Highland Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00354392) surveys from 6/25/2025 to 7/3/2025, the facility did not ensure a resident's right to be free from misappropriation of property. This was evident for 1 (Resident #5) of 3 residents investigated for abuse. Specifically, Resident #5's personal food was not stored safely and was eaten by staff, and facility staff diverted Resident #5's income directly to the facility without the resident's consent or knowledge. The findings are:The facility policy titled Abuse Prevention dated 5/23/2023 documented examples of misappropriation of resident property included identity theft, theft of money from bank accounts, and unauthorized or coerced purchases from resident's funds. The facility policy titled Food Preparation - Food Brought by Family/Visitor dated 6/2025 documented food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification and abbreviated (NY00356178) surveys conducted from 6/25/25 - 7/3/25, the facility did not ensure that Comprehensive Care Plans were reviewed and/or revised for 1 of 5 residents (Resident #345) reviewed for Accidents and 1 of 3 residents (Resident #363) reviewed for Abuse Specifically, 1. for Resident #345, there was no documented evidence the comprehensive care plan was reviewed and/or revised after a 6/22/25 fall and 2. there was no documented evidence comprehensive care plans were reviewed and/or revised to address Resident # 363's ongoing behaviors after 9/8/24, 9/12/24 and 9/22/24 episodes of physical and/or verbal aggression. The findings included:1. Resident #345's diagnoses included end stage renal disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and long-term use of opioid analgesic.A care plan titled Activities of Daily Living, dated 6/17/25, 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 observation, interview, and record review conducted during the recertification survey from 6/25/2025 to 7/3/2025, the facility did not ensure resident/s received necessary treatment and services to prevent new pressure ulcers from developing and/or promote healing of a facility acquired pressure ulcer for 1 of 2 residents (Resident #19) reviewed for pressure ulcer. Specifically, for Resident #19 with a documented 2/20/2025 superficial (surface) sacral wound, Braden Assessment/s were incomplete and did not include a score to determine resident risk for pressure ulcer, labs were not obtained as per the 2/20/2025 medical doctor note, and use of an air mattress as per the 3/3/2025 wound doctor note was not implemented until 3/20/2025. Subsequently the sacral wound progressed to stage 4 (full thickness tissue loss with exposed bone and tendon).The findings include:The 2/2025 policy titled Pressure Injury Prevention and Management/Wound Rounds, documented all residents were assessed for the risk of pressure injuries and appropriate preventive care plans will be implements when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the recertification and abbreviated surveys (NY00372410), the facility did not ensure each resident received adequate supervision consistent with resident's needs to prevent accidents. This was evident for 1 of 5 residents (Resident #67) reviewed for accidents. Specifically, Resident #67 was assessed to be at high risk for falls, had multiple unwitnessed falls and complete investigations were not done to determine the root cause and/or add interventions to protect the resident. The findings included:The facility policy titled, Falls, and Fall Risk Managing Fall, last reviewed 3/25, documented: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why…

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.

FACILITY Based on observations, record review, and interviews during the recertification survey from 6/25/25 to 07/03/25, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 4 of 40 opportunities (10.0%) resulted in error for 1 of 4 residents (Resident #22) observed. Specifically, 1) Resident #22 was administered two inhalant medications (Incruse Ellipta and Fluticasone-Salmeterol) in succession without having the resident rinse their mouth in between and after inhalations or waiting one to three minutes in between inhaler administration. 2). Resident #22 was administered two different eye drops medications (artificial tears and cyclosporine emulsion) to the bilateral eyes without waiting three to five minutes in between administation to allow for absorption. The findings are: The facility policy titled Administration of Medication - General, revised 3/25, documented: It is the facility policy that medications will be administered to residents in a timely and accurate manner by a licensed nurse or physician.…

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 from 6/25-7/3/25, the facility did not ensure that all drugs and biologicals accessible for use were not expired and that all drugs and biologicals were stored in locked compartments accessed only by authorized personnel. Specifically, 1) nine boxes of Sequirus Flucelvax influenza vaccine were observed in freezer section of the Third floor unit medication refrigerator, 2) expired biologicals and medications for five residents no longer in the facility or no longer receiving medications were found stored in the Third floor medication room and not returned to the pharmacy or disposed of and 3) expired and undated medications were observed in the Second and Third floor units medication carts. Findings include:The Facility policy titled, Storage of Medication, revised 1/2/25, documented that the facility stores all drugs and biological in a safe, secure and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1) During an observation and…

