Northeast Ctr For Rehabilitation And Brain Injury

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during the recertification survey from 11/13/24 to 11/21/24, the facility did not ensure residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, for two of three residents (Resident #8 and #104) reviewed for Beneficiary Protection the facility did not ensure the Notice of Medicare Non-coverage form CMS-10123 was provided to the resident and/or representative at a minimum of two days prior to the end of Medicare Part A covered services. The findings are: The undated Facility Policy titled Notice of Medicare Non-Coverage documented when a resident is no longer eligible for skilled coverage under Medicare Part A, the facility must issue a Notice of Medicare Non-Coverage to the resident or their legal representative with a minimum notice of two days. If the resident is incompetent deliver the Notice of Medicare Non-Coverage to the resident's legal representative. You must notify them 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 observation and interview conducted during the recertification survey from 11/13/24 to 11/21/24, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior were provided. Specifically, 1) room [ROOM NUMBER] A/B had soiled walls with chipped paint/scratches/holes, garbage can was soiled/privacy curtains were stained and 2) feeding tube pumps and/or poles contained dried formula for five residents (#35, #193, #172, #215, #150) on the VENT unit. The findings are: 1) On 11/13/24 at 11:31 AM room [ROOM NUMBER] B was observed to have walls in disrepair with holes, scratches, and chipped paint. The room had an odor of urine. On 11/13/24 at 11:32 AM room [ROOM NUMBER] A was observed to have walls soiled with stains, and areas of disrepair such as chipped paint, holes, and scratches. The privacy curtain was soiled and stained. The wall near the garbage and dresser had brown soiled stains on it. The dresser and garbage were also soiled…

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, record review conducted during the recertification and abbreviated (NY00348027 and NY00340876) from 11/13/2024 to 11/21/2024, the facility did not ensure baseline care plans were developed and implemented for each resident. This was evident for 3 (Resident #676, #677, and #208) of 41 total sampled residents. Specifically, 1) a baseline care plan was not developed for Resident #676 upon their admission to the facility on 5/17/2024, 2) a baseline care plan was not developed for Resident #677 upon their admission to the facility on 4/10/2024, and 3) a baseline care plan was not developed within 48 hours of Resident #208's admission to the facility. The findings are: The facility policy titled Baseline Care Plan dated 2/2024 documented the baseline care plan must be developed within 48 hours of admission or readmission. 1) Resident #676 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis (a neurodegenerative disease) and respiratory failure. 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 the recertification and abbreviated (NY00344233 and NY00340876) surveys from 11/13/2024 through 11/21/2024, the facility did not ensure 3 of 3 residents (#573, #677 and # 87) reviewed for quality of care received treatment and care in accordance with the professional standards of practice. Specifically, 1) a follow-up Urology appointment was not provided for a newly placed suprapubic catheter for Resident #573, 2) Resident #677 did not receive a Neurology consultation as recommended in their hospital discharge instructions and 3) Resident #87 with limited range of motion of bilateral lower extremities was observed in a high back chair, sliding down with their buttocks resting at the end of the seat, both knees were bent/both feet were positioned behind the knees. The findings are: The facility policy titled Admission/readmission of the Resident Neighbor dated 5/2024 documented licensed staff verified orders with the Physician, transcribed orders,…

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 11/13/2024 to 11/21/2024, for one (Resident #208) of ten residents reviewed for nutrition, the facility did not ensure services were provided to maintain acceptable parameters of nutritional status. Specifically, for Resident #208, weight measurements were not obtained timely as per physician order when a significant change in weight occurred. The findings are: Resident # 208 had diagnoses including Cerebral Infarction, Acute Respiratory Failure, and Type 2 Diabetes. The Physician orders dated 10/24/24 documented weigh on admission, weekly weights from 10/24/24-11/14/24, then monthly weights. The 10/24/24 weight documented Resident #208 was 183 lbs. The 10/30/24 admission Minimum Data Set (an assessment tool) documented Resident #208 had severely impaired cognition, was dependent with all activities of daily living and had no weight loss. The 11/1/24 weight documented Resident #208 was 181.2 lbs. The 11/7/24 weight documented Resident #208 was 166.0 lbs. (This was a 9.29% weight…

