Livingston Hills Nursing And Rehabilitation Center

Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #664249), the facility did not maintain a pest-free environment and an effective pest control program on two (2) of two (2) resident units. Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas.This is evidenced by:During observations on 7/21/2025 through 7/30/2025 between 8:00 AM and 5:00 PM fly activity was always identified in the below locations throughout the duration of the survey at various intensities noted in the North Unit activity room which was provided to the team as the survey team meeting area.During initial interviews on 7/21/2025 at 10:58 AM, flies were noted to be in the room of Resident #10.During an interview on 7/21/2025 at 12:22 PM, flies were noted to be in the office of Regional Nursing Coordinator #1.During initial interviews on 7/21/2025 at 1:22 PM, small flying insects were noted in the bathroom of Resident #87.During a test tray observation on 7/29/2025 at 8:16 AM, flies were noted in the room 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.

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure residents were aware of the grievance process. Specifically, (1.) residents on South Unit did not have the option to file a grievance anonymously; and (2.) seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they did not know the process by which to file a grievance.This is evidenced by:Facility Policy titled, Grievance Reporting and Response, last revised 7/01/2022 documented it was the policy of the facility to investigate and respond to all resident grievances in a timely manner. The procedure to file a grievance included filling out a grievance form and giving it to the Director of Social Services or put it in the grievance box located by the social work office. Grievances could also be filed verbally with the Director of Social Services or Administrator. Grievances may be named or anonymous when put in the drop box.During a surveyor led Resident Council meeting on 7/22/2025 at 10:32 AM, seven out of eight 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This is evidenced by:The policy and procedure titled, Comprehensive Care Plans, last revised 5/2024, documented interdisciplinary comprehensive care plans would identify problems and needs, reflecting the resident's strengths, limitations, and goals.Resident #2Resident #2 was admitted to the facility with the diagnoses of dementia, major depressive disorder, and atrial fibrillation (irregular heartbeat). The Minimum Data Set (an assessment tool) dated 7/02/2025, documented the resident was able to understand others, be understood, and was severely cognitively impaired.During a general observation of the unit on 7/21/2025 at 10:52 AM, Resident #2 was still in bed, still sleeping, and did not appear to have been gotten up or cleaned up for the day. The resident was noted to have floor mats next to their bed, call bell on the floor.Resident #2's Comprehensive Care Plan for Risk for Falls, dated 11/30/2024, documented to keep the resident's environment safe and clutter free, call bell within reach and encourage use.…

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 survey (Case #664249), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for six (6) (Resident #s 2, 47, 50, 71, 77, and 97) of ten (10) residents reviewed. Specifically, (a.) Resident #2 was observed to be unkempt and in need of assistance to perform activities of daily living; (b.) Resident #47 did not receive twice weekly showers as per the resident's plan of care; (c.) Resident #50 was observed on 7/22/2025 at 1:41 PM, 7/24/2025 at 1:10 PM, 7/28/2025 at 10:00 AM, and 7/29/2025 at 11:22 AM, in their room with door closed, temperature warm and sweltering, disheveled appearance, clothing soiled, unshaven, hair unkempt with strong urine odor; (d.) Resident #71 was not regularly offered or provided the opportunity to get of bed and was not given a bed bath or shower in accordance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for three (3) (Resident #'s 34, 50, and 71) of four (4) residents reviewed. Specifically, Resident #'s 34, 50, and 71 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by:The Facility Policy titled; Activity Programs, last revised 5/2024, documented (a.) activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs; (b.) the activity programs consisted of individual, small, and large group activities that were designed to meet the needs and interests of each resident; (c.) individual and at least 4 group activities were offered per day; and (d.)…

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 survey, the facility did not ensure that its medication error rate did not exceed 5 percent for Four (4) (Resident #33, 36, 76, and 11) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 84 percent.This is evidenced by:The Facility's Policy and Procedure titled; Administering medications, effective 1/2024, 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 ad with other applicable Federal and State Laws. Medications will be administered using the six rights of medication administration: right resident, right medication, right dose, right time, right route, right documentation. If medication supply is found to be equal or less than 7 days, the refill icon should be clicked to initiate…

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 a recertification survey, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for three (3) (Residents #'s 10, 29, and 47) of three (3) residents reviewed for self-administration of medication. Specifically, (a.) Resident #'s 10 and 29 were observed with unprescribed medications on their nightstands; and (b.) Resident #47 was noted to have discontinued Clindamycin Phosphate cream in their nightstand. There was no documented evidence that Resident #'s 10, 29, and 47 were assessed by an interdisciplinary team to determine their ability to safely self-administer medications, and there was no physician order for self-administration of medications.This is evidenced by:The Facility Policy titled, Resident Self-Administration of Medication, created 7/2020, documented that residents who expressed a wish to self-administer…

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 reviews, and interviews conducted during the recertification survey, the facility did not ensure that residents had the right to be treated with respect and dignity to retain and use personal possession, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents for one (1) (Resident #14) of five (5) residents reviewed for personal property. Specifically, (a.) for Resident #14 was observed at nurses' station, in a common area, wearing a hospital gown. Resident #14 stated they were wearing a hospital gown because their clothing was not returned to them from the off-site laundry facility. This is evidenced by: The Facility's Policy titled; Resident Rights last reviewed 7/2022 documented resident have the right to keep and use their personal belongings and property as long as they did not interfere with the rights, health, or safety of others.Resident #14 was admitted to the facility with diagnosis of Parkinson's Disease (a progressive neurological disorder that primarily…

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.

