Van Duyn Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during survey, the facility failed to ensure ongoing provision of programs to support residents in their choices of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for two (Resident #3 and #243) of two residents reviewed. Specifically, Resident #3 and Resident #243 both required the use of a mechanical lift to get out of bed, and were not provided with meaningful, accommodating activities to maintain their highest quality of life. Findings include: The Policy and Procedure titled, Activities/Therapeutic Recreation Program Policy revised 01/2026, documented, It is the policy of Van Duyn Center for Rehabilitation and Nursing (VDC) to provide a structured and individualized program of activities and therapeutic recreation that meets the interests and enhances the quality of life the residents residing at the facility. Van Duyn Center aims to ensure that each resident has 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 interviews conducted during survey, the facility failed to ensure that its medication error rate did not exceed 5 percent for two (Resident #230 and #245) of five residents observed during medication administration with 33 observations. This resulted in a medication error rate of 6.06 percent.Findings include:The facility's policy and procedure titled Self-Administration of Medications reviewed 01/2026, documented in order to maintain residents high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (or equivalent) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure residents received routine and/or emergency dental services, including assistance in obtaining dental evaluation and treatment for two of three residents (Resident #155 and #162) reviewed. Specifically, (1.) Resident #155 was discovered to have a broken front tooth by family and was not referred to dental services to rule out any potential issues/problems. (2.) On 04/15/2026, Resident #162 was known to be missing upper dentures but their diet was not adjusted to account for this factor until five days later on 04/20/2026, when a dental consult documented to adjust diet as needed. Resident #162's full upper denture impressions were not completed until 05/10/2026. The delay in dental follow-up and denture replacement had the potential to impact the resident's ability to chew, nutritional status, and overall oral health. Findings include: The facility policy titled In-House Dental Services Coordination…

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 reviews and interviews conducted during survey, the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for one (Resident #412) of three residents reviewed. Specifically, the facility failed to ensure overall systems were established for documentation of all meals by nursing staff and were being maintained according to standards of practice and facility policy when they failed to document breakfast, lunch, and dinner for Resident #412 between the dates of 11/01/2025 through 11/30/2025. Findings include:Resident #412 was admitted to the facility with diagnoses of osteomyelitis of vertebra, lumbar region (a serious infection of the bones in the spine,) acute and subacute infective endocarditis (a life-threatening infection of the heart's inner lining or valves,) and Type 2 Diabetes mellitus, without complications (a disease that affects how the body uses blood glucose (sugar). The Minimum Data Set (a resident assessment tool) dated 11/04/2025 documented that they could…

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

Based on observation, record review, and interviews conducted during survey, the facility failed to provide drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration for one (Resident # 118) of three residents reviewed. Specifically, the facility failed to ensure Resident #118 received water and ice per their preference to maintain hydration. Findings include: Resident #118 Resident # 118 was admitted to the facility with diagnoses of unspecified anemia (low levels of healthy red blood cells and can cause tiredness, weakness, and shortness of breath), urinary tract infection, and adult failure to thrive (a state of decline that manifests as weight loss, decreased appetite, poor nutrition, and inactivity). The Minimum Data Set (a resident assessment tool) dated 02/26/2026, documented the resident was cognitively intact, was able to make themselves understood, and usually understood others. The Policy and Procedure titled, Nourishment Program Policy and Procedure, dated 10/06/2025, documented it was 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 observations, record review, and interviews conducted during survey, the facility failed to properly dispose of garbage and refuse. Specifically, on 05/05/2026, three garbage receptacles located within the main kitchen had no liners and contained refuse. One of the garbage cans was next to a wall that had dried, liquified spatter covering approximately two square feet of the wall above it. Additionally, dirty garbage lids were observed in the main kitchen storage utility room. This was observed in the Main Kitchen during the initial tour. Findings include: Cross reference to F-925, Maintains Effective Pest Control Program.Policy and procedure titled, Insect and Rodent Control, last revised 05/2025, documented the purpose of pest control was to prevent entry into the facility and reduce the threat of infection and disease; to provide a safe and sanitary environment; and to maintain the appearance of the facility. It further documented, equipment was to be properly cleaned on a daily basis following Centers for Medicare and Medicaid Services policies and procedures. Proper…

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 conducted during survey, the facility failed to ensure appropriate infection prevention and control practices were followed for one of eight residents (Resident #138) reviewed for infection control practices. Specifically, Certified Nurse Aide # 6 failed to remove personal protective equipment prior to exiting the room of Resident #138 who was on special contact droplet precautions and the facility failed to provide a receptacle for disposable of used personal protective equipment inside the resident's room. This deficient practice had the potential to affect residents through increased risk of transmission of infectious agents. Findings include:The policy and procedure titled, Covid 19 Action Plan, revised on 03/06/2020, documented health care personnel should wear personal protective equipment for suspected or confirmed COVID infection including respirator with N95 filters (face mask used to filter airborne particles), gown, gloves, and eye protection. The policy and procedure titled, Transmission Based Precautions, revised on…

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

Based on record review and interviews, the facility failed to ensure an incident of staff abuse toward a resident was immediately reported to the State Agency, law enforcement, and the Administrator for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Certified Nurse Aide #1 witnessed Certified Nurse Aide #2 abuse Resident #1, and the incident was not reported to facility Administration, law enforcement, and New York State Department of Health until approximately five (5) hours after the incident occurred. Additionally, the required five (5)-day investigative report was not submitted until 12 days following the witnessed abuse. Refer to: F600 Free from Abuse and Neglect F656 Develop/ Implement Comprehensive Care Plan. Findings include: The facility policy Prevention of Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation, revised 02/2026, documented the facility recognized all allegations of abuse, with or without injury, as falling into the immediate reporting category. All employees reported allegations of abuse immediately, but no later than two (2)…

