The Grand Rehabilitation and Nursing At Rome

Based on observations, record review, and interviews the facility failed to 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) of three (3) residents (Residents #61 and #146) reviewed. Specifically, staff did not wear the required personal protection equipment while caring for Residents #61 and #146 who were on contact precautions.Findings include: The 04/03/2024 Centers for Disease Control recommendations documented transmission-based precautions are the second tier of basic infection control and are used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment appropriately. Wear a gown and gloves for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the abbreviated (NY00339441) survey the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 5 residents (Resident #293) reviewed. Specifically, Resident #293 developed a Stage 2 (partial-thickness skin loss) facility-acquired pressure ulcer when incontinence care was not provided routinely or as planned and treatments to the area were not consistently administered. Subsequently, the pressure injury progressed to an unstageable pressure ulcer (full thickness tissue loss in which the base of the wound is covered with dead tissue). Findings include: The facility policy, Prevention of Pressure Ulcers/Injuries, revised 1/2024, documented residents' skin was to be inspected daily when staff were performing or assisting with personal care or activities of daily living. Any signs 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 observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure a safe, clean, comfortable, and home-like environment for 4 of 4 Units (Units 100, 200, 300, and 400) reviewed. Specifically, floors, walls, ceilings, and resident chairs were damaged or unclean on Units 100, 200, 300, and 400; drain flies were observed in the Unit 200 shower room; and there was no negative air pressure in Units 200, 300, and 400 soiled utility rooms (negative pressure rooms have a lower air pressure, created by ventilation, to reduce the flow of potentially contaminated air or odors from leaking into the surrounding areas). Findings include: The facility policy, Housekeeping Responsibilities, reviewed 1/2022, documented the facility would maintain a clean, safe, and sanitary environment for the residents. Routine cleaning included daily cleaning of all horizontal surfaces with an acceptable grade disinfectant/germicide. A schedule of cleaning tasks…

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

Based on observation, record review and interviews during the recertification and abbreviated (NY00340701, NY00330066, NY00333069, and NY00328237) surveys conducted 6/24/2024 - 6/28/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 11 residents (Residents #56, #80, #90, and #127) reviewed. Specifically, Resident #127 had untrimmed fingernails and was not wearing their glasses; and Residents #56, #80, and #90 had unclean and untrimmed fingernails. Findings include: The facility policy, Resident Care with Activities of Daily Living, reviewed 1/2022, documented the facility was to accurately assist with residents' needs to support basic activities of daily living function. The supervisor was to be notified if the resident refused care and to report other information in accordance with facility policy and professional standards of practice. The facility policy, Care of Fingernails/Toenails, reviewed 1/2024, documented nail care…

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 (NY00340613, NY00328237, and NY0330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (6/26/2024 breakfast meal and 6/26/2024 lunch meal) reviewed. Specifically, the breakfast and lunch meals were not served at safe and appetizing temperatures. Findings include: The facility policy, Policy and Procedure Food Temperatures, reviewed 01/2023, documented the temperatures of all food items would be taken and properly recorded prior to service of each meal. All hot food would be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Hot food items would not fall below 135 degrees Fahrenheit after cooking, unless it was an item which would be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit (for a minimum of 15 seconds) prior to serving.…

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 (NY00330066 and NY00331744) surveys conducted 6/24/2024-6/28/2024, the facility did not provide one or more rooms designated for resident dining and activities that were adequately furnished and had sufficient space to accommodate all activities for 2 of 4 dining rooms (Units 100 and 400). Specifically, Units 100's and 400's dining rooms had tables that did not accommodate residents' social and physical needs with inadequate space for dining or activities, and residents were lined up in the hallways during meals. Findings include: The facility policy, Preparing the Resident for a Meal, reviewed 1/2024, documented residents should be encouraged, not forced, to eat in the dining room to provide each resident the opportunity to socialize and make friends. Be sure the room was comfortable (i.e., not too warm, or cold) and had a relaxing environment (free of odors, loud noises, and bright lights). The following observations were made on Unit 100. The unit census was 36 residents. - During 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 observations, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure residents had the right to a dignified existence for 2 of 18 residents (Resident #28 and #44) reviewed. Specifically, Residents #28 and #44 were referred to with undignified labels (feeders); and Resident #44 was assisted with eating while staff stood over them. Findings include: The facility policy, Quality of Life-Dignity, reviewed 1/2024, documented residents would be treated with dignity and respect at all times. Ttreated with dignity meant the resident would be assisted in maintaining and enhancing their self-esteem and self-worth and staff should speak respectfully to residents at all times, including addressing the resident by their name of choice and not labeling or referring to the resident by their room number, diagnosis, or care needs. 1) Resident #28 had diagnoses including dementia, cerebral infarction (stroke), and bipolar depression. The 4/26/2024 Minimum Data Set assessment documented 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 interview and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions were referred for a Level II Pre-admission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care and a Level II PASARR identifies the specialized services required by the resident) for 1 of 2 residents (Resident #101) reviewed. Specifically, there was no documentation Resident #101 was referred for a Level II Preadmission Screening and Resident Review when the resident was newly diagnosed with a serious mental health disorder. Findings include: The New York State Department of Health Instruction Manual for DOH-695 (2/2009) documented if a Residential Health Care Facility resident is newly diagnosed with a mental illness, a new SCREEN and Level II referral must be completed…

