Westchester Center For Rehabilitation & Nursing

Based on record review and interviews during the Recertification and Abbreviated (NY#00336657) surveys from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's designated representative had the right to be informed in advance, by the physician or other practitioner or professional, of treatment options and to choose the alternative or option they preferred for 1 (Resident # 233) of 2 residents reviewed for resident rights. Specifically, the facility administered Donepezil (a medication for dementia) to Resident #233 and the resident representative had requested the medication to not be given. Findings include: Resident # 233 was admitted with diagnoses including dementia, chronic obstructive pulmonary disease and gastroesophageal reflux disease. The facility's policy and procedure titled Resident Rights, revised 11/2024, documented the resident rights to be notified of his or her medical condition and of any changes in his or her condition; A resident has the right to be informed in advance, by the physician or other Practitioner or professional, of the risks 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to reside and receive services in the facility with reasonable accommodation of their needs and preferences. This was evident for 1 (Resident #167) of 7 residents reviewed for Environment. Specifically, Resident #167's wheelchair was unable to maneuver around their bed preventing Resident #167 from being able to access and use their own bathroom. The findings are: The facility policy titled Resident Rights dated 11/2024 documented a resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Resident #167 had diagnoses of postherpetic polyneuropathy and chronic obstructive pulmonary disease. Minimum Data Set 3.0 assessment dated [DATE] documented Resident #167 was cognitively intact. The Comprehensive Care Plan related to activity of daily living function - mobility…

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 and abbreviated (NY00352407) from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to receive written notice, including the reason for the change, before the resident's room was changed. This was evident for 1 (Resident #10) of 7 residents reviewed for Choices. Specifically, Resident #10's Health Care Agent did not receive written notice of or explanation for the resident's room change on 10/11/2024. The findings are: The facility policy titled Transfers - Room Changes dated 4/11/2024 documented the facility will inform the resident and/or resident representative of the room change both verbally and written, including the reason for the change, the effective date of the change and the location of the change. Resident #10 had diagnoses of Alzheimer's disease and cerebral infarction with right hemiplegia and hemiparesis. Minimum Data Set 3.0 assessment dated [DATE] documented Resident #10 was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the recertification and abbreviated (NY00344201) from 1/22/2025 to 1/29/2025, the facility did not ensure a resident's right to manage their financial affairs. This was evident for 1 (Resident #182) of 3 residents during Personal Funds review. Specifically, the facility diverted Resident #182's income to a personal needs account managed by the facility without informing the resident's court-appointed Legal Guardian. The findings are: The facility policy titled Resident Rights dated 11/2024 documented residents had the right to manage their personal funds. Resident #182 had diagnoses of unspecified dementia and schizoaffectove disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #182 was severely cognitively impaired, the resident and their family participated in the assessment, the resident's family provided discharge status information, and did not document that Resident #182 had a Legal Guardian. The admission Agreement dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during the recertification survey from 1/22/25-1/29/25, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #333) reviewed for Respiratory Care. Specifically, Resident #333 was receiving continuous Oxygen, and the facility was unable to provided documented evidence that a Respiratory/Oxygen Care Plan was in place. The findings are: The facility policy titled Care Planning Process and Care Conference last revised on 7/2023 documented that the facility will develop a comprehensive, resident centered care plan for each resident/patient. Care plan development, renewal and revision will be based upon the results of the resident assessment. The care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care…

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 interviews and record review during the recertification survey from 1/22-1/29/24 the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #92) reviewed for insulin. Specifically, Resident #92's insulin order had a dicrepency and the order was not being followed as written. Findings include: Resident #92 had diagnoses including Diabetes Mellitus, End Stage Renal Disease, and Seizure Disorder. The Quarterly Minimum Data Set (assessment tool) dated 11/13/2024 documented Resident #92 with moderate cognitive impairment. Medications received included hypoglycemic and injections on 3 days. The Comprehensive Care Plan for Diabetes Mellitus dated 12/3/24 documented the resident would be free of observable signs and symptoms of hyperglycemia and hypoglycemia. Interventions included administering medications as ordered and monitoring for signs and symptoms of hyperglycemia and hypoglycemia. A Physician order dated 12/18/24 documented Humalog Kwik Pen (U-100) Insulin 100unit/ml subcutaneous,…

