The Wartburg Home

Based on observation and interviews conducted during the recertification survey from 7/22/25 to 7/28/25, the facility did not ensure food was stored, prepared, and distributed in sanitary conditions in accordance with professional standards for food service safety. Specifically, there were unlabeled and undated food items in the kitchen, storeroom, and unit pantry, there was expired foods in the kitchen, storeroom, and unit pantry, there was a cell phone on the food prep area, dietary staff did not wear proper hair and beard restraints, there were boxes stored on the floor, there was personal staff item in kitchen food prep area and there were poor sanitary conditions in unit pantries. Findings include: The facility policy Food and Supply Storage, last revised 1/2025 included documentation that food past the use by date or expiration date should be discarded; opened packages should be covered, labeled and dated; and items should be stored at least 6' above the floor and 18' below sprinklers. The facility policy Uniform Dress Code, last revised 1/2025 included documentation 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.

Based on observations and interviews during the recertification survey from 7/22/25 to 7/28/25, the facility did not ensure that essential kitchen equipment was maintained in safe operating condition. Specifically, dishwashers in all four-unit pantries were broken, Unit 1 South pantry food warmer, tall standing freezer, and steam table were broken, and the main kitchen dish machine did not reach proper temperature for sanitization in wash (150-165 degrees), rinse, or final rinse (180 degrees) modes. The findings are: During an observation of the Unit 1 South pantry on 7/24/25 at 12:48 PM, a puddle of water was observed by the right front leg of the food warmer and a towel was observed inside the bottom of the upper door frame. Dietary Aide #8 stated the food warmer was broken and leaking water. They also stated the steam table was not working and they were using the hot box to keep food warm, the tall freezer was broken, and the dishwasher was broken. They stated they had verbally told the supervisor about the broken equipment weeks ago, which was the procedure they used to inform…

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 from 7/22/25-7/28/25, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice for one of one resident (Resident #7) reviewed for respiratory care. Specifically, Resident #7 was receiving oxygen via nasal canula tubing which was observed in the resident's mouth instead of in the resident's nostrils.The findings are:The Policy and Procedure titled Respiratory Care last revised 6/25/2021, documented each resident's respiratory function shall be maintained and optimized to the fullest extent possible. Nurses and certified nurse aides were responsible to monitor nasal cannula, BIPAP, CPAP (or any other respiratory device) placement and condition each shift.Resident #7 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, heart failure, and non-Alzheimer's dementia. The 7/3/25 Physician's Orders documented continuous oxygen at 2 liters per minute via nasal canula.The 7/14/25…

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

Based on observation, record review and interviews conducted during the 7/22/25-7/28/25 recertification survey, the facility did not ensure that all medications were secured in a locked storage area. Specifically, Symbicort (budesonide-formoterol) aerosol inhaler was observed on Resident #35's room table, not under direct supervision of authorized staff. The findings are:The undated Policy and Procedure titled Storage of Medications documented only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. The undated Policy and Procedure (P&P) titled Self-Administration of Medications documented those residents deemed capable, and who desire to self-administer their medications, will be permitted to do so, after appropriate counseling and with the specific order of the resident's physician.Resident #35 was admitted to the facility with diagnoses which included chronic obstructive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during an abbreviated survey (NY00327590), the facility did not ensure prompt efforts were made to resolve a resident's grievance. Specifically, Resident #1's Family Representative (FR) complained to the facility on [DATE] regarding incontinence care and bathroom ambulation needs not being rendered. There was no evidence that a grievance form was initiated and completed in accordance with the facility policy and there was no documented evidence that the complaints were addressed. The findings are: A review of the facility's grievance policy, titled Grievance Policy, dated 8/16/2017 stated each resident has the right to voice grievance. Such grievances include those with respect to care and treatment which has been furnished, as well as that which has not been furnished, the behavior of staff, and other concerns regarding their Long-Term Care (LTC) facility stay. The voice grievance is not limited to formal, written but may include a resident's verbal complaint to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews during the recertification and abbreviated surveys (NY00306039) 6/13/23 to 6/20/23, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy for 4 of 5 residents reviewed for hospitalization. Specifically, Residents #257, #103, #74, and #97. were transferred to the hospital and the facility did not provide evidence that a written notice of the facility Bed Hold Policy was given to the residents or representatives. Findings include: The facility Policy and Procedure, titled Bed Hold and Return to Facility, revised 6/1/19, documented the facility would provide written information about the bed hold duration and payment amount before transfer to the hospital or therapeutic leave. 1. Resident #257 was readmitted to the facility with diagnoses including left femur fracture, fall, and post procedural pain. The 4/15/22 Significant Change Minimum Data Set (MDS, an assessment tool) documented the resident 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 record reviews and interviews conducted during a recertification survey 6/13/2023-6/20/2023, the facility did not ensure that the certified nurse aides (CNA) were provided the required 12 hours of training and annual in-service on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 8 out of 10 CNAs (CNA #1, 2, 3, 4, 5, 6, 7, and 8), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The findings are: Review of the facility CNA annual in-service training records revealed: - CNA #1 and #4 lacked 11 of the 12 hours of mandatory training. - CNA #2, #7 and #8 lacked 10 of the 12 hours of mandatory training. - CNA #3 and #5 lacked 12 hours of mandatory training including resident abuse prevention and dementia care management. - CNA #6 lacked 10.5 hours of mandatory training. During an interview on 6/20/2023 at 2:15PM, the Nurse Educator stated they were new in their role and could not find the old nurse educator documentation. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review during a recertification survey conducted 6/13/23-6/20/23, the facility did not ensure that baseline care plans were initiated for 2 of 5 residents reviewed for unnecessary medications. Specifically, Residents #46 and 17 were prescribed anticoagulation medications by the physician, and there were no care plans initiated within 48 hours of admission. The findings are: The Policy and Procedure titled Baseline Care Plan Policy revised 11/28/2017 documented the facility will develop and implement a baseline care plan within 48 hours of admission which provides instructions for care of the resident, increases resident safety, and safeguards against adverse effects. 1. Resident #46 was admitted on [DATE] with diagnoses including orthopedic aftercare, lung cancer and acute embolism/deep vein thrombosis in the lower extremity, The 6/3/23 admission Minimum Data Set (MDS, a resident assessment tool) documented the resident received anticoagulant medication for the past 7 days. 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 a recertification survey conducted 6/13/23-6/20/23, the facility did not ensure that 1 of 3 residents (#17), reviewed for pressure ulcer, was provided the appropriate care to prevent the development of a pressure ulcer. Specifically, there were no physician ordered skin checks/monitoring for Resident # 17 with a left knee immobilizer and the resident developed a pressure ulcer. The findings are: The policy and procedure titled Pressure Ulcer Prevention revised 12/29/22 documented it is the policy that all residents shall be provided with consistent, comprehensive, interdisciplinary care focused on the prevention of pressure ulcers. Resident #17 had diagnoses including diabetes, hip fracture, and unspecified fracture to lower end of left femur. The 2/16/23 hospital transfer summary documented Resident #17 was non weight bearing to the left lower leg and wore a knee immobilizer. The 2/17/23 physical therapy (PT) evaluation documented the resident was admitted after a fall at home. It further documented resident was non weight bearing to left…

