Onondaga Center for Rehabilitation and Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00340114) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 (North and South units) resident units and the main dining room. Specifically, on the North unit resident rooms [ROOM NUMBERS] had used incontinence briefs on the floor and nightstand; resident 209 smelled of urine; resident room [ROOM NUMBER]'s door handle was broken; and resident rooms [ROOM NUMBER] had sliding glass door restrictors that were not maintained. On the South unit resident rooms [ROOM NUMBERS] light fixtures were missing covers, had open light sockets, and exposed wiring; and there was a broken table in the main dining room. Additionally, residents received cold beverages in disposable cups at meals. Findings include: The facility policy Resident Rights revised 2/2020 documented the residents had a right to a dignified…

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 (NY00212922, NY00310702, and NY00310431) surveys conducted 5/6/2024-5/10/2024, 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 4 of 10 residents (Resident #1, #12, #35, and #37) reviewed. Specifically, Resident #1 was not assisted with dressing; Resident #12 was not assisted with bathing; Resident #35 was not assisted out of bed or supervised with meals; Resident #37 had unclean and untrimmed fingernails. Findings include: The facility policy Activities of Daily Living Care and Support revised 3/13/2024 documented residents received activities of daily living care and support in accordance with current standards of practice based on the resident's assessed needs, personal preferences, and goals of care. Care and support were provided to residents who were unable to carry…

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 (NY00312922) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plans of care for 2 of 2 nursing units (North unit and South unit) observed. Specifically, resident meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes. Findings include: The facility policy Meal Service revised 4/2022 documented meals would be delivered promptly to assure quality. During an interview on 5/6/2024 at 8:30 AM Resident #19 stated sometimes the meals came late due to the kitchen being short staffed. The facility's posted schedule documented the following mealtimes: Breakfast: -North Unit 8 AM. -South Unit 8:15 AM. -Dining room [ROOM NUMBER]:35 AM and 8:45 AM. Lunch: -Dining room [ROOM NUMBER]:15 PM 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, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler floor and door, walk-in freezer door, hood filters, the wall beside the coffee station, and the ceiling were in disrepair and there were several unclean surfaces present throughout the kitchen. Findings include: The Food Service Department policy Cleaning Policy last reviewed 1/2023 documented the nutrition and food service staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. There was no documented evidence of a kitchen cleaning schedule. During an initial main kitchen tour on 5/6/2024 the following was observed: - at 6:11 AM, one filter was out of place at the right end of the hood above the flat top stove. - at 6:20 AM, the door to the walk-in freezer would…

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 and abbreviated (NY00312922 and NY00310431) surveys conducted 5/6/2024-5/10/2024, 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 2 of 10 residents (Residents #36 and #45) reviewed and the facility lacked a water management plan to reduce the risk of growth and spread of Legionella (a bacteria found in water systems). Specifically, staff was observed not wearing the required personal protective equipment in Resident #45's room who was on transmission-based precautions; and Resident #36 had extended-spectrum beta-lactamase (enzyme resistant to most antibiotics) in their urine with an indwelling medical device and enhanced barrier precautions were not properly maintained. Additionally, the facility did not have a water management plan that detailed their policy and procedures for reducing the risk of growth…

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 5/6/2024-5/10/2024, the facility did not maintain equipment in safe operating condition for 2 of 2 unit kitchenette refrigerators. Specifically, the unit kitchenette refrigerators did not maintain proper temperatures. Findings include: During an observation on 5/6/2024 at 7:30 AM, the South Unit kitchenette had an upright white refrigerator labeled, out of order-do not use. The refrigerator portion was empty. The thermometer inside read 65 degrees Fahrenheit. The freezer portion held some frozen food items that included ice cream bars, frozen drinks, and individual portions of ice cream. Additionally, there was a small black refrigerator that had the door left ajar a few inches. There were drinks for resident use had a measured temperature of 41.7 degrees Fahrenheit. The door hit the side of the cooler and had to be physically pushed closed for the door to seal properly. During an observation on 5/6/2024 at 7:13 AM, the North Unit kitchenette refrigerator thermometer read 58 degrees…

