Renaissance Rehabilitation And Nursing Care Center

Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 9/5/24 to 9/13/24, it was determined the governing body did not establish and implement policies regarding the management and operation of the facility to ensure regulatory compliance. Specifically, the large elevator was not working consistently since the spring of 2024 and the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service. Findings include: The facility policy, 'Elevator Breakdown-Single Car Operation' last review April 2024 documented during downtime of one elevator car, the facility will continue to operate with as little impact as possible to resident convenience, quality of life, and provision of services. The Administrator and Maintenance Director/designee must be notified immediately upon awareness of elevator outage event with identification of specific elevator car…

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 (NY00352254, NY00345799 and NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for the entire facility. Specifically, the large elevator was out of order since the spring of 2024. The findings are: The facility policy, 'Elevator Breakdown-Single Car Operation' last review April 2024 documented during downtime of one elevator car, the facility will continue to operate with as little impact as possible to resident convenience, quality of life, and provision of services. The Administrator and Maintenance Director/designee must be notified immediately upon awareness of elevator outage event with identification of specific elevator car that is not operational. Downtime of larger elevator car will potentially impact meal delivery, evacuation processes, and movement of larger items that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from 9/5/2024 to 9/13/24, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment. This was evident during environmental observations of resident Units 1 and 2. Specifically, on Unit 2, resident rooms were observed with sticky floors, garbage receptacles overflowing, garbage was strewn the floor, and soiled adult briefs were observed lying on floor; and on Unit 1, the floor near the nursing station and in front of the elevator was littered with garbage, and appeared stained and the Unit 1 dining room floor was observed with dried spills of coffee, and breakfast trays were still on tables at 12:35 PM. The findings are: During observations on 09/05/24 on Unit 1, at 10:12 AM debris was on floors by the Unit 1 nursing station with straws, paper, caps to bottles, and other particles of dust or dirt. The floor by nursing station in front of elevator appeared stained and dirty. At…

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 (NY00346428), conducted 9/5/24 to 9/13/24, the facility did not ensure each resident remained as free of accident hazards as possible for 4 of 5 residents (#35, #161, #18, and #87) reviewed for accidents. Specifically, 1) Resident #161 had falls on 6/29/24 and 7/4/24, was on an anticoagulant (blood thinner) medication and there was no documented evidence of neuro-checks following falls on 6/29/24 and 7/4/24 and the resident was not sent to the hospital for evaluation, 2) Resident #35's shepherd's hook/enabler rail was loose and not functionable for over one month, 3)Resident #18 had a fall on 8/2/2024 and sustained a hip fracture and the fall care plan was not updated with new interventions to prevent recurrence of falls, and 4) Resident #87 had falls with major injuries on 2/8/24, 2/29/24 and 5/8/24 and the fall care plan was not updated with new interventions to prevent recurrence of falls. Findings include:…

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 the recertification and abbreviated surveys (NY00352254 and NY00340278) from 09/05/24 to 9/13/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the actual staffing from April 1, 2024 through June 30, 2024 and August 9, 2024 through September 9, 2024 on all three shifts for each unit, the facility did not provide adequate nurse staffing to meet the needs of the residents on multiple occasions during each of the months reviewed, based on the Facility-Wide Assessment. The findings are: The Facility-Wide assessment dated [DATE] and reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 8/22/24, stated the below facility resources were needed to provide competent resident support and care daily and during emergencies: Facility-Wide Assessment Staffing Plan:…

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 survey from 9/5/24 to 9/13/24, it was determined that the facility did not use the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week per the regulations. Specifically, the facility was unable to provide documented evidence that a Registered Nurse had worked 4/12/24, 4/13/24, 4/27/24, and 5/18/24. Findings include: Review of the nurse staffing reports (report posted to inform residents and visitors of the number and hours of nursing staff working) for dates 4/1/24 through 6/30/24 and 8/9/24 through 9/9/24 provided by the facility Staffing, Human Resources and Payroll Coordinator, the facility did not have a Registered Nurse assigned to staffing for the facility's three shifts on 4/12/24, 4/13/24, 4/27/24, and 5/18/24. During an interview on 09/13/24 at 10:52 AM with the Staffing, Human Resources and Payroll Coordinator, they stated staffing minimums were based on recommendations from the Facility Report and New York State requirements and based on resident census.…