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 staff interviews and review of facility records during the recertification and abbreviated surveys (NY00348027, NY00343016, NY00357012) from 11/13/24 through 11/21/24, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, two of five randomly selected Certified Nurse Aides (#19, #20) did not have a performance review documented at least once every 12 months. Findings include: There was no documented evidence that performance reviews were completed in the last 12 months for Certified Nurse Aide (#19, and #20). During an interview on 11/19/24 at 2:44 PM, the Director of Human Resources stated they reviewed the requested personnel files and could not locate the performance reviews completed in the last 12 months for Certified Nurse Aide #19 and #20. They stated the unit manager was responsible for completing the performance reviews. They stated they send the unit managers a list of performance reviews that are due. They stated they monitor the completion by tracking the performance review completion…

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 survey from 11/13/24-11/21/24, the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for expiration dates. Specifically, expired medications and a Lantus Insulin Pen not discarded after 28 days of being open were found in one of the five medication storage rooms and one of eight medication carts (Vent Unit) observed for medication storage. Additionally, one medication refrigerator behind a locked door containing Lorazepam (a controlled substance) was not secured to a permanent fixture in the room. The findings are: The facility policy titled Medication Storage dated 11/1/2013, revised 6/2024, documented resident medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with Department of Health Guidelines. All medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by…

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 conducted during the recertification and abbreviated surveys (#NY00340049 and #NY00351730) from 11/13/24-11/21/24, the facility did not make prompt efforts to resolve grievances or inform the complainant of the grievance investigation outcome for 2 (Resident #177 and #72) of 2 residents reviewed for grievances. Specifically, 1) for Resident #177, there was no evidence that grievances were documented on the tracking log in the grievance book, or that the complainant was notified of the outcome of the grievance and 2) Resident #72's friend stated they made a verbal complaint to the social worker and no grievance was initiated. The findings are: Policy & Procedure titled Grievance/Complaint Procedure that was last revised on 8/2024 documented; when grievances are made it is procedure to keep a detailed tracking log of such concerns. Within ten (10) working days of the date the report was filed, the complainant will be informed of the results of the investigation. 1)Resident #177…

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 00350609) from 11/13/24-11/21/24, the facility did not ensure resident's rights to be free from abuse for 2 of 8 residents (Residents #102 and #73) reviewed for abuse. Specifically, interventions were not implemented as per care plan and/or physician order for Resident #102 with a history of physical aggression and documented episodes of verbal aggression on 8/6/24 at 3:00PM, 4:00 PM and 5:00 PM, resulting in Resident #102 punching Resident #73 on the right side of their head on 8/6/24 at 7:00 PM. Findings include: The 11/13/03 policy with a revision date of 6/24 titled Increased Supervision and Close Visual Observation documented additional supervision for those individuals who are at risk, may be at risk of injury, or who may place others at risk. Close Visual Observation (one staff member monitoring resident always.) The Community Support Specialist must report any issues of concern to the nurse on duty. The policy with a revision date of 9/24 titled Abuse 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.

Based on observation, record review, and interview conducted during the recertification and abbreviated (NY00349188, and NY00349049) surveys from 11/13/24 to 11/21/24, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 2 (Residents #212 and #177) of 9 residents reviewed for Activities of a Daily Living. Specifically, Resident #212 and #177 who required dependent assistance with Activities of Daily Living, did not receive showers as scheduled for multiple months according to the Certified Nurse Aide documentation. The findings are: The facility policy, Activities of Daily Living, reviewed 3/1/2022, documented showers or baths are scheduled and assistance is provided when required. Resident #212 was admitted with diagnoses including unspecified injury of cervical spinal cord, need for assistance with personal care, and generalized muscle weakness. The 6/14/24 Quarterly Minimum Data Set assessment documented Resident #212 had intact cognition and required…

