Northern Manor Geriatric Center Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews during an abbreviated survey (NY00343390, NY00339693), the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, the kitchen floor by the washing machine had about 2 inches of water pooled, and staff were actively working in the area, multiple areas of the building had chipped paint, scratched paint, scuff marks, visible dirt and stains on the walls and floors, peeling wallpaper and foul odors. Finding include: During an observation in the kitchen on 9/6/2024 at 10:20AM, surveyor observed a pool of water about 2inches on the floor by the wash machine. During an interview on 090/06/2024 at 10:20 AM, the Dietary Aide stated an outside vendor was called to repair the leak from the wash machine which had been leaking for a week. The vendor came in on 9/4/2024 with their supervisor and the repairs was not completed. There was still water on the floor after they left. During a walk through on the units…

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 an abbreviated survey (NY00333515, NY00331035, NY00327139, NY00321114) the facility did not ensure the resident representative was immediately informed of a significant change in the resident's physical status or a need to alter treatment significantly. This was evident for 3 out of 4 residents (Residents #17, #19, #20) reviewed for notification of changes. Specifically, (1) Resident #17 had an electrocardiogram on 12/22/2023 in the facility which revealed a low heart rate, and their anti-hypertension medication was discontinued, Resident #17's guardian was not informed. (2) Resident #19 on 10/05/2023 was discontinued from the tracheostomy collar oxygenation and was placed on a ventilator, Resident 19's daughter was not notified. (3) Resident #20 had an episode of respiratory distress with decreased oxygen saturation on 07/29/2023, and on 07/30/2023 they vomited x 1 and had decreased oxygen saturations and was placed on a ventilator. There was no documented evidence…

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 an abbreviated survey (NY00339693, NY00341303, NY00343390, NY00333515,) the facility did not ensure resident's right to be free from misappropriation of resident property. This was evident for 3 out of 3 residents (Resident #14, #16, #17) reviewed for personal property. Specifically, Resident #14's advocate stated the resident's glasses went missing during one of their hospitalizations and they have not been returned yet. 2) Resident #16's cell phone was not returned to the family after they expired in the facility on [DATE]. Resident #16's family stated the cell phone was being used by someone in the facility after they expired, and they have since had the service turned off. 3)Resident #17's guardian stated the resident's wallet was missing after their admission to the facility. They discovered a charge from the facility on the debit card shortly after their admission to the facility. There was no documented grievances or investigations, or local enforcement…

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 an abbreviated survey (NY00343390, NY00339693, NY00345193, NY00341303, NY00331035, NY00325315) the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 6 out of 7 residents (Residents #1, #14, #15, #16, #19, #21) reviewed for quality of care. Specifically, (1) Resident #1's certified nurse assistant accountability documentation revealed that in a 2-month period, there were no signatures for bladder/incontinence care being provided on 9 occasions; (2) On 090/06/2024 Resident #14 was observed lying in bed with a catheter draining leg bag in place Review of Resident #15's certified nurse assistant accountability record revealed that in a 3-month period there were no signatures for bladder/bowel incontinence care being provided on 25 occasions; (4) Resident #16's certified nurse assistant accountability report for April 2024 revealed on 5 occasions there was no signature indicating bladder/bowel…

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

Based on record review and interviews during an abbreviated survey (NY00343390, NY00345193, NY00341303, NY00339693, NY00333515, NY00331035, NY00327139, NY00321114, NY00325315), the facility did not ensure residents were free from significant medication errors. This was evident for 13 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) out of 19 residents reviewed for medication administration. Specifically, the Residents on the Center 2 Unit did not receive their scheduled medications on 06/09/2024 during the 7:30 AM to 3:30 PM shift. There was no evidence in the Medication Administration record that the scheduled physician prescribed medications were administered to the residents and no notification to the physician the medications were missed or not administered. Findings include: The Facility Medication Administration policy dated 09/2015 and last revised 08/2019 documented Licensed Nurses must ensure that prior to the end of their shift all medications administered/refused/held etc., are properly documented on the Medication Administration Record. Failure to do so…

