Troy Victorian Rehabilitation & Nursing Care Cntr

Based on observations, record review, and interviews (iQIES intake 2727573), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of one (1) resident (Resident #17) reviewed. Specifically, Resident #16 had an existing Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum (large bone at the base of the spine) and treatments were not administered as ordered and the wound was not monitored consistently. Findings include: The facility policy Pressure Ulcer Prevention and Managing Skin Integrity, last reviewed 12/2025, documented care and interventions regarding pressure ulcers included implementation of appropriate evidence-based care, and close monitoring of the responses to treatment.Resident #16 had diagnoses including a Stage 4 pressure ulcer to the sacrum, impaired circulation and urinary incontinence (loss of bladder control). 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 the facility failed to ensure that each resident received adequate supervision to prevent accidents for four (4) of six (6) residents (Residents #1, #6, #115, and #119) reviewed. Specifically, Residents #1 and #6, were at risk for aspiration (inhaling food or liquids into the lungs) and were not supervised or monitored when eating; Residents #115 and #119 had mattresses that were not adequately fitted to the bed frame and their beds tilted laterally causing a downward slope; and Resident #119 had a loose enabler bar on their bed. Findings include: The facility policy Aspiration Precautions, last reviewed 04/2026 documented no resident on aspiration precautions would use a straw for the delivery of nutrition or fluids, unless otherwise specified by the Speech Language Pathologist; no resident on a thickened liquid diet shall use straws; and residents on aspiration precautions would receive frequent monitoring by nursing staff. The facility Maintenance Policy, updated 05/2026, documented routine preventative maintenance schedules…

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, the facility failed to provide the necessary care and services to prevent urinary tract infections, to the extent possible, for one (1) of one (1) resident (Resident #26) reviewed. Specifically, Resident #26 had an indwelling urinary catheter (a tube that removes urine from the bladder), wore a urinary collection leg bag (a small, wearable, and discreet bag) and was not provided with a large capacity urinary collection bag. The urinary collection leg bag was not positioned below the level of the bladder to prevent backward urine flow. Findings include: The facility policy Catheter, Foley Insertion, Removal and Care, last reviewed 07/18/2022, documented the facility would provide catheter care during morning and evening care to residents that had indwelling catheters to prevent infection and reduce irritation. When using a leg bag, they should be checked and emptied every 2 hours. Resident #26 had diagnoses including obstructive uropathy (a condition that blocks the flow of urine), urine retention, and urinary tract infections.…

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, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #2) reviewed. Specifically, Resident #2 received hemodialysis treatments at a community-based dialysis center and did not have consistent on-going assessments or oversight before and after dialysis treatments; there was no documented evidence the resident's dialysis access site was routinely assessed; and the resident did not receive a bagged lunch for missed meal during their dialysis treatment.Findings include: The facility policy Care of Resident Receiving Hemodialysis, last reviewed 10/2025, documented the staff were to enter the pre-treatment information per the form fields in the dialysis communication book and enter the resident's departure into the clinical record. When a resident returns from dialysis the staff were to obtain vital signs, observe the access site for bleeding or redness,…

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, 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) of five (5) residents (Resident #12 and #101) reviewed and for legionella (a bacteria causing Legionnaires' disease-a respiratory disease) testing. Specifically, Residents #12's and #101's transmission-based precaution orders were not followed; and the facility did not perform legionella testing as required based on positivity rate and a legionella positivity rate greater than 30% was not reported to the Department of Health as required. Findings include:Isolation Precautions:The facility policy Infection Control, Transmission-Based Precautions, dated 11/2025, documented transmission-based precautions were used for residents known or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond standard…

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 that alleged violations involving elopement were reported immediately, but not less than two hours later to the State Survey Agency for one (Resident #5) of two residents reviewed for elopement. Specifically, the facility was unable to locate Resident #5 until Health Care Proxy #1 informed the facility that Resident #5 had left the facility and was in a local hospital emergency department. The incident was not reported to the New York State Department of Health.Cross reference F689This is evidenced by:The Policy and Procedure titled Elopement, dated 7/14/2021, stated if an employee discovered a resident was missing, they should make a thorough search of the building and premises, and notify the administer and director of nursing services, the resident's legal representative, attending physician, and law enforcement agencies. Resident #5 Resident #5 was admitted to the facility with the diagnoses of alcohol abuse (when a person can't stop drinking even when it puts their health and safety at risk) with withdrawal…

