Loretto Health And Rehabilitation Center

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, 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 one (1) of three (3) residents (Resident #546) reviewed. Specifically, Resident #546's bilevel positive airway pressure machine (a noninvasive ventilator that helps with breathing) was not cleaned as ordered and had brown debris in the mask. Findings Include: The facility policy Bilevel positive airway pressure, Continuous positive airway pressure Trilogy, effective 2/2020 documented non-invasive ventilator support was provided to patients with compromised airways or chronic pulmonary/cardiac diseases. Use of the machine required a physician's order, and the respiratory therapist was notified when used. The facemask was cleaned daily with sterile water and left to dry. The tubing was cleaned weekly with sterile water and left to dry.…

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 review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for one (1) of one (1) resident (Residents #21) reviewed. Specifically, Resident #21 did not have their prescribed pain patch placed as ordered and they did not have the effectiveness of their pain treatment documented.Findings include:The facility policy Pain Assessment, Management, and Evaluation, dated 12/16/2024, documented the resident would receive appropriate and timely assessment, evaluation, and treatment with pain-relieving drugs, adjunctive drugs, and non-drug therapies as needed and in accordance with best practice standards. Pre-pain assessment and post administration pain assessment must be completed on all pain medications in the indicated areas. In the Electronic Medical Record when an order was written for a routine pain medication, the order automatically triggered a pre pain level to be documented. 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.

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure that residents who required dialysis (treatment to filter waste products from the blood when the kidneys do not work) received such services consistent with professional standards of practice for two (2) of two (2) residents (Residents #7 and #336) reviewed. Specifically, Residents #7 and #336 did not have pre-and post-dialysis assessments as ordered. Findings include:The facility policy Dialysis Care, dated 4/2025, documented residents receiving dialysis were to have a care plan and all dialysis observations, assessments, and care must be documented in the medical record on each dialysis day prior to dialysis and upon return. The order set and template were to be added to the resident's orders which included the Dialysis: Daily Observation/Assessment and interfacility transfer report order. The Dialysis Observation/Assessment was completed on each dialysis day, prior to dialysis and upon return. 1) Resident #7 had diagnoses including end…

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, interviews, and record review during the recertification survey conducted 8/25/2025-8/29/2025, the facility did establish and maintain an infection 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 one (1) of five (5) residents (Resident #282) reviewed. Specifically, Resident #282 was on enhanced barrier precautions and Certified Nurse Aides #56 and #57 did not wear proper personal protective equipment while performing care. Findings included:The facility policy Infection Prevention and Control Program for Long Term Care Facilities, dated 10/30/2024, documented the program was to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. Employees were to adhere to all policies and procedures related to infection control.The facility policy Enhanced Barrier Precautions, dated 1/28/2025, documented Enhanced Barrier Precautions were an infection control…

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 4/15/2024-4/23/2024 the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records for 8 of 8 residents (Residents #1, #10, #133, #158, #305, #323, #325, and #397) reviewed. Specifically, Residents #1, #10, #133, #158, #305, #323, #325, and #397 identifying and personal information was posted in a public area visible to others. Findings include: The undated facility policy, Identifying Protected Health Information documented the facility was committed to ensuring the privacy and security of individual health information. To support this commitment, the facility would ensure that the appropriate steps were taken to properly identify and secure individuals' protected health information as required. Any health information relating to the past, present, or future physical or mental health or condition of an individual or the provision of health care to an individual would be protected. During observations on 4/18/2024 at 10:33 AM 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 and abbreviated (NY00321560, NY00336003, NY00320334, NY00318518, NY00315691 and NY00330793) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 14 resident units ([NAME] Units 3, 4, 8, 10, 11, and 13) reviewed. Specifically: - on [NAME] Unit 3, room [ROOM NUMBER]-W had overflowing laundry bags, the bathroom was visibly dirty and had a strong urine odor, and the room floors were sticky. - on [NAME] Unit 4, room [ROOM NUMBER]-W's alternating pressure mattress machine had a missing right hook to secure the machine, and a ceiling tile was missing. - [NAME] Unit 11 had sticky floors; room [ROOM NUMBER]-W had a dirty wall, and liquid and debris on the floor; and room [ROOM NUMBER]-W had a broken stone windowsill. - [NAME] Unit 8's and 13's common area ice and water machine had white dried matter along the grate/catcher plate, the table,…

