Colonial Park Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the abbreviated (iQIES reference number 2610929) survey the facility did not ensure residents were free of significant medication errors for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order for intravenous (directly into a vein) cefepime and vancomycin (antibiotics) every 12 hours that were not administered on 04/10/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/18/2025, and 04/19/2025.Findings include:The facility policy Administering Medications, reviewed 01/2025 documented medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. If a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should document in the electronic Medication Administration Record for that drug and dose. The person who withheld,…

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

Based on record review and interviews during the abbreviated (iQIES reference number 2610929) survey the facility did not ensure laboratory services were obtained to meet the needs of its residents for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had physician orders for laboratory tests to check their vancomycin (antibiotic) trough level (blood test used to monitor the antibiotic's effectiveness and to minimize toxicity) and the laboratory tests were not performed timely or accurately. Findings include:The facility policy Vancomycin Management, dated 01/2025, documented renal function should be monitored at least twice weekly or more frequently based on physician orders. Trough level monitoring should be completed to ensure adequate serum levels for efficacy while avoiding toxicity. Lab draw should happen within 30 minutes prior to the fourth dose, after dose adjustments, significant changes in renal function, or during prolonged therapy. With prolonged therapy testing should be repeated every 3-5 fays or per physician orders. Nursing would…

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

Based on record review and interviews during the abbreviated survey (NY00334012), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive medications as ordered on multiple occasions. Findings include: The facility policy, Medication Administration, revised 1/2024, documented the nurse should document all medications administered to each resident on the resident's medication administration record. Documentation must include name and strength of the drug, dosage, method of administration, date and time, and reason(s) why a medication was withheld, not administered, or refused. In the event a medication pass time had passed, the nurse would inform the medical professional and obtain orders to either give the medication, hold, or discontinue. The nurse must inform the Nursing Supervisor of the medication administration event. Resident #2 had diagnoses including…

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, observation, and interview during the recertification and abbreviated (NY00340720) surveys conducted 7/15/2024-7/22/2024, the facility did not ensure they had a process in place for residents to have their grievances addressed appropriately for 13 of 13 (12 anonymous residents, and Resident #16) reviewed. Specifically, 12 anonymous residents present at the Resident Council meeting stated they did not know who the grievance officer was, how grievances were handled, or receive communication on the progress of grievance resolutions; and Resident #16 filed a grievance regarding a care concern that was not resolved. Findings include: The facility policy, Filing Grievance Complaints, last reviewed 1/2024, documented the facility must establish a grievance policy that ensured the prompt resolution of all grievances regarding the residents' rights. The facility assisted residents in filing grievances and/or complaints when such requests were made. The facility notified residents individually or through postings in prominent locations throughout the facility of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, hot food was improperly cooled, the mechanical dishwasher was not functioning as designed, and outdated foods were present in the walk-in cooler. Findings include: The facility policy, Food Safety and Sanitation dated as reviewed 1/2024, documented leftovers were used within 72 hours (or discarded). The facility policy, Cleaning Dishes/Dish Machine, dated as reviewed 1/2023 documented the dish machine would be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The facility Cook/Time Temperature Cooling Log revised 12/1/2017, documented items had 2 hours to decrease from 135 degrees Fahrenheit to 70 degrees Fahrenheit and 4 hours to decrease from 70 degrees…

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

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 3 medication carts (Unit 1- medication cart 1, Unit 2- medication cart 1, and Unit 2- medication cart 2) reviewed. Specifically, - Unit 1- medication cart 1 contained 7 medications that were not labeled with resident specific identifiers or with opened/ discard dates; 7 resident specific multidose insulin (treats blood sugar) pens, 1 multidose eye drop, and 1 multidose eye ointment that were not labeled with opened and discard dates; and 1 unopened insulin pen that was not stored appropriately in the refrigerator. - Unit 2- medication cart 1 contained 1 multidose insulin pen that was not labeled with resident specific information and 1 resident specific multidose insulin pen that was not labeled with an opened or discard date. - Unit 2- medication cart 2 contained stock…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, 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 1 of 1 resident (Resident #59) reviewed. Specifically, staff was observed not wearing the required personal protective equipment in Resident #59's room who was on transmission-based precautions. Findings include: The undated facility policy. Isolation-Categories of Transmission-Based Precautions, documented transmission-based precautions were additional measures that protected staff, visitors, and other residents from becoming infected. When a resident was placed on transmission-based precautions, appropriate notification was placed on the room entrance door, so personnel and visitors were aware of the need for the type of precaution. The signage…