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 (NY00341303) the facility did not ensure that services being provided meet professional standards of quality in clinical practice for 1 out of 16 residents (Resident #16) reviewed for medication administration. Specifically, Resident #16 was noted to have an elevated Prothrombin time (which measures the time it takes for liquid portion of blood to clot) and INR (International Normalizing Ratio (a blood test that measures how long it takes the blood to clot) PT/INR of 71.6/7.4(seconds) on [DATE] with a reference range of (PT-9.9-12.7/INR-0.9-1.1) indicating the blood is taking longer than normal to clot. Resident #16 was ordered to receive 10mg Vitamin K (vitamin needed for blood clotting) to be administered intramuscularly by the physician on [DATE] at 4:47PM. The Vitamin K was not readily available in the facility. Staff did not notify the physician that the Vitamin K was not available. Resident #16's Vitamin K was not administered until 12:58…

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 (NY00339051), the facility did not ensure residents right to be free from abuse for 2 of 4 residents reviewed for abuse. Specifically, on 4/12/2024, Resident #3 was transferred to a different unit due to verbal aggression with their roommate. The receiving unit was not notified of the incident of verbal aggression with their roommate which prompted the transfer. Resident #3 punched Resident #4 in the face and was transferred to the hospital and was admitted for psychosis. Findings include: The facility policy, 'Abuse' revised 12/2022 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews conducted during the abbreviated surveys (NY00339051), the facility did not ensure that appropriate behavioral care was provided to address the problem of refusals and delusions for 1 of 4 residents (Resident #3) reviewed for the use of psychoactive medications. Specifically, Resident #3 refused their antipsychotic medication Haldol as ordered by the medical provider at 9 AM and 5 PM on 4/11/24, refused to eat, and stated they thought they were being poisoned, and the medical provider was not notified. The following day, Resident #3 punched their roommate in the face, Resident #3 was transferred to the hospital, and was admitted for psychosis. Findings include: The Facility Policy titled Psychotropic Medication revised 7/2019 documented that the facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical and /or behavioral interventions as well as psychopharmacological medications can 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 interviews during the abbreviated survey (NY00339051), the facility did not ensure that a resident was free of significant medication errors for 1 of 4 residents (Resident #3) reviewed. Specifically, on 4/11/2024 Resident #3 refused their significant medications that included antipsychotic medication, anticoagulant, cardiovascular, and steroid/bronchodilator. There was no consistent documentation on the Medication Administration Record of the refusal and that the medical provider was notified of the missed medications. Consequently, on 4/12/2024, Resident #3 punched their roommate in the face and was transferred and admitted to the hospital with admitting diagnosis of psychosis. The findings are: The facility policy, 'Medication Administration' revised 12/2019 documented medications must be administered in accordance with the orders, including any required timeframe. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document as such in designated format (hard copy 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.

Based on record review and interviews conducted during an abbreviated survey (NY00312813), the facility did not ensure grievances were resolved in a timely manner. This was evident for 1 of 3 resident (Resident # 3) reviewed for grievances/complaints. Specifically, there was no documented evidence that a thorough investigation was completed after Resident #1 and family representative reported missing clothing's. The findings are: The facility Policy and Procedure titled Investigation of Grievance/concerns dated 3/2016, reviewed on 1/18/2023 documented that the facility residents and representatives may submit a grievance orally, in writing and anonymously. The Director of Social Work is the facility's Grievance Officer and is responsible for facilitating the complaint/grievance process, and the corresponding department will investigate the allegation(s) and submit a written report of such findings within 7 business days. Resident # 3 was admitted with diagnoses including but not limited to Urinary tract infection, benign neoplasm of the meninges (brain), and seizures. The admission…

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 (NY0333863), the facility did not ensure that an alleged violation involving abuse was reported to the New York State Department of Health. In addition, the results of all investigation were not reported within 5 working days of the incident with corrective action taken to the New York State Department of Health in accordance with State law. This was evident for 1 (Resident# 1) out of 3 residents reviewed for abuse. Specifically, Resident #1 alleged they reported that they were sexually assaulted 3 times by facility staff on 12/2/23 and 12/3/23, there was no documented evidence that the allegation was reported to the New York State Department of Health. Findings include: Resident#1 had diagnoses that included dependence on respirator [ventilator] status, neuromuscular dysfunction of the bladder and legal blindness. The Discharge Minimum Data Set (MDS, an assessment tool) dated 12/7/23 documented that the resident had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the an abbreviated survey (NY03333863) , the facility did not ensure that an alleged violation involving abuse was reported to the New York State Department of Health. In addition, the results of all investigation were reported within 5 working days of the incident with corrective action taken to the New York State Department of Health in accordance with State law. This was evident for 1 (Resident# 1) out of 3 residents reviewed for abuse. Specifically, Resident #1 alleged they were sexually assaulted 3 times by facility staff on 12/2/23 and 12/3/23, there was no documented confirmation or receipt of reporting of the allegation or the results of the allegation to the New York State Department of Health. Findings include: Resident#1 was admitted to the facility on [DATE] with diagnoses that included dependence on respirator [ventilator] status, neuromuscular dysfunction of the bladder and legal blindness. The Discharge Minimum Data Set (MDS, an assessment tool) dated…