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 that comprehensive care plan interventions were implemented, for 2 (two) (Resident #5 and Resident #9) of 18 residents reviewed for care plans. Specifically, Resident #5 and Resident #9 were not adequately supervised as per their care plans resulting in elopement. Cross reference F689 This is evidenced by:Care Plan Policy and Procedure dated 06/20/2025 documented:INTENT: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident. PROCEDURE: 1. The following health care professionals contribute to the Interdisciplinary Care Plan by collaboration and direct documentation: Registered Nurse, Licensed Practical Nurse, Certified Nurse Assistant, Physical Therapist, Occupational Therapist, Speech Therapist, Respiratory Therapist, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #s NY00353853, NY00355929, NY00356190, and NY00357360), the facility did not provide effective housekeeping and maintenance services on two (2) of two (2) resident units. Specifically, floors, walls, ceilings and tables were not clean or maintained. This is evidenced by: During observations on 5/05/2024 at 10:00 AM, the second-floor unit corridor floors were sticky when walked upon. During observations on 5/06/2025 from 10:17 AM through 1:49 PM: 1) The floors in the following areas were soiled with dirt or grime next to walls and/or in corners: 1a- Resident room #s 171, 173, 175, 177, 180, 189, 191, 199, 201, 203, 220, 305, 326, 328, 334, 338, 340, 342, 344, 346, 348, 402, 404, 406, 408, 410, 422, 418, 416, 414, 424, 426, 428, 430, 434, 436, 438, and 440. 1b- First Floor Unit and Second Floor Unit corridors including door thresholds. 1c- First Floor Unit Soiled Holding Room. 1d- Second Floor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (case # ' s NY00362000 and NY00379563), the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 16 (Residents #s 6, 10, 13, 28, 31, 37, 52, 61, 70, 72, 86, 103, 107, 262, 413, and 415) of 32 residents reviewed for Care Plans. Specifically, (a.) Resident #6 ' s, care plan did not address foot care; (b.) Resident #13 ' s care plan did not include person centered interventions for behavior and diabetes mellitus management; (c) Resident #28 ' s, pain care plan was not implemented for monitoring for effectiveness of administered pain medication; (d) Resident #52 ' s at risk for malnutrition care plan lacked person centered interventions: (e)…

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 a recertification and abbreviated survey (Case # ' s NY00371796, NY00358669, NY00357360, NY00363370, NY00371256, NY00353853, NY00347329 and NY00378103), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents stated they were not assisted with care when requested; staff stated they were unable to consistently provide incontinence care, showers, or bed baths due to being short-staffed; and an analysis of the actual staffing schedule showed that on multiple occasions from 3/01/2025 to 4/28/2025, the facility did not ensure minimum staffing levels were met based on the facility assessment. This is evidenced by: Cross reference to F550, F580, F584, F600, F609, F636, F645, F656, F657, F684, F686, F755, F756, F759, F760, F761, F804, F812, F814, F836, F842, F880, F919, F921, F923, F924, F925. Upon entrance to the facility 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 interview conducted during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review that included, but was not limited to, timeframes for the different steps in the process. Additionally, the drug regimen of each resident was not reviewed at least once a month by a licensed pharmacist. Specifically, the facility policy titled, Medication Regimen Review, did not identify time frames for steps in the medication review process. Additionally, there was no documented evidence of a pharmacist's review of the medication regimens for January, February, and March of 2025, affecting all residents. This is evidenced by: The facility policy titled, Medication Regimen Review, created 7/19/2019 with no updates or revisions, documented the Consultant Pharmacist should review the medication regimen of each resident at least monthly. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. If the situation was serious enough 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.

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5 percent for one (1) (Resident # 6) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 36 percent. This is evidenced by: The facility ' s Policy and Procedure titled, Administering medications, effective 3/13/2024, documented medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #6 Resident #6 was admitted to the facility with the diagnoses of congestive heart failure (when the heart can't pump blood well enough to give the body a normal supply), chronic obstructive pulmonary disease (a lung condition caused by damage to the lungs resulting in swelling and irritation), and depression (a constant feeling of sadness and loss of interest).…

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 a recertification and abbreviated survey (Case #'s NY00344251, NY00348580, NY355929, NY00347329 and NY00371796), the facility failed to ensure residents were free of significant medication errors for six (6) (Resident #s 10, 70, 82, 86, 107 and 416) of six (6) residents reviewed for medication administration. Specifically, (a.) Residents #s 10 and 70 had orders for antibiotic eye ointment that were not administered as ordered. (b.) Resident #82 had an order for narcotic pain medication that was not administered as ordered. (c.) Residents #s 86 and 107 had orders for antibiotics that were not administered as ordered. (d) Resident #416 was given medication that was not ordered for them. This is evidenced by: The facility policy titled, Medication Administration, created 4/2013 and last revised 12/2019, documented medications shall be administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time…

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 Regulation §483.45(h)(2): The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) of two (2) Medication Rooms (2nd floor); and for two (2) of three (3) medication carts (first floor unit 100 and second floor unit 300) reviewed. Specifically, (a.) two (2) open bottles of lidocaine injectable solution had no open and or expiration dates (b.) seven (7) insulin kwik pens had no expiration dates (c.) one (1) inhaler had no open and or expiration date,…