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

Based on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure certified nursing aide performance reviews were completed at least once every 12 months for 5 of 5 Certified Nurse Aides ( #8, #19, #20, #21, #22) reviewed. The findings are: During an interview on 09/09/24 03:45 PM with Director of Nursing/Staff Educator, they stated they are responsible for documentation of the Certified Nurse Aide annual performance reviews. The Director of Nursing/Staff Educator, was provided with a random sample of five Certified Nurse Aides, and documentation of their annual performance appraisals was requested. Review of Certified Nurse Aides (#8, #19, #20, #21 and #22) dates of hire provided by the facility, revealed all five of the Certified Nurse Aides had been working at the facility for more than one year. The Director of Nursing stated they have not completed annual performance appraisals for the Certified Nursing Aides since they started employment in November 2022. The Director of Nursing was not able to provide…

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 9/5/24 to 9/13/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, meat, mashed potatoes, milk, and super shake were not maintained within the acceptable temperature range for food safety during a dinner observation on 9/5/24. Additionally, perishable foods were not labeled and dated and nonperishable foods were expired during observations in the kitchen. The undated facility policy, Dietary Department -Food Temperatures documented it is the policy of the dietary department to take temperatures of all food items served to residents before the tray line begins. All parts of potentially hazardous foods requiring cooking will be heated to at least 170°F with the exception of poultry, pork, and roast beef. All poultry, poultry stuffing, stuffed meats, and stuffing containing meat will be heated so all parts are at least 165°F with no interruption of the cooking process. Pork and food…

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 surveys (NY00352254 and NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service. Specifically, the large elevator was not working consistently since the spring of 2024 and was shut down in mid July 2024, and the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service which included but was not limited to food not being maintained at safe temperatures when served on the units, residents were eating on disposable plastic plates, approximately 10 residents who had previously been eating lunch in the main dining room on the main floor before the large elevator was shut down could no longer do so, and live music performances did not occur 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 interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) The facility did not have a current Water Management Plan in place that defined potential areas of Legionella risk that was updated yearly, 2) infection control precautions were not properly implemented for residents with Covid-19 infection, 3) during administration of medication there was a breach in infection control practices with a glucometer, and 4) the facility was not implementing Enhanced Barrier Precautions. The findings are: 1. The undated policy on Legionella documented, It is the policy of Renaissance Rehabilitation and Nursing Center to comply with the New York State regulations on Legionella culture sampling and analysis. A request was made to the Director of Maintenance on 9/9/2024 at 8:45 AM to see the facility's Water Management…

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 a recertification survey from 9/5/24 to 9/13/24, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide documentation of tracking antibiotic use which included appropriate use of antibiotics and duration of antibiotic treatment. The findings are: The undated Antibiotic Stewardship Policy documented it is the policy of the facility to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to track infections and reduce possible adverse events associated with antibiotic use. During an interview on 9/12/2024 at 10 AM, Registered Nurse Unit Manager #2 stated there were residents on antibiotics in July and August 2024. Registered Nurse Unit Manager #2 further stated they did not track the antibiotic use or report it. They stated they were not familiar with the term 'antibiotic stewardship'. During an interview on 9/11/24 at 3:00 PM, the Director 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.

