Rosewood Rehabilitation And Nursing Center

Based on observation, record review and interviews conducted during a survey, the facility did not ensure that drug records were in order, that an account of all controlled drugs was maintained and periodically reconciled in four (4) of four (4) narcotic books reviewed on Units one (1) and two (2), and that nurses were properly documenting narcotic administration. Specifically, (a) for the shift-to-shift staff signature form for controlled drugs, titled Controlled Drugs-Count Record, did not consistently include the signatures of staff members at each shift change, validating the correct narcotic count; (b) Licensed Practical Nurse #8 did not document the administration of narcotics to Resident #5 at the time of administration.This is evidenced by: An undated facility policy titled Controlled Substances, documented that the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Additionally, nursing staff must count controlled medications at the end of each…

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, resident and staff interviews, review of facility policies and procedures, staffing records, resident records, accident and incident reports, and the facility's maintenance records during a survey, it was determined the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements, which affected or had potential to affect all residents in the facility. These failed practices directly impacted 35 of 35 residents sampled (Resident #s 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 14, 19, 25, 29, 31, 32, 33, 34, 35, 43, 44, 49, 50, 52, 53, 61, 64, 67, 70 , 72, 75, 80, 82, 90). Specifically, the lack of effective oversight and planning on the part of facility administration had the potential to adversely affect the health and safety of all residents residing in the facility. This is evidenced by: Deficiencies related…

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, it was determined the governing body did not establish and implement policies regarding the management and operation of the facility. The governing body did not maintain a consistent Administrator who was responsible for the management of the facility to ensure regulatory compliance. Specifically, multiple deficiencies were identified on the recertification survey including repeat deficiencies in the areas of safe/clean/comfortable/homelike environment(F584), develop/implement comprehensive care plan(F656), care plan timing and revision (F657), and Influenza and pneumococcal immunizations (F883).This is evidenced by: Facility was cited for the following on recertification survey:F550 as it pertains to the facility's failure to resident dignity.F580 as it pertains to the facility's failure to notify providers and resident representatives about changes of condition.F584 as it pertains to the facility's failure to provide a safe, clean, comfortable and homelike environment.F600 as it pertains 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 observation, record review and interviews conducted during a survey, the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not develop written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, (a) the facility had repeat deficiencies in the areas of comprehensive care planning and implementation (F656), evaluation and revision of comprehensive care plans (F657), and providing flu and/pneumococcal immunizations (F883), cited during the recertification survey, completed on 6/23/2023, were implemented as indicated by the same deficiencies being issued on the current survey; (b) policies and documents provided by the facility were noted to be undated, improperly titled, were missing information, had outdated information and/or were not signed; (c) key Quality Assurance Performance…

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 that it developed, implemented, and maintained an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Specifically, for five (5) employees education records reviewed, one (1) employee received a comprehensive orientation with all the required educations. This is evidenced by: The Facility Assessment, dated 1/2026, documented under Staff training/education and competencies, the following topics, in addition to others, will be presented to staff: Communication, Resident Rights and facility responsibilities, Emergency planning, Person centered care, Dementia and behavioral management, substance abuse identification, trauma informed care/PTSD, proper body mechanics, Abuse, neglect, and exploitation, Infection control, Culture change, Required in-service training for nurse aides. In-service training must: Be enough to ensure the continuing competence 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 interview and record review during a recertification and Extended survey, the facility did not ensure that an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for five (5) of five (5) employee files reviewed, the facility did not provide mandatory training that outlines and informs staff of the elements and goals of the facility's Quality Assurance Performance Improvement program as part of its Quality Assurance Performance Improvement program.This is evidenced by:Cross reference: F726 The Facility Assessment, dated 1/2026, documented under Staff training /education and competencies, the following topics, in addition to others, will be presented to staff: Communication, Resident Rights and facility responsibilities, Emergency planning, Person centered care, Dementia and behavioral management, substance abuse identification, trauma informed care/PTSD, proper body mechanics, Abuse, neglect, and exploitation, Infection control, Culture change, Required in-service training for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the survey, the facility did not ensure that each resident received, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident for three (3) of 35 residents sampled (Resident #s 75, 85, 87) and residents residing in the facility. Specifically, (a) for Resident #75, the facility did not monitor or medicate the resident, causing multiple admissions to the hospital for constipation; (b) for Resident #85, the facility delayed testing and treatment of a urinary tract infection causing the resident to go to the hospital with urosepsis; and (c) no meaningful activities were provided to the facility residents, resulting in lack of mental stimulation. This is evidenced by: Cross Reference:Please refer to F550 as it pertains to the facility's failure to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the a survey, the facility did not ensure that physician notes were entered and maintained accurately according to professional standards for ten (10) (Residents #4, 13, 31, 33, 34, 53, 72, 75, 80, and 90) of ten (10) residents reviewed. Specifically, (a.) on 8/12/2025, Residents #4, 13, 31, 33, 34, 53, 72, 75, 80, and 90 dated 08/12/2025 had the same provider encounter note by Medical Director #1 entered into their electronic medical records erroneously;, (b.) Resident #13 had a provider visit encounter by Medical Director #1 in their electronic medical record for Resident #33 dated 12/17/2025 erroneously that was not signed until 01/04/2026; and (c.) Resident #75 had a provider encounter note dated 11/13/2025 was not signed by Nurse Practitioner #1 until 01/12/2026.This is evidenced by: The facility provided a policy titled Medical Provider Policy (undated and unsigned) that outlined the responsibilities of all providers. The policy medical services 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.

