Waterview Hills Rehabilitation And Nursing Center

Based on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure that a resident's right was supported by the facility for 1 or 3 residents reviewed. Specifically, Resident #1 filed a grievance which was reported to the Director of Nursing in January 2025 that they prefer not to receive cares from Certified Nurse Aide #1 because they were too strong in their touch and at times manhandled them. On 3/18/2025, Certified Nurse Aide #1 provided care to Resident #1 and the resident reported to their family representative that Certified Nurse Aide #1 came to their room at approximately 4:45 am, woke them out of their sleep and provided cares to them after they refused the care. Resident #1 also alleged that they were manhandled by Certified Nurse Aide #1. There was no documented evidence that Resident #1's care plan was updated with their preference. The facility did not provide evidence that the Nurses and Certified Nurse Aides were made aware of Resident #1's preference. The findings are: The 7/1/2019 facility policy title Activities…

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 the Abbreviated Survey (NY00375616), the facility did not ensure for 1 (Residents #1) of 3 residents reviewed for abuse, had the right to be free from abuse, neglect, or mistreatment. Specifically, Resident #1 was awaken at 4:45am by Certified Nurse Aide #1 to provide personal hygiene care. Resident #1 refused cares but Certified Nurse Aide #1 continued to provide cares despite Resident #1's refusal. Resident #1 reported Certified Nurse Aide #1 mishandled them. Resident #1 was very upset because thier sleep was interrupted by Certified Nurse Aide #1 and reported to their family representative. The findings are: The 1/28/21 Facility policy titled Abuse Prevention/Prohibition documented that all Residents will be free from abuse, mistreatment, neglect, exploitation, misappropriation of property, corporal punishment, and involuntary seclusion. The 1/23/28 Facility policy titled Residents Rights documented that all residents have a right to a dignified existence and self-determination, has a right to make choices about aspects 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.

Based on record review and interviews conducted during the Abbreviated Survey (NY00375616), the facility did not ensure for 1(Residents #1) of 3 residents reviewed for abuse, that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation is made, to the State Survey Agency in accordance with State law through established procedures. Specifically, 1.) On 3/18/25, the facility initiated an investigation of alleged abuse due to a report from Resident #1's family on 3/18/25 that Resident #1 called them early in the morning on 3/18/25 upset that two certified nurse aides came into their room at approximately 4:45 am while they were asleep and insisted on changing them despite their refusal and while providing cares, they were manhandled by the Certified Nurse Aides. Resident #1 was very upset by the actions of the Certified Nurse Aide #1 & #2. The findings are: The 1/28/21 Facility policy titled Abuse Prevention/Prohibition documented the Federal 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 interviews and record review, conducted during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every 3 months. This was evident for 3 (Residents # 11,14, and 23) of 18 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments for Resident #11, Resident #14, Resident #23, were not completed within 14 days of the Assessment Reference Date. The findings are: The facility's policy titled Minimum Data Set Completion, initiated 9/1/18 last reviewed 6/14/24 documented assessments will be completed no later than 92 days after the previous Assessment Reference Date. 1) Resident #11's Quarterly Minimum Data Set (an assessment tool) with an Assessment Reference Date of 8/6/24 documented a completion date of 10/1/24, more than 14 days (8 weeks) after the Assessment Reference Date. 2) Resident #14's Quarterly Minimum Data Set (an assessment tool) with an Assessment Reference Date of 8/21/24 documented a completion date of 10/1/24, more…

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

Based on observation, record review and interview during the recertification survey, the facility did not ensure 1 of 3 residents (Resident #16) reviewed for positioning and range of motion, had the necessary treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, Resident #16 was observed poorly positioned and their plan of care did not include interventions to address body, head, and neck positioning. Findings include: Resident #16 was admitted to facility with diagnoses including Diabetes, Non-Alzheimer's Dementia, and osteoarthritis of the right shoulder. The 10/1/24 Quarterly Minimum Data Set (MDS) an assessment tool documented Resident #16 had moderately impaired cognition, received regularly scheduled pain medication, and was not receiving rehab services. The Minimum Data Set documented Resident #16 required set up or clean up assist for eating. The Activities of Daily Living Care Plan created 10/16/15 documented Resident #16 required set up and supervision for feeding. The 6/11/24 Occupational Therapy evaluation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure that each resident received necessary respiratory care including oxygen therapy that was in accordance with professional standards of practice and as ordered by the practitioner for 1 of 2 residents (Resident #312) reviewed for respiratory care. Specifically, Resident #312 had an order for oxygen therapy but there was no documented evidence of monitoring to ensure it was being administered, and there was no evidence the nasal canula tubing was changed per policy. Findings include: The facility policy and procedure titled Oxygen Administration with effective date 3/30/10, last reviewed on 7/8/24, documented the following information should be recorded in the resident's medical record: the rate of oxygen flow, route, and rationale, the frequency and duration of the treatment, the date and time that the procedure was performed, the name and title of the individual who performed…