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 survey, the facility failed to develop, implement, and maintain an effective compliance and ethics program that is likely to be effective in preventing and detecting criminal, civil, and administrative violations and promoting quality of care. Specifically, the facility failed to create and promote a program contact to which individuals may report suspected violations, as well as an alternate method of reporting suspected violations anonymously without fear of retribution. Findings include:The undated and unsigned facility policy Code of Conduct documented all affected individuals were to abide by standards outlined in the Code of Conduct and to conduct all business in a manner consistent with the facility policies set forth in the Code of Conduct and Compliance documents. Illegal acts or unethical conduct was not acceptable, staff were to perform duties with honesty and integrity, and supervisors and managers were responsible for ensuring that the affected individuals within their supervision were acting ethically 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 reviews and interviews, the facility failed to ensure incidents of abuse were reported to the State Agency as required for one (1) of three (3) residents (Resident #1) reviewed. Specifically, on 09/10/2025 Resident #1 threw coffee at staff and subsequently hit another resident seated at the table; on 09/30/2025 Resident #1 hit Resident #3 on the cheek when Resident #3 attempted to take food from Resident #1's plate. The facility failed to report the resident to resident altercations to the New York State Department of Health as required. Findings include: The 09/2024 revised facility policy, Reporting and Monitoring Accidents and Incidents, documented the Director of Nursing, Assistant Director of Nursing, Director of Investigations or designee was responsible to review all incidents for alleged abuse, mistreatment or neglect, injury of unknown origin or resident elopement. All incidents involving alleged abuse, mistreatment or neglect, injury of unknown origin, misappropriation of resident property, or resident elopement, must be reported to Administration…

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 reviews and interviews conducted during the survey, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1 exhibited escalation of behavioral symptoms including resident-to-resident altercations, and physical and verbal abuse directed toward others and there was no documented evidence of a comprehensive care plan addressing the resident's behavioral symptoms with specific interventions to be implemented. Findings include:Cross Reference to F 600 Free from Abuse and NeglectCross Reference to F 609 Reporting of Alleged violations The facility policy Care Planning/Care Conference, revised 05/20/2025, documented care plans should reflect person-centered care with resident specific interventions. Care plans are to be updated/initiated at the time of any change in the resident's status, needs, goals, and/or interventions. Resident #1 had…

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

Based on interviews and record review conducted during the survey, the facility failed to ensure allegations of neglect were thoroughly investigated for one (1) of three (3) residents (Resident #2) reviewed. Specifically, on 02/24/2025, Resident #2 left the facility undetected, was last seen by staff at 2:00 PM, and their absence was not discovered until 5:45 PM. Resident #2 left the facility without their required oxygen and did not receive their medications or evening meal as ordered. There was no documented evidence of a thorough investigation when Resident #2 eloped from the facility on 02/24/2025. Findings include:Cross reference to F689: Free of Accident Hazards/Supervision/Devices and F 600 Free from Abuse and NeglectThe facility policy Reporting and Monitoring Accidents and Incidents revised 09/2024, documented to report and investigate any accident/incident involving a resident of the facility to rule out or report abuse, mistreatment or neglect as a cause of the incident, to the New York State Department of Health. All incidents would be reviewed for alleged abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the survey, the facility failed to ensure that it provided respiratory care consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #11) of three (3) residents reviewed. Specifically, the facility did not ensure Resident #11 was administered four (4) liters of oxygen as prescribed, when assessed by the Respiratory Therapist for shortness of breath during the evening shift on 11/25/2025. This is evidenced by: Cross-referenced to F580: Notification of Changes (Injury/Decline/Room, Etc.) Resident #11:Resident #11 was admitted to the facility on [DATE] with diagnoses of respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body), unspecified whether with hypoxia (level of oxygen in the blood becomes dangerously low) or hypercapnia (level of carbon dioxide become dangerously high), obstructive sleep apnea (breathing is interrupted by the airway blocking…

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 a survey, the facility failed to ensure it maintained medical records in accordance with accepted professional standards and practices, and that medical records on each resident were complete, accurately documented, readily accessible, and systematically organized for one (1) (Resident #11) of three (3) residents reviewed. Specifically, there was no documentation in the medical record of [a.] an assessment of Resident #11 by Registered Nurse #8 when the resident had respiratory and mental status changes on 11/26/2025, [b.] the resident's response to oxygen treatment provided by Registered Nurse #8 and Licensed Practical Nurse #4 on 11/26/2025, and [c.] the resident's vital signs (heart rate, blood pressure, respiratory rate, and temperature) on 11/26/2025. This is evidenced by: Cross-referenced to F580: Notification of Changes (Injury/Decline/Room, Etc.)Resident #11:Resident #11 was admitted to the facility on [DATE] with diagnoses of respiratory failure (condition…

