Central Park Rehabilitation And Nursing Center

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/5/2025, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for one (1) of one (1) resident (Resident #95) reviewed. Specifically, Resident #95 did not receive double portions per their preference. Additionally, during the facility's April 2025 Food Committee Meeting 20 residents voiced concerns regarding double portions. Findings include: The facility policy Fine Dining- Meal Captain, revised 4/2024 documented the facility would provide a Meal Captain for each meal to coordinate the efficient process of the meal and to ensure that all residents have an enjoyable meal experience. The Meal Captain would give the dietary staff the residents' meal tickets, and the food would be prepared as directed on the ticket and served to the resident. Resident #95 had diagnoses including depressive disorder, anxiety, and heart failure. The 4/18/2025 Minimum Data Set assessment documented the resident had intact…

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

Based on observation, record review and interview during the abbreviated survey (NY00341649), the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's bedroom had food debris on the floor, there were no linens on the bed, the mattress had large tears, and the privacy curtain was stained. Findings include: The facility's Housekeeping Operations Manual, revised 3/2020, documented daily procedures for cleaning a resident room included dust mopping the floor, damp mopping the floors, and cleaning vertical and horizontal surfaces. Resident #2 had diagnoses including dementia and Parkinson's disease (a progressive neurological disorder). The 2/28/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required partial/moderate assistance with toileting, personal hygiene, and transfers, and did not have behavioral symptoms. The 3/21/2024 comprehensive care plan documented the resident was at risk for falling, needed assistance with…

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 and abbreviated (NY00318580, NY00315254, NY00312648, NY00302926, NY00315085, and NY00314497) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2, 3, and 4). Specifically, floors were unclean, windows were damaged or had missing components, and linen items were not available in sufficient quantities for resident use on all units. Finding include: The facility policy Work Orders dated 9/11/2023, documented the system was utilized to report issues requiring maintenance and/or housekeeping attention. The housekeeper job description documented daily resident room cleaning included proper techniques for all vertical and horizontal surface cleaning, sweeping, and mopping floors, sanitizing, and disinfecting restrooms. All housekeepers must report problems, concerns, and maintenance issues to the supervisor. 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 during the recertification and abbreviated surveys(NY00302926, NY00311496, NY00314497, NY00315085, NY00315254, NY00317770, NY00318580, and NY00321728) conducted 9/5/2023-9/12/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain adequate nutrition, and personal care including grooming and oral hygiene for 7 of 9 residents (Residents #3, 27, 76, 95, 110, 133, and 417) reviewed. Specifically, Resident #3 was not dressed in clean clothes or shaved as they preferred; Resident #27 was not assisted with range of motion (ROM) as planned; Resident # 76 was not toileted every two hours as planned; Resident #95 was not turned and positioned, shaved, or provided with nail care as planned; Resident #110 was not changed when visibly incontinent in the dining area; and Residents #133 and 417 were not assisted with showering. The facility policy Activities of Daily Living (ADLs)…

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 (NY00315085 and NY00318580) conducted 9/5/2023-9/12/2023, the facility did not ensure residents were treated with respect and dignity and cared for in a manner that promoted quality of life and protected the residents' rights for 2 of 5 residents (Residents #70 and 133) reviewed. Specifically, Resident #133 wore other residents' clothing that did not fit and attended an appointment wearing the clothing; Resident #70's urinary catheter collection bag was not covered and visible to other residents and visitors. Findings include: The facility policy Quality of Life-Dignity revised 3/2023 documented residents shall be treated with dignity and respect at all times. Treated with dignity meant the resident would be assisted in maintaining and enhancing their self-esteem and self-worth. Residents shall be groomed as they wish. Residents shall be encouraged and assisted to dress in their own clothes. Staff should promote…

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 and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction were posted in a place readily accessible to residents, family members, and legal representatives. Specifically, the survey results and plan of correction were in a black plastic file bin on the wall, approximately 4-foot off the ground behind a 5-foot sign. Findings include: During the resident council meeting on 9/6/2023 at 10:15 AM, an anonymous resident stated they could not access the previous survey results. During an observation on 9/6/2023 at 1:55 PM, the survey results binder was in a dark corner near the palm scan time clock behind a 5-feet tall by 2-feet-wide facility advertisement sign with clear plastic containers resting at the foot of sign. Survey results binder were in the black file bin approximately 4 feet off the ground. During observations on 9/11/2023 at 12:01 PM and 9/12/23 at 2:25 PM the survey results were observed…

