Eddy Village Green At Beverwyck

Based on record review, observations, and interviews during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the Main Kitchen and in the house kitchens for House 21 and House 31. Specifically, proper labeling/dating of open items was not followed, and expired food items were found stored ready for use in the refrigerators and freezers. Findings include:Policy titled, Production, Purchasing, Storage; subject Food and Supply Storage, revised 01/2026, documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Foods past the use by, sell by, best by, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections of an orange label. Products are good through the close of business on the date noted on the label. Date and rotate…

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 conducted during a survey, the facility failed to report all alleged violations involving abuse, neglect, and injuries of unknown source immediately, but not later than two (2) hours after the allegation was made, to the administrator of the facility and to other officials (including to the State Agency) for two (2) (Resident #s 12 and 27) of five (5) residents reviewed. Specifically, (a) Resident # 12 reported an incident with alleged abuse on 01/05/2026 at 9:00 PM. This incident was reported to the Department of Health on 01/06/2026 at 9:59 AM. (b) Resident # 27 reported an incident with alleged abuse on 03/30/2025 at 10:09 AM, which was reported to the Department of Health on 03/30/2024 at 6:42 PM. Findings Include:The facility's Policy and Procedure dated 03/25/2025 titled Abuse Prevention & Investigation documented, the incident must be reported immediately upon witnessing or learning of a suspected allegation of abuse to a direct supervisor, charge nurse, administrator, Director of Nursing Services, or other appropriate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a survey, the facility failed to ensure that each resident had a person-centered individualized care plan developed and implemented according to professional standards of practice for two (2) (Resident #'s 4 and 22) of 17 residents reviewed. Specifically, (a) for Resident #4, their medicated dandruff shampoo was not noted to be required in the resident's Comprehensive Care Plan; and (b) for Resident #22, the Comprehensive Care Plan did not address the resident's difficulty with speaking. Findings Include: The facility's policy and procedure dated 06/27/2023 titled Interdisciplinary Care Conference and Care Planning documented that at a minimum the baseline care plan will include healthcare information necessary to properly care for each resident immediately upon their admission and address resident-specific health and safety concerns. The plan will include initial goals, physician orders, medications, dietary orders, therapy orders, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a survey, the facility failed to ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment, recognized, evaluated, and addressed the needs of every resident for three (3) (Resident #s 12, 20, and 22) of three (3) residents reviewed for nutrition/hydration status maintenance. Specifically, Residents #s 12, 20, and 22 had significant weight changes that were not assessed timely.Findings include:Facility policy titled, Clinical Nutrition Services, dated 05/1995 and last revised 01/2024, documented that the registered dietitian or designee would complete a nutrition evaluation within 72 hours of admission. The dietitian would complete a comprehensive nutrition assessment according to the admission date and Minimum Data Set schedule. The dietitian would monitor regularly to ensure residents maintained acceptable parameters of nutritional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice. This was evident for 2 (House #s 21 and 31) of 2 Houses reviewed. Specifically, 1) the medication carts in House 31 contained an expired stock medication, 2) the medication carts in House #31 contained 3 insulin pens not labeled with the dates opened and the expiration dates after opening, 3) the medication carts in House #'s 21 and 31 contained 2 bottles of eye drops and 2 bottles of nasal sprays not labeled with the dates they were opened and the expiration dates after opening, and 4) the medication cart in House #31 contained an inhaler not labeled with the date opened, and the expiration date after opening. This was evidenced by: Documentation provided by the facility's Nursing Chief Executive Office on [DATE] at 9:32 AM included their pharmacy's policy regarding the storage…

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, staff interviews, and record review during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure food was stored in accordance with professional standards for food service safety for two (2) of 2 resident central kitchens. Specifically, bulk food items and outside items were (A) not labeled for their contents, (B) not date-labeled after open or labeled with an expiry date, (C) and were not discarded by the best use date to discard food items. This was evidenced by: House # 31 During observations on 11/30/2023 from 10:35 AM to 11:26 AM, the following was noted within the main kitchen area for House # 31: A) Eleven (11) items did not have labels describing what they were: Container of grated cheese located within a refrigerator Bag of carved meat located within a refrigerator Package of butter located within a refrigerator Frozen waffles located within a freezer Frozen scones located within a freezer Frozen cookies located within a freezer Frozen hamburger buns…