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 conducted during the recertification and abbreviated (NY00348027) survey from 11/13/2024 to 11/21/2024, the facility did not ensure a resident received care to prevent pressure ulcers. This was evident for 1 (Resident #676) of 7 residents reviewed for Pressure Ulcers. Specifically, Resident #676 was admitted to the facility with redness to their buttocks and did not receive a comprehensive skin assessment until they developed a stage 3 facility-acquired sacral pressure sore. The findings are: The facility policy titled Skin/Pressure Injury Preventions and Intervention Program dated 4/2024 documented a risk assessment for pressure injury will be completed by the Registered Nurse upon admission and every week for 4 weeks after admission. Weekly skin evaluations will be done on every resident. 1) Resident #676 had diagnoses of amyotrophic lateral sclerosis (a neurodegenerative disease) and respiratory failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification and abbreviated (NY00340876) survey from 11/13/2024 to 11/21/2024, the facility did not ensure a resident's total program of care, including medications and treatments, were reviewed at each visit. This was evident for 1 (Resident #677) of 41 total sampled residents. Specifically, Nurse Practitioner #1 did not review and ensure the accuracy of transcribed medication orders upon Resident #677's admission to the facility. The findings are: The facility policy titled Admission/readmission of the Resident Neighbor dated 5/2024 documented licensed staff verified orders with the Physician, transcribed orders, and filled out other diagnostic test slips. Resident #677 had diagnoses of bipolar disorder and mononeuropathy (a type of nerve damage). The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #677 was moderately cognitively impaired, did not receive pain medication, and received antipsychotic medication. The Hospital 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 interview and record review conducted during the recertification and abbreviated (NY00340876) survey from 11/13/2024 to 11/21/2024, the facility did not ensure a resident received behavioral health services to attain their highest practicable well-being, in accordance with the comprehensive assessment and plan of care. This was evident for 1 (Resident #677) of 5 residents reviewed for Behavioral/Emotional Status out of 41 total sampled residents. Specifically, Resident #677 was diagnosed with a mental illness, received antipsychotic medication, and was not evaluated by a psychiatrist in accordance with a Physician Order. The findings are: The facility policy titled Behavior Intervention dated 10/2024 documented residents requiring staff intervention due to physical assault or aggression will be reviewed weekly by the Behavior Event Committee, including the Psychiatrist. Resident #677 had diagnoses of bipolar disorder and cognitive communication deficit. The admission Minimum Data Set 3.0 assessment…

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 (NY00336137) from 3/22/2024 to 3/25/2024 the facility did not ensure residents rights to be free from physical abuse for 1 (Resident #1) out of 3 residents reviewed for abuse. Specifically, on 3/15/2024, Certified Nursing Assistant(staff #2) and Licensed Practical Nurse(staff #1) witnessed Resident # 1 being hit in the face by a Community Support Specialist(staff #3), after Resident #1 threw their food on them. The community support staff's job description and tasks did not include assisting/passing of trays to residents. Findings include: Review of the Abuse policy and procedure dated 11/1/2013 last revised 11/2023 documented it is the policy that neighbors will be protected from abuse in accordance with State and Federal regulations. Abuse means the willful infliction of injury with resulting physical harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. All alleged or suspected incidents of abuse of neighbors will be thoroughly investigated and finings 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.

Based on record review and interviews conducted during an abbreviated survey (NY00336137), the facility did not report the results of the investigation of a physical abuse allegation to the New York State Department of Health in accordance with State law within 5 working days of the incident for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not submit the 5-day investigative report until 3/26/2024 for an incident that occurred on 3/15/2024. Finding include: The Facility Policy and Procedure on abuse and reporting dated 11/1/2013 last revised 11/2023 documented the reporting requirements include notification to the New York State Department of Health will occur based on the reporting requirement identified by the Nursing Home Incident Repoorting Manual. If it is determined that there is sufficient evidence for a prudent person to believe that abuse, neglect or mistreatment occurred, the administartor or designeee will report the findings of the investigation to the New York State Department of Health based upon the reporting requirements identified…

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 (NY00336137), the facility did not ensure a comprehensive person-centered care plan was developed or implemented for 1 (Resident #1) out of 3 residents reviewed for care plans. Specifically, Resident # 1 who was assessed for mood and behaviors indicating they were at risk for abuse by staff and other residents but there was no comprehensive care plan developed with interventions to prevent the resident from being abused. Findings include: A review of the comprehensive care plan policy dated 6/10/2013 and last revised 11/1/2013 documented each resident will have a comprehensive care plan. Comprehensive care plans include residents strengths and weaknesses, measurable objectives, and timetables to meet the resident's medical, nursing and psychological needs that are identified in the Minimum Data Set (an assessment tool). The comprehensive care plan is initiated by the nurse on admission and is a reflection of the resident's needs,…

