The Pearl Nursing Center of Rochester

Based on interviews and record review conducted during the Recertification Survey, for two (1st and 2nd floor units) of three residential care units reviewed, the facility did not ensure that an accurate reconciliation of all controlled substances (narcotic medications) was consistently completed. Specifically, the narcotic count logs which included reconciliation of narcotic medications at the end of each shift were not consistently signed to indicate the count had been done and the correct count of narcotic medications had been verified by two nurses. This was evidenced by the following: The facility policy Medication - Controlled Substances, dated April 2019, included that narcotics would be counted with two professional nurses and documentation that the count was completed and accurate would be completed at the beginning and end of each shift. Any discrepancy in a shift-to-shift count must be immediately communicated to the Director of Nursing. 1. Review of the second-floor south medication cart on 6/27/24 at 10:30 AM revealed that the Controlled Substance Inventory logs 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.

Based on observations and interview conducted during the Recertification Survey, the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment was not maintained in proper working condition. The findings are: Observations in the basement laundry room on 6/25/24 at 8:40 AM included one of two dryers and one of three washing machines were not functional. When interviewed at this time, a housekeeping/laundry staff member stated that all of the laundry is done in-house, and it would help to have them all working. 10 NYCRR: 415.29, 415.29(b), 415.29(c)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification Survey, the facility did not ensure that services were provided and/or arranged for the accepted standards of quality that should have been provided for two (Residents #9 and #70) of five residents reviewed. Specifically, lab services were not provided as recommended by pharmacy and ordered by the Physician. This is evidenced by the following: When requested, the facility was unable to provide any policies related to obtaining lab work or a blood draw protocol. 1. Resident #70 had diagnoses that included dysphagia (difficulty swallowing), pneumonitis (inflammation of lung tissue), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented the resident was moderately impaired cognitively and did not exhibit behaviors or refusals of care at that time. The current Comprehensive Care Plan revised on 2/16/24 revealed Resident #70 required tube feeding related to dysphagia and could not have foods or fluids by mouth. Nursing…

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 and complaint investigation (NY00313302), it was determined that for one (Resident #10) of six residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was no documented evidence that Resident #10 had received their antipsychotic medication (medications used to treat mental illness) on multiple days. This is evidenced by the following: Resident #10 had diagnosis that included paranoid schizophrenia (a type of mental illness), Crohn's disease (an inflammatory bowel disease), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented the resident had moderate impairment of cognitive function and no refusals of care or behaviors at that time. Physician orders dated 12/15/23 through 3/22/24 included clozapine 300 milligrams to be given at bedtime for chronic paranoid schizophrenia. Physician orders dated 1/2/24…

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 interview conducted during the Recertification Survey, it was determined that the facility did not properly dispose of garbage and refuse. Specifically, garbage and refuse were not contained within dumpsters and receptacles were not covered. The findings are: Observations during the exterior tour of the facility on 6/24/24 at 11:42 AM included three dumpsters with one uncovered located on the northwest corner of the property. Additionally, there was trash around and behind the dumpsters including, but not limited to: part of a lift chair, plastic gloves, various paper and plastic items, and an empty medication blister pack displaying a resident's name and drug information. During an interview following this observation, the Acting Director of Nursing was given the medication blister packet and stated that it should have been shredded, not put in the garbage. Observations on 6/27/24 at 9:24 AM included two of the three dumpsters were left with the covers open. 10 NYCRR: 415.29 (i)(1), 415.29(j)(6)(i), 415.14(h), Subpart 14-1.150