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 record review and interviews during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure they were in compliance with all regulatory requirements when they chose to ask residents or their representatives to enter into an agreement for binding arbitration for 3 (Resident #'s 1, 3, and 5) of 4 residents reviewed for binding arbitration. Specifically, the facility binding arbitration agreement (A) for Resident #1 did not explicitly grant the resident or their representative the right to rescind the agreement within 30 calendar days of signing it; (B) for Resident #3 did not explicitly state that neither the resident nor their representative were required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility, and; (C) for Resident # 5 did not provide for the selection of an arbitration venue that was convenient to both parties. This was evidenced by: A) Resident #1 was admitted to 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 staff interviews during the recertification survey from 11/28/2023 to 12/01/2023, the facility did not ensure hand hygiene procedures were followed by staff involved in direct resident contact for 2 (House #'s 21 and 31) of 2 houses reviewed for infection control. Specifically, for House #21, the facility did not ensure facility staff performed hand hygiene between doffing (removing) and donning (putting on) gloves while preparing dessert in the kitchen on 11/29/2023. For House #31, the facility did not ensure gloves were doffed and hand hygiene was performed by staff exiting the kitchen on 11/28/2023, and gloves were doffed, and hand hygiene performed by a staff member after touching 5 resident drink glasses, a resident, and prior to entering/exiting the kitchen on three occasions while passing drinks to residents in the dining room on 11/30/2023. This was evidenced by: The policy and procedure titled Hand Hygiene/Artificial Fingernails and dated 04/12/2022 documented handwashing was to be done before and after touching a resident, before…

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 staff interviews during the recertification survey from 11/28/2023 to 12/1/2023, the facility did not dispose of garbage and refuse properly. This was evident for 4 of 9 trash bins in the trash collection area. Specifically, trash bins located in the trash collection area overflowed with waste and the trash collection area was open. This was evidenced by: During an observation of the trash collection area on 11/30/2023 at 1:05 PM, four (4) trash bins overflowed with waste. Three (3) of the trash bins were not fully covered with trash overflowing the bins, and one (1) trash bin was left uncovered with trash overflowing the bin. The trash collection area to the trash bins had a fenced in area with double swing doors for access, with one door left open and unsecured. The policy titled Trash Removal-(facility name), last revised on 8/13/2018, documented step-by-step instructions on how the facility was to remove trash from buildings daily, with resident care coordinators to empty individual house trash bags and remove the trash bags to the trash…

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 record review and interviews during the recertification survey dated from 11/28/2023 to 12/01/2023, the facility did not ensure each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated, or the resident had already been immunized. This was evident for 1 (Resident #5) of 5 residents reviewed for immunizations. Specifically, Resident #5 was not offered a pneumococcal immunization upon admission. This was evidenced by: Resident #5 was admitted to the facility on [DATE] with diagnoses of hypothyroidism, osteoarthritis, and iron deficiency anemia. The Minimum Data Set (an assessment tool) dated 10/04/2023 documented the resident was able to make themselves understood, able to understand others, was cognitively intact. The Minimum Data Set documented the resident's pneumococcal immunization status was not up to date / not received. The Policy and Procedure titled Immunizations: Standard of Care and dated 6/30/2023 documented the resident and/or their…

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 interviews during the recertification survey from 11/28/2023 through 12/2/2023, the facility did not ensure comprehensive person-centered care plans were implemented. This was evident for 1 (Resident #7) of 12 residents reviewed for Comprehensive Care Plans. Specifically, Resident #7 was found alone on the floor in the bathroom with a skin tear on their right forearm, and their safety awareness care plan documented staff were not to leave the resident alone in the bathroom. This is evidenced by: The policy and procedure titled Falls Management Policy and revised 12/2022 documented the facility would prevent and/or reduce the number of falls by providing an individualized, person-centered care approach with managing fall risk through the process of assessment, planning, implementation, and evaluation. The policy and procedure titled Care Plans - Comprehensive and revised 12/2022 documented the comprehensive care plan included measurable objectives and timetables to meet 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.