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 (NY00329990, NY00329232) the facility did not ensure pharmaceutical services that assure timely acquiring, receiving, and administering medications met the needs of 2 of 3 residents (Resident #2 and #5) reviewed for medication administration. Specifically, Resident #2 was prescribed Dronabinol (an appetite stimulant) 2.5 milligram, 2 capsules twice a day. Resident #2 missed 46 doses when the medication was unavailable. Resident #5 was prescribed Bupropion300 milligram tablet by mouth daily for depression and 8 doses of the medication was not administered. There was no documentation for reasons why doses were missed. The findings are: The Policy and Procedure titled Medication Administration, undated, documented medications shall be administered in a safe and timely manner and as prescribed to assist the resident to meet their highest practicable mental and psychological wellbeing. If a medication is not available, the nurse must contact…

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 (NY00329990, NY00329232), the facility did not ensure that residents are free of significant medication errors. This was evident for 2 of 3 residents (Resident #2 and #5) reviewed for medication administration. Specifically, Resident #2 was prescribed Dronabinol (an appetite stimulant) 2.5 milligram, 2 capsules twice a day. Resident #2 missed 46 doses when the medication was unavailable. Resident #5 was prescribed Bupropion300 milligram tablet by mouth daily for depression and 8 doses of the medication was not administered. There was no documentation for reasons why doses were missed. The findings are: The Policy and Procedure titled Medication Administration, undated, documented medications shall be administered in a safe and timely manner and as prescribed to assist the resident to meet their highest practicable mental and psychological wellbeing. If a medication is not available, the nurse must contact the Nursing Supervisor and the…

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

Based on observation, record review and interviews during an abbreviated survey (NY00329232, NY00329990 and NY00326047), the facility did not ensure a resident's actual food, dietary needs and choices were met for 1 out of 5 residents (Resident #5) reviewed for food and meals. Specifically, Resident #5, did not receive double portions as per his dietary recommendations, physician order, and meal ticket. The findings are: Resident #5 had diagnoses including benign prostatic hyperplasia, obstructive uropathy (the flow of urine is blocked), and depression. The admission Minimum Data Set (MDS-resident assessment tool) dated 11/13/23 documented the resident's cognition was intact and the resident was on a therapeutic diet. The Comprehensive care plan for nutrition dated 11/7/23 documented the resident was on a regular, no concentrated sweets, thin liquids and double portions diet. Interventions included adhering to the resident's foods preferences. A physician order dated 11/10/23 documented the resident's diet as double portions, no concentrated sweets, and regular consistency. A…

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

Based on observation and interview conducted during an abbreviated survey (NY00326047) the facility did not ensure proper storage of refrigerated food in accordance with professional standards for food safety. Specifically, food items in the walking refrigerator were unlabeled and undated. The findings are: The policy and procedure titled cold food storage and shelf life dated 1/20/15 documented foods must be labeled with date made or date received. The item then must be properly stored and refrigerated. Food must be discarded after three days. During a tour of the facility kitchen on 12/21/23 at 10:30am, the walk-in refrigerator had a pan with meat marinated in a brown liquid covered with a plastic wrap with no label and no date. In addition, a small plastic container about 4.7 inches wide with a lid had a green paste with no label or date. During an interview on 12/21/2023 at 10:40 PM with the Food Service Director, they stated the containers should be dated and labeled. When not labeled the staff would not know what is in the container and for how long it has been in the…

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

Based on record review and staff interview during an abbreviated survey (#NY00326982), the facility did not ensure 2 of 4 residents (Residents # 1 and 4) reviewed, had the right to be free from abuse and neglect. Specifically, on 7/8/23 Resident #1 and Resident #4 had a verbal altercation and were separated. Later that day they had a resident-to-resident altercation involving Resident #1 punching Resident #4 in the face, which resulted in Resident #1 being injured with a bleeding lip. Findings include: The Policy and Procedure (P&P) Abuse dated 11/1/13 documented abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Resident #1 was admitted to facility 10/27/22 with diagnoses including cerebral vascular attack, anxiety disorder, psychotic disorder, and flaccid hemiplegia. The quarterly Minimum Data Set (MDS), an assessment tool, dated 9/29/23 documented Resident #1 had moderate impairment in cognition. The MDS further documented Resident #1 needed extensive assist of 2 for transfer,…