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 from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards, including expiration dates when applicable for 2 of 2 medication storage rooms, and 1 of 4 med carts reviewed. This was evident for 2 (Medication Storage Rooms 3 South Unit and 2 North Unit) of 2 medication storage rooms and 1 of 4 medication carts observed. Specifically, the 3 South Unit and 2 North Unit Medication Storage Rooms had an expired box of hydrocolloid wound dressing and an expired box of safety needle, the 3 South Unit medication cart contained an open and undated 32 ounce bottle of supplement. The findings are: The facility policy titled Medication Storage last reviewed on 2/2024 documented the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey from 1/22/25 through 1/29/25, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 1 of 3 residents reviewed for transmission-based precautions; and 2 of 10 staff reviewed for influenza vaccinations. Specifically, 1) Resident #483 was on Enhanced barrier Precautions and staff was observed providing care without wearing proper protective equipment. 2) Licensed Practical Nurse #17 and Certified Nurse Aide #15 did not receive the influenza vaccine and were observed not wearing a mask. Findings include: 1. The facility policy titled General Infection Transmission- Based Precautions revised date 1/1/2024 documented the use of transmission-based precautions (isolation precautions) to manage specific, highly transmissible, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review during the recertification survey from 1/22-1/29/2025, the facility did not ensure that residents' financial records were available to the residents through quarterly statements for 1 of 4 residents reviewed for personal funds. Specifically, Resident #92 was not aware that they had any personal funds and the facility financial office was not able to provide proof that the resident received quarterly statements. Findings include: Facility Policy titled Resident's Funds last reviewed 10/2024 documented 24/7 access to funds, maintaining and managing resident accounts, and process for accessing funds. It did not document a process for providing residents with quarterly statements. Resident #92 had diagnoses including Diabetes Mellitus, End Stage Renal Disease, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition, and the resident and family participated in goal setting. During an interview on 1/23/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during an abbreviated survey (NY00341327, NY00358946), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 6 residents (Resident #3 & #10) reviewed. Specifically, (1) Resident #3 who had a history of suicidal attempts and cut their left wrist sustaining a laceration that was unwitnessed by staff on 05/04/2024 was placed on 1:1 monitoring following the incident had no documented 1:1 monitoring. Resident #3 was found by Certified Nurse Aide with blood on his gown and on the floor on 5/5/2024 and was transferred to the hospital for further evaluation. The investigative summary concluded Resident #3 used a pointed pencil to harm self; (2) Resident #10 who had severe cognition impairment and had history of multiple falls sustained a head injury from an unwitnessed fall on 10/09/2024 and was transferred to the hospital for further evaluation Resident #10 had falls with no injury on 02/18/2024, 04/09/2024, 04/22/2024,…