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 5/6/2024-5/10/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 had lidocaine-prilocaine cream (topical cream used to numb skin before a medical procedure) at their bedside and there was no documented evidence the resident was assessed for their ability to safely self-administer the medication. Findings include: The facility policy Medication-Self Administration reviewed 7/2019 documented the staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident. If the team determined that a resident could not safely administer medications, all medications would be administered by a nurse from the stored medication in the med cart. Staff would identify and give the charge nurse any medications found at the bedside that were not authorized 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 of resident (Resident #72) reviewed. Specifically Resident #72 did not have resident-specific interventions for their language barrier or for their potential to become a victim of verbal or physical abuse. Findings include: The facility policy Translation Services last revised 1/2020, documented the facility's language access program would ensure that individuals with limited English proficiency shall have meaningful access to information and services provided by the facility. The facility policy Residents Rights last revised 2/2020, documented residents had the right to communication with and access to people and services, both inside and outside the facility The facility policy Behavior Management last revised 5/2020, documented the facility must provide an interdisciplinary…

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 conducted 5/6/2024-5/10/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 2 residents (Residents #13 and #36) reviewed. Specifically, Residents #13 and #36 were not offered meaningful activities of their choosing as care planned. The facility policy Recreational Services last reviewed 5/2019 documented the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. 1) Resident #13 was had diagnoses including depression and left lower leg amputation. The 8/17/2023 Minimum Data Set 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00340114, NY00310431, NY00336364, and NY00310702) surveys the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #60) reviewed. Specifically, Resident #60 had a recommendation for a follow up appointment with nephrology (kidney specialist) and there was no documented evidence the follow-up appointment was scheduled or occurred. Findings include: The facility policy Residents Rights last revised 2/2020 documented residents had the right to communication with and access to people and services, both inside and outside the facility. Resident #60 was admitted to the facility with a diagnose including chronic kidney disease, and acute kidney failure. The 2/22/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and required partial to moderate assistance with transferring and ambulation.…

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 (NY00312922 and NY00314056) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 9 residents (Residents #42 and #379) reviewed. Specifically, Resident #379's bed was not maintained in the low position and their call bell was not in reach and Resident #42 was observed wandering, unsupervised, into other resident rooms without interventions in place for monitoring; Findings include: The facility policy Falls Management and Prevention revised 11/2019 documented the interdisciplinary team would identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The staff would implement goals and interventions with resident/ family for inclusion in the interdisciplinary care plan based on the resident's individual needs. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification and abbreviated (NY00312922) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #75) reviewed. Specifically, Resident #75 was not weighed as ordered, did not received fortified pudding, and was not assisted with meals as care planned. Findings include: The facility policy Nutrition Assessment revised 8/2020 documented the nutritional assessment would be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Once current conditions and risk factors for impaired nutrition were assessed and analyzed, individual care plans would be developed that addressed or minimized to the extent possible the resident's risks for nutritional complications. Such interventions would be developed…

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 5/6/2024-5/10/2024, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 received hemodialysis (a treatment that filters the blood), had a physician order to remove the dialysis access site dressing 6-8 hours after dialysis and the dressing was scheduled to be removed prior to going to dialysis and was not completed. Findings include: The Entrance Conference Worksheet provided to the facility on 5/6/2024 included information needed from the facility regarding dialysis contracts, agreements, arrangements and policies and procedures. The facility responded they did not currently have any residents who received dialysis. There was no documented evidence of a hemodialysis agreement or policy and procedures. Resident #45 had diagnoses including end stage renal disease (kidney disease) and dependence on renal dialysis. The 4/16/2024 Minimum…

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 5/6/2024-5/10/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Medication cart #2 on South unit) reviewed. Specifically, medication cart #2 on the South unit had an insulin lispro pen (short acting insulin) for Resident #25 that was not dated with an opened or expiration date; an insulin glargine pen (long acting insulin) for Resident #62 that was not dated with an opened or expiration date; and an Anoro Ellipta inhaler (used to treat chronic lung disease) for Resident #72 that was not dated with an opened or expiration date. Findings include: The facility policy Medication Storage revised 1/2019 documented medications were stored in a manner that maintained the integrity of the product, ensured the safety of residents and was in accordance with department of health guidelines. Expired medications were removed from 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 survey conducted 5/6/2024-5/10/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and appetizing for 2 of 2 test trays (5/7/2024 and 5/8/2024 lunch trays) reviewed. Specifically, on 5/7/2024 the beef stew was 114 degrees Fahrenheit and the green and yellow bean mix was 108 degrees Fahrenheit; and on 5/8/2024 the French-fried potatoes were cold and undercooked. Findings include: The facility Beef Stew recipe documented hold food for service at an internal temperature of 140 degrees Fahrenheit. The facility policy Meal Service last revised 1/2023, documented meals would be served promptly to maintain adequate temperature and appearance. During an interview on 5/6/2024 at 8:37 AM, Resident #66 stated the food was cold. During the lunch meal observation on 5/7/2024 at 12:00 PM, the temperature of the food on the meal service line was checked. The beef stew was 173 degrees Fahrenheit, yellow and green…

