Jewish Home Of Central New York

Based on record review and interview during the abbreviated survey (iQIES #734057), the facility did not ensure residents received proper foot care and treatment in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for one (1) of three (3) residents (Resident #3). Specifically, Resident #3 was recommended for routine podiatry care by a wound care provider and there was no documented evidence of podiatry care in the resident's record for eight (8) months. Findings include: The facility did not have a documented policy/procedure that addressed how podiatry consults were obtained or who was responsible to schedule them. Resident #3 had diagnoses including Alzheimer's Disease, diabetes and peripheral vascular disease (reduced blood flow to the limbs). The 02/04/2024 Minimum Data Set assessment documented the resident's cognition was moderately impaired; they were at risk of pressure ulcers, and they had no unhealed pressure ulcers or venous or arterial ulcers. The 08/06/2024 renewal physician order, (first became…

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, observation, and interview during the recertification survey and abbreviated (NY00311928 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (Terrace floor unit, first floor unit, and second floor unit) reviewed. Specifically, the Terrace floor unit had unclean resident wheelchairs, damaged and sticky flooring, and damaged countertops; the first floor unit had sticky floors in the dining room; and the second floor unit had a resident room with a damaged commode, a spa room with a water damaged cabinet, cigarettes and loose tobacco were kept in the second floor unit kitchenette, and the noise level in the dining room was loud during meal service. Additionally, the Terrace floor unit, first floor unit, and second floor unit had spa access doors that self-locked from the inside when opened too hard. Findings include: The facility policy, Safe, Clean, Homelike Environment 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 and abbreviated (NY00311928 and NY00320383) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 of 8 residents (Residents #31, #95 #103) reviewed. Specifically, Resident #31 was not assisted with showering, washing their hair, and removing facial hair; Resident #95 was not assisted with nail care; and Resident #103 was not assisted with toileting. Findings include: The facility policy, Physical Care/ADLs (activities of daily living) dated 11/2014, documented each morning and evening, the resident had attention to elimination, partial bathing, mouth care, hair combing, and dressing in clean clothing. Each resident had a minimum of one shower or tub bath per week and one bed bath per week. Nursing provided some choices in the bathing schedule. Each resident had an individualized…

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

Based on observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 4 of 4 residents (Residents #26, #41, #109 and #119) reviewed. Specifically, Residents #26, #41, #109 and #119 were not offered meaningful activities of their choosing as care planned. Findings include: The facility policy, Activity revised 3/2024, documented the activity department would provide an organized and ongoing program for the residents. The program would meet the interests, physical, mental, and psychosocial well-being for reach resident. The activity programs would be developed in accordance to meet resident specific and individual needs/interests. All residents would be encouraged, reminded, and assisted to be involved no matter their level of ability. Each resident's monthly participation would be tracked by the activity…

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 5/16/2024-5/23/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, did not review the risks and benefits of bed rails with the resident or resident representative, and did not obtain informed consent prior to the installation of bed rails for 4 of 4 residents (Resident #48, #59, #109, and #119) reviewed. Specifically: - Resident #109 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed rail installation. Additionally, the resident's enabler bar was not removed timely, and the resident was found with their arm between the enabler bar and the mattress. - Residents #48, #59 and #119 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 3 medication carts (second floor Ridge cart), and 1 of 2 medication rooms (first floor) reviewed. Specifically, the second floor Ridge medication cart was unlocked and unattended; and the first floor medication room had 3 bottles of alcoholic beverages stored in a brown paper box on the floor. Findings include: The facility policy, Medication Storage Policy last revised 4/2024, documented all drugs would be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. The facility policy, Medication Administration last revised 10/11/2023 documented the medication carts were to always be locked when not in use for medication administration; 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 observation, record review, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/24, the facility did not 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 8 staff (Certified Nurse Aides #10, #11, #13, #20 and #21; Licensed Practical Nurses #8 and #18, and the Assistant Director of Nursing) observed; and for 1 of 2 residents (Resident #4) reviewed. Specifically, - Licensed Practical Nurse #8 did not perform hand hygiene or wear gloves when administering medication via a gastrostomy tube (feeding tube) to Resident #44 who was on enhanced barrier precautions. - Resident #25 was on contact precautions and Licensed Practical Nurse #8 did not put on the required personal protective equipment prior to entering the resident room and administering insulin; Certified Nurse Aides #10 and #11 entered Resident #25's room and did not put on personal protective…