Based on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure the Infection Preventionist completed specialized training in infection control prior to starting their role. Specifically, the facility designated Infection Preventionist was the Director of Nursing, and did not have documented evidence of completed specialized training in infection prevention and control. The findings are: On 9/6/24 a request was made to see documentation of the Infection Preventionist's specialized training in infection prevention and control. A review of the training certificate provided, documented the Director of Nursing completed 4 hours New York State Infection Control Mandatory Training Certificate on 10/15/2023. On 9/09/24 at 3:25 PM during an interview, the Director of Nursing stated they did not have any other specialized training in infection control. 10NYCRR 415.19

Based on record review, and interviews during the recertification and abbreviated surveys (NY00340278, NY346428) from 9/5/24 to 9/13/24, the facility could not provide evidence that training was provided annually to their staff on resident abuse prevention. The findings are: The undated facility policy titled abuse, neglect, mistreatment, and misappropriation of resident property included that the policy of the facility includes training employees, through orientation and ongoing sessions on issues related to abuse and prohibition practices. It documented that staff and volunteers will receive education about abuse upon first employment and annually after that. On 9/9/24 at 3:45 PM, during the staffing task, the surveyor requested from the Director of Nursing, the training logs of five sampled certified nurse aides. The Director of Nursing provided training logs for only for two of the five certified nurse aides. On 9/10/24 at 11:15 AM the Director of Nursing was asked to provide documentation of staff abuse prohibition and prevention training which had been completed in the past 12…

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 the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure 1 of 1 residents (Resident #161) reviewed for death, had the right to formulate advance directives. Specifically, Resident #161's Medical Orders for Life Sustaining Treatment were completed by Resident #161 who presented with changes in cognition, and there was no documentation that the physician determined the resident's capacity at the time of the Medical Orders for Life Sustaining Treatment completion. Findings include: 1) Resident #161 was admitted [DATE] with diagnoses including diabetes mellitus, status post left above knee amputation, osteomyelitis and rheumatoid arthritis. The 5/21/24 Medical Orders for Life Sustaining Treatment (MOLST) form documented Do Not Resuscitate and Do Not Intubate, send to hospital, trial intravenous treatment, trial feeding tube and antibiotics. The MOLST form was not signed and documented 'resident gave verbal…

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 (NY00346428) from [DATE] to [DATE], the facility did not ensure that the designated representative of 1 of 3 residents (#161) reviewed for notification of change was promptly informed of a change in the resident's declining condition and change in advance directives. Specifically, there was no documented evidence that the resident representative was promptly informed of the resident's change in advance directives to Do Not Hospitalize on [DATE] and was not notified until [DATE], and the resident expired on [DATE]. The finding is: Resident #161 was admitted with diagnoses including metabolic encephalopathy, white matter disease, and delusional disorder. The [DATE] Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 had had a Brief Interview of Mental Status score of 13 that indicated resident cognition was intact. The [DATE] Social Work note documented 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 record review and staff interview during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage form CMS-10123. This was evident for one (1) of three (3) (Resident #43) residents reviewed for Beneficiary Protection Notification. The findings are: Review of the medical record for Resident #43 on 09/11/2024, revealed the resident last received rehabilitative services on 03/26/2024 and Resident #43's designated representative was given Notice to Medicare Provider Non-coverage via telephone to inform them of their right to an expedited review of a service termination on 03/25/2024, one day prior to the termination of services. On 9/12/24 at 6:02 PM, the Social Worker stated the reason why notice of non-coverage Notice 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 record review and interviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure residents right to be free from abuse for 1 of 3 residents (Resident #14) reviewed for abuse. Specifically, on 7/30/2024 Resident #14 who was known to be physically/verbally abusive punched Resident #45 in the stomach, and new intervention of 30-minute safety checks were not initiated or carried out to prevent further abuse. Findings include: The undated facility policy titled abuse, neglect, mistreatment, and misappropriation of resident property included documentation that abuse is defined as the willful infliction of injury or intimidation with resulting physical pain or mental anguish. Willful is defined as meaning the individual must have acted deliberately. The facility leadership will assess the needs of the residents and the facility to be able to identify concerns in order to prevent potential abuse. The 'overview of seven components' included…