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and record review 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 6/24/24 at approximately 9:00 AM, a carbon monoxide detector was observed in the basement kitchen above the prep sink area, and the kitchen was also observed to contain a natural gas-powered range. Further observations in the basement included natural gas boilers in the boiler room and a natural gas-powered generator in the generator room. Observations on 6/26/24 from 10:46 AM to 11:05 AM included carbon monoxide detectors located on the walls in the corridor on the second floor outside resident rooms [ROOM NUMBERS]. On 6/26/24 at 10:39 AM, the surveyor requested a list of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during an Abbreviated Survey (complaint #'s NY00321305, NY00322131, NY00312328), it was determined that for three of three residents reviewed, the facility failed to ensure that the residents were free from significant medication errors. Specifically, Resident #3 did not receive multiple doses of Zonisamide (anti-seizure medication) and levothyroxine (thyroid hormone replacement medication). Resident #5 did not receive multiple doses of multiple medications including but not limited to Bactrim (antibiotic), Seroquel (an antipsychotic medication) and levothyroxine. Resident #6 did not receive multiple doses of valproate (anti-seizure medication). This is evidenced by: The undated facility policy Prescribing and Ordering of Medications, documented that for new/re-admissions, hand write all orders utilizing pre-printed admission Physician's Order Sheets or send orders electronically. The facility Policy on Medication Reordering, dated 6/2/21, documented when a…

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 an Abbreviated Survey (complaint #NY00320053, #NY00321305, and #NY00322131) it was determined that for three (first, second, and third floors) of three resident use floors the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, the telephone and fax systems were not functional or not functioning properly. The findings are: During an interview on 8/23/23 at 8:48 AM Certified Nursing Assistant CNA #1 stated that they do not have phones up here (third floor) and if they need help, they have to take the stairs to get help. CNA#1 stated that they had an emergency a little over a month ago and had to run downstairs to get the nurse. During an interview on 8/23/23 at 9:12 AM Director of Nursing (DON) #1 and the Assistant Director of Nursing (ADON) #1 stated that the FAX machine is not working and that the phones went out when there was a bad rainstorm, and they are now into month two with no phone system. The ADON also 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review conducted during an Abbreviated Survey (complaint investigations #NY00312328, #NY00320053, #NY00321305, #NY00322131) it was determined that for two (second and third floors) of three resident use floors the facility did not properly maintain the resident call system. Specifically, the nurse call systems were not functional.? The findings are:? During an interview on 8/23/23 at 8:37 AM Resident #4 stated that they have a tap bell, but no one ever comes, and it takes staff anywhere from one to two-hours to come to the room. Resident #4 also stated that staff yell out from nurse's station: who's ringing that bell and what do you want? During an interview on 8/23/23 at 8:48 AM Certified Nursing Assistant (CNA) #1 stated that the call lights have been broken for three to four-months. During an interview on 8/23/23 at 9:03 AM a representative from an outside vendor stated that they were installing wiring for the call lights and would probably be done tomorrow. This…

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 an Abbreviated Survey (complaints #NY00323332, #NY00322131) it was determined that for 2 (Residents #3 and #6) of 13 residents reviewed, the facility did not ensure that the residents received treatment and care in accordance with professional standards of practice and medical orders. Specifically, Resident #3 had insufficient monitoring of bowel function and a delay of treatment for complications and Resident #6 had insufficient monitoring and physician orders for bowel interventions were not followed in a timely manner. This is evidenced by the following: The facility policy Lab and Diagnostic Test Results/ Clinical Protocol Policy, revised November 2018, documented that the physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests, and the laboratory, diagnostic radiology provider, or other testing source will report…

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 an Abbreviated Survey (#NY00312328), it was determined that for one (Unit two) of one unit reviewed for medication storage, the facility did not ensure that medications were properly supervised and secured. Specifically, a large number of prescription medications were unlocked and unsupervised in a resident's dresser drawer and a blister packet (28 pills) of a prescription medication was left unsecured and unsupervised on top of a medication cart with no nurse in sight. This is evidenced by the following: The facility policy Medication Storage reviewed on 1/3/23 documented that medications are stored in an orderly manner in cabinets, drawers, or carts sufficient to size to prevent crowding. All medication in medication carts and treatment carts are locked. 1.In an observation and interview during a unit tour on 8/24/23 at 9:53 AM, a blister packet containing 28 pills of the medication Austedo (medication used to treat involuntary movements as…

