Safire Rehabilitation Of Northtowns, L L C

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00365639) during a Standard survey completed on 3/28/25, the facility did not ensure the resident's right to be free from physical restraints imposed for the purposes of discipline or convenience and is not required to treat the residents' medical symptoms for one (Resident #48) of four residents reviewed. Specifically, Resident #48 was physically restrained by a staff member in bed. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents with a revised date of 2/2023 documented acts of abuse against residents were absolutely prohibited. Abuse includes control of resident's behavior through corporal punishment. Unlawful restraint is intentionally or knowingly using physical or chemical restraints or medication on a care-dependent person. The policy and procedure titled Resident Rights dated 3/1/17 documented Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free…

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 reviews conducted during the Standard Survey completed on 3/28/25, the facility did not provide services consistent with professional standards of quality for one (Resident #444) of 25 residents reviewed. Specifically, Resident #444 did not receive an intravenous medication as ordered by the physician and the physician was not notified of those omissions. The policy and procedure titled administering medication/treatments dated 12/1/17, documented medications shall be administered in a safe and timely manner and as prescribed including any required time frame and state regulations. If the drug is withheld or refused, the licensed nurse administering the medication will document accordingly in the electronic medical record and notify the nursing supervisor. 1. Resident #444 had diagnoses that included diabetes mellites, acute osteomyelitis (infection of the bone) of the left foot, and orthopedic aftercare. The comprehensive care plan dated 3/11/25, documented Resident #444 was alert and oriented. The care plan documented Resident #444 had an infection…

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 conducted during a Complaint investigation (#NY00335062, NY00338640, and NY00347069) during the Standard survey completed on 3/28/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (Resident #82, #19 and #79) of six residents reviewed. Specifically, Resident #82 had long fingernails with brown debris underneath them on multiple observations; Resident #19 had facial hair that they wanted removed and during morning care observation staff did not offer shaving; Resident #79 had disheveled, oily hair on multiple observations and during a morning care observation, staff did not wash their face and underarms, oral care was not provided, hair wasn't washed or combed, and they were not dressed in their personal clothing or transferred out of their bed to a chair. The findings are: The policy titled Activities of Daily Living dated…

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 Standard survey completed on 3/28/25, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (1) (Resident #19) of three (3) residents reviewed. Specifically, staff did not follow physician orders when completing a pressure ulcer treatment. In addition, there was a delay in assessments and notification to the physician regarding a declining skin concern and newly identified pressure ulcer. The finding is: The policy and procedure titled Skin and Wound Care Policy dated 5/10/18 documented, the purpose is to facility the prevention and or treatment of impaired skin integrity, by assessing and planning care immediately upon identification of residents at risk or with existing wounds. To provide skin and wound care protocols for use in determining appropriate interventions. A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage to underlying tissue. Stage 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 observation, interview, and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #48) of five (5) reviewed for accidents. Specifically, staff did not remove Resident #48 from the common area/dining room to a lesser stimulating environment as care planned when they had increased agitation and the resident fell out of their Geri chair (specialized chair designed for elderly or disabled individuals), hitting their head on the floor; staff inappropriately transferred the resident from the floor back into their chair and the resident landed on their face. Additionally, care plan interventions were not revised after the resident fell on 3/24/25. The finding is: The policy titled Accidents and Incidents - Investigating and Reporting revised 12/10/21 documented the facility will ensure that the residents environment remains as free from accident hazards as is possible while providing adequate supervision and assistive…