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

Based on record review and interview conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure that all alleged violations involving abuse and neglect were thoroughly investigated to rule out abuse/neglect and were reported to The New York State Department of Health for 1 of 3 residents (Resident #161) reviewed for abuse. Specifically, Resident #161 went to a Vascular appointment on 6/24/24 and alleged abuse by a staff member when the provider inquired about a bruise on their forehead. The provider contacted the facility regarding the alleged abuse on 6/24/24 and spoke to the Social Worker and Nurse Practitioner who determined the bruise was from a fall and did not investigate or document the allegation until 7/2/24. The findings are: Resident #161 was admitted with diagnoses including diabetes, status post left above knee amputation, osteomyelitis and rheumatoid arthritis. The 6/14/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 was independent in cognition. 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 the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood for 2 of 2 residents (Residents #38 and #18) reviewed for hospitalization. Specifically, Resident #38 and Resident #18 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident representatives. Findings include: The facility policy, 'Admission, Transfers, and Discharge; last revised November 26th, 2022, documented that when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as possible. 1.Resident #38 was admitted to the facility with diagnoses which included urinary tract infection,…

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

Based on record review and interviews during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents or resident's representatives were notified in writing of the facility policy for bed hold for 1 of 2 residents (Resident #38) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the resident or their representative. The findings are: The undated facility policy, Bed Hold and Return to Facility documented that it is the policy of the facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the state's bed hold duration and payment amount before the transfer. Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. Resident #38 was admitted to the facility with diagnoses which included urinary tract infection, retention 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.

Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the resident highest practicable physical mental and psychosocial well-being for 1 of 2 residents (Resident #162) reviewed for dialysis. Specifically, Resident #162 did not have a care plan for dialysis. The findings are: The 10/2/21 Policy titles Comprehensive Care Plan documented the facility will utilize an interdisciplinary team approach to provide an individualized and comprehensive, resident assessment and care planning process to maximize and maintain every resident functional potential and quality of life. The team will update the comprehensive care plan to keep it current on an ongoing basis. Resident #162 had a diagnosis of chronic kidney disease, diabetes and obesity. The 3/25/24 Quarterly Minimum Data Set (assessment tool) documented Resident #162 was cognitively intact and had renal insufficiency.…

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 conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not review and revise the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 2 of 5 residents (#87, #18) reviewed for accidents. Specifically, 1) Resident #87 had falls on 2/8/24 and 2/29/24 and the fall care plan was not updated with new interventions to prevent recurrence of falls, and 2) Resident #18 had a fall on 8/2/2024 and sustained a hip fracture the fall care plan was not updated with new interventions to prevent a recurrence. The findings are: 1) Resident #87 was admitted on [DATE] with diagnoses and conditions including other displaced fracture of upper end of right humerus, subsequent for fracture with nonunion, Non-Alzheimer's Dementia, and Depression. The quarterly Minimum Data Set (resident assessment tool) dated 9/1/24 documented the resident's cognition was intact; the resident required partial to moderate assist for bed mobility…

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, interview and observation during the recertification survey conducted from 9/5/24 to 9/13/24, the facility did not ensure that residents received the necessary services to maintain good personal hygiene for 3 of 6 Residents ( Residents #45, #66, #78) reviewed for activities of daily living. Specifically, Resident #45, Resident #66, and Resident #78 who required staff assistance for personal hygiene and toileting did not receive morning cares in a timely manner. The findings are: An undated Facility Policy and Procedures titled: Quality of Care documented it is the policy of Renaissance and Rehabilitation and Nursing Care Center to ensure that each resident receive and provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan or care, in accordance with State and Federal Regulations. Based on the comprehensive assessment of the resident, the facility will ensure that the resident receives care, consistent with professional…

