Kirkhaven

Based on interviews and record review conducted during the Recertification Survey conducted from 12/02/2024 to 12/09/2024, the facility did not refer the resident who had an intellectual disability to the appropriate state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) for recommendations for one (Resident #115) of two residents reviewed. Specifically, the resident had a letter from the admitting hospital documentation that the resident required a full Level II assessment (referral process for individuals who were known or suspected of having serious mental illness for care planning recommendations) prior to admission or when a significant change occurred. Consequently, Resident #115 received no Level II referrals or services if needed. Findings include: The facility's revised SCREEN/ PASRR policy, dated 12/13/2018, documented for prospective residents a Level II assessment, based on screen indicators completed by the referring hospital or agency, admissions would request results of the assessment, and once obtained from the hospital or…

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

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #4) of two residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standard of practice, and the resident's care plan, goals, and preferences. Specifically, Resident #4 was observed intermittently wearing oxygen via a tracheostomy (a surgically created opening in the neck and into the windpipe to breathe through) collar (a soft plastic mask used to deliver oxygen to a person with a tracheostomy tube). There was no physician's order in place for supplemental oxygen use or documentation in the resident's medical record that reflected the use and care of the oxygen. Additionally, the facility was unable to provide evidence that nursing staff had been educated or trained to care for Resident #4's Airvo machine (machine that provides humidified high flow oxygen). This is evidenced by the following: The facility Airvo 2 policy, dated June 2024, included (but…

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 the Recertification Survey from 12/02/2024 to 12/09/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were multiple undated food items not in their original containers and a food item was stored uncovered. The findings are: The undated facility policy titled Prepared Foods and Leftovers documented the maximum storage time for refrigerated prepared food items and leftovers was 72 hours and any foods stored beyond that date were to be discarded. Observations in the main kitchen on 12/02/2024 at 8:50 AM, and in the presence of the Food Service Director/Registered Dietitian #2, included the following: - The breakfast preparation cooler contained one undated two-quart container of cooked pureed eggs, one undated pan of cooked bacon, and one undated pan of cooked pancakes. - The cold production cooler contained 8 undated dishes of pumpkin souffle and one uncovered metal bowl of undated vanilla…

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

Based on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, for three (Residents #36, #41, #42) of eight residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #41 had their blood sugar checked by a nurse not wearing gloves. Resident #42 was on enhanced barrier precautions (a strategy used by nursing homes to decrease transmission of infectious disease) and received high-contact care from staff not wearing the required personal protective equipment, and infection control practices were not followed during the care of a cholecystostomy (a procedure that creates a surgical opening of the gallbladder to drain it) site. Resident #36 was on enhanced barrier precautions, had an indwelling urinary catheter, and received high-contact care from staff who were not wearing the required personal…

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 Recertification Survey from [DATE] to [DATE], for one (Resident #127) of 36 residents reviewed, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, the facility did not ensure Residents #127's advance directive identifiers were consistent with the resident's wishes. This is evidenced by the following: The facility policy Advanced Directives and Code Blue, dated [DATE], included an advanced directive should be maintained in the resident's medical record and should the resident wish to review or revise their advanced directive, the Social Service/Nursing/Designee would be contacted to assist the resident if necessary. All follow-up education…