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 conducted during the survey, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality for seven (7) of seven (7) anonymous residents reviewed. Specifically, seven (7) anonymous residents stated staff use foul language, ethnic slurs and laugh at other residents in the hallways and around residents, making them feel uncomfortable.Findings include:The facility policy Dignity and Respect last revised 05/2025, documented residents had the right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of their self-worth. Residents were to be treated in a manner that enhanced their quality of life, free from humiliation, harassment or threats. Staff were to ensure residents were treated as individuals, provided residents with safe, clean and comfortable surroundings. The undated facility policy Code of Conduct documented that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the survey, the facility failed to provide effective housekeeping and maintenance services on five (5) of five (5) resident units. Specifically, the facility did not ensure that resident rooms and common areas were clean and in good repair.Findings include: During observations on 12/03/2025 from 10:11 AM through 3:00 PM, on 12/04/2025 from 8:31 AM through 9:16 AM, on 12/05/2025 from 8:33 AM through 1:30 PM, on 12/08/2025 from 9:41 AM to 10:34 AM, and on 12/10/2025 at 10:53 AM: Strong urine odors were detected in rooms #555, #566 (two (2) observations), and #671 and in the north elevator lobby area. The toilets in rooms #572, #558, #655, and #671 were soiled with black or brown stain marks in the bowl. The soap dispenser located within the bathroom of room [ROOM NUMBER] was broken, and no soap was available. The paper towel dispenser was empty in rooms #565 and #568. The bedding had brown stains in room [ROOM NUMBER] (two (2) observations). The bedside 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 and interviews conducted during the survey, the facility failed to ensure services provided by the facility met professional standards of quality. Specifically, medication pass times were broad and carried a risk of over medicating or under medicating five (5) (Residents #1, 7, 11, 98, and 527) of five (5) residents reviewed. This affects all residents receiving medication at the facility. The findings are:Cross reference F 842: Resident Records - Identifiable InformationThe Policy and Procedure titled General Medication Administration dated 05/2025, stated scheduled medications requiring specific time increments for administration were to be administered no more than one (1) hour before or one (1) hour after the ordered time. These medications include but are not limited to insulins, oral antihyperglycemic agents, antibiotics, pain management medications, anti-seizure medications, anti-hypertensives, thyroid medications, and warfarin therapy.The Policy and Procedure titled Medication Administration Times revised 05/2025, stated medications would 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 observation, record review, and interviews conducted during the survey, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for six (6) (4th floor North Medication Cart C and D; 5th floor North Medication Cart A; 6th floor North Medication Cart C and D; 6th floor North Treatment cart used as a medication cart) of ten (10) medication carts reviewed, and five (5) (3rd floor North Medication Room; 4th floor North Medication Room C and D; 6th floor North Medication Room C and D) of nine (9) medication rooms reviewed. Specifically, (a.) five (5) insulin pens were not labeled and or dated; (b.) medication room refrigerator temperatures were not recorded; (c.) narcotic books were not reconciled each shift; (d.) narcotics were not secured in a double lockbox until use. (e.) a narcotic was not signed out upon administration; (f.) Loose pills were found in medication cart; (g.) three (3) multi-use vial medications had no resident name, open and or expiration dates; (h.) two (2) separate cups of pre-poured…

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

Based on observations and interviews conducted during the survey, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (lunch meal on 12/08/2025 and breakfast meal 12/09/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meal of 12/08/2025 and breakfast meal on 12/09/2025. Additionally, seven (7) anonymous residents during a resident council meeting and seven (7) residents (Resident's #4, 121, 175, 211, 238, 277, 493) separately interviewed stated the food did not taste good and was cold. Findings include:The 09/2025 revised facility policy Fine Dining Policy and Procedure documented the Certified Nursing Aides would serve the residents their food per meal ticket and would ensure the tray was accurate. The United States Department of Agriculture Food Safety and Inspection Service guide provided by the facility stated hot food would be held at 140 degrees Fahrenheit or warmer and cold food would be held at 40 degrees…

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 conducted during the survey, the facility failed to ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for five (5) of five (5) resident unit kitchens and the main kitchen. Specifically, the automatic dishwashing machine was not sanitizing, the chemical sanitizer for manual equipment washing was too concentrated, and equipment and surfaces were not clean and/or in good repair. Findings include:During observations in the main kitchen on 12/03/2025 at 10:07 AM: The automatic dishwashing machine final rinse was zero (0) parts per million of chlorine. The automatic dishwashing machine information data plate stated that the final sanitizing rinse is to be 180 degrees Fahrenheit and provided no instruction for chemical sanitizing. The concentration of quaternary ammonium compound sanitizing chemical utilized in the manual sanitizing of food contact equipment was five hundred (500) parts per million when measured at 68 degrees Fahrenheit. The label directions on the sanitizer…

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 interviews during the survey, the facility failed to ensure garbage and refuse was disposed of properly. Specifically, the trash compactor loading area was unclean and heavily soiled. Findings include:During an observation on 12/03/2025 at 10:40 AM, the trash compactor and loading dock area (part of the refuse disposal area) were heavily soiled with black drip marks below the compactor access portal, splash marks and discoloration on the walls, and cobwebs throughout the area. During an interview on 12/08/2025 at 3:45 PM, Director of Environmental Services #1 stated that they would thoroughly clean the trash compactor and loading dock area. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observations and interviews conducted during the survey, the facility failed to ensure it was 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 of each resident. Specifically, administration failed to ensure residents' rights to a safe, clean, comfortable and homelike environment. Administration failed to ensure that their infection prevention and control program was developed and implemented to prevent the spread of infectious diseases for all residents, staff, volunteers, and visitors.Findings include:Refer to F584 Safe/Clean/Comfortable/Homelike environment-S/S-FRefer to F880 Infection Control Prevention-S/S-FRefer to F804 Food Nutritive Value/Appearance, Palatability/Prefer Temperatures-S/S=F Refer to F812 Food Procurement Storage/Prepare/Serve in Sanitary Conditions-S/S=F The facility job description Administrator, undated, documented the Administrator reports to the Corporate Chief Operating Officer and directs all aspects of facility…