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 interviews during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure information on filing grievances was available for 11 of 11 anonymous residents present at the Resident Council meeting. Specifically, 11 anonymous residents present at the Resident Council meeting stated they did not know how to file an anonymous grievance. Findings include: The facility policy, Complaint Management Policy dated 2/21/2022 documented all residents would be informed at admission of their right to file a grievance and the information would be posted throughout the facility. Complaints could be filed either in written or in oral format to any staff member. The Director of Nursing served as the grievance official. During a Resident Council Meeting on 4/15/24 at 2:04 PM, eleven anonymous residents stated they were unaware of who the facility grievance officer was. They were told they had to report their concerns to their social worker. They stated they did not always receive follow up on grievances expressed and did not feel…

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 (NY00315691, NY00318518, NY00320334, NY00321560, NY00329469, NY00330471, NY00331762, and NY00332641) surveys conducted 4/15/2024 through 4/23/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the residents medical and nursing needs for 3 of 4 residents (Residents #62, #150 and #201) reviewed. Specifically, Resident #201 did not have a comprehensive care plan developed to include outside privileges or smoking outside on facility grounds; Resident #62 did not have a positioning pillow, palm guard, or pressure reduction boots as planned; and Resident #150 was not wearing their pressure reducing heel boots as planned. Findings include: The 8/8/2022 facility policy Comprehensive Care Planning, documented the facility must develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident'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 observation, record review, and interviews during the recertification and abbreviated surveys (NY00315691, NY00318518, NY00321560, NY00329469, NY00330555, NY00332641, NY00334153, NY00336003, and NY00338231) conducted 4/19/2024-4/23/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 10 of 13 residents (Residents #62, 117, 124, 133, 150, 215, 305, 325, 384, and 414) reviewed. Specifically: - Resident #62 had unkempt hair, excessive facial hair, and unkept fingernails; - Resident #117 had unkept fingernails; - Resident #124 had unkept fingernails, greasy hair, and excessive facial hair; - Resident #150 remained in bed due to mechanical lift battery issues and was poorly positioned for meals; - Resident #133 was poorly positioned in bed for breakfast meals; - Resident #215 was not toileted as planned and had excessive facial hair; - Resident #305 was not toileted for over 5 hours; - Resident #325 had greasy hair and was not…

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 4/23/2023 -4/23/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles for 5 of 12 medication carts ([NAME] units 3, 4, 8, 10, and 14) reviewed, and 1 of 6 medication rooms ([NAME] unit 5) reviewed. Specifically, the medication cart on [NAME] unit 3 had nicotine patches without resident labels; [NAME] unit 4 had expired medications; [NAME] unit 8 has insulin without a labeled open date; [NAME] unit 10 had inhalers not in the correct pharmacy box and without labeled open dates and unlabeled eye medications; [NAME] unit 13 had personal food items stored with resident medications; and [NAME] 5 medication room had a refrigerator with a significant amount of ice buildup. Findings include: The facility policy Over the Counter (OTC) Medications- Floor Stock dated 4/5/2019 documented that eye drops, nasal spray, and eardrops should be obtained from 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 and interview during the recertification and abbreviated (NY00330555) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 3 test trays reviewed (4/16/2024 and 4/18/2024 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures. Findings include: The facility policy Food Temperature Control and Correction dated 1/1/2004 documented: - Proper food temperature control and safe food practices were essential to prevent contamination or spoilage that could cause infection or poisoning. - A temperature of 41 degrees or lower was required for all entrees, meats, vegetable, cereals, eggs, starches, soups, desserts, fruits, and milks. - The Dining Service Manager was responsible to record the temperature of all foods at the start of each tray line or meal services. Trayline temperatures should be taken 1 hour from the start 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 during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 4 of 14 food preparation and pantry storage areas ([NAME] Unit 4, and [NAME] Units 4, 5, 6) and in the main kitchen. Specifically, the pantry storage areas on [NAME] Unit 4, and [NAME] Units 4, 5, 6 were soiled with food spills and the refrigerators were not cleaned of food debris and spills. Additionally, the main kitchen tray line had cold food tables with food items temperatures ranging from 40- 55 degrees Fahrenheit. Findings include: The facility policy Food Temperature Control and Correction dated 1/1/2004, documented the dining services management staff were responsible for checking temperatures before food serving starts. Serving of food would not begin until all foods were at the proper cold temperature. A temperature of 45 degrees or lower 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 observation, record review, and interview during the recertification and abbreviated (NY00321560, NY00315691, and NY00336003) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure each resident was treated with respect and dignity in a manner that promoted maintenance or enhancement of their quality of life for 2 of 5 residents (Residents #384 and #414) reviewed. Specifically, Resident #384 sat in bed sheets soiled with vomit and was not cleaned in a timely manner and Resident #414 was not shaven, had unkept hair, and had an unclean room. Findings include: The facility policy Resident Rights & Notice of Resident Rights and Responsibilities reviewed 8/8/2022 documented residents would be treated with kindness, respect, and dignity. Resident rights included a dignified existence, to be treated with respect, kindness, and dignity, self-determination, privacy and confidentiality, and equal access to quality care. The facility policy Quality of Life-Dignity dated 1/10/2023 documented each resident shall be cared for in a manner that promoted and enhanced their sense…