This is evidenced by:The Facility Policy titled, Resident Right- Right to Survey Results/Advocate Agency Information, last reviewed 11/2024, documented it was the policy of the facility to inform residents of survey results and advocate agencies in such manner to acknowledge and respect resident rights. The facility will post in a place readily accessible to residents, family members, and legal representatives of residents the results of the most recent survey of the facility. The facility will post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.During a surveyor led Resident Council Meeting on 7/22/2025 at 10:32 AM, eight (8) of eight (8) anonymous residents present stated they did not know where survey results were located for them to read.During a walkthrough of the facility on 7/22/2025 at 11:50 AM, a white binder with survey results was observed on the second shelf of a shelving unit in the lobby. There was a sign listing visiting hours taped to the shelf above the binder. The sign hung down directly in front…

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, the facility did not ensure a base line care plan was developed and implemented for each resident within 48 hours of admission for one (10 (Resident #114) of 30 residents reviewed for baseline care plans. Specifically, for Resident # 114, a baseline care plan was not developed within 48 hours of admission.This is evidenced by:Resident #114 was admitted to the facility with the diagnoses of vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and metabolic encephalopathy (a condition where brain function is disrupted due to chemical imbalances in the body, often resulting from illnesses or organ dysfunction). The Minimum Data Set (an assessment tool) dated 7/23/2025 documented the resident was usually able to be understood, was usually able to understand others, and was severely…

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 conductedion during the recertification survey, the facility did not ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident for two (2) (Resident #'s 16, and 47) of 30 residents reviewed. Specifically, (a.) for Resident #16, there was no documented evidence that the Comprehensive Care Plan for Psychotropic Drug Use was reviewed and revised after a psychotropic medication change occurred on 7/03/2025; and (b.) Resident #47's Comprehensive Care Plan for Physical Therapy was not reviewed and revised after each assessment or after they discharged from physical therapy services on 7/15/2025. This is evidenced by:The Facility Policy titled; Comprehensive Care Plans dated 4/2019 documented the care plan would be complete, current, realistic, time specific and appropriate to each resident's individual needs. A comprehensive care plan would be reviewed…

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 reviews, and interviews conducted during the recertification survey, the facility did not ensure that the residents received the necessary care and services to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) (Resident #37) of 30 residents reviewed. Specifically, for Resident #37, the resident's room was bare of home-like touches and furniture with no care-planned reason or physician order.This is evidenced by:Resident #37 was admitted to the facility with the diagnoses of type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), dementia (a group of thinking and social symptoms that interferes with daily functioning), and schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania). The Minimum Data Set (an assessment tool) dated 5/08/2025…

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 a recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards for one (1) (Resident #16) of 30 residents reviewed. Specifically, for Resident #16, a large bruise was not reported and assessed in a timely manner.This is evidenced by:Resident #16 was admitted to the facility with the diagnoses malignant neoplasm of kidney (cancerous tumor characterized by uncontrolled cell growth that can invade nearby tissues and spread to other parts of the body), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure (a condition where the heart can't pump enough blood to meet the body's needs). The Minimum Data Set (an assessment tool) dated 7/06/2025 documented the resident was understood, could understand others, and was cognitively intact. During an observation on 7/29/2025 at 8:51 AM, Resident #16 was noted to have a large bruise on their left outer leg, from…

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 a recertification survey, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (1) (Resident #4) of two (2) residents reviewed for range of motion. Specifically, for Resident #4, a washcloth roll was not applied to the resident's left hand for contracture management as indicated by physician orders.This is evidenced by:The facility's Policy titled; Physical Rehabilitation Department Issuing and Use of Splints, undated, documented the Physical Rehabilitation Department staff were responsible for the evaluation and determination of appropriate splinting devices with assistance from Orthotist when necessary. The treating therapist assessed the resident's need for a positioning device for the involved extremity/body part and made recommendations for resident splinting needs (that is monitor for contracture, type of splint, indications and contraindications). If a splint…

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 a recertification survey, the facility did not ensure that resident environments were as free from accidents hazards as is possible for one (1) (Resident #10) of nine (9) residents reviewed for accidents hazards. Specifically, Resident #10 resided in a semi-private room and two (2) disposable razors, and an unlabeled electric razor were observed in the resident's shared bathroom.This is evidenced by:Resident #10 was admitted to the facility with diagnoses of multiple sclerosis (a chronic, often debilitating disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and tachycardia (a condition where the heart beats faster than normal, typically more than 100 beats per minute). The Minimum Data Set (an assessment tool) dated 7/22/2025, documented the 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 observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice, for one (1) (Resident #s 43) of two (2) residents reviewed for dialysis. Specifically, nursing did not consistently complete, reviewed, and logged dialysis communication sheets for Resident #43 between 4/08/2025 and 7/21/2025.This is evidenced by:The Facility's Policy and Procedure titled Care of Residents Receiving Hemodialysis, revised 9/2023, documented: Before Dialysis: Locate resident's dialysis Communication Book and enter pre-treatment information per the form fields. Include any relevant continuity of care information and vital signs. Ensure resident receives Activity of Daily Living and hygienic care well prior to departure time; ensure that resident takes Communication Book to treatment. Care After Dialysis: Obtain vital signs. If blood pressure drops more than 20 millimeters of mercury from the supine to upright position, the following…