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, observation, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 3 nursing floors (first and second floors). Specifically, there was evidence of drain flies and fruit flies on the first and second floors. Findings include: The Pest Sighting Service Report Log, located in the mail room, documented that no pests were observed by staff from 2/28/2024 to 4/24/2024. The Pest Control Vendor Invoice documented that no pests were observed from 2/28/2024 to 4/24/2024. The Pest Siting Service Report and the Pest Control Vendor Invoice forms did not document the facility areas checked by the vendor. The following observations were made: - on 5/16/2024 at 11:40 AM in the second floor Ridge side spa room, there were 4 live drain flies and multiple dead drain flies. - on 5/17/2024 at 12:15 PM in the second floor kitchenette, there was 1 live fruit fly. - on 5/17/2024 at 12:30 PM in the first floor kitchenette, there were 2 live fruit…

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 (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for 13 of 13 residents (Residents #59 and 12 anonymous residents) reviewed. Specifically, Certified Nurse Aide #36 was observed speaking loudly near the main dining room about Resident #59's urinary drainage device; and multiple staff were observed using their personal communication devices in care areas during working hours. Findings include: The facility Employee Handbook revised 3/1/2015, documented staff were not permitted to use cell phones during work hours and individual earphones were prohibited. The facility policy, Safe, Clean, Homelike Environment revised 3/2024, documented the facility was committed to providing residents with a homelike environment that de-emphasized the institutional character of the setting. The facility policy, Resident Rights revised 6/2000,…

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 (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #48) reviewed. Specifically, Resident #48 did not have the capacity to make medical decisions and their health care proxy (person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident developed a wound which required treatment. Findings include: The facility policy, Criteria for Assessing Changes in Resident Condition revised 10/11/2023 documented a change in condition was defined as an improvement or decline in physical, mental and/or psychosocial status. Skin breakdown and open areas were included but not limited to examples of a condition change. The licensed nurse notified the provider for further orders, management, or treatment. New orders were initiated by the licensed nurse and a change of condition progress note 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.

Based on record review and interview during the recertification and abbreviated (NY00326481 and NY00334060) surveys conducted 5/16/2023-5/23/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 2 of 3 residents (Resident #48 and 119) reviewed. Specifically, Resident #48 had an unwitnessed fall that was not investigated; and Resident #119 had injuries of unknown origin that were not thoroughly investigated. Findings included: The facility policy, Falls Management and Prevention revised 10/11/2023, documented after a fall, the licensed nurse initiated an incident report and staff provided written statements. Written statements included time and location the resident was last seen, behavior pattern of the resident, what the resident was doing at the time of the incident if known, and any change in activity of daily living status. The supervisor on duty contacted the provider and the resident's family and documented in the medical record and included the time and the person spoken with. A resident 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 observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 of resident (Resident #52) reviewed. Specifically, Resident #52 did not have resident-specific interventions for the use of an indwelling urinary catheter (a tube placed in the bladder to drain urine). Findings include: The facility policy, Foley Catheter Use dated 12/2017, documented specific guidelines for the use of foley catheters would be provided on all patients within the facility and a comprehensive resident centered care plan would be developed. Resident #52 had diagnoses including cerebral vascular accident with right side hemiplegia (stroke with right side paralysis) and an unspecified open wound to the buttock. The 3/30/2024 Minimum Data Set assessment (resident assessment tool) documented the resident had severe cognitive impairment, had an indwelling urinary…

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 (NY00320383 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 6 residents (Resident #48) reviewed. Specifically, Resident #48 developed moisture associated skin damage (open areas resulting from moisture on the skin) on 2 occasions when incontinence care was not provided routinely or as planned. Findings include: The facility policy, Incontinent Product Usage/ Attends Briefs created 8/2014 documented residents were cared for incontinence with a program that promoted healthy skin and kept residents dry and comfortable, while their dignity was maintained, and their quality of life was improved. Incontinence briefs were checked frequently for wetness and changed when soiled. Any redness, rashes, or blisters were reported to the charge nurse and all residents…

