The Grand Rehabilitation And Nursing At Utica

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of four (4) residents (Resident #91) reviewed. Specifically, Resident #91 who resided on the Dementia Care Unit had cough drops at their bedside not ordered by the medical provider. Findings include: The facility policy Medications Brought to the Facility by the Resident/Family, revised 1/2025, documented the facility would not permit residents and families to bring medications into the facility. Residents and families had to report to the nursing staff any medications they wanted to bring or have brought into the facility. If the medication was not otherwise available and was determined to be essential to the resident's life, health, safety, or well-being, the Director of Nursing, nursing staff, the attending physician, and the consultant pharmacist checked to ensure state law and regulations allow the use, the medications had been ordered by the resident's 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.

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure residents were evaluated for hydration care consistent with the resident's comprehensive assessment for 1 (one) of 3 (three) residents (Resident #144) reviewed. Specifically, Resident #144's hydration needs were not reassessed or reviewed for adequacy by clinical nutrition staff after they were diagnosed with urinary tract infections. Findings include: The facility policy Resident Hydration and Prevention of Dehydration, last reviewed 1/2025, documented the dietitian would assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need; the dietitian, nursing staff, and the physician would assess factors that may contribute to inadequate fluid intake; nursing would monitor and document fluid intake and the dietitian would be kept informed of status; and the interdisciplinary team would update the care plan and document resident response to interventions until team agrees that fluid intake and…

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

Based on observations, record review, and interviews during the recertification and abbreviated (NY00372942) surveys conducted 5/27/2025-6/6/2025, the facility did not ensure residents received respiratory care consistent with professional standards of practice for one (1) of one (1) resident (Resident #57) reviewed. Specifically, Resident #57 did not receive bilevel positive airway pressure (BiPAP/a device to assist with breathing) as ordered. Findings include: The facility policy Continuous Positive Airway Pressure /Bilevel Positive Airway Pressure, last reviewed 1/2025, documented, Continuous Positive Airway Pressure /Bilevel Positive Airway Pressure, was provided for support of spontaneous breathing for residents with continuous positive airway pressure with or without supplemental oxygen. Resident #57 had diagnoses including chronic respiratory failure, obstructive sleep apnea (stops breathing while sleeping), obstructive pulmonary disease (restricted airway). The 4/16/2025 Minimum Data Set assessment documented the resident had intact cognition, was dependent for most…

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

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for one (1) of five (5) medication carts (4th floor cart) and one (1) of four (4) medication storage rooms (4th floor medication room). Specifically, the 4th floor medication cart and medication room had expired stock medications and biologicals. Findings include: The facility policy Storage of Medications, last reviewed 1/2025, documented the facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs would be returned to the pharmacy or destroyed. During a 4th floor medication room storage observation on 5/29/2025 at 1:43 PM with Licensed Practical Nurse #49, the following were observed: - 1 unopened 12-ounce bottle of antacid with a manufacturer's expiration date of 2/2025. - 1 unopened 12-ounce bottle of antacid with a manufacturer's expiration date of 3/2025. - the medication refrigerator had 1 opened…