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 an observation, record review, and interviews conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, daily nurse staffing levels for staff working in the facility on each shift was not posted in the facility on July 21, 2025, through July 25,2025, and July 28, 2025, through July 29, 2025.This is evidenced by:Facility Policy titled, Posted Nurse Staffing Information, last revised 09/2024, documented it was the policy of the facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. The nursing staffing sheet would be posted on a daily basis at the beginning of each shift. The information posted would be presented in a clear and readable format and in a prominent place readily accessible to residents and visitors.During an observation on 7/22/2025 at 11:50 AM, nurse staffing information was not posted at the reception desk, in the lobby,…

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 (Complaint #NY00342787, #NY00355908, and #NY00348307) completed on [DATE], the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented for three (3) (Resident #3, #4, and #5) of three (3) reviewed for medical records. Specifically, the facility transitioned to another electronic medical record company [DATE] and the facility did not have access to resident medical information for any residents that are current, discharged or expired prior to [DATE]. This is evidenced by: The facility policy titled Resident Medical Record dated 5/2025 documented the following: it is the policy of the facility to maintain Medical Records in accordance with State and Federal regulations. The facility will maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately…

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 (Complaint #NY00342787, #NY00355908, and #NY00348307) completed on 7/14/2025, the facility did not effectively communicate and implement the standards of its compliance and ethics program that is likely to be effective in preventing care violations and promoting quality of care. Specifically, at a minimum, the facility did not implement the standards of its compliance and ethics program-resident medical records dated prior to November 2024 were not accessible. A risk area of record retention is associated with the delivery of health care to nursing facility residents. This could place all residents at risk of diminished quality of care. This is evidenced by: The facility policy titled, Compliance and Ethics Program, undated, identified as current by Administrator #1 documented the following: we are accountable and responsible for fulfilling out pledge to safeguard the welfare of each resident in a lawful and principled manor. The compliance and ethics program includes ongoing monitoring and auditing 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, interview and record review conducted during an Abbreviated Survey (Compliant #NY00378346) completed on 7/14/2025, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #1) of one (1) resident reviewed for infection control practices. Specifically, Resident #1 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment while providing wound care and did not change gloves and wash hands according to standards of practice. This is evidenced by: The facility policy and procedure titled, Enhanced Barrier Precautions, revised 2/19/2025, documented the following: it is the policy of the facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Novel or…

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 (Compliant #NY00378346) completed on 7/14/2025, the facility did not ensure an effective training program for all new and existing staff was developed, implemented and maintained based on the facility assessment for two (2) of two (2) staff (Licensed Practical Nurses #1 and #3) reviewed. Specifically, there was no documented evidence Licensed Practical Nurses #1 and #3 had peripheral intravenous training and competencies and they administered antibiotics via peripheral intravenous to Resident #2. This is evidenced by: The Facility Assessment Tool completed 4/23/2025, documented the following: Medication awareness of any medications that residents need, by route including intravenous) peripheral or central lines). Facility resources needed to provide competent support and care for our resident population every day and during emergencies included staff training / education and competencies for medication administration and specialized care. The facility policy and procedure titled, Core Competencies, dated…

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 a recertification survey, it was determined that the governing body did not implement policies regarding the management and operation of the facility. Specifically, the facility did not ensure professional staff were licensed, certified, or registered in accordance with applicable Federal and State laws for a full-time, onsite Administrator. The facility did not appoint a licensed and currently registered Nursing Home Administrator to provide onsite, full time oversight prior to expiration of New York State Department of Health Unlicensed Acting Administrator approvals. Additionally during the recertification survey, there was no Nursing Home Administrator onsite. This is evidenced by: Record review of New York State Department of Health 'notification and request for approval of unlicensed acting administrator' forms revealed the following: • Facility Operator signed a request on 5/04/2023, submitted to the New York State Department of Health 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 observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00317289, NY00325414, NY00334048, NY00335064, NY00336444, and NY00336400), the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not develop written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, the facility had repeat deficiencies in the areas of safe/clean/comfortable/homelike environment (F-584), food procurement, store/prepare/serve-sanity (F-812), and infection control (F-880); the facility did not ensure that previously approved Plans of Correction for F-584, F-812, and F-880 cited during Recertification Surveys completed on 5/10/2023, 4/14/2021, and 4/05/2019 were implemented as indicated by the same deficiencies being issued on the current survey. This is evidenced by: The facility policy titled, Quality Assurance 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 observations, record reviews and interviews during recertification survey, the facility did not protect and promote the rights of the resident; did not provide equal access to quality care regardless of diagnosis or severity of condition; and did not ensure residents had the right to be free of interference from the facility in exercising their right to wear clothing for 3 of 3 residents (Resident #'s 61, 63 and 89) reviewed for resident rights and exercise of rights. Specifically, (a) Resident #61 did not have access to their clothing, and staff who were interviewed stated it was difficult to find clothing that fit Resident #61. (b) For over an hour, Resident #63 was viewable from the hallway wearing a hospital gown with their back and buttocks exposed without any underclothes or briefs on. (c) Resident #89 was noted to smell of feces and wear clothing that was soiled with what looked like feces. This is evidenced by: Resident #61 was admitted to the facility with diagnoses which included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews during recertification survey, the facility did not ensure that the facility did not exercise reasonable care for the protection of the resident's property from loss or theft for 4 (Residents #1, 34, 73, and 108) of 4 residents reviewed for missing property. Specifically, Residents #1, 34, 73, and 108 personal belongings sent out for laundering were not returned to the residents timely. This is evidenced by: A facility policy titled, Personal Property Theft and Loss Risk and dated October 2023, documented the facility provided for the reasonable safekeeping of personal property and funds for residents in the facility per state and federal requirements. The policy further documented that the facility provided labeling of the resident's clothing and personal property. Additionally, all resident property was to be listed on the inventory record and updated when new items were obtained. Resident #1 was admitted with diagnoses of Waldenstrom Macroglobulinemia (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 observations, record reviews and interviews during recertification survey, the facility did not ensure that grievances were resolved in a timely manner for 3 (Residents #1, 34, and 73) or 3 residents reviewed. Specifically, resident's concerns were not documented and resolved through the facility grievance process. This is evidenced by: A facility policy titled, Grievance Reporting and Response and dated 10/01/2022, documented that to make a complaint or a recommendation, fill out a grievance form and put it in one of the grievances boxes located by the Social Work office and on each unit. Forms would be collected and brought to the attention of the Administrator and/or Director of Nursing Services for review and resolution by the appropriate party. Grievances could also be filed verbally with the Director of Social Work or the Administrator. If a grievance included issues involving abuse, neglect, or misappropriation, the administrator and the Director of Nursing would be notified immediately, and 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, record reviews and interviews during recertification survey, the facility did not ensure to develop or implement a comprehensive person-centered care plan for each resident for 3 (Residents #1, #23, #63) of 3 residents reviewed for comprehensive person-centered care plans. Specifically, for Resident #s 1 and 23, a care plan was not developed, or interventions implemented for use of anticoagulants (blood thinners). For Resident #63, care plan did not document physician's supervision for significant weight loss or interventions implemented. This is evidenced by: A facility policy titled Comprehensive Care Plans dated 9/2023, documented that every resident would have an Interdisciplinary Care Plan, with the Interim/baseline Interdisciplinary Care Plan initiated within 48 hours of admission. The care plan would identify priority problems and needs to be addressed by the interdisciplinary team, and would reflect the resident's strengths, limitations, and goals. The care plan would be complete, current, realistic, time specific and appropriate to the individual…

