Massena Rehabilitation & Nursing Center

Based on observations, record review, and interviews during the recertification and abbreviated (NY00357525) surveys conducted 8/11/2025-8/15/2025, the facility did not provide on-going assessment and monitoring of bed rails (side rails) for three (3) of three (3) residents (Residents #4, #30, and #126) reviewed. Specifically, Resident #4 had bilateral bed rails and did not have an order or a comprehensive care plan that included the use of bed rails, regular assessments to ensure the bed rails remained appropriate or documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use; Residents #30 and #126 had bilateral bed rails and did not have regular assessments to ensure the bed rails remained appropriate or documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use; and the facility did not have documented evidence of inspections of bed frames, mattress, and bed rails as part of a regular maintenance…

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 the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (3) of four (4) medication carts (Units A2, B2 and C1) and two (2) of two (2) medication rooms (Units A and C) reviewed. Specifically, the Unit A2 medication cart had opened and undated eye drops and multiple prefilled medication cups; the Unit C1 medication cart had opened and undated eye drops and an inhaler; the Unit B2 medication cart was left unattended and unlocked; and the medication refrigerator temperatures on Units A and C were not consistently monitored.Findings include:The facility policy Storage and Maintenance of Medications, revised 10/2017, documented medications were stored safely, securely, and properly following the manufacturer's recommendation or those of the supplier under proper temperature. The refrigerator must maintain a proper temperature of 36-46 degrees Fahrenheit. Medications were checked regularly 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 observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (lunch meals on 8/12/2025 and 8/13/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 8/12/2025 and 8/13/2025. Findings include:The facility policy Food and Nutritional Services, effective 5/2019 documented each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking in the preferences of each resident. The undated facility policy Temperature Maintaining Equipment, documented the facility would hold and maintain the temperature of hot and cold food items during meal service inside the dietary department, dining rooms, and during transportation to resident units. During an interview on 8/11/2025 at 10:44 AM, Resident #98 stated the food was not good, the portions…

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

Based on observations, record review, and interviews during the recertification and abbreviated (IQIES 525144 and 2582064) surveys conducted 8/11/2025-8/15/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for six (6) of six (6) staff (Licensed Practical Nurse #12, and Certified Nurse Aides #22, #51, #52, #53, and #54) observed. Specifically, during meal service on Unit A2 residents were observed being fed by Licensed Practical Nurse #12, and Certified Nurse Aides #22 and #51 while standing; and Licensed Practical Nurse #12, and Certified Nurse Aides #52, #53, and #54 addressed residents as honey and feeders. Findings include: The facility policy Maintaining Resident Respect and Dignity, revised 5/27/2025, documented the facility provided loving care to all residents in a timely manner that best bespeaks dignity, respect, compassion, sensitivity, and concern. The care embraced the physical, emotional, and spiritual needs of all residents. They respected…

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

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure all residents were fully informed of and participated in their treatment, including the right to be fully informed in a language that they can understand of their total health status, including but not limited to, their medical condition, and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternatives or the option they prefer for one (1) of two (2) residents (Residents #53) reviewed. Specifically, Resident #53 was not informed of a medical order for a chest x-ray nor of the results of the x-ray. Findings include:The facility policy Resident Rights, revised 3/2025, documented residents had a right to be informed and make their own decisions. Residents had the right to be fully informed about their total health status, medical condition, and participate in decisions that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for two (2) of four (4) residents (Residents #69 and #126) reviewed. Specifically, Resident #69 did not have access to a telephone and Resident #126 had to make phone calls at the nurse's station where others could overhear their conversations. Findings include: The facility policy Resident Right to Forms of Communication/Privacy, effective 4/7/2023, documented the facility protected and facilitated the resident's right to communicate with individuals and entities within and external to the facility. Resident's had easy access to telephones and a place in the facility where calls could be made without being overheard. 1) Resident #69 had diagnoses including fractured left arm and anxiety. The 8/2/2025 Minimum Data Set…