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

Based on record review and interviews conducted during an abbreviated survey (NY00312813), the facility did not ensure that a resident was given the opportunity to participate in their care plan meeting. This was evident for 1 out of 3 residents (Resident #3) reviewed for care plans. Specifically, there was no documented evidence that the resident and resident representative/family was invited and/or attended a care plan meeting during their stay in the facility. The findings are: Resident # 3 was admitted with a diagnosis including but not limited to Urinary tract infection, benign neoplasm of the meninges (brain), and seizures. The admission Minimum Data Set (MDS, an assessment tool) dated 1/30/2023 documented the resident was cognitively intact and was able to make self-understood and understands others. Record review of the Social Services Progress Notes revealed no documented evidence that Resident #3 participated in any interdisciplinary care plan meeting during their stay in the facility from 01/30/2023 to 03/16/2023. During an interview on 4/30/24 at 11:04 am, Social Worker…

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 conducted during an abbreviated survey (NY0333863), the facility did not ensure a resident that had an indwelling catheter received appropriate treatment and services as evidenced for 1 (Resident #1) out of 3 residents reviewed for indwelling catheter care. Specifically, Resident #1 who had a history neuromuscular dysfunction of the bladder had no documented evidence of receiving indwelling catheter care every day and every shift as ordered on 7 occasions in December 2023 and subsequently was diagnosed with a urinary tract infection. Findings include: Review of the catheter care policy dated 7/2016 and last revised 5/2019 documented that the purpose of the procedure is to prevent catheter-associated urinary tract infections and provide required care of resident's who have an indwelling catheter. Resident#1 was admitted to the facility on [DATE] with diagnoses that included dependence on respirator [ventilator] status, neuromuscular dysfunction of the bladder and legal…

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 abbreviated survey (NY00334847), the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 of 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7). Specifically, on 3/3/2024 during the 11:30 PM to 7:30 AM shift the residents who resided on the third-floor dementia unit did not receive their scheduled medications due to inadequate staffing. The scheduled licensed practical nurse for the unit did not arrive for their shift and the night nursing supervisor was not able to administer the resident's medications, due to being called to other units. The findings include: Review of the facility Policy and procedure titled, Staffing Hours revised on 04/2019 documented 1. Our facility maintains adequate staffing on each shift to ensure that our resident'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 conducted during an abbreviated survey (NY00334847), the facility did not ensure that residents were free of significant medication errors. This was evident for 7 of 7 Residents (#1, #2, #3, #4, #5, #6 and #7) reviewed for medication administration. Specifically, a registered Nurse did not follow physician orders to administer scheduled medications during the 11:30pm to 7am shift on 2/2/2024, 2/3/2024, 2/4/2024, 2/5/2024, 2/8/2024, 3/2/2024, 3/3/2024, 3/4/2024, and 3/7/2024. There was no evidence in the Medication Administration record that the scheduled physician prescribed medications were administered to the residents. The findings are: The facility Policy titles Medication Errors dated 10/2015 and revised 8/2019 stated the staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. The Director of Nursing should investigate the error. Counsel staff members as needed. Educate staff members on how to avoid making similar errors in…

