The Hurlbut

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure each resident with pressure ulcers (ulcers on the skin due to prolonged pressure) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for two (2) (Residents #43 and #95) of three (3) residents reviewed. Specifically, for Resident #43, staff did not follow physician's orders when completing a pressure ulcer treatment. For Resident #95, there was a lack of consistent weekly pressure ulcer assessments (including staging, measurements, or a description of the wound) and ongoing monitoring of a left medial ankle pressure ulcer. Additionally, assessments completed for Resident #95 had conflicting documentation to include treatment instructions and location of the pressure ulcer. The findings are:The facility policy Medication Orders, dated September 2011, documented each resident must…

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 interviews and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure pharmacist reported irregularities were reviewed by the attending physician and acted upon timely for two (2) (Residents #69 and #77) of five (5) residents reviewed. Specifically, the facility could not provide documentation supporting the consultant pharmacist's monthly recommendations were acted upon by the facility's Medical Director, attending physicians, or designees. For Resident #77 the facility could not provide evidence the Director of Nursing or an attending physician had reviewed the consultant pharmacist's recommendations for ten (10) of twelve (12) months reviewed, and for nine (9) of twelve (12) months reviewed for Resident #66. The findings are: The facility policy Pharmacy Services, dated November 2017, included the pharmacist would conduct a monthly drug regimen review for each resident in the facility. The pharmacist would report any irregularities (drugs…

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 07/24/2025 to 07/31/2025, for one (1) (Resident #52) of two (2) residents reviewed, the facility did not ensure a resident's environment remained as free of accident hazards as possible. Specifically, there were multiple observations of a bottle of pills labeled as zinc (a supplement that helps the immune system and metabolic function) left at Resident #52's bedside and there were no medical orders in place for the medication or to self-administer (the practice of an individual taking their own prescribed or over-the-counter medications independently, without direct assistance or supervision) the medication. Additionally, there was no documented evidence the resident had been reviewed by the interdisciplinary team for their ability to safely self-administer the medication or a comprehensive care plan in place to include measurable goals and interventions, for self-administration. The findings are:Review of the facility policy Self-Administration of Medications, dated 10/20/2024,…

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 07/24/2025 to 07/31/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, raw shell eggs were stored above ready to eat foods, there was bare-hand contact with ready to eat food, and there was a missing section of floor tile that was dirty. The findings are: Review of the undated facility policy Food Storage (item #11e - refrigerated storage) included cooked foods must be stored above raw foods to prevent contamination. Raw animal foods should be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers.During an observation on 07/24/2025 at 8:55 AM, there was a cardboard box with crates of raw shell eggs stored on the third shelf of a wire storage rack directly above a pan with plastic wrapped thin-sliced ready to eat meats (ham and salami) inside the walk-in cooler in the main kitchen. During 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 observations, interviews, and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not establish and maintain 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 two (2) (Residents #43 and #95) of three (3) residents reviewed for pressure ulcers. Specifically, Resident #43 was on enhanced barrier precautions (techniques used to prevent transmission of infectious disease utilizing gloves and gowns with all high-contact care) and staff were observed providing wound care without the appropriate personal protective equipment (gown). Resident #95 did not have enhanced barrier precautions signage outside their room and staff were observed providing hands on care without appropriate personal protective equipment (gown and gloves). Additionally, there was lack of hand hygiene and glove changes during wound…

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 the Standard Recertification Survey, it was determined that for three (Employees #1, #2, and #5) of six recently hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and/or misappropriation of resident property related to screening of prospective employees. Specifically, a nurse aide registry abuse screening was not completed for recently hired employees prior to starting work. The findings are: A review of the undated facility policy titled: Abuse, Neglect and Mistreatment Prohibition, Investigation, and Reporting included that all staff that are being considered for hire must also be checked with the New York State Nurse Aide Registry (Prohibition/Prevention Procedures, Section 3). On 2/14/24 from 8:30 AM to 9:48 AM, recently hired employee files were provided to the surveyor for review and included the following: Employee #1 was hired on 8/21/23 as the Dietary Director and the nurse aide registry screen for prior abuse findings was not completed until 8/30/23.…