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 4/15/2024-4/23/2023, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 2 resident (Resident #31) reviewed. Specifically, Resident #31 was not able to use their bathroom sink to effectively perform activities of daily living. Findings include: The facility policy Quality of Life-Dignity dated 1/10/2023 documented each resident shall be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem, and were treated with dignity and respect at all times. Resident #31 was admitted to the facility with diagnoses including hemiplegia (paralysis on one side of the body) affecting the dominant side, kidney disease, and obesity. The 2/12/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitation in the upper and lower extremities on one side, and required substantial/maximum…

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 4/15/2024-4/23/2024, the facility did not ensure residents were free from involuntary seclusion for 1 of 1 resident (Resident #429) reviewed. Specifically, Resident #429 reported feelings of social isolation when they were not allowed to leave their room to attend activities, have meals in the dining room, or socialize with peers and family because their portable oxygen tank was empty and was not refilled. Findings include: The facility policy Resident Abuse Reporting dated 8/1/2023 documented the facility to prohibited mistreatment, neglect, or abuse. The facility would not tolerate or permit verbal, mental, sexual, or physical abuse including involuntary seclusion of residents. Involuntary seclusion was defined as separation of a resident from other residents in their room against the residents will or the will of the legal representative. The facility policy Portable Liquid Oxygen System dated 10/10/2029 documented the oxygen cylinders must be filled from the stationary reservoir when…

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 and abbreviated (NY00320334) surveys conducted 4/15/2024-4/23/2023, the facility did not ensure the discharge needs of each resident were identified and resulted in the development of a discharge plan for 1 of 1 resident (Resident #429) reviewed. Specifically, Resident #429 did not have an active discharge plan, expressed interest in a lateral transfer to local nursing facilities, and was not updated on the status of a lateral transfer request. Additionally, Resident #429 was not invited to participate in the development of a person-centered care plan. Findings include: The facility policy Discharge Planning, revised 1/30/2015, documented the interdisciplinary care planning team and social worker would collaborate with the resident/designated representative regularly and reviewed the resident's potential for discharge to establish a projected discharge date . The social worker arranged and facilitated the resident/designated representative discharge planning meeting to discuss rehabilitation progress, clinicals…