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 abbreviated survey (NY00326982), the facility did not ensure that all alleged violations involving abuse were reported no later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 (Resident #1 ) of 4 residents reviewed for abuse and neglect. Specifically, the facility did not report allegations of resident-to-resident abuse involving Resident #1 and Resident #4. Findings include: Resident #1 was admitted to facility 10/27/22 with the following diagnoses: cerebral vascular attack, anxiety disorder, psychotic disorder, and flaccid hemiplegia. The quarterly Minimum Data Set (MDS) an assessment tool dated 9/29/23 documented resident has moderate impairment in cognition. The MDS further documented resident needs extensive assist of 2 for transfer, extensive assist of 1 for bed mobility. Resident was able to eat independently with set up. 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 reviews and staff interviews on an abbreviated survey (NY00326982), the facility did not ensure that necessary monitoring was performed to maintain weight and prevent loss for 1 (Resident #1) of 3 residents reviewed for nutrition. Specifically, Resident #1, who had a history of weight fluctuations since 1/23, had MD orders for monthly weights but were not carried out as prescribed. The findings are: Resident #1 is a [AGE] year-old admitted to facility 10/27/22 with the following diagnoses: Cerebral Vascular Accident (CVA), Psychotic Disorder, obstructive and reflux uropathy. The quarterly Minimum Data Set (MDS) an assessment tool dated 9/29/23 documented resident has moderate impairment in cognition. The MDS further documented resident needs extensive assist of 2 for transfer, extensive assist of 1 for bed mobility. Resident was able to eat independently with set up. No dental issues. The nursing care plan for Nutrition dated 10/27/22 document's goal; Resident will attain/maintain…

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 an abbreviated survey (NY00317036, NY00317748, NY00318254, NY00318419), the facility did not ensure that when a restraint was indicated, the least restrictive alternative for the least amount of time was used and included ongoing re-evaluation of the need for the restraint for 2 of 5 residents (Resident #4 and #5) reviewed. Specifically, restraints were implemented for Resident #4 since admission and the resident was not assessed to determine if the restraints used were appropriate and/or the least restrictive. Resident #5 had multiple restraints that were not consistently assessed to determine if their use remained appropriate and/or was the least restrictive, there were no physician orders for the restraints and the comprehensive care plan (CCP) did not identify all the restraints in use for the resident. Findings include: The facility Restraint Minimization Program Policy revised 06/2023 documented the restraint minimization program will evaluate 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, interview, and record during the abbreviated surveys (NY00317036, NY00317748, NY00318254 & NY00318419), the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the necessary treatments and services to promote healing for 1 of 5 residents (Residents #4) reviewed for pressure ulcers. Specifically, Resident #4 was not provided with adequate pressure relieving interventions upon admission resulting in the resident developing multiple pressure ulcers. In addition, after the resident developed the pressure ulcers, pressure relieving devices were not consistently implemented and the plan of care was not re-evaluated for effectiveness. Findings include: Resident #4 had diagnoses including traumatic brain injury, craniotomy, and cognitive deficit disorder. The 03/29/2023 admission Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, was total dependent…

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 abbreviated surveys (NY00317036, NY00317748, NY00318254 & NY00318419), the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents in 3 of 3 bathing/shower rooms observed. Specifically, 3 bathing/shower rooms were unclean with scattered debris on the floors, with cracked, broken, and missing tiles, with shower stall floor in disrepair and stained shower curtains. Findings include: During an observation conducted on 07/13/23, the below were observed: -At 9:07 AM and again at 11:45 AM room [ROOM NUMBER]-404 bathing/shower area contained flacking and missing coating on the shower stall floor and several missing tiles to the entrance into the shower. Several inches of the bottom of the shower curtain contained a brownish rust color stain. There was a built up of soap scum on the tiles on the shower walls. There were multiple used towels and washcloths scatter on the floor throughout the bathroom. In front of a linen bin was a pile…

