Warren Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a survey, the facility failed to ensure that Comprehensive Care Plans were reviewed and/or revised to reflect the resident's current condition for one (1) (Resident #85) of six (6) reviewed for accidents. Specifically, for Resident #85, there was no documented evidence that the Comprehensive Care Plan was reviewed and/or revised after a fall that occurred on 5/04/2026. Findings include: The facility policy titled Care Plans- Comprehensive last reviewed 8/02/2024, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. It documented that assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed. The interdisciplinary team reviewed and updated the care plan when there was a significant change in the residents'…

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 during a survey, the facility failed to ensure necessary services were provided to maintain good nutrition and activities of daily living for 1 (one) of 4 (four) residents reviewed for activities of daily living care (Resident #41). Specifically, For Resident #41, the facility failed to provide appropriate assistance and cueing during meals as this resident required support when eating. Findings include: Review of the facility policy titled Activities of Daily Living Care and Support, revised 11/6/2025 documented Activities of Daily Living care and support are to be provided in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, including assistance with hygiene, mobility, toileting, and dining. The policy further documented the interdisciplinary team would have monitored the resident's ability to perform Activities of Daily Living and revise the plan of care as indicated, and the amount of assistance provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 6 and 9) of two (2) residents reviewed. Specifically, (a.) Resident #6 was nearing end of life and was not provided with any stimulation or one-to-one interaction or visits; and (b.) Resident #9 stated they felt like a prisoner and were not provided with time outdoors per their preference. Additionally, perfume sampling was included on the activities agenda on 4/14/2026 and could have caused adverse reactions for some residents. Findings Include: The facility policy titled Activity Program last reviewed 5/2019, documented the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice 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 observations, interviews, and record review during a survey, the facility failed to ensure respiratory care services were provided in accordance with professional standards for 2 of 2 residents (Resident #87 and #7) with a tracheostomy (surgical opening in the neck necessary for breathing). The facility failed to support a clean environment or the maintenance of the availability of required tracheostomy supplies. The facility failed to ensure the availability of an Ambu bag (rescue breathing device) at the bedside for residents with a tracheostomy. The facility had not ensured staff consistently performed, documented, and demonstrated competent tracheostomy care in accordance with facility policy. This deficient practice had the potential to result in ineffective airway management, increased risk for infection, and compromised respiratory status. This failure had the potential to affect the resident's ability to receive timely emergency airway support. Findings include: The facility policy titled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 6 and 9) of two (2) residents reviewed. Specifically, (a.) Resident #6 was nearing end of life and was not provided with any stimulation or one-to-one interaction or visits; and (b.) Resident #9 stated they felt like a prisoner and were not provided with time outdoors per their preference. Additionally, perfume sampling was included on the activity's agenda on 4/14/2026 and could have caused adverse reactions for some residents. Findings Include: The facility policy titled Pain-Management revised 4/28/2025, documented the facility would recognize and manage a resident's pain in accordance with the resident's goals and preferences, current standards of practice and State and Federal Guidelines 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, record review, and interviews conducted during a survey, the facility did not ensure that its medication error rate did not exceed 5 percent for two (2) (Resident #9 and #22) of seven (7) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 24 percent. Findings include: The Facility's Policy and Procedure titled Medication Administration revised 12/2019, documented Medications shall be administered in a safe and timely manner, and as prescribed. PROCEDURE: The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #9 was admitted to the facility with diagnosis of Hemiplegia (severe or complete paralysis on one vertical side of the body, affecting the arm, leg, and sometimes the face), Hemiparesis (weakness, numbness, or reduced movement on one side of the body), following Cerebral Infarction (stroke i.e.: when blood flow to part 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, record review and interviews conducted during a survey, the facility did not ensure residents were free from significant medication errors for one (1) (Resident #9) of seven (7) residents reviewed, for a total of twenty-five (25) observations. Specifically, Resident #22 had a medication dose discrepancy for an anti-seizure medication that was not addressed for twenty-one (21) days after the order was changed. Findings include: The Facility's Policy and Procedure titled Medication Administration revised 12/2019, documented Medications shall be administered in a safe and timely manner, and as prescribed. PROCEDURE: The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #9 was admitted to the facility with diagnosis of Hemiplegia (severe or complete paralysis on one vertical side of the body, affecting the arm, leg, and sometimes the face), Hemiparesis (weakness, numbness, or reduced movement on one…