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 9/5/24 to 9/13/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #45) reviewed for skin conditions. Specifically, Resident #45 was not assessed and a care plan was not put in place in a timely manner for changes in the Resident's skin condition. Resident #45's diagnoses included cognitive communication deficiency, chronic kidney disease, and generalized anxiety disorder. The 8/12/24 Quarterly Minimum Date Set assessment documented the resident had severe cognitive impairment. The annual Minimum Data Set documented the Resident no ulcers, wounds and skin problems. A resident care plan titled Wound Prevention / Skin Care Plan effective 10/12/2020 documented Resident #45 was at risk for impaired skin integrity, pressure wounds, ulcer, skin tears, etc. secondary to impaired mobility, vitamin deficiency dementia. The goals were the resident would maintain intact skin and would not…

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

Based on observation, record review, and interviews during a recertification survey from 9/5/24 to 9/13/24/202, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 4 residents (Resident #78) reviewed for pressure ulcers. Specifically, Resident #78 had care plan interventions and physicians order recommendations to offload heels while in bed; however, the resident was observed in bed with their heels resting directly on the mattress and there was no pillow on the mattress for the resident's feet. Findings include: Resident #78 had diagnoses which included osteomyelitis, dementia, and insomnia. The 6/27/24 admission Minimum Date Set assessment documented a Brief Interview for Mental Status of 3, indicating the resident had severe cognitive deficits. The admission Minimum Data Set documented the resident was a risk for pressure ulcers. The Facility policy and procedure titled, Managing Skin Integrity (dated 10/2023) documented that nursing, in collaboration with the health care team will assess…

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 surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure residents who required dialysis (a process that filters blood for the kidneys) received such services, consistent with professional standards of practice for 2 of 2 residents (Resident #13 and #162) reviewed. Specifically, 1) Resident #13 had no dialysis communication book, and 2) Resident #162 received hemodialysis treatments at a community-based dialysis center and did not have on going assessments and oversight before and after dialysis treatments. Findings include: The undated facility policy, title Dialysis documented, after dialysis monitor for and report hypotension ( low blood pressure) tachycardia ( fast heart rate) complaints of dizziness or light headedness or headache. 1. Resident #13 had diagnoses of end-stage renal (kidney) disease and dependence on renal dialysis and polycystic kidney adult type. The 5/13/2024 Minimum Data Set (assessment tool) documented the resident had intact cognition and 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 9/5/24 to 9/13/24, the facility did not ensure timely identification and removal of expired medications. Specifically, two bags of IV Vancomycin had expiration dates of 7/17/24, one bag of IV Vancomycin had an expiration date of 7/18/24, one bag of IV Vancomycin had an expiration date of 8/7/24, and two bags of IV Vancomycin had expiration dates of 8/10/24 were located in the first floor unit medication room. The findings are: The facility policy last revised August 2023, 'Storage of Drugs' included documentation that discontinued drug containers shall be removed from the medication cart and marked to indicate that the drug has been discontinued. Discontinued drugs shall be disposed of in accordance with the procedures set forth in this manual under the section entitled disposal of drugs and supplies, and drugs should not be kept on hand after the expiration date on the label. On 09/09/24 at 02:55 PM in the 1st floor unit medication room with Licensed Practical Nurse #5, two bags 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.

Based on record review and interviews during the recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that the attending provider documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, actions had been taken to address it. This was identified for 1 of 5 residents (Resident #43) reviewed for unnecessary medications. Specifically, the Medication Regimen Review for Resident #43 dated 4/26/2024 documented a recommendation from the consultant pharmacist for Enoxaparin 40 mg injection to be reviewed for a stop date and appropriate use based on diagnosis and patient mobility. The provider agreed with the recommendation and documented that the medication was discontinued; however, did not address the recommendation and did not document the plan in Resident # 43's medical record. The findings are: The undated facility policy for the Drug Regimen Review documented it is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a…

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

Based on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used for anticoagulation. This was evident for 1 of 5 residents (Resident # 43) reviewed for unnecessary medications. Specifically, there was inadequate monitoring of an anticoagulant medication. The findings are: The undated facility policy for the Drug Regimen Review documented it is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist needs to conduct the medication regimen review more frequently depending on the resident condition, review of short stay residents and risk of adverse consequences. The licensed pharmacist will report in writing, any irregularities to the attending physician, the facility's medical director and the Director of Nursing to be acted upon. A Physician's Order dated 8/30/2024, documented Enoxaparin 40 milligrams (MG) inject 0.4 milliliters (ml) QD…