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 during the Recertification survey conducted from 5/16/22- 5/25/2022, the facility failed to maintain a safe, clean, comfortable, and home-like environment for 1 of 1 resident units (Vent Unit) and 1 of 1 resident (Resident #61) reviewed for tube feeding. Specifically, on the Vent unit in room [ROOM NUMBER] there were sticky floors; old, dried tube feeding on the floor under the tube feeding pole and, on the tube, feeding pole and machine. Findings include: The facility's Daily Patient Room Cleaning policy dated 1/1/2000 documented to follow the 5-step room cleaning method that included: 1. Empty trash; 2. Horizontal dusting; 3. Spot cleaning with a cloth and disinfectant; 4. Dust mop the floor; and 5. Damp mop the floor. The facility's Feeding Poles/Cleaning/Disinfecting policy undated documented, feeding poles are to be cleaned and disinfected with an EPA (environmental protection agency) approved solution. Feeding poles are to be spot cleaned daily when debris/tube feed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview during the Recertification Survey conducted from 5/16/2022-5/25/2022, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with quality of care includes measurable objectives and time frames to meet a resident nursing, mental and psychosocial needs for 2 (residents # 108 and # 403). Specifically, 1. the facility did not ensure that a personalized care plan was developed and implemented for cleaning the resident's room for Resident #108 with a history of refusal of care and 2. the facility did not ensure a comprehensive care plan was developed and implemented to address the use of a long call bell for Resident # 403 with aggressive behaviors. The Findings Are: The Policy and Procedure titled, Comprehensive Care Plan (CCP), dated 11/1/13, reviewed 1/15/22, documents the purpose of the CCP Policy is to promote the highest practicable level of function for each resident psychosocial…

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

Based on record review and interview conducted during a Recertification and Abbreviated Survey (Complaint #NY00281259) conducted from 5/16/2022-5/25/2022, it was determined the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan. This was evident for 1 of 1 residents (R#253) reviewed for change of condition. Specifically, Resident #253 who was being treated with medication for constipation was discharged to the hospital with a diagnosis of bowel obstruction. Record review revealed facility staff did not consistently document resident's bowel movement in the electronic medical record (EMR). Additionally, the facility did not update the Physician timely as per Care Plan interventions when the resident had a change in bowel status. The findings are: Resident #253 was admitted with diagnoses including traumatic subarachnoid hemorrhage gastroparesis and tachycardia. The 3/26/21 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, required extensive…

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 a Recertification and Abbreviated Survey (NY00295316) conducted form 5/16/2022-5/25/2022 the facility did not ensure they provided an environment that is free from accident hazards for 1 of 5 Residents (#18) reviewed for accidents. Specifically, the facility did not provide maintenance to Resident#18's electric wheelchair as per the manufacture's specification. The findings are: The facility Policy and Procedure titled Electrical Equipment/Quality Control documented, as follows: Prior to the initial use of any electrical item in patient care vicinity testing and inspection is required, if repairs or modification are performed on any electrical equipment a re-inspection is required, electrical equipment used in patient vicinity must be tested and inspected, all items must be tagged with an asset label, dated, signed, and marked as passed, and a log must be updated with the inspection details. Review of the facility policy and procedure did 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 interviews and record reviews conducted during the most recent recertification survey, the facility did not ensure for 4 of 4 residents (#149, #181, #212, #265) reviewed for hospitalization/discharge that the resident, resident's representative and/or the Office of the State Long-Term Care Ombudsman were notified in writing of transfers to the hospital, including the effective date of transfer, location of transfer, and reason for transfer. The findings include: 1. Resident #149 has diagnoses and conditions including uterine bleeding secondary to pelvic/uterine mass, Schizophrenia, and Respiratory failure. The Annual Minimum Data Set (MDS; a resident assessment and screening tool) dated 12/1/18 documented the resident has severely impaired cognition. The Licensed Practical Nurses' note dated 11/17/18 revealed that the resident had serosanguinous blood noted in Depends and scant amount of blood coming out of vagina. The Registered Nurses' note dated 11/19/18 indicated that the physician was informed 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 interview and record review conducted during a recertification survey, the facility did not ensure that residents or their representatives were notified in writing of the facility bed hold policy prior to discharge or transfer. This was evident for 4 of 4 residents reviewed for discharge. (Residents # 149, #181, # 212, # 265). The findings are: 1. Resident #149 had diagnoses and conditions including uterine bleeding secondary to pelvic/uterine mass, Schizophrenia, and Respiratory failure. The Minimum Data Set (MDS; a resident assessment and screening tool) dated 12/1/18 documented the resident had severely impaired cognition. The resident's medical record indicated the resident is a [NAME] of the State. The Licensed Practical Nurse (LPN) progress note dated 11/17/18 documented the resident had serosanguinous material in her diaper and a scant amount of vaginal bleeding. The Registered Nurse (RN) note dated 11/19/18 documented she spoke with the Medical Doctor (MD) who advised that the resident be sent…