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 reviews and interviews during the recertification survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility did not perform the appropriate competency evaluations for the licensed nursing staff to measure the pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles or occupational functions successfully. This is evidenced by: Resident #73 was admitted with diagnoses of atherosclerotic heart disease, cachexia, and severe protein-calorie malnutrition. The Minimum Data Set (an assessment tool) dated 4/28/2024, documented that the resident could be understood and understand others and follow direction. The Brief Interview of Mental Status score was assessed to be 15/15 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews during recertification survey, the facility did not ensure that the drug regimen of each resident were reviewed at least once a month by a licensed pharmacist for 4 (Resident #'s 23, 78, 30, 67) of 4 residents reviewed. This is evidenced by: Resident #23 was admitted to the facility with diagnoses of fatty liver, fibromyalgia (a chronic condition where there is heightened pain and widespread pain), and unspecified mood disorder. The Minimum Data Set (an assessment tool) dated 4/12/2024, documented the resident was cognitively intact, could be understood and could understand others. Resident #78 was admitted to the facility with diagnoses of chronic systolic congestive heart failure, acquired deformity of right lower leg and major depressive disorder severe with psychotic symptoms. The Minimum Data Set, dated [DATE], documented the resident had minimal cognitive impairment, could be understood and could understand others. Resident #30 was admitted to 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 during the recertification survey, the facility did not maintain drugs and biologicals, labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration date when applicable for 3 of 3 units reviewed. Specifically: (1) urine was stored in the same refrigerator with multiple insulin pens and insulin vials; (2) purified protein derivative solution stored in the refrigerator with no open date was expired on 3/2024; (3) eye drops, ear drops, Vitamin D, and insulin pens in the medication cart opened did not have expiration dates. Additionally, the controlled substance cabinet inside lock was broken. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 1/2024 documented section 1. Controlled substances were obtained from the double-locked controlled substance cabinet. The facility's Pharmacy Services Policy and Procedure, effective 2022, documented drugs and biologicals used in the facility would be labeled in accordance 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 and staff interview during the recertification survey from 05/13/2024 to 05/23/2024, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and one (1) of 3 kitchenettes. Specifically, dented cans were with the common stock, the food temperature thermometer was out of calibration, and kitchen and kitchenette equipment were not clean and/or in good repair. This is evidenced by: During observations in the main kitchen and unit kitchenettes on 05/13/2024 from 11:05 AM through 12:02 PM: • One #10-sized can mashed potatoes found in the common stock had a V-shaped dent in top seam of the can. • Two #10-sized cans of red pepper strips found in the common stock had metal touching metal at top seam of the can. • The slicer, stainless steel utility cart, handwashing sink, and floor under cooking equipment line were soiled with food particles and/or dirt. • The food temperature thermometer was found not in calibration when tested in a standard ice-bath method as follows: 25…

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 the recertification survey, the facility did not ensure residents have the right to and the facility must promote and facilitate resident self-determination through support of resident choice, and that the resident had a right to make choices about aspects of their life in the facility that are significant to the resident for 1 (Resident #80) of 1 resident reviewed Specifically, Resident #80 did not get out of bed due to facility not having the appropriate wheelchair. This is evidenced by: The facility's Policy and Procedure titled, Resident Rights and effective 8/2022, documented Resident of [NAME] Hills had the Right (including but not limited) to: dignity, respect and a comfortable living environment quality of care and treatment without discrimination freedom of choice to make your own, independent decisions be informed in writing about services and fees before you enter the nursing home the safeguard of your property and money appeal a transfer or…

