Woodland Pond At New Paltz

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the abbreviated (NY00370838 and NY00371165) and recertification surveys from 4/21/2025-4/24/2025, the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1). multiple residents and family members complained about long wait times after initiating the call bell, 2). Resident #28 had to wait 66 minutes on 2/1/2025 to receive incontinence care, 3) Resident Council attendees reported long wait times to receive assistance from staff for activity of daily living, and 4) Resident #6 was observed waiting an extended period of time for assistance with morning care due to staff inability to manage their assignment, refer to F677. The findings included: The policy titled Staffing documented provide adequate staffing to meet needed care and services for resident population. 1) The Call Bell Logs from October 2024-January…

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

Based on observation, interview, and record review conducted during the recertification survey from 4/21/2025 to 4/24/2025, the facility did not ensure the resident's right to be notified of facility's grievance official and of their right to obtain a copy of their grievance decision in writing. This was evident for 7 (Resident #30, #15, #4, #12, #18, #9 and #7) Resident Council attendees out of 38 total residents. Specifically, Resident #30, #15, #4, #12, #18, #9, and Resident #7's Family Representative did not know the Grievance Official for the facility and were unaware of their right to receive written copy of grievance investigation decisions. The findings are: On 4/22/2025 at 11:10 AM, a Resident Council meeting was held with Resident #30, #15, #4, #12, #18, #9, and Resident #7's Family Representative in attendance. All attendees stated they were unaware of who held the title of Grievance Official for the facility, and they could receive a copy of their grievance investigation decision in writing. On 4/24/2025 at 12:13 PM, Resident #7's Health Care Agent was interviewed 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 and abbreviated (NY00371165 and NY00370838) survey from 4/21/2025 to 4/24/2025, the facility did not ensure a resident unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This was evident for 2 (Resident #6 and #28) of 3 residents reviewed for activities of daily living. Specifically, 1) Resident #6 reported long wait times to receive assistance with incontinence care and personal hygiene, and 2) Resident #28 was dependent on assistance for activities of daily living and had to wait 66 minutes on 2/1/2025 to receive incontinence care. The findings are: The facility policy titled Activities of Daily Living dated 4/22/2025 documented resident activities of daily living performance skills would be assessed and a care plan would be completed. 1) Resident #6 had diagnoses of left femur fracture and altered mental status. The Quarterly Minimum Data Set (resident…

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

Based on observation and interview conducted during the recertification survey from 4/21/25-4/24/25, the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, food items were not properly sealed and dated in the main kitchen walk in refrigerator, clean wet pots were stacked on a drying rack and dietary staff were observed without hair nets or beard covers while in the kitchen and while serving food in the dining room at the steam table. The findings include: The policy titled Hygiene Guidelines dated 6/1/2022 documented hair could be both a direct and indirect vehicle of contamination. A hair restraint keeps dislodged hair from ending up in the food. The policy titled Food Labeling and Dating Guidelines dated 12/6/2022 documented labeling requirements for used by date is required. During initial inspection of the kitchen conducted with the Food Service Director on 4/21/25 at 12:30 PM the following was observed: Dietary Staff #4 was not wearing a hair net or beard cover. - The walk-in refrigerator contained roasted…

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

Based on observation, record review, and interview conducted during a recertification survey from 4/21/2025 to 4/24/2025, the facility did not ensure infection control and prevention practices were maintained. Specifically, Licensed Practical Nurse #1 was observed administering medication to Residents #20 and #28 without performing hand hygiene during administration of eye drops and preparation of medications via gastrostomy tube. The findings include: The facility policy titled Medication Administration last reviewed on 11/2024 documented administer medications safely and appropriately by a licensed nurse to treat, prevent and alleviate symptoms of a disease. Always practice hand hygiene before and after the procedure. During interview and observation of medication administration on 04/23/2025 from 9:05 AM to 10:23 AM, on Unit S1 the following was noted: Licensed Practical Nurse #1 removed eyedrops from the medication cart, held the bottle with their left hand, read the name on the bottle and checked the expiration date. With their right hand holding the computer mouse, checked the…