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 conducted during the survey, the facility failed to ensure that medical records were kept in accordance with professional standards. Specifically, (a.) documentation for oxygen tubing for Resident #143 was not kept in an accurate and professional record; and (b.) full access to medical records was not granted on request as required by regulation.The findings include:The facility Policy and Procedure titled Oxygen Therapy dated 04/04/2024 stated oxygen tubing was to be changed every two (2) weeks per order and was to be labeled, dated, and documented in the administration record.The Policy and Procedure titled General Medication Administration dated 05/2025 stated all medications and treatments should be documented as administered at the time they are given. Resident #143Resident #143 was admitted to the facility with diagnoses including chronic respiratory failure (when the respiratory system cannot adequately provide oxygen to the body) with hypoxia (when oxygen is insufficient at the tissue level to maintain adequate…

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 conducted during the survey, the facility failed to ensure a Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility did not implement systems that ensured the care and services it delivered met acceptable standards of quality in accordance with recognized standards of practice. The facility had repeat deficiencies in the areas of Resident Rights (F550), Self-Administration of Medications (F554), Self-determination (F561), Safe/Clean/Comfortable/Homelike Environment (F584), Develop/Implement Comprehensive Care Plans (F656), Quality of Care (F684), Label/Storage of Drugs and Biologicals (F761), Food Nutritive Value/Appearance, Palatability/Prefer Temperatures (F804), Food Procurement Storage/Prepare/Serve in Sanitary Conditions (F812), and Infection Prevention and Control (F880). Findings includeRefer to F550 Resident Rights- S/S-ERefer to F554 Self-Administration of Medications- S/S-DRefer to F561…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the survey, 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 two (2) (Resident #11 and Resident #336) of two (2) residents reviewed. Specifically, Resident #11 and Resident # 336 were observed with their urinary drainage bag on the floor without a barrier separating the floor from the drainage bag; the sink in room [ROOM NUMBER] was not functioning for the duration of the survey, and the resident (Resident #5) in room [ROOM NUMBER] was on enhanced barrier precautions. Additionally, Resident's #11, #64, #467, #478, #542, and #651 were diagnosed with influenza and multiple unvaccinated staff were observed in resident areas not wearing a facemask or wearing a facemask improperly.Findings include:The facility policy Infection Control 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 conducted during the survey, the facility failed to ensure the comprehensive person-centered care plan was implemented to ensure a resident's nursing needs were met for three (3) (Residents #1, #7, and #98) of 38 residents reviewed. Specifically, a.) Resident #1's comprehensive care plan for dementia was not person-centered and there were no care plan addressing activities, b.) Resident #7's comprehensive care plan did not address the use of anticoagulants, and insulin, and c.) Resident #98 did not have a care plan initiated for oxygen use. Findings include: The facility policy titled Care Planning/Care Conference, last reviewed 05/20/2025, documented the purpose of the comprehensive person-centered care plan is developed for each resident to include measurable objectives and timetables to meet a residents' medical, nursing, mental and psychosocial needs. The comprehensive care plan should reflect person-centered care with resident specific interventions 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 observations, record review, and interviews conducted during the survey, the facility failed to provide ongoing programs to support each resident in their choice of activities for two (2) (Resident #15 and #163) of two (2) residents reviewed. Specifically, Resident #15 was not offered meaningful activities that included their interests and preferences, and Resident #163 was not included in activities of their preference. Findings include:The facility policy Activities/Therapeutic Recreation Program Policy effective 10/2025 documented the facility provided a structured and individualized program of activities and therapeutic recreation that meets the interests and enhances the quality of life for residents residing at the facility. Each resident had the opportunity to engage in meaningful activities designed to promote physical, mental, and psychosocial well-being, in accordance with their comprehensive care plan, preferences, and abilities. Resident #15 had diagnoses including cerebral palsy (group of movement disorders), cortical blindness (vision loss from damage to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the survey, the facility failed to ensure that residents with limited mobility received the appropriate services, equipment, and assistance to maintain mobility and prevent complications for two (2) (Residents #15 and #301) of two (2) residents reviewed. Specifically, Resident #15 did not consistently receive a hand device (palm guard) to right hand and Resident #301 did not consistently receive a rolled cloth to left hand for hand contractures (shortening of the muscles, tendons, and skin) to prevent complications per Occupational Therapy recommendations and as ordered by the physician.Findings include: The facility policy titled Splints revised 11/2025, documented the Occupational Therapy department will evaluate the resident to determine need for splinting and determine type of splint to be used. An order recommendation will be written stating instructions to nursing staff on application, length of time it is to be worn, and precautions.Resident #15 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 survey, the facility failed ensure residents who required dialysis services, received such services consistent with professional standards of practice for one (1) (Resident #14) of one (1) resident reviewed for dialysis. Specifically, Resident #14 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and/or after dialysis treatments. Findings include:Resident #14 was admitted to the facility with diagnoses of end stage renal disease (kidneys no longer work as they should), status post sepsis (a serious condition in which the body responds improperly to an infection), and congestive heart failure (long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply). The Minimum Data Set (a resident assessment tool) dated 11/28/2025, documented resident was cognitively intact, could be understood, and understand others. The facility's policy and procedure titled; Dialysis, reviewed 08/2025, documented…