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 conducted during the Standard survey completed on 3/28/25, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for two (Resident #13 and #19) of three residents reviewed. Specifically, infection control practices were not maintained when caring for residents with an indwelling foley catheter. Resident #13's foley catheter drainage bag (used to collect urine) was observed on the floor and Resident #19's foley catheter drainage bag was improperly emptied. Additionally, the comprehensive care plan was not developed to include the use of an indwelling foley catheter and the Minimum Data Set ( a resident assessment tool) was coded inaccurately (#13). The findings are: The policy and procedure titled Urinary Catheter Care dated 8/2022 documented use aseptic technique (a method used to prevent contamination with microorganisms)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a Standard survey completed on 3/28/25, the facility did not ensure that the pharmacist reported irregularities to the attending physician and the facility's Medical Director, and the Director of Nursing, and that these reports were acted upon for two (Residents #25 and #75) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not report a gradual dose reduction for a psychotropic medication had not been attempted at least annually per the facility protocols (#25). In addition, the Consultant Pharmacist recommendations on 10/17/24 and 12/5/24 were not acted upon (#75). The findings are: The policy and procedure titled, Coordination of Consultant Pharmacist Monthly Review and Recommendations revised 11/28/2017, documented the facility will ensure that all pharmacist recommendations are coordinated with the Physician and nursing services timely and appropriate actions and follow up actions occurs to ensure each…

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 the Standard survey, completed on 3/28/25, the facility did not provide or obtain dental services to meet the resident's needs for one (Resident #74) of one resident reviewed. Specifically, there was a lack of timely follow - up on dental recommendations for extractions (removal of teeth). The finding is: The policy titled Dental Services, last revised 1/26/2020, documented routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The Director of Nursing or their designee was responsible for notifying social services of a resident's need for dental services and coordinating appointments with Medical Records/ Unit Clerks. Social Services personnel would be responsible for assisting the resident in making dental appointments and transportation arrangements as necessary whenever an outside dentist was requested. All dental services were recorded in the resident's medical record. The Medical Records Department/ Unit…

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, interviews, and record review conducted during the Onsite Post Survey Revisit #1, the facility did not ensure all menus were followed for four (Residents #1, 2, 3 and 4) of 7 residents reviewed. Specifically, residents were not served a ground consistency diet as planned. This is a continuing deficiency from the abbreviated survey completed 11/12/2024. The findings are: The policy and procedure titled, Tray Identification dated 2/17/17, documented the purpose of the policy was to assist in setting up and serving the correct food trays/diets to residents. The Food Services Manager or Supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If there is an error, the Nurse Supervisor will notify the Dietary Department Immediately by phone so that the appropriate food tray can be served. The policy and procedure titled, Therapeutic Diets dated…

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 Abbreviated survey (complaint # NY00329948) completed on 2/15/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one kitchen had issues that included undated and outdated food, a cooked food item stored adjacent to raw meat, flies observed, no single service towels at the handwash sink, multiple soiled surfaces, missing wall tiles, and missing floor tiles. The findings are: The policy and procedure titled Food Receiving and Storage, reviewed 10/4/23, documented foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator will be covered, labeled, and dated. Uncooked and raw animal products will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. The policy and procedure titled Sanitization, reviewed 10/4/23, documented the food service area shall be maintained in a clean and sanitary manner. 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.

Based on interview and record review conducted during a Standard survey completed on 9/18/23, it was determined that the facility did not ensure maintenance of 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 infection for one of one facility water management systems. Specifically, water samples that tested positive for Legionella was not reported to the New York State Department of Health (NYS DOH) and institute short-term control measures when control measures were not met. Additionally, staff that administered the facility's Potable Water Sampling and Management Plan did not notify the facility Infection Preventionist of the positive Legionella water sample results. The findings are: 1. The policy and procedure P&P titled, Legionella Water Management Program dated 12/01/2017, it documented that the purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce…

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 a Standard survey completed 9/18/23, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services. The finding is: Refer to F 804, F 809, and F 812 The undated policy and procedure (P&P) titled Food and Nutrition Services documented it is the policy of the facility to ensure that facility staff supports the nutritional wellbeing of the residents while respecting an individual's right to make choices about his or her diet. If a qualified dietitian or other clinically qualified nutrition professional is not employed full time, the facility must designate a person to serve as the director of food and nutrition services who for designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1…

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 Standard survey completed 9/18/23, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for four (1st, 2nd, 3rd, and 4th floors) of four test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #1, #5, #19, #34, #40, #55, #57, #77, #341, and #388 were involved. The findings are: The undated/unsigned document labeled Food and Nutrition Services documented it was the policy of the facility to ensure that staff support the nutritional wellbeing of the residents while respecting their right to make choices about their diet. In addition, it documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that met their nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy and procedure (P&P) titled Food Preparation and Service dated…