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

Based on observation, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6242024-6/28/2024, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 7 residents (Resident #111) reviewed. Specifically, Resident #111 had a physician order for a chopped consistency diet and was served a whole sandwich. Findings include: The facility policy, Food Consistencies and Definitions, reviewed 1/2024, documented diets with a chopped consistency were nearly regular textures with exception of very hard, sticky, or crunchy foods. Foods should be tender and easy to break into pieces with a fork. Lunch/Dinner foods such as meatballs, thinly sliced deli meat, and grilled cheese sandwiches should be chopped. The policy did not include definitions for a mechanical soft diet. The facility policy, Accuracy and Quality of Tray Line, revised 1/2024 documented all meals would be checked for accuracy by the Food and Nutrition staff, and by the service staff prior 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.

Based on observation, interview, and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 1 resident (Resident #59) reviewed. Specifically, Resident #59 did not receive ordered fluids on their meal tray and was not offered a substitution when they requested a sandwich. Findings include: The facility's Always Available Menu documented lunch and dinner entree alternates included the following sandwiches; ham, egg salad, tuna salad, turkey, bologna, sliced cheese, peanut butter and jelly, and chicken salad. Resident #59 was had diagnoses including Alzheimer's Disease and chronic kidney disease. The 5/19/2024 Minimum Data Set assessment documented the resident was cognitively intact, had a poor appetite most days, required supervision or touching assistance for eating, did not have a swallowing disorder, had obvious or likely cavity or broken natural teeth, and did not require a mechanically altered diet…

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

Based on observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well-being of each resident. Specifically, the facility received a letter from Centers for Medicare and Medicaid Services dated 2/09/2024, prohibiting the provision of a Nurse Aide Training and Competency Evaluation Program, conducting onsite nurse aide competency exams, or utilizing onsite clinical training by an off-site nurse aide training program, effective through 10/2025, and the facility was observed conducting an off-site nurse aide training program. Findings include: The facility contract with a local community college effective for the period of March 1, 2023, through December 31, 2024, documented the parties proposed to collaborate to provide for the certified nurse aide students at the college the In-Agency learning experiences necessary for them to become responsible…

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 (NY00304388), the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated; did not ensure residents were protected while the investigation was in process; did not implement plans to prevent reoccurrence; and did not ensure incidents were reported to the New York State Department of Health (NYS DOH) when required for 2 of 3 residents reviewed (Residents #1 and 2). Specifically, - Resident #1, whose cognition was severely impaired, had a sexual encounter with a cognitively intact resident (Resident #2) and a plan was not implemented to protect Resident #1 from further potential abuse. Additionally, recommendations from the psychiatric nurse practitioner (NP) for 15-minute checks were not implemented. - Residents #1 and 2 had 2 more documented episodes of inappropriate touching that were not reported to the NYS DOH as required. - Resident #1 was found deceased with food in their mouth and the incident was not thoroughly investigated to rule out abuse/neglect…

