The Grand Rehabilitation and Nursing at Barnwell

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews (iQIES Intakes 2747995, 2961519, 2976530), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one of 12 residents (Resident #56) reviewed. Specifically, Resident #56 had a fall that was not immediately reported, and diagnostic imaging was not completed as ordered to rule out fracture. Findings include:The facility policy Change in a Resident's Condition or Status, last reviewed 01/2026, documented the facility notified the resident, attending physician, and resident representative of changes in the resident's medical condition and/or status including an accident or incident that involved the resident.The facility policy Lab and Diagnostic Test Results-Clinical Protocol, reviewed 01/2026, documented the physician identified and ordered diagnostic testing based on diagnostic and monitoring needs. Staff processed test requisitions…

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 the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of one (1) resident (Resident #3) reviewed. Specifically, Resident #3 was observed with a BiPAP (bilevel positive airway pressure) machine in their room and did not have a physician order or care plan for the device, and the mask was unclean. Findings include: The facility policy CPAP/BiPAP, revised 01/2026, documented the facility provided continuous positive airway pressure with or without supplemental oxygen to the spontaneous breathing resident to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. The physician ordered the oxygen concentration and flow and the positive end expiratory pressure for the machine. The humidifier chamber was filled with distilled water only and cleaned weekly, disinfecting with vinegar-water solution (1:3) in clean humidifier, soaking for 30 minutes 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, the facility failed to ensure that residents who required dialysis services (a process that filters blood when the kidneys do not work efficiently) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #122) reviewed. Specifically, Resident #122 received dialysis, had a dialysis access and there was no documented evidence pre and post dialysis evaluations were consistently completed. Findings Include:The facility policy Dialysis Communication, last reviewed 01/2026, documented on the days of dialysis the nurse will take vital signs and document relevant labs and pre-dialysis weight in the dialysis communication book. An evaluation of the resident's access site will be completed and all findings documented in the communication book as well as the resident's medical chart. Resident #122 had diagnoses including end stage kidney disease and dependence on dialysis. The 04/16/2026 Minimum Data Set assessment documented the resident had intact cognition and required dialysis…

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, the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychological well-being for one (1) of five (5) residents (Resident #145) reviewed. Specifically, Resident #145 had a history of anxiety and depression, expressed worsening depression symptoms and there was not consistent or timely support provided by the facility addressing the resident's psychosocial well-being. Findings include: The facility policy Behavioral Assessment, Intervention and Monitoring, last reviewed 01/2026, documented the facility provided and residents received behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services were provided by qualified staff who had the…

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

Based on observations and interviews the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards and principles for one (1) of six medication carts (Unit 5 B Medication cart) reviewed. Specifically, the Unit 5 B Medication Cart had one (1) undated Humalog insulin vial and one (1) expired Trelogy Inhaler cartridge.Findings include:The facility policy Storage of Medications, last reviewed 01/2026, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that had missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing; the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.During an observation on 05/12/2026 at 1:37 PM with Licensed Practical Nurse #23, the Unit 5 B Medication Cart top drawer contained one undated vial of Humalog insulin and one expired Trelogy inhaler cartridge dated…

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

Based on record review and interviews during an abbreviated survey (Case #s NY00376223 and NY00377464), 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 ensure narcotics were counted by two (2) licensed staff members on the B-side of unit two (2), on 2/23/2025 at the end of the 3:00 PM to 11:00 PM shift. On 2/24/2025, the 7:00 AM - 3:00 PM nurse discovered twenty (20) Oxycontin extended release 10 milligram (extended-release narcotic pain medication) prescribed for Resident #1 were missing. During the facility's investigation it was determined that narcotic counts were not done by the required two (2) nurses. The physician reordered the medication on 2/24/2025 and was received in the facility on 2/25/2025. On 2/25/2025 at 9:00 PM, the medication administration record documented the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (Case #s NY00376223 and NY00377464), the facility did not ensure residents were free from significant medication errors for seven (7) (Resident #s 2, 3, 4, 5, 6, 7, and 12) of seven (7) residents reviewed. Specifically, the facility did not ensure accurate medication administration and documentation of controlled substances for a) Clonazepam (treats anxiety) for Resident #s 2, 5, and 12, b) Clonazepam and Tramadol (narcotic pain medication) for Resident #3, c) Alprazolam (treats anxiety) for Resident #4, and d) Oxycodone (narcotic pain medication) for Resident #s 6 and 7. This is evidenced by: The Policy and Procedure titled, Controlled Substance/Narcotic Management Protocol, reviewed 1/2025, documented it was the facility's policy to prescribe, administer, store and destroy all controlled substances within accepted regulations of the responsible governing body. All controlled substances ordered would be ordered in accordance with best practice…