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

Based on observation, interview and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #303 and Resident #352) of five (5) residents observed during a medication pass for a total of 28 observations. This resulted in a medication error rate of 10.71 percent. Findings Include:The facility's policy and procedure titled General Medication Administration last reviewed 05/2025, documented medications will be administered by a Licensed Practical Nurse or a Registered Nurse. All medications will be administered and documented using the Electronic Medical Record. Check all resident orders carefully before administering the medications. Keep the basic rules of safe administration in mind: right drug, right resident, right time, right dose, right route, review for allergies, and review expiration date of medication. Avoid distractions when administering medications. Carefully check the resident's identification band before administering any medication. Do not leave medications at 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 observations and interviews conducted during the survey, the facility failed to provide a safe, functional, sanitary, and comfortable environment on three (3) of five (5) resident units. Specifically, strong urine odors were detected in several areas throughout the facility. Findings include: During observations on 12/03/2025 from 10:11 AM through 3:00 PM, on 12/04/2025 from 8:31 AM through 9:16 AM, on 12/05/2025 from 8:33 AM through 1:30 PM, on 12/08/2025 from 9:41 AM to 10:34 AM, and again on 12/10/2025 at 10:53 AM, strong urine odors were detected in rooms #555, 566 (two (2) observations), and 671 and in the north elevator lobby area on the third floor. During an interview on 12/09/2025 at 3:01 PM, Director of Environmental Services #1 stated that they would contact the nursing department to help investigate the odors. 10 New York Codes, Rules, and Regulations 483.90(i)

Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident reviewed (Resident #314). Specifically, Resident #314 was observed on 12/03/2025 and 12/05/2025 with a bottle of unprescribed Clinical Treat Anti-Fungal Powder (treats fungal or yeast infections of the skin) NDC #5332916979 sitting on their bedside table in their room. There was no documented evidence of an assessment in the medical record and/or a physician order for the resident to self-administer the medication. The finding is:The facility's Policy and Procedure titled Self-Administration of Medications revised 08/2020, documented in order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team (or equivalent) has determined that the practice would be safe for 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 observations, record review, and interviews during the recertification survey, the facility failed to ensure resident's right to make choices about aspects of his or her life in the facility that are significant for one (1) (Resident #211) of one (1) resident reviewed. Specifically, Resident #211 was not provided with food items recommended by the nutritionist's meal plan and resident's preferences, requiring the resident to purchase recommended items from an outside source. Findings include: The undated facility policy, Resident Orientation Handbook, documented residents have the right to be offered choices and allowed to make decisions and to receive services with reasonable accommodations for individual needs and preferences. Resident #211 was admitted to the facility with diagnoses that included Hodgkin lymphoma (cancer of the lymphatic system), pain, and anemia. The Minimum Data Set (a resident assessment tool) dated 09/24/2025 documented the resident was cognitively intact, could be understood and understands others. The Comprehensive Care Plan revised 11/04/2025…

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 conducted during the survey, the facility failed to ensure each resident's right to file a grievance and/or prompt efforts were made to resolve grievance for one (1) (Resident #380) of three (3) residents reviewed for grievances. Specifically, there was no documented evidence that a grievance was filed, an investigation was conducted, and/or a grievance was resolved when Resident #380's responsible party reported to staff the resident was missing a new pair of sneakers and multiple clothing items. The finding is:The policy titled Lost or Missing Items, review/revision dated 05/16/2025, documented the facility will review and investigate all lost and missing items and unauthorized use or removal of resident's property. Upon noting a loss, the staff receiving the complaint or designee will initiate the missing items report form and include all known information about the item. Staff will follow the checklist on the missing item form to search for the item. If the item is not found, staff will notate that on the form, and the form will be forwarded…

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

Based on observations, record reviews, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards for one (1) (Resident #1) of one (1) resident reviewed. Specifically, Resident #1 was observed to have an old bandage on their left forearm with no documentation in the resident's medical records.Findings include:Resident #1 was admitted to the facility with diagnoses of Parkinson's disease (a progressive brain disorder affecting movement), dysphagia (difficulty swallowing food or liquids), and dementia (a group of symptoms affecting memory, thinking, and social abilities). The Minimum Data Set (a resident assessment tool) dated 10/10/2025 documented the resident was understood, could understand others and was cognitively intact.During an observation on 12/04/2025 at 9:54 AM, a bandage was noted on Resident #1's left forearm dated 12/01/2025. Resident #1 stated they did not know what was under the bandage but that it might be a skin tear.During an observation on 12/05/2025 at 11:47 AM, the bandage was noted to still…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the survey, the facility failed to 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' physician orders for one (1) (Resident #143) of four (4) residents reviewed. Specifically, Resident #143 was observed with oxygen tubing dated [DATE] and not changed as ordered. The finding is: The facility policy Oxygen Therapy Policy and Procedure revised [DATE] documented nasal cannula or OxyMask were labeled and dated when set up. Nasal cannulas or OxyMasks were changed every two (2) weeks or as needed if visibly soiled. When the nasal cannula or OxyMask was changed it was labeled, dated, and documented in the administration record. Resident #143 was admitted to the facility with diagnoses including acute and chronic respiratory failure with hypoxia (tissues do not get enough oxygen to function properly), pneumonia,…