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

Based on observation, record review, and interview during the recertification and abbreviated (NY00315085, NY00318580, NY00321728) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure residents were free from abuse for 1 of 2 residents (Resident #422) reviewed. Specifically, CNA #60 was witnessed verbally abusing Resident #422 and CNA #60 was not immediatley removed from the facility and returned to the unit after the abuse had occurred. Findings include: The facility policy Resident Rights revised 3/2023 documented the residents were to be treated with respect, kindness, and dignity. Each employee was given a copy of resident rights upon being hired and was responsible to read and learn them. Training related to resident rights was completed in orientation and annually. The facility policy Abuse Prevention revised 3/2023 documented residents were to be free from verbal, mental, sexual, and physical abuse, as well as corporal punishment, and involuntary seclusion. Staff was educated on techniques to protect all parties. Residents were protected from abuse, neglect, 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 interview during the recertification survey conducted 9/5/2023-9/12/2023 the facility did not ensure that within 14 days after completion of a resident's assessment they electronically transmitted encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS (Centers for Medicare and Medicaid Services) System for 4 of 4 residents (Residents #24, 30, 81, and 100) reviewed. Specifically, the MDS assessments for Residents #24, 30, 81, and 100 were not transmitted within 14 days of completion. Findings include: The CMS Minimum Data Set (MDS) Resident Assessment Instrument Version 3.0 Manual documented that comprehensive assessments must be transmitted electronically to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network within 14 days of the care plan completion date and all other MDS assessments must be submitted within 14 days of the MDS completion date. The facility's MDS Transmission Logs for 9/7/2023 documented: - Resident #100 had a significant change in status…

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 survey conducted 9/5/2023-9/12/2023, the facility did not implement a person-centered care plan to meet the medical, mental, and psychosocial needs for 3 of 3 residents (Residents #119, 143, and 505) reviewed. Specifically, Resident #119 did not speak English and was not provided a communication board as planned; Resident #143 was addressed by a name not included in their care plan; and Resident #506 required glasses and was observed wearing broken glasses. Findings include: The undated facility policy Care Planning/Care Conference documented the comprehensive care plan (CCP) should describe the resident's medical, nursing, physical, mental, and psychosocial needs, and preferences and how the facility will assist in meeting these needs and preferences. Care plans should reflect person-centered care with resident specific interventions. 1) Resident #119 was admitted to the facility with a diagnosis of cerebral infarction (stroke). 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 during the recertification and abbreviated (NY00312648 and NY00315085) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure the resident environment remained free of accident hazards as is possible for 2 of 7 residents (Residents #65 and #95) reviewed. Specifically, Resident #65 had unidentified medications on the floor of their shared room, and following falls, Resident #95's care plan was not updated with recommended interventions for fall prevention (fall mats) and they were not implemented as recommended. Findings include: The facility policy General Medication Administration revised 3/2023 documented that medications were not to be left at the bedside. If a resident refused their medications, they were to be reapproached twice, if refusal continued medications were discarded and notification was made to the provider. The facility policy Fall Protocol revised 3/2023 documented the facility completed a fall assessment on every resident upon…