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 and abbreviated (NY00340720) surveys conducted 7/15/2024-7/22/2024, the facility did not immediately inform the resident's representative when there was a need to commence a new treatment for 1 of 2 residents reviewed (Resident #525). Specifically, Resident #525 was prescribed an antibiotic for symptoms of infection and the resident's representative was not notified. Findings include: The facility policy, Change in a Resident's Condition or Status, last revised 1/2024, documented the facility promptly notified the resident, their attending physician, and representative of changes in the resident's medical/mental condition and/or status. Except in medical emergencies, notifications were made within 24 hours of a change that occurred in the resident's medical/mental condition or status. Resident #525 had diagnoses including stroke, sacral (lower back) pressure ulcer, and a history of infections. The 4/16/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had a urinary tract infection…

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

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 1 of 2 residents (Resident #3) reviewed. Specifically, Resident #3 was not provided a large print Bible or glasses to meet their interests and preferences. Findings include: The facility policy, Activity Programs, effective 1/2022, documented activity programs were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered were based on the comprehensive resident based assessment and the preferences of each resident. Adequate space and equipment were provided to ensure that needed services identified in the resident's plan of care were met. Resident #3 had diagnoses including left sided hemiplegia (paralysis or weakness to one side of the body), unspecified visual loss, and depression. The…

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

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 3 residents (Residents # 27and #67) reviewed. Specifically, Residents #27 and #67 had physician orders for air low air loss mattresses (a specialty mattress that provides air flow to relieve pressure) that did not include settings and were not monitored to ensure appropriate settings for current weights. Findings include: The undated facility policy, Air Mattress Guidelines, documented a low air loss mattress was a mattress designed to prevent and treat pressure wounds. Residents were assessed for the appropriateness of an air mattress upon admission based on risk factors and /or the existence of actual or history of pressure injuries. An air mattress was provided to those residents to prevent skin breakdown, promote…

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

Based on observation, record review, and interview during the recertification and abbreviated (NY00314958) surveys conducted 7/15/2024-7/22/2024, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #7) reviewed. Specifically, Resident #7 had a diagnosis of dysphagia (difficulty swallowing) and was care planned for line-of-sight supervision for meals with specific swallowing strategies and was observed eating a meal alone in their room. Findings include: The facility policy, Meal Observation, reviewed 1/2024, documented nursing provided supervision and observation during mealtime, in dining areas and patient/ resident rooms. Staff ensured all residents received the appropriate consistency altered diets as ordered. The facility policy, Assistance with Meals, reviewed 1/2024, documented residents received assistance with meals in a manner that met the individual needs of each resident. Facility staff helped residents who required assistance with eating. Residents were fed with attention to safety, comfort, 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 observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 1 resident reviewed (Resident #19). Specifically, Resident #19's bilevel positive airway pressure machine (non-invasive mechanical ventilator that applies pressure to keep airway open when sleeping) was not cleaned per professional standards. Findings include: The facility policy CPAP/BiPAP Support [continuous positive airway pressure/bilevel positive airway pressure] , revised 1/2024, documented specific cleaning instructions were obtained from the manufacturer/supplier. The machine was to be cleaned once a week and as needed. The mask, nasal pillow, and tubing were to be cleaned daily using warm soapy water and allowed to air dry. Resident #19 had diagnoses including respiratory failure, sleep apnea (breathing stops and starts during sleep), and chronic obstructive pulmonary disease (lung disease). The 6/18/2024 Minimum…

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

Based on observation, record review, and interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure that residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #59) reviewed. Specifically, Resident #59 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site. Additionally, there was not consistent ongoing communication and collaboration between the facility and the dialysis center. Findings include: The 10/21/2021 facility Dialysis Service Agreement with the community-based dialysis center documented the care facility agreed to furnish all appropriate medical information including current treatments and medications provided to the resident. The facility policy, Dialysis Communication, last…

