Richmond Center for Rehabilitation and Specialty H

Based on interviews and record review conducted during the Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure residents' right to communicate with individuals and entities external to the facility. This was evident for 11 of 11 attendees of the Resident Council meeting. Specifically, the facility did not have a system in place for residents to receive and send mail on Saturdays. The findings are: The facility's policy titled Resident Mail revised 09/2021 documented all resident mail/packages need to be delivered daily, including Saturdays. On 08/16/23 at 11:00 AM, a Resident Council meeting was held with 11 residents of the facility. All eleven residents present at the meeting stated that they were not able to receive mail on Saturdays and the Recreation Director delivers the mail Monday through Friday. On 08/21/23 at 10:57 AM, the Director of Recreation (DOR) was interviewed and stated that when mail is delivered, it is sorted and dispersed to the Recreation department from the admission department. If packages are delivered they are provided to Security…

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 during the Recertification survey conducted from 08/14/2023 to 08/21/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 5 residents (Resident #336, #99, #155, #335, and #325) out of 38 total sampled residents. Specifically, 1) hand hygiene was not performed during tracheostomy care, 2) a Licensed Practical Nurse (LPN) was observed not donning Personal Protective Equipment (PPE) appropriately prior to entering the room of a resident on contact precautions for Candida Auris. In addition, blood sugar monitoring devices and insulin pen placed on surfaces in the resident's room were taken out of the room to be discarded/stored on the medication cart without being sanitized; 3) an LPN used a stethoscope for a resident on contact isolation, did not sanitize it upon leaving the resident's room, and placed in on the top surface of the medication cart, 4) hand hygiene was not performed appropriately during…

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 8/14/2023 to 8/21/2023, the facility did not ensure the resident's right to a dignified existence. This was evident for 2 (Resident #225 and #166) of 35 total sampled residents. Specifically, 1) Resident #225 was fed by staff standing over them, and 2) Resident #166 was not provided with clothing to ensure they were dressed appropriately. The findings are: The facility policy titled Quality of Life/Dignity dated 10/2022 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Resident #225 had diagnoses of autism and hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #225 had severely impaired cognition and required limited assistance of one person for eating. On 8/14/2023 at 12:20 PM, Licensed Practical Nurse (LPN) #6 was observed standing over Resident #225 while feeding the resident. During an…

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 interview conducted during the Recertification survey from 8/14/2023 to 8/21/2023, the facility did not ensure the resident and their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 4 (Residents #170, #327, #351, and #334) of 35 total sampled residnts. Specifically, 1) Resident #170's designated representative was not provided with a copy of the resident's BCP, 2) Resident #327 was not provided with a copy of their BCP, 3) Resident #351 was not provided with a copy of their BCP, and 4) Resident #334 was not provided with a copy of their BCP. The findings are but not limited to: The facility policy titled BCP dated 4/2023 documented the facility will provide the resident and the representative (if applicable) with a written summary of the BCP by completion of the comprehensive care plan (CCP). Facility will document and record receipt of information by family in the resident's clinical record. 1) Resident #170 had…

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 8/14/2023 to 8/21/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's goal, and address the resident's medical, physical, mental, and psychosocial needs. This was evident for 1 (Resident #351) of 1 resident reviewed for Dental out of 38 total sample residents. Specifically, there was no documented evidence that a CCP was developed and implemented for oral/dental concerns for a resident who was observed with missing teeth and poor dentition. The findings are: The facility's policy and procedure titled Care Plans - Comprehensive reviewed 8/21/2023 documented it is facility's policy that the Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered, care plan for each resident. The comprehensive, person-centered care plan is…

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, records review, and interviews during the Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure that a resident with a sacral pressure ulcer receive the necessary care and treatment to prevent infection of ulcer. Specifically, there was no dressing observed to the sacral area for a resident with a Stage Suspected Deep Tissue Injury pressure ulcer. This was evident for one (1) of three (3) resident reviewed for Pressure Ulcers out of 38 sampled residents. (Resident # 335). The finding is: Resident #335 was initially admitted with diagnoses that included Diabetes Mellitus, Necrotizing Fasciitis, and Gastrostomy status. The admission Minimum Data Set assessment dated [DATE], documented Resident #335 was severely cognitively impaired, required dependent assistance of two staff with activities of daily living, was at risk for pressure ulcer, and had one Stage 4 and two unstageable pressure ulcers present on admission. The Physician Order dated 7/24/2023 documented to apply…

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 8/14/2023 to 8/21/2023, the facility did not ensure a resident maintained acceptable parameters of nutritional status. This was evident for 1 (Resident #166) of 4 residents reviewed for nutrition out of 35 total sampled residents. Specifically, interventions to address Resident #166's significant weight loss were not implemented to prevent further weight loss. The findings are: Resident # 166 had diagnoses of diabetes mellitus and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #166 was severely cognitively impaired, required extensive assistance with feeding, and had an unplanned weight loss. The Comprehensive Care Plan (CCP) related to nutritional status last reviewed 05/23/2023 documented Resident #166 had a significant undesired 3-month weight loss. Interventions included a gastroenterologist (GI) consult for possible feeding tube. the goal was to maintain Resident #166'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.