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

Based on record review and interviews during the abbreviated survey (NY00361295), the facility did not ensure they provided or obtained routine and emergency medications and biologicals in order to meet the needs of each resident for 2 of 3 residents reviewed (Residents #2 and 4). Specifically: Resident #2 had physician orders for Lithium (psychotropic medication for mood stabilization), the Lithium was not obtained timely and as a consequence, the resident had a low Lithium blood level. Resident #4 was a newly admitted and had physician orders for Sevelmer and cinacalcet ( for kidney disease) and the medications were not obtained timely (11 days). Findings include:The 9/2018 facility policy, “Ordering and Receiving Non-Controlled Medications,” documented medications and related products were received from the pharmacy on a timely basis. Medications were reordered based on estimated refill date and the pharmacy prescription label, or at least 3 days in advance to ensure adequate supply was on hand. The refill order was called in, faxed, sent electronically, or otherwise transmitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification and abbreviated (NY00358079) survey conducted 4/6/2025-4/18/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for five (5) of five (5) resident floors (3rd, 4th, 5th, 6th, and 7th floors). Specifically, the 4th, 5th, 6th, and 7th floors had unattended and unlocked treatment/medication carts; the 3rd, 4th, and 7th floors had medication refrigerators without daily temperature monitoring; the 3rd, 5th, and 6th floors had medications without open dates; and the 4th and 7th floors medication rooms had an excessive number of discontinued medications. Findings include: The facility policy Storage of Medications, dated 8/2020, documented all medications dispensed by the pharmacy were stored in the pharmacy container with the pharmacy label. When the original seal of a manufacturer's container or vial was initially broken, the container or vial would be dated. If 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 observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen, and 1 of 2 (Northwest Unit) kitchenette nourishment areas. Specifically, food was held at the improper temperature for service during two (2) meals observed that could have affected all residents, eight (8) of nine (9) handwashing sinks were not properly equipped in the food production and service areas and improper handwashing was observed. Findings include: The facility policy, Fine Dining Policy and Procedure, dated revised 3/2025, did not document temperatures of meals during service. The undated facility Meal Service Food Temperature Log documented the hot food items measured should have been between 135 and 155 degrees Fahrenheit. If they fell below the standard they were to reheat the item to 165 degrees Fahrenheit and document the corrective action. The facility policy, Hand Washing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for four (4) of six (6) resident units (Units 3 North and South, Units 4 North and South, Units 6 North and South, and Unit 7) reviewed. Specifically, several residents' rooms and common living areas were unclean, had scraped or cracked walls, dirty soiled linens left on the floors, dirty tables and chairs, several pieces of paper trash collecting on resident floors, and there were unpleasant/offensive odors. Findings include: The facility policy Dignity and Respect, dated 8/2023 documented staff must ensure they provided residents with a safe, clean, and comfortable room and surroundings. Units 3 North and South The following observations were made on 4/6/2025: - at 9:30 AM, room [ROOM NUMBER] had a scraped wall behind the bed, the wall under the base board was crumbling, there was a hole cut out for an electric…

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 4/6/2025-4/18/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 4 of 6 residents (Residents #27, #167, #274, and #419) reviewed. Specifically, Resident #27 had an order not to receive straws due to oral phase dysphagia (difficulty swallowing) and was observed using straws; Resident #167 had medications left at their bedside; Resident #274 had a used needle and vacuum from a blood draw disposed of in the trash can in their room; and Resident #419 sustained a burn after using a microwave independently to heat food. Findings include: The facility policy Standard Precautions, revised 6/2019, documented used disposable needles would be placed in appropriate puncture-resistant containers located as close as practical to the area in which the items were used. The facility policy, Reheating of foods, effective 1/8/2020 documented food would be reheated to appropriate temperatures for resident satisfaction and to ensure food safety by staff…

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

Based on observations and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for three (3) of three (3) meals reviewed (Lunch meals on 4/6/2025 and 4/8/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 4/6/2025 and two (2) lunch meals on 4/8/2025. Additionally, 12 anonymous residents during a resident council meeting and six (6) residents (Resident #80, 160, 285 336, 355, and 425) interviewed stated the food did not taste good and was cold. Findings include: The undated facility Meal Service Food Temperature Log documented holding temperatures were hot beverages and soups greater than 135 degrees Fahrenheit; hot food items greater than 135 degrees Fahrenheit, and cold food and beverages 45 degrees Fahrenheit or less. If hot food temperatures fell below standards, it must be reheated to 165 degrees F and hold temperature for 15 seconds. During an interview with Resident #336…

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 from 4/6/2025-4/18/2025, the facility failed to ensure each resident received food that accommodated resident allergies, intolerances, and preferences for three (3) of five (5) (Resident #306, 336, and 704) reviewed. Specifically, Resident #306 was missing food items including their nutritional supplements at meals; Resident #336 was missing food items at meals; and Resident #740 was missing food items including their nutritional supplements at meals. Additionally, 12 anonymous residents during a resident council meeting and five (5) residents (Resident #80, 160, 210, 355, and 480) interviewed stated their meal trays were frequently missing food items. Findings include: The facility policy Fine Dining, revised 3/2025 documented certified nurse aides would serve residents their food per their meal ticket and ensure proper accuracy. Nursing staff would be assigned to deliver and monitor the residents with room trays. 1) Resident #306 had diagnoses including dementia and failure to thrive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not maintain an effective pest control program so that the facility was free of pests for the administrative area and for 3 of 7 units (3rd, 4th, and 6th floors) reviewed. Specifically, there were fruit flies observed in the administrative area, and the 3rd, 4th, and 6th floors. Findings include: The facility policy, Insect and Rodent Control, revised 3/2020 documented to prevent insect and rodent entry into the facility, the facility would ensure proper cleaning of the facility daily per Centers for Medicare and Medicaid policies and procedures, proper food storage in the facility, ability to identify rodent infestation and notify proper personnel when a rodent infestation was identified. An outside vendor was contracted to manage insect and rodents at the facility and vendor books would be placed at the nursing stations for staff to update and report any sightings. The vendor would follow up…

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 4/6/2025-4/18/2025, the facility did not ensure the interdisciplinary team determined a resident's ability to appropriately self-administer medications for one (1) of one (1) resident (Resident #50) reviewed. Specifically, Resident #50 had medications in their room they stated they could self-administer. Findings include: The facility policy, Self-Administration of Medications, revised 8/2020, documented if the resident desired to self-administer medications, the interdisciplinary team conducted an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. Resident #50 had diagnoses including deafness, pain, and atherosclerotic heart disease (plaque buildup in the arteries). The 3/4/2025 Minimum Data Set assessment documented the resident was cognitively intact and independent with activities of daily living. The Comprehensive Care Plan revised 12/30/2024 documented the resident's cognition, psychosocial, mood…