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 recertification survey and abbreviated survey (Case #NY00373240), the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for five (5) (Resident #'s 4, 8, 22, 61, and 265) of 32 residents reviewed. Specifically, (a) Resident #'s 4, 8, and 22 who resided on the same nursing unit, expressed feeling degraded when they would ask for help; (b) Resident #61 expressed feeling like they were an object and not a human being when they accidentally defecated in their incontinence brief and the Certified Nurse Aides that helped them discussed it in an undignified manner (c) Resident #265 was crying when they expressed feeling humiliated when they had a bowel movement in their bed because the Certified Nurse Aide would not bring them a bedpan upon request. This is evidenced by: The undated Policy and Procedure titled, Resident Rights,…

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

Based on record review and interview conducted during the Recertification and Complaint Survey (NY00355131 and NY00349007), the facility did not report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action was taken. This was evident in three (3) (Resident #48, #78 and 416) out of seven (7) residents reviewed for abuse and neglect. Specifically, Resident #48 struck Resident #78 in the face while grabbing a personal item from Resident #78. Resident #416 ' s transfer status was two-person maximum mechanical lift; two Certified Nurse Aides transferred resident via stand pivot on 6/03/2024. Resident #416 was lowered to floor during the transfer from chair to bed and later that evening diagnosed with a femur (leg bone) fracture. This is evidenced by: Cross-referenced to F600: Free from Abuse and Neglect The facility ' s Policy and Procedure…

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 reviews, and interviews conducted during a recertification and abbreviated survey (Case #NY00377938), the facility did not ensure that Comprehensive Care Plans were reviewed after each assessment and revised based on the changing goals, preferences, and needs of the resident and in response to current interventions for four (4) (Residents # ' s 13, 37, 97, and 415) of 32 residents reviewed. Specifically, (a) for Resident #13, the resident ' s allergy care plan was not updated to reflect the resident ' s current medication allergies; (b) for Resident #37, the resident ' s comprehensive care plan was not updated to reflect the resident's safety concerns regarding other residents entering their room; (c) for Resident #97, there was no care plan meeting held to review and revise the comprehensive care plan with the resident/resident ' s representative; and (d) for Resident #415, the resident ' s comprehensive care plan was not updated to reflect the resident's pressure ulcers. This is…

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 recertification and abbreviated survey (Case # ' s NY00348580; NY00355929; NY00348873; NY00351874 and NY00347329), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for four (4) (Resident #s 6, 28, 61, and 262) of 32 residents reviewed. Specifically, (a.) Resident #61 was noted by nursing staff on 2/19/2025 to have signs and symptoms of cellulitis (bacterial skin infection) on the left leg. The facility did not have evidence of monitoring of the resident ' s condition from 2/20/2025 to 3/3/2025; there was no order for periodic skin checks. The resident was not seen by the provider until 3/04/2025 and was diagnosed and treated for cellulitis of the left leg. (b.) Resident #28 was observed with severely edematous (swelling caused by excess accumulation of fluid) legs and the resident reported the facility was not doing anything to treat the condition. (c.) Resident #6 ' s feet were dry, scaly,…

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

Based on record review and interview during a recertification survey, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, (a.) the facility did not document receipt of Oxycodone (narcotic pain medication) by the pharmacy for Resident #82, and (b.) did not document nursing unit narcotics as having been counted by two licensed staff members and signed as appropriate on the facility-provided narcotic record sheets for two (2) of two (2) nursing units. This is evidenced by: The Policy and Procedure titled, Medications – Controlled Substances, effective 3/13/2024, documented it was the facility ' s policy to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and…

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

Based on observation, record review, and interview conducted during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and two (2) (First Floor Unit and Second Floor Unit) of two (2) kitchenettes. Specifically, the dishwashing machine final rinse water pressure was too low, equipment was not in good repair, and surfaces were not clean. This is evidenced by: During observations of the main kitchen and unit kitchenettes on 4/29/2025 from 6:26 PM through 7:45 PM: • The water pressure during the final rinse of the automatic dishwashing machine was zero pounds per square inch; the dishwashing machine data plate stated that the water pressure was to be between 15 and 25 pounds per square inch. • The steamtable sink faucet leaked, the cold-water faucet did not work, and the faucet fixture was loose. • The handwashing sink paper towel dispenser was empty. • The metal finish was torn off on two 6-inch sections on the exterior bottom of the walk-in freezer and one…

