New Vanderbilt Rehabilitation and Care Center, Inc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that a resident was provided with appropriate treatment and services to maintain or improve their ability to ambulate. This was evident for 1 (Resident #143) 5 residents reviewed for Activities of Daily out of 39 sampled residents. Specifically, Resident #143 was not provided with floor ambulation program as per physical therapy and in accordance with physician's order. The findings are: The facility's policy and procedure titled Restorative Nursing Services revised 1/1/2024 documented resident will receive restorative nursing care as needed to help promote optimal safety and independence. Resident #143 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Hypertension, and Hyperlipidemia. The Quarterly Minimum Data Set, dated [DATE] documented Resident #143 had intact cognition, required supervision…

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/ Complaint Survey from 07/09/2024 to 07/16/2024, the facility did not ensure that a resident with indwelling catheter receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bowel function to the extent possible. This was evident for 2 (Residents #20 and #160) of 3 residents reviewed for Catheter care out of a sample of 39 residents. Specifically, the Foley urinary collection bag was improperly positioned compromising the devices' ability to maintain gravity drainage and prevent reflux of urine. The findings are: The facility's policy and procedure titled Catheter Care, Urinary with a revision date of 12/2019, documented that the drainage bag should be positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1.Resident #20 was admitted to the facility with diagnoses that included Coronary Artery Disease, Neurogenic Bladder,…

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 staff interviews conducted during the Recertification survey conducted from 7/09/24 to 7/16/24, the facility did not ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 1 (Resident #222) of 5 residents reviewed for Unnecessary Medications out of 39 sampled residents. Specifically, the attending physician did not address the consultant pharmacist's recommendations for Resident #222 as documented that they agreed and will do. The findings include: The facility's policy titled Consultation Review Policy, last revised 3/1/24, documented all consultation will be reviewed by the Medical Doctor/Nurse Practitioner upon consult completion to ensure that there is no delay in diagnosis, treatment, and service. Resident #222 was admitted to the facility with diagnoses that include Alzheimer's Disease and Anxiety Disorder. The Quarterly Minimum Data Set, dated…

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 (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure a resident was free from physical abuse. This was evident for 1 (Resident #36) of 5 residents reviewed for Abuse out of 39 total sampled residents. Specifically, on 6/09/24 at 6:51 PM, the Dayroom Attendant sprayed Resident #36 with hand sanitizer when Resident #36 was trying to exit the dayroom. The findings are: The facility policy and procedure titled Abuse Prevention with a revision date of 1/07/2024 documented that residents will be protected from abuse, mistreatment, exploitation, or misappropriation of resident property in accordance with State and Federal Regulations. Resident #36 was admitted with diagnoses that included Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus. The Minimum Data Set, dated [DATE] documented that Resident #36 had moderately impaired cognition. The Comprehensive Care Plan titled Potential 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 record review and interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health, but not later than 2 hours after the allegation was made. This was evident for 2 (Resident #36 and #102) of 5 residents reviewed for Abuse out of 39 total sampled residents. Specifically, a resident-to-resident altercation between Resident #36 and #102 was not reported to the New York State Department of Health within 2 hours of occurrence. The findings are: The facility policy and procedure titled Abuse Prevention with a revision date of 1/07/2024 documented all allegations of abuse must be immediately reported to the Administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury.…

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 (NY00344855) survey from 7/09/2024 to 7/16/2024, the facility did not ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #36) of 5 residents reviewed for Abuse out of 38 total sampled residents. Specifically, the alleged staff-to-resident abuse involving the Dayroom Attendant and Resident #36 was not thoroughly investigated. The findings are: The facility policy and procedure titled Abuse Prevention with a revision date of 1/07/2024 documented the facility will investigate all incidents of alleged and actual abuse, complaints/grievances, misappropriation, and injuries of unknown origin. The investigative process will include statements from staff, witness, residents, interviews with staff, witness, residents, medical record review if applicable, review of employee records. All findings of investigations will be documented. An investigative report will be completed within 5…

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

Based on observation, record review and staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan related to Activities of Daily Living was not revised quarterly. This was evident for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living out of 38 total sampled residents. The findings are: The facility's policy and procedure titled Comprehensive Care Plan revised 1/1/2024 documented each resident will have an individualized interdisciplinary plan of care in place. Resident #143 was admitted to the facility with diagnosis of Cerebrovascular Accident, Hypertension and Hyperlipidemia. The Quarterly Minimum Data Set assessment was completed on 2/26/2024 and 5/20/2024. The Care Plan for Activities of Daily Living Functional/Rehabilitation Potential created 11/13/2023 was last revised 12/22/2023. There was no documented evidence that 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 staff interviews conducted during the Recertification and Abbreviated (NY00344855) survey from 07/09/2024 to 07/16/2024, the facility did not ensure psychotropic drugs were not given to residents unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 1 (Resident #102) of 5 residents reviewed for Unnecessary Medication out of 39 total sampled residents. Specifically, Resident #102 displayed worsening of behavioral symptoms and psychotropic medication was increased without Resident #102 being assessed for possible underlying medical cause. The findings are: The facility policy titled Role of the Attending Physician at New Vanderbilt Rehab and Care Center dated 05/2023 documented the attending physician will periodically review all medications and monitor both for continued need based on validated diagnosis or problems and for possible adverse drug reactions. The medications review should…