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 4/6/2025-4/18/2025, the facility did not ensure a resident's right to be free from misappropriation of property/funds for two (2) of two (2) residents (Residents #50 and #102) reviewed. Specifically, Activity Aide #5 had possession of Resident #50's money; and Resident #102 had multiple bags of deposit cans redeemable for cash removed from their room and did not receive the deposit money. Findings include: The 10/2028 facility Staff Member Handbook documented the expectation was all staff members would conduct themselves in a professional manner that would contribute to the provision of the highest quality of care for the residents and the safety and security of residents. Just cause for discipline, up to and including termination would include but not be limited to: accepting gratuities (except for in kind gifts of a minimal value, e.g., baked goods) from residents, family members, supplies, or vendors. 1) Resident #50 had diagnoses including deafness, and non-speaking. The 3/4/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for one (1) of nine (9) residents (Resident #50) reviewed. Specifically, the facility did not complete a timely investigation when they were notified a facility staff member was in possession of Resident #50's money (see F 602) and did not report the incident to the New York State Department of Health as required. Findings include: The facility policy Reporting and Monitoring Accidents and Incidents, revised 9/2024 documented all incidents were reviewed for alleged abuse, mistreatment, neglect, injury of unknown origin, misappropriation of resident property, or resident elopement and must be reported to Administration immediately. The incident report system was used to document, assess, investigate and develop interventions for any accident/ incident that involved a resident. A description of…

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

Based on observations, record review, and interviews during the recertification survey conducted 4/6/2025 - 4/18/2025, the facility did not ensure the accuracy of resident assessments reflective of the resident's status during the observation period of the Minimum Data Det assessment for one (1) of three (3) residents (Resident #200) reviewed. Specifically, the most recent Minimum Data Set Resident Assessment inaccurately documented the resident as nonverbal and severely cognitively impaired. Findings include: The facility policy Accuracy of the Resident Assessment, revised 6/24/2016, documented all personnel who complete any portion of the Minimum Data Set Assessment, tracking form, or correction request form must sign assessment certifying the accuracy of that portion of the assessment. Resident #200 had diagnoses cancer of the mouth and throat with absence of larynx (voice box) and had a tracheostomy (a hole created in the neck into the windpipe). The 2/18/2025 Minimum Data Set Assessment documented the resident had absence of spoken word, was sometimes able to express ideas 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 observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of two (2) residents (Resident #372) reviewed. Specifically, Resident #372 did not have their wheelchair leg rests applied or included in their care plan as recommended by physical therapy. The facility policy Care Planning/Care Conference, issued 8/7/2024 documented the Comprehensive Care Plan should describe the resident's medical, nursing, physical needs and preferences and how the facility would assist in meeting those needs and preferences. The facility policy Wheelchair Transporting (Leg Rest), 2/2017 documented wheelchair leg rests must be used for all residents at all times unless otherwise care planned. Resident #372 had diagnoses including edema (swelling caused by fluid), gout (a type of arthritis), and rheumatoid arthritis (a chronic inflammatory…

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 4/6/2025-4/18/2025, the facility did not ensure that services were provided to meet professional standards of quality for five (5) of five (5) resident units (Units 3, 4, 5, 6, and 7) reviewed. Specifically, direct care staff wore electronic earbuds; were scrolling or talking on their personal phones in resident care areas; and were observed in the breakroom for extended periods longer than documented break/mealtimes or at the end of their shifts. Additionally, 12 of 12 residents present at the Resident Council Meeting complained staff did not answer their call bells timely, were rude, and made them feel disrespected. Findings include: The facility Staff Member Handbook, revised 10/2018, documented staff were permitted one 15-minute break for each 7.5 hours of work per day and a half hour meal period during a shift that lasted more than six hours. Cell phones were not to be used during working hours and may only 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification and abbreviated (NY00374160) surveys conducted 4/6/2025-4/18/2025, 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 two (2) of five (5) residents (Residents #160 and #336) reviewed. Specifically, Residents #160 and #336 were not provided with oral hygiene or hair care. Findings include: The facility policy Hygiene/Grooming, revised 3/2023, documented personal hygiene, skin integrity, personal dignity, and a feeling of well-being was maintained for each resident. Residents requiring assistance with activities of daily living received a partial bed bath daily. Residents were provided the opportunity for a bed bath, shower, or whirlpool once a week unless otherwise indicated in their plan of care. Resident hygiene included hair care, nail care, foot care, and mouth care. 1) Resident #160…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for two (2) of three (3) residents (Residents #71 and #114) reviewed. Specifically, Resident #71's and #114's physician orders for alternating air mattresses (a specialty mattress providing air flow to relieve pressure) did not include individualized settings and the mattresses were not monitored to ensure appropriate settings for the resident's current weights. Findings include: The Alternating Air Mattress Manual documented it was recommended the pressure-selector knob was set to firm or pressed auto firm on the touch panel each time the mattress was first inflated. Thereafter the air mattress was easily adjusted to the desired firmness according to the patient's weight. 1) Resident #71 had diagnoses including left sided…