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 (NY00319194), the facility did not ensure residents rights to be free from neglect for 1 of 4 sampled residents (Resident #1) reviewed. Specifically, Resident #1 had a physician's order for two-person physical assistance with transfers via Hoyer lift that was also documented on the facility Task List and Care Flow Sheet for Certified Nursing Assistant (CNAs). CNA #1 transferred Resident #1 by themselves on 6/28/2023. During the transfer, Resident #1 slid out from the Hoyer lift pad and fell sustaining laceration and bleeding to the left eyebrow and swelling to the left eye. Resident #1 was transferred to the hospital and was diagnosed with intracranial hemorrhage (bleeding in the brain). The findings are: The Facility Policy on Neglect last revised on 02/2022 documented that the facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, mistreatment, and / or misappropriation of property. Neglect was defined 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 record reviews and interviews conducted during an abbreviated survey (NY00319194), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately but no later than 2 hours to the New York State Department of Health (NYSDOH). This was evident for 1 of 4 residents (Residents #1) reviewed for neglect. Specifically, Resident #1 fell out from the Hoyer lift pad during transfer sustaining laceration and bleeding to the left eyebrow and swelling to the left eye on 06/28/2023 at 10:40 AM. The facility reported the incident to the NYSDOH on 06/29/2023 at 11:44 AM. The findings are: The Facility Policy on Abuse last revised on 02/2022 documented that the facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, mistreatment, and / or misappropriation of property. Neglect was defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Notify the appropriate State Agency (s) immediately (no…

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 conducted during and abbreviated survey (NY00317907), the facility did not ensure that a resident was cared for in a manner that maintained or enhanced their dignity. This was evident for 1 of 3 residents (Resident # 6) reviewed for dignity. Specifically, Resident #6's foley catheter bag and tubing were not covered and was visible from the hallway. The findings are: The facility policy and procedure titled Resident Rights created on 9/2013, last revised 2/2020 documented employees shall treat all residents with kindness, respect, and dignity. Residents of this facility has the right to privacy and confidentiality. Resident #6 was admitted to the facility with diagnoses that included urinary tract infection, sepsis, schizoaffective disorder. The admission Minimum Data Set (MDS, an assessment tool) dated 6/27/2023, documented Resident #6 was severely impaired of cognitive function. Resident #6 had a foley catheter and required extensive assist of 2 staff for bed mobility, dressing, and toileting. During an observation conducted on 7/27/2023 at 10:45…

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 conducted during an abbreviated survey (NY00317907), the facility did not ensure residents were provided a clean, safe, and homelike environment for residents who resided on the dementia unit. Specifically, the dining room on center 3 where residents were being monitored was dirty, with multiple puddles of liquid and trash on the floor, and body fluids on the table. The findings are: The facility policy and procedure on Cleaning and Disinfection of Environmental Surfaces created 10/2015, last revised 6/13/2023 documented that the facility will clean and disinfect environmental surfaces according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection of healthcare facilities. Floors and tabletops will be cleaned and disinfected on a regular basis when spills occur and when the surfaces are visibly soiled. During an observation conducted on 7/26/2023 at 11:15AM on Unit Center 3 (dementia unit) dining room, the survey team observed 9 residents present, 4 were sitting at the table and others were…

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, interviews, and record reviews conducted during an Abbreviated Survey (NY00317907), it was determined that for 1 of 3 residents (Resident #4) reviewed for Quality of Care, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plan. Specifically, Residents on enteral feedings did not have the appropriate labeling of the enteral feeding and free water supply. The findings are: The facility policy and procedure titled Infection Prevention and Control created 10/2015, last revised 4/26/2023 documented this facility follows infection prevention and control policies, procedures, and practices intended to maintain a safe, sanitary, and comfortable environment while helping to prevent the development and transmission of communicable diseases and infections. This facility follows standards of practice in regards to infection and prevention and control guidance. The facility policy and procedure titled Enteral Feedings created 1/2015, last revised 4/2020…

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 6/27/2022-7/6/2022 Recertification Survey, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one of three residents (resident #97) reviewed for ADL's. Specifically, resident #97 had long and dirty fingernails during multiple observations. The findings are: The facility Policy and Procedure (P&P) titled ADL Support dated 10/2019, revised 3/2022 documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Additionally, if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume is refusing or declining care. Resident #97 had diagnoses including chronic obstructive pulmonary disease (unspecified),…