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 interview during the recertification survey conducted 7/15/2024-7/22/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 test tray meals (the 7/16/2024 lunch meal and the 7/18/2024 lunch meal) reviewed; and for 12 of 12 anonymous residents present at the Resident Council meeting. Specifically, the 7/16/2024 and 7/18/2024 lunch meals were not served at palatable and appetizing temperatures and were not flavorful; the 7/18/2024 lunch meal test tray contained a foreign substance and had a missing item. Additionally, 12 of 12 anonymous residents at the Resident Council meeting stated the food was not flavorful, was not served at appetizing and palatable temperatures, and often had missing items; and Resident #15 stated the food was often flavorless. Findings include: The facility policy, The Dining Experience, reviewed 1/2024 documented the dining experience enhanced each individual's quality of life by providing nourishing, palatable, 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 during the abbreviated survey (NY00312863), the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 had a significant weight loss that was not addressed by clinical nutrition staff. Additionally, the resident was not consistently provided with their ordered nutritional supplement. Findings include: The 1/2024 Weight Assessment and Intervention Policy documented the dietitian would review the weight record. Any weight change of 5% or more since the last weight would be retaken the next day for confirmation. At the discretion of the dietitian, in conjunction with the resident's presentation and team assessment, additional reweights may be requested. The dietitian would respond within 7 days upon receipt of notification of a weight change depending on the severity of the weight change. Resident #1 had diagnoses including failure to thrive and dementia. The 7/26/2022 Minimum Data Set assessment documented the resident's cognition was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00258908, NY00291516, NY00276440, NY00296424, NY00286768, and NY00285103) conducted 5/31/22-6/3/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 2 resident units (A and B units) reviewed. Specifically, there were loose and unclean handrails, unclean floors, and walls and furniture in disrepair on the A (100s) and B (200s) units. Findings include: The facility policy Cleaning and Disinfection of Environmental Surfaces reviewed 1/2022 documented non-critical items were those that come in contact with intact skin. Non-critical environmental surfaces included bed rails, bedside tables, furniture, and floors. Housekeeping surfaces such as floors would be cleaned on a regular basis and when surfaces were visibly soiled. The following observations were made on 5/31/22: - at 9:24 AM the Unit B kitchenette floor was sticky. - at 10:05 AM the floor in room [ROOM NUMBER]…

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

Based on observation, record review, and interview during the abbreviated (NY00290033) and recertification surveys conducted from 5/31/22-6/3/22, the facility failed to protect residents from abuse for 2 of 3 residents reviewed (Residents #26 and 47). Specifically, Resident #4 exhibited sexually inappropriate behaviors towards Residents #26 and 47 and a plan of care was not developed and implemented to protect Residents #26 and 47 from further abuse. Findings include: The facility's policy Abuse Prevention Program/Abuse and Neglect- Clinical Protocol/Abuse Investigation and Reporting revised 1/2022 documented the facility's residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included sexual or physical abuse. The facility was to develop and implement policies and procedures to aid in preventing abuse, neglect, or mistreatment of the residents. The facility was to implement measures to address factors that may lead to abusive situations and protect residents during abuse investigations. The facility policy 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 interview during the recertification and abbreviated surveys (NY00286768 and NY00296424) conducted 5/31/22-6/3/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 of 2 meal test trays, and for 1 meal service in the kitchen. Specifically, 2 lunch meal test trays and several food items on the kitchen lunch service line had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable. Findings include: The facility policy General HACCP (Hazard analysis and critical control points) Guidelines updated 1/2022 documented food must be held greater than 135 degrees Fahrenheit (F) or less than 41 degrees F. Check to be sure the staff take food temperatures and take them accurately. The facility's Daily Mealtime Temperature Log documented the following: - the acceptable hot holding temperature range was 140-180 degrees F. - on 5/19 - dinner hot foods: rice, hamburger, BBQ ribwich, spinach, and mashed potatoes had recorded…

