The Paramount At Somers Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (2619941), the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice for one (1) of four (4) residents reviewed. Specifically, Resident #1 who had moderate cognitive impairment and a history of constipation was triggered on the facility bowel list report in June, July, and August 2025 for no bowel movement. The facility bowel protocol was not initiated for the resident. Prior to discharge on [DATE] the resident received a dose of Milk of Magnesia on 08/08/2025 with no documented evidence of the effectiveness of the Milk of Magnesia. Subsequently Resident # 1 was admitted to the hospital on [DATE] after discharge and was found to have large amounts of stool seen in the rectum with rectal mural thickening on Computed Tomography of the abdomen.The Findings are: The facility's undated Treat in Place Guidelines for Constipation and Bowel Protocol documented the following Symptoms…

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 an abbreviated survey (2619941), the facility did not ensure a resident right to voice a grievance, and to make prompt efforts to resolve grievances the resident may have for 1 out of 3 residents (Resident #1) reviewed for grievances. Specifically, Resident #1's representative informed the Patient Relations Concierge #1 that Resident #1 had several items that went missing from their room. Resident # 1's representative stated that they did not receive any follow-up from the facility regarding the missing items and no grievance was completed by the facility. The findings are: The facility Grievance/Concerns policy dated 02/14/2023 documented the residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Any resident, family…

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 an abbreviated survey (2619941), the facility did not ensure all relevant resident information necessary to meet the resident's needs was conveyed to avoid risk of complications at time of discharge to the home for 1 (Resident #1) of 3 residents reviewed for discharge planning. Specifically, Resident #1 was scheduled to be discharged from the facility on 08/09/2025 with home care services. Resident #1's home care services were delayed due to the late submission of necessary information to the home care agency. Resident #1's home care services was not initiated until 08/14/2025. The findings are:The facility Discharge/Summary and Plan dated 01/27/2025 documented when a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and their representative. Residents who are…

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 an abbreviated survey (2619941) the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) residents (Resident # 1) reviewed for constipation. Specifically, Resident # 1 was admitted to the facility on [DATE] and had a diagnosis of constipation with no care plan in place to address the constipation until 6/15/2025. On 8/9/2025, Resident # 1, was discharged from the facility and admitted to the hospital on [DATE] with a diagnosis of severe sepsis. Review of the Facility Care Plan Policy last revised March 2022 documented that Resident Care Plans are developed according to the timeframes and criteria established by S483.21.The facility's undated Treat in Place Guidelines for Constipation and Bowel Protocol documented Symptoms and Interventions: -if no bowel movement for six shifts, give 30 ml, sorbitol by mouth for one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated survey (2615374), the facility did not ensure that services being provided meet professional standards of quality in clinical practice for 1 out of 3 residents (Resident #8) reviewed for quality of care/treatment. Specifically, Resident #8 who had a history of stroke was noted to have a sudden onset of slurred speech by Licensed Practical Nurse #6 on 12/07/2024. Nurse Practitioner #3 was informed by Registered Nurse #1 of Resident #8's slurred speech and instructed the staff to place the resident back to bed for rest. Resident #8's slurred speech continued and was reported to Nurse Practitioner #3 and they ordered to treat the resident with intravenous fluids and obtain a speech evaluation done. Resident #8 continued with slurred speech and weakness on 12/07/2025 and was not transferred to the hospital for evaluation until 12/08/2025, after their representative demanded their transfer to rule out a stroke. Resident #8 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (2619941), the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit for 2 out of 3 residents (Resident #1 and #10) reviewed for follow up consultation visits. Specifically, (1) Resident #1 who was admitted to the facility status post a right hip fracture had a follow up Orthopedic consultation visit on 06/12/2025. The consultation report documented Resident #1 was to be scheduled for a follow up visit in six weeks. Resident #1 was discharged home on [DATE] without getting the Orthopedic consultation. There was no documented evidence of a Physicians order for the six week follow up visit that needed to be scheduled by the facility for Resident #. The resident was discharged home from the facility on 08/09/2025 and instructed to follow up post discharge with the Orthopedic.(2) Resident #10 was admitted to the facility status post a left hip fracture and had an Orthopedic…

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 an abbreviated survey (NY00385588/568719, NY00373004/568714) the facility did not ensure that the comprehensive care plan was updated and revised for 2 out of 4 residents (Resident #1, Resident #3)) reviewed for falls. Specifically, (1) Resident #1 had a fall from the Hoyer lift while being transferred by Certified Nurse Aide #1 and Certified Nurse Aide #2 on 07/02/2025. Review of Resident #1's fall risk care plan revealed it was not updated to reflect the actual fall. (2) On 03/10/2024, Resident #3 had an unwitnessed fall in their room and sustained laceration to their left eyebrow. Review of Resident #3's care plans revealed their risk for fall care plan was not updated with the actual fall that occurred on 03/10/2024.The findings are:The facility Fall Prevention protocol policy created 08/20/2018 documented a goal of the facility is to provide a safe and healthful environment for residents, visitors and employees. A comprehensive approach to safety, which…