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

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure they established and maintained 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 three (3) of three (3) residents (Resident #33, #118, and #211) reviewed. Specifically, Resident #118's urinary drainage bag was observed uncovered and lying directly on the floor; and Residents #33 and #211 were administered eye drops by Licensed Practical Nurse #49 who did not perform hand hygiene or don gloves. Additionally, the facility did not conduct legionella (a bacteria that causes Legionnaire's disease, a type of pneumonia) testing as required. Findings include: The facility policy Administering Medications, last reviewed 1/2025, documented staff should follow established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions, etc.) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated survey (NY00332276) conducted [DATE]-[DATE], the facility failed to ensure resident preferences and physician orders related to cardiopulmonary resuscitation (perform chest compressions in the event of a cardiac arrest), and other advance directive issues were communicated throughout the facility so that staff knew immediately what action to take or not to take when an emergency arose. Specifically, staff were unable to consistently identify resident code status indicators in the event of cardiac arrest. On [DATE], Resident #400 was found without a pulse in a non-residential area of the facility. Staff did not know the resident's code status and initiated cardiopulmonary resuscitation (chest compressions). The resident had a physician order documenting do not attempt resuscitation (allow natural death). In addition, resident code status identification bracelets were documented as being in place and were observed not in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the recertification and abbreviated (NY00299391, NY00325885, and NY00331016) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 18 isolated areas (resident rooms 263, 266, 270, and 273; second floor south hallway; second floor south dining room; second floor activities room kitchenette; second floor west shower room; second floor west lounge bathroom; second floor west soiled utility room; second floor south telephone room; second floor south closet near social workers office; resident rooms [ROOM NUMBERS]; third floor shower room; fifth floor hallway near resident room [ROOM NUMBER]; sixth floor hallways near elevator; and, resident room [ROOM NUMBER]). Specifically: - On multiple floors the halls, walls, and ceilings were in disrepair. - The hot water in second floor south dining room did not work. - The second floor activities room kitchenette had a broken paper towel…

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

Based on observation, record review, and interview during the recertification and abbreviated (NY00328424) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles, and include the expiration date when applicable for 3 of 5 medication carts (4th floor, 6th floor and 7th floor) and 7 of 7 medication refrigerators (2 South, 2 West, 3rd floor, 4th floor, 5th floor, 6th floor and 7th floor) reviewed. Specifically, the 4th floor medication cart had eye drops for Resident #61 and Resident #136 without labeled open dates or discard dates; the 6th floor medication cart had eye drops for Resident #9 without labeled open or discard dates, and opened house stock cough syrup without labeled open date or discard date; and the 7th floor medication cart had eye drops for Resident #74 and Resident #94, and two insulin pens for Resident #105 that were not labeled with open or discard dates. Additionally, medication refrigerators on 2 South, 2 West, 3rd floor, 4th floor, 5th floor, 6th…

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

Based on observation and interview during the recertification and abbreviated (NY00323751) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (1/25/2024 breakfast and 1/26/2024 lunch meals). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures. Findings include: The facility's policy Dining Experience, revised 1/2024, documented the kitchen would provide nourishing, palatable, and attractive meals that met the individuals' daily nutritional needs and food and beverage preference. During an interview on 1/24/2024 at 10:01 AM, Resident #98 stated they did not eat breakfast because the eggs were always cold. During an interview on 1/24/2024 at 10:10 AM, Resident #31 stated the food was always cold. During an interview on 1/24/2024 at 12:53 PM, Resident #185 stated that the food was cold most of the time. During an observation on 1/25/2024 at 8:30 AM, a breakfast tray was…

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

Based on observation, record review, and interview during the recertification survey conducted 1/24/2024 - 2/1/2024 the facility did not ensure each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plans of care for 4 of 6 nursing floors (2 [NAME] and 2 South floors, 3rd floor, 5th floor, and 6th floor) observed. Specifically, resident meal trays were delivered to nursing floors up to 43 minutes after the scheduled mealtimes. Findings include: The facility policy Frequency of Meals revised 1/2024 documented each resident would receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and the plan of care. The 2 South meal delivery times documented Breakfast at 8:30 AM, Lunch at 12:30 PM, Dinner at 5:30 PM. The following observations were made on 2 South: - on 1/24/2024 at 12:57 PM the lunch meal cart arrived on the floor. At 12:58 PM the first lunch tray was…

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

Based on observation, record review, and interview during the recertification and abbreviated (NY00325885) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure the facility stored, prepared, distributed, and served food in accordance with professional standards for food service safety for 1 of 1 kitchens (the main kitchen) reviewed. Specifically, multiple areas of the main kitchen were unclean; the steamer, a hand wash sink, and the high temperature were in disrepair; there was a an expired package of hot dog rolls and an expired jar of peanut butter; there was an unlabeled package of bread crumbs; there was an undated bag of chocolate mix and two opened containers of chicken paste with no opened date; there was a dented can of pears and a dented can of an unknown product; and there was three sections of sheet cake that were not covered. Findings include: A facility policy Cleaning & Sanitation of Dining and Food Service Areas, last reviewed 1/2024, documented: - Cleaned after each use - all appliances, all small equipment, counters, stove tops (range and griddle),…