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 conducted during a Recertification Survey, handrails were not maintained on two (2) of two (2) resident units. Specifically, handrails had broken plastic and missing pieces exposing sharp edges. This is evidenced by: During observations on 04/29/2025 at 7:51 PM through 8:58 PM: • The Second Floor Unit south corridor handrail had a six (6)-inch section of broken plastic with sharp edges. • The Second Floor Unit Elevator one (1) corner guard had broken plastic with sharp edges. • The First Floor Unit handrail had six (6) areas where the edge turn pieces missing exposing sharp edges. During an interview on 5/07/2025 at 3:03 PM, Director of Maintenance #1 stated that they would repair the broken plastic and install the missing pieces on the handrails. 10 New York Codes, Rules, and Regulations 713-1.8(a)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #s NY00354621, NY00355929, NY00356190, and NY00357360), the facility did not maintain a pest-free environment and an effective pest control program on two (2) of two (2) resident units. Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas. This is evidenced by: During observations on 4/29/2025 at 8:45 PM, a resident was heard yelling, ' There is a bee in my room, ' and a wasp was found flying in resident room [ROOM NUMBER]. Director of Maintenance #1 immediately found and killed the wasp. During observations on 5/05/2025 at 1:55 PM, gnat-like flies were found in the conference room. During observations on 5/06/2025 from 10:17 AM through 1:49 PM, gnat-like flies or ants were found in resident room [ROOM NUMBER] and the employee break room. During observations on 5/07/2025 at 11:12 AM, gnat-like flies were found in the main kitchen dishwashing area. 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 record review and interviews conducted during a recertification and abbreviated survey (Case #NY00371796), the facility did not ensure it consulted with the resident ' s physician and notified the resident ' s representative when there was a significant change in the resident ' s physical status for two (2) (Resident #s 61 and 10) of two (2) residents reviewed. Specifically, (a) the facility did not immediately notify the provider on 2/19/2025, when Resident #61 developed new wounds on the left leg. The changes in the resident ' s condition were documented in the Nurse Practitioner communication book and were not reported to the provider until 3/04/2025; and (b) for Resident #10, the resident ' s representative was not notified on 1/25/2025, when there was a significant change in the resident ' s physical status and a new order for treatment which included administration of TobraDex ointment (treats bacterial eye infection) for conjunctivitis (or pink eye; very contagious intection that causes the white…

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 a recertification survey, the facility did not ensure the facility conducted initially and periodically comprehensive, accurate, standardized reproducible assessments of each resident's functional capacity and completed not less than once every 12 months for two (2) (Resident #s 28 and 415) of 32 residents reviewed for Comprehensive Resident Assessments. Specifically, (a) for Resident # 28, the Comprehensive Resident Assessments were not completed to assess the patient's edema, and (b) for Resident #415, the Comprehensive Resident Assessments were not completed to assess items from their baseline care plan. This is evidenced by: Cross reference to F656: Develop/implement Comprehensive Care Plan A facility's undated policy and procedure titled Comprehensive Care Plans documented that the assessment must accurately reflect the resident's status and be reflective of the resident's state at the time of assessment. A comprehensive care plan will be developed…

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 a record review and staff interviews conducted during a recertification survey, the facility did not ensure that Preadmission Screening was complete for two (2) (Resident #s 31 and 103) of the 32 residents reviewed. Specifically, an accurate Preadmission, Screening and Resident Review (PASARR) was not completed or corrected. This is evidenced by: The Policy and Procedure for admission Screening and Approval Process for Long Term Care (New York State) documented the admission process to the facility from a hospital or other health facility. A qualified Registered Professional Nurse assessor must complete a Patient Review Instrument, and the Preadmission Screening must be completed and signed by a qualified assessor. Resident #31 Resident #31 was admitted to the facility with the diagnoses of bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of mania or hypomania to periods of depression), chronic obstructive pulmonary disease (term for certain types of irreversible lung and airway damage that…

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 The facility policy and procedure titled, Pressure Ulcer Prevention, dated 3/01/2024, documented it was the policy of the facility to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation included reviewing the resident ' s care plan and identifying risk factors as well as interventions designed to reduce or eliminate those considered modifiable. Inspect the skin daily when performing or assisting with personal care or activities of daily living. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. The facility policy and procedure titled, Protocols for Treatment of Pressure Ulcers Pressure Ulcers/Injuries (undated), documented weekly wound rounds, and wound meetings were to occur to evaluate the progress of treatment and change and update treatment if…

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 a recertification survey the facility did not ensure food and drink were palatable and attractive for two of two units test trays and one (1) (Resident #61) of one (1) resident reviewed for palatable and appealing food and drink. Specifically, (a) resident #61 complained that the food was usually inedible, often unidentifiable, and not what was on the meal ticket. (b) Test trays on two (2) of two (2) units were identified by surveyors as unpalatable. This is evidenced by: The Minimum Data Set, dated [DATE], documented the Resident #61 was cognitively intact, was able to make themselves understood and understood others. During an interview on 4/30/2025 at 12:28 PM, Resident #61 stated the quality of the food was not good. They stated they were served a mystery meat patty covered with gravy and vegetables are overcooked. Alternate was a sandwich on stale bread. Resident #61 further stated sometimes they were supposed to have coleslaw but receive macaroni salad instead.…

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 conducted during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpster was not closed, and garbage littered the area. This is evidenced by: During observations on 4/29/2025 at 7:03 PM, the side door of the garbage dumpster was not closed, and garbage littered the area around the dumpster and side of the parking lot. During an interview on 4/29/2025 at 7:30 PM, Food Service Director #1 stated that they would re-educate staff to keep the dumpster doors closed and would speak with the maintenance and housekeeping departments regarding picking up the litter. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation and interview conducted during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. Specifically, carbon monoxide detection was not installed in main kitchen by gas fuel fired equipment (e.g., stove). This is evidenced by: During observations in the main kitchen on 4/29/2025 at 6:26 PM, a carbon monoxide detector was found on the shelf below the steamtable and not installed as required in the stove area. During an interview on 5/07/2025 at 3:14 PM, Director of Maintenance #1 stated that they would consult with corporate maintenance and reinstall the carbon monoxide detector. 10 New York Codes, Rules, and Regulations 400.2 2015 International Fire Code, Section 915