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 staff interviews conducted during the Complaint (NY#00335874) and Recertification survey from 7/9/2024 to 7/16/2024, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Resident #143 was not provided with floor ambulation program, but documentation reflected that resident was provided with a floor ambulation program. This was evident for 1 (Resident #143) of 5 residents reviewed for Activities of Daily Living out of 39 sampled residents. The findings are: The facility's policy and procedure titled Restorative Nursing Services revised 1/1/2024 documented resident will receive restorative nursing care as needed to help promote optimal safety and independence. Resident #143 was admitted to the facility with diagnosis that included Cerebrovascular Accident and Hypertension. The Quarterly Minimum Data Set, dated [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 observations, record review, and interviews conducted during an abbreviated survey (NY00321932), the facility failed to protect a resident's right to be free from physical abuse by nursing home staff. This was evident for 1 of 7 residents reviewed for abuse (Resident #1). Specifically, a review of the facility surveillance camera revealed that on 08/10/2023 at 12:16 AM, Resident #1 exhibited agitation and physical aggression. Resident #1 struggled with CNA #1 and stumbled on the floor. While Resident #1 was on the floor, CNA #1 held Resident #1's arms and their left knee rested on Resident #1's left hip preventing Resident #1 from getting up and as a means to control Resident #1's behavior. A review of the camera also showed at 12:22 AM that CNA #1 held Resident #1 against the wall when Resident #1 chased CNA #1 in the hallway. Cross reference: F604 - Right to be Free from Physical Restraints The findings are: The Facility's Policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation…

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 an abbreviated survey (NY00321932), the facility failed to protect a resident's right to be free from physical restraint. This was evident for 1 of 7 residents reviewed for abuse (Resident #1). Specifically, a review of the facility surveillance camera revealed that on 08/10/2023 at 12:16 AM, Resident #1 exhibited agitation and physical aggression. Resident #1 struggled with CNA #1 and stumbled on the floor. While Resident #1 was on the floor, CNA #1 held Resident #1's arm and their left knee rested on Resident #1's left hip preventing Resident #1 from getting up. A review of the camera also showed at 12:22 AM that CNA #1 held Resident #1 against the wall when Resident #1 chased CNA #1 in the hallway. Cross Reference: F600 - Free from Abuse and Neglect The findings are: The Facility's Policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Residents' Property with the last review date of 10/24/2022 documented that it…

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 (NY00321932), the facility failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This was evident in 1 of 7 residents reviewed for abuse (Resident #1). Specifically, Resident #1 exhibited several incidents of aggressive behavior towards staff and other residents. The facility did not evaluate the effectiveness of the interventions to address Resident #1's aggression. The findings are: The facility's Policy titled Behavioral Health Services with effective date of 10/2022 stated that each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with comprehensive assessment and plan of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the facility did not ensure resident Comprehensive Care Plan (CCP) was reviewed and revised upon each assessment. This was evident for 3 (Resident #60, #546, and #97) of 39 total sampled residents. Specifically, 1) Resident #60 did not have their CCP related to fluid restriction revised upon change in fluid restriction, 2) Resident #546 was not invited to their CCP meeting, and 3) Resident #97 did not have their CCP related to smoking revised upon noncompliance with facility smoking policy. The findings are: The policy and procedure titled Interdisciplinary Care Plan Conference dated 1/20 documented that the facility to hold an interdisciplinary care planning conference to identify resident needs and establish goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents. 1) Resident #60 had diagnoses of chronic kidney disease and…

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

Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not ensure a surety bond was purchased to secure all personal funds of residents deposited with the facility. This was evident for 160 residents with personal funds accounts (PFA) out of 249 residents. Specifically, the facility's PFA for 160 residents exceeded the facility's surety bond amount. The findings are: The facility policy titled Resident Funds dated 9/13 documented that the facility's policy to ensure the safeguard of resident funds and ensure fund are accessible as appropriate in accordance with applicable regulations. The resident's personal funds surety bond effective date from 11/14/22 to expire date to 11/14/23 documented the facility obtained a surety bond for $350,000. The facility resident balances as of 5/24/23 documented a total balance of $361,013.10. The facility did not ensure a surety bond was obtained to cover the total value of residents' funds held by the facility. On 05/26/23 at 11:46 AM, the Director of Account Receivable (DAR) was…