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

Based on record review, observation and interview conducted during the Recertification Survey started on 6/27/22 and completed on 7/6/22, the facility did not ensure the Consultant Pharmacist reported irregularities to the attending physician and the facilities Medical Director and Director of Nursing (DON) for one (Residents #68) of five residents reviewed for drug regimen reviews. Specifically, the lack of Consultant Pharmacist's identification and recommendation regarding the continued use of Risperdal (antipsychotic medication) without attempt of a gradual dose reduction (GDR) for resident #68. The findings are: The policy and procedure (P&P) titled Antipsychotic Medication Use revision dated 2/2022 documented antipsychotic medication will be prescribed at lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Diagnoses alone do not warrant the use of antipsychotic medication. Antipsychotic medications will generally only be considered if the following if the following criteria are also met: a. The behavioral symptoms…

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

Based on record review, observation and interview conducted during the Recertification Survey started on 6/27/22 and completed on 7/6/22, the facility did not meet the nutritional needs of residents in accordance with established national guidelines and follow the prepared menus. Specifically, three (North 1, Center 1, and South 1) of seven units were not served proper portion size of starch (mashed potatoes) during the lunch meal on 6/29/22. The finding is: The policy and procedure (P&P) titled Portion Control Policy updated 9/2021 documented menu items shall be served according to pre-determined portion size. 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. Appropriate serving utensil is used to accurately serve designated portion size. The undated Portion Control Guide documented the portion size for starches, including mashed potatoes, was ½ cup, #8 scoop (gray scoop) or 4 oz (ounce) spoodle (green spoodle). The undated Scoops, Ladles & Proper Portion Control…

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 survey, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. Specifically, a resident who requested more than one shower a week was not accommodated by the nursing staff. This was evident for 1 resident reviewed for choices.(Resident #86). The findings are: Resident # 86 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and traumatic brain injury During an interview on 12/31/18 at 10:00 AM the resident stated that he only gets one shower per week, though he had requested 2 showers weekly. A review of the admission Minimum Data Set (MDS, a resident assessment tool) dated 11/9/18 revealed that the Brief Interview for Mental Status(BIMS) score was a 15 out of a possible score of 15 indicating the resident is cognitively intact. The interview for daily preferences documented that it was very important to the resident 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 observations, interviews and record review conducted during the most recertification survey, the facility did not ensure that advance directives regarding Cardiopulmonary Resuscitation (CPR) formulated for 3 of 10 would be honored at all times. Specifically, staff did not consitently implement the system developed by the facility to readily identify each resident status regarding CPR in the event that CPR was indicated. The findings are: According to the facility's policy on Advanced Directives a resident with a written consent not to be resuscitated should be identified by the wearing of a red identification band/bracelet. Observation revealed that this policy was not implemented for the following residents: 1. Resident #5 is an [AGE] year old wheelchair bound female with diagnoses to include dementia. The resident has had a written consent for a Do Not Resuscitate (DNR) order since at least [DATE]. On [DATE] at 12:15 PM and on [DATE] in the morning the resident was on observed without any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during a recertification survey, the facility did not develop and implement a person-centered care plan with measurable objectives and time frames in accordance with comprehensive assessments for 1) one of three residents' (R #4) reviewed for behavioral/emotional problems, 2) one of two residents' (R#113) reviewed for bowel and bladder incontinence, and 3) one of two resident's (R#127) reviewed for dementia care. The findings include: 1. Resident #4 was admitted with diagnoses including Non-Alzheimer's Dementia, Schizophrenia and Diabetes. The Annual Minimum Data Set (MDS-a resident assessment and screening tool) of 1/5/19 indicated the resident was receiving antipsychotic and antidepressant medications during the last 7 days of the assessment period. The January 2019 physician's orders indicated the resident's current psychotropic medications included Risperdal, an antipsychotic and Wellbutrin, an antidepressant. Review of the comprehensive care plan (CCP) revealed…

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 care plans were reviewed and revised based on the comprehensive assessment for 1 of 1 residents (Resident #214) reviewed for tube feeding, 1 of 3 residents (#30) reviewed for respiratory care, and 1 of 5 residents (R#74) reviewed for pressure ulcers. Specifically, no new interventions were initiated to address the 1. care and placement of a g-tube for R#214, 2. to address tracheostomy care for R#30 and 3. to prevent further skin breakdown for R#74. The findings include: 1.Resident #214 had diagnoses and conditions including Non-Alzheimer's Dementia, Anemia, and Atrial Fibrillation. The Annual Minimum Data Set (MDS- a resident screening and assessment tool) of 10/23/18 indicated the resident had severely impaired cognition, received extensive assist x one staff support for eating, had a feeding tube and was on a mechanically altered therapeutic diet. Current Physician's orders included;…