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 Standard survey completed 9/18/23 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: floors throughout kitchen, walk in cooler, and dry storage room had debris build-up and/ or dark black substance along the perimeters/ corners, plexiglass in front of the steam table was soiled and cracked, outdated, undated, and/or unlabeled food items, multiple packages of bread products had a green mold like growth on them with outdated sell by date, multiple containers had small dead flies and/or black mold like spots on their lids/ sides, small metal racks and condenser in the walk-in cooler had copious amounts of thick dark black mold like build-up, walk-in cooler had a musty/ mildew smell, outside surface of reach-in cooler had a buildup of grease and food splatters, several crates/ boxes containing sherbet and ice cream were soft/ not frozen, ice build under the freezer condenser, multiple uncovered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Standard Survey completed on 9/18/23, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Residents #26) of 3 residents reviewed for resident choices. Specifically, residents were not provided a choice to take a tub bath because there was no working bathtub in the facility. The finding is: The policy and procedure (P&P) titled Quality of Life - Self Determination and Participation dated 9/1/17 documented the facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident shall be allowed to choose activities, schedules and health care that are consistent with his or her interests including personal care needs such as bathing methods. To facilitate resident choices staff shall gather information about 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 interview and record review conducted during a Complaint investigation (#NY00294631) during a Standard survey completed on 9/18/23, the facility did not ensure that the resident's representative was notified immediately of a change of condition for one of three residents (Resident #12) reviewed for notification of change. Specifically, Resident #12's representative was not notified of the resident's tooth pain, loose tooth, and the loss of the tooth that required treatment. The finding is: 1. Resident #12 was admitted to the facility with diagnosis of dementia and high blood pressure. The Minimum Data Set (MDS - a resident assessment tool) dated 8/18/23 documented Resident #12 was moderately cognitively impaired, understood by others, and understands others. The MDS documented that the resident did not have any oral or mouth issues. Review of the Resident #12's dental order and progress note dated 4/17/23 documented the resident's tooth (#18 - lower left quadrant second molar tooth) was loose and the resident had refused an extraction. The dental order and progress note…

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 conducted during a Standard survey completed on 9/18/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (Resident #5) of one resident reviewed for activities. Specifically, Resident #5 was not provided accommodations for activities for an individual who was visually impaired. In addition, the facility did not develop an activities comprehensive person-centered care plan for Resident #5 to accommodate special needs related to visual impairment. The finding is: The policy & procedure (P/P) titled Activity Programs revised 3/30/2020, documented that activity…

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

Based on observation, interview and record review conducted on a Standard survey completed 9/18/23, the facility did not ensure each resident be provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for three (Unit 1, Unit 2, and Unit 3) of three units. Specifically, resident meal trays were served up to 60 minutes after scheduled mealtimes. Residents' #1, 59, 61 and 75 were involved. The findings are: The undated policy and procedure titled Food and Nutrition Services documented it is the policy of the facility to ensure that facility staff supports the nutritional wellbeing of the residents while respecting an individual's right to make choices about his or her diet. Each resident will receive, and the facility will provide at least three meals daily at regular times comparable to normal mealtimes in the community, or in accordance with resident needs, preferences, requests, and plan of care. Review of the Facility Survey Report dated and signed 9/12/23…

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 Standard survey completed on 11/19/21, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees A, B, C, and F) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: Per Part 415 - Nursing Homes - Minimum Standards: Nursing home shall develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of residents and misappropriation of resident property. The facility shall not employ individuals who have had a finding entered into the New York State Nurse Aide Registry concerning abuse, neglect or mistreatment of residents or misappropriation of their property. The facility's policy titled, Registry of Nurse…