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 the recertification and abbreviated surveys (NY00296424) conducted from 5/31/22-6/3/22, the facility failed to ensure that the discharge needs of each resident were identified and resulted in the development of a discharge plan for each resident for 1 of 1 resident (Resident #174) reviewed. Specifically, Resident #174 was discharged to home following a rehabilitation admission and did not have home care services set up at the time of discharge. Findings include: The facility policy Discharge Summary and Plan revised 1/2022 documented when the facility anticipates a resident's discharge to a private residence, another nursing care facility, a discharge summary, and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The post-discharge plan would be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and would include: - Where the individual plans to reside. - Arrangements that have been made for follow-up care 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00258908, NY00265830, NY00291516, NY00274357, NY00264477) conducted 5/31/22-6/3/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents reviewed (Resident # 24). Specifically, Resident # 24 was not provided timely incontinence care as planned. Findings include: The facility policy Certified Nursing Aide Documentation, reviewed 1/2022 documented all care will be delivered as per the resident's plan of care/[NAME] (care instructions). Resident #24 had diagnoses of cerebral infarction (stroke), diabetes, and acute kidney failure. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition, did not reject care, required extensive assistance of 2 for bed mobility, transfers, and toileting, was frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted on 5/31/22-6/3/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Residents #32 and 38) reviewed. Specifically, Residents #32 and 38, both on aspiration precautions, were unsupervised and not positioned safely during meals. Additionally, Resident #32 was not provided the correct diet consistency during an observed lunch meal. Findings include: The facility Aspiration Precautions policy, reviewed 3/2022, documented all licensed and unlicensed personnel will be instructed in and take appropriate precautions to minimize the risk of aspirations in residents. Residents noted with aspiration precautions in place must be fed within direct supervision of a licensed personnel. Residents unless otherwise specified will be fed in an upright position and left in this position post feeding to avoid aspiration. Ensure residents receive the…

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

Based on observation, interview, and record review during the recertification survey conducted 5/31/22-6/3/22, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions for 1 of 2 (A-1 medication cart) medication carts reviewed. Specifically, controlled drugs were not stored in the separately locked compartment in the A-1 medication cart. Findings include: The facility policy Medication: Controlled Substances revised 1/2022, documented: - The facility should comply with all laws, regulations, and other requirements related to handling and storage of controlled substances; - Only authorized licensed nursing should have access to controlled drugs maintained on premises; and - Controlled substances must be stored in the medication room in a locked container. This container must remain locked at all times, except when it was accessed to obtain medications for residents. During a medication storage observation of the A-1 medication cart on 6/1/22 at 1:03 PM…

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 the recertification and abbreviated surveys (NY00286768 and NY296424) conducted 5/31/22-6/3/22, the facility failed to ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 of 1 resident (Residents #17) reviewed. Specifically, Resident #17 had a gluten allergy (a protein found in grains), and the resident was served mashed potatoes instead of gluten free pasta listed on the approved menu. Findings included: The facility policy Nutritional Assessment revised 1/2022 documented the nutritional assessment would be conducted by the multidisciplinary team and shall identify at least the following components: food restrictions, including food allergies and cultural or religious practices affecting food choices. The undated facility policy Menu Substitution documented a menu substitute would be provided when an uncontrollable situation, such as inventory shortage, had temporarily made the item unavailable. Decisions on menu substitutions would be made…

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

Based on observation, record review and interview during the recertification survey conducted 5/31/22-6/3/22, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19 for 1 of 11 staff (licensed practical nurse [LPN] #10) reviewed. Specifically, the facility did not implement their contingency plan for LPN #10 who was not vaccinated for COVID-19 due to an exemption based on clinical contraindications. Findings include: The facility policy COVID-19 Vaccination Requirements for Staff and Residents revised 2/22, documented those staff who were not yet fully vaccinated or had been granted an exemption or accommodation as authorized by law must adhere to additional precautions that were intended to mitigate the spread of COVID-19. The facility may implement the following to reduce the risk of COVID-19 transmission: - Requiring twice weekly testing for exempted staff. -…

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.