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 during a survey, the facility failed to ensure food brought into the facility from outside sources was stored, labeled, and maintained in accordance with professional standards of practice to prevent contamination and foodborne illness, for two (2) of two (2) residents reviewed (Resident #2 and Resident # 86). Specifically, Perishable food items (milk, mayonnaise and lettuce) were observed stored in a resident's window were unrefrigerated and not maintained at a safe temperature and were not managed in accordance with facility policy. Findings Include: The facility policy titled Food - From Outside, revised 07/12/20, documented all perishable foods must have been refrigerated, labeled, and discarded within 48 hours, and that foods left without temperature control for more than 2 hours were to have been discarded. Nursing staff were responsible for having monitored resident rooms for spoilage, contamination, and safety Resident #2 Resident #2 was 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 interview and record review conducted during the survey, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. Specifically, the Facility assessment dated [DATE], documented under Special Treatment and Conditions, the number/average or range of residents were zero (0). The facility actually had one (1) active (#7) and one (1) discharged (#87) tracheostomy resident at the time of review. Findings include: The Facility assessment dated [DATE] documented Part 2:Services and Care We Offer Based on our Residents' Needs: Other special care needs - Dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, end of life care. Facility assessment dated [DATE], documented under Special Treatment and Conditions, the number/average or range 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 observation, interview, and record review conducted during a survey, the facility failed to maintain records in accordance with accepted professional standards and practices, as accurately documented and completed for two (2) (Resident #'s 65 and 84) of 23 residents reviewed. Specifically, (a.) for Resident #65, there was no documentation in the electronic medical record that a verbal order was received from the Medical Provider to schedule the resident's pain medication and no documentation that the nurses administered the resident's pain medication after the order was changed on 4/14/2026; and (b.) for Resident #84 there was missing documentation in the Certified Nurse Aide tasks record that care was provided to the resident. Additionally, the narcotic book shift count for the south unit was signed in advance. The findings include: The facility policy titled Charting and Documentation- CNA dated 3/2020, documented all services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record.…

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 conducted during the survey, the facility did not ensure an infection prevention and control program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of two (2) residents reviewed for infection control practices (Resident #2 and Resident #7). Specifically, the facility did not ensure proper storage of perishable food items to prevent bacterial growth and potential foodborne illness and did not ensure staff adhered to infection control practices including hand hygiene, use of personal protective equipment, and appropriate handling of contaminated equipment. Findings include: The Facility's Policy and Procedure titled Infection Prevention and Control Program, revised 01/21/2026, documented the facility maintained an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment…

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 (Case #s NY00337932 and NY00340604), the facility did not ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 (Resident #s 1, 2, and 3) of 3 residents reviewed. Specifically, the facility did not ensure it revised the residents' care plan to include A) Resident #1's five (5) falls that occurred from 1/09/2024 to 4/25/2024, B) Resident #2's incident of alleged sexual abuse that occurred on 4/18/2024, and C) Resident #3's fall that occurred on 4/7/2024. This is evidenced by: The Policy and Procedure titled, Care Plans - Comprehensive, last revised 10/2019, documented assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition change. Resident #1: Resident #1 was admitted to the facility with history of falling, malignant neoplasm (cancer) of prostate, and dementia with behavioral disturbance. The Minimum Data Set (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 observation, record review and interviews during the recertification survey conducted from [DATE] through [DATE], the facility did not ensure drugs and biologicals used in the facility were stored, and labeled in accordance with currently accepted professional principles, on 2 of 4 medication carts. Specifically, the facility did not ensure medications (floor stock bottle of Colace) on 1 of the 2 medication carts on the North/East (NE) Unit, and medications (opened insulin pens and an unrefrigerated bottle of insulin) on the South/West (SW) Unit were stored in accordance with facility policy and accepted professional standards. This was evidenced by: The policy and procedure (P&P) titled Medication Storage, dated 1/2019, documented expired, discontinued and/or contaminated medications would be removed from the medication storage areas, and disposed of in accordance with facility policy. The policy also documented that medication would be stored at the appropriate temperature in accordance with 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, record review, and interviews during the recertification survey dated 10/31/2023 through 11/06/2023, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen. Specifically, two (2) of 3 food temperature thermometers were not calibrated to 32 degrees Fahrenheit (F) when tested in a standard ice-bath method; the thermometers registered 37F and 37F; the slicer, microwave oven, kitchen door, dining room, wall around the keypad from the dining room, and mop room floor were soiled with food particles, and/or dirt: and the facility did not have the correct test kit to check the concentration of sanitizing solution used to manually sanitize food contact surfaces. This was evidenced as follows: During observations of the main kitchen on 10/31/23 at 9:32 AM, 2 of 3 food temperature thermometers were not calibrated to 32 degrees Fahrenheit (F) when tested in a standard ice-bath method the thermometers registered 37F and 37F. The following items were soiled with food…