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 survey, the facility did not ensure discharge planning needs were addressed for one of two residents (Resident #87) reviewed for discharge. Specifically, the resident's discharge plan, which noted that he would reside in the facility long term was not updated to address the resident's desire to leave the facility. The findings are: Resident #87 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Distress, Chronic Obstructive Pulmonary Disease and Schizo-affective Disorder. The admission Minimum Data Set (MDS- an assessment instrument) dated 4/5/18 revealed that the resident achieved a Brief Interview for Mental Status (BIMS) score of 15 which suggested that the resident's cognition was intact for daily decision making; required limited assistance of one-person for bed mobility, transferring, dressing, toileting and hygiene; participated in the assessment process; and expected to remain in the facility long…

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 interview conducted during a recertification survey, the facility did not ensure that safe and effective assistive devices were provided to each resident when indicated to prevent accidents. Specifically, one of three residents reviewed for accidents (Resident #33) reported a fall that occurred 12/4/2018 during transfer out of bed to wheelchair with a mechanical (Hoyer) lift utilizing a sling. The facility did not ensure that 1) the sling was laundered according to the manufacture's instructions, 2) staff was trained on how to check the sling for functionality and durability before use, 3) and that a system was in place to routinely inspect all slings. As a result of the fall, the resident sustained a fracture of the left femur revealed by an x-ray and was transferred to a hospital where an open reduction and internal fixation (ORIF) procedure was done. Complaint ID #: NY00230705 The findings are: Resident #33 was admitted to the facility on [DATE] with diagnoses…

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 re-certification survey, the facility did not ensure that one of two residents reviewed for urinary incontinence (resident #113) was provided the necessary care to decrease his level of urinary incontinence. Specifically, the nursing staff did not develop and implement a person-centered toileting program for the resident who is cognitively impaired and had multiple episodes of incontinence in order to attempt to decrease the frequency of incontinence. The findings are: Resident #113 was admitted to the facility on [DATE] with diagnoses of Dementia and Diabetes Mellitus. The Minimum Data Set (MDS-an assessment tool) dated 7/2/18 revealed that the resident had severe cognitive impairment, required extensive assistance with transfers, ambulation and toileting, used a wheelchair at times for locomotion, was frequently incontinent of bladder, and was not placed on a toileting program. The most recent quarterly MDS dated [DATE] revealed that 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 observations, record review and interview conducted during the recertification survey, it was determined that for one of three residents reviewed for respiratory care, the facility did not provide care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the resident was performing self suctioning without physician's orders and without a Comprehensive Care Plan. (Resident #30). The findings are: Resident #30 had diagnoses and conditions including Hemiplegia, Cerebrovascular Accident and Respiratory Failure. Review of the 7/9/18 Significant Change MDS (minimum data set-a resident assessment tool) indicated the resident was cognitively intact, received total assist x two for personal hygiene, had diagnoses including Pneumonia, CVA, and Hemiplegia, and received oxygen, ventilator, suctioning and tracheostomy cares. The 10/9/18 Quarterly MDS indicated the resident was cognitively intact, received total assist x one staff support for personal hygiene, had diagnoses including Hemiplegia, CVA, and Respiratory Failure,…

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 conducted during the most recent recertification survey, the facility did not ensure that nursing staff followed proper hand hygiene while administering medications. The findings are: On 1/3/19 at 1:05 PM a Licensed Practical Nurse (LPN #4) was observed administering Medication to Resident #190. LPN #4 used hand sanitizer prior to pouring the resident's medication. After administering the medications to Resident #190, LPN#4 discarded the empty medication and water cups, wiped top of the resident's night stand and pushed the medication cart to the front of resident #140's room. Without washing her hands LPN #4 proceeded to administer medications to Resident #140. Immediately after the LPN finished administering medications to Resident #140, the surveyor informed the Director of Nursing (DON) of the failure of the LPN to wash her hands before administering medications to Resident #140. The DON then proceeded to address this matter with LPN #4. The DON later that day informed the surveyor that the LPN stated that she was not aware that she should have…

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.