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 and interviews conducted during the Standard Recertification Survey completed on 12/16/22 and complaint investigations (NY00299364, NY00269879, NY00281833, NY00282526, NY00283899, and NY00287604) it was determined that for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically: floors, walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, bathroom exhausts were not functioning, bathing fixtures were not provided at a ratio of one per 20 residents, plumbing fixtures were not maintained and/or working properly, there were ceiling and sewer leaks, heating units were dented and damaged, resident care items were stored on floors, hand sanitizer dispensers were empty, overhead lights were not functional, light lenses and covers were missing, and furniture and…

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

Based on record review and interview conducted during the Standard Recertification Survey completed on 12/16/22, it was determined that for five of five newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work. The findings are: A review of the facility policy and procedure titled: 'We Care Health Centers Freedom from Abuse, Neglect, and Exploitation Policy' included that the policy serves to provide protection for residents for their health and physical, emotional, and mental well-being; pre-employment screening includes that all individuals being considered for employment will be verified through the NYS Nurse Aide Registry. The policy also included that the State Nurse Aide Registry shall be queried as part of the hiring procedure for all unlicensed personnel positions. On 12/16/22 from 8:45 a.m. to 10:10 a.m.,…

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 reviews conducted during the Recertification Survey, completed on 12/16/22, it was determined that for two (Resident #46 and #87) of six residents reviewed for rehabilitation services, two (Residents #13 and #57) of six residents reviewed for unnecessary medications, and the facility's Infection Control and Prevention Program, the facility did not safeguard medical record information against loss or was readily accessible. Specifically, the facility could not provide Resident #46 and Resident #87's Physical Therapy records, could not provide monthly pharmacy reviews and recommendations, if any, for Resident #13 and Resident #57 and could not provide evidence of a consistent infection prevention program or an antibiotic stewardship program. This is evidenced by the following: 1. Resident #87 was admitted to the facility on [DATE], with diagnoses of paraplegia, ankylosing hyperostosis (abnormal bone formation involving the ligaments of the spine) and a lumbar spinal cord injury.…

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, interview, and record review conducted during the Standard Recertification Survey and complaint investigation #NY00283899 completed on 12/16/22, it was determined that the facility did not properly maintain the resident call system. Specifically, elements of the nurse call system were damaged and/or not functioning properly. The findings are: Observations on 12/12/22 from 9:51 am to 2:30 p.m. included the following: a) The nurse call station in resident room [ROOM NUMBER] did not illuminate above the door when pressed. In an interview at this time, Resident #60 stated that the call bell does not always work, and they have to yell to get staff assistance. b) The nurse call station on the wall in the second-floor shower room near room [ROOM NUMBER] was pulled out from the wall and did not activate the light above the door when the string was pulled. c) The nurse call station in resident room [ROOM NUMBER] did not illuminate above the door when pressed. d) The nurse call stations on the walls…

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, completed on 12/16/22 it was determined that for one (Resident #52) of two residents reviewed for choices, the facility did not allow each resident the right to make choices in regard to their bathing preferences consistent with their wishes. Specifically, the resident was not showered once weekly per their plan of care or stated preference. This is evidenced by the following: Resident #52 was admitted to the facility with diagnoses that included morbid obesity, cellulitis left lower limb, and heart failure. The Minimum Data Set Assessment, dated 2/17/22, included that the resident was cognitively intact, was totally dependent on staff for bathing, required 2 assists of staff for transfers using a Hoyer (mechanical) lift for showering, was occasionally incontinent of urine, and that choosing their type of bathing was very important to them. Review of the current Certified Nursing Assistant (CNA) Bedside Care Plan revealed that the resident would like their showers one time a week 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.

Based on interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00304062 and #NY00289336) completed 12/16/22 it was determined that for one (Residents #37) of four residents reviewed, the facility did not ensure that alleged violations of abuse, mistreatment or neglect, including injuries of unknown injury and misappropriation of property were thoroughly investigated. Specifically, the facility did not initiate an investigation of the resident's missing cell phone or report the incident to the state agency. This was evidenced by the following: Resident #37 was admitted to the facility with diagnoses that included, cellulitis of the left lower leg, respiratory failure, and morbid obesity. The Minimum Data Set (MDS) Assessment, dated 10/16/22, revealed the resident was cognitively intact. In an interdisciplinary team progress note dated 9/22/22, Social Worker #2 (SW) documented that they had followed up on Resident #37 when they reported they were missing a light blue iPhone, which went missing when the resident went to the hospital.…