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 an abbreviated survey (NY00385588), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for falls and supervision. Specifically, on 07/02/2025 Resident #1 who was dependent for transfers fell out of the mechanical lift while being transferred by Certified Nurse Aide #2. Resident #1 fell striking their head on the leg of the mechanical lift. Certified Nurse Aide #1 was in the room with their back turned getting the Resident #1's chair closer to the bed for transfer.The findings are:The facility Fall Prevention protocol policy created 08/20/2018 documented a goal of the facility is to provide a safe and healthful environment for residents, visitors and employees. A comprehensive approach to safety, which considers the hazards identified in the environment and individual resident risk factors and then…

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 conducted during the recertification and abbreviated surveys (NY00338981) from 10/31/24 to 11/07/24, the facility did not ensure the residents' environment remained as free of accidents hazards as possible for 2 (Residents #631 and #226) of 10 residents reviewed for accidents. Specifically, 1) Resident #631 had a physician order for a pureed diet with nectar thick liquids, and was able to consume thin liquids and a cookie while in a supervised area, and required oral suctioning to clear their throat. 2) Resident #226 had an electric air mattress overlay, on top of their mattress, that was not inspected by the maintenance department for safety until after the start of survey. The findings are: 1) Resident #631 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia, and dysphagia (difficulty swallowing). The Minimum Data Set (an assessment tool) dated 3/8/24 documented the resident had impaired cognition, required…

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 conducted during the recertification survey from 10/31/24 to 11/07/24, the facility did not ensure that they treated each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #66) of two residents reviewed for dignity. Specifically, Resident #66's room was located on the first floor and looked out to the staff parking lot. The window had a broken screen and a broken window shade that was fully up and could not be pulled down to provide the resident with privacy. The findings are: The facility policy titled Window safety Policy dated 7/20/21 and revised on 06/2023 documented that is the facility policy that all facility windows be maintained in a safe and functional order, and the windows will be provided with blinds and insect screens. If a blind or screen needs repair, the facility will utilize and third-party vendor to repair/replace blind or screen. 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 interviews conducted during the recertification survey from 10/31/24 to 11/07/24, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene for one (Resident #226) of six residents reviewed for Activities of a Daily Living. Specifically, Resident #226 required total assistance with Activities of a Daily Living cares by facility staff, did not receive Activities of a Daily Living cares on multiple shifts, according to the October 2024 Certified Nurse Aide documentation. A private duty aide stated they provided all the cares for the resident 8 hours a day, 7 days a week. The findings are: The Private Duty/Companion Education Guidelines for Facility Entry, Exit and Visit documented that private duty/companions are not permitted to provide resident care at any time during their visit. Resident #226 was admitted with diagnoses including but not limited to dementia, Parkinson's disease, and seizures/epilepsy. The 10/05/24…

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

Based on record review and interviews conducted during the recertification and abbreviated (NY00349833) surveys from 10/31/24 to 11/7/24, the facility did not ensure a resident who was fed by enteral means (delivery of nutrients through a feeding tube directly into the stomach) received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #182) reviewed for tube feeding. Specifically, the facility did not have the physician prescribed gastrostomy tube size available. The findings are: The facility November 2018 policy titled Changing a Percutaneous Endoscopic Gastrostomy Tube, documented assemble equipment and supplies needed, and gastrostomy tube (size ordered by physician). Resident #182 was admitted with diagnoses which included aphasia, respiratory failure, and gastrostomy status. The 6/7/24 Quarterly Minimum Data Set (resident assessment) documented Resident # 182 had severely impaired cognition, and received feeding via a feeding tube 51% or more. The Physician's Dietary Orders documented 3/27/24 NPO (nothing by mouth). 4/6/24 Enteral…