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 interviews conducted during the recertification and abbreviated (Case #'s NY00350251, NY00357834, NY00359849, NY00360717) survey, the facility did not provide effective housekeeping and maintenance services on six (6) of six (6) resident units. Specifically, floors and resident units were not clean and maintained. This is evidenced by: During observations on 6/08/2025 between 1:30 PM and 5:30 PM: • The floors were sticky in the corridors on resident units One (1), Three (3), and Six (6). • The floors were sticky in resident Room #s 305, 605, and 606. • Trash was found in the corridor on Unit One (1). • The bathroom toilet and floor were soiled in resident room [ROOM NUMBER]. • The bathroom floor was littered wads of used toilet paper, and the wallpaper was improperly patched in resident room [ROOM NUMBER]. • The baseboard below sink was warped in resident room [ROOM NUMBER]. • The privacy curtain was stained in resident room [ROOM NUMBER]. During observations on 6/08/2025 at 3:03 PM, the…

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

Based on observation, record review, and interviews during a recertification and abbreviated (Case #s NY00350251, NY00350678, NY00350852, NY00359849, NY00366370, NY00380238, and NY00381177, NY00360717) survey, 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, (a.) staff reported a lack of sufficient staffing, and (b.) residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered promptly and long wait times for care to be provided. This is evidenced by: Upon entrance to the facility on 6/08/2025, there were 222 residents residing in six (6) units. The Facility Assessment, last reviewed on 6/02/2025, documented that the facility's bed capacity was 226, with an average daily census of 222 - 225 residents. Section 3.2, titled Staffing Plan, documented the following: - Day shift required 6-11 Licensed Nurses providing direct…

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 conducted during the recertification and abbreviated survey (Case #'s NY00349022 and NY00368315), the facility did not ensure licensed nurses and Certified Nurse Aides had the specific competencies and skills necessary to care for residents' needs. Specifically, nursing staff did not possess the knowledge needed to complete the tasks assigned to their position regarding the mentally disabled and intellectually disabled residential population. This is evidenced by: The facility assessment dated [DATE] documented the following: - Section 1.1 resident profile numbers documented that they are licensed to care for 236 residents with six nursing units. Units 3,4,5, & 6 are each 40-bed units that are for long-term care. Unit 1 is a 30-bed secured unit for those with Dementia/Alzheimer's. Unit 2 is a 47-bed unit that provides long-term care and short-term rehab. There are no designated beds secured for residents with mental health or behavioral disorders. - Section 1.3 that the…

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

Based on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case #'s NY00349022, NY00360717, NY00368315, NY00369256, NY00374241), the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) (3rd floor) of three (3) (medication rooms and five (5) of six (6) (2nd floor cart A; 3rd floor cart A; 4th floor (cart A and B; and 5th floor cart A), medication carts reviewed. Specifically, (a.) 1 bottle of purified protein derivative (PPD) solution had no open and or expiration date; (b.) an opened insulin vial had no open and or expiration date; (c.) one (1) inhaler had no open and or expiration date; (d.) a bottle of liquid Metformin had no open or expiration date; (e.) 2 stock medications had expired; (f.) 8 opened stock medications had illegible expiration dates; (g.) a discharge resident's open medication remained on cart. This is evidenced by: The facility's Policy and Procedure titled, Storage of Medication reviewed 01/2025 documented, the facility shall…