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 (NY00304388), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents reviewed (Resident #1). Specifically, facility Administration, including the Director of Nursing (DON) did not ensure residents received adequate supervision to prevent accidents (choking), did not complete a thorough investigation into resident choking, and did not report neglect as required to the New York State Department of Health (NYS DOH). Findings include: Refer to F689 - Free of Accident Hazards/Supervision/Assistance Devices On 10/18/2023 at 3:38 PM, Immediate Jeopardy and Substandard Quality of Care (SQC) was identified during an abbreviated complaint survey. Concerns rising to the level of immediate risk to resident health and safety included the facility's failure to provide adequate supervision to Resident #1 while eating. Approximately 30 minutes after being provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00271335, NY00276204, NY00290644, NY00293364, and NY00297551) conducted 8/8/22-8/15/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2, 3, and 4) reviewed. Specifically, there were sticky/unclean floors, scrapped/damaged walls, exposed electrical wires, water dripping from a ceiling vent, resident clothing left on the ground in a clean utility closet, a loose/unsecured toilet bowl, and a loose/unsecured resident room doorknob. Additionally, Resident #48's room was not personalized and/or homelike. Findings include: 1)Unclean Floors/Scraped Walls The Maintenance Schedule for Floors, revised 1/28/21, documented that two resident room floors would be stripped and waxed each day. The following observations of floors and walls were made: - on 8/8/22 at 10:18 AM, and 8/9/22 at 9:31 AM, the floor in resident room [ROOM NUMBER] was sticky 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 8/8/22-8/15/22, the facility failed to ensure services provided or arranged by the facility met professional standards of quality for 23 of 39 residents (Residents #2, 4, 13, 19, 32, 34, 36, 37, 39, 43, 44, 57, 66, 81, 82, 87, 89, 100, 102, 104, 111, 146, and 155) reviewed. Specifically, during a medication storage review of the Unit 1 medication cart, 23 residents had pre-poured medications in cups, stored in the top drawer of the Unit 1 medication cart. Findings include: The facility policy Administering Medications reviewed 1/2022 documented medications must be administered within 1 hour of their prescribed time, unless otherwise specified. The individual administering the medication must initial the resident's medication administration record (MAR) after giving each medication and before administering the next ones. Medications ordered for a particular resident may not be administered to another resident. The facility policy Storage of Medications reviewed 1/2022 documented drugs shall…

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 8/8/22-8/15/22, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 2 of 7 medication carts (Units 1and 4) and 3 of 4 medication storage rooms (Units 1, 3, and 4) observed. Specifically, Units 1 and 4 had expired stock medications in the medication rooms and medication carts and the Unit 3 medication storage room refrigerator had an expired biological multi-dose vial. Findings include: The facility policy Storage of Medications reviewed 1/2022 documented the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. Only persons authorized to prepare and administer medications should have access to the medication room. During an observation on 8/9/22 at 4:11 PM, the Unit 1 medication storage was observed with licensed practical nurse (LPN) #32. The following…

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 (NY00271335) surveys conducted 8/8/22-8/15/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's main kitchen and emergency food supply room. Specifically in the main kitchen: - the hand-washing sink, near the dishwasher area, had a faucet that was leaking water. - The metal vent system, over the dishwasher, was rusty and soiled. - The metal support pieces for the ceiling tiles in the dishwasher area were unclean/rusty. - The wall behind the dishwasher was soiled with food and unclean. - The floor behind the 3 bay sink area was unclean with debris on it. - A section of floor between the 3 bay sink and a food heating oven had standing water and was unclean. - The walk-in milk cooler contained undated sliced cheese. - The dishwasher clean storage rack had two 8 quart measuring cups with orange colored debris on them. - The storage room contained two dented 62 ounce (oz.) mushroom cans 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, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 of 1 resident (Resident #55) reviewed. Specifically, the facility did not provide Resident #55, whose primary language was not English, with a plan for communication of needs and preferences. The findings are: The facility policy Translation and/or Interpretation of Facility Services reviewed 1/2022 documented the facility's language access program would ensure that individuals with limited English proficiency (LEP) would have meaningful access to information and services provided by the facility. Resident #55 had diagnoses including dizziness and anxiety. The 5/3/22 Minimum Data Set (MDS) assessment documented the resident needed or wanted an interpretor 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 observation, record review and interview during the recertification survey conducted 8/8/22-8/15/22 the facility failed to determine the clinical appropriateness of self-administration of medications for 1 of 8 residents (Resident #124) reviewed. Specifically, Resident #124 had a physician order documenting the resident was not capable of self-administering medications and multiple creams and Melatonin (a hormone that promotes sleep) were observed in the resident's locked bedside table. Findings include: The facility policy Administering Medications reviewed 1/2022, documented residents may self-administer medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, determined they had the decision-making capacity to do so safely. Resident #124 had diagnoses of chronic kidney disease, schizoaffective disorder, and history of intentional self-harm poisoning by medications. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact…