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 record review and interview during the recertification survey conducted 1/24/2024 - 2/1/2024, the facility did not ensure 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. Specifically, the required quarterly Legionella (type of bacteria that causes Legionnaire's disease) water testing was not completed after 30% of the annual water samples detected Legionella. Findings include: The facility's Legionella Management Plan, Potable Water System, dated December 2022, documented if detected levels of Legionella was greater than 30% it would require immediate implementation of short-term control measures and the water system should be re-sampled no later than 4 weeks after disinfection to determine the efficacy of the treatment. Documentation included procedures to be followed, directives issued, testing performed and procedures for disinfection that prevented exposure to contaminated water. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted 1/24/2024-2/1/2024 the facility did not ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member for 2 of 6 units (Unit 2 and Unit 3) reviewed. Specifically, non-functioning call lights were observed on Unit 2 in resident rooms 266, 274, 269, 263, 261, 250, 248, 245, 241, the second floor south shower room, and the second floor dining room; and, on Unit 3 resident room [ROOM NUMBER]. Findings include: The facility policy Answering the Call Light reviewed by the facility 1/2024 documented: - Be sure the call light was plugged in at all times. - Be sure the call light was within easy reach of the resident. - Report all defective call lights to the nurse supervisor promptly. On 1/24/2024 the following observations were made on Unit 2: - At 10:02 AM resident room [ROOM NUMBER] bathroom had no call light cord. - At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00300181, NY00323751, and NY00325885) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure the residents' rights to a private space for 2 of 13 residents (Residents #3 and #44) reviewed. Specifically, Residents #3 and #44 did not have keys to access a privately locked space. Findings include: The facility policy Locked Drawers and Keys revised 1/2024 documented residents were informed of their right to a locked drawer in which they could store their belongings. Nursing and social work was responsible for ensuring residents were notified upon admission that a key for the locked drawer could be obtained from the maintenance department. If a key was lost or no longer worked, staff informed the maintenance department to repair or replace the key and in the interim the facility offered an alternate space for belongings to be locked. Maintenance was responsible to keep track of room changes and switched keys…

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

Based on observation and interview during the recertification survey conducted 1/24/2024 - 2/1/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members and legal representatives of residents. Specifically, the most recent survey results and plan of correction were in a binder in a file bin on the wall, approximately 4-feet off the ground, around the corner from the main front lobby desk, and not easily accessible. There were no notices posted advising the residents, family members and legal representatives of the survey results location. Findings Include: During the Resident Council Meeting on 1/24/2024 at 1:53 PM, 10 anonymous residents stated they did not know where the binder of previous survey results was located. During an observation 1/24/2024 at 3:53 PM, a binder with 3 years of past surveys/complaints was around the corner of the lobby in a plastic file bin on the wall. There were no signs posted throughout the facility identifying the location of survey results. 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 record review and interview during the recertification and abbreviated (NY00299391 and NY320041) surveys conducted 1/24/2023-2/1/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 2 of 4 residents (Resident #134 and 400) reviewed. Specifically, Resident #135 had injuries of unknown origin that were not thoroughly investigated, and Resident #400 was provided a regular consistency sandwich on a ground consistency diet and was later found unresponsive on the floor and the incident was not investigated. Findings included: The facility policy Accident and Incident Investigation and Reporting reviewed 1/2023 documented all accidents or incidents involving residents should be investigated and reported to the Administrator. The Nurse Supervisor, charge nurse, or Department Director should promptly initiate the investigation and include all pertinent information. Witness statements should be obtained. The Report of Incident/Accident form was to be submitted to the Director of Nursing within 24 hours.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00325885, NY00328424 and NY00331016) conducted 1/24/2024-2/1/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 7 residents (Residents #38, #64, #80) reviewed. Specifically, - Resident #38 received rapid-acting insulin (starts to lower glucose levels 15 minutes after injection) greater than one hour before meals. - Resident #64 was observed with a vacuum assisted wound closure device (a type of therapy used for wound healing) that was not functioning. - Resident #80 was found on the floor, was not assessed by a qualified professional timely, did not receive a physician ordered X-ray immediately as ordered, and was diagnosed with a right hip fracture. Findings include: The facility policy Lab and Diagnostic Test Results Protocol revised 1/2022 documented the physician would identify and order diagnostic and lab testing based 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 observation, record review, and interview during the recertification and abbreviated (NY00322708 and NY00325885) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #24) reviewed. Specifically, Resident #24 was observed in their bed with their air mattress (a specialty mattress that provides air flow to relieve pressure) not functioning. Findings include: The facility policy Use of Low Air Loss Mattress revised 1/2022, documented residents would be assessed for the appropriateness of an air mattress based on risk factors and/or the existence of actual or history of pressure injuries. An air mattress would be provided to prevent skin breakdown, promote circulation, and provide pressure relief and reduction. Staff would check at least daily that the air mattress was on, was set appropriately, and functioning. 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.