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, observations and interviews during the recertification survey and abbreviated survey (Case #'s NY00366370, NY00349022, NY00365338), the facility did not ensure each resident received and the facility provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature of greater than 135 degrees Fahrenheit (F) for warm food and less than 41 degrees Fahrenheit for cold food for four (4) (Resident #s 23,35, 109, and 198) of four (4) residents reviewed. Specifically, (a.) residents complained that the food was cold, appeared uncooked, and was generally unpalatable during the resident council meeting; (b.) Resident #23 complained about cold, undercooked, and unappetizing food; (c) Resident #35's meal was not palatable and not served at a safe and appetizing temperature during lunch service on 6/13/2025; (d.) Resident #109 and their family member complained about cold and unappetizing food; and (e.) Resident #198 complained about cold, undercooked food. 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 observation, record review, and staff interview conducted during the recertification survey, the facility did not prepare and store food in accordance with professional standards for food service safety in the main kitchen and six (6) of six (6) kitchenettes. Specifically, food was not cooled safely, the automatic dishwashing machine was not operating within specifications, test papers to check sanitizing solution were not available, and equipment was not clean. This is evidenced by: During observations on 6/08/2025 from 1:34 PM through 2:34 PM: Stewed beef labeled as prepared on 6/07/2025 was 47 degrees Fahrenheit: Dietary Supervisor #1 immediately disposed the beef. The automatic dishwashing machine final rinse temperature was 173 degrees Fahrenheit at 5 pounds per square inch water pressure: the data plate instructions on the dishwashing machine stated that the final rinse is to be 180 degrees Fahrenheit with the water pressure to be between 15 and 25 pounds per square inch. When checked utilizing…

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, resident and staff interviews, review of facility policies and procedures, staffing records, resident records, accident and incident reports, and the facility's maintenance records, during the recertification survey, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements, which affected or potentially affected all residents in the facility. These failed practices directly impacted 37 of 37 residents sampled (Resident #s 8, 11, 12, 16, 23, 27, 35, 36, 42, 43, 44, 59, 64, 78, 84, 89, 98, 101, 104, 107, 109, 120, 143, 147, 148, 158, 164, 166, 167, 171, 177, 183, 190, 192, 198, 202, 220, 221, 222, 473, 474, 524, and #723). Specifically, the lack of effective oversight and planning on the part of facility administration had the potential to adversely affect the health and safety of all residents residing in the facility. This is evidenced 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, record review, and interviews during an onsite post-survey revisit conducted from 10/29/2025 through 11/05/2025, the facility did not ensure it had an active governing body that was responsible for establishing and implementing policies regarding the management of the facility. Specifically, based on multiple deficient practices that were identified during the onsite Post Survey Revisit and continued deficient practices identified during the post-survey revisit in the areas of (F644), (F804), and (F835), there was inconsistent communication between the facility Administrator and the Governing Body to ensure management of the facility and regulatory compliance. This is evidenced by:The facility policy titled, Quality Assurance and Performance Improvement Plan, undated, documented under Element 2, the Governing Body and Administration of the facility potentiated high quality resident care by developing and leading the Quality Assurance Performance Improvement program. The administrator would ensure a leadership role and encouraged input from facility staff,…

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

Based on observation, record review, and interviews conducted during the recertification and abbreviated survey, ( Case #s NY00382178, NY00381725, NY00381177, NY00377863, NY00376073, NY00375451, NY00374739, NY00374241, NY00371608, NY00371134, NY00370863, NY00369256, NY00368315, NY00366370, NY00365338, NY00365247, NY00364461, NY00362053, NY00361234, NY00360717, NY00360609, NY00359849, NY00359427, NY00357834, NY00357492, NY00354249, NY00352656, NY00351455, NY00351346, NY00351150, NY00350999, NY00350852, NY00350771, NY00350678, NY00350495, NY00350251, NY00350241, NY00349939, NY00349553, NY00349022), the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not develop written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, the facility had repeat deficiencies in the areas of resident dignity (F550), self-administration of medications (F554), Preadmission Screening…