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 survey conducted 8/8/22 to 8/15/22, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in process for 1 of 3 residents (Resident #99) reviewed. Specifically, certified nurse aide (CNA) #10 was not removed from having contact with residents immediately following an alleged incident of abuse, neglect, or mistreatment involving Resident #99. Findings include: The facility policy Abuse and Neglect - Clinical Protocol revised 1/2022 documented abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Neglect was defined as the failure of the 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, record review and interview during the recertification and abbreviated (NY00276204, NY00294053, NY00297551, NY00264591, NY00293364, NY00300052, and NY00290644) surveys conducted 8/8/22-8/15/22, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 10 residents (Residents #17, 37 and 48) reviewed. Specifically, Resident #17's hair was unclean, Resident #37 was not dressed daily, and Resident #48's nails were unclean, and their clothing was not changed daily. Findings include: The facility policy Brushing and Combing Hair dated 1/2022 documented the resident's hair should be brushed and combed every morning before breakfast and whenever necessary throughout the day. Staff were to comb and style the resident's hair according to their preferences. The facility policy Dressing and Undressing the Resident dated 1/2022 documented staff were to encourage the resident 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.

Based on observation, interview and record review during the recertification and abbreviated (NY00300052 and NY00264591) surveys conducted 8/8/22-8/15/22, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident (Resident #73) reviewed. Specifically, Resident #73 did not have Prevalon boots (a boot that floats the heels to reduce pressure) applied to their bilateral heels while in bed or in their wheelchair as planned. Findings include: The facility policy Care plans- Baseline revised 1/2022 documented a baseline care plan was to be developed for the resident within 48 hours to assure the resident's immediate care needs were met and maintained, including initial goals and physician's orders. The facility policy Pressure Ulcers/Skin Breakdown Clinical Protocol reviewed 4/2022 documented the physician would help the staff review and modify the care plan as appropriate, especially when wounds…

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 (NY00268090) conducted on 8/8/22-8/15/22, the facility failed to ensure the resident environment remained free of accident hazards as possible and residents received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #108) reviewed. Specifically, Resident #108 had smoking materials in their room which were not secured per facility policy and the resident's plan of care and other care planned interventions to promote smoking safety were to implemented as planned. Findings include: The facility policy Smoke Free Policy, revised 1/2022, documented it was the policy of the facility to maintain a smoke free facility. The facility was to possess all smoking and lighting materials at all times. The resident would be evaluated on admission, quarterly, and upon a significant change to determine if the resident was a smoker or non-smoker. If a smoker, the evaluation would include current level and frequency of tobacco consumption; ability to smoke…

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 8/8/22-8/15/22, the facility failed to assist residents in obtaining routine dental care for 1 of 3 (Resident #96) residents reviewed. Specifically, the facility did not obtain the services of a dentist for Resident #96 when their lower dentures were missing and not recovered. Findings include: The facility policy Dental Services reviewed 1/2022 documented routine and emergency dental services were available to meet the residents' oral health services in accordance with the resident's assessment and plan of care. Social services representatives would assist residents with appointments and transportation arrangements. Direct care staff would assist residents with denture care, including removing, cleaning, and storing dentures. Dentures would be protected from loss or damage to the extent practicable, while being stored. If dentures were damaged or lost, residents would be referred for dental services within 3 days. If the referral was not made within 3 days, documentation would be provided…

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

Based on observation, record review and interview during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure the menus reflect, based on a facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population for 1 of 1 resident reviewed (Resident #48). Specifically, Resident #48 had limited intake due to cultural and ethnic food preferences and there was no documented evidence the facility attempted to obtain foods that would meet the resident's preferences. Findings include: The facility Resident Food Preferences Policy and Procedure dated 1/2022 documented that upon the resident's admission the dietitian or nursing staff would identify a resident's food preferences. Nursing staff would document the resident's food and eating preferences in the care plan. If the resident refused or was not happy with their diet, the staff would create a care plan that the resident was satisfied with. The Food Service Department would offer a variety of foods at each scheduled meal. Resident #48 had diagnoses including Parkinson's disease…

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

Based on observation, record review and interview during the recertification and abbreviated (NY00294053) surveys conducted 8/8/22-8/15/22, the facility failed to 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 2 certified nurse aides (CNAs #20 and 45) and activity aide #51 observed for appropriate mask wearing. Specifically, CNAs #20 and 45 and activity aide #51 were observed not wearing face masks appropriately in resident care areas. Findings include: The facility policy Personal Protective Equipment - Using Face Masks reviewed 1/2022 documented an objective of using face masks was to prevent transmission of some infections that were spread by direct contact with mucous membranes. Be sure that face masks covered the nose and mouth while performing treatment or services for the patient. The facility policy Updated Guidance on COVID-19 revised 1/10/22 documented all staff and contractors must wear a face mask 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.