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

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two (3) of seven (7) residents (Residents #22, and #83) reviewed. Specifically, Resident #22 did not have an enabler bar on their bed as care planned; and Resident #83 was transferred with assistance of one and not two as care planned.Findings include: The facility policy Comprehensive Care Planning, revised 12/15/2025, documented the Comprehensive Care Plan included measurable objectives to meet the resident's medical, nursing and psychosocial needs identified from admission assessments, the comprehensive assessment, and application of the Resident Assessment Protocols. Other problems, strengths or needs identified by the Interdisciplinary Team were included in the Comprehensive Care Plan as appropriate. Types of problems which should be included were, risk for falls and activities of daily living. The facility policy Sit to Stand Mechanical…

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

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025 the facility did not ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of two (2) residents (Residents #18 and #6) reviewed. Specifically, Resident #18 had an emergency department visit due to suicidal ideations, did not receive follow up from social services or psychology services upon return, did not receive psychotherapy services timely as requested and did not have a person-centered care plan and interventions in place to address their mental health; and Resident #6 did not have person-centered care plan interventions in place to address their mental health. Findings include: The facility policy Comprehensive Care Planning, revised 12/15/2024 documented comprehensive care plans would include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs identified by…

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

Based on observations, record review, and interviews during the recertification survey conducted 8/112/2025-8/15/2025, the facility did not ensure planned menus were followed for three (4) of thirteen (13) residents (Residents #8, #69, #98, and #148) reviewed. Specifically, Residents #69, #98, #148 did not receive Mighty Shakes (nutritional supplement) as planned; Resident #148 was missing multiple items listed on their meal ticket; and Resident #8 received bread at meals when care planned for no bread. Findings include: The facility policy Food and Nutritional Services, effective 5/2019, documented each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking in the preferences of each resident. 1) During a lunch meal observation on 8/11/2025 at 12:14 PM, Resident #98's lunch meal ticket documented the resident was to receive a Mighty Shake. The meal tray did not include a Mighty Shake. During a lunch meal observation and interview on 8/13/2025 at 12:51 PM, Resident #98's lunch meal ticket documented…

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

Based on record review and interviews during the recertification survey conducted on 8/11/2025 to 8/15/2025 the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for one (1) of five (5) residents (Resident #1) reviewed. Specifically, Resident #1 was referred to Urology and was supposed to have dental and podiatry follow ups the facility did not follow up on in a timely manner. Findings include:The facility policy Consults-Outside Facility, revised 11/18/2024, documented the provider ordered all medical appointments and clinic visits. The Nurse Manager/designee initiated the consult form and filled out the name of the medical provider requesting the appointment, the medical clinic, the phone number, and the reason for the consult. The appointment was to be made in a timely manner, and they were to inform the provider if they were unable to do so. The resident/resident representative of the appointment were notified of the appointment, and the consult packet was made. Upon the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of three (3) residents (Resident #8) reviewed. Specifically, Resident #8 was on contact precautions (used to prevent transmission of pathogens that are spread by direct person-to-person or indirect contact with the resident or environment) and Licensed Practical Nurse #20 changed a gastrostomy tube dressing (a tube inserted in the stomach through the abdomen) without wearing required personal protective equipment. Additionally, the facility Infection Prevention and Control policies and standards were not reviewed annually to ensure effectiveness and were in accordance with current standards of practice for preventing and controlling…

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 abbreviated survey (NY00359676), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's wound consultant recommended to start an antibiotic for a wound infection and the recommendation was not reviewed timely. Findings include: The facility policy, Consults-Outside Facility, effective 7/2023, documented upon return from an outside appointment, the Nurse Manager/designee followed up with the physician to discuss any new consult recommendations (this could be done by telephone or in-person if attending was in the facility at the same time resident returned from consultation). The attending physician might not agree with consultation recommendations which required documentation in the medical record by the Nurse Manager/designee. Resident #2 had diagnoses including diabetes, Stage 3 chronic kidney disease, and peripheral…