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 during the Recertification Survey completed on 12/16/22, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative for three (Residents #200, #57, and #64) of three residents reviewed. Specifically, there was no documented evidence a written notice of the facility's bed hold policy was provided to the resident or/or their representative upon discharge or as soon after as possible following hospitalizations. The findings are: Review of an undated facility policy and procedure titled, Bed Hold and Return to Facility, it states that residents and their representative will be provided a copy of the bed hold and return information at the time of admission and before a hospital transfer or therapeutic leave. 1. Resident #200 was admitted to the facility with diagnoses of diabetes, depression, and end stage kidney disease. The Minimum Data Set (MDS - a resident assessment tool) dated 10/3/22…

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 reviews conducted during the Recertification Survey and complaint investigations (#NY00300460), completed on 12/16/22, it was determined that for one (Resident #46) of 36 residents reviewed for Professional Standards of Quality, the facility did not ensure the services provided or arranged by the facility as outlined in the resident's Comprehensive Care Plan (CCP) met professional standards of quality. Specifically, there was lack of documentation that Resident #46's wound care treatments were administered as ordered by the medical team. This is evidenced by the following: Resident #46 had diagnoses of sepsis, gangrene (infected dead tissue) of the gallbladder, and obesity. The Minimum Data Set assessment dated [DATE], documented that Resident #46 was cognitively intact, and had a surgical wound requiring wound care. Review of the current CCP revealed that Resident #46 had an impairment to skin integrity from surgery and interventions included to follow facility protocols 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 observations, interviews and record review conducted during the Recertification Survey completed on 12/16/22, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible. Specifically, Resident #46 who had a history of keeping vaping materials in their room, was observed with vaping materials at bedside. Additionally, there was no evidence that any interventions had been done following the initial incident with the vaping materials. This is evidenced by the following: Resident #46 was admitted to the facility on [DATE], with diagnoses including sepsis (serious infection in the blood), gangrene (infected dead tissue) of the gallbladder, and obesity. The Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #46 was cognitively intact, required extensive assistance with bed mobility, and was totally dependent on staff for transfers and locomotion off the unit. The MDS assessment dated [DATE], revealed that Resident #46 was not…

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

Based on observations conducted during the Standard Recertification Survey completed 12/16/22, it was determined that the facility did not properly dispose of garbage and refuse. Specifically, garbage and refuse were not contained within dumpsters and receptacles were not covered. The findings are: Observations during the exterior tour of the facility on 12/13/22 at 8:18 a.m. included an uncovered 'roll-off' dumpster full of trash and garbage located on the northwest corner of the property. Additionally, there were four garbage dumpsters at this location and three were partially uncovered with bags of garbage heaped. Further observations around and behind the dumpsters included the following items on the ground: ripped open black bags of garbage, cardboard boxes, a white pair of crocs, plastic cups, plastic gloves, tires, lids, a shopping cart, aluminum cans, milk cartons, wrappers, green hose, and spray cans. 10NYCRR: 415.29 (i)(1), 415.29(j)(6)(i), 415.14(h), Subpart 14-1.150.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigations (#NY00288521, #NY00296879, and #NY00300460), completed on 12/16/22, it was determined that for one (Resident #401) of six residents reviewed for Rehabilitation, the facility did not ensure specialized rehabilitative services were provided as ordered. Specifically, Resident #401 did not receive consistent physical therapy as ordered by a physician. This is evidenced by the following: Resident #401 was admitted to the facility on [DATE] with diagnoses of bilateral knee osteoarthritis, morbid obesity, and pulmonary embolism (blood clot in lung). The Minimum Data Set Assessment, dated 11/11/22, documented that the resident was cognitively intact. Review of the current Comprehensive Care Plan (CCP) revealed that Resident #401 was full weight bearing to the lower extremities, was non-ambulatory at the time, and required the use of a Hoyer (mechanical) lift for transfers. Review of a Social…