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 most recertification survey, the facility did not exercise reasonable care for the protection of resident's property from loss or theft for one of twelve residents (Resident #36 ) reviewed for personal property. Specifically, Resident #36 reported that eight months ago when he was admitted all his new clothing was lost. The facility did not ensure that the system in place to protect residents' clothing was implemented for this resident. The findings are: On 1/29/19 during the late morning, the resident stated that he notified the Ombudsman and the social worker that his clothing was lost. To date nothing has been done. The resident further stated that he is using donated clothing the facility provided and that he washes his clothes in the sink in his room for fear of sending them to the laundry. On the morning of 2/04/19 review of the resident's electronic record (e-record) for personal belongings did not reflect any information on the resident's missing clothing. Areas in the e-record for lost/missing items 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 interview and record review conducted during the most recent recertification survey, the facility did not report to the State agency in a timely manner an incident of alleged sexual abuse. Specifically, this allegation of sexual abuse involving Resident #219 and Resident #43 was not reported within the required time frame of two hours after the facility became aware of it. The findings are: Resident #219 is a [AGE] year-old woman who was admitted to the facility on [DATE] with the medical conditions of frontal lobe and executive function deficit and other specified injuries of the head. An assessment dated [DATE] noted that Resident #219 did not have sufficient mental capacity to engage in sexual relationship due to extremely impaired cognitive functioning The most recent Minimum Data Set (MDS, an assessment tool) dated 12/26/18 indicated that the resident has severe cognitive impairment for decision making. Resident #43 is a [AGE] year-old male who was admitted to the facility on [DATE] with the…

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

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that care was provided to prevent pressure ulcers for 1 of 3 residents (#194) reviewed for pressure ulcers. Specifically, the use of off loading booties recommended by the physician was not implemented for a resident at risk for pressure ulcers. The findings are: Resident #194 had diagnoses including Cerebrovascular Accident, Hemiplegia and Seizure Disorder. The admission MDS (minimum data set-an assessment tool) dated 12/3/18 indicated a BIMS ( brief interview for mental status) could not be performed secondary to severe cognitive impairment. The MDS further documented the resident had a stage 4 pressure ulcer on admission to the facility, was at risk for pressure ulcers, had a pressure relieving device for the bed and wheelchair and received pressure ulcer care. Physician Orders Included: 12/25/18- Air Mattress daily, 12/26/18- liquid protein 30 ml via G-tube daily and Multiple Vitamins with Minerals 5 ml daily, 1/29/19- Off loading Booties every shift. 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 interview conducted during a recertification survey, the facility did not ensure food was prepared in accordance with professional standards for food service safety. Specifically, Dietary staff did not perform proper hand hygiene while performing tasks in the kitchen. The findings are: Observations and interviews conducted during the initial tour of the kitchen between 10:45 AM and 12:00 PM on 1/29/19 revealed the following: A Dietary Aide (DA) was preparing sandwiches, then manually opened the lid of a garbage pail to discard her disposable gloves, then put on clean disposable gloves without first washing her hands. She then resumed preparing sandwiches. The DA repeated this process three times. Upon surveyor inquiry, the Food Service Director (FSD) intervened. The FSD was interviewed at that time and revealed she did not have any documentation of employee in-service education for food preparation. She further stated she would be in-servicing all employees. The DA was interviewed and stated she is supposed to wash her hands after removing gloves. 415.14(h)