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

Based on record review and interview during the abbreviated survey (NY00331713), the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 6 residents reviewed (Resident #1). Specifically: Resident #1 had a significant weight loss, noted worsening of wounds, decreased appetite/intakes, and a nurse practitioner's recommendation for a dietary consult, and the resident was not reassessed by clinical nutrition staff timely. Findings include: The 5/2019 Nutritional Assessment Policy documented an individualized care plan should address to the extent possible identified causes of impaired nutrition; the resident's personal preferences; goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. The 7/2023 Consults - Outside Facility policy documented upon the residents' return from an outside appointment, the Nurse Manager/designee would follow-up with the physician to discuss any new consult recommendations. The attending physician might not agree with consultation recommendations which required…

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

Based on record review and interview during the recertification survey conducted 12/11/2023 -12/15/2023, the facility did not ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility water cooling towers had not been tested monthly for Legionella in 2023, and the annual Legionella testing was not completed in 2022. Findings include: The Legionella Culture Sampling and Analysis, effective 5/2019, documented: Provisions requiring Legionella culture sampling and analysis at intervals not to exceed 90 days for the first year following adoption of the sampling and management plan. Thereafter, the plan should include provisions for annual Legionella culture sampling and analysis. The policy did not reference any sampling of the cooling towers. There was no documented evidence the facility water cooling towers had been tested monthly for Legionella in 2023. The monthly testing for the facility water…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the recertification and abbreviated (NY00319488, NY00326236, NY00319036) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure residents' rights to a safe, clean, comfortable, and homelike environment for 12 isolated areas (C1 unit handicap bathroom, C1 unit bathroom near the lobby, C1 unit central bath room [ROOM NUMBER], C1 unit central bath room [ROOM NUMBER], B2 unit central bath room [ROOM NUMBER], A1 unit resident room [ROOM NUMBER], C1 unit long hall soiled utility room, A1 unit long hall soiled utility room, A1 unit resident room [ROOM NUMBER], second floor main dining area, occupational therapy/physical therapy room, A2 unit central bath room [ROOM NUMBER]). Specifically, call light devices were not functioning for multiple rooms (C1 unit handicap bathroom, C1 unit bathroom near the lobby, C1 unit central bath room [ROOM NUMBER], C1 unit central bath room [ROOM NUMBER], B2 unit central bath room [ROOM NUMBER], A1 unit resident room [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 and abbreviated (NY00314558, NY00315659, NY00319036, NY00326236, and NY00327075) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 6 of 6 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner, and for four residents (Residents #22, #38, #89 and #107) reviewed. Specifically, during a confidential group meeting (resident council), 6 residents stated they had long wait times before their call lights were answered, Resident #22 was observed being provided care at an inappropriate assistance level, Resident #38's call light was answered after 72 minutes, Resident #89's call light was answered after 53 minutes and Resident #107's call light was answered after 74 minutes. Additionally,…

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

Based on observation, record review, and interview during the recertification survey conducted 12/11/2023 - 12/15/2023, the facility did not ensure sufficient support personnel to safely carry out the functions of the food and nutrition services for 2 of 4 resident units (Unit A1 and Unit C1), the downstairs dining room and the main kitchen. Specifically, Unit A1, Unit C1 and the downstairs dining room had resident meal trays delivered over one hour after the posted scheduled meal times, and concerns were identified with the effectiveness of meal preparation and other food and nutrition services. Additionally, deficiencies related to food and nutrition services were identified in the areas of: Menus Meet Resident Needs/Prepare in Advance/Followed; Nutritive Value/Appear, Palatable/Prefer Temperature; and, Food Procurement, Store/Prepare Serve-Sanitary. Findings include: The Resident Listing Report, dated 12/11/2023, documented the facility's resident census was 152. On 12/11/2023, the facility provided a dietary employee schedule which documented the projected schedule for the week…

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

Based on record review, observation, and interview during the recertification and abbreviated (NY00319036) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety for the main kitchen. Specifically, the main kitchen had undated and outdated food; staff were not wearing hair nets as required; floors, walls and other items were not clean; food scoops were left in sugar and flour bins; there were fruit flies within the kitchen; the three-bay sanitizer strips were expired; and the dish machine water temperatures were out of range. Findings include: The Use of Dish Machine policy, effective date 5/2023, documented that the operator would check temperatures using the machine gauge with each dishwashing machine cycle, and record the results in a facility approved log. The operator would monitor the gauge frequently during dishwashing machine cycles. Inadequate temperatures were to be reported to the supervisor and corrected immediately. The placard…