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 the recertification and abbreviated surveys (NY00351352) from 10/31/24- 11/7/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) Multiple residents reported during interviews and the Resident Council Group meeting that the facility was short staffed at times, 2) Several nursing staff members reported lack of sufficient staffing to provide care to the residents, and 3) a review of the actual staffing sheets from 10/1/24 to 10/31/24 showed that on multiple occasions the facility was below the minimum levels documented on the Facility Assessment. Findings include: The Payroll Base Journal, Quarter 1 2024 (October 1 - December 31), documented a one star staffing rating and excessively low weekend staffing. The facility staffing sheets from 10/1/24-10/31/24 and the Facility Assessment, for residents to direct care nursing staff ratios, documented the facility was understaffed 19 days of 31 days covering various shifts as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview conducted during a recertification survey from 10/31/24-11/7/21, the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards, labeling and the expiration date. Specifically, expired medications were found in the medication cart on one of five units (Westminister Unit) and unlabeled medication was found in the medication storage refrigerator on one of four units ([NAME] Unit) observed for medication storage. The findings are: During observation on 11/6/24 at 4:50 pm of the medication storage room refrigerator #3 on the [NAME] Unit, two boxes of Ascor were found in a plastic bag. The two boxes of Ascor and the plastic bag did not contain a resident name and pharmacy label. There was one bag containing three boxes of Ascor that had the resident name and pharmacy label. During an interview on 11/6/24 at 4:50 pm Licensed Practical Charge Nurse #16 stated all Ascor was ordered for the same resident and should be in…

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

Based on observations and interviews conducted during the recertification survey from 10/31/24 to 11/7/24, the facility did not ensure storage of food in accordance with professional standards for food service safety for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, the kitchen walk-in freezer insulation door seals were not attaching properly causing formation of ice on the freezer's floor, the freezer's door, and plastic curtain inside the freezer. Finding include: The facility policy Walk-in freezer/refrigerator dated 8/21/20 documented proper maintenance of the walk-in freezer is crucial for food safety, energy efficiency, and the longevity of the facility's equipment. Daily maintenance tasks included but not limited for door seal inspection to ensure door seals and gaskets are functioning properly. Monthly Maintenance Tasks included insulation inspection to check insulation and make necessary repairs. During an initial tour of the kitchen on 10/31/24 at 9:53 AM, conducted with Food Service Director, the walk-in freezer was observed with ice accumulation on inside…

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 (NY00346322), the facility did not ensure the right to receive services with reasonable accommodation of needs and preferences for 1 of 2 residents (Resident #212) reviewed for choices. Specifically, Resident #212 requested to use an electric wheelchair while at facility and was not assessed for ability to use an electric wheelchair. The findings are: Resident #212 had diagnoses including to Heart Failure, Arthritis, and Anxiety. The 9/16/24 Annual Minimum Data Set assessment documented Resident #212 was cognitively intact and required assistance with most activities of daily living. Resident has used a manual wheelchair and was dependent upon staff to be wheeled in the wheelchair. The facility Motorized Wheelchair Policy, dated 8/6/2019, documented motorized wheelchairs are designed for people who lack the motor function or cardiovascular strength to operate a manual wheelchair. This includes people with mobility issues. It is important to assess the resident's ability to utilize…

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 interview during the Recertification survey 10/31/24- 11/7/24 and abbreviated survey (NY00338981) the facility did not ensure residents received treatment and care in accordance with professional standards of quality for 1 of 4 (Resident # 631) residents reviewed for accidents. Specifically, for Resident # 631 there was no documented evidence of a Registered Nurse assessment of breath sounds or pulse oximetry after a resident received a food not on their diet plan and began coughing requiring oral suctioning. The findings are: Resident #631 was admitted with diagnoses of chronic obstructive pulmonary disease, dementia, and dysphagia. The Minimum Data Set (an assessment tool) dated 3/8/24 documented the resident had impaired cognition, required supervision for eating and was totally dependent on staff for activities of daily living. The Speech Pathologist assessment dated [DATE] documented the resident exhibited mild prolonged mastication, holding of food and frequent throat clearing…