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, interviews, and record review conducted during the abbreviated survey (NY00351516) from 8/19/24 to 8/20/24, the facility did not ensure a resident's preferences were incorporated in developing care plan goals for 1 (Resident #1) of 3 residents reviewed for pain management. Specifically, when Resident #1 was placed on comfort care, the facility did not include the designated representative (family) in pain management care planning. The findings are: The Facility policy, 'Pain Management', last reviewed 8/24 documented the facility is committed to reducing physical and psychosocial symptoms associated with pain. The interdisciplinary team works with the resident and significant others to establish a plan of care that will address the individual resident goals for comfort and function. The Resident/family will be included in the evaluation of pain, potential interventions and determine resident's pain goal and acceptable level of pain. The facility will develop, review and /or revise the resident' plan of care as needed, communicate interventions to all 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, interviews, and record review conducted during the abbreviated survey (NY00351516) from 8/19/24 to 8/20/24, the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 3 residents reviewed. Specifically, Resident #1 was placed on Comfort care without a plan for pain management. The family requested morphine for pain on 8/9/24 and 8/10/24 because the resident was in pain. There is no documentation that the facility staff consistently assessed the resident to determine their pain/comfort level and the need for alternate medication. The findings are: The Facility Policy, titled 'Pain Management', last reviewed 8/24 documented the facility is committed to reducing physical and psychosocial symptoms associated with pain. The facility promotes resident self-reporting as the most reliable indicator of pain. The interdisciplinary team works with the resident and significant others to establish a plan of care that will address the individual resident goals for comfort 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 interviews conducted during an abbreviated survey (NY00311197) the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed for physical abuse. Specifically, Resident #1 reported they were shoved by Certified Nurse Assistant #1 that on 2/20/2023 at 12am. Resident #1 tried to show the Certified Nurse Aide how to operate the overhead light and Certified Nurse Assistant #1 shoved Resident #1 with their shoulder onto the bed in the resident's room. Finding include: A review of the abuse policy-prevention and management dated 3/2016 and last revised 9/8/22 documented the facility prohibits the mistreatment and abuse of residents by anyone including staff. The Facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. The Facility must provide a safe resident environment and protect residents from abuse. Resident #1 was admitted to the facility with diagnoses including Asthma, Syncope and collapse and lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00311197, NY00332234) the facility did not ensure an allegation of abuse was thoroughly investigated and the results of the investigation reported to the New York State Department of Health, in accordance with State law within 5 working days of the incident for 2 (Resident #1, #4) of 6 residents reviewed for abuse. Specifically, Resident #1 reported that they were shoved by a Certified Nurse Aide on 2/20/23 at approximately 12 AM in their room, when trying to show them how to work the overbed lighting of their roommate. The facility did not provide documentation of the completed investigation and no report was submitted to the New York State Department of Health. 2) Resident #4 reported to Certified Nurse Assistant #5 that on 1/25/2024, Licensed Practical Nurse #2 pinched them on the left lower leg. The facility did not provide any statements obtained from Resident #2's roomate and staff and Licensed Practical Nurse #2 contiued to to provode…

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

Based on record review and interviews conducted during an abbreviated survey (NY00311197), the facility did not ensure the comprehensive care plan was reviewed and revised for 1 (Resident #1) out of 3 residents reviewed for care planning. Specifically, Resident #1's abuse care plan was not updated to reflect an allegation of abuse on 2/20/2023. Finding include: A review of the abuse policy-prevention and management dated 3/2016 and last revised 9/8/2022 documented the facility prohibits the mistreatment and abuse of residents by anyone including staff. The Facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. The Facility must provide a safe resident environment and protect residents from abuse. Resident #1 had diagnoses including asthma, syncope and collapse and other lack of coordination. A Quarterly Minimum Data Set (an assessment tool) dated 2/4/2024 documented the resident had a Brief Interview of Mental Score (BIMS) Score of 15/15, indicating cognitively intact. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00303362) the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #2) of 3 residents reviewed for accident. Specifically, Resident #1 upon admission was scored as a mild fall risk and there was no documented evidence of any safety measures or assistive devices in place for use to prevent an accident. Resident #1 subsequently had a fall on 10/12/2022 and sustained a left wrist fracture and a laceration to the left eye. Finding include: A review of the facility's undated fall prevention/bed alarm/chair alarm/risk management policy under philosophy documented residents will be assessed on admission, readmission or whenever a change in condition occurs, for risk factors to prevent accident/incidents. Subsequently, an individualized plan of care will be formulated in conjunction with the comprehensive care plan that identifies risk factors and intervention of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity. Specifically, a urine filled catheter bag was observed with no covering and visible from the unit hallway for 1 of 2 residents reviewed for dignity (resident #155) . The findings are: Review of the facility policy and procedure, titled, Catheter-Foley, dated 4/2021, documented when catherization is determined to be clinically indicated, staff should maintain the resident's privacy and dignity. The policy also documented infection control considerations; do not allow catheter bag or tubing to lay on floor. Resident #155 was readmitted on [DATE] with a medical history of multiple strokes with left hemiplegia and dysphagia. Resident's baseline functional status was bed bound and eye movement. Review of physician orders dated 1/26/22 documented an order for foley catheter, and 1/27/22 documented daily foley catheter care with soap 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Record review Observation and Interview conducted during a Recertification Survey and Abbreviated Survey (#292469) the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental and psychosocial needs for 1 of 1 residents reviewed for positioning/mobility (#82) and 1 of 1 residents reviewed for respiratory care (#102. Specifically, 1) no CCP was developed and implemented to address the resident's range of motion and contractures (Resident #82), and 2) no CCP was developed and implemented for the nebulizer treatment ordered by the Physician to address the resident's Chronic Obstructive Pulmonary Disease (COPD)/Shortness of Breath (SOB) (Resident #102). 1) Resident # 82 was admitted to the facility 02/16/2018, with diagnoses that included Hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, Seizure Disorder, Muscle weakness (generalized). The Annual Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the Recertification/complaints survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident with contractures on both upper extremities was not provided with the splint device as per order, this was evident for 1 out of 2 residents reviewed for Limited ROM, (Resident #82) The findings are: The facility's Policy for Use of Assistive Devices dated 07/2015, last revised 08/27/2021, documented that the nurse or designee in accordance with the Rehab Team will assess the resident periodically to determine the need to continue the use of the mobility device. Resident #82 was admitted to the facility 02/16/2018, with diagnoses that included Hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, Seizure Disorder, Muscle weakness (generalized). The Annual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the Recertification / Complaint survey (NY00292469)), the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, 1) nebulizer tubing was observed in the resident's room not properly protected from infection, with no label, and there was no documented evidence that the tubing was changed, this was evident for 1 resident reviewed for respiratory care, (Resident #102). 2) the facility failed to ensure that the glucometer was sanitized between resident's use, a nurse was observed using 1 glucometer to perform blood glucose check on the residents without sanitizing the meter in between use for the residents, this was evident for 3 residents observed for blood glucose check/insulin administration, (Resident #126, #141, & #53). The findings are: - The facility Policy and Procedure for Handheld Nebulizer/Small Volume…