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

Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, it was determined that the facility did not ensure residents were free from significant medication errors for 3 (Residents #38, #104, #89) of 23 residents reviewed for medication administration. Specifically, 3 residents did not receive medications in accordance with the prescriber's orders and accepted health standards established by national boards and councils. This included but was not limited to antibiotic, antidiabetic pill, vitamin, supplement, antihypertensives, inhaler for chronic obstructive pulmonary disease, and antipsychotic which were not administered at the prescribed time on 9/5/24. The findings include The facility policy, 'Administration of Medications' last reviewed January 2024 documented that a licensed nurse will be responsible for passing medications to residents in accordance with techniques approved for use in the facility and compliance with New York State codes rules and regulations and with other applicable federal…

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 conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice. Specifically, the 2nd floor unit south side medication cart was observed with expired 22-gauge insyte autogaurd needles which are used to administer intravenous medications. Findings include: The facility policy, 'Storage of Drugs' last revised [DATE] did not document the facility policy regarding the storage of medical supplies such as intravenous needles. On [DATE] at 4:34 PM, the 2nd floor unit south side medication cart was observed with three 22-gauge insyte autogaurd needles with expiration dates of [DATE]. On [DATE] at 4:39 PM, Licensed Practical Nurse #4 stated the insyte autogaurd needles should not be on the medication cart. They stated the nurse who starts an intravenous line is responsible for checking that the insyte…

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 conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides ( #9, #19, #20, #21, and #22), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The Facility Assessment Tool Report, dated 7/1/24, documented: In accordance with New York State Department of Health requirements, in-service training is provided for Certified Nurse Aides sufficient to ensure their continuing competence. Training is at least 12 hours per year and includes dementia management and resident abuse prevention training. All staff receive annual training related to safety, emergency code and plans, and specific training required for their position. The findings are: During an interview on 09/09/24 at 03:45 PM, the Director 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 observation and interviews conducted during the recertification survey and abbreviated survey (301827) conducted from 10/3/2022-10/12/2022 the facility did not maintain a safe, clean, comfortable, and home-like environment for 2 of 2 units (Units 1 and 2). Specifically,(1) the facility did not ensure that adequate housekeeping services were provided to maintain floors, bathrooms, and resident sinks on unit 2. the facility did not maintain an appropriate hot water temperature for the residents. The Findings are: The Policy and Procedure titled Housekeeping undated documented in order to prevent and control the spread of disease it is the objective of the housekeeping departments to present as far as possible aesthetic clean and contamination free surroundings for patients' visitors and personnel. An initial tour of the facility was conducted on 10/3/2022 between 9:30am and 12.00pm and the following was observed. The elevator on the second floor had strong smell of urine, room [ROOM NUMBER]-1 had garbage…

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, resident and staff interviews and record review conducted during a Recertification Survey and Abbreviated Survey (294084) the facility did not ensure that sufficient nursing staff was consistently provided for 2 of 20 residents interviewed and 7 of 10 residents who attended a group meeting (Resident Council) who expressed complaints regarding lack of sufficient staffing, delay in and not receiving care in a timely manner. Additionally, according to the Facility Assessment resident to staff ratios, Nurse and Certified Nurse Aide (CNA) levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. The findings are: During individual interviews conducted at various times during the initial phase of the survey from 10/03/22 through 10/12/22, 2 of 20 residents interviewed confidentially stated that the facility did not have sufficient staff and 7 of 10 residents who attended a group meeting (Resident Council) also complained of staffing concerns specifically at night or on the weekends. During a 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 interview and record review conducted during the Recertification Survey the facility did not ensure that 3 of 10 randomly reviewed Certified Nursing Assistants (CNAs), CNAs #5, #6 and #7, completed the required 12 hours of annual in-service training. In addition, 2 of 10 randomly reviewed CNAs, CNA #6 and CNA #7 recently hired, did not receive a facility orientation The findings are: Three of ten CNA training records reviewed lacked evidence that they were provided 12 hours of training annually to include abuse prevention as evidenced by the following: In an undated list provided on 10/12/22 CNA #5 was hired on 09/12/1994, CNA #6 was hired on 06/6/22 and CNA #7 was hired 8/12/22. Review of in-service sign-in sheets revealed there were no sign in sheets for CNA #5, #6 and #7. There was no evidence that CNA #5, #6, and #7 attended an in-service on abuse prevention during this year. During an interview with Staff Developer (SD) on 10/12/22 at 3:30 PM, SD stated that they did not have the required 12-hour mandatory trainings for CNA#5, #6, and #7. SD stated CNA #5 was hired…