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 during the recertification and abbreviated surveys (NY00315659, NY00327075, and NY00319488) conducted 12/11/2023 - 12/15/2023, the facility did not ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 5 residents (Resident #22) reviewed. Specifically, Resident #22 developed three facility acquired pressure ulcers and: - The pressure relieving air mattress (specialty mattress used to relieve pressure) was not accurately set to the resident's weight. - There was no treatment ordered to the Stage 4 (full thickness skin and tissue loss with muscles, tendons or bones exposed) to left gluteal fold (the skin crease below the buttocks, separating the upper thigh from the buttocks) from 12/8/2023 - 12/14/2023. - Pressure relieving devices were not implemented as care planned. - The resident was…

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

Based on record review, observation, and interview during the recertification survey conducted 12/11/2023 -12/15/2023, the facility did not ensure 4 of 4 resident assistants (resident assistants #7, #8, #9, and #10) who completed a Nurse Aide Training and Competency Evaluation Program and working in the capacities of nurse aide trainees, were in compliance with the state approved Nurse Aide Training and Competency Evaluation Program. Specifically, the facility received a letter from Centers for Medicare and Medicaid Services dated 10/11/2023, prohibiting the provision of a Nurse Aide Training and Competency Evaluation Program for a period of two years, effective 6/28/2023 through 6/27/2025. The facility hired resident assistants #7, #8, #9, and #10 after the 10/11/2023 prohibition letter to work as nurse aide trainees while waiting to take their nurse aide certification exam. Findings include: The undated facility job description for resident assistants documented they worked under the supervision of nurses to perform assigned functions of non-medical care to residents. Essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during recertification and abbreviated (NY00319036) surveys conducted 12/11/2023 through 12/15/2023, the facility did not ensure menus were followed for 1 of 2 residents (Resident #95) reviewed. Specifically, during 5 meal observations, Resident #95 had missing menu items from their meal trays, and substitutions were not consistently provided as planned. Findings include: The undated facility policy, Food and Nutritional Services, documented that each resident was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs and took into consideration the preferences of each resident. Meal trays would be assembled, and all required items would be placed on the meal tray in an organized fashion. Food and nutrition services staff would inspect food trays to ensure that the correct meal was provided to each resident. If an incorrect meal was provided to a resident, or a meal did not appear palatable, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the recertification and abbreviated (NY00319036) surveys conducted 12/11/2023 - 12/15/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (12/11/2023 and 12/13/2023 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures. Findings include: During an observation on 12/11/2023 at 2:17 PM, the last lunch meal tray passed on Unit A1 was taken as a test tray in the presence of activities aide #19. The tray was tested, and a replacement was ordered for the resident. At 2:19 PM, the food temperatures were measured with the following results: the milk was 57 degrees Fahrenheit; and carrots were 118 degrees Fahrenheit. The milk and carrots were not held at palatable temperatures. During an observation on 12/13/2023 at 12:37 PM the lunch tray had been left in room [ROOM NUMBER]A Unit B2 before…

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

Based on record review and interview during the abbreviated survey (NY00328448), the facility did not provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for 3 of 3 employees reviewed (Employees #1, 2, and 3). Specifically, the facility did not complete the required health screenings Employees #1, 2, and 3 and the employees' health records were not completed accurately based on available information and standards of nursing practice. Additionally, Employees #1 and 2's health records included they received the influenza (flu)vaccinations when they had not received them. Findings include: The undated Employee Health Program policy documented the Employee Health Program consisted of: - pre-employment physical examinations and testing. - Providing immunization programs for recommended or required vaccines upon hire and annually when indicated. - Providing employee screening for communicable diseases and infections. The 5/2019 Influenza Vaccine policy documented for employees…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews during the recertification survey conducted from 11/15/21- 11/19/21, the facility failed to maintain a safe, clean, comfortable, and home-like environment for 1 of 4 resident units (Unit B2) and 3 of 29 residents (Resident #3, 2, and 24) reviewed. Specifically, on Unit B2 there were stained, non-waxed, and sticky floors; sticky, unclean walls, baseboards, wall handrails; unclean wheelchairs; and unclean, ripped lift equipment used by residents. Additionally, Unit A2 and B2 did not have enough bath linens for morning care and enough clothing protectors available for use during lunch. Findings include: Housekeeping The facility's Your Rights as Nursing Home Resident in New York State dated June 2010, documents as a nursing home resident they have the right to dignity, respect, and a comfortable living environment. The nursing home must provide the resident with safe, clean, and comfortable rooms and surroundings. The facility's Environmental Services Cleaning Guidebook 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.