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

Based on record review and interview during the recertification survey conducted 06/25/25 to 07/03/25, the facility did not ensure each resident was offered influenza and pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Resident #25) reviewed. Specifically, there was no documented evidence Resident #25 had been offered, declined, or educated about the influenza and pneumococcal and immunization.Findings include:The facility policy for Influenza Vaccine dated 3/2024 and reviewed 3/2025 documented the purpose is to reduce morbidity and mortality from influenza by vaccinating all residents who meet criteria established by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices The facility policy for Pneumococcal Vaccination dated 5/23/23 and last reviewed 3/2025 documented, it is the policy to provide pneumococcal vaccinations to all residents on admission to reduce morbidity and mortality in accordance with Centers for Disease Control and Prevention and…

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

Based on observation and interview during the Recertification Survey from 8/21/23 to 8/25/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. multiple kitchen employees did not use hygienic practices and were observed not wearing a hair restraint over their beard, and 2. a cook did not follow safe food handling practices when recording food temperatures and did not ensure that cold foods were held at 41 degrees Fahrenheit or lower. The findings are: The initial tour of the kitchen was conducted on 8/21/2023 from 9:42 AM- 10:20 AM and the following were identified: On 8/21/23 at 9:56 AM [NAME] #1 was observed in a food preparation area not wearing a hair restraint over their beard. In an interview at that time, cook #1 stated that they use a beard guard when they have them and they are waiting for the delivery of beard guards to arrive. On 8/21/23 at 9:58 AM the Food Service Director (FSD) stated they did not know that there were no beard coverings, and if they had…

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

Based on observation and interviews conducted during the Recertification Survey from 8/21/23 to 8/25/23, the facility did not ensure that all essential kitchen equipment was maintained in safe operating condition. The issues included use of a low temperature dishwasher (chemical sanitization) without properly monitoring the chemical sanitizer concentration of the final rinse. According to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code, the recommendations for Low Temperature Dishwasher (chemical sanitization) are: - Wash - 120 degrees F; and - Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. The findings are: A tour of the kitchen was conducted on 8/21/23 between 9:42 AM and 10:20 AM and revealed dishwashing in progress. In interviews conducted on 8/21/2023 at 10:04 AM and at…

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

Based on observation, record review and interview during the recertification survey, the facility did not ensure that the call bell system was accessible for 1 of 3 residents (Resident #5) reviewed for activities of daily living (ADL). Specifically, the call bell for Resident #5 was not within reach on multiple occasions. The findings are: Resident #5 was admitted to the facility with diagnoses including dementia, a fractured femur (leg), and hemiplegia following cerebral infarction affecting right dominant side. The Minimum Data Set (MDS) Assessment, dated 6/18/23, revealed the resident had severely impaired cognition and required the extensive assistance of one staff member for bed mobility and toileting, and total assistance of two staff members with transfers. The comprehensive care plan (CCP) dated 6/26/23, documented the resident was at high risk for falls related to gait/balance problem hemiplegia. Interventions included making sure the resident's call light was within reach, and encouraging the resident to use it for assistance as needed. On 08/21/23 at 9:43 AM Resident #5…