Based on observation and interviews conducted during a survey, the facility did not ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature. Specifically, for three (3) of three (3) meals reviewed (Breakfast meal 02/17/2026, Lunch meals on 2/13/2026 and 2/17/2026). Specifically, food was not served at a palatable and appetizing temperature during the breakfast meal 02/17/2026 and lunch meals on 02/13/2026 and 02/17/2026.This is evidenced by: Observation: During a meal tray sampling on 02/13/2026 at 1:06 PM, Resident #72's lunch tray was tested, and a replacement tray was provided with an extended wait time of 32 minutes from requesting. The lunch tray was tested for taste and temperature, and the results were as follows: coffee 119.3 degrees Fahrenheit, whole milk 49.1 degrees Fahrenheit, seafood casserole 125.5 degrees Fahrenheit, California blend vegetables 122.2 degrees Fahrenheit, and chocolate cake 68.5 degrees Fahrenheit. During a meal tray sampling on 02/17/2026 at 7:46 AM, Resident #67's breakfast tray was tested, and a replacement…

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 storage and preparation of food was maintained according to professional standards. Specifically, incidents of potential for contamination of finished food, improperly functioning thermometers, and improperly stored food were identified throughout the kitchen.This is evidenced by: During the initial kitchen tour on 2/11/2026 from 10:24 AM to 11:00 AM and the follow-up visits on 2/19/2026 between 11:00 AM and 2:30 PM, the following observations were made:One (1) of four (4) thermometers tested for accurate calibration was outside of acceptable range. When tested in ice water bath, the thermometer displayed 37 degrees Fahrenheit.Improper storage of food was identified in the following areas:In the walk-in refrigerator open bags of peperoni and hot dogs were found undated.In the walk-in freezer open bags of chicken, green beans, sausage patties and egg patties were found undated.In dry storage room eight (8) bags of English muffins were observed on the shelves. Product label…

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 a recertification and abbreviated survey (Case #s 598982 and 2586123), the facility did not ensure the resident representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for two (2) (Resident #'s 52 and 75) of two (2) residents reviewed. Specifically, (a.) for Resident #52, the resident's representative was not notified of a self-reported fall with injury on 8/05/2025; (b.) for Resident #75, the resident's representative was not notified of a resident-to-resident verbal/physical altercation on 6/22/2025, during the night shift. This is evidenced by: Cross-referenced to F609: Reporting of Alleged Violations The Policy and Procedure titled, Change in a Resident Condition or Status, revised 12/2019, documented the facility would promptly notify the representative of changes in the resident's medical/mental condition and/or status. Licensed nursing staff, which included either the nurse/unit…

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, the facility did not ensure residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) resident (Resident #52) of three (3) residents reviewed. Specifically, Resident #52, who remained in the facility after receiving covered services, was not provided with timely notification of at least two (2)-day notification of the termination of Medicare Part A services with completion of the required Notice of Medicare Non-coverage and Advance Beneficiary notice of Non-coverage form prior to the of the termination of Medicare Part A services.This is evidenced by: Facility policy titled NOMNC & ABN (Notice of Medicare Non-Coverage and Advance Beneficiary Notice of Non-Coverage) (undated) documented the facility shall issue a Notice of Medicare Non-Coverage and/or an Advance Beneficiary Notice of Non-Coverage in accordance with Medicare requirements when skilled Medicare Part A services are ending or a service is expected to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during a survey, the facility did not ensure the resident's right to be free from abuse and neglect for two (2) (Resident #'s75 and 87) of nine (9) residents reviewed. Specifically, (a.) Resident #75 was not free from abuse on 6/22/2025, during the night shift when Resident #34 entered their room, verbally harassed them and then poured water from their water bottle onto them. No staff responded to Resident #75 when they yelled out for help and Resident #75 called 911; (b.) Resident #87 was not free from neglect when the resident fell on 1/13/2026 and it was not reported to the registered nurse. As a result, the oncoming licensed practical nurse was not informed of the fall. When the family member called the facility in response to the resident's concern for refracture of their hip, the licensed practical nurse told the family member the resident did not fall and was lying. The family member called 911 and the resident was taken to the hospital. This is…

