NYS Veterans Home in NYC

Based on record review and interview conducted during an abbreviated survey (# 2623262), the facility did not ensure they reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident. This was evident for one (1) of three (3) residents (Resident #1) reviewed. Specifically, the results of the investigation for Resident #1 was not submitted to the New York State Department of Health within five working days of the incident.The findings are: The facility policies titled 'Prevention of Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property' dated 01/2025 and 'Resident's Accidents Investigation and Reporting dated 8/25 did not document a report of the result of the investigation should be submitted to the Department of Health within five (5) working days of the incident. Resident #1 had diagnoses which included Dementia, Alzheimer's Disease, and Parkinson Disease. The Accident…

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 during abbreviated Survey (NY00361611, NY00363114), the facility did not protect a resident's right to be free from physical abuse by nursing home staff. This was evident in two out of seven residents sampled (Resident #1 and #4). Specifically, on 12/04/2024 at 10:37 AM, the facility's surveillance camera recording was reviewed and showed on 11/23/2024 at 3:00 PM, there was a physical altercation between Resident #1 and Security Guard #1. The facility's investigative notes dated 11/27/2024, documented on 11/23/2024, Registered Nurse Supervisor #1 and Registered Nurse #1 observed Security Guard #1 grabbed Resident #1 by the collar of Resident #1's clothes and held Resident #1 against the wall. There were no injuries to Resident #1. Specifically, on 12/03/2024 at 9:30 PM, the Facility's Incident Report documented Certified Nursing Assistant #3 reported to Registered Nurse #3 that Resident #4 was combative and refused personal care. Registered Nurse #3 accompanied…

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 conducted during the Recertification survey from 05/09/2024 to 05/16/2024, the facility did not ensure food was stored, prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during kitchen observation. Specifically, milk was stored above 41 degrees Fahrenheit and expired food was observed in the dry storage room in the kitchen. The findings are: The facility policy titled Food Service Sanitation Guidelines dated 4/2024 documented if potentially hazardous food exceeded 41 degrees Fahrenheit for more than 2 hours, discard the food. On 05/09/2024 at 09:50 AM, the kitchen was observed with the Dining Services Director. Refrigerator #3 was observed with milk and eggs on the shelf and the refrigerator thermometer read 51 degrees Fahrenheit. The dry storage room was observed with 6 5-pound bags of instant mashed potatoes with a expiration date of 5/4/2024. During an interview on 05/13/2024 at 12:58 PM, Food Service Worker #1 stated they forgot to label 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 observations, record reviews, and interviews, conducted during the Recertification survey from 05/09//2024 to 05/16/2024, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent infection and promote healing. This was evident for 1 (Resident #139) reviewed for Pressure Ulcer Injury out of 38 sampled residents. Specifically, during wound care observation, Resident #139 did not receive the physician ordered pressure ulcer treatment. The findings are: The facility policy titled Pressure Ulcer Injury and Wound Prevention dated 4/2022 documented that the residents of the facility will have a pressure injury prevention and intervention program to identify risk factors, prevent pressure ulcer formation, when possible, and promote skin integrity, as well as implement interventions to heal existing pressure ulcer injury, prevent infection, and prevent new ulcer/ injuries from developing. Resident #139 had diagnoses of unhealed pressure ulcers 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.