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 (NY00320383 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not post daily, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, accessible to residents and visitors for 4 of 6 days reviewed. Specifically, the current daily resident census was not documented, and the licensed nurse staffing was not divided into licensed practical nurses and registered nurses for each shift in a 24-hour period. Findings include: The undated facility policy, Staffing Plan documented the facility provided 24-hour nursing services sufficient to meet the total nursing needs of the residents. Daily staffing sheets were completed by the night nursing supervisor and posted in the lobby. The daily resident census and nurse staffing information was observed posted to the right of the front receptionist desk: - on 5/16/2024 at 9:30 AM. - on 5/17/2024 at 8:28 AM. - on 5/20/2024 at…

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

Based on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure planned menus were followed for 2 of 2 residents (Resident #23 and #117) reviewed. Specifically, Residents #117and #23 did not receive menu items as planned per their individual meal tickets. Findings include: The undated facility policy, Meal Delivery documented dietary staff were responsible to ensure that all items were placed on the meal tray as indicated on the meal ticket, including requested condiments. During an observation on 5/17/2024 at 1:23 PM, Resident #117's lunch tray was delivered to their room, used for a test tray, and a new tray was ordered for the resident. The original tray ticket documented the resident was to receive peppers, matzo ball soup, and gravy. None of these items were on Resident #117's tray. During an observation on 5/20/2024 at 12:38 PM, Resident #23's lunch tray was the last tray in the hot box brought from the kitchen. The resident's meal was used to for a test tray, and a…

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

Based on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch meals on 5/17/2024 and 5/20/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures for lunch on 5/17/2024 and 5/20/2024. Findings include: The undated facility policy Palatability documented hot food was served at no less than 140 degrees Fahrenheit after following proper cooking. Cold food was served at no higher than 40 degrees Fahrenheit after following proper procedure for portioning, holding, and storage. Carts were plugged in on the floors and maintained temperature during tray pass for each meal to maintain a meal temperature palatable to most residents. During an observation on 5/17/2024 at 1:23 PM, Resident #117's lunch meal tray was delivered to their room, used for a test tray, and a new tray was ordered 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.

Based on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen, and 1 of 3 unit kitchenettes (Terrace unit kitchenette). Specifically, in the main kitchen the ventilation hood system was missing a grease trap, there were multiple stained ceiling tiles, there was a hole in one of the kitchen walls with exposed wiring, the meat side of the freezer floor was in disrepair, and there was expired and undated food; and the Terrace unit kitchenette had expired and undated food. Findings include: The facility policy, Guidelines for Receiving and Stock Rotation, revised 6/1/2022, documented the code date on products was noted: best before date, expiration date or use by date; and stock was rotated so that old stock was used before the new stock. The facility Daily Cleaning Schedule documented the meat side freezer was swept and mopped daily. 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 survey conducted 5/16/2024-5/23/2024, the facility did not ensure resident call systems were accessible to call for staff assistance for 2 of 2 residents (Residents #15 and #56) reviewed. Specifically, Resident #15 was observed with their call light out of reach, and Resident #56 was left alone in the shower room without access to the call light. Findings include: The facility policy, Call Light, revised 3/2024, documented all residents would have access to and know how to operate the facility call light system to ensure residents' physical and safety needs were met in a timely manner. 1) Resident #15 had diagnoses including amnesia (loss of memory), unspecified pain, and repeated falls. The 3/8/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, severely impaired vision, two falls, and required substantial/maximal assistance for all transfers. The comprehensive care plan dated 9/19/2023 documented Resident #15 was at risk for falls. Interventions included to ensure…

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 abbreviated survey (NY00322111), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated; did not ensure residents were protected while the investigation was in process and did not ensure incidents were reported to the New York State Department of Health (NYS DOH) when required for 1 of 4 residents reviewed (Resident #4). Specifically, Resident #4 was found on the floor by staff on [DATE] and remained on the floor without a registered nurse (RN) assessment for approximately two and a half hours and when the resident was assisted off the floor, they expired shortly thereafter. The facility's investigation was not thorough and complete as it did not: - Identify neglect occurred when 5 certified nurse aides (CNAs #1, 16, 17, 18, and 26), 1 licensed practical nurse (LPN #5), 1 resident helper (resident helper #27), and 1 housekeeper (housekeeper #47) walked by the resident for approximately two…