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

Based on observation, record review and interview during the recertification survey and abbreviated (NY00315254) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure that a resident being fed by enteral means (tube placed in the stomach for feedings) received the appropriate treatment and services to prevent complications for 1 of 2 residents (Resident #17) reviewed. Specifically, Resident #17 did not receive the ordered amount of feeding formula in a 24 hour period and the resident's medication administration, tube flushes, tube placement checks, and feeding tube care were not performed according to acceptable professional standards. Additionally, the resident was on transmission based precautions and staff did not wear personal protective equipment (PPE) when providing care. The facility policy Tube Feeding revised 4/2020, documented the purpose of the tube feeding was to provide adequate nutrition/hydration for residents who are unable to orally ingest adequate nutrients to meet nutritional and metabolic demands. The caloric and nutritional needs were determined 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00312648) surveys conducted 9/5/2023-9/12/2023, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #28 and #33) reviewed. Specifically, Resident #28's portable oxygen tank was not replaced when it was empty, Resident #28's care plan did not include directions for oxygen use, and Resident #33's care plan did not include the need for oxygen therapy. Findings include: The facility policy Oxygen Administration revised 3/2023 documented oxygen therapy was delivered by way of an oxygen mask or nasal canula using a portable oxygen cylinder or oxygen concentrator and must be verified by a physician order. Once the appropriate setup was placed on a resident, observe the resident periodically thereafter for flow 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 and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not post the following required information for resident and visitor viewing on a daily basis: the current resident census and the actual number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the last posted report during the survey period was 9/9/2023. During an observation on 9/12/2023 at 12:20 PM, the resident census and staff hours list was posted on the desk in the main lobby and was dated 9/9/2023. During an interview on 9/12/2023 at 12:20 PM, the Director of Nursing (DON) stated that the posted document that included the resident census and staff hours was for 9/9/2023, and the posted staffing was required to be updated every day. They were not certain who was responsible to gather and post the required nursing staff information. During an interview on 9/12/2023 at 2:43 PM, staff coordinator #29 stated they provided the staffing details to Nursing Administration for the next 48 hours every…

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

Based on observation, record review, and interview during the recertification survey conducted 9/5/2023-9/12/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 4 of 4 nursing units (1, 2, 3, and 4) and the main kitchen. Specifically, there was evidence of live fruit fly infestation on Units 1, 2, 3, 4 and the main kitchen. Findings include: The facility policy Pest Control dated 3/2023, documented the facility maintained an effective pest control program. Staff would report staff sightings via the pest sighting logs. Sightings will report the type, number, and location of pests noted. Pest control vendor records dated 7/7/2023 and 4/26/2023, documented flies as a targeted treatment pest. During an observation in the main kitchen on 9/05/2023 at 10:00 AM 20 fruit flies were in the main kitchen. Observations on the nursing units included the following fruit fly sightings: - On 9/05/2023 at 11:00 AM, 5 fruit flies were in the 4th floor soiled utility room. - On 9/05/2023 at 11:26 AM, 20 plus fruit flies were in the 3rd floor…

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 and abbreviated (NY00280835) surveys conducted 2/9/22-2/17/22, the facility failed to properly maintain a clean comfortable and homelike environment for 4 of 4 units (Units 1, 2, 3 and 4) reviewed. Specifically, there were unclean floors, surfaces, privacy curtains, wheelchairs, and linens; and comfortable sound levels were not maintained during meal service on the 4th floor. Findings included: The facility Resident Orientation Handbook documents residents have the right to dignity, respect, and a comfortable living environment. During a Resident Council Meeting on 2/11/22 at 9:08 AM, 2 anonymous residents stated that their surrounding environments and rooms were not kept clean. Floors: The following observations were made: - on 2/9/22 at 10:52 AM, there was a 2 inch round brown layered substance on the floor next to Resident #18's bed and a paper cup under bed. - on 2/09/22 at 10:56 AM, there were three red circular stains the dining…

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 during the recertification survey conducted 2/9/22-2/17/22 the facility failed to ensure to the extent practicable, the participation of the resident and resident's representative(s) in the development of the comprehensive care plan (CCP) for 3 of 3 residents (Residents #30, 126, and 256) reviewed. Specifically, there was no documented evidence Residents #30, 126 or their representatives were invited to or attended comprehensive care plan meetings, and Resident #256 was not invited to attend a meeting regarding their care and discharge plan and was not updated timely following the meeting. Findings include: The facility policy Interdisciplinary Care Conference Meeting revised 7/16/19 documented the resident, the resident's family and/or the resident's legal representative/guardian or surrogate are invited to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings to accommodate the resident and family. 1) Resident #30 had diagnoses including cerebral palsy, diabetes,…