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

Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for two (Residents #4 and #53) of six residents reviewed, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs including resident goals, desired outcomes and preferences related to their ongoing smoking habits. Specifically, the facility was aware that Residents' #4 and #53 continued to smoke against facility policy and there was no care plan in place to ensure the residents remained safe. This is evidenced by the following: 1. Resident #4 had diagnoses that included chronic respiratory failure, anxiety, and a tracheostomy (surgically created hole in the windpipe that provides alternative airway for breathing). The Minimum Data Set Resident Assessment, dated 09/23/2024, revealed Resident #4 was cognitively intact and used a wheelchair. Review of the Smoking Assessment Policy and Assessment form, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that residents received care in accordance with professional standards of practice, their person-centered care plan, and resident's choice for 2 (Residents #53 and #81) of 29 residents reviewed for quality of care. Specifically, Resident #53 was not wearing a physician ordered compression wrap following a recent amputation of their right lower extremity on multiple observations. Resident #81 had multiple falls, one resulting in a major injury, and there was no documented evidence that the resident had been assessed by a Registered Nurse or that neurological checks had been completed following a fall with a potential head injury. This is evidenced by the following: The facility's undated Resident Fall Policy documented that prior to moving a resident after a fall, the Registered Nurse/Licensed Practical Nurse must assess/evaluate the resident for physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #11) of two residents reviewed for communication, the facility did not ensure the resident received treatment and/or assistive devices to maintain their hearing. Specifically, the facility did not ensure the resident's hearing aids were repaired in a timely manner. This is evidenced by the following: Resident #11 had diagnoses that included auditory hallucinations, high blood pressure, and depression. The Minimum Data Set Resident Assessment documented Resident #11 was cognitively intact, was hard of hearing, and wore hearing aids. During an observation and interview on 12/02/2024 at 10:00 AM, Resident #11 was not wearing either hearing aid. Resident #11 stated at this time they could not hear unless voices were raised as they normally wore hearing aids, but had not had them for the last two months because they were broken. The Comprehensive Care Plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00361034) from 12/02/2024 to 12/09/2024, the facility did not ensure acceptable parameters of nutritional status for one (Residents #127) of five residents reviewed. Specifically, nutritional assessments by a registered dietician were not performed during Resident #127's initial and readmission to the facility and documented weight losses were not identified timely. This is evidenced by the following: The undated facility policy Nutrition Assessment included that a registered dietician would perform a comprehensive nutrition assessment on residents to determine their risk for malnutrition or nutrition-related problems. A nutrition assessment would be completed on all residents on admission, annually, quarterly, and as needed. The assessment would include (but not limited to) review of documented weights, weight histories as available, clinical factors, and interviews with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the Recertification Survey and complaint investigation the facility did not ensure a resident who displays or is diagnosed with dementia, received the appropriate services to maintain their highest practicable mental and psychosocial well-being for two (Residents #34 and #89) of five residents reviewed for dementia care. Specifically, Resident #34 had a diagnosis of dementia and did not have individualized interventions in place to guide direct care staff in managing behavioral symptoms. Resident #89 who had a history of dementia and behaviors sexual in nature was not appropriately care planned to include interventions to prevent further occurrences. Findings include: 1. Resident #34 had diagnoses that included dementia, repeated falls, and muscle weakness. The 07/30/2024 Minimum Data Set Resident Assessment documented the resident had severely impaired cognition, wandered daily, ambulated with a walker, and required supervision/ touching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #22) of five residents reviewed for nutrition, the facility did not ensure food was prepared in a consistency to meet the residents needs per speech-language pathologist recommendations and physician orders. Specifically, Resident #22 had a history of dysphagia (difficulty swallowing), was on a mechanical soft diet (a diet that consists of easy to chew and swallow foods), and received a food item that was not appropriate on a mechanical soft diet. Additionally, Resident #22 was not care planned for a risk of aspiration (chance of food or liquids accidently inhaled into the lungs requiring close supervision with eating). This is evidenced by the following: The facility policy Modified Textured Diets, last revised 01/15/2024, included modified texture diets are offered based on facility and speech-language pathologist preference. Consult with the speech-language…

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 reviews conducted during the Recertification Survey, completed on 3/16/23, it was determined for four (Resident #49, #75, #303, and #307) of five residents reviewed for dialysis, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, physician orders and resident's goals and preferences. Specifically, the issues included: a. That the facility did not have evidence of total fluid intake monitoring for Resident #75 who was on a medically ordered fluid restriction, b. Did not ensure medications were administered as ordered by the physician on dialysis days for Residents #49, #75, #303, and #307. c. Did not have evidence of ongoing communication with the dialysis facility to include the resident's status prior to and post dialysis for Residents #49, #75, #303 and #307. d. Did not monitor or document Residents #75 and #303 dialysis catheter sites (vascular access used…