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 abbreviated survey (NY00322111) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #4) reviewed. Specifically, Resident #4 had medical orders including: - a one-time dose of 200 milligrams (mg) of Seroquel (antipsychotic medication) and was administered the one-time dose in addition to the routine dose of 150 mg Seroquel on 6 consecutive days. - Finger sticks (blood glucose monitoring) before meals and at bedtime and call the medical provider if the result was less than 70 milligrams/deciliter (mg/dl). The resident had a fingerstick of 64 mg/dl and there was no documented evidence the medical provider was notified. - Diazepam (Ativan, sedative used to treat seizures) as needed for seizures, call 911 if the seizure lasted more than 5 minutes. The resident had a seizure lasting 10 minutes, was not administered diazepam, and 911 was not called as ordered. Findings include: The facility policy Blood Glucose Monitoring revised 2/11/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview during the abbreviated survey (NY00322111), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #4). Specifically, facility Administration, including the Director of Nursing (DON) did not ensure residents were free from neglect, did not complete a thorough investigation into resident neglect, did not ensure staff were removed from having access to residents while neglect investigations were pending, and did not report neglect as required to the New York State Department of Health (NYS DOH). Findings include: Refer to F600 - Free From Abuse and Neglect On [DATE], Immediate Jeopardy and Substandard Quality of Care (SQC) was identified during an abbreviated complaint survey. Concerns rising to the level of immediate risk to resident health and safety included the facility's failure to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 nursing units (Terrace Unit, Unit 1, and Unit 2) and for 2 of 2 residents (Residents #10 and 63) reviewed. Specifically, the Terrace Unit had unclean rolling window shades in the dining room and a torn fall mat in resident room [ROOM NUMBER]; Unit 1 had a damaged ceiling in the Ridge shower room and loose handrails; and Unit 2 had a damaged section of wall in resident room [ROOM NUMBER]. Additionally, Resident #10 had an unclean wheelchair and Resident #63 had an unclean scoot chair. Findings include: The facility policy Resident Services - Maintenance of Facility updated 4/1/17, documents a maintenance logbook will be kept in the Maintenance shop for documentation of areas in need of maintenance services and work orders should be called into [specified extension] from any phone 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 survey conducted 3/1/22-3/8/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, there were damaged sinks, unclean/soiled floors, unclean soiled deep fryers, unused lids, and containers stored on an unclean shelf, improperly stored food scoops, missing ceiling tiles, and uneven floor surfaces. Findings include: The undated facility weekly 7-3 & 3PM Shifts task sheet and the undated Daily Cleaning Lists did not include: - cleaning the floors within and around the cooking areas; - cleaning cooking equipment and food surfaces; and - to report deficient issues identified as per the facility maintenance policy. The following kitchen observations were made on 3/1/22 between 12:30 PM-1:30 PM: - the kitchen hand wash sink near the meat cooking area was loose and not attached to the wall; - the corner of the floor near the meat cooking area stove had loose grains of rice; - a water pipe…

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 3/1/22-3/8/22, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction with respect to the facility. Specifically, the facility did not post the survey results and plan of correction from the most recent Life Safety Code Federal survey conducted on 9/11/19. Findings include: During observations on 3/1/22 at 2:50 PM and 3/2/22 at 9:15 AM, the survey result binder located next to the front desk included the results from the 9/11/19 Federal Health Recertification Survey. The results from the 9/11/19 federal Life Safety Code Survey and the corresponding plan of correction was not included inside the binder. During an interview on 3/2/22 at 5:37 PM, the Administrator stated that the plan of corrections for the Health Recertification Survey and the Life Safety Code Survey from the last federal survey in 2019 were…