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 (NY00318518, NY00318847, NY00320334, NY00331963, and NY00338231) the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 9 residents (Residents #117 and #323) reviewed. Specifically, Resident #117 was found on the floor between their bed and the wall due to the bed brakes not being locked; and Resident #323 had a history of sexually inappropriate behaviors and propelled their wheelchair independently throughout the facility without an adequate supervision plan. Findings include: The facility policy Resident Abuse Reporting, dated 8/1/2023, documented each resident had the right to be free from all types of abuse, neglect, misappropriation of resident property, and exploitation. The facility policy Off Unit/Leave of Absence, dated 10/2023, documented the resident must notify nursing on the unit and sign out 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, interview, and record review during the recertification and abbreviated (NY00329469, NY00331762, NY00330471) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 2 residents (Resident #168) reviewed. Specifically, Resident #168 did not receive adequate pain management following a fall with a hip fracture. Findings included: The facility policy Pain Assessment, Management, and Evaluation dated 8/24/2022, documented the interdisciplinary team identified residents in need of pain management and completed on-going assessments to control the resident's pain. All residents would have a pain assessment completed upon admission, quarterly, annually, and with a significant change. Resident #168 had diagnoses including Alzheimer's disease, weakness, and osteoarthritis (degeneration of joints). The 10/22/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, was independent with ambulation, 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 and abbreviated (NY00336003) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure licensed nurses had the specific competencies and skills necessary to care for residents' need, as identified through resident assessments, and described in the plan of care for 3 of 5 licensed nurses (licensed practical nurse Unit Manager #4, licensed practical nurse Unit Manager #33, and licensed practical nurse #34) reviewed. Specifically, licensed practical nurse Unit Manager #4 did not have timely online training, annual competencies, or documented orientation competencies completed; licensed practical nurse Unit Manager #33 did not have annual competencies, or documented orientation competencies completed; and licensed practical nurse #34 did not received annual competencies that covered key skill-set areas as outlined in the facility assessment. Findings include: The 4/2024 Facility Assessment Tool documented nurse competencies in the facility included: person-center care, activities of daily living, disaster planning,…

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 recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 2 of 5 certified nurse aides (certified nurse aides #20 and #21) reviewed. Specifically, there was no documented evidence certified nurse aides #20 and #21 who had worked for the facility more than 12 months, had performance reviews completed at least once every 12 months. Findings include: The facility policy Appendix A - [NAME] Code of Conduct, dated 5/2023 documented that each supervisor and manager was responsible for monitoring that their personnel were acting ethically and in compliance with applicable federal, state, or local statues, ordinances, executive orders, rules, regulations, judicial, or administrative decisions, ruling or orders, the facility's policies and procedures and the Code. All personnel were responsible for acquiring sufficient knowledge to recognize potential compliance issues…

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 4/15/2024-4/23/2024, the facility did not ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #158) reviewed. Specifically, Resident #158 had a diagnosis of dementia and was not provided with preferred person-centered activities. Findings include: The facility policy Managing Behavioral Symptoms of Dementia, dated 4/29/2019, documented the facility was committed to ensuring that the needs of residents who experienced behavioral symptoms of dementia were met as much as possible. Behaviors often indicated unmet needs. Behaviors were no longer referred to as aggressive, disruptive, challenging, or difficult. Staff were to obtain history, favorite things, hobbies, personal interests to be included in non-pharmacological strategies and plans of care. A resident-centered plan of care would be developed 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.

Based on observation, interview, and record review during the recertification and abbreviated (NY00330471 and NY00331762) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure the medical provider was promptly notified of radiology results for 1 of 1 resident (Resident #168) reviewed. Specifically, Resident #168 had x-rays ordered by the medical provider, the radiology provider reported the results to the facility, and the results were not relayed to the medical provider timely. Findings included: The facility policy Radiology Services dated 1/2024, documented radiology services would be provided to all residents in a manner that prevented errors, assured accurate communication, and provided timely ordered service and timely results to the medical provider. The nurse confirmed the order for radiology or diagnostic test in the electronic medical record and notified the technician of an x-ray/diagnostic test by calling the radiology company contracted with the facility. The radiology technician conducted the x-ray/diagnostic test and then notified the charge nurse once…

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 9/19/22-9/23/22, the facility failed to ensure residents had the right to a dignified existence for 1 of 4 residents (Residents #127) reviewed. Specifically, Resident #127's urinary catheter drainage bag (collects urine) was not covered and was visible in the dining room and from the hallway while the resident was in their room. Findings include: The undated facility policy, Quality of Life and Dignity documented each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality by maintaining privacy for medical devices (urinary bags). Resident #127 had a diagnosis of unspecified dementia and neuromuscular dysfunction of the bladder. The 7/20/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was totally dependent with activities of daily living (ADLs) and had a suprapubic catheter (urinary tube placed through 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 survey conducted 9/19/22-9/23/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 12 resident units (Units 5, 7, 9, 11, and 13), for 3 residents (Residents #148, 186, and 416), and for 2 resident rooms (rooms [ROOM NUMBERS]). Specifically, there were multiple unclean, stained, and damaged areas, furniture, and equipment throughout the facility and fruit flies were observed in a dining area. Resident #148 had an unclean wheelchair, linen, furniture, and sticky floors; and Residents #186 and 416 had unclean Broda (positioning) chairs. Additionally, resident rooms [ROOM NUMBERS] had hot water temperatures at the sinks exceeding 120 degrees Fahrenheit (F). Findings include: The facility's undated Daily Housekeeping Task List included the following tasks: - stock toilet paper in resident bathrooms; - clean off resident bed tables; - wipe up any food crumbs or other debris on furniture; - mop…