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 Recertification Survey conducted from 10//22-10/12/22 the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 7 out of 10 alert and oriented residents from 2 out of 2 units, that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack, they were not provided with an evening snack. The findings are: A resident council meeting was conducted on 10/04/22 01:36 PM 7 out of 10 residents in attendance stated they were not provided or offered evening snacks and if they asked for an evening snack, they were told by the staff that, no snacks were available, or that the pantry was closed for the night. The Residents stated snacks-were not offered between 6 PM and 8AM and they were told after dinner the pantry is locked and residents are not allowed to enter the pantry. Observations on 10/06/22 at 06:54 PM revealed the 1st floor pantry had 5 cookies and 5 puddings. Observation on 10/06/22 at 07:14 PM revealed the…

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

Based on observation, interview conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure proper maintenance of the unit pantry refrigerator according to professional standards for food safety. Specifically, a pantry refrigerator was not maintained in a sanitary condition in accordance with standards for food service safety. This was evident for 1 of 2-unit pantries (Unit 2). The findings are: The facility Policy and Procedure (P&P) titled Between Meal Feeding undated documented rotation of stock and sanitation of the nursing pantry areas is the responsibility of the respective nursing units and Nutritional Services. The policy further documented procedures for cleaning and care of the nursing pantry area have been developed by Nutritional Services and are posted in each pantry. On 10/5/22 at 9:39 AM, a tour of the Unit 2 pantry with the RNC (Regional Nurse clinical) present revealed an unclean refrigerator with a few cans of ginger ale, a few cups of apple sauce and puddings for the residents. The freezer was observed with old…

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 Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure that a Comprehensive Care Plan was developed to ensure treatment and services were provided to maintain the resident's highest practicable physical well-being for 1 of 3 residents (Resident #101) reviewed for pain management. Specifically, a pain management care plan was not developed for Resident #101 who was prescribed Neurontin and Tramadol for chronic pain syndrome. The Findings Are: The facility Policy and Procedure titled Comprehensive Care Plan (CCP) undated documented the CCP will include measurable goals to meet the resident's medical, nursing, psychosocial needs. Problems, strengths, or needs identified by members of the Comprehensive Care Plan team will be included in the CCP as appropriate. The policy further documented nursing will evaluate goal achievement within the expected date of goal achievement. Resident #101 had diagnoses including Atherosclerosis of Native Arteries of Extremities with Intermittent…