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, interviews and record review conducted during the most recent recertification survey, the facility did not ensure that care was provided in accordance with the written Plans of Care addressing pain management and nutrition for 2 of 40 sampled residents (Residents #9 and #131) reviewed. Furthermore, the facility did not ensure that interventions for catheter care and maintaining skin integrity were identified in the Plans of Care for 2 of 40 sampled residents (Residents #205 and #407). Specifically, Resident #9 was not being monitored for the presence of pain in terms of location and intensity as directed in the Plan of Care; Resident #131 was not provided the dietary supplements or additional water as directed in the Plan of Care. Interventions necessary for the monitoring and care of a surgical wound as well as a skin ulceration were not included in the plan of care for Resident #407. Additionally, interventions for the care of a Foley catheter were not included in the plan of care 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 observations, interviews and record review during a recertification survey, the facility did not implement effective monitoring procedures to ensure the resident assistive equipment remain free from a repeat accident hazard. Specifically, the corrective action plan did not provide a consistent monitoring action by the laundry staff to effectively test and track Hoyer lift pads after they have been washed and dried. These are the findings Resident #169 is a [AGE] year-old female admitted to the facility 06/19/2018 with diagnoses of Hypertension, chronic pain, anemia, Parkinson's disease. MDS (minimum data sheet, an assessment tool) annual assessment 06/05/2019 indicates the resident is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #169 requires a two-person assist with transfers to wheelchair. Review of an accident record dated 05/05/2019 shows that Resident #169 sustained a thoracic spine compression fracture and a hematoma to the side of her head secondary 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 and interview during the recent recertification survey, the facility did not ensure proper sanitation and food handling procedures were implemented to prevent the potential for foodborne illness. Specifically, potentially hazardous food items delivered to the facility were not put away in a timely manner; the walk-in freezer was packed up to the door and leaving no space for air to circulate around the items and the dishwasher was not sanitizing dishes or utensils during the final rinse cycle. The findings are: 1. During the initial tour of the kitchen on 7/9/19 at 9:30 AM the facility was in the process of receiving a food delivery. At the time of the tour there were multiple boxes of food on the floor, not in the freezer. Among them were fresh beef and chicken. Observation of the freezer at that time revealed the temperature was 45 degrees F. Surveyor inspection in the presence of the Food Service Manager showed ice buildup on the floor and ceiling, the boxes in the freezer were wet and ice cream was soft. The Food Service Manager was interviewed at that time…