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, the facility did not ensure comprehensive person-centered care plans were developed, and implemented for 2 (Resident #'s 5, and #47) of 2 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #5, the facility did not ensure oxygen (O2) was being provided at 2 liters via nasal cannula (2LNC) as ordered by the physician between 10/31/2023 through 11/02/2023; and for Resident #47, a pillow was not placed under their left side while in bed to discourage them from leaning on 10/31/2023, 11/02/2023, and 11/03/2023. This was evidenced by: The policy and procedure (P&P) titled Care Plans - Comprehensive, revised 10/2019, documented the CCP included measurable objectives, and timetables to meet the resident's physical, psychosocial, and functional needs, and was developed, and implemented for each resident. Resident #5 Resident #5 was admitted to the facility with diagnoses of chronic obstructive pulmonary…

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 and abbreviated survey (Case #NY00261136) the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 7 (Resident #'s 2, 10, 40, 44, 71, 220, and 272) of 22 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #2, the facility did not ensure a care plan was developed to address the resident's dental care; for Resident #10, did not ensure the CCP for wound care and pain management was implemented, and ensure the CCP for ADL care had resident specific interventions; for Resident #40, did not ensure a CCP for depression and anxiety contained resident specific non-pharmacological interventions; for Resident #44, did not ensure the CCP for Activities of Daily Living's intervention to provide supervision and setup for personal hygiene was implemented; for Resident #71, did…

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, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #'s 10, 19, and #44) of 5 residents reviewed for ADLs. Specifically, for Resident #10, the facility did not ensure the resident was provided assistance necessary to maintain good personal hygiene daily or was consistently transferred out of bed per resient prefernce; for Resident #19 did not ensure the resident, who was unable to carry out ADLs, received weekly showers to maintain good personal hygiene; and for Resident #44, did not ensure the resident, who was unable to carry out ADLs, received peri care daily with morning and evening care. This is evidenced by: The Policy and Procedure (P&P) titled ADL - Personal Hygiene dated 10/2019, documented appropriate care and services will be provided for residents who are…

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 a recertification survey and abbreviated survey (NY00281118) on 8/16/2021, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #s 4 and 47) residents of 22 residents reviewed for Quality of Care. Specifically, for Resident #4, the facility did not ensure that physician orders for a urinalysis and a urine culture and sensitivity were obtained from 7/24/21 through 7/30/2021 when the resident was transferred to the hospital for a change in condition and diagnosed with a urinary tract infection. For Resident #47 the facility did not ensure that physician orders for the application of [NAME] wraps and protective heel boots to the resident's right lower extremities was implemented. This was evidenced by: The Policy & Procedure (P&P) titled Urinary Tract Infection and dated 12/2019 documented It is the policy of the faciity to provide the highest…

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 during the recertification survey, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept in good repair and equipment is to be kept clean. Specially, food and non-food contract surfaces were not kept clean and/or in good repair. This is evidenced as follows. The main kitchen and kitchenettes were inspected on 09/08/2021 at 9:15 AM. In the main kitchen the meat slicer, can opener, stove top, oven, food preparation table, electrical outlets under the food preparation tables, and walls behind the grill line and the ice machine were soiled with grease or food particles, and the gasket on the door of the ice machine was ripped. The Director of Food Service stated in an interview on 09/08/2021 at 10:00 AM, that he will clean the food and non-food contact surfaces in the kitchen and replace the ripped gasket on the ice machine. The Administrator stated in an interview on 09/09/2021 at 2:55 PM, that the facility will…