Based on interviews, observations and record reviews conducted during a Recertification survey from 8/14/23 to 8/21/23, the facility did not ensure timely identification and removal of expired medications. Specifically, expired medications were observed in the Emergency Medication Box on Unit 4. The findings are: The facility's policy and procedure entitled Medication Storage effective 2/2014 and revised 1/2022 documented that expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy. On 08/17/2023 at 04:15 PM, during the Medication Storage task conducted on Unit 4, the sealed emergency box medication checklist documented that Narcan 0.4mg/ml, quantity of 2, had an expiration date of 7/23/2023. Licensed Practical Nurse (LPN) #2 was interviewed immediately and stated that all nurses are supposed to check the emergency box. On 08/17/23 at 04:51 PM, LPN #8 was interviewed and stated that the emergency box monthly is checked monthly if it is not opened. LPN #8 also stated that they had looked…

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 staff interviews conducted during a Recertification survey conducted from 8/14/23 to 8/21/23, the facility did not ensure that all medications and biologicals were labeled properly and stored appropriately. Specifically, multiple bags of IV antibiotics were observed stored in a medication refrigerator without a thermometer, and one opened, undated vial of insulin was observed in the Medication cart. This was evident during observations conducted for the Medication Storage Task. (4th Floor) The findings are: The facility policy titled Medication Storage dated 2/2014 and 1/2022 documented refrigerators used for medication storage will contain a thermometer to indicate the temperature within. Temperature will be checked daily to ensure it is within the specific range. If temperature is out of range, the refrigerator thermostat will be adjusted. On 08/17/2023 at 04:15 PM, three large Ziploc bags containing multiple bags of IV Vancomycin were observed stored in a refrigerator that did not contain a thermometer. Labeling on the packages indicated store at or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification and complaint (NY00318827) survey from 8/14/2023 to 8/21/2023, the facility did not ensure all alleged violations involving major injury were reported to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #505) of residents reviewed for Abuse of 35 total sampled residents. Specifically, the facility did not report Resident #505's unwitnessed fall resulting in a head laceration was not reported to the NYSDOH. The findings include: The facility policy titled Abuse, Neglect, Mistreatment, Exploitation Prohibition dated 12/2022 documented the facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone. Resident #505 had diagnoses of anemia and coronary artery disease (CAD). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #505 was severely cognitively impaired and required the assistance of 2 people to complete activities 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 interview and record review conducted during a recertification and complaint (NY00318827) survey from 8/14/2023 to 8/21/2023, the facility did not ensure a resident received adequate supervision and assistance to prevent accidents. This was evident for 1 (Resident #505) of 35 total sampled residents. Specifically, Resident #505 fell and sustained a head laceration when a Certified Nursing Assistant (CNA) stepped away from the resident while providing care. The findings include: The facility policy titled Abuse, Neglect, Mistreatment, Exploitation Prohibition dated 12/2022 documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse, neglect, and mistreatment. Resident #505 had diagnoses of anemia and coronary artery disease (CAD). The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #505 was severely cognitively impaired and required the assistance of 2 people to complete activities 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 observations, record reviews and interviews conducted during the recertification survey the facility did not ensure that the resident meals were attractive, palatable, delivered timely and that the meal temperatures were at an appetizing temperature. Specifically: 1)Residents complained of food palatability, lack of attractiveness, missing items, and hot meals served cold. (Res #s 29, 211, 253, 296, 303, 305, 212, and 5) 2) During dining task plate waste was observed during lunch meal. (3A/3B ) 3 )Lunch Test trays checked were found to be below the appetizing temperature for resident (res) consumption, and food trucks arrived late on 3 of 13 units. (Neuro 2EF, 2CD, 4EF, 4K and 3A, 3B, & 4th floor) 4 )The Resident Council President (Resident #351) and resident council minutes verified ongoing complaints of cold food, late meals, and other food quality complaints. This was evident for 7 of 13 units reviewed for Dining (Neuro 2EF, 2CD, 4EF, 4K and 3A, 3B, & 4th floor) and 8 of 36 sampled residents (Res #s 29, 211, 253, 296, 303, 305, 212 and 5). The findings include but are…