Based on observation, interview, and record review during the recertification survey conducted 11/15/21 - 11/19/21, the facility failed to store, prepare, distribute and serve food in accordance with professional standards during the initial kitchen tour on 11/15/21 Specifically, there were multiple undated/unlabeled food items in coolers, employee personal food items in with resident food, soiled soda cans were stored with clean dishes, scoops were in bulk bin items, a plastic container of pizza sauce was not covered fully in the freezer, 1 box of frozen croissants were stored on the floor in the freezer, there were dented cans on a shelf in the dry storage room, and ice buildup in the walk-in freezer. Findings include: The 10/2018 facility policy Proper Food and Drink Storage and Labeling documented that all food and drink will be properly stored and labeled to ensure safe consumption. All food and drink are required to have labeling for easy identification. The facility will properly store and label food and drink items thereby maintaining sanitary and safe conditions in order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review during the recertification survey conducted 11/5/21-11/19/21, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of quality of life for 1 of 3 residents (Residents #59) reviewed. Specifically, Resident #59 was observed lying in bed in their room exposed from the waist down. The resident's door was open, the privacy curtain was not pulled, and the resident was visible from the hallway. Additionally, a housekeeper was in the resident's room cleaning. Findings include: The facility policy Resident Dignity effective 9/2018 documents the facility promotes care for residents in a manner and environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. Staff were to respect the resident's private space and cover the resident 's skin while in bed. Resident #59 had diagnoses including Alzheimer's disease and anxiety. 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 conducted 11/15/2021-11/19/2021, the facility failed to ensure results of the most recent federal/state survey were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the Statement of Deficiency 3-ring binder in the main lobby did not include results from the last recertification survey on 7/11/19 or the 1/21/21 Focused Infection Control Survey. Findings include: The facility policy Your Rights as a Nursing Home Resident dated June 2010, documented the home shall make available for examination the results of the most recent survey of the facility conducted by Federal or State surveyors including any statement of deficiencies, any plan of correction in effect with respect to the facility and any enforcement actions taken by the Department of Health. They shall be made available in a place readily accessible to residents and designated representatives without staffing assistance. During an observation on 11/16/21 at 12:19 PM, the Statement of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification and abbreviated surveys (NY00276030 and NY00283911) conducted 11/15/21- 11/19/21, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Residents #14, 37, and 52) reviewed. Specifically, Resident #52 did not receive timely meal assistance at 3 observed meals, Resident #37 was observed wearing the same soiled clothing for 3 days, and Resident #14 did not receive incontinence care as care planned. Finding included: The facility policy Activities of Daily Living dated 9/2017 documented residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. Care and services for ADLs included hygiene, elimination, and dining. 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, interview, and record review during the recertification and abbreviated (NY00280353) surveys conducted from 11/15/21-11/19/21, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested (breakfast). Specifically, food was not served at palatable and safe temperatures for the 11/16/21 breakfast meal. Findings include: The facility's meal cart times documented the breakfast tray line started in the main kitchen at 7:25 AM and the meal carts arrived to the A2 Unit at 8:05 AM. During the breakfast meal observation on 11/16/21 the meal cart arrived to the A2 Unit Dining Room at 8:13 AM. At 08:53 AM, staff was observed bringing the last meal tray on the cart to an anonymous resident's room. Facility staff were asked to provide the resident with another breakfast tray and the original tray was used to measure food temperatures. The poached egg was 105 degrees Fahrenheit (F), the egg was firm and the consistency of a hard-boiled egg, 1 glass of ginger ale was 59.7 degrees F, 1…

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.