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 #'s NY00350852, NY00350999, NY00351150, NY00351346, NY00351455, NY00352656, NY00362053, NY00365247, NY00349022, NY00349553, NY003716080), the facility did not ensure the resident's right to be free from abuse and neglect for four (4) (Resident #s 52, 158, 192, and 208) of ten (10) residents reviewed for abuse and neglect. Specifically, (a.) on 10/16/2024, Resident #192 was injured by Resident #158 after the resident entered their room and hit them in the face causing a laceration to Resident #192's face above and below their left eye requiring an emergency room visit. Resident #158 was sent out for evaluation to the emergency room due to repeated aggressive behaviors; (b.) on 12/17/2024, Resident #158 punched Resident #52 in the face while attempting to take an item from their walker resulting in an injury to Resident #52's pinky; (c.) on 3/20/2025 Resident #158 punched Resident #475 in the face…

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 (Case #'s NY00349022, NY00349553, NY00350241, NY00350495, NY00351346, NY00357834, NY00368315, NY00369256) survey, the facility did not develop and implement 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 seven (7) (Resident #s 59, 98, 104, 167, 171, 198, and 524) of 37 residents reviewed for care plans. Specifically (a.) Resident #104 was a risk for elopement, and their electronic monitoring device was not implemented and continued upon return from the hospital on 5/16/2025; (b.) Resident #171 was assessed to have a small open area to their coccyx area on 2/16/2025. There was no care plan developed that documented the discovery of this open area with interventions/tasks to be completed as a result of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews conducted during a recertification and abbreviated survey, (Case #'s NY0035099, NY00371608, NY00349022, NY00350241, NY00350495, NY00351346, NY00357492, NY00357834, NY00365247, NY00366370, NY00368315, NY00369256) survey, the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for six (6) (Resident #'s 16, 101, 147, 158, 198, and 202) of 37 residents reviewed for comprehensive care plans. Specifically, (a.) for Resident #16 comprehensive care plan for dental care was not revised; (b.) for Resident #101 the comprehensive care plan was not revised for refusal of recommended psychotropic medications; (c.) for Resident #147 the respiratory and the skin integrity care plan was not revised to include the physician's order for protective padding behind the ears to prevent skin breakdown; (d.) for Resident #158 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 observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that followed professional standards of practice, for six (6) (Residents #s 8, 35, 78, 98, 147, and 190) of seven (7) residents reviewed for oxygen administration. Specifically, (a.) for Residents #s 8, 78, 98, and 190, supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; (b.) for Resident #147 supplemental oxygen was not provided as ordered by the physician; and (c.) Residents # 35 and 98 oxygen delivery devices (BiPAP (bilevel positive airway pressure - noninvasive ventilation) machine were not appropriately cleaned to prevent respiratory infections. This is evidenced by: A review of the facility policy titled, Oxygen Administration, dated 01/2025, documented that the facility was to provide oxygen by way of an oxygen mask, nasal cannula, and/or nasal catheter. oxygen…

