, NY00331846), the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility was unable to provide an infection/antibiotic tracking report as requested on 01/25/2024. In addition, the Infection Control Preventionist (Staff #13) stated that there was no infection / antibiotic tracking in place in the facility. The findings are: The facility policy titled Infection Control - Antibiotic Stewardship reviewed/revised on 08/2021, 09/2022, 04/2023 documented that it is the intent of the facility to support the judicious use of antibiotics in accordance with Stage and Federal Regulations, and national guidelines. The Policy Procedure documented the following: (1) the facility will establish protocols for antibiotic prescribing in accordance with national guidelines and treatment protocols; (2) The facility will establish algorithms for appropriate diagnostic testing (i.e.…

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 an abbreviated survey (NY00323727) the facility failed to provide diabetic management according to acceptable standards of care to ensure residents remained free from hypoglycemic( caused by lw blood sugar) reactions for 1 of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 had a diagnosis of Diabetes Mellitus (DM) and had a physician order for blood sugar (BS) testing twice a day, to notify provider if BS less than 70 or above 250. The facility did not provide monitoring of Resident #1's (BS) levels as ordered on 9/8/2023 at 4PM and no BS levels documented on 9/1, 9/2/, 9/3, 9/4 and 9/5. There was no evidence that the physician or nurse practitioner was notified. Resident #1 was transported to the hospital on 9/8/2023 where they were admitted and diagnosed with Hypoglycemia. The Facility Undated Policy and Procedures titled Diabetes Management documented Physician/NP will review resident's diabetic…

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.