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 interview and record review conducted during the abbreviated (NY00347929) survey from 7/23/2024 to 7/24/2024, the facility did not ensure the resident's right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option they prefer. This was evident for 1 (Resident #1) of 3 total sampled residents. Specifically, a mood stabilizer medication, Depakote, was ordered and administered to Resident #1 without the resident's Designated Representative being informed in advance of the risks and benefits of the medication and alternative treatment options. The findings are: The facility policy titled Family Notification dated 9/20/2021 documented family will be notified regarding resident changes and next steps. Progress notes regarding clinical changes should also include which familial contact was spoken to. Change in medication is an example of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the abbreviated (NY00347929) survey the facility did not ensure the resident right to a clean, comfortable, and homelike environment. This was evident for 1 ([NAME] Unit) of 7 resident units. Specifically, a strong pervasive odor of urine was observed throughout the [NAME] Unit including in resident rooms. The findings are: The facility policy titled Carpet Cleaning and Operating the Speed-Ex Carpet Machine dated 7/22/2022 documented carpets located throughout the facility are shampooed weekly and spot-cleaned as needed. If the area is too soiled, full cleaning will be instituted. On 07/23/2024 at 11:29 AM and 07/24/2024 at 2:13 PM, the [NAME] Unit was observed to have a strong pervasive odor of urine throughout the unit and in resident rooms. The locked unit had double doors requiring a code to enter. The odor was noticeable and intense as the doors to the unit were opened. Approximately 20 residents were stationed at a lounge area in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated survey (NY00347929), the facility did not ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner. This was evident for 1 of 4 residents (Resident #2) reviewed for behaviors. Specifically, Resident #2's At Risk for Fall Comprehensive Care Plan (CCP) was not updated after a fall incident on 04/02/2024. The findings are: The Facility Polity titled Care Plans, Comprehensive Person-Centered dated March 2022 documented that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #2 had diagnoses that included Chronic Obstructive Pulmonary Disease, Abnormalities with Gait and Mobility, Bipolar Disorder, and Alzheimer's…

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 interview and record review conducted during the abbreviated (NY00347929) survey from 7/23/2024 to 7/24/2024, the facility did not ensure a resident who was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #1) of 4 residents reviewed for behaviors. Specifically, Resident #1's Comprehensive Care Plan related to dementia care was not reviewed and revised to address the resident's increasing dementia-related behaviors. The findings are: The facility policy titled Dementia - Clinical Protocol dated 11/2018 documented the interdisciplinary team will maximize the resident-centered care plan for remaining function and quality of life. The interdisciplinary team will review changing needs as they arise. The facility policy titled Behavioral Assessment, Intervention and Monitoring dated 3/2019 documented the facility will provide and residents will receive…

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 abbreviated (NY00347929) survey from 7/23/2024 to 7/24/2024, the facility did not ensure a facility-wide assessment was conducted to determine what resources are necessary to care for its residents competently. This was evident for 1 ([NAME] Unit) of 7 resident units. Specifically, the Facility Assessment did not identify the [NAME] Unit as a specialized dementia unit and did not identify the staffing assignment necessary to care for residents during day-to-day operation. The findings are: The facility policy titled Facility assessment dated 10/2018 documented the Facility Assessment is intended to help determine budget, staffing, training, equipment, and supplies needed. The Facility assessment dated [DATE] documented common resident diagnoses included impaired cognition, Alzheimer's disease, and non-Alzheimer's dementia. The facility uses basic par levels for each residential unit as a standard measure: Licensed Nurses = 10, Nurses' Aides…

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 reviews and interviews during an abbreviated survey (NY00301968, NY00314825), the facility did not ensure that Certified Nursing Assistant (CNA) performance reviews were completed at least once every 12 months for seven (CNA's # 4,5,6,7,8,9 and 10) of nine CNA's reviewed. The findings are: A facility policy titled 'In-Service Training, Nurse Aide' dated 5/19/23 documented that the facility completes a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews. The facility was unable to provide documented evidence that the CNA's (CNA #'s 4,5,6,7,8,9, and 10) had performance reviews completed at least once every 12 months. A facility document titled 'Copy of CNA's + Hire Dates' documented CNA #'s 4,5,6,7,8,9, and 10 have been employed by the facility for greater than one year. During an interview conducted with the Director of Nursing (DON) on 8/30/23 at 3:20 PM, the DON stated that the facility does not perform annual performance evaluations on their CNA's. During an interview conducted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review conducted during a recertification survey, the facility did not ensure that proper hand hygiene to prevent cross contamination and the spread of infection was followed during a lunch meal observation on 1 of 5 facility units ([NAME] Unit) for residents #140, #149, #257 and #260. Additionally, proper hand hygiene was not followed during a wound care treatment for 1 of 5 residents (#261) reviewed for pressure ulcers. The findings are: 1) During a dining observation on 2/8/19 at 12:30 PM a Certified Nursing Assistant (CNA #8) picked up a piece of paper from the floor in the dining room and proceeded to feed Resident #149 without first washing her hands. During a dining observation on 2/8/19 at 12:35 PM the following was observed: 1) CNA #9 touched the arm of resident #257, then proceeded to feed resident #140. 2) CNA #9 lifted the arm of resident #257 placing a blanket under her arm and then continued to feed resident #140. 3) CNA #9 then opened a container 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, interviews and record review conducted during the most recent recertification survey, the facility did not ensure that advance directives would be implemented according to residents' wishes. This was evident for 3 of 5 residents reviewed for advanced directives who had Do Not Resuscitate (DNR) orders (Residents #271, 183 and 224). The findings are: According to the facility's policy on Advanced Directives, if a resident does not want cardiopulmonary resuscitation (CPR) or has an order indicating do not resuscitate (DNR), a yellow dot will be placed on the wrist band (identification band) and on the spine of the chart to indicate the resident's wishes not to be resuscitated. Observations revealed that this policy was not implemented for the following residents: 1. Resident #271 is an [AGE] year old male who was admitted to the facility on [DATE] with a diagnosis of Dementia. An advanced directive was formulated for the resident on [DATE], which stated that the resident did not want to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during the Recertification Survey, the facility did not ensure that a significant change Minimum Data Set (MDS) Assessment (a tool to assess a resident's care needs) was completed within the 14 day requirement. This was evident for a resident with two Stage 3 pressure ulcers (Resident #224). The findings are: Resident #224 was admitted to the facility on [DATE] with a diagnosis of Non Alzheimers Dementia. A Significant Change MDS assessment dated [DATE] indicated the resident had a stage 3 pressure ulcer which was not present on admission. The wound notes were reviewed and indicated the following: 11/27/18 stage 3 pressure ulcer on the left buttock, 2cm x 4cm x 0cm. 12/4/18 stage 3 pressure ulcer on the left buttock, 1cm x 1cm x 2.5cm. 12/10/18 stage 3 pressure ulcer on the left buttock, 2cm x 1.5cm x 0.2cm and stage 3 on the right sacrum, 1.5cm x 1.5cm x 0cm. 12/17/18 stage 3 on the left buttock, 2cm x 1cm x 0.1cm, stage 3 on the right sacrum, 1cm x 8cm x 0.1cm.…