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 from 8/21/23 to 8/25/23, the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #74) reviewed. Specifically, the facility was unable to provide documented evidence that Resident #74 or their Representative received the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (expiration date 8/31/23) documents a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification Survey from 8/21/23-8/25/23, the facility did not ensure the residents or the residents' representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 2 of 3 residents (#11 and #91) reviewed for hospitalizations. Specifically, Resident #11 and Resident #91 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the residents' representatives or that notification was sent to the Ombudsman. The findings are: The facility policy, 'Transfer/ Discharge Notice', effective date 10/24/22, documented that before a resident is transferred or discharged specific notification procedures must be followed which included the reason for transfer/discharge, the effective date of the transfer/discharge, the location to which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey from 8/21/23 to 8/25/23, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy for 2 of 3 residents reviewed for hospitalization. Specifically, Residents #11 and #91 were transferred to the hospital and the facility was unable to provide evidence that written notice of the facility Bed Hold Policy was given to the residents or their representatives. The findings are: The facility policy, 'Bed Hold Policy', effective date 5/2017, documented that written notice must be provide to the resident/representative regarding bed hold upon transfer to the hospital. 1. Resident #11 was admitted to the facility with diagnoses which included dependence on hemodialysis, anemia, and hyperkalemia. The Minimum Data Set (MDS-a resident assessment tool) admission assessment dated [DATE] documented Resident #11 had moderately impaired cognition. The resident required assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a recertification survey, the facility did not review and revise the resident's comprehensive care plan with appropriate interventions for 1 of 3 residents (#84) reviewed for urinary catheter. Specifically, Resident #84's Foley catheter was discontinued on 7/18/2023 and the care plan was not reviewed and revised to address urinary incontinence care. The findings are: Resident #84 was admitted to the facility with diagnoses including cardio-respiratory conditions, cancer, Benign Prostatic Hypertrophy (BPH), and Parkinson's. A significant change Minimum Data Set (MDS: a resident assessment tool) dated 4/16/2023 documented Resident #84's cognition was intact; they were dependent on staff and required 2 staff assistance with toilet use which included management of ostomy or catheter; and they had an indwelling catheter. A Quarterly MDS dated [DATE] documented Resident #84 required 2-persons assist with extensive assistance for toilet use which included management…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that special eating equipment and utensils for residents who need them was provided for 1 of 2 residents (R) # 45 reviewed for adaptive equipment. Specifically, a divided scoop plate and built up bendable (bent to the L) utensil were not provided for Resident #45 as per physician order and therapy evaluation and recommendation. The findings are: Resident #45 had diagnoses including cerebral vascular accident (CVA,stoke), hemiplegia (paralysis of one side of body), altered mental status (AMS), and major depressive disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate impairment of cognitive function and required supervision of staff for eating. An Occupational Therapy Progress Report dated 07/08/2023 documented the resident will safely perform self-feeding tasks with contact guard assist (CGA) with use of Adaptive Equipment (AE) as needed…

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

Based on observations and interviews conducted during the recertification and abbreviated surveys (NY00312542, NY00296734) from 8/21/2023 to 8/25/2023, the facility did not provide a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. This was evident for two (Resident #42, #69) of 8 residents reviewed for Environment. Specifically, the care equipment for Residents #42 and #69 was not maintained in a sanitary condition. The findings are: During an observation of Resident #42 on 8/21/23 at 10:32 AM and 8/24/2023 at 3:14 PM their wheelchair was noted with heavy soiling and their black seat cushion was ripped and the foam interior was exposed. During an observation of Resident #69 on 8/21/23 at 12:56 PM and 8/24/23 at 3:18 PM, the resident's tube feeding pump control unit was soiled with an accumulation of a yellowish-colored dried substance, and their portable tube feeding pole and the pole base were heavily soiled with dried, yellowish-colored and brownish-colored raised-to-the-touch grime. A focused environmental rounds with the Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the Recertification and Abbreviated surveys (NY00296734), conducted from 8/21/2023 to 8/25/2023, the facility did not ensure that care was provided to promote healing of an existing pressure ulcer and prevention of new pressure ulcer for 1 of 4 residents (Resident # 249) reviewed for pressure ulcers. Specifically, Resident #249 had a Stage 2 pressure ulcer on admission and had no treatment in place for 5 days. The findings are: The facility's Policy and Procedure, 'Pressure Injury Prevention and Management' dated 11/2021, documented to assess all residents for the risk of pressure injuries and to have an appropriate interdisciplinary preventative care plan implemented. Resident #249 was admitted to the facility on [DATE] with diagnoses including diabetes, a hip fracture, and coronary artery disease. The Minimum Data Set (MDS, a resident assessment tool) 5-day assessment dated [DATE], documented the resident had severely impaired cognition, and required…