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 (NY00288029, NY00276190, NY00278739, NY00280835, NY00289363, NY00261027, NY00264434, NY00269202, NY00269912, NY00271865, NY00272787, NY00274516, NY00276582, NY00275967, NY00277089, NY00280135, NY00281096, NY00281327, NY00283023, NY00289363, NY00261027) conducted 2/9/22-2/17/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 10 residents (Residents #9, 18, 88, 125, and 256) reviewed and 2 anonymous residents at the Resident Council Meeting. Specifically, Residents #9 and 125 were not provided toileting care, Resident #18 was not assisted out of bed and provided daily care at the time they requested, Resident #256 was not provided regular showers/baths, and Resident #88 was not provided timely care including dressing and toileting. Findings include: 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, record review and interview during the recertification and abbreviated surveys (NY00267849 and NY00288029) conducted 2/9/22-2/17/22, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #43, 73, and 96) reviewed for isolation precautions, 2 of 31 residents (Residents #44 and 87) reviewed for COVID-19 vaccinations, and 1 of 4 (Unit 3 high side) medication cart storage areas. Specifically, Residents #43, 73, and 96 were COVID-19 positive and the facility did not ensure precautionary measures were in place to prevent transmission of COVID-19; there was no documented evidence Residents #44 and 87 were offered a COVID-19 vaccination; and an opened bag of potato chips and a water bottle were observed in the Unit 3 high side medication cart. Findings include: The facility policy Isolation-Categories of Transmission-Based Precautions revised…

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 survey conducted 2/9/22-2/17/22, the facility failed to ensure the right to reside and receive services in the facility with reasonable accomodation of resident needs and preferences for 2 of 9 Residents (#56 and 89) reviewed. Specifically, Residents #56 and 89 were not properly positioned during mealtime to maximize eating abilities and comfort. Findings included: The facility Meal Captain, Fine Dining Policy and Procedure dated 5/27/16 documented to observe and report to charge nurse/ Nurse Manager/Assistant Director of Nursing (DON) any meal consumption changes, and difficulty with chewing or swallowing that residents may be having. Assess for diet change, need for adaptive equipment and/or change in feeding technique. 1) Resident #56 had diagnoses including dementia, cervical disc (vertebrae in neck) degeneration, and repeated falls. The 12/21/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired…

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

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00287571) conducted 2/9/21-2/17/22, the facility failed to ensure each resident had the right to be free from abuse for 3 of 5 residents (Residents #54, 109, and 141) reviewed. Specifically, Resident #109 had a history of sexually inappropriate behaviors and was care planned to be supervised when in common areas with other residents. Residents #54 and #109 were left unsupervised in a common area together and Resident #109 touched Resident #54 in a sexually inappropriate manner. Findings include: The policy Prevention of Abuse, Neglect, Involuntary Seclusion and Misappropriation of Property revised 5/5/16 documents to assure that all staff are familiar with the abuse prevention program to ensure that all residents are protected form abuse, neglect, involuntary seclusion, and misappropriation of property. All employees shall be trained through regular in-services on how to recognize events and occurrences. During an investigation of abuse, the facility shall take every precaution…

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 during the recertification survey conducted 2/9/22-2/17/22, the facility did not provide based on the comprehensive assessment and care plan and the preference of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (Resident #15) reviewed. Specifically, Resident #15 was not offered meaningful activities and was not provided with activities of their choosing. Findings include: Resident #15 had diagnoses including stroke, multiple muscle contractures, and traumatic brain injury. The 1/28/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition; had difficulty hearing; did not speak; was unable to make self understood; sometimes understood others; had highly impaired vision; preferred music, doing things with groups of people, and participating in favorite activities; required extensive assistance to total dependence with most activities…

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 during the recertification and abbreviated (NY00280835) surveys conducted 2/9/22 -2/16/22, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #9) reviewed. Specifically, Resident #9 had a medical order for TEDS (thrombo-embolic deterrent stockings, compression stockings), the stockings were not applied and were documented as applied by licensed practical nurse (LPN) #19. Findings include: Resident #9 had diagnoses including Alzheimer's disease and hypertension. The 1/28/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance with dressing. The 11/10/21 comprehensive care plan documented the resident required extensive assistance with dressing. A physician progress note dated 11/11/21 documented the resident was being seen for lower leg swelling (up to mid-calf) which had prompted an ED (Emergency Department) visit on October 18. Podiatry, occupational 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 2/9/21-2/17/21, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 3 (Resident #125) residents reviewed. Specifically, Resident #125 was at risk for pressure ulcers, did not have an air mattress in place as ordered, and nursing documented the air mattress was in place. Findings include: The facility policy Skin assessment and prevention revised 7/16/19, documented preventative measures will be applied according to protocols and resident needs. High risk protocol includes air mattress overly on bed as appropriate. Resident #125 was admitted to the facility on [DATE] with Alzheimer's disease and a displaced fracture of left femur. The Minimum Data Set (MDS) dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance of 2 for all activities of daily living (ADLs), was at risk developing…