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

Based on interviews and record review, the facility did not ensure a residents representative was immediately notified of the need to alter treatment. Specifically, the Unit Nurse Manager did not inform a resident's family member when changes were made to the resident's psychotropic medication regimen. This was evident for 1 of 1 residents reviewed for Notification of Change (Resident #66). The finding is: Policy titled, Change in Condition Notification last reviewed 2/2021 documented the licensed nurse will notify the resident's next of kin/responsible person when a change in resident's medical or clinical treatment as identified by resident's Medical Doctor (MD). Resident #66 was diagnosed with respiratory failure with vent dependence and tracheostomy. The most recent Minimum Data Set (MDS) was dated 3/27/21 and documented Resident # 66 had severely impaired cognition, required extensive to total assistance of 2 persons with all Activities of Daily Living, had 2 stage IV pressure ulcers, and 1 deep tissue injury. The resident and family did not participate in the assessment.…

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, interviews, and record review conducted during the recertification survey, the facility did not ensure that a resident's Comprehensive Care Plan (CCP) was person-centered and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the CCP related to cognition was not complete with individualized interventions to meet the resident's needs. This was evident for 1 of 36 sampled residents (Resident #66). The finding is: A facility policy titled Care Plans - Comprehensive was dated 10/2020 and documented care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, identify professional services responsible for each element of care, and updates the care plan at least quarterly. Resident # 66 was diagnosed with respiratory failure with vent dependence, tracheostomy, and stage III pressure ulcer to the left heel. The most recent Minimum Data Set (MDS) was dated 3/27/21 and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews conducted during a recertification survey (37JG11) completed on 6/30/2021, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, on 05/22/2021, Resident #313 had a fall and complained of left shoulder pain. The recommended left shoulder x-ray was not ordered and completed timely, and the resident was not diagnosed with a left clavicle fracture until 5/26/21, 4 days after the fall. This was evident for 1 of 4 residents reviewed for Accidents (Resident #313). The finding is: The policy and procedure titled Accident-Incidents revised 07/2020 documented the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. An incident is any occurrence not consistent with the routine operational of the center, normal care 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, record review and interview conducted during the Recertification survey, the facility did not ensure that residents received necessary respiratory care consistent with professional standards of practice and the comprehensive care plan. Specifically, residents on oxygen therapy were receiving oxygen at the incorrect flow rate. This was evident for 2 of 6 residents reviewed for respiratory care out of a sample of 36 residents. Resident (#210 and 253). The findings are: 1) Resident #210 was admitted to the facility on [DATE] with diagnoses which include Chronic Obstructive Pulmonary Disease (COPD), Hypertension, and Unspecified Cerebrovascular Disease. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognitive status was severely impaired. The MDS also documented that the resident required extensive assistance for Activity of Daily Livings (ADLS). On 06/24/21 at 11:56 AM, the resident was observed sitting in a wheelchair (w/c) in…

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

Based on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure drugs and biologicals were stored in accordance with professional principles and the manufacturer's specifications. Specifically, a medication refrigerator was observed with melting ice from the freezer causing water leakage and pooling in and around the medications stored there, and an insulin pen was stored directly underneath the freezer, which was encased in ice. This was evident for 1 of 2 medication rooms reviewed during the Medication Storage task (Floor 4-AB) The findings are: Facility policy titled Medication - Storage was dated 2/2021 and documented medications will be stored in an orderly clean manner. Refrigerator should be defrosted regularly if required. Employee or resident food may not be stored in the medication refrigerator. The following are the Lantus-Solostar Manufacturer storage requirements for Lantus-Solostar insulin pens: Keep your Solostar® in cool storage (36°F-46°F [2°C-8°C]) until first use. Do not allow it to freeze. Do not put 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.

Based on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure proper storage of residents' personal food items according to professional standards for food safety. Specifically, a pantry refrigerator was observed to have undated and unlabeled resident food items with no use by date; and, one container of a spoiled substance. This was evident for 1 of 13 Unit Pantries. (Unit 4B) The findings are: A facility policy titled Food - From Outside was dated 2/2021 documented food left with the resident to consume later will be labeled, stored, and clearly distinguishable from facility prepared food. All refrigerator items will be discarded within 48 hours a perishable item will be labeled with a discard date. Nursing staff will monitor unit pantry and refrigeration units for food and beverage disposal. Nursing staff will discard any foods that show signs of potential foodborne danger (foul odor). On 06/24/21 at 12:37 PM, an observation was made of the Unit 4B pantry with Registered Nurse (RN) #5 present. The pantry room…

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 (37JG11) completed on 06/30/2021, the facility failed to ensure that infection control practices and procedures were maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) a Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #1 failed to perform required hand washing during a dressing change; and, 2) A Behavioral Health Specialist (BHS) #1 did not perform hand hygiene after resident care. This was evident for 1 of 2 residents reviewed for Pressure Ulcer (Resident #66) and 1 of 11 units (Unit - 2AB) observed for Infection Control. The findings are: 1) Facility policy titled, Pressure Ulcer (PU) Treatment was dated 11/2014 and documented procedure for wound dressing as: wash hands before treatment, apply gloves, remove soiled dressing and place in opened plastic bag, also remove…

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.