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

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that dignity was maintained during a wound care procedure for one resident (Resident#196). The findings are: Resident#196 was admitted to the facility with diagnoses of, but not limited to; Deep Vein Thrombosis, Diabetes Mellitus, and Chronic Kidney Disease. Review of the physician's orders dated 1/6/2020 revealed orders for weekly skin checks, heel booties to be worn at all times, Betadine and dry sterile dressings to both heels daily on every day shift, cleanse coccyx wound with Dakin's solution, apply Santyl ointment to wound base, pack loosely with Calcium Alginate, and cover with foam dressing daily and as needed on the evening shift. A wound observation was conducted on 1/29/2020 at 3:50 PM on the 2nd floor and the following was noted; during the wound care dressing change LPN#1 left the resident with her lower body/wound site and thighs/legs exposed to staff and visitors in the room or at the door while she left the room to obtain supplies. The privacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the recertification survey, it was determined that the facility did not develop a person-centered care plan with measurable goals, time frames and appropriate interventions based on comprehensive assessments for 2 of 3 residents (#35 and #46 ) reviewed for positioning and mobility and for 1 of 5 residents (#89) reviewed for pressure ulcers. Specifically, 1. Resident #35 did not have a care plan with measurable goals and appropriate interventions to address right sided hemiplegia and the use of a physician prescribed right resting hand splint and right lower extremity ankle foot orthotic; 2. Resident #46 did not have a care plan with measurable goals and interventions to address contracture of the right hand; and 3. Resident #89 did not have a care plan with measurable goals and interventions to address dementia and for the same resident there was no care plan to address skin integrity under a soft cast. The findings are: 1. Resident #35 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, interview and record review conducted during the most recent re-certification survey and an abbreviated survey (#NY00248106), the facility did not ensure that the plan of care for each resident was evaluated when indicated to reflect each resident's current status and/or address the effectiveness of planned interventions. This was evident for 1 of 3 residents (Resident #27) reviewed for activities of daily living and 1 of 4 residents reviewed for nutrition (Resident #46). The findings are: 1. Complaint #NY00248106: Resident #27 was admitted to the facility on [DATE]. The resident's diagnoses and medical conditions include Anxiety Disorder, legal blindness, and Heart failure. The admission Minimum Data Set (MDS, an assessment instrument) dated 5/6/19 showed that the resident had highly impaired vision, no cognitive impairment, was not able to ambulate, required extensive assistance with locomotion, used a walker and a wheelchair, and was receiving rehabilitation services-- occupational…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the most recent recertification survey and an abbreviated survey (#NY00248106), the facility did not ensure that 1 of 3 residents (Resident #27) reviewed for activities of daily living was provided appropriate care or services to prevent decline in ambulation. Specifically, after the resident completed rehabilitation services, the interdisciplinary team did not promptly 1) address with the resident the negative impact of not complying with planned interventions to promote ambulation. and 2) offer the resident other treatment options to maintain the resident's ambulation status. The findings are: Complaint: #NY00248106 1. Resident #27 was admitted to the facility on [DATE]. The resident's diagnoses and medical conditions include Anxiety Disorder, Legal Blindness, and Heart Failure. The admission Minimum Data Set (MDS, an assessment instrument) dated 5/6/19 showed that the resident had highly impaired vision, no cognitive impairment, was not able…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during the most recent recertification survey, it could not be ensured that the facility provided appropriate care to prevent the development of Pressure Ulcers (PUs) or Deep Tissue Injuries (DTIs) to 2 of 3 residents (Residents #89 and #196) reviewed for skin integrity. Specifically, 1) the facility did not ensure that ongoing interventions were established and implemented in accordance with Resident #89's clinical condition and risk factors to prevent the development of DTIs and 2) the facility did not ensure implementation of the use of heel booties at all times for Resident #196 to promote healing of DTIs and the prevention of wounds. The findings are: 1. Resident #89 was admitted to the facility on [DATE] with diagnoses including right foot second metatarsal fracture, Peripheral Vascular Disease (PVD), Dementia and a history of Cerebrovascular Accident (CVA). The admission Minimum Data Set (MDS, an assessment tool) dated 12/31/2019 indicated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the most recent recertification survey, the facility did not ensure that residents were provided the appropriate treatment and services to improve and/or prevent a further decline in range of motion (ROM). Specifically, 1) a resident did not have a right resting hand splint, and right lower extremity AFO applied as per the Physician's order; and 2) a resident with a right hand contracture was not provided a right resting hand splint as per occupational therapy recommendation. This was evident for 2 of 3 residents ( Residents #35 and #46) reviewed for positioning and limited mobility. The findings are: 1. Resident #35 was admitted with diagnoses and medical conditions including but not limited to Hypertension, Hemiplegia of the right dominant side, and muscle weakness. The 10/29/19 admission Minimum Data Set (MDS: an assessment tool) revealed resident #35 had severe cognitive impairment, impairment on one upper extremity, and bilateral lower…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the most recent recertification survey and an abbreviated survey (#NY00248106), the facility did not ensure that 1 of 3 residents (Resident #27) reviewed for bowel and bladder incontinence was provided appropriate care or services to address a decline in bowel continence and to address occasional bladder incontinence. The findings are: Resident #27 was admitted to the facility on [DATE]. The resident's diagnoses and medical conditions include Anxiety Disorder, Heart Failure and legal blindness. The admission Minimum Data Set (MDS, an assessment instrument) dated 5/6/19 showed that the resident had highly impaired vision, no cognitive impairment, used a walker and a wheelchair, required extensive assistance with toileting, was occasionally incontinent of bladder and bowel. This plan also noted that the resident was on a toileting program to address bladder incontinence, which did not result in decreased wetness and was on a toileting program to address bowel…