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 review conducted during the Recertification Survey, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored for 1 (Residents #316) of 1 resident reviewed. Specifically, Resident #316's advance directive (code status) identifiers were not consistently documented to reflect Medical Orders for Life-Sustaining Treatment orders that could be easily identified by for all staff. This is evidenced by: Resident # 316 was admitted to the facility with the diagnoses of unspecified dementia, without behavior disturbances, early onset of Alzheimer's disease, and type 2 diabetes. The Minimum Data Set (an assessment tool) dated documented the resident had severe cognitive impairment, could understand others and make themselves understood. A review of the facility's policy and procedure titled, Medical Order for Life-Sustaining Treatment and revised on 6/2023, documented 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 survey, the facility did not ensure Significant Change Minimum Data Set assessment was completed for a 1 (Resident #36) of 1 resident reviewed for significant changes in health status. Specifically, Resident #36 experienced a change in respiratory status, was sent to the hospital on 4/18/2024 and returned on 4/19/2024 with diagnosis of respiratory bronchiolitis interstitial lung disease requiring oxygen and inhaler use. This is evidenced by: Resident #36: The resident was admitted to the facility on with the diagnoses of chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could understand others, and could make themselves understood. The Policy and Procedure titled, Comprehensive Care Plans and dated 9/2023, documented every resident will have an Interdisciplinary Care Plan, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during a recertification and abbreviated survey (Case #s NY00317289 and NY00325414), the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission for 1 resident (Resident #115) of 3 residents reviewed for baseline care plans. Specifically, Resident #115 baseline care plan was not completed by staff and signed by the resident within 48 hours of their admission to the facility. This is evidenced by: The Policy and Procedure titled, Comprehensive Care Plans and dated 9/2023, documented every resident will have an Interdisciplinary Care Plan, with the Interim/baseline Interdisciplinary Care Plan initiated within 48 hours of admission. Resident #115 The resident was admitted to the facility with diagnoses of a fractured back, diabetes, and chronic bladder inflammation. The Minimum Data Set (an 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 a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #'67) of 1 resident reviewed. Specifically, for Resident #67's\ Comprehensive Care Plan for psychotropic medications was not reviewed and revised after medication changes. This is evidenced by: Resident # 67 was admitted to the facility with diagnoses of unspecified dementia with agitation, major depressive disorder, and hypertension. The Minimum Data Set (an assessment tool) dated 6/13/2023 documented the resident had moderate cognitive impairment, could understand others, and could make self-understood. A review of Policy and Procedure for Dementia Care, last revised 10/2023, documented that in certain cases and after interdisciplinary considerations a resident may benefit from the use of medication when clinically indicated and as necessary to treat a specific condition and target…

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 the recertification survey, the facility did not ensure to complete a comprehensive assessment of a resident, to receive treatment and care in accordance with professional standards of practice for 1 (Resident #89) of 1 resident reviewed Specifically, Resident #89's standing order for compression stockings was not carried out and staff stated compression stockings were never placed because the resident would take them off. This is evidenced by: Resident #89 was admitted with diagnoses of Alzheimer's Disease (a disorder of brain causing dementia, impaired ability to think or make decisions), Atherosclerotic Heart Disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), and depression. The Minimum Data Set (an assessment tool) dated 02/25/2024, documented resident had severe impaired cognition a Brief Interview of Mental Status score assessed them with severe cognitive impairment. The facility Policy and Procedure titled, Comprehensive Care Plans and revised 9/2023, documented comprehensive…

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 during a recertification survey, the facility did not ensure that it provided a residential environment that was as free from accident hazards as possible, and that each resident received adequate supervision to prevent accidents for 1 (Resident #36) of 1 resident reviewed for accident hazards. Specifically, Resident #36 was observed using tobacco in their room without supervision; approach was utilized to communicate observed hazards related to the accessibility of the resident's use of tobacco supplies, and the facility did not develop and implement an individualized care plan to address the resident's potential or actual non-compliance with the facility's smoking policy. This is evidenced by: Resident #36: The resident was admitted to the facility on with the diagnoses of chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes. The Minimum Data Set documented the resident was cognitively intact, could…

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 reviews and interviews during recertification survey, the facility did not ensure that resident care was supervised by a physician for their immediate need for 1 (Resident #63) of 1 resident reviewed for physician care. Specifically, Resident #63 had a significant amount of weight loss and did not receive adequate medical supervision to intervene. This is evidenced by: Resident #63 was admitted with diagnoses of traumatic subdural hemorrhage, urinary calculus, and scoliosis. The Minimum Data Set (an assessment tool) dated 4/11/2024, documented that the resident had significant cognitive impairment, could sometimes be understood and sometimes understand others. A facility policy titled, Visiting Consultant Visits and dated 9/2023, documented visiting consultants will be vetted per Federal and State guidelines for credentialing and provided with HIPAA compliant access to the Electronic Medical Record. They will be oriented to facility, unit, room, and care team prior to and ongoing during period of provision of services. Appropriateness of visiting…

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 reviews, and interviews during recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, which was any drug used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences which indicated the dose should be reduced or discontinued for 1 (Resident #78) of 4 resident reviewed for unnecessary medications. Specifically, Resident #78's physician order for Abilify (antipsychotic medication) did not include an indication for use in accordance with professional standards. This is evidenced by: Resident #78 was admitted to the facility with diagnoses of chronic systolic congestive heart failure, acquired deformity of right lower leg and major depressive disorder severe with psychotic symptoms. The Minimum Data Set (an assessment tool) dated 4/30/2024, documented the resident had minimal cognitive impairment, could be understood and could understand others. An undated facility policy titled, Mediation…