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, observation and interview conducted during a Recertification Survey the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, Physician's Orders and facility's policy. This was evident for 1 of 1 residents reviewed for accidents (Resident #169), 1 of 3 residents (Resident #406) reviewed for pain management, 1 of 6 residents (Resident #407) reviewed for Skin Impairment and 1 of 5 residents (Resident #179) reviewed for the administration of medications. Specifically, Resident #169 sustained a fall from a Hoyer lift and did not receive timely treatment and care for complaints of pain. Resident #407 did not receive timely treatment and care for a left heel ulcer or monitoring and treatment for left upper leg staples; and Resident #179 had critically elevated potassium level for which medication was not promptly provided as per physician's order. The findings are: 1. Resident #169 is a [AGE] year-old female admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review observation and record review conducted during the most recent recertification survey, the facility did not ensure that 1 of 1 resident (Resident #205) reviewed for indwelling catheter (tube inserted into the bladder to drain urine) received the appropriate care and services. Specifically, there was no documented evidence that the resident who was admitted to the facility with a Foley catheter received catheter cares and urine output monitoring in accordance with the Care Plan. The findings are: Resident #205 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Anemia, and Hyperkalemia. The 6/14/19 admission Minimum Data Set (an assessment tool) indicated Resident #205 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 14. Resident #205 also received extensive assistance for toileting and had a Foley catheter. During observation on 7/9/19 at 11:45 AM and 7/11/19 at 9:30 AM it was confirmed that a Foley catheter leg bag was under 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 the facility did not ensure that medications were available when needed to meet the needs of each resident. Specifically, two doses of Kayexalate, a medicine used to lower high serum potassium levels, was not given to a resident for eleven hours after it was first ordered by the physician which put the resident at risk for complications associated with hyperkalemia and caused the resident to be transferred to the emergency room for evaluation and treatment. The findings are: Resident #179 is a [AGE] year-old female with diagnoses of sickle cell crisis, diabetes, unstable angina, a heart condition. On 7/11/2019, labs were performed on Resident #179 which showed that her potassium level was elevated at 7.5 mg/dl; normal range is 3.5 mg/dl-5.5 mg/dl. The physician was contacted and prescribed Kayexalate to be administered immediately. The medication administration record (MAR) was reviewed and it was noted that on 7/11/2019 the 12-midnight dose contained an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, during the recent recertification survey, the facility did not ensure the results from diagnostic monitoring for a resident receiving an antipsychotic medication were available for review by the primary care physician (PCP). Specifically, electrocardiogram (EKG or ECG) monitoring every 2 weeks was ordered, initiated on 1/29/19. The EKG results were not available for review until surveyor intervention. This was evident for 1 of 5 residents reviewed for unnecessary medications (Resident #66). The findings are: Resident #66 was admitted to the facility on [DATE]. Current diagnoses included Hypertension, Ischemic Heart Disease, Diabetes Mellitus, Depression, Dementia and Psychosis. The admission Minimum Data Set (MDS) dated [DATE], a tool to assess a resident's care needs, was reviewed. The section for Behavior had no documented behaviors that were had been assessed. The Brief Interview for Mental Status indicated the resident scored a 13 indicating good cognition. The MD orders…

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, interview and record review the facility did not ensure that medications were secured in a locked storage area. Specifically, prescription eye drops were found in resident's top drawer of night table during a medication pass. The findings are: During med pass 07/12/2019 09:11 with LPN #2, Dorzolamide 2% eye drops, Brimonidine .2% eye drops and Natural Tears eye drops were due to be administered to Resident #179. LPN #2 was observed to search the medication cart to no avail. LPN #2 then went to Room # 335 where the resident was sitting on the bed and asked her if the eye drops were in the bedside table drawer to which the resident replied yes. The resident then opened the top bedside table drawer and produced the all 3 bottles of eyedrops in a plastic bag. The prescription eye drops in the plastic bag were verified and the resident's name and prescription were on the drops. On record review, there was no physician order indicating the resident was permitted to self-administer the eye drops or have the drops in her possession. Also, there was no care plan…

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.