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 upon observation, interview, and record review conducted during a recertification survey the facility did not ensure labeling, dating, and monitoring of refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. This was identified during the initial tour of the kitchen. The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes. The findings are: A facility policy and procedure titled Food Supply and Storage dated 5/95 and revised 1/21 documented: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures included but were not limited to: Most,…

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 a recertification survey, the facility did not develop a person-centered care plan with measurable objectives, time frames and appropriate interventions based on comprehensive assessments for 1 of 1 resident (Resident #93 ) reviewed for dialysis and 2 of 6 residents (Residents # 97 and #368) reviewed for unnecessary medications. Specifically, there were no care plans to address End Stage Renal Disease on Hemodialysis or Anticoagulation with Coumadin use for Resident # 93, Hypertension or Anticoagulation with Lovenox and Aspirin use for Resident # 97, or Chronic Obstructive Pulmonary Disease (COPD) or Diabetes Mellitus for Resident # 368. The findings are: The facility Policy and Procedure titled, Care Plans dated 8/27/2001 and revised 1/7/2020 documents the Baseline Care Plan will be developed and implemented within 48 hours of admission which will include the minimum healthcare information necessary to properly care for a resident including but…

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 a recertification survey the facility did not ensure that the care planning team 1. established and implemented the frequency by which a nasal cannula with tubing should have been changed for two of two residents reviewed for respiratory care (Residents #84 and #268) using oxygen, and 2. for 1 of 2 residents (Resident #268) the facility did not ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for Resident #84, there was no evidence to indicate the oxygen tubing/cannula was being changed, labeled with date and initialed. For Resident #268, no protocols were ordered for oxygen monitoring and care of the nasal cannula (nc) and tubing, and Resident #268 was not accepting continuous oxygen as ordered by the Medical Doctor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that current acceptable professional standard of practice regarding storage of multi-dose insulin injection medication were followed. Specifically, (1) Multi-dose Insulin Pens were opened, undated and not discarded after the recommended 28-day period per manufacture specifications; and (2) A multi-dose Insulin Pen was not stored in the refrigerator according to the manufacture specification. This was evident during review of the facility's medication storage for two of six facility units (3 [NAME] and 1 South Units). The findings are: -Observation of 3 [NAME] unit was conducted on [DATE] at 2:11PM. An opened, undated, and in use multi-dose Lispro Kwik Pen Insulin (Humalog) assigned to resident #25 was found in the low side medication cart. The pen had no dispense date. Review of Resident #25 current physician orders dated [DATE] and the corresponding medication administration record (MAR)…

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 facility staff followed proper hand hygiene and gloving techniques to prevent cross-contamination and the spread of infection. Specifically, (1) cross-contamination of wounds and wound supplies was observed; and (2) removal of soiled gloves and hand hygiene were not observed during wound care procedures for 2 of 5 residents (Residents #52 and #73) reviewed for pressure ulcer/injury. The findings are: 1.Resident #52 had diagnoses and conditions including Stage IV Sacral Pressure Ulcer (PU), Stage II PU of the right hip and Generalized Muscle Weakness. Review of the 3/8/2021 admission Minimum Data Set (MDS; a resident assessment and screening tool) showed that Resident #52 had Stage II, III, and IV PUs that were present on admission. Review of Resident #52's Physician's Orders dated 4/27/2021, showed that staff were to cleanse Resident #52's left hip with Dakin's solution, apply Santyl 250mg/gram topical ointment to the wound bed, pack with Dakin's moist gauze…

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.