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 recertification survey, the facility did not ensure that resident received respiratory care according to professional standards for one (1) (Resident #43) of three (3) residents reviewed. Specifically, Resident #43's continuous positive airway pressure machine (aka CPAP, used to treat sleep apnea) was not administered on 01/11/2026, 01/12/2026, 01/23/2026, 02/06/2026, or 02/12/2026, and their continuous positive airway pressure machine was not maintained on 01/11/2026, 01/12/2026, 01/23/2026, 02/01/2026, or 02/12/2026.This is evidenced by: Policy and procedure titled, continuous positive airway pressure machine/Bilevel positive airway pressure support, revised 01/2026 documented:Purpose To provide spontaneous breathing resident with continuous positive airway pressure To improve arterial oxygenation in resident with obstructive sleep apnea To promote residents comfort and safetyPreparation Only qualified and appropriately trained nurse or respiratory therapist should administer continuous positive airway pressure…

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 recertification survey, the facility did not ensure that accurate staffing information based on payroll data was correctly submitted to Centers for Medicare & Medicaid Services. Specifically, during Fiscal Quarter 4 (July 2025 through September 2025), payroll data submitted to Centers for Medicare & Medicaid Services indicated that less than eight (8) hours of consecutive Registered Nurses were available in the facility on 7/19/2025, 7/23/2025, 7/25/2025, 7/28/2025, 7/29/2025, 7/30/2025, 8/02/2025, 8/03/2025, 8/09/2025, 8/10/2025, 8/16/2025, 8/31/2025, 9/01/2025, and 9/13/2025. Inspection of timecards and internal facility reports documented that submitted data did not capture hours worked by Director of Nursing #1.This is evidenced by: The Centers for Medicare & Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal, Long Term Care Facility Policy Manual version 2.7 dated 06/2025 documented Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing…

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 survey, the facility did not ensure each resident was offered pneumococcal and influenza immunizations and received education regarding the benefits and potential side effects of the immunizations for one (1) (Residents #25) of four (4) residents reviewed. Specifically, there was no documented evidence Resident #25 was offered, declined, or educated on the pneumococcal or influenza immunizations, and did not complete the tuberculosis testing required as required.This is evidenced by:A facility policy titled admission policy and dated 8/2018, documented in pertinent part that when a resident was admitted to the nursing unit, the Nurse must record data (as each may apply) in appropriate place in the record (paper) or electronic health record. The recorded information listed included (p.) notation of any signs or symptoms of an infectious or communicable disease; (q.) Immunization history, immunization required and tuberculosis testing. Resident #25 Resident #25 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 observation and interviews conducted during a recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the self-closing device on the Walk-in freezer was not functioning as intended.This is evidenced by: During observations on 2/17/2026 at 11:00 AM as part of inspection of the walk-in freezer, the self-closing mechanism on the main entry door was inoperable and not pulling the door closed to ensure a tight seal.During an interview on 2/17/2026 at 2:00 PM, Food Service Director #1 stated that the company was just there several days ago and left several items in disrepair and they would contact them and have it addressed. 10 New York Codes, Rules, and Regulations 415.5(e)(1)(2)

Based on record review and interviews conducted during a survey, the facility did not ensure that in-service training for nurse aides was sufficient to ensure the continuing competence of nurse aides and be no less than 12 hours annually to include dementia care and abuse. This was identified for 11 of 14 Certified Nurse Aides (Certified Nurse Aides #'s 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 14) reviewed for nurse aide training. Specifically, the facility was unable to provide evidence that Certified Nurse Aide #s 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 14 were provided 12 hours of mandatory annual training.This is evidenced by: The facility assessment, dated 1/2026, documented that the following topics, in addition to others, would be presented to staff: Communication, Resident's Rights and Facility Responsibilities, Emergency Planning, Person-Centered Care, Dementia and Behavioral Management, Substance Abuse Identification, Trauma Informed Care, Proper Body Mechanics, Abuse, Neglect and Exploitation, Infection Control, and Culture Change. Additionally documented was that required…