Based on observation, record review, and interview during the recertification and abbreviated (NY00299391, NY00322708, and NY00331016) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure each resident received adequate supervision to prevent accidents and the environment remained free of accident hazards for 2 of 10 residents (Residents #128 and #400) reviewed. Specifically, Resident #400 was given food not consistent with their physician ordered diet, and Resident #128 had an unidentified medication on the floor of their room. Findings include: The facility policy Administering Medications revised 1/2024, documented for residents unavailable to receive medication on the medication pass, the nurse was to return to the missed resident to administer the medication. If a drug was withheld or refused, the individual administering the medication shall initial and circle the medication administration record space for that specific medication. The individual administering the medications must sign for them in the medication administration record prior to giving the next ones.…

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

Based on observation, interview, and record review during the recertification and abbreviated (NY00299391 and NY00322708) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 8 residents (Resident #184) reviewed. Specifically, Resident #184 had a significant weight loss, their nutritional interventions were not reassessed, and the resident had additional weight loss. Additionally, there was no documented evidence medical was made aware of the resident's significant weight loss. Findings include: The facility policy Nutritional Assessment revised 1/2024 documented a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, would be conducted for each resident. The registered dietitian along with the interdisciplinary team would conduct nutritional assessments for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment would be a systemic multidisciplinary…

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

Based on observation, record review and interview during the recertification survey conducted 1/24/2024-2/1/2024, the facility did not ensure that a resident being fed by enteral means (tube placed in the stomach for feedings) received the appropriate treatment and services to prevent complications for 3 of 3 residents (Residents #2, #24, and #134) reviewed. Specifically, Residents #2, #24, and #134 did not have their tube feeding formula labeled with a date and time. Findings include: The facility policy Enteral tube feeding via gravity effective 10/1997 and revised 1/2024, documented when administering a tube feeding on the formula label document initials, date, and time the formula was hung/administered, and initial that the label was checked against the order. 1) Resident #2 was admitted to the facility with diagnoses including alcohol induced dementia and dysphagia (difficulty swallowing). The 10/17/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, was totally dependent on staff for eating, did not have swallowing disorder, had a feeding…

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

Based on observation, record review, and interview during the recertification survey conducted 1/24/2024-2/1/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, or obtain informed consent prior to the installation of bedrails for 3 of 3 residents (Residents #88, #160 and #192) reviewed. Specifically, for Residents #88, #160 and #192, there was no documented evidence there were bed rail assessments prior to bed rail installation, the risks and benefits of bed rails were explained to the residents or their representatives, or that consents were obtained prior to bed rail installation. Findings include: The facility policy Proper Use of Side Rails effective 10/2018 with a review date of 1/2024, included: - Side rails were used to treat a resident's medical symptoms or to assist with mobility and transfer. - An assessment would be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. - Consent…