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 3/1/22-3/8/22, the facility failed to ensure that when a restraint was indicated, the least restrictive alternative for the least amount of time was used and included ongoing re-evaluation of the need for the restraint for 1 of 2 residents (Resident #48) reviewed. Specifically, Resident #48 had an alarming wheelchair seat belt that was not assessed to determine if it was the least restrictive device, and a plan was not implemented to ensure the device was used for the least amount of time. Findings include: The facility Restraint Policy dated 11/2021 documents it was the policy of the facility to promote restraint reduction to ensure greater functional independence and a less restrictive environment, while ensuring resident safety. If a resident can tell you why the safety measure is in place and they can release restraint, it is not considered a restraint. If resident has a noted change in condition and can no longer recall, care plan and CNA sheets will be updated, and it would now be…

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 3/1-3/8/22, the facility failed to ensure, to the extent practicable, the participation of the resident and the resident's representative in the development of the comprehensive care plan for 1 of 2 residents (Resident #50) reviewed. Specifically, Resident #50 was not invited and did not attend their comprehensive care plan meetings. Findings include: The facility policy Comprehensive Care Plans dated 11/2021 documents it is the policy of the facility to provide each resident with a Comprehensive Plan of care to assist the resident to attain or maintain their optimal, physical, mental, and psychosocial functioning. Social Services was to set up care plan meetings as needed, all care plans are reviewed at that time (families may join meetings via phone or face time, families are not required to attend, and residents are encouraged to attend). Families may request care plan meetings at any time. Resident #50 had diagnoses including depression and anxiety. The 1/6/22 Minimum Data Set (MDS) 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, record review and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Residents #100 and 253) reviewed. Specifically, Resident #100 did not receive toileting assistance; and Resident #253 was not assisted with care timely and did not have a care plan to address behavioral symptoms when requesting care. Findings include: The facility policy Toileting Residents dated 12/2018 documents the registered nurse (RN) will indicate the frequency in which the resident shall be toileted in [electronic medical record] and care plan. The time selected reflects the individual needs of the residents on a two (2) to four (4) hour basis and as needed basis (PRN) during the night. Certified nurse aide (CNA) assignment sheet, residents care plan and [electronic medical record] will reflect the resident's toileting needs. Staff will ensure…

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 (NY00257605) surveys conducted 3/1/22-3/8/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #97) reviewed. Specifically, Resident #97 had a significant weight loss without timely nutritional assessments and interventions, and weekly weights were not consistently obtained as ordered. Findings include: The facility policy Nutritional Assessment and Care Plan dated 12/21 documents all residents will receive a comprehensive nutritional assessment by a qualified professional (registered dietitian [RD] or dietetic technician). Assessment and documentation of nutritional concerns is documented and recorded in a timely manner in the medical record to ensure the provision and documentation of optimal nutritional care for all residents. Each assessment and care plan may include, but is not limited to, consideration of the resident's diet history,…

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 (NY00281008) surveys conducted 3/1/22-3/8/22, 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 disease and infections for 4 staff (registered nurse [RN] Unit Manager #21, receptionist #31, security guard #27, and activity aide #30) observed. Specifically, RN Unit Manager #21, receptionist #31, and security guard #27 were observed wearing masks inappropriately and security guard #27 and activity aide #30 wore masks of unsuitable materials. Findings include: The facility policy Coronavirus (COVID-19) dated 2/22 documents the facility recognizes the need to minimize exposure to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for the COVID-19 and to adhere to Federal and State/Local recommendations. All healthcare personnel will be correctly trained and capable of…

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

Based on observation, record review and interview during the recertification and abbreviated (NY00281008) surveys conducted 3/1/22-3/8/22, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19 for 3 of 11 staff (security guards #27, 28, and 29) reviewed. Specifically, the facility did not maintain documentation of COVID-19 vaccination status for 3 contract staff, security guards #27, 28, and 29, and did not implement a contingency plan to address non-vaccinated employees. Findings include: The facility policy Coronavirus (COVID-19) dated 2/22 documents health care personnel must be counseled to continue strict adherence to all recommended non-pharmaceutical interventions, including hand hygiene, and the use of face masks as well as the importance of being vaccinated. (All employees are offered and encouraged to get COVID-19 vaccination boosters). No Unvaccinated…

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.