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 and abbreviated survey conducted from 06/26/2023 - 06/30/2023, the facility did not ensure residents were informed both orally and in writing, of their rights and rules and regulations governing resident conduct and responsibilities during the resident's stay for residents on 2 (North and South) of 2 Units reviewed for residents' rights. Specifically, the facility did not ensure resident rights were provided or reviewed during monthly Resident Council meetings. This is evidenced by: An undated Policy and Procedure titled Guidelines: Resident Council provided during the recertification survey on 6/26/2023 documented the following: 1. Every facility will conduct a general monthly resident council meeting as per Centers for Medicare and Medicaid Services (CMS). 2. All residents will be invited to attend and be afforded the opportunity to express issues/concerns related to their care. 3. It is recommended that resident elections be held in January and DNR and Health Care Decisions and Residents Rights…

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 5 (Resident #'s 45, 46, 61, 62, and 68) of 18 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident's #45, 46, and 68 the facility did not ensure an antipsychotic medication care plan was developed and implemented for Risperdal (an antipsychotic medication); Specifically, for Resident #61 the facility did not ensure a CCP for dementia with behavioral disturbances that included measurable goals and resident specific interventions was developed and implemented; Specifically, for Resident #62, the facility did not ensure the CCP included resident specific goals and interventions to address dialysis care. This is evidenced by: The Policy and Procedure (P&P) titled Care Planning Process and Baseline, dated 8/2022, documented each resident's CCP was designed to incorporate identified problem areas,…

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 interviews during a recertification survey, the facility did not ensure Comprehensive Care Plans (CCP) were reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions for 6 (Resident #'s 25, 27, 30, 45, 46, and #61) of 18 residents reviewed. Specifically, for Resident #25, the facility did not ensure the CCP for psychotropic medication was reviewed and revised with the comprehensive assessment, for Resident #27 the facility did not ensure the CCP for nutrition was reviewed and revised with the comprehensive assessment, for Resident #30, the facility did not ensure the CCP for Risk for Abuse and Resident Preferences were reviewed or revised quarterly, for Resident #46, the facility did not ensure the CCP for depression, antidepressant medications, and altered mood status were reviewed quarterly, for Resident #61, the facility did not ensure the CCPs for communication, advanced…

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 residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 4 (Resident #'s 25, 45, 46, and #68) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #25, the facility did not ensure an antipsychotic medication (Risperidone, a drug used to treat schizophrenia, bipolar disorder, and irritability caused by autism) was ordered for a clinically indicated medical diagnosis, for Resident #45, the facility did not ensure an antipsychotic medication (Risperidone, a drug used to treat schizophrenia, bipolar disorder, and irritability caused by autism) was ordered for a clinically indicated medical diagnosis (was ordered for dementia with agitation), for Resident #'s 46, the facility did not ensure Risperidone, an antipsychotic drug used to treat…

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 recertification survey, the facility did not ensure it provided separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility used single unit package drug distribution systems in which the quantity stored was minimal and a missing dose could be readily detected for 1 (South Unit) of 2 units reviewed. Specifically, the facility did not ensure that only authorized personnel were permitted access to the locked, permanently affixed narcotic storage box inside the refrigerator of the South Unit medication storage room. This was evidenced by: The facility policy titled Storage of Controlled Substances revised 12/22/2022, effective date 1/4/2023 documented, Drugs listed in Schedule II, lll, lV and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 and any State specific…

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 during the recertification survey, the facility did not ensure each resident was offered influenza and/or pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 (Residents #10 and #61) of 5 residents reviewed. Specifically, the facility did not ensure Resident #10 was offered, declined or educated on the influenza and pneumococcal immunizations, and the facility did not ensure Resident #61 was offered, had declined or was educated on the influenza immunization. This was evidenced by: The facility policy titled Resident & Employee Health/Immunizations undated, documented the purpose of this policy is to protect the health and safety of residents, employees, family members, and the community as a whole by providing consistent testing and immunization standard for all Health Care Personnel. The facility did not provide policy and procedures for influenza or pneumococcal immunizations. Resident #10: Resident #10 was admitted to the facility with diagnoses of depression,…

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

Based on interviews and record review during a recertification survey, the facility did not develop baseline care plans for 12 (Resident #'s 1, 19, 21, 35, 39, 42, 43, 53, 63, 64, 68, and #71) of 12 residents reviewed. Specifically, for Resident #'s 1, 19, 21, 35, 39, 42, 43, 53, 63, 64, 68, and #71 the facility did not ensure a baseline care plan that included instructions needed to provide resident care was developed within 48 hours of the residents' admission. This is evidenced by: The Policy and Procedure (P&P) titled Care Planning Process and Baseline, last reviewed 7/2020, documented the nurse will create from the assessment a baseline care plan. The Interdisciplinary Team (IDT) will review at Clinical Morning Meeting to further enhance and specialize the baseline care plan for all care needs related to the individual resident within 48 hours. The resident or responsible party will receive a copy. There will be documentation in the electronic medical record (EMR) that the baseline care plan was provided to the resident or responsible party and the method it was 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.