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 survey, the facility did not ensure that its medication error rate did not exceed 5% for three (3) (Resident #s 46, 206, and 67) of four (4) residents observed during a medication pass for a total of 27 observations. This resulted in an error rate of 59.26%. This is evidenced by: The Policy and Procedure titled, Administering Medications, reviewed 01/25, documented medications would be administered in a safe and timely manner, and as prescribed. Medications would be administered in accordance with the orders, including any required time frame. Medications would be administered within one (1) hour of the prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #46: Resident #46 was admitted to the facility with diagnoses of epilepsy (a brain condition that causes recurring seizures), chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that there was no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, a nourishing bedtime snack was provided when there was a greater than 14-hour time span between the evening meal and breakfast. This is evidenced by: The Policy and Procedure titled Food and Nutrition Services revised on 1/2025 documented nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. The Policy and Procedure titled Snacks (between meal and bedtime) effective 10/1997 reviewed 01/2025 documented snacks were to be placed on the overbed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for three (2) (Resident #'s 27 and 120) of the 37 residents reviewed. Specifically (a.), for Resident #27, administration of ceftriaxone sodium solution was not accurately documented on the resident's medication administration record at time of administration; (b.) for Resident #120, the Medication Administration Record was not completed to reflect administration of medications. This is evidenced by: A review of the Policy and Procedure titled Administering Medications effective 10/1997, reviewed 1/2025 documented the individual administering the medication must sign the residents electronic Medication Administration Record as indicated by the software after giving each medication and before administering the next ones. As required or indicted for a medication, 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 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 the grounds were not clean and maintained. This is evidenced by: During observations on 6/08/2025 at 4:18 PM, the blocks in the retaining wall on the west end of the property were crumbling, the propane tank area was overgrown with vegetation and the wooden fence in disrepair, brickwork in the loading dock wall was crumbling, the east exterior wall stucco had black water staining, and grounds along the west exterior wall was littered and had a build-up of leaves and overgrown vegetation. During an interview on 6/10/2025 at 11:11 AM, Director of Plant Operations #1 stated that they would repair the walls and fencing and cut the overgrown vegetation. New York Codes Rules and Regulations Title 10 §415.5(h)(4)

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 #'s NY00350241, NY00366370, NY00368315, NY00369256, and NY00374241), 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 three (3) (Resident #s 11, 35, and 89) of 35 residents reviewed. Specifically, (a.) Resident #11 expressed in general that certified nurse aides were rude and or ignored them when asking for help; (b.) Resident #35 expressed they did not get out of bed because they were a two-person mechanical lift and there were not enough staff to assist, and or if they were to get out of bed, they would not be able to go back to bed until late night hours. In addition, they stated they did not take showers or tub baths due to not enough staff to assist; (c.) Resident #89 was observed eating in the common area in front of television with food smeared 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #35) of 37 residents reviewed. Specifically, Resident #35 was observed with a bottle of prescribed fluticasone steroid inhaler and a bottle of unprescribed Deep Sea Nasal spray (purified salt solution nasal spray) in their room and there was no documented evidence of assessment in the medical record and/or physician order for the resident to self-administer the medications. This is evidenced by: The Policy and Procedure titled, Self-Administration of Medications, reviewed 1/2025, documented residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff 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 interviews conducted during a recertification survey, the facility did not ensure residents received services in the facility with reasonable accommodation for one (1) (Resident #42) of 37 residents reviewed. Specifically, the Resident #42 did not have a call bell that was accessible as Resident #42 had a visual impairment and the call bell was not left in a spot they could locate. This is evidenced by: Resident #42 was admitted to the facility with diagnoses of blindness right eye category three (3) (ability to see clearly at a distance was severely limited, but can still perceive light and potentially some detail) and blindness left eye category four (4) (may be able to distinguish between light and dark, but cannot see objects or shapes), chronic ischemic heart disease (a condition where the heart muscle does not receive enough blood and oxygen due to narrowed coronary arteries), and type two (2) diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set (an assessment…

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

Based on record review and interviews conducted during a recertification and abbreviated (Case #'s NY00350852, NY00360717, NY00362053, NY00365247, NY00374739) survey, the facility did not ensure alleged violations involving abuse were reported immediately, but not later than two (2) hours after the allegation was made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (1) (Resident #148) of ten (10) residents reviewed. Specifically, an alleged sexual interaction between a physical therapist and Resident #148 on 10/29/2025 was not reported to the New York State Department of Health within two (2) hours of the allegation being made. This is evidenced by: The Policy and Procedure titled Abuse-Prohibition Protocol, Types of Abuse, Response/Reporting, last reviewed 1/2025, documented the following information should be reported to the supervisor/nurse: the names of the residents involved; the date and time that the…