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 Standard survey completed on 11/19/21, the facility did not maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Specifically, a shower plumbing device and hose did not have a vacuum breaker installed to prevent backflow. Also plumbing pipes were open and uncapped. This affected three (Basement, First and Second floors) of four resident use floors. The findings are: 1a. Observation in the Second floor Beauty Shop on 11/15/21 at 8:11 PM revealed the hair washing sink had a shampoo nozzle and hose that did not have vacuum breakers installed. The shampoo nozzle had a hose attached to it that allowed the nozzle to lie flush with the interior of the sink's bowl. The length of the hose allowed the shampoo nozzle to be submerged if the sink's drain did not drain. 1b. Observation in the Second floor Shower room on 11/15/21 at 8:12 PM revealed one of the two shower stalls had a shower and shower wand that did not have vacuum breakers installed. The shower had a shower wand attached…

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 Standard survey completed 11/19/21, the facility did not ensure that grievances were filed on behalf of residents and thoroughly investigated. Specifically, residents voiced complaints of missing personal belongings, the facility did not file grievances on behalf of the residents and did not complete investigations into the missing personal belongings. This involves Residents #5, 18, 40, 47, 66. The findings are: The facility policy and procedure (P&P) titled Resident Council dated 4/12/19 documented the facility would act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility and the facility will be able to demonstrate their response and rationale for such response. The facility P& P titled Investigation of Grievances/Concerns dated 6/2019 documented the facility was committed to fair and equal treatment of all residents and will complete a prompt thorough investigation of all grievances and/ or concerns filed with the facility. In addition, the resident,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a Complaint investigation (NY00282505) during the Standard survey completed on 11/19/2021, the facility did not ensure all alleged violations involving injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. Specifically, two (Residents #20, 33) of five residents reviewed for abuse bruising of unknown origin was not reported to the New York State Department of Health (NYSDOH) as required. The findings are: The facility policy and procedure (P&P) titled Abuse, Neglect and Exploitation of Residents revised 11/2021 documented once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information. An investigation must be directed by the Administrator/ designee immediately, report to Department of Health within 2 hours of their knowledge of 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, interview, and record review conducted during the Standard Survey (Complaint# NY00272002 & NY00272117) completed on 11/19/21, the facility did not have the evidence that all alleged violations of abuse were thoroughly investigated for three (Resident #9, 33, 68) of five residents reviewed. Specifically, there was a lack of thorough investigations into injuries of unknown origin (#33, 68) and resident self-reported alleged abuse (#9). The findings are: The policy and procedure titled Abuse, Neglect and Exploitation of Residents dated 11/21 documented each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone. The policy and procedure titled Identification and Initiation of Investigation dated 6/21 documented all reports of resident abuse, neglect and injuries of unknown source shall be promptly 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 interview and record review conducted during the Standard survey completed 11/19/21, the facility did not ensure that residents who require dialysis received services consistent with professional standards of practice for one (Resident #56) of one resident reviewed. Specifically, the resident's left arm Arteriovenous (AV) fistula (a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site was not monitored for patency by checking for bruit (a rumbling or whooshing sound you can hear) and thrill (a rumbling or buzzing sensation that you can feel) per physician's order. The finding is: The facility policy and procedure titled Dialysis dated 1/19/2019 documented the facility had established standards of care for the dialysis resident. The Registered Nurse (RN) or designated Licensed Nurse will maintain the established standard of care. The access site would be monitored per doctor's order, palpate for thrill and auscultate bruit every shift for the presence of blood flow. Absence of thrill / bruit (for shunt) may indicate…

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 Standard survey completed on 11/19/21, the facility did not provide food prepared in a form designed to meet individual needs for one of 3 residents (Resident #35) reviewed for food. Specifically, the facility did not ensure proper ground consistency was provided. The finding is: The facility policy and procedure (P&P) titled Therapeutic Diets with a revision date of 11/1/21 documented therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his/her goals and preferences. If a mechanically altered diet (requires change in texture of food or liquids) is ordered, the provider will specify the texture modification of ground, chopped or puree. 1. Resident #35 was admitted to the facility with diagnoses including depression, anxiety, and asthma (lung disorder characterized by narrowing of the airways causing shortness of breath, wheezing and cough). The Minimum Data Set (MDS- a resident assessment tool dated 9/13/21 documented Resident #35…

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.