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 during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, one (1) of 3 dumpsters was leaking waste and the dumpster area was not clean. This is evidenced by:. During observations on 05/13/2024 at 11:56 AM, the front dumpster was leaking a black oily liquid from the bottom, and a build-up of brown leaves was found on the ground around the back dumpster. During an interview on 05/14/2024 at 2:01 PM, Corporate Director of Maintenance #1 stated that the leaking dumpster would be replaced. During an interview on 05/20/2024 at 10:55 AM, Assistant Administrator #1 stated that the leaky dumpster had been replaced, and the area around the dumpsters would be cleaned that day. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure infection control practices in accordance with professional standards of care for 1 (Resident #24) of 1 resident reviewed. Specifically, Resident #24 peripheral inserted central catheter dressing changes were not done per physician orders to prevent infection. This is evidenced by: The Facility's Peripheral Inserted Central Catheter Insertion and care Policy and Procedure effective 1/17/2019, documented general guidelines to include: 1. Dressings must stay clean, dry, and intact. 2. Change transparent semi-permeable membrane dressings at least every 5-7 days and as needed (when wet, soiled, or not intact). The following information should be recorded in the resident's medical record: 1. Date and time dressing was changed. 2. Location and objective description of insertion site. 3. Any complications /interventions that were done. 4. Condition of sutures (if present). 5. Any questions, education given to resident, resident's statement regarding intravenous therapy…

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 During an abbreviated survey (Case #'s NY00325764, NY00324136, and NY00321074) the facility did not maintain sufficient nursing staff to ensure that residents received care and services as determined by assessment of resident needs and plans of care and in accordance with the facility assessment. Specifically, there was not sufficient nursing staff to meet the residents' needs including activities of daily living in accordance with individual plans of care and the facility assessment for 3 of 3 care units at the facility. In addition, three (3) of the complaints investigated onsite had allegations of insufficient nursing staffing levels and during resident and staff interviews on 1/24/2024, 2/11/2024, 4/9/2024, 4/10/2024 and 4/24/2024 multiple residents and staff reported care was not being provided due to insufficient staffing levels and expressed concerns for resident safety. This is evidenced by: Cross-referenced to: F550: Resight Rights, F584: Safe,…

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 reviews and interview during an Abbreviated survey (Case #NY00325764), the facility did not ensure that the facility assessment addressed the care required by the resident population considering the types of disabilities, overall acuity, and other pertinent facts within the population. Specifically, the facility assessment did not account for the total resident population and their care needs. This has the potential to affect all residents. This is evidenced by: Cross-referenced to F725: Sufficient Nursing Staff, F677: Activities of Daily Living for Dependent Residents The Policy and Procedure, titled Facility Assessment, last revised August 2023, read in part that it was the intent of the facility assessment for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents required, in accordance with State and Federal Regulations. The Facility Assessment, dated 12/20/2023, documented the facility as being licensed for one hundred-twenty (120) beds with an average daily census of 95…

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 during a post survey revisit on 8/16/2024, the facility did not maintain an effective pest control program on (3) of 3 units. Specifically, house flies were noted on the A) North, B) East, and C) South residential units, in the hallways and in resident rooms. This is evidenced by: House flies were noted on the North unit: During observation of the North unit on 8/8/2024 at 9:35 AM, Resident #3 was in the hall and told the surveyor they wanted to talk to them. At 9:38 AM, the surveyor entered Resident #3's room and a house fly landed on the surveyor's head and the surveyor then swatted flies away from them with their clipboard. Resident #3 stated that every resident room had flies, according to what they heard from the other residents. They stated the facility was aware of the flies and gave residents fly swatters and showed the surveyor the fly swatter. Resident #3's roommate (Resident #4) was in bed and covered with a blanket. The surveyor noted 3 house flies crawling on Resident #4's blanket, a fly on the resident's dresser, and a fly on 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 and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life. Specifically, (A) three residents (Resident #'s 1, 4 and 8) did not receive regular, timely assistance to carry out activities of daily living, which impacted their right to be treated in a dignified way; residents reported feeling their dignity was impacted by lack of showers and not receiving care in a timely fashion; (B) Resident #11 reported that loud sounding call bell alarms would be going off constantly on their unit, which impacted their ability to sleep; and (C) residents were served with plastic utensils rather than silverware. This was evident for 45 residents (Resident #'s 1, 4, 11, 8; and 39 of 39 residents on the South Care Unit). This is evidenced by: Cross-referenced to: F584: Safe, Clean, Comfortable Home-like Environment, F677: Activities of Daily Living for Dependent Residents and F725: Sufficient 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 observations, record review and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure a safe, clean, comfortable, home-like environment for 3 of 3 resident care units. Specifically, the facility did not ensure that the resident rooms and common spaces were clean and sanitary and that areas of disrepair were repaired. This is evidenced by: Cross-referenced to: F550: Resident Rights The Policy and Procedure titled, Housekeeping and Sanitation, last reviewed 8/03/2023, read in part, in order to prevent and control the spread of disease, it was the objective of the housekeeping department to maintain a clean, sanitary, clutter free, and safe environment for residents, visitors, and staff. The Policy and Procedure titled, Resident Right - Safe/Clean/Comfortable/ Homelike Environment, last revised September 2023, read in part, that it was the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect 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 record review and interviews during an abbreviated survey (Case #'s NY00325764, NY00333406, and NY00333793) the facility did not ensure residents were free from abuse. Specifically, the facility did not implement effective interventions to manage aggressive behaviors exhibited by Resident #3 and resulted in two incidents of resident-to-resident altercations that resulted in Resident #3 being punched by Resident #6 and in a separate incident where Resident #3 hit Resident #18. Prior to both incidents occurring, the resident was named in the complaint for having aggressive behaviors and altercations with other residents. This is evidenced by: The Policy and Procedure, titled Resident Abuse Prevention and Reporting, last revised 10/13/2022, read in part it was the policy of the facility that all residents be treated with respect and dignity, with self-determination and freedom from abuse, mistreatment, neglect and misappropriation of property. The Policy and Procedure titled, Resident to 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 during an abbreviated survey (Case #NY00325724) the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #'s 1, 4, 5, 6 and, 8) of 5 residents reviewed for activities of daily living. Specifically, Resident #'s 1, 4, 5, 6 and 8 did not receive required assistance to perform activities of daily living as determined by assessment of the residents' needs and individual plans of care. This is evidenced by: Cross-referenced to: F550: Resident Rights, F692: Nutrition/ Hydration Status Maintenance, F725: Sufficient Nursing Staffing, F838: Facility Assessment The Policy and Procedure titled, Activities of Daily Living/Maintain Abilities, last revised October 2023, read in part that it was the intent of policy of the facility to create and sustain an environment that humanizes and individualizes each resident's quality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case # NY00325764), the facility did not provide needed care and services in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 3 (Resident #'s 2, 30 and 31) of 3 sampled residents reviewed for nursing assessments after an accident/incident. Specifically, Residents #'s 2, 30 and 31 were not assessed by a Registered Nurse after accidents/incidents that were unwitnessed and/or when the residents observed with injuries. This is evidenced by: Cross referenced to: F689: Accident Hazards, F725: Sufficient Nursing Staff According to New York State Education Law §6902, Licensed Practical Nurses typically provide the following services: (a) administer immunization, most types of medications, and some blood products (with additional training) (b) bedside nursing care in hospitals and nursing homes (c) clinical procedures (i.e., urinary catheterizations, tracheal suctioning, sterile…