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 (NY00276799, NY00284318, and NY00271865) conducted on 2/9/22-2/17/22, the facility failed to ensure 3 of 6 residents (Residents #38, 87, and 88) reviewed received adequate supervision and assistance devices to prevent accidents and/or their environments remained as free of accident hazards as possible. Specifically: - Resident #38 was on an altered consistency diet and had a history of attempting to consume other residents' meal items. Interventions were not implemented to prevent reoccurrence and the resident consumed food that was included with their ordered food consistency. - Resident #87 did not have interventions in place to prevent wandering and elopement and the resident exited the building. - Resident #88 did not have a thorough investigation to rule out abuse, neglect or mistreatment or a plan to prevent recurrence for a hematoma. Findings include: The facility policy, Elopement Prevention Program,…

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 (NY00280835) conducted on 2/9/22 through 2/17/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 6 residents (Resident #9 and 34) reviewed. Specifically, Resident #9 did not receive all their food items at 2 meals and weekly weights were not completed as ordered. Resident #34 had a significant weight loss and weekly weights were not completed as ordered. Findings include: The facility policy Meal Captain, Fine Dining revised 5/27/16 documents meal captains would be identified on the assignment sheet for the day and evening shifts. Certified nurse aides (CNA) will serve the resident's their food per their meal ticket and ensure proper consistency. The facility policy Resident Weights revised 5/18/18 documents weights are an overall assessment tool to monitor the status of each resident. Weights are essential to assess the nutritional and fluid status.…

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 during the recertification survey conducted 2/9/22-2/17/22, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 4 (first floor) nursing unit steam tables reviewed. Specifically, hot food items in the first floor steam table for the lunch meal on 2/9/22 were not held above 135 Fahrenheit (F). Findings included: The undated facility policy Tray Accuracy documents hot food will be kept hot (>135 degrees F). During an observation on 2/9/22 at 12:37 PM, a resident meal tray was measured for temperatures. The meal was a regular diet with a baked quarter of chicken, collard greens and rice pilaf. The food was plated directly from the steam table and immediately tested behind the steam table in the first floor kitchenette. The following temperatures were measured; baked chicken 120 F, collard greens 121 F, and the rice pilaf 115 F. When interviewed on 2/9/22 at 1:00 PM, food service aide #12 stated supervisors checked the temperatures of food in the…

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

Based on observation, record review and interview during the recertification and Focused Infection Control Surveys conducted 2/9/22-2/17/22, the facility failed to develop and implement policies and procedures to ensure proper precautions to prevent the spread of COVID-19 in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and the regulations for 3 of 6 employees (housekeepers #16 and #38, and certified nurse aide #39) reviewed. Specifically, housekeepers #16 and #38 and certified nurse aide (CNA) #39 were not fully vaccinated for COVID-19 and there was no process to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for staff who were not fully vaccinated. Findings include: The facility 3/6/20 COVID Action Plan policy documented all employees, agency staff, affiliated parties, contracted staff, medical, nursing, students and volunteers are fully vaccinated against COVID-19 in accordance with the New York State Department of Health under public Health Law Sections 225, 2800, 2803,…

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 during the recertification survey conducted 2/9/22-2/17/22, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 4 (Unit 1) nursing unit kitchenette steamtables. Specifically, the Unit 1 steam table did not maintain power and had a faulty AC (alternating current) plug and a faulty electrical wall outlet. Findings include: The facility maintenance work order for the steam table on Unit 1 documented the order had been entered on 2/9/22 at 11:11 AM by the Food Service Director. The description documented the outlet for the steam table was loose in the wall housing and shorted out occasionally when the cord was moved. The work order did not include documentation the issue was reviewed or assigned by maintenance. When observed on 2/9/22 at 2:08 PM, the Unit 1 steam table was not operating properly when plugged into the wall outlet. The Regional Food Service Director attempted to turn the steam table on and check for proper operation. The steam table power indication…

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.