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 staff interviews conducted during the recertification and complaint survey (NY00309251) from 5/22/23 to 5/26/23, the facility did not ensure that each resident was free from abuse. This was evident for 1 (Resident #143) of 4 residents reviewed for abuse out of 39 total sampled residents. Specifically, on 01/24/23 Resident #143 was slapped on the buttocks by Certified Nursing Assistant (CNA) #3 while being assisted with ADL care. The findings include: The facility's current Policy and Procedure, titled Abuse Prevention Policy and Procedure stated that the facility prohibits all forms of abuse. Physical abuse is hitting, slapping, pinching, and kicking and control of behavior with corporal punishment. All prospective employees will be screened prior to employment to rule out any history of abuse, neglect or mistreatment or resident. All employees would be trained on abuse prevention policy. All incidents will be investigated. The facility will report all incident or violations where…

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 5/22/23 to 5/26/23, the facility did not ensure each resident remained free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. This was evident for 1 (Resident #126) out of 1 resident reviewed for Physical Restraint out of a sample of 39 residents. Specifically, Resident #126, a resident with severely impaired cognition, was observed with bilateral full side rails in place, and there was no assessment, physician's order for the bilateral full side rails (SR), or medical justification. In addition, there was no assessment for the half-side rails that were ordered. The findings are: The facility policy titled Restraints last updated on 12/2009 documented restraints may be used for medical, emergent and in an extreme situation to protect the residents from injury. The policy also documented that all restraints must have a physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during a recertification /complaint survey (NY 00309251) from 5/22/23 to 5/26/23, the facility did not ensure all alleged violations involving abuse were reported to the New York State Department of Health (NYSDOH) immediately, but no later than 2 hours after the allegation was made. This was evident for 2 (Resident #143 and #18) of 39 sampled residents. Specifically, 1) Resident #143 reported an allegation of abuse and the facility did not report the allegation to the NYSDOH timely, and 2) the facility did not report a resident-to-resident altercation that resulted in pain to NYSDOH involving Resident #18. The findings are: The facility policy titled Abuse Prevention Policy and Procedure stated that All incidents will be investigated. The facility will report all incident or violations where abuse, neglect, mistreatment of misappropriation of property is suspected to NYSDOH according to protocol. 1) Resident #143 had diagnoses which included atrial fibrillation…

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 staff interview conducted during a Recertification survey from 05/22/23 to 05/26/23 the facility did not ensure that each portion of the Minimum Data Set (MDS) assessment accurately reflects the resident's status. Specifically, The MDS assessments did not accurately document that four side rails were used with a resident. This was evident for 1 of 1 resident reviewed for Physical Restraints out of a of 39 sample residents. (Resident #126). The findings are: Resident #126 had diagnoses which include Restlessness and agitation, Dependence on respirator [ventilator] status, and Seizure Disorder. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #126 had severely impaired cognition and required total assistance of one person for transfers and toilet use. The MDS also documented that bed rails were not used. On 05/22/23, from 9:55 AM to 01:55 PM, Resident #126 was observed in bed, alert and awake with padded bilateral full side rails in place. Resident #126 appeared…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification survey conducted from 5/22/23 to 5/26/23, the facility did not develop and implement a Baseline Care Plan (BCP) within 48 hours of admission. This was evident for 1(Resident #546) out of 1 resident reviewed for Care Planning out of a sample of 35 residents. Specifically, Baseline Care Plan was initiated but not completed within 48 hours of admission, and residents and their representatives were not provided with a written summary of the baseline care plan. The findings are: The policy and procedure titled Baseline Care Plans dated 3/16/22 documented that it is the facility's policy to develop and implement a Baseline Care Plan (BCP) to each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Resident #546 was admitted to the facility on [DATE] with diagnoses of Chronic Gout, End Stage Renal Disease, and Hyperlipidemia. The Minimum Data Set 3.0…

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 reviews and interviews conducted during the recertification survey from 05/22/23 to 05/26/23, the facility did not ensure that comprehensive care plans (CCP) were developed. This was evident for 2 (Resident #60 and #547) of 39 sampled residents. Specifically, a dialysis care plan was not developed for Resident #60, and an anticogulant care plan was not developed for Resident #547. The findings are: 1) Resident #60 had diagnoses of chronic kidney disease and type 2 diabetes. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #60 was cognitively intact, received dialysis, and received a therapeutic and mechanically altered diet. On 05/25/23 at 10:01 AM, Resident #60 was interviewed and stated they are scheduled for testing for a kidney transplant today and desires a more liberal diet and meal planning. Medical Doctor Orders (MDO) last renewed 5/7/23 documented Resident #60 was ordered to receive a no concentrated sweets/no added salt diet, non-carb ProSource 30cc twice daily, Nepro…