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

Based on observation, interview and record review conducted during a recertification survey, it was determined that the governing body did not implement policies regarding the management and operation of the facility Water Management Plan. Specifically, the facility Legionella Sampling and Management Plan. The findings are: The facility did not adhere to the recommended water sampling points on the water sampling tests done in 3/2019 and 4/2019. Review of the Facility Water Analysis Result dated 03/21/2019 revealed that 3 out of 11 (27.27%) sample sites tested positive for Legionella. Review of the Facility Water Analysis Result dated 5/15/2019 revealed that 3 out of 11 (27.27%) sample sites tested positive for Legionella. The facility water supply has tested positive for Legionella in 7/2019 and 8/2019. Review of the Facility Water Analysis Result dated 8/15/2019 showed that 11 out of 16 (68.75%) sample sites tested positive for Legionella. Review of the Facility Water Analysis Result dated 9/17/2019 showed that 11 out of 16 (68.75%) sample sites tested positive for Legionella.…

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 staff interview conducted during the recertification survey it could not be ensured that the facility maintained a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, (1) the facility did not have enough water sampling points on Legionella tests done in 3/2019 and 4/2019, (2) facility water supply has tested positive for Legionella on tests done in 7/2019 and 8/2019, and (3) no water sampling was done from 9/2019 to 2/28/2020. The findings are: 1. Review of the Facility Water Analysis Results dated 3/21/2019 and 5/15/2019 revealed that 11 sample sites were tested for Legionella. Additional testing sites (16) are indicated. Of note, 3 of 11 (27.27%) sample sites showed positive Legionella results. An interview was conducted on 2/26/2020 at 03:18PM with the Director of Facilities (DOF) where he stated that on 4/15/2019 after he attended a Department of Health (DOH) Legionella Training Session, he became aware that they should increase water sampling points in the facility from 11 to 16. 2. Review of the…

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

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure foods were stored in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, opened and/or expired potentially hazardous foods (beef, chicken) were observed to be stored in a refrigerated unit. The findings are: The facility policy dated 1/30/2012 and titled, Ground Beef Policy documented that the shelf life of the product is 21 days from manufacturer's pack date. The facility policy dated 1/30/2012 and titled CVP (Cryovac: a way of vacuum sealing meat to keep harmful bacteria out and to extend the shelf life of the meat by keeping it fresh longer) Fresh Chicken Guidelines documented that the shelf life of product is 14 days from the manufacturer's pack date, frozen items must be used within 48 hours after thawing and that staff are to use opened packages of CVP chicken within 2-3 days of opening. 1. The initial tour of the kitchen was conducted on 2/25/2020 at 11:10AM with the Dining Director (DD)…

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

Based on observation, record review and interview conducted during the recertification survey, it could not be ensured that the facility stored medications under proper temperature controls. Specifically, the temperature in the facility medication refrigerator was noted to be below the manufacturers' specifications during two observations. The findings are: The facility policy on refrigerated medications revised on 2/2019 documented that the medication refrigerator temperatures are to be checked daily and documented. The temperature range should be between 36° Fahrenheit (F) and 41° F. If refrigerator temperatures are above or below this range, maintenance is to be notified immediately. An observation was conducted on 2/25/2020 at 12:58PM with LPN #2. The medication refrigerator was observed via a thermometer to be at a temperature of 32° F. An interview conducted with LPN#2 at that time revealed that the LPN did not know the correct temperature range for the refrigerator nor does she know what actions to take should the temperature be out of range. An observation was conducted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that proper hand hygiene was performed during wound care for 2 of 2 residents (#2 and #13) reviewed for pressure ulcers. The findings are: Review of the Wound Dressing Policy revised on 11/2019 documented that after removing the old dressing, staff must remove gloves, wash hands and apply a clean pair of gloves. Review of an undated Competency Dressing Change Checklist documented that for both sterile and non-sterile dressing changes, staff must remove gloves and perform hand hygiene after removing old and / or soiled dressings. 1. Resident #2 was admitted with diagnoses that included Fracture of Right Acetabulum (socket of the hip bone), Alzheimer's Disease and Generalized Anxiety Disorder. The Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 2/26/2020 documented a Brief Interview for Mental Status (BIMS) score of 3, denoting severe cognitive impairment. Section M of 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.