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 recertification survey conducted 9/19/22-9/23/22, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's nursing needs for 1 of 1 resident (Resident #264) reviewed. Specifically, Resident #264 was care planned to be dependent on 2 with transferring and was transferred by 1. Findings include: The facility's undated policy Resident's Care Assignment Sheet documented: - Nursing staff would follow the plan of care as indicated on the resident's care assignment sheet and notify the charge nurse immediately if the resident's care needs change. - Staff were to check the [NAME] and the dashboard for any changes or updates. - It was the responsibility of the Nursing Care Team to ensure that the plan of care was accurately followed for each resident. Resident #264 had diagnoses including hemiplegia (one-sided paralysis), hemiparesis (one-sided weakness)…

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 surveys (NY00299609, NY00300895, NY00293668, and NY00257181) conducted 9/19/22-9/23/22, 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 4 of 15 residents (Residents #8, 238, 264, and 386) reviewed. Specifically: - Resident #8 was not assisted with oral care and their toothbrush was observed on their bathroom sink unopened in a plastic wrapper. - Resident #238 was observed in the same clothing for 5 consecutive days. - Resident #264 was not toileted for more than 5 hours and was not supervised at meals as care planned. - Resident #386 was not assisted with meals and was observed eating independently and spilling food. Findings include: The facility policy Activities of Daily Living (ADLs) dated 1/21/20 documented residents who were unable to carry out 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 observation, record review, and interview during the recertification survey conducted 9/19/22-9/23/22 the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #171) reviewed. Specifically, Resident #171 was on aspiration (inhaling food into lungs) precautions due to impaired swallowing and was observed consuming their meal in their room unsupervised with the door closed. Findings include: The undated facility policy Aspiration Precautions and Standards of Care documented aspiration precautions were the measures implemented to prevent or lessen the risk of food, fluids, or other ingested material from entering the respiratory tract. The standards of care to prevent aspiration did not include resident supervision during eating and/or drinking. Resident #171 had diagnoses including Alzheimer's disease, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease. The 7/29/22 Minimum Data Set (MDS) assessment documented 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 (NY00299609) surveys conducted 9/19/22-9/23/22, the facility failed to ensure residents were free of any significant medication errors for 2 of 15 residents (Residents # 33 and#368) reviewed. Specifically, Residents #33 and #368 did not receive blood sugar (blood glucose) monitoring or insulin administration as ordered. Findings include: The undated facility policy titled Insulin Injection Preparation documented the purpose of insulin injections was to enhance glucose (blood sugar) utilization by all cells in the human body. The medication would only be administered with a physician order including the type of insulin, the dose, and the time frequency. A registered nurse (RN) or licensed practical nurse (LPN) were able to perform the injections. A post-procedure included recording the insulin administration on the medication administration record (MAR). The 8/2021 facility policy Medication Administration documented utilization of registered nurses (RNs) and licensed practical nurses (LPNs)…

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 9/19/22-9/23/22, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal test tray (Resident #355) reviewed. Specifically, Resident #355's replacement meal was not measured for an appropriate and safe internal food temperature range after being reheated and prior to being served to the resident. Findings include: The facility policy Foods Brought in By Family/Friends for the Intent of Resident's Consumption dated 11/10/21 documented all items that needed to be heated would be heated to the proper temperature before being served to the resident. Food would be heated to an internal temperature of 165 F (Fahrenheit) in the microwave oven, covered, and rotated so it heated evenly. During an observation on 9/21/22, Resident #355's lunch tray was used for testing and a replacement meal was ordered. At 12:45 PM the resident's replacement lunch tray was brought to the 9th…

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.