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

Based on record review and interview during the recertification survey conducted 1/24/2024-2/1/2024, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with facility assessment for 3 of 8 staff personnel records (Licensed practical nurse #67, licensed practical nurse #68, and registered nurse #69) reviewed. Specifically, licensed practical nurse #67, licensed practical nurse #68 and registered nurse #69 did not receive annual competencies that covered key skill-set areas as outlined in the 2023 facility assessment and per regulations. Findings include: The Facility Assessment Year 2023 received during the survey entrance conference, documented nurse competencies in the facility included: 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, interview, and record review during recertification and abbreviated (NY00323751) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure menus were followed for 1 of 3 residents (Resident #64) reviewed. Specifically, Resident #64 had missing menu items from their meal trays and did not receive double entrees as care planned. Findings include: The facility policy Accuracy and Quality of Tray Line Service dated 1/2024 documented tray line positions and set-up procedures would be planned for efficient and orderly delivery. All meals would be checked for accuracy by the food/nutrition staff and the service staff prior to serving of meals. The meal would be checked to ensure that foods were served as listed on the menu. The director of food and nutritional services or designee would be responsible for assuring that all foods needed for meal assembly were present at the appropriate time. Each meal would be checked for proper portion sizes. Resident #64 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview during the recertification and abbreviated surveys post survey revisit conducted 4/4/2024-4/9/2024, the facility did not ensure it was administered in a manner that enabled it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the call bell system for Unit 2 was not functioning properly (see F 919); foods were not maintained at palatable and safe temperatures (see F 804); medication refrigerator temperatures were not consistently logged to ensure maintenance of safe temperatures for medications and education regarding medication refrigerator temperatures and logbooks was not completed as planned (see F 761); and resident areas had fruit flies and floors in disrepair (see F 584). Findings include: The 1/2024 facility policy and procedure Quality Assurance and Performance Improvement Program documented the objective was to provide means to establish and…

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

Based on observation, record review, and interview during the recertification survey conducted 1/24/2024 - 2/1/2024, the facility did not ensure facility equipment was maintained in proper operating condition for 1 of 7 resident floors (5th floor). Specifically, the fifth floor ice machine was not functional. Findings include: The facility could not provide any work orders that documented the fifth floor ice machine was not working. During an observation on 1/24/2024 at 1:00 PM, the fifth floor ice machine dispensed water but not ice. During an observation on 1/26/2024 at 12:25 PM and during a follow-up observation on 1/30/2024 at 1:24 PM, the fifth floor ice machine had been removed from the unit dining room, and there was no ice on the unit. During an interview on 1/30/2024 at 1:26 PM, the Corporate Director of Facilities stated the ice machine was removed from the fifth floor dining room on 1/26/2024 and was not returned to the floor because the facility was awaiting parts. They were not sure how ice was currently being brought to the fifth floor. It was important that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during an abbreviated survey (NY00321085) the facility did not maintain a safe, clean, comfortable, and homelike environment for 2 of 7 nursing units (Unit 2 [NAME] and Unit 7). Specifically, there were active and old roof leaks that caused water damage and water infiltration into two resident areas on Units 2 [NAME] and Unit 7 (corridor adjacent to Resident room [ROOM NUMBER], clean linen room on Unit 2 West, and Resident room [ROOM NUMBER]). Findings include: Review of the roof vendor quote dated 3/23/2023, documented the need for roof repairs and clean up as well as replacement of materials. Observations made on 8/9/2023 at 12:26 PM on Unit 2 [NAME] included: - an active roof leak within the corridor adjacent to Resident room [ROOM NUMBER] and the cross-corridor fire doors. - A 33 gallon trash can under a cut out section of ceiling (approximately 1 foot x 3 feet) to catch leaking roof water. There was also water on the floor around the trash can. - A small…