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure resident medical records contained an accurate representation of the actual experiences of the resident and included enough information to provide a picture of the resident ' s progress, including their response to treatments and services, and changes on their condition, plan of care, objectives, and/or interventions. Specifically, (a.) for Resident #61, the facility did not ensure Daily Medicare Notes accurately documented the resident ' s wounds and, (b.) for Resident #s 70 and 86, the facility did not ensure documentation of the residents ' condition that required antibiotic treatment. This is evidenced by: Resident #61: Resident #61 was admitted to the facility with diagnoses of displaced fracture of greater trochanter of right femur (fracture of upper part of thigh bone), multiple myeloma (cancer that forms in a type of white blood cell), and unspecified heart failure (a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews conducted during a recertification survey, the facility did not ensure an infection control program was implemented to prevent the transmission of communicable diseases to residents. Specifically, (a.) for Resident #64, enhanced barrier precautions were not implemented for the resident who had an indwelling catheter; (b.) for Resident #97, the resident's nebulizer equipment was not stored to prevent contamination of the equipment. This is evidenced by: Resident #64 Resident #64 was admitted to the facility with the diagnoses of polyneuropathy (peripheral nervous system disorders that impact nerve function), chronic obstructive pulmonary disease (lung disease characterized by chronic respiratory symptoms and airflow limitation), and type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 2/24/2025 documented the resident understood, could understand others, had moderately impaired cognition, and had an indwelling urinary catheter. The policy…

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 the recertification and abbreviated survey (Case #NY00354621), the facility did not adequately provide for residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area on two (2) of two (2) units. Specifically, the facility nurse call system did not function in resident room #s 203 and 320. This is evidenced by: During observations on 4/29/2025 at 8:03 PM, the call bell device in the resident room [ROOM NUMBER] bathroom was missing from the mounting hardware and the wires were hanging out of the mounting hardware. During an observation on 05/06/2025 at 1:02 PM, the call bell device was hanging by wires and not mounted to wall in resident room [ROOM NUMBER]. Workorders dated 10/29/2024 through 4/15/2025 documented 10 instances of call bell disrepair. There was no documented evidence that workorders were submitted to repair the call bells in room #s 203…

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 conducted during the recertification survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the exterior of the facility building, and grounds were not clean and maintained. This is evidenced by: During observations on 5/05/2025 from 12:04 PM through 12:31 PM: Sections of the lower portion of the building façade was covered with moss and algae. Piles of old construction materials and accumulations of leaves and litter were found on the grounds along the building. The garbage dumpsters were not seated in the designated fenced area; vegetation was encroaching on the fencing. During an interview on 5/07/2025 at 3:09 PM, Director of Maintenance #1 stated that they would have the construction debris and litter picked up, the vegetation cut back and direct the vendor to place the dumpster in the designated area. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observation and interviews conducted during the recertification, the facility did not ensure adequate ventilation of one (1) (second floor) of (2) resident units. Specifically, the Second Floor Unit Soiled Holding Room and shower room were not adequately ventilated. This is evidenced by: During observations on 4/29/2025 at 8:47 PM, unpleasant odors were found in the Second Floor Unit Soiled Holding Room and a heavy must odor was found in the Second Floor Unit shower room. During an interview on 5/07/2025 at 3:10 PM, Director of Maintenance #1 stated that the motors servicing the ventilation system for the Second Floor Unit Soiled Holding Room and the Second Floor Unit shower room were not powerful enough to remove the odors and required replacement. 10 New York Codes, Rules and Regulations 483.90(i)(2)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during an abbreviated survey (Case #'s NY00364049 and NY00364977), the facility did not ensure the environment remained free of accident for 1 (Resident #1) of 1 reviewed for accident hazards. Specifically, for Resident #1, who had Nothing by Mouth (NPO) diet order was due to high risk for aspiration pneumonia was fed pizza. This is evidenced by: Policy and Procedure for nutrition and diet dated 12/13/2024, documented residents who are designated as nothing by mouth (NPO) need to be closely monitored to ensure no access to food is allowed. Resident #1 entered on 11/04/2024 with diagnoses of Cerebral Palsy, Parkinson ' s Disease, and developmental disabilities. The Minimum Data Set (an assessment tool) dated 11/10/2024, documented the resident could be understood, and understand others with severely impaired cognition for decision making. The resident was nonverbal and communicated by using a communication board. The resident had recently received 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 observation, record review, and interviews during an abbreviated survey (NY00348162 and NY00348192), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's staffing minimum staffing levels were not met each day from 7/01/2024 through 7/16/2024 per facility assessment. This is evidenced by: Upon entrance to the facility on 7/16/2024 there were 113 residents residing on 2 units. The Facility Assessment conducted on 5/14/2024 documented, the facility's staffing plan for direct residential care. The assessment documented that they were to have at a minimum for Licensed Practical Nurses and Certified Nurse Aides for the day, evening, and night shifts. For Licensed Practical Nurses, the facility was to have 6 for the day shift, 6 for the evening shift, and 3 for the night shift. For Certified Nursing Aides, the facility was to have 11 for the day shift, 11 for the evening shift,…