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 an abbreviated survey (Case #'s NY00325764 and NY00324136), the facility did not ensure the provision of nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment, therapeutic diet and preferences for 2 (Residents #4 and #5) of 3 sampled residents reviewed for weight loss. Specifically, the facility did not ensure that Residents #4 and #5, who were dependent on staff for meal assistance, regularly received meal assistance, were regularly monitored for meal intake, were provided with adaptive feeding equipment and that they received their full, correct meal orders. This is evidenced by: Cross-referenced to: F689: Accidents/Hazards, F677: Activities of Daily Living for Dependent Residents and F725: Sufficient Nursing Staff. The Policy and Procedure, titled Management of Resident Weight, revised 10/20/2022, read in part, that any resident with an unplanned weight loss or gain of 5 percent in one…

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 during an abbreviated survey (Case #NY00325764), the facility did not ensure to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of communicable infections for 3 of 3 care units. Specifically, the facility did not ensure that staff appropriately used and discarded of personal protective equipment and that the resident environment was sanitary. This is evidenced by: Cross-referenced to F584: Safe/clean/comfortable homelike environment. The Policy and Procedure titled, Housekeeping and Sanitation, last reviewed 8/03/2023, read in part, in order to prevent and control the spread of disease, it was the objective of the housekeeping department to maintain a clean, sanitary, clutter free and safe environment for residents, visitors and staff. The undated Policy and Procedure titled, Standard and Transmission-based Precautions, read in part that it was 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 (Case # NY00325764), the facility did not ensure a resident was assessed by the interdisciplinary to determine a resident's ability to safely administer their own medications if clinically appropriate for one 1 (Resident #7) out of 3 residents reviewed for medication administration. Specifically, Resident # 7 was observed with medications in their room and self-administered those medications without being evaluated as to whether they could safely do so. This is evidenced by: The Policy and Procedure titled, Activities of Daily Living, last revised October 2023, read in part, that Residents who expressed a wish to self-administer medications would be assessed by nursing and by rehabilitation services for ability to do so safely. This assessment would include parameters of cognitive ability, awareness of dosing times, understanding of purpose for medication and awareness of potential outcomes if not completed, manual dexterity, ability to understand and observe any applicable infection control 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 record review and interviews, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than two (2) hours to the State Survey Agency for 2 of 2 qualifying reportable incident and accident investigations reviewed. Specifically, when Resident #2 was observed with injuries of an unknown origin on 2/01/2024 and 2/18/2024, the facility did not report the incidents to the State Survey Agency. This is evidenced by: Cross-referenced to: F610: Investigate/Prevent/Correct Alleged Violations The Policy and Procedure titled, Injuries of Unknown Origin, last revised September 2023, read in part that it was the policy of the facility that injuries of unknown origin would be investigated to rule out abuse and to determine etiology for the purposes of education and prevention of recurrence. Immediately upon discovery of an injury or change in condition/ the origin of which was unknown, the Nursing Supervisor must be…