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

Based on observation, record review, and interviews during the Recertification and abbreviated (Case #'s NY00350678, NY00350852, NY00362053,365247, NY00374739) survey, the facility did not ensure that all allegations of abuse and neglect were thoroughly investigated for one (1) (Resident #89) of ten (10) residents reviewed. Specifically, Resident #89 reported a staff member was rough with them in September of 2024. The investigation was closed without interviewing and or obtaining statement from resident, other residents, staff, family, visitors and or establishing timeline of event. This is evidenced by: The facility's Policy and Procedure titled, Abuse Investigation and Reporting, reviewed 01/2025, documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) should be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations would also be reported. If an incident or…

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 reviews and interviews conducted during the recertification and abbreviated (Case #'s NY00349022, NY00349553, NY00350241, NY00350495, NY00351346, NY00357492, NY00357834, NY00365247, NY00368315, NY00369256) survey, the facility did not ensure assessments accurately reflected the resident's status for one (1) (Resident #167) of 37 residents reviewed. Specifically, for Resident #167, the Minimum Data Set (an assessment tool) did not reflect a diagnosis of a psychiatric condition and the administration of an ordered anti-depressant medication. This is evidenced by: Resident #167 was admitted to the facility with the diagnoses of dementia (a group of conditions characterized by the impairment of at least two brain functions, such as memory and judgment), delusional disorders (mental illness in which a person has delusions, a specific symptom of psychosis), and osteoarthritis (a type of arthritis that occurs when the flexible, protective tissue at the end of bones wears down over time). The Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure assessments were coordinated with the Pre-admission Screening and Resident Review program under Medicaid for two (2) (Resident #s16 and 167) of 37 residents reviewed. Specifically, for (a.) Resident #16, the facility did not ensure that the Pre-admission Screening and Resident Review accurately reflected the resident's abilities, and the services suggested were appropriate for them. Specifically, for Resident #167, the resident was diagnosed with major depressive disorder after admission and no Level II screen was completed to determine if additional services were necessary. Resident #16 Resident #16 was admitted to the facility with the diagnoses of obsessive-compulsive personality disorder (a mental health condition characterized by recurring, intrusive thoughts and repetitive behaviors or mental acts that individuals feel drive to perform), paranoid personality disorder (a mental…

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 a recertification and abbreviated survey, the facility did not ensure that a Level II PASARR (Preadmission Screening and Resident Review) assessment was reported to the designated agency for one (1) (Resident # 12) of 37 residents reviewed with a diagnosis of mental illness/intellectual disability. Specifically, Resident #12's the Preadmission Screen and the Resident Review form dated completed prior to admission on [DATE] documented Resident #12 triggered for a Level II referral. There was no documented evidence that a Level II was completed. This is evidenced by: Record review of facility policy and procedure titled, PP Screen and PASRR, last revised 1/2025, documented the following: It is the policy of this facility that all individuals applying for a new admission to this facility must be screened to identify serious mental illness or mental retardation/developmental disability per New York State Department of Health regulations. All applicants who are positive…

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 staff interviews conducted during the Recertification and Abbreviated survey (Case #'s NY00349553, NY00351346, NY00357492, NY00365247, NY00365338, NY00371134, NY00366370), the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADLs) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for one (1) (Resident #35) of ten (10) residents reviewed for activities of daily living. Specifically, Resident #35 was not assisted out of bed during observed dates of 6/09/2025, 6/10/2025, 6/11/2025, 6/12/2025, 6/13/2025, 6/16/2026, and 6/17/2025. Resident #35 stated they did not get out of bed because they were a two - person mechanical lift transfer and there were not enough staff to assist. In addition, Resident #35 was no longer offered showers only bed baths due to need for mechanical lift and two-person transfer. This is evidenced by: The facility Policy and Procedure titled, Quality of Life - Dignity,…

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 residents received treatment and care in accordance with professional standards of practice for one (1) (Resident # 8) of 37 residents reviewed. Specifically, Resident #8 who was bed bound was not turned and repositioned every 2 hours as required per facility's policy. This is evidenced by: A review of the Policy titled, Repositioning dated 01/2025 documented that the purpose is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Residents who are in bed should be on at least a two-hour repositioning schedule. Resident #8 was admitted to the facility with diagnoses of muscular dystrophy