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 an Abbreviated Survey (Case #NY00345181), the facility did not ensure the resident's right to be free from neglect for 1 (Resident #1) of 1 resident reviewed for abuse and neglect. Specifically, the facility did not ensure supervision and oversight was provided following an attempted elopement on 6/11/2024. This resulted in an actual elopement on 6/14/2024. This is evidenced by: The Policy and Procedure titled, Elopement, effective 4/01/2024, documented it was the responsibility of all personnel to report any resident attempting to leave the premises to the Unit Manager and/or Charge Nurse immediately. The Policy and Procedure titled, Wander Guard, effective 4/1/2024, documented any resident with a new elopement attempt was to have an electronic monitoring device applied and care plan updates immediately. Should an elopement attempt/episode occur, the contributing factors, as well as the interventions tried, would be documented on the nurses' notes. Resident #1 was admitted to the facility with diagnoses 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 record review and interviews during an abbreviated survey (Case # NY00345181), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 resident (Resident #1) of 1 resident reviewed for abuse, neglect, and mistreatment. Specifically, Resident #1 was found by staff in the parking lot approximately 40 feet from the front entrance to the facility. The incident was not reported to the…

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

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint NY00334205), the facility did not ensure residents were free from physical abuse for two (Residents #8 and 9) of three residents reviewed. Specifically, the facility did not implement interventions following resident-to-resident abuse (Resident #8, 9) incidents on 12/18/2023 and 2/06/2024 resulting in third incident on 2/23/2024. Findings include: The policy and procedure titled Abuse, Neglect and Mistreatment Prevention dated 9/2021 documented that Department Managers and Administration will identify residents whose personal histories and diagnoses render them at risk for abusing other residents. Develop strategies to prevent occurrences and monitor for changes that would trigger abusive behavior. Systemically reassess these interventions to monitor their effectiveness. Ensure adequate assessment, care planning, and monitoring of residents. In particular, focus on residents with history of aggressive, wandering, or self-injurious behaviors. Resident #8 Resident #8 was admitted 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.

Based on observations, interviews, and record reviews conducted during the abbreviated survey (Case #NY00333272), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #7) of 9 residents reviewed. Specifically, the facility did not ensure that Resident #7's property was secured in a locked drawer. This is evidenced by: Resident #7 Resident #7 was admitted to the facility with the diagnoses of Guillain-Barre syndrome (a rare disorder of the immune system), chronic kidney disease and type 2 diabetes. The Minimum Data Set (an assessment tool) dated 2/9/2024 documented the resident was able to be understood and was able to understand others. The Brief Interview for Mental Status documented a score of 12/15, significant for a moderate cognitive impairment. The Policy and Procedure titled Abuse, Neglect, and Mistreatment - Definitions and Examples dated 9/2022 was reviewed and defined misappropriation as the theft, unauthorized use or removal, embezzlement, or intention destruction of the resident's personal…

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 abbreviated survey (NY00332433), the facility did not ensure care plans were reviewed and revised in a timely manner for 1 (Resident #6) of 9 residents reviewed for Comprehensive Care Plans. Specifically, for Resident #6's Comprehensive Care Plan for at risk for falls was not reviewed and revised after a fall in which the intervention of a floor mat was added on the Accident and Incident report. This is evidenced by: Resident #6 Resident #6 was admitted with the diagnoses of aftercare following joint replacement surgery, muscle weakness, and dysphagia (difficulty swallowing). The Minimum Data Set (an assessment tool) dated 1/17/2024 documented the resident was able to be understood and was able to understand others. The Brief Interview for Mental Status documented the resident scored 13/15, indicating the resident was cognitively intact. The facility's policy and procedure titled Resident Assessment and Care Planning dated 2/19/2022 was reviewed and…