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

Based on observation, record review, and interview during the recertification and abbreviated (NY00269688 and NY00273974) surveys conducted on 12/13-12/21/21, the facility failed to ensure 2 of 13 residents (Residents #184, and 224) reviewed received adequate supervision and assistance devices to prevent accidents and/or their environments remained as free of accident hazards as possible. Specifically, - Resident #184 exited the secure unit (2S) undetected and made it to a non-resident area, and the incident was not thoroughly investigated, nor was a plan implemented to prevent further unsafe wandering. Resident #184 subsequently eloped from the facility and was found walking in the roadway by the local police after certified nurse aide (CNA) #24 did not appropriately respond when the wander guard system (to alert staff of resident wandering) alarmed. - Resident #224 had a fall in their bathroom on a wet floor. The accident hazard was not addressed timely to prevent falls and the incident was not investigated to ensure a plan was implemented to prevent reoccurrence. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey conducted 12/13/21-12/21/21, the facility failed to ensure 1 of 2 residents (Resident #31) reviewed was free from physical restraints. Specifically, Resident #31's restraint was not released at least every 2 hours and at meals as care planned. Findings include: The 3/2020 Use of Restraints policy documented restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used upon written order of a physician. Care plans for residents in restraints will reflect interventions that not only address the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. Resident #31 was admitted to the facility with diagnoses of dementia with behavioral disturbance, restlessness, and anxiety.…

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

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00281850, NY00270904, NY00269162 and NY00281169) conducted on 12/13/21-12/21/21, the facility failed to ensure 1 of 7 residents (Resident #2) reviewed received the necessary services to maintain good nutrition. Specifically, Resident #2 was not assisted with meals timely. Findings include: Resident #2 had a diagnosis including dysphagia (difficulty swallowing). The 11/26/21 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; required extensive assistance with eating; had a 5% weight loss in the last month; and was not on a prescribed weight-loss regimen. The 11/22/21 physician's orders documented the resident was on a regular diet with pureed texture and nectar thickened liquids. The 12/7/21 comprehensive care plan (CCP) documented the resident was at risk for malnutrition, needed an altered consistency diet, and required extensive assistance with eating. The care instructions, active 12/20/21, documented the resident required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey conducted on 12/13-12/21/21, the facility failed to ensure 1 of 4 residents reviewed (Resident #145) maintained acceptable parameters of nutritional status. Specifically, Resident #145 had a significant weight loss which was not reassessed timely by clinical nutrition staff. Findings include: The facility's revised 1/2021, Weight Assessment and Intervention policy documented: - Nursing staff will weigh residents. - Weights will be recorded in each unit's weight book and in the resident's medical record. - Any weight change of 5% or more since the last weight assessment will be taken the next day for confirmation. If the weight is verified, nursing will immediately notify the registered dietitian (RD) in writing. Verbal notification must be confirmed in writing. - The RD will review the unit's weights by the 15th of the month. - Negative weight trends will be evaluated by the treatment team whether criteria for significant weight…

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

Based on observation, interview, and record review during the recertification survey conducted on 12/13/21- 12/21/21, the facility failed to ensure the menu was prepared in advance, followed, and reflect, based on reasonable efforts, input from the residents for 4 of 35 residents reviewed (Residents #28, 91, 111, and 215). Specifically, Residents #28, 91, and 111 received a substitution of peas instead of spinach at the 12/13/21 lunch without documented rationale for the substitution. Resident #28 received incorrect items at 2 meals and Resident #215's meal preferences were not honored, and they received foods they did not like. Finding included: The 1/2021 Food Services policy and procedure documented individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Upon the resident's admission (or within 24) hours after his/her admission the dietitian or nursing staff will identify a resident's food preferences. MENU NOT FOLLOWED: 1) The 2021 Fall/Winter Menu Week 2 Menu documented the vegetable served for lunch meal on 12/13/21 was…

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

Based on observation, interview, and record review during the recertification survey conducted on 12/13/21 through 12/21/21, the facility failed to provide food and drink that is palatable and at a safe and appetizing temperature for 1 of 2 test trays reviewed. Specifically, a breakfast tray was served at unpalatable temperatures to Resident #2 and Residents #6, 28, #103, 111, and 133 reported receiving food at unpalatable temperatures. Findings include: The undated Test Tray Audit form documents acceptable temperatures of hot foods including entrees and hot cereals should be 140 degrees Fahrenheit (F) or above; and cold foods including beverages should be 40 degrees. Resident interviews included: - On 12/13/21 at 2:24 PM on Unit 2 West, Resident #28 stated the hot food was not served hot. - On 12/13/21 at 2:32 PM on Unit 2 West, Resident #111 stated the food did not arrive on time and was cold at times. - On 12/14/21 at 8:48 AM on Unit 7, Resident #133 stated the food was unbelievably bad, the hot food was not hot, and the cold foods were semi-warm. Ice cream was often melted by…