Based on observations, record review, and interviews conducted during the Recertification Survey from 05/09/2024 to 05/16/2024, the facility did not ensure infection control practices were maintained. This was evident for 2 (Pine Unit and Maple Unit) of 6 floors. Specifically, 1) Certified Nursing Assistant #6 did not perform hand hygiene and did not sanitize the blood pressure cuff in between each resident use and 2) Certified Nursing Assistant #7 did not sanitize the blood pressure cuff in between resident use. The findings are: 1) On 05/09/2024 at 11:26 AM and 11:36 AM, Certified Nursing Assistant #6 was observed rolling the blood pressure machine to Resident #90 in the Pine Unit floor dayroom. Certified Nursing Assistant #6 did not perform hand hygiene and did not sanitize the blood pressure cuff before applying the cuff to Resident #90's right arm. After obtaining Resident #90's blood pressure reading, Certified Nursing Assistant #6 removed the cuff, did not perform hand hygiene, did not sanitize the cuff, and applied the blood pressure cuff to Resident #49's left arm. After…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated (NY00334937) survey from 5/9/2024 to 5/16/2024, the facility did not ensure services provided met professional standards. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, Licensed Practical Nurse #5 did not inform the Registered Nurse and Medical Doctor when Resident #24 had a fall incident. The findings are: The facility's policy titled Standards of Nursing Practice and Nursing Care dated 1/22/2022 documented standards of care employed by the nurse includes implementing nursing actions and interventions that promote, maintain, and or restore physical and mental health, prevent illness, and effect rehabilitation and recovery and/or enhance quality of life. Resident #24 had diagnoses of cerebral infarction and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #24 had severely impaired cognition. A Nursing Note dated 3/1/2024 documented Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated (NY00334937) survey from 5/9/2024 to 5/16/2024, the facility did not ensure a resident received quality of care. This was evident for 1 (Resident #24) of 38 total sampled residents. Specifically, Licensed Practical Nurse #5 did not inform the Registered Nurse when Resident #24 sustained a fall, delaying an assessment of the resident's condition and potential injuries. The findings are: The facility's policy titled Standards of Nursing Practice and Nursing Care dated 1/22/2022 documented standards of care employed by the nurse includes implementing nursing actions and interventions that promote, maintain, and or restore physical and mental health, prevent illness, and effect rehabilitation and recovery and/or enhance quality of life. Resident #24 had diagnoses of cerebral infarction and atrial fibrillation. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #24 had severely impaired cognition. A Nursing…

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 Complaint Survey ( NY00336934 & NY0032139 ) from 5/9/2024 through 5/16/2024, the facility did not ensure that the resident environment remains as free of accident hazards. This was evident for 2 (Resident #72 and #33) of 38 total sampled residents. Specifically, 1) Certified Nursing Assistant #5 transferred Resident #72 without assistance and the resident required 2 person assistance for transfer, and 2) Resident #33 was not adequately supervised to prevent them from being found outside the building unsupervised on 8/2/2023 and from being missing for over an hour on 3/5/2024. The findings are: The Facility's Policy and Procedure titled Wandering and Elopement: Risk Assessment and Interventions dated last reviewed 5/2024, documented it is the policy of the home to ensure that the resident environment remains free as free from accident hazards as is possible and that 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 record reviews and interviews conducted during the recertification and complaint survey (NY00336988) from 05/09/2024 to 05/16/2024, the facility did not ensure that all residents were free of significant medication errors. Specifically, Resident #109 did not receive antianxiety medication in accordance with Physician's Orders. The findings are: The facility policy titled Medication Administration General Procedure dated 04/2022 documented medications are to be charted as soon as they are given. Resident #109 had diagnoses of schizoaffective disorder and anxiety. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident @109 was cognitively intact. The facility Investigation Report documented Resident #109 was ordered to receive Ativan, an antianxiety medication, at 10 PM on 3/24/2024. The blister pack count at the beginning and end of the evening shift (3PM to 11PM) was 9 pills of Ativan, indicating that the 10PM dose of Ativan was not administered. The facility investigation concluded 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, record review, and interview, the facility did not ensure the Minimum Data Set 3.0 (MDS) assessment accurately reflected the resident's status. This was evident for 1 of 5 residents reviewed out of a total 32 sampled residents (Resident #99). Specifically, Resident #99's evaluation for Gradual Dose Reduction (GDR) of psychotropic drugs was documented in the MDS. The findings are: The facility policy titled MDS, and Care Area Assessment (CAA) Process dated revised 09/2016 documented that MDS and CAA must be completed prior to the care plan meeting. Resident #99 had diagnoses of non-Alzheimer's dementia, depression, post-traumatic stress disorder (PTSD). The MDS dated [DATE] and 03/15/2022 documented Resident #99 was severely cognitively impaired, GDR was not attempted, and the GDR was not documented by a physician as clinically contraindicated. Physician's Orders (MDO) dated 07/21/2021 documented Resident #99 was prescribed Olanzapine 5 mg twice daily. On 11/19/2021, MDO documented…

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