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 Standard Recertification Survey completed on 12/16/22 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 12/14/22 at 9:21 a.m., records for inspection and testing of facility carbon monoxide detectors were reviewed. The logs included a monthly signoff including one dated 11/2/22 that listed the locations of carbon monoxide detectors in the following areas: laundry, kitchen, boiler room, and the clean and soiled work rooms on the 1st, 2nd, and 3rd floors. On 12/14/22 at 9:32 a.m. it was observed that a battery powered carbon monoxide detector was mounted to the wall in the third-floor clean utility room, and the device was marked with: 'Replace by 3/2021'. Additionally, there were no carbon monoxide…

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 Standard Recertification Survey completed on 12/16/22, it was determined that the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, a suction machine, and resident beds were not in proper working condition. The findings are: On 12/12/22 at 12:00 p.m. a crash cart with a suction machine was observed to be located in the first-floor lounge across from the nurse's station. While observing the cart it was noted that there was no glass reservoir to collect liquids attached to it. In an interview at this time, the records staff member at the nurse station was asked if this was the suction machine that would be used on this floor. The answer was yes. Observations in the basement laundry room on 12/12/22 at 2:55 p.m. included one of two dryers and one of three washing machines were not functional. When interviewed at this time, a…

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 and interviews during the Recertification Survey, it was determined that for three (first, second and third floors) of three resident sleeping floors and one of one basement, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there were dirty shower rooms, missing and stained ceiling tiles, water leaks, a dirty sit-to-stand lift, non-functioning light fixtures, a loose handrail, soiled resident items, and a broken heater cover. This is evidenced by the following: 1. Observations during the initial tour of the facility on 9/8/20 from 12:48 p.m. to 2:37 p.m. revealed the following: a. There was black, pink, and brown residue, mold, and mildew along the base of the floor and wall located in the shower stall of the third floor shower room closest to room [ROOM NUMBER]. b. The ceiling tiles in front of and inside the third floor clean and soiled utility room were stained brown and/or bowed. In 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 observations, interviews, and record reviews during the Recertification Survey, it was determined that for one (Resident #83) of one resident reviewed, the facility did not provide services with reasonable accommodation of resident's needs and preferences directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being to the extent possible. Specifically, the resident was not toileted per their preferences. This is evidenced by the following: Resident #83 has diagnoses including a stroke, depression, and heart failure. The Minimum Data Set Assessment, dated 8/19/20, revealed the resident was cognitively intact, required extensive assist of staff for toileting, and was always incontinent of bladder and bowel. The Comprehensive Care Plan and the current Certified Nursing Assistant (CNA) [NAME] included that the resident had a self-care deficit related to a stroke, was able to be transferred using the APEX standing frame with extensive assist of one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the Recertification Survey, it was determined that for one (Resident #94) of one resident reviewed, the facility did not provide the treatment and services in the resident's plan of care to maintain functional ability. Specifically, the resident was not consistently ambulated by staff per the resident's individualized plan of care. This is evidenced by the following: Resident #94 had diagnoses including depression, blindness in one eye, and recent cellulitis of the right knee. The Minimum Data Set Assessment, dated 8/13/20, included that the resident had severely impaired cognition and required extensive assist of staff for ambulation. The Comprehensive Care Plan (CCP), dated as last revised on 8/14/20, and the current Certified Nursing Assistant (CNA) [NAME] included that the resident has limited physical mobility. Interventions documented in the ambulation section included contact guard up to 75 feet using a four-wheeled walker and wheelchair to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews during the Recertification Survey, it was determined that for one (Resident #95) of three 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. Specifically, oxygen therapy was not provided per physician orders. This is evidenced by the following: Resident #95 was readmitted to the facility on [DATE] following an acute stay for hypoxic (low oxygen levels) respiratory failure and pulmonary hypertension. The Minimum Data Set Assessment, dated 8/13/20, revealed the resident had severely impaired cognition and was on oxygen. The hospital Discharge summary, dated [DATE], included the resident was being discharged on 5 liters of oxygen and to wean if possible. Physician orders, dated 8/5/20, included oxygen at 4 liters via nasal cannula continuous for respiratory failure. The Comprehensive Care Plan, dated as last 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.