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 3. Resident #141 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Osteoarthritis and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) dated 12/20/18 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 which suggested severe cognitive impairment with daily decision making; required extensive assist of one person with transferring, walking in the room and corridor, and locomotion on and off the unit. The mobility device used was a wheelchair. The MDS also documented that the resident felt down, depressed or hopeless, had little interest or pleasure doing things and felt tired or having little energy for 2-6 days. The resident also had difficulty concentrating. There were no behavioral issues documented. Multiple observations were made during the survey, and the following was observed. Resident #141 was observed on 2/5/19 at 11:45 AM-12:15 PM. She was awake,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the most recent recertification survey, the facility did not ensure that the necessary care was provided to prevent complications related to hemodialysis for one resident reviewed for dialysis (Resident#128). Specifically, 1) daily assessment of the dialysis access for a bruit and a thrill to ensure adequate blood flow was not being done; and 2) the resident's care did not routinely include pre and post dialysis assessments. The findings are: Resident #128 is a [AGE] year-old male with diagnoses including Sickle Cell Anemia, Hypertension, Cerebrovascular Disease, and End Stage Renal Disease requiring hemodialysis two days weekly on Mondays and Fridays. A review of the current plan of care for dialysis in effect in February 2019 included a goal for the resident to tolerate dialysis with no complications. Good AVF (arteriovenus fistula) care will help maintain the patency (open and unobstructed) of the vascular access. Patency can be assessed by feeling…

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 interview during the recent recertification survey, the facility did not ensure that the pharmacy consultant's recommendation was implemented. Specifically the consultant pharmacist recommended that parameters be included for blood sugar levels that would indicate the need to call the physician. This was evident for one of five residents reviewed for unnecessary medications (Resident #12) The findings are: Resident # 12 was admitted to the facility on [DATE]. Current diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Hypertension, , Hyperlipidemia, Anxiety and Diabetes Mellitus. The Minimum Data Set (an assessment tool) annual assessment dated [DATE] was reviewed. Medications received included insulin injections on all 7 days of the assessment period. The monthly medication regimen review completed by the consultant pharmacist for the month of November included the following recommendation, Resident has an order for fingerstick without insulin coverage. Please clarify…

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 483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. Based on observation, interview and documentation review, the facility did not ensure that all mechanical equipment was maintained in safe operating condition. Reference is made to diesel exhaust odors noted on the Berkshire unit (2nd floor, and Stairwell # 4) originating from one of two boilers (boiler no. 1) located in the basement of that building. The findings are: On 2/13/2019 at 9:45 AM during the recertification survey, a tour of the 2nd floor of the Berkshire nursing unit was conducted. At that time, an odor of diesel exhaust was noted in the corridor between resident rooms B217, B219 and B221 and stairwell #4. The Berkshire unit and basement had been toured between 9:00 AM - 12:00 PM on 2/8/19 and there had been no diesel exhaust odors noted at that time. In an interview at 9:45 AM on 2/13/19, The Director of Building Services stated that the boiler room was located directly under the Berskshire…

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.