Carmel Richmond Healthcare and Rehabilitation Cent

Based on record review and interviews conducted during an abbreviated survey (ID#2720832), the facility failed to ensure that a designated resident representative was notified of changes in the resident's condition. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, Resident #1 was assessed on 08/14/2025 to have developed moisture associated skin damage (caused by prolonged exposure to moisture from sources such as urine, stool, sweat or wound drainage) to sacrum and bilateral buttocks and treatment was ordered. Resident #1's designated representative was not notified of changes in Resident #1's skin condition. The findings are: The facility policy and procedure titled Notification of Resident's Change in Condition dated 04/2020 documented detection of a resident's change in condition can be reported to a licensed nurse by staff at any level, and to the resident's responsible party. The nurse is responsible for documenting in the medical record the date, time, and name, each time the Physician/Physician Extender, Resident or Responsible Party…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Abbreviated Survey (ID #2720832) the facility failed to ensure the Minimum Data Set assessments accurately reflect each resident's status. This was evident in one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident 1 was admitted to the facility from the hospital on [DATE] and was identified with Cellulitis (a common, potentially serious bacterial skin infection). The Minimum Data Set, dated [DATE] assessment did not reflect Resident #1's skin condition. 2) the hospital discharged , and Patient Review Instrument dated 12/30/2025, revealed Resident #1 was discharged to the facility with eight wounds to various body areas. A facility admission note dated 01/02/2026 documented Resident #1 had wounds to sacrum, bilateral buttocks, bilateral hips, and gangrene to all toes and bilateral heels. The Minimum Data Set assessment dated [DATE] did not reflect Resident #1's wounds. The findings are: The facility policy titled Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00353123), the facility failed to provide adequate supervision to a resident to prevent accident. This was evident for one (1) of six (6) residents (Resident #3) sampled. Specifically, Certified Nursing Assistant #9 transferred Resident #3 out of bed to the recliner chair by themself at 8:00 AM [DATE]. After breakfast, Certified Nursing Assistant #9 transferred Resident #3 back to bed by themself at 10:51 AM. While Certified Nursing Assistant #9 was in the process of providing morning care to Resident #3 at 10:51 AM, they observed Resident #3 with a discoloration on the left inner thigh. Registered Nurse #2 and Registered Nurse Supervisor #3 assessed Resident #3 who had a bruise on the left inner thigh. An x-ray result dated [DATE] documented an acute fracture of the left hip. Resident #3 was transferred to hospital on [DATE] at 9:21 PM and returned to the facility on [DATE] at 3:45 PM with principal discharge diagnosis…

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 an abbreviated survey, (NY00368833), the facility did not ensure the residents' right to be free from physical abuse. This was evidence for one out of six residents reviewed (Resident #1). Specifically, on 01/13/2025 at 07:18 PM, Licensed Practical Nurse #1 reported to Registered Nurse Supervisor #1, Certified Nursing Assistant #1 threw a cup of melted ice cream on Resident #1's. Registered Nurse Supervisor #1 assessed Resident #1 and observed a wet stain on the top of Resident #1's clothes. The findings are: The facility's Policy and Procedure entitled Abuse Prevention, dated 10/2022, documented it is the policy of the organization to ensure that all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. The facility prohibits verbal, mental, sexual, and physical abuse and corporal punishment or involuntary seclusion by any staff, volunteer, or other resident. Resident #1 was admitted to the facility on [DATE],…

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 07/31/2024 to 08/07/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident in 1 (Resident #132) of 6 residents reviewed for accidents, out of 38 total sampled residents. Specifically, the facility did not report to the New York State Department of Health an unwitnessed incident on 07/21/2024 when Resident #132 was observed on the floor with lacerations to the forehead and nose bridge. The findings are: The facility policy titled Identification, Investigation Protection and Reporting Physical Abuse,…

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 07/31/2024 to 08/07/2024, the facility failed to ensure that a Significant Change in Status Assessment was completed within 14 days after a determination had been made in the resident's status from baseline occurred. This was evident in 1 (Resident # 167) of 1 resident reviewed for pressure ulcer / injury out of 35 total sampled residents. Specifically, on 06/30/2024, Resident #167 was identified with an unstageable pressure injury to the sacrum and deep tissue pressure injury to the left heel. The facility did not have a Significant Change in Status Assessment completed after the change in condition was identified. The findings are: The facility policy titled Minimum Data Set Completion with a revised date of 10/2023 stated that the Minimum Data Set is completed on all residents according to a mandated assessment schedule. The purpose of the policy was to ensure all Minimum Data Set assessments are completed in a timely manner…

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 Survey from 07/31/2024 to 08/07/2024, the facility did not ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. This was evident during the Kitchen Task observation. Specifically, 1.) 2 boxes containing 20 (14 ounces) packages of bratwurst in the kitchen refrigerator and the freezer in the emergency food area were stored beyond the best by date, and 2.) potentially hazardous food were not maintained at an acceptable temperature to limit the growth of pathogen. The findings are: The facility's policy on Food and Supply Storage with a revised date of 03/2024 documented all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell by, best by, enjoy -by or use-by should precede the date. Foods past the use-by, sell-by,…

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 conducted during the recertification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a discharge assessment was not transmitted within 14 days after completion. This was evident for 1 of 1 resident reviewed for the Resident Assessment task. (Resident # 4). The finding is: Resident #4 was discharged from the facility on 06/22/2019. Nursing progress note dated 6/22/19 documented resident was discharged home accompanied by ambulette attendants. Medications were reviewed and discharge instruction was given. Review of the medical record revealed no documented evidence that a discharge MDS assessment had been completed. On 10/07/2019 at 11:30 AM, the State Agent (SA) requested the discharge MDS. MDS Coordinator # 2 processed and transmitted the discharge assessment on 10/07/2019. On 10/08/2019 at 10:33 AM, an interview was conducted with MDS Coordinator…

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, the facility did not ensure that the Minimum Data Set 3.0 (MDS) accurately reflected the resident's status. Specifically, (1) a resident with no pressure ulcer during the assessment period was documented on the MDS as having an unhealed Stage 2 pressure ulcer and, (2) a diagnosis of Anxiety Disorder was not captured on the MDS of a resident receiving anti-anxiety medication. This was evident for 2 residents reviewed out of a total investigation sample of 38 residents. (Resident # 117 and 276). The findings are: 1. Resident #117 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Non-Alzheimer's Dementia, Peripheral Vascular Disease, Aphasia, Cerebrovascular Accident, and Hemiplegia. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident is totally dependent on two staff persons for bed mobility, transfer and toilet use. The MDS also documented that the resident had one unhealed Stage 2 pressure ulcer. 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.