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 a Recertification Survey between 10/3/2022-10/12/2022 it was determined that the facility did not ensure that each resident and/or resident representative was offered the opportunity to be involved in the their care plan for one of four residents reviewed for care planning, Specifically, Resident #95 was not invited to participate in the care plan meeting with the interdisciplinary team. The Finding Is: The Policy and Procedure titled Comprehensive Care Plan undated documented Responsibility of the Social Worker she will schedule initial quarterly annual significant change and Medicare Comprehensive Care Plan Meeting for each resident as appropriate. The Social Worker chairs and lead the meeting to ensure that all medical records for the resident being discussed are present at the meeting. Resident # 95 was admitted to the facility on [DATE] with a diagnosis of Atherosclerosis of Aorta, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for Residents # 60 and #89 who were reviewed for ADL's. Specifically, 1. Resident #60 did not receive twice a week showers as per the care plan and unit shower schedule and 2. Resident #89 was observed wearing the same attire for multiple days, and a Comprehensive Care Plan (CCP)was not revised timely to address the resident's refusals with ADL cares. The findings are: The facility Policy and Procedure (P&P) titled ADL Support undated documented OBRA requires that nursing facilities care for residents in a dignified manner that promotes self-worth and physical, psychological, and emotional well-being. It is important to promote quality of life. 1. Resident #60 had diagnoses including Secondary Parkinsonism…

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 during the recertification survey conducted 10/3/22-10/12/22, it could not be ensured that the facility maintained acceptable parameters of nutritional status for 2 of 5 residents (Residents #51 and #42) reviewed for Nutrition. Specifically, Resident #51 received nutrition via G-Tube, had a significant weight loss, and was not reassessed by clinical nutrition staff until10/05/22 and Resident #42 was assessed for 19.69% significant weight loss in one month on 8/30/22 and orders for supplements were not added until 10/3/22. The findings include: Review of the facility's policy and procedure revised 9/2022 titled, Height and Weight Monitoring documented that if a weight change of (+) or (-) 5 lbs or more from the previous weight is evident, the Dietician will review the weights, ensure there is documentation on the resident's diet, assess and summarize their consumption and update the Physician/NP as needed, the purpose being to implement corrective actions and prevent the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a Recertification Survey conducted from 10/03/22-10/12/22, the facility did not ensure that medical supervision was provided for 1 of 5 residents (#51) reviewed for nutrition. Specifically, the Physician and/or the Nurse Practitioner did not address the resident's significant unplanned weight loss between 7/7/22 and 8/25/22 of 8.6 pounds through the review date of 10/11/22. The finding is: Review of the facility's policy and procedure revised 9/2022 titled, Height and Weight Monitoring documented that if a weight change of (+) or (-) 5 lbs. or more from the previous weight is evident, the Dietician will review the weights, ensure there is documentation on the resident's diet, assess and summarize their consumption and update the Physician/NP as needed, the purpose being to implement corrective actions and prevent the weight change from progressing to a 5% weight change, evaluate and update the residents plan of care, make recommendations 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 record review and interview during the Recertification and Complaint Survey (NY00302051) conducted from 10/3/22-10/12/22, the facility did not provide pharmaceutical services to assure the administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 residents (#70) reviewed for drugs and medications. Specifically, the facility did not ensure that an anxiety medication, was administered as ordered. Subsequently, the Resident did not receive Xanax on 9/23/22 and the resident's Medication Administration Record had Xanax documentation omissions on 8/21/22, 8/29/22, 9/23/22, and 9/28/22. The finding is: The Resident was admitted to the facility on [DATE] with diagnoses including but not limited to Anxiety Disorder, Depression, and Acute & Chronic Respiratory Failure. The Minimum Data Set (MDS; an assessment tool) dated 7/25/22 documented that resident has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score…

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 and Abbreviated Survey ( NY 00301827, 00294084 and NY00302051) conducted from 10/3/2022- 10/12/2022, the facility did not ensure that medical records were complete and accurately documented for 2 of 2 residents (Residents # 119 and #120) reviewed for Pressure Ulcers and 1 of 6 residents (Resident #70) reviewed for Medication Administration. Specifically, the Certified Nursing Assistant (CNA) documentation for turning and positioning task for (Residents #119 and #120) was incompete, and the Medication Administration Record documentation for Xanax administration for Resident #70 was incomplete. The Findings are: The facility Policy and Procedure (P&P) titled Pressure Ulcer Protocol: Prediction, Prevention and Treatment undated documented prevention strategies maybe implemented regardless of risk/score based on nursing judgement and [NAME]. The policy further documented pressure relief interventions will be instituted 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.