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 reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/23-05/26/23, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident for 1 (Resident #35) of 1 resident reviewed for Infection Control, out of a sample of 38 residents. Specifically, there was no documented evidence that a Pulmonary consult that was ordered for a resident (Resident #35), with Respiratory Syncytial Virus (RSV), was done. The findings are: The facility's policy titled Consultation Request and Report, dated January 2022, documented that the purpose is to ensure that all consults ordered by the Attending Physician, will be done in a timely manner. Resident #35 was admitted to the facility with diagnoses that include Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease (COPD) and Non-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 observation, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure residents received adequate supervision to prevent accidents and hazards. This was evident for 1 (Resident #107) of 5 residents reviewed for Accidents/Hazards out of 39 total sampled residents. Specifically, Resident #107, a resident with a history of holding their own smoking materials against facility policy, did not receive adequate supervision to prevent the resident from smoking in their room. The findings are: The facility policy titled Non-Smoking Facility Revised 9/5/2020, documented the facility will provide appropriate safety education, including location of the designated smoking area. Residents who identified as smokers will keep all smoking materials/paraphernalia with the Recreation Department to ensure safe storage of materials. Resident #107 had a diagnosis of diabetes mellitus and pulmonary embolism. The Minimum Data Set 3.0 (MDS) dated documented…

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, interviews, and record review conducted during the recertification survey from 5/22/23 to 5/26/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 resident (Resident #18) reviewed for Pain Management out of 38 total sampled residents. Specifically, Resident #18 received opiod pain medications and treatment without ongoing monitoring of the efficacy of the pain management. The findings are: The policy titled Pain Management dated 7/2022 documented the nurse should document the pain scale reported by the resdient and a pain scale after interventions were rendered. Resident #18 had diagnoses of bipolar disorder and spinal stenosis. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 had moderate cognitive impairment, received opioid medication 7 out of 7 days prior to the assessment, and reported they had no pain at time of 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 staff interview conducted during the Recertification survey, the facility did not ensure that if bed rails are used, correct installation, use, and maintenance was maintained. This was evident for 1 (Resident #126) resident reviewed for Physical restraint out of a sample of 39 residents. Specifically, Resident #126 had full side rails in use without (1) An assessment for risk for entrapment from bed rails prior to installation; (2) review of the risks and benefits of bed rails with Resident #126's representative to obtain informed consent prior to installation, and (3) An evaluation to ensure the bed's dimensions are appropriate for Resident #126's size and weight. The findings are: The facility policy titled Side Rail Use dated 2017 documented that resident will be assessed for functional status on admission, readmission and quarterly. Partial side rails will only be used by a resident to assist with his or her bed mobility. Full side rails are only be used when 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 observation, record review, and interviews conducted during the Recertification survey from 5/22/23 to 5/26/23, the facility did not ensure a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet their needs. This was evident for 1 (Resident #446) of 39 total sampled residents. Specifically, a resident was prescribed Allopurinol once a day and nurses were administering twice a day. The findings are: The facility Policy on Medication Administration dated September 2021, documented: The RN shall write verbal and telephone orders and shall read the order back to the ordering Physician or Authorized Practioner for confirmation of accuracy. Also documented Verify the medication selected matches the order and label. and The Licensed Nurse shall verify active medication orders prior to administration and ensure that the intent of the order is carried out. Resident #446 was admitted…

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 reviews, and interviews during the Recertification and Complaint Survey (NY00308839), from 05/22/23-05/26/23, the facility failed to establish and maintain infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases. Specifically, the facility did not follow their policy and procedures to maintain Contact precautions on a resident (Resident#35). with Respiratory Syncytial Virus (RSV). This was evident for 1 of 1 resident reviewed for Infection Control, out of a sample of 38 residents. The findings are: The facility's policy titled Guidelines for Isolation Precautions: preventing transmission of infectious agents in healthcare settings dated May 2020, documented that the purpose is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for residents, visitors, and employees. The policy also…

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 5/22/23 to 5/26/23, the facility did not ensure residents, staff, and the public were provided with a safe, sanitary, and comfortable environment. This was evident for 2 (Elevator 1 and 3) of the 3 elevators. Specifically, Elevator 1 and Elevator 3 were observed with detached ceiling panels and dust buildup. The findings are: On 05/25/23 at 10:00 AM, Elevators #1 and #3 were observed with ceiling panels that were warped with multiple screws missing. Ceiling panels in each elevator were detached from the ceiling where screws were missing and the panels were observed hanging off of and separated from the ceiling. The wooden molding on the ceiling of Elevator 1 and Elevator 3 bordered the panels and was observed with splintered peeling wooden strips. The center of the ceiling in Elevator 1 and Elevator 3 had a raised dome with ornate metal casing that was covered with dust and grime. One side of the ventilation panel on the ceiling of Elevator 3 was not screwed in, was detached, and was…

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.