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

Based on observations and interviews conducted during the recertification survey from 10/3/24 to 10/10/24, the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, there was undated and without expiration dates food stored in the walk-in freezer and refrigerator. Finding include: The facility policy Food Inventory Receiving and Storage effective 09/09/2018 and reviewed 2/14/2024, documented each item must be dated and labeled. Any items opened/used and returned to storage shall be wrapped, labeled, and dated from initial date of use. During an initial tour of the kitchen on 10/03/24 at 9:08 AM, conducted with Food Service Director, the following were observed in the walk-in freezer: 1. A bag of frozen pork butt, without original box, with receiving date 9/26/24, no expiration date. 2. Open bags of hash brown patties, and French fries, both bags were undated. Observation of walk-in refrigerator on 10/03/24 at 9:21 AM revealed opened and undated packs of American cheese, liverwurst, Raskas Cream Cheese and a bag 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.

Based on record review and interview conducted during a recertification survey 10/3/24- 10/10/24, the facility did not properly establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, the facility had not updated the Water Management Plan since 12/16/19. The findings are: During a review of the Legionella Assessment and Water Management Plan on 10/7/24 at 11:50 AM with the Director of Engineering, the facility's Water Management Plan was dated 12/16/19. The facility Administrator and Director of Nursing's names were handwritten on the form over white out from the former Administrator and Director of Nursing. During an interview on 10/7/24 at 11:50 AM, the Director of Engineering stated they were responsible for updating the plan annually but had not done it in the last year. The Director of Engineering stated it was important to have updated information and a current Management team. The plan was to have an outside company come in to do an assessment and formulate a Management Plan, which was scheduled…

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 that foods were stored in accordance with professional standards for food safety practice. Specifically, for 2 of 4 nourishment refrigerators (Armonk and Canterbury units): (1) freezer thermometer readings did not reflect acceptable temperatures and no corrective action had been taken, and (2) foods stored in freezer compartments were not frozen solid. The facility's freezers must be in good working condition and must keep frozen foods frozen solid. The finding is: An Engineering policy and procedure for Temperature Logs dated October 2018 revealed the Engineering Mechanic fills out logs for refrigerators and freezers on a daily basis; freezer temperatures should be between -10 and 0 degrees F and notifies Engineering Director of any temperatures that do not fall in the proper ranges. An inspection of all nourishment refrigerators in the facility conducted on 5/1/19 between 12:00 PM and 12:30 PM with the Food Service Director (FSD) present revealed: (1)…

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 that a comprehensive person-centered care plan with measurable goals and interventions was developed to address the resident's diabetic needs. Specifically, 1 of 5 residents (Resident # 83) did not have a care plan in place to address his diabetic needs. The findings are: Resident # 83 had diagnoses and conditions including Major Depression and Diabetes. In an interview with the resident on 4/24/2019 at 1:54 PM he stated that his blood sugar levels had not been managed properly. He stated that the levels were usually in the 300's. According to the 3/22/2019 minimum data set (MDS- a resident assessment tool) the resident had a brief interview for mental status (BIMS) score of 14/15, which indicated intact cognition, dependent on insulin for Diabetes, and required extensive assistance with his activities of daily living (ADLs). The 4/8/19 physician orders had instructions for Lantus insulin 5 units subcutaneous at bedtime and Humalog Insulin sliding scale before…

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 residents received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 resident reviewed for vision and hearing. ( Resident #55). The finding is: Resident #55 was admitted with diagnoses that included Hypertension, Diabetes Mellitus and Depression. Review of the Quarterly Minimum Data Set (MDS-a resident assessment tool) dated 03/01/2019 documented that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of a possible 15 indicating severe cognitive impairment. The MDS further documented that the resident had minimal hearing difficulty with no hearing aid. Review of the Annual MDS dated [DATE] documented that the resident had minimal hearing difficulty and used a hearing aid. Review of the admission Nursing Evaluations dated 10/17/2018 and 02/25/2019 documented that the resident had adequate hearing to both ears and does not…

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.