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

Based on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident (Resident #81) reviewed for respiratory care was provided appropriate care to maintain adequate respiratory functioning. Specifically, the physician did not specify parameters for the administration of oxygen with an order for it to be administered to up to 3 liters. Additional, the resident was routinely being administered oxygen with no routine monitoring of the resident's oxygen saturation levels. The findings are: Resident #81 had diagnoses include Anxiety Disorder, Chronic Obstructive Pulmonary Disease and Cerebrovascular Accident. The physician's current January 2020 orders included an order for the use of a BIPAP machine ( a type of breathing apparatus, delivering pressurized air through a facial or nasal mask to one's airways) at hours of sleep and as needed and for oxygen to be increased up to 3 liters. No parameters were indicated for use of the machine as needed and when oxygen should be increased to 3 liters. Also, the order did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident reviewed for dialysis (#33) was provided the necessary care related to dialysis in accordance with professional standards of practice. Specifically, the resident's plan of care did not address the assessment of the resident before and after receiving dialysis and the nursing staff did not consistently conduct pre and post dialysis assessments of the resident. The findings are: Resident #33's diagnoses include Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Schizophrenia. The annual Minimum Data Set (MDS, an assessment instrument) dated 1/25/19 and the most recent quarterly MDS dated [DATE] revealed that the resident was receiving dialysis. According to the physician's orders, the resident was to be dialyzed three days weekly, Mondays, Wednesdays and Fridays. The dialysis care plan dated 6/4/19 included: checking thrill and bruit, checking for bleeding, use 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, interview and record review conducted during the most recent recertification survey, the facility did not ensure that the care provided for 2 of 3 residents (Residents #31 and #35) reviewed for position and mobility was accurately documented in the residents' medical record. Specifically, 1) the certified nursing assistant (CNA) inaccurately documented a resident that remained in bed (Resident #31) was transferred with extensive assist of 2 staff support; and 2) the nurse inaccurately documented a resident (Resident #35) who was not wearing physician prescribed positioning devices was wearing a right hand resting splint and an ankle foot orthotic (AFO). The findings are: 1. Resident #31 was admitted with diagnoses including Cardiovascular Accident, Chronic Obstructive Pulmonary Disease and Anemia. The 11/19/19 Quarterly MDS (Minimum Data Set: an assessment tool) revealed resident #31 had mild cognitive impairment and was dependent on staff for transfers. The January 2020 CNA Task form revealed Resident #31 was transferred on 1/24/20 and 1/27/20 with extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that nursing staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 2 of 3 residents (Residents #194 and #196) reviewed for pressure ulcers (PU). The findings are: 1. Resident #194 was admitted on [DATE] with diagnoses and conditions not limited to Fracture of Tibia and Hypertension. According to the 1/20/2020 wound care plan, the resident had a right heel Deep Tissue Injury (DTI) related to immobility. Goals included, but were not limited to: the resident would have intact skin by the next review. Interventions included to administer medication and treatment as ordered and monitor for effectiveness. The physician's orders dated 1/17/2020 included orders for Skin Prep to right heel blister every shift, cleanse right knee surgical site with Normal Saline, apply non-stick gauze, secure with kling wrap, and wrap with ACE bandage. A wound observation…

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.