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care; providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. Specifically, for Resident #'s 34 & #46, the facility did not ensure two staff members competency in skills and techniques necessary to care for residents' needs for wound care and infection control were demonstrated and evaluated. This is evidenced by: The findings are: Resident #34 Resident #34 was admitted to the facility with diagnoses of cerebral infarction with hemiplegia and hemiparesis, depression, and stage IV pressure ulcers. The Minimum Data Set (MDS- an assessment tool) dated 10/20/2021 documented the resident had two stage III pressure ulcers (full thickness skin loss) and two venous ulcers (leg ulcers caused by problems with…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition to protect the integrity of the contents, toxic substances shall be labeled, food temperature thermometers shall be calibrated, equipment is to be in good repair, food contact surfaces shall be cleaned after use, and walls and floors are to be kept clean. Specifically, cans of food were dented; spray bottles were not labeled, food temperature thermometers were not in calibration; equipment was not in good repair; and food contact surfaces, walls, and floors were not clean. This is evidenced as follows. The main kitchen was inspected on 11/29/21 at 6:38 AM. One #10 can of stewed tomatoes found in the common stock had a V-shaped dent in the top seam. A spray bottle with pink liquid not labeled. One in-use thermometer was found out of calibration at 28 degrees Fahrenheit when checked by the standard ice-bath method. The gasket on walk-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 observation, record review and interviews during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP), that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs for 6 (Resident #s 3, 21, 35, 53, 58, and #67) of 23 residents reviewed for comprehensive care plans. Specifically, the facility did not ensure that CCP's were developed to address Resident #3's urinary catheter; Resident #21's impaired skin integrity; Resident #35's pain; Resident #53's psychotropic medication or hypothyroidism; Resident #58's edema and Resident #67's activities of daily living and pressure ulcers. This is evidenced by: Facility Policy and Procedure (P&P) titled Care Planning Process & Baseline revised 7/2020 documented the comprehensive care plan (CCP) should incorporate identified problem areas and risk factors, reflect resident's wishes and treatment goals with timetables and measurable outcomes, and is revised as information about the 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, record review and interviews during the recertification survey and abbreviated survey (Case #NY00282450), the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 2 (Resident #'s 34 and #67) of 4 residents reviewed for pressure ulcers. Specifically, for Resident #34, the facility did not ensure wound care was provided as ordered by the physician and per professional standards of practice, for Resident #67, who did not have skin breakdown upon admission to the facility, the facility did not ensure the resident's risk for skin breakdown was evaluated, did not evaluate the need for preventative interventions to avoid skin breakdown and did not ensure treatment for a newly discovered pressure sore was started until 6 days post discovery on 11/29/2021. This is evidenced by: The Policy and Procedure P&P titled, Pressure Ulcer Treatment, dated 6/18, documented the steps in the procedure for wound care were: check the treatment administration record and obtain necessary…

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 and abbreviated survey (Case #s NY00282450 and NY00278611 and NY00279874), the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 7 (Resident #'s 1, 21, 23, 34, 46, 67, and #70) of 23 residents reviewed. Specifically, for Resident #1, the Treatment Administration Record (TAR) dated November 2021 did not accurately reflect the provision of wound care, and did not ensure the treatment accurately reflected the physician orders, for Resident #21, the facility did not ensure daily wound care to the bilateral below the knee amputation (BKA) wounds were accurately documented, for Resident #23, the Medication Administration Record (MAR) dated November 2021 did not accurately reflect the provision of medications, for Resident #34, the TAR dated 11/2021 did not accurately reflect the provision of wound care and did not ensure the documented treatments accurately reflected the physician orders, for 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, interview and record review during a recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #'s 34 and #46) of 3 residents reviewed for wound care. Specifically, for Resident #34, the facility did not ensure facility staff cleansed scissors after using them to remove a contaminated dressing and prior to using the scissors to cut a wound packing, and did not place a contaminated item in a multi-resident use treatment cart. Additionally, for Resident #46 the facility did not ensure a facility staff member performed hand hygiene after doffing soiled gloves and prior to donning clean gloves, or between wounds. The findings are: The Policy and Procedure P&P titled, Pressure Ulcer Treatment, dated 6/18, documented the steps in the procedure for wound care were: Check the treatment administration record and obtain necessary…

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.