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

Based on observations, interview, and record review conducted during the Standard Recertification Survey completed on 3/16/23, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, or serve food in accordance with professional standards (U.S. Food and Drug Administration's Model Food Code) for food service safety. Specifically, a low-temperature, mechanical dish washing machine did not maintain an acceptable sanitizer concentration on dishes after the final rinse and had a leak. The findings are: 1. During the initial tour of the main kitchen on 3/9/23 from 8:50 a.m. to 9:35 a.m., it was observed that water was leaking from the vacuum breaker located at the top of the mechanical dish washing machine while the unit was running. Further observations included that when tested with the facility's chlorine test strips, the water on the top of a dish after the final rinse cycle showed a chlorine concentration of zero parts per million (ppm) after each of four full runs of the dish machine. The manufacturer nameplate located on the dish…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during the Recertification Survey completed on 3/16/23, it was determined that for one (Resident #303) of one reviewed for choices the facility did not ensure the resident's right to make choices about aspects of life that were significant to them. Specifically, the resident was not given the choice of bathing opportunities. This is evidenced by the following: Resident #303 was admitted to the facility on [DATE] with diagnoses including right femur fracture, diabetes mellitus, depression, and a pressure ulcer. The Minimum Data Set Assessment, dated 2/27/23, documented that the resident was cognitively intact, required extensive assistance with bathing and that type of bathing was very important to them. Review of Resident #303's current medical orders revealed skin observations with weekly shower every Monday. Review of Resident #303's current Comprehensive Care Plan and Certified Nursing Assistant (CNA) [NAME] (care plan used by the CNA for daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the Recertification survey and complaint investigation (NY00301678) completed on 3/16/23, it was determined that for one of six residents reviewed for abuse the facility failed to protect the residents right to be free from abuse. Specifically, Resident #353 was held down by multiple staff members and an injection was given against the resident's wishes. The resident was observed with bruising on both legs the following day which was believed to be caused by the incident. Resident #353 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, status post cerebral vascular accident (CVA) with aphasia and right sided monoplegia arm and hand contracture. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, had no hallucinations or delusions, no physical behaviors symptoms directed towards others, and had verbal behavioral symptoms directed towards others, and other behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review conducted during the Recertification survey and complaint investigation (#NY00301678) completed on 3/16/23, it was determined that for one of six residents reviewed for abuse the facility did not ensure that an incident of physical abuse was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #353 was held down by multiple staff and an antibiotic injection administered. The facility did not interview all staff involved and did not put measures in place to prevent further occurrence. Resident #353 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, status post cerebral vascular accident (CVA) with aphasia and right sided monoplegia arm and hand contracture. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, had no hallucinations or delusions, no physical behaviors symptoms directed towards others, had verbal behavioral symptoms directed towards…

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 completed on 3/16/23, it was determined that for one (Resident #49) of 5 residents reviewed for dialysis, the facility did not ensure that each resident was free from significant medication errors. Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the physician orders or acceptable professional standards of practice (principles which apply to professionals providing services. Accepted professional standards and principles include various practice regulations in each state, and current commonly accepted health standards, established by national organizations, boards, and councils). Specifically, antihypertensive medications were not administered prior to dialysis per the physician orders, and medical providers were not notified the medications were omitted for Resident #49. The finding is: The facility policy, Medication Administration/Documentation, revision dated 12/30/22 documented medications are administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during the Recertification Survey, it was determined for one of two residents reviewed the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan, goals and preferences. Specifically, Resident #77 did not have medical orders or a care plan for the administration and care of oxygen therapy. This is evidence by the following: Review of a facility policy, Oxygen Therapy, dated April 2020, directs oxygen may be administered to a resident in apparent respiratory distress or chest pain at a rate of one to two liters (L) per minute. All other oxygen treatment will require a physician order for amount in liters and frequency. Oxygen tubing and nasal cannula for residents on long-term oxygen use will be changed every seven days. Documentation of the change is recorded in the Treatment Administration Record (TAR). Resident #77 had diagnoses…

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

Based on observations, interviews and record review conducted during the Recertification Survey, it was determined for one of one resident reviewed, the facility did not ensure that, for a resident receiving dialysis, the services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for Resident #12, medical orders to monitor the dialysis catheter access site for complications and to notify the medical team if present were not documented as being done. This is evidenced by the following: Review of a facility policy, Dialysis, dated 3/9/20, directs that all residents who require hemodialysis will have established care standards including: to check the site every shift for bleeding and add to the Treatment Administration Record (TAR). Remove the dressing per dialysis instructions and add to the TAR. Any individualized interventions required for dialysis care will be included in the Comprehensive Care Plan (CCP). Resident #12 had diagnoses including end stage kidney disease…

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.