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 5/6/2024-5/10/2024, the facility did not ensure residents received and the facility provided a diet in a form designed to meet individual needs for 1 of 1 resident (Resident #33) reviewed. Specifically, Resident #33 was provided food items that were not consistent with their physician ordered diet. Findings include: The facility policy Modified Food Consistency last reviewed 2/2023, documented the texture and consistency-modified diets would be individualized with modifications made by the speech/language pathologist and physician in conjunction with the registered dietitian nutritionist and Director of Food and Nutrition services. A written order was needed. Resident #33 had diagnoses including dementia, diabetes, and cervicalgia (neck pain). The 4/25/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required supervision or touching assistance with eating, did not have a swallowing disorder, and did not receive a mechanically altered diet. 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 during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents had a means of directly contacting staff for assistance for 1 of 1 resident (Resident #35) reviewed. Specifically, Resident #35's call bell was out of reach and not accessible. Findings include: The facility policy Call Bells revised 8/2019 documented timely response was provided to residents in need of assistance and was essential that high quality resident outcomes were ensured. When the resident was in bed staff ensured the call light was within easy reach of the resident. Resident #35 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (lung disease), heart failure, and atrial fibrillation (irregular heartbeat). The Minimum Data Set assessment dated [DATE] documented the resident had moderately impaired cognition and was dependent for toileting, bathing, transfers, and dressing. The comprehensive care plan initiated…

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 survey conducted 5/6/2024-5/10/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 1 of 1 resident room. Specifically, there was evidence of mice in resident room [ROOM NUMBER]. Findings include: The third-party pest control vendor service reports documented resident room [ROOM NUMBER] was treated for mice and rodents on 1/17/2024, 3/6/2024, 3/13/2024, and 3/20/2024. The third-party pest control log dated 5/8/2024 did include documentation about mice or treatments for rodents in the facility. The log documented the facility was inspected and serviced. During an interview on 5/6/2024 at 8:22 AM, Resident #66 who resided in room [ROOM NUMBER] stated they had caught a mouse in their room recently but there was another they were still trying to catch. They stated they had a mouse come out of the heater the past two nights in a row. The mouse ran out of their room and into the…

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

Based on record review and interview during the abbreviated survey (NY00320770), the facility did not ensure services provided met professional standards of quality for 1 of 4 residents reviewed (Resident #8). Specifically, Resident #8 had orders to apply a condom catheter (urinary collection device) in the evening and the order was not implemented timely. Findings include: Resident #8 had diagnoses including benign prostatic hyperplasia (inability to completely empty urine from the bladder) and Parkinson's disease. The 7/8/2023 Minimum Data Set assessment documented the resident's cognition was moderately impaired, they required extensive assistance with most activities of daily living and were frequently incontinent of urine. The 7/6/2023 comprehensive care plan documented the resident had an alteration in the urinary system related to diagnoses and a history of urinary tract infections. Interventions included monitoring intake and output per policy, monitoring and reporting signs and symptoms of urinary tract infections, and a urology consult as needed. The 7/6/2023 physician'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.

Based on record review and interview during the abbreviated survey (NY00324772), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was admitted with a continuous positive airway pressure machine (applies pressure to keep airway open when sleeping) and the facility did not clarify the hospital discharge instructions and did not consult with the medical provider to have the resident's need for the machine evaluated. The resident's continuous positive airway pressure machine was removed by the family prior to any clarification of the resident's needs. Findings include: The Respiratory-PAP (positive airway pressure) Equipment policy revised 3/2021 documented: - Patients with obstructive sleep apnea use continuous positive airway pressure or bilevel positive airway pressure to force air through their obstructed airways. - A sleep study should be done to determine the proper pressure levels. - The physician's order is to 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 interview during the abbreviated survey (NY00317600), the facility did not ensure all alleged violations were thoroughly investigated for 1 of 19 residents reviewed (Resident #12). Specifically, the facility identified that controlled substances for Resident #12 were unaccounted for and the facility's investigation was not thorough and complete. All involved staff were not re-educated on the process for accounting for controlled substances to prevent reoccurrence and the incident was not reported to the New York State Department of Health (NYS DOH) as required. Findings include: The facility Narcotic Count policy dated 8/2018 documented the on-coming and off-going nurse assignment to the medication cart will be responsible for ensuring the accuracy of the controlled drug count. The policy further documented the 2 nurses would look at the medication cards, bottles, etc. together and would verify and document the count. If the amount documented and the number of pills did not match, nurses were to stay on the unit, determine why there was a discrepancy, call…