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

Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00261136, NY00281118), the facility did not ensure a quality assurance and performance improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. Specifically, the facility had repeat deficiencies from the previous two recertification surveys (September 2018 & September 2019) in the areas of quality of care (F684), development and implementation of comprehensive care plans (F656), Food procurement (F812) and maintaining resident records (F842) and the facility had a repeat deficiency from one recertification survey from the previous recertification survey (September 2019) in the area of Safe/clean/comfortable and home like environment (F584), and there was no evidence there was a QAPI plan in place to meet the specific needs of the facility. The facility Policy & Procedure (P&P) titled, Quality Assurance and Performance Improvement Plan dated 9/20, docuemnted it would establish and implement plans to correct deficiencies…

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 reviews and interviews during a recertification survey, the facility did not ensure 1 (Resident #63) of 4 residents reviewed were treated with dignity and respect in an environment that maintained or enhanced their quality of life. Specifically, for Resident #63, the facility did not ensure the resident was treated with dignity and respect when staff talked on personal cell phones and used inappropriate language while providing personal care and while in hallways on the unit. This is evidenced by: The Policy and Procedure (P&P) titled Quality of Life-Dignity dated 9/2019, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The P&P also documented staff shall speak respectfully to residents at all times, and demeaning practices and standards of care that compromise dignity of care are prohibited. Resident #63: Resident #63 was admitted to the facility with diagnosis of diabetes mellitus, atrial fibrillation, and malignant neoplasm of left kidney. The 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.

Based on observation, record review and interviews during the recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #10) of 4 residents reviewed for pressure ulcers. Specifically, for Resident #10, the facility did not ensure wound care was provided per physican orders and per professional standards of practice. This is evidenced by: Resident #10: Resident #10 admitted to the facility with diagnoses of osteomyelitis of sacral area, pressure ulcer of the sacral region, and pressure ulcer of the right hip. The Minimum Data Set (MDS- an assessment tool) dated 6/11/21, documented the resident had four Stage 4 pressure ulcers (pressure ulcers that expose underlying muscle, tendon, cartilage or bone) and one Unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). A facility Policy & Procedure for wound care was…

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 recertification survey, the facility did not ensure the resident's environment remained as free of accident hazards as was possible for 1 (Resident #2) of 5 residents reviewed for accidents. Specifically, for Resident #2, the facility did not ensure the resident's fall risk was reassessed and the root causes of the fall were determined after the resident, who had previously fallen multiple times, fell and sustained a skin tear to the right cheek requiring steri-strips (thin adhesive bandages) at 2:18 AM on 9/5/2021. This is evidenced by: Resident #2: Resident #2 was admitted to the facility with the diagnoses of anxiety disorder, psychotic disorder, and vascular dementia. The Minimum Data Set (MDS - an assessment tool) dated 8/31/2021 documented the resident had severely impaired cognition, could sometimes understand others and could make self-understood. The Policy and Procedure (P&P) for Accidents and Incidents dated 7/2020, documented the Nursing Supervisor/Charge Nurse, Unit Manager and/or the department Director or Supervisor…

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 a recertification survey, the facility did not ensure the medication regimen for one (Resident #272) of six residents reviewed for unnecessary medication, were free from unnecessary medication. Specifically, for Resident # 272, the facility did not ensure the resident's medical record included a clinical indication to support the use of an opioid pain medication (Oxycodone) was adequately documented and included documentation to support an increase in the frequency of Oxycodone (pain medication) from three times a day to four times a day. This is evidenced by: Resident #272: This resident was admitted to the facility with diagnoses of dementia without behavioral disturbance, anxiety, restlessness and agitation and aphasia. The Minimum Data Set (MDS-an assessment tool) dated 8/30/21, documented the resident had severe cognitive impairment, was rarely or never understood, and had disorganized thinking. The MDS documented the resident received opioid medications seven out of seven days, and the resident did not receive non-medication…

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 reviews during a recertification survey, the facility did not ensure each resident's drug regimen was free from unnecessary psychotropic drugs for one (Resident #272) of six residents reviewed for unnecessary medications. Specifically, for Resident #272, the facility did not ensure that non-pharmacologic interventions, documentation of behaviors, and effect of medication for an anti-anxiety medication were consistently documented in the medical record. Additionally, the facility did not ensure the resident's increase in lethargy and refusal to eat was documented in the medical record and reported to the MD after the resident received an increase in a psychotropic medication. The Policy & Procedure titled Behavior Management and dated 05/20, documented behavioral symptoms and approached should be placed in the resident-specific care plan and communicated in the shift-to-shift report. Residents on as needed psychoactive medication should have at least two non-pharmacological interventions tried prior to giving the medication. This should be recorded 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.