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

Based on record review and interviews during an abbreviated survey (Case # NY00322286), the facility did not ensure - in accordance with accepted professional standards and practices - it maintained medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #8) of 4 residents reviewed. Specifically, for Resident #8, the facility (1) did not document observations made during suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) care; (2) did not document an evaluation of the resident's condition on 9/18/2023 in the nursing progress notes when on 9/18/2023, the resident was admitted to the hospital with diagnoses of suprapubic catheter obstruction and complicated urinary tract infection, and did not document that the physician was notified; and (3) did not document blood sugar level and insulin administration for three days. This is evidenced by: Refer to F690 Resident #8: Resident #8 was readmitted to the facility with diagnoses 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 record review and interviews during an abbreviated survey (Case # NY00307000), the facility did not ensure it treated each resident with respect, dignity, and care for 1 (Resident #3) of 7 residents reviewed. Specifically, Resident #3 received undignified statements about them and their care needs by Certified Nurse Aide #2 on 12/14/2022. Director of Nursing #2 saw the resident following the incident and documented the resident presented with weepiness, sadness, and embarrassment. This is evidenced by: Resident #3: Resident #3 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, depression, and pain in left lower leg. The Minimum Data Set (an assessment tool) dated 12/19/2022 documented the resident with a Brief Interview of Mental Status score was cognitively intact. The Policy and Procedure titled Resident Rights, last revised 3/2023, documented employees would treat all residents with kindness, respect, and dignity. The comprehensive care plan last revised 12/1/2022 for Limited Physical Mobility related to weakness, impaired balance,…

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 an abbreviated survey (Case #NY00297444), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #6) of 7 residents reviewed. Specifically, the facility did not ensure that an allegation of physical abuse reported by Resident #6 on 6/12/2022 at 9:45 AM was reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 6/13/2022 at 11:47 AM. This is evidenced by: Refer to F610 Resident #6: Resident #6 was readmitted to the facility with diagnoses of hemiplegia and hemiparesis (related conditions that cause weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) affecting left non-dominant side, recurrent major depressive…

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 an abbreviated survey (Case #NY00297444), the facility did not ensure that in response to an allegation of abuse, that it had evidence that all alleged violations were thoroughly investigated for 1 (Resident #6) of 7 residents reviewed. Specifically, the facility did not maintain documentation that an allegation of physical abuse reported by Resident #6 on 6/12/2022 was thoroughly investigated. This is evidenced by: Resident #6: Resident #6 was readmitted to the facility with diagnoses of hemiplegia and hemiparesis (related conditions that cause weakness on one side of the body) following nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) affecting left non-dominant side, recurrent major depressive disorder, and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia and symptoms of a mood disorder). The Minimum Data Set (resident assessment tool) dated 5/17/2022 documented the resident was cognitively intact. The Policy and Procedure titled 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 during an abbreviated survey (Case # NY00322286), the facility did not ensure that a resident with an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible for 1 (Resident #8) of 4 residents reviewed. Specifically, Resident #8 had a suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) and was admitted to the hospital on [DATE] with diagnoses of sepsis, complicated urinary tract infection, and obstruction of suprapubic catheter. During readmission to the facility on [DATE], the facility did not ensure orders were in place for daily care of the suprapubic catheter to prevent infection until [DATE]. Additionally, the comprehensive care plan did not include interventions for the suprapubic catheter to prevent infection and for monitoring for signs and symptoms of a urinary tract infection. This is evidenced by: Refer to F842 Resident #8: 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 observation and staff interview during the recertification survey dated 04/16/23 through 04/20/23, the facility did not provide effective housekeeping services on two (2) of 2 resident units, the lobby, the service corridor to the Beauty Salon, the main kitchen, 2 of 2 kitchenettes, and 2 of 2 elevator cars. Specifically, the ceiling in the main kitchen was soiled with food splatters; the corridor floors were soiled with old wax build-up next to walls and door thresholds in the lobby, on Unit One and Unit Two, and in the service hallway to Beauty Salon; old gum was found in the handrails in elevator car #1 and elevator car #2; the Unit One and Unit Two kitchenette floors were soiled with dirt and food particles; a dried red/brown substance was dripping on the wall next to room [ROOM NUMBER]; dried brown food splatters soiled the corridor floor between room #'s 402 and #404; the floors were soiled in corners with dirt and old wax build-up in resident room #'s 169, 171, 183, 326, 336, 344, 404, 406, 430,…

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

Based on observation, record review and interviews during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented to meet the needs of each resident for 5 (Resident #'s 13, 59, 60, 95, and #109) of 25 residents reviewed for CCP. Specifically, for Resident #13, the facility did not ensure care plans were developed for multiple conditions the resident was currently receiving treatment for (SOB/wheezing, anticoagulation, hyperlipidemia, high blood pressure, constipation, A-fib, and alcohol abuse), and care plans for antidepression medication and depression did not include person-centered interventions; for Resident #59, the facility did not ensure a CCP was developed to address the resident's shortness of breath and wheezing; for Resident #60, the facility did not ensure person-centered care plans were developed for psychotropic medications; for Resident #95, the facility did not ensure a CCP was developed to address the resident's agitated behaviors that were directed toward other residents, including yelling, going into…