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 4/6/2025-4/18/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for two (2) of two (2) Residents (Residents #306 and #740) reviewed. Specifically, Resident #306 had significant weight loss and did not receive fortified cran-apple juice, Magic Cups (fortified frozen dessert) and double portioned entrees as planned; and Resident #740 had significant weight loss and planned preferred food items for weight maintenance were missing from their meal trays. Additionally, Resident #306 was not assisted with eating in a dignified manner. The facility policy Comprehensive Nutritional Assessment, revised 9/2023 documented the Registered Dietitian or designee helped identify nutritional risk factors and recommended nutritional interventions based on the individual's medical condition, needs, desires, and goals. The facility policy Fine Dining, revised 3/2025 documented certified nurse aides would serve residents their food per their meal ticket 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 observations, record review, and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice for one (1) of one (1) resident (Residents #179) reviewed. Specifically, Resident #179 did not have their prescribed pain patch placed as ordered and the pain patch was signed as administered. Findings include: The facility policy Pain Management Program, effective [DATE] documented pain would be managed and assessed to promote optimal functioning and maintain quality of life. The facility Medication Administration Policy and Procedure, revised 11/2021, documented the nurse administering medication was responsible to administer the right medication to the right resident in the right dose at the right time, using the right method of administration and the right method of documentation. Resident #179 had diagnoses including pain, morbid obesity, 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 observations, record review, and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not provide on-going assessment and monitoring of bed rails (side rails) for one (1) of one (1) resident (Resident #41) reviewed. Specifically, Resident #41 had bed rails on both sides of the bed and did not have an order for bed rails, a comprehensive care plan that included the use of bed rails, regular maintenance inspections for entrapment, or regular assessments to ensure the bed rails remained appropriate. Findings include: There was no documented evidence of a facility policy for the use of bedrails. Resident #41 had diagnoses including quadriplegia (weakness or paralysis of arms and legs), reduced mobility, and need for assistance with personal care. The 2/27/2025 Minimum Data Set assessment documented the resident was cognitively intact, was dependent for all activities of daily living, and did not reject care. The Comprehensive Care Plan, initiated 1/29/2024 and revised 12/8/2024, documented the resident was dependent for activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the recertification survey conducted 4/6/2025-4/18/2025, the facility did not ensure a resident's total program of care, including medications and treatments, was reviewed by the medical provider for one (1) of one (1) resident (Resident #322) reviewed. Specifically, Resident #322 was readmitted to the facility from the hospital with sliding scale insulin (the amount of insulin administered was based on the blood glucose readings) instructions that were not initiated, the resident's finger sticks (blood glucose readings) were not consistently done as ordered and there was no evidence the provider was aware. Subsequently, the resident was readmitted to the hospital with hyperglycemia (above normal blood glucose levels). Findings include: There were no documented facility policies on Admission/readmission medical orders. Resident #322 had diagnoses including diabetes and end stage kidney disease. The 10/9/2024 Minimum Data Set assessment documented the resident had…

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

Based on observations, record review, and interviews during the recertification surveys conducted 4/6/2025-4/18/2025, the facility did not ensure that residents were free of any significant medication errors for one (1) of one (1) resident (Resident #1098) reviewed. Specifically, Resident #1098 was administered lispro insulin (a fast-acting insulin) and was not provided food. Findings include: The facility policy Medication Administration Policy and Procedure, last revised 11/2021, documented when medications were ordered before or after meals, assure the medicine was given correctly in relationship to meals Resident #1098 had diagnoses including diabetes. The 4/1/2025 Minimum Data Set assessment documented the resident had intact cognition, required set up assistance for eating, and received insulin injections daily. The Comprehensive Care Plan, initiated 3/31/2025, documented the resident had diabetes with hyperglycemia. Interventions included monitor for signs and symptoms of high glucose levels and insulin shock. The 4/1/2025 Nurse Practitioner #23's orders documented a glucose…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during the recertification and abbreviated (NY00358079 and NY00376311) surveys conducted 4/6/2025-4/18/2025, the facility did not assist residents in obtaining routine and emergency dental care for two (2) of three (3) residents (Residents #102 and #336) reviewed. Specifically, Resident #336 did not receive their dentures as planned and Resident #102 was not scheduled for an outside dental consult for a tooth extraction as recommended by the in-house dentist. Findings include: 1) Resident #336 had diagnoses including dysphagia (difficulty swallowing), obesity, and dehydration. The Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact, was dependent on staff with activities of daily living, did not have broken natural teeth, or mouth pain/discomfort with chewing. The Comprehensive Care Plan revised 4/14/2025 documented an activities of daily living deficit. Interventions included dependency on one staff for assisting with oral…

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 (NY00325653) the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 4 nursing floors (4th and 5th floors) reviewed. Specifically, there was evidence of cockroaches on the 4th and 5th floors. Findings include: The facility policy Pest Control revised 8/2019 documented work orders will be placed for maintenance to address areas that may facilitate pests access or harbor growth, for example, unsealed cracks or holes in walls/doors, or low grout that collects food debris and water. An approved pest control contractor comes into complete routine preventative treatments at prescheduled times. Staff will report pest sightings via the pest sighting logs. Sightings will report the type, number, and location of pests noted. If a pest situation is reported, maintenance may treat the area and will request the contractor come in as soon as possible to treat the areas identified. 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 record review and interviews during the abbreviated survey (NY00323044, NY00322098) the facility did not ensure that the Office of the State Long Term Care Ombudsman received a written notice of transfer or discharge at least 30 days before the resident was transferred or discharged for 2 of 3 residents reviewed (Residents #1 and 2). Specifically, Residents #1 and 2 were issued facility-initiated discharge notices and the Office of the State Long Term Care Ombudsman were not provided the notifications. Findings incude: The Discharge Planning policy revised 3/2018 did not contain any information related to notification of the Office of the State Long Term Care Ombudsman when residents were discharged . On 9/11/2023 at 4:08 PM, the Administrator stated there were no other polices related to any aspect of discharges, including discharge planning, notices, or facility-initiated discharges. 1) Resident #1 had diagnoses including dementia, PTSD (post-traumatic stress disorder), personal history of self-harm, major depressive disorder, and unspecified psychosis. The 7/15/2023…

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.