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 during the abbreviated survey (NY00306191), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 7 residents(Resident #7) reviewed. Specifically, Resident #7 had abnormal laboratory values and there was no documented evidence the medical provider was notified. Findings include: The facility policy Lab Procedure revised 5/2021 documented lab results were checked by the clinical nurse and the physician was notified of the results. The notification would be written on the Lab Results form. All lab results were kept in a designated place until seen and signed by the physician. Resident #7 was admitted to the facility with diagnoses including stroke, diabetes, and end stage renal disease (ESRD). The 8/16/2022 admission Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance with most activities of daily living (ADL). The 10/15/2022…

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 abbreviated survey (NY00315289), the facility did not ensure a resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 1 of 3 residents (Resident #11) reviewed. Specifically, Resident #11 returned to the facility with an indwelling urinary catheter (a tube that removes urine from the bladder into a drainage bag) after a hospital stay, was not assessed for continued need of the urinary catheter and did not receive a urology consultation per medical recommendation. Findings include: The facility policies Catheter-Female Insertion, revised 2/2019; Catheter Care revised 5/2019; and Catheter Guidelines created 8/2019 did not include documentation related to indications for catheter use and/or catheter removal. Resident #11 was admitted to the facility with diagnoses including multiple sclerosis (MS, a progressive central nervous system…

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 surveys (NY00288852) conducted 3/6/22-3/14/22, 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 72 of 78 residents reviewed. Specifically, on during the lunch meal on Sunday 3/6/22, residents received their food on disposable dishes. Additionally, during the resident group meeting 1 anonymous resident stated meals were frequently served on plastic disposable dishes on the weekends. Findings include: The facility Your Rights as a Nursing Home Resident booklet dated 6/2010 documents each resident has the right to be treated with dignity, respect, and consideration at all times. The facility Meal Service Policy revised 9/2021 documents a comfortable and attractive atmosphere will be maintained. The 3/6/22 Food Service staff schedule documented: - 1 [NAME] scheduled 6 AM - 2 PM, - 1 Diet Aide scheduled 8 AM - 8 PM, - 1 Diet Aide scheduled 6 AM - 2 PM, which documented Called…

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 the recertification and abbreviated surveys (NY00262523, NY00280940, NY00270167, NY00288852, NY00276986, NY00282348, NY00283195, NY00285834 and NY00290976) conducted 3/6/22-3/14/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 11 residents (Residents #35, 50, 71 and 75) reviewed. Specifically, Resident #50 did not receive incontinence care as requested; Resident #71 did not receive assistance with care and transfers out of bed as requested and missed therapy; Resident #75 did not receive a shower on their designated/care planned day: and Resident #35 did not have their call bell answered timely. Findings include: The facility policy ADL Support revised 10/2019, documents the residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability 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 during the recertification and abbreviated (NY00288852) surveys conducted 3/6/22- 3/14/22, the facility failed to ensure the resident menus were followed for 5 of 18 meals observed. Specifically, the facility ran out of preplanned menu items and substituted with items that were not nutritionally equivalent, served inadequate portion sizes, and did not inform the residents of menu substitutions. Finding included: The facility policy Portion Control dated 4/2019 documents the menu items shall be served according to pre-determined portion size. The portion size on spreadsheet reflects the amount of the menu item required to provide nutrient standards for that item when prepared according to the standardized recipe. The facility policy Menu Substitution revised 4/2019 documents food substitutions will be made as appropriate and necessary. The Food Service Director, in conjunction with the clinical [registered] dietitian (RD) or diet technician registered (DTR) may make food substitutions as appropriate or necessary. The food service…

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 and abbreviated surveys (NY00288852 and NY00270167) conducted 3/6/22-3/14/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 meals observed and for 1 of 2 meal test trays. Specifically, the cranberry juice served at dinner on 3/8/22 was watered down and not palatable, the chicken noodle soup served at lunch on 3/8/22, was not attractive, and the test tray for the dinner meal on 3/7/22 was bland and not served at safe and appetizing temperatures. Additionally, Residents #13, 34, 37, 44, 50 and 75 and several anonymous residents during the resident group meeting stated the food was not palatable, appetizing, and was often served cold. Findings include: The facility policy Food Safety-Food Handling revised 9/2021 documents the food will be stored prepared, handled, and served so that the risk of foodborne illness is minimized. The facility policy Meal Service revised 9/2021 documents meals will be served promptly to maintain adequate…