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

Based on observation and interview during the recertification survey conducted on 12/13/21-12/21/21, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes affecting 1 of 7 units (Unit 2S) reviewed. Specifically, the Unit 2S dining room's heat was not working, residents were displaced to their rooms and hallways for meals, and the facility did not report the heat outage to the New York State Department of Health (NYS DOH) as required. Findings include: On 12/13/21 at 10:38 AM, the Unit 2S dining room was observed to be locked. On 12/13/21 at 10:40 AM, licensed practical nurse (LPN) Manager #2 stated the dining room was closed because the heat was not working. Residents were to eat in their rooms or the hallways. At 12:25 PM, LPN Manager #2 stated there were 16 residents who typically ate in the dining room that were currently eating in the hallway due to the closed dining room. LPN #2 stated the dining room had been closed for 2 to 3 weeks. When observed on 12/13/21 at 4:10 PM, the Unit 2S dining…

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

Based on observation, interview, and record review during the recertification survey conducted 12/13/21-12/21/21, the facility failed to furnish services by a person or agency outside the facility if the facility does not employ a qualified professional to furnish a specific service for 2 of 3 residents (Residents #6 and 175) reviewed. Specifically, Resident #6 missed a virtual medical appointment; and Resident #175's outpatient nephrology appointment was canceled, the cancellation was not communicated, and the resident went to the canceled appointment with a family member. Findings include: The 1/2021 Consultations policy documents the facility is responsible to provide consultation services for any resident as needed. The facility assumes responsibility for obtaining services that meet professional standards. The attending physician will write an order for a consult and the reason in the medical record. Designated staff will schedule the consult; if using outside consultant, the employee will arrange the appointment, transportation, and notification of resident designated…

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

Based on observation, record review and interview during the recertification and abbreviated surveys (NY00272513) conducted 12/13/21-12/21/21, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #83) reviewed. Specifically, registered nurse (RN) #30 did not change gloves after removing an old dressing and cleansing a wound and did not perform hand hygiene between glove changes during wound care for Resident #83. Findings include: The facility policy Wound Care reviewed 1/2021, documented the following procedural steps; arrange supplies, wash, and dry hands thoroughly, put on exam gloves, remove dressing, pull glove over dressing and discard into appropriate receptacle, wash, and dry hands thoroughly, put on gloves, apply treatment as indicated, discard all soiled laundry in soiled laundry container, remove disposable gloves and discard into designated container,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey conducted on 12/13/21-12/21/21, the facility failed to conduct testing based on parameters set forth by the Secretary for 3 of 4 residents (Residents #76, 132, and 156) reviewed. Specifically, Residents #76, 132 and 156 were identified as having a close contact with a COVID-19 positive staff member (certified nurse aide, CNA, #54) and were not tested per the outbreak testing guidelines on Day 2. Findings include: The 9/10/21 Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes documents residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but not earlier than 2 days after the exposure) and, if negative, again 5-7 days after the exposure. During an interview on 12/16/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00273974) conducted from12/13/21-12/21/21, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 7 resident units (2S Unit). Specifically, the 2S Unit (secured dementia unit) elevator was not disabled by the presence of a wander alert bracelet (used to alert staff of resident wandering). Subsequently, Resident #184 was able to take the elevator to the first floor, unsupervised, while wearing a wander alert bracelet. Findings include: The facility policy Wander Guard System revised 1/2021 documented: - The facility would provide and maintain a secure environment to prevent negative outcomes for residents who exhibit unsafe wandering and or elopement behaviors. - The Wander Alert system will alarm when a wanderer or potential eloper attempts to leave the facility unaccompanied. - Alarms are placed on all exits on the first 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.