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 recertification survey dated 4/16/2023 - 4/20/2023, the facility did not ensure policies and procedures were developed and maintained for the monthly Drug Regimen Review (DRR), that included timeframes for the different steps in the process. Specifically, the facility's DRR policy did not include timeframes for steps in the DRR process and steps the pharmacist must take when an irregularity required urgent action. This was evidenced by: The Policy and Procedure (P&P) titled Drug Regimen Reviews, dated 10/24/2022, documented if irregularities were found during the DRR, the consultant pharmacist would provide the administrator with a written, signed, dated copy of the report, listing the irregularities found and their recommendations. The DRR policy did not include timeframes for the steps in the DRR process and steps the pharmacist must take when an irregularity identified required urgent action. During an interview on 04/20/23 at 11:34 AM, the Director of Nursing (DON) stated they were not aware of the regulation requiring their DRR…

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 conducted during the recertification survey, it was determined that the facility did not ensure that medication error rates were not 5 percent or greater. Specifically, for two (Residents #'s 47 and #77) of four residents reviewed for medication administration the facility did not ensure medication was administered within their prescribed time frame as ordered by the physician for 14 of 28 observations of medication administration opportunities with an error rate of 50 percent. This is evidenced by the following: The facility Policy and Procedure (P&P) titled Medication Administration dated 9/15/2022 stated medications must be administered in accordance with the orders, including any required time frame and medications must be administered within one hour of their prescribed time. Resident #47 Resident #47 was admitted to facility with a diagnosis of anemia. The Minimum Data Set (MDS - a resident assessment tool) dated 3/23/2023 documented the resident was cognitively intact, was understood and understood others. During an…

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

Based on observation and interviews during the recertification survey dated 04/16/23 through 04/20/23, the facility did not dispose of garbage and refuse properly. Specifically, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered with plastic and paper waste. This is evidenced as follows: During observations on 04/16/23 at 9:50 AM, the side doors to the two outdoor garbage dumpsters were not closed, the sides of the dumpsters below the doors were soiled with food drips, and the grounds around dumpsters were littered with plastic and paper waste. During interviews on 04/16/23 10:11 AM, the Administrator and Director of Food Service stated that the dumpsters and grounds will be cleaned, and staff will be in-serviced on closing the dumpster door. 10 NYCRR 415.14(h)

Based on record review and interviews during a recertification survey on 4/16/2023 through 4/20/2023, the facility did not ensure the resident and the resident's representative(s) were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and did not send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident # 38) of 1 resident reviewed for hospitalization. Specifically, for Resident #38, the facility did not ensure the resident and the resident's representative were provided with written notification upon the resident's transfer to the hospital on 1/13/2023, 2/12/2023, and 4/9/2023 and did not ensure a copy of the notice was sent to the Ombudsman. This is evidenced by: Resident #38: Resident #38 was admitted with diagnoses of epilepsy, Alzheimer's disease, and Parkinson's disease. The Minimum Data Set (MDS- an assessment tool) dated 3/21/2023 documented the resident had moderately impaired cognition, could usually understand others and could usually make…

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 during the recertification survey on 4/16/2023 to 4/20/2023, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital for 1 (Residents #38) of 1 resident reviewed for hospitalization. Specifically, for Resident #38, the facility did not ensure a written notice of the facility's bed hold policy was provided to the resident and/or their representative upon transfer to the hospital on 1/13/2023, 2/12/2023, and 4/9/2023. This is evidenced by: Resident #38: Resident #38 was admitted with diagnoses of epilepsy, Alzheimer's disease, and Parkinson's disease. The Minimum Data Set (MDS- an assessment tool) dated 3/21/2023 documented the resident had moderately impaired cognition, could usually understand others and could usually make themselves understood. The undated Policy and Procedure titled Bed-Holds and Returns documented prior to transfers and therapeutic leaves, residents or resident representatives would be informed in writing 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 interview and record review during a recertification survey on 4/16/2023 through 4/20/2023, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 25 residents reviewed. Specifically, for Resident #65, the facility did not ensure physician ordered acidophilus (probiotics- bacterium) was available to administer in accordance with the physician order and comprehensive care plan and did not ensure the physician was notified when the acidophilus was not available to administer. This is evidenced by: Resident #65: Resident #65 was admitted with diagnoses of diabetes, atrial fibrillation, and irritable bowel syndrome (IBS) without diarrhea. The Minimum Data Set (MDS-an assessment tool) dated 1/18/2023 documented the resident was cognitively intact, could understand others and could make themselves understood. The Policy and Procedure (P&P) titled Medication Administration dated 9/15/2022 documented the policy was to ensure medication…

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 a recertification survey on 4/16/2023 through 4/20/2023, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #59) of 5 residents reviewed for accidents. Specifically, for Resident #59, the facility did not ensure the resident had a physician order to self-administer medication, a care plan to self-administer medication, or a nursing assessment that documented the resident was able to self-administer medication that was left at bedside. This is evidenced by: Resident #59: Resident #59 was admitted with diagnoses of Schizophrenia, diabetes, and congestive heart failure. The Minimum Data Set (MDS-an assessment tool) dated 1/31/2023 documented the resident was cognitively intact, could understand others and could make themselves understood. The Policy and Procedure (P&P) titled Medication Administration dated 9/15/2022, documented residents may self-administer their own medications only if the Attending…

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.