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 (NY00288852) surveys conducted 3/6/22-3/14/22, the facility failed to ensure suitable, nourishing alternative meals and snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 2 of 2 nursing units (North Unit and South Unit) observed. Specifically, residents did not have snack items available on the nursing units. Findings include: The facility policy Clinical Operations dated 4/2020 documents snacks are available 24 hours per day for any resident based on customary routine, request or requires additional calories due to inadequate meal consumption, promote weight gain or maintenance, need for additional protein for wound healing, or other therapeutic considerations. Dietary is responsible for stocking each nursing pantry with a variety of snacks to be available between meals for those who desire them and/or need…

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 3/6/22-3/14/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, the mechanical dishwasher was not clean and did not adequately sanitize dishware: expired milk was observed in the walk-in cooler for two days; and there was improper hot holding of hot dogs, mashed potatoes, and soup. Findings include: The facility policy Dish Washing and Storage updated 6/17/19, documents: - Dishes, pots, and pans will be washed and dried using procedures, chemicals and equipment that result in clean, sanitized dishes, pans, flatware, and utensils. - Low Temperature Dishwasher: Spray Type Dish Machines Using Chemicals to Sanitize Minimum Wash temperature: 120 degrees Fahrenheit (F). Final Rinse Temperature of 120 F and sanitization 50 parts per million (PPM) Hypochlorite. Dishes, pots, pans, utensils and flatware, must be air dried before being stored. Do not dry with towels. -…

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 (NY00292100 and NY00262523) conducted 3/6/22-3/14/22, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote the healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #71) reviewed. Specifically, Resident #71 developed unstageable pressure ulcers (full-thickness tissue loss with the wound bed obscured by dead tissue) on their right and left heels and the planned intervention of heel protection boots was not consistently implemented. Findings include: The facility policy Pressure Wound Prevention revised 10/2021, documents to inspect skin on a daily basis when performing or assisting with personal care or ADLs. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.), moisturize dry skin daily, reposition resident as…

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 and abbreviated (NY00280940 and NY00285834) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 6 residents (Resident #71) reviewed. Specifically, Resident #71 developed a pressure ulcer, and a timely nutritional assessment was not completed, and weights were not obtained as ordered. Findings include: The facility policy Weight Assessment and Interventions revised 5/2021 documents the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for the residents. Obtaining weights: the nursing staff will measure the resident weight within 24 hours of admission, weekly for four weeks, and then monthly. Weights will be recorded in the medical record for each resident. Any weight change of 5 pounds (lbs) in a month and 3 lbs in a week since the last weight assessment will be retaken within 48 hours. The licensed nurse will notify the dietitian of the weight change once reviewed. The…

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

Based on observation, record review, and interview during the recertification and abbreviated (NY00287009) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents are free of any significant medication errors for 1 of 12 residents (Resident #21) reviewed. Specifically, Resident #21 had a physician order for 1000 milligrams (mg) of Metformin (used to lower blood sugar) and was administered 500 mg of Metformin. Findings include: The facility policy Medication Administration, revised 12/2019, documents medications shall be administered in a safe and timely manner, and as prescribed. Resident #21 was admitted to the facility with diagnoses including diabetes. The 1/18/22 Minimum Data Set (MDS) assessment documented the resident had mild cognitive impairment and required extensive assistance for most activities of daily living (ADL). Physician orders dated 2/8/22 documented Metformin HCl tablet 500 mg, administer 1,000 mg by mouth two times a day for diabetes. The 3/2022 medication administration record (MAR) documented Metformin HCl 500 mg tablet starting 2/7/22. Staff…

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 and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 4 residents (Resident # 35) reviewed. Specifically, Resident #35 was not provided their soft salad sandwich at mealtime and was not offered a suitable substitution. Finding include: The facility policy Menu Substitution revised 4/2019 documents food substitutions will be made as appropriate and necessary. The Food Service Director, in conjunction with the clinical [registered] dietitian (RD) or registered diet technician (DTR) may make food substitutions as appropriate or necessary. The food service shift supervisor will make substitutions only when unavoidable. The resident's likes and dislikes will be considered when making substitutions. The 3/8/22 Lunch Production tally documented there were 2 orders of bite sized…

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.