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 interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: On 2/13/24 from 8:35 AM to 11:50 AM the surveyor was provided with facility preventative maintenance, testing, and inspection records. A review of these records did not include testing documentation for carbon monoxide detectors located throughout the facility. During an interview on 2/13/24 at 10:21 AM, the Director of Environmental Services stated that there is a sticker on the carbon monoxide detector to show the date tested. The Director of Environmental Services further stated that they would ask the Maintenance Worker if they keep a log of testing. During an interview on 2/13/24 at 10:30 AM, the Maintenance Worker stated that…

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, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, one of who much be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide evidence that the Infection Preventionist attended the Quality Assurance Improvement Performance meetings on a regular basis. This is evidenced by the following: Review of the facility's Quality Assurance and Performance Improvement meetings last three Sign-In Sheets dated 8/8/23, 10/17/23 and 1/23/24 did not include the presence of the Infection Preventionist. During an interview on 2/16/24 at 2:19 PM, The Administrator stated the Quality Assurance and Performance Improvement Committee meetings are held quarterly and members in attendance included departmental leadership, the Medical Director, the Director of Nursing, and the Administrator.…

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 interviews and record review conducted during the Recertification Survey it was determined that for one (Residents #67) of five residents reviewed for immunizations, the facility was unable to provide documentation that the resident who was eligible had been offered, declined, and/or educated on the pneumococcal immunization or had received it prior to admission. This is evidenced by the following. The facility policy, Resident Influenza and Pneumococcal Vaccine, dated November 2023, included that each resident (upon admission) will be offered the pneumococcal vaccine and the influenza vaccine. Before offering the vaccines each resident/resident representative will receive education and information regarding the benefits and potential side effects of the immunizations. Resident #67 was admitted to the facility over two years ago and had diagnoses that included malnutrition, chronic obstructive lung disease and chronic pain. The most recent Minimum Data Set Resident assessment dated [DATE] revealed…

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

Based on observations and interviews, and conducted during the Recertification Survey completed on 5/13/22, it was determined that for one of one main kitchen, the facility did not store, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a storage unit containing potentially hazardous foods was not maintained in good repair, a refrigeration unit had a damaged seal, a handwash sink was not accessible, and a ceiling fan and tiles were dirty. This is evidenced by the following: 1. During the initial brief tour of the main kitchen on 5/9/22 from 8:45 a.m. to approximately 9:15 a.m., observations and interviews included the following: a. A 'curtain cooler' (portable one door refrigeration unit) used for production beverages was inoperable with regard to refrigeration, and the door did not latch closed. Trays with milk and other beverages were observed within this cooler and the temperature of chocolate milk in a cup was 59 degrees Fahrenheit (°F). During an interview at this time, the Food Service Director (FSD) stated that 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, interviews and record review conducted during the Recertification Survey conducted 5/9/22 to 5/13/22, the facility did not establish and maintain 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 disease and infections. Specifically, three Certified Nursing Assistants (CNAs) did not apply the appropriate personal protective equipment (PPE) prior to entering and exiting resident's rooms that were on transmission-based precautions (TBP or quarantine) due to COVID-19 infections and/or exposures. This was evidenced by the following: The facility policy, R2 HCC Quarantine and Isolation Precautions COVID-19 Guidelines dated August 2021, under subtitles quarantine and isolation, documented that all staff are to comply with the recommendations of the CDC, and the Department of Health when using PPE. 1.In an observation on 5/9/22 at 10:09 a.m., CNA #1 (listed by facility…

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 a Recertification Survey completed 5/9/22 to 5/13/22 the facility did not ensure that all staff, except for those staff who have been granted exemptions to the vaccination requirements or staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the Centers for Disease Control and Prevention (CDC) have received, at a minimum, one dose of a single-dose vaccine or all doses of a multiple vaccine series prior to providing care/treatment/services for the facility and/or its residents. This resulted in a 94.1% COVID-19 staff vaccination rate. In addition, the facility had 13 residents who were currently positive for COVID-19 and had observations of noncompliant infection control practices by staff. This was evidenced by the following: The Centers for Medicare & Medicaid Services (CMS) Quality Safety & Oversight (QSO) memorandum 22-07-ALL, Long-Term Care and Skilled Nursing Facility Attachment A, posted 12/28/21 and revised 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.