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

Based on record review, and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure thorough and accurate investigations were conducted after injuries of an unknown origin were for 2 of 2 facility investigations reviewed. Specifically, when Resident #2 was observed to have injuries of an unknown origin during two separate incidents, the facility did not follow their investigative process, did not thoroughly investigate the injuries to rule out abuse, and did not determine when or how the resident injured themself to prevent further injury. This is evidenced by: Cross-referenced to: F609: Reporting, F689: Accident Hazards and F684: Quality of Care The Policy and Procedure titled, Injuries of Unknown Origin, last revised September 2023, read in part, that it was that policy of this facility that injuries of unknown origin would be investigated to rule out abuse and to determine etiology for the purposes of education and prevention of recurrence. Immediately upon discovery of an injury or change in condition/range of motion, the origin of which 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 interviews during the recertification survey dated 05/04/23 through 05/10/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment on three (3) of 3 resident units, the lobby and core area, and the service areas. Specifically, on the South Unit, the south-end toilet was soiled with a brown substance; the corridor floors including next to walls and where door frames meet the floor were soiled with dirt; the floors were soiled with dirt in corners and next to walls in resident room #s 203, 205, 206, 212, 216, 217, 218, and 222; the shower A floor tiles were soiled with a black build-up; the bottom of the frames of the overbed tables in room #s 217 and 222 were soiled with drip marks and dust; the wall was scraped behind bed B in room [ROOM NUMBER], cobwebs were found on the ceiling in room #s 203 and 218; windows were soiled with airborne debris and water stains in 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 observation, record review and interviews during the recertification survey, the facility did not ensure the resident and the resident's representative(s) were notified in writing and in a language and manner they understood and did not send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 (Resident #'s 4, 74, and 116) of 3 residents reviewed for hospitalization. Specifically, for Resident #4, the facility did not ensure the resident and resident's representative were provided with written notification upon the resident's transfer to the hospital on 3/02/2023 and did not ensure a copy of the notice was sent to the Ombudsman, for Resident #74, the facility did not ensure the resident and resident's representative were provided with written notification upon the resident's transfer to the hospital on 3/02/2023 and did not ensure a copy of the notice was sent to the Ombudsman, for Resident #116, the facility did not ensure the resident and 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 during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or resident's representative upon transfer to the hospital for 3 (Resident #'s 4, 74, and 116) of 3 residents reviewed for hospitalization. Specifically, for Resident #4 the facility did not ensure a copy of the bed hold policy was provided to the resident and or/residents representative upon transfer to the hospital, for Resident #74, the facility did not ensure the resident and family received a copy of the bed hold policy upon discharge to hospital, for Resident #116, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or resident's representative upon the resident's transfer to the hospital on 3/23/2023. This was evidenced by: The undated Policy and Procedure (P&P) titled Private Resident's Bed Hold Policy, documented the resident/designated representative…

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 and interviews during the recertification and abbreviated survey (Case #s: NY00297245 and NY00311218), the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 units. Specifically, the meal trays tested on [DATE] were not served at palatable and appetizing temperatures on the East, North and South units. Additionally, the facility did not ensure thermal insulated domes were utilized on all resident meal trays where required during meals observed between 5/8/2023 - 5/9/2023. This was evidenced by: The Policy and Procedure (P&P) titled Meal Tray Preparation and Tray Pass undated, documented it is the policy of the Dietary Department to assemble and pass meal trays that are nutritious, appetizing, palatable, and at appropriate temperature. Findings included: Finding #1: The facility did not ensure residents on the East Unit received food and drink that was palatable,…

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 during the post survey revisit survey dated 07/13/23, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety for the main kitchen and two (2) of 3 units kitchenettes. Specifically, in the main kitchen, the can opener and holder, mixer, slicer, microwave oven, bulk food containers, drawers, shelf under worktables, walls, and floor in corners and next to walls, and under equipment were soiled with food particles; the South Unit kitchenette and the East Unit kitchenette microwave ovens were soiled with food particles; and the East Unit kitchenette cabinets and walls were soiled with food splatters. This is evidenced as follows: Finding #1 - Main Kitchen: During observation on 07/13/23 at 2:30 PM, the can opener and holder, mixer, slicer, microwave oven, bulk food containers, drawers, shelf under worktables, walls, and floor in corners and next to walls, and under equipment were soiled with food particles. Finding #2 - Unit Kitchenettes: During observation on 07/13/23 at 2:30 PM,…

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 during the recertification survey dated 05/04/23 through 05/10/23, the facility did not ensure corridors were equipped with firmly secured handrails on each side in the core area. Specifically, the following sections of handrailing was missing in core area: 32-feet, 16-feet, 6- feet, 10-feet, 36-feet, 14-feet, 2-feet, 6-feet, 10-feet, 6-feet, 33-feet, 12-feet, 29-feet, and 8-feet. This is evidenced as follows: During observations on 05/10/23 at 10:05 AM, the following sections of handrailing was missing in core area: 32-feet, 16-feet, 6- feet, 10-feet, 36-feet, 14-feet, 2-feet, 6-feet, 10-feet, 6-feet, 33-feet, 12-feet, 29-feet, and 8-feet. During an interview on 05/10/23 at 1:28 PM, the Regional Director of Nursing, the Administrator of Record, the Acting Administrator, and the Director of Maintenance stated that the core area is in the process of being refinished with new handrails being installed by the end of June 2023. 483.90(i)(3)

Based on observation, record review and interviews the facility did not ensure an infection control prevention and control program was implemented to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #74) of 1 residents. Specifically, the facility did not ensure Resident 74's urinary catheter drainage bag was kept off the floor in a privacy bag. The Policy and Procedure (P&P) titled Management of Indwelling/Foley Catheters dated 2/2023 stated the collection bag will be kept in a privacy bag both when in and out of bed for infection control and resident dignity. Resident #74 Resident #74 was admitted to the facility with the diagnoses of metabolic encephalopathy, other specified disorders of kidney and ureter, and hydronephrosis with renal and ureteral calculous obstruction. The Minimum Data Set (MDS - an assessment tool) dated 2/28/2023 documented the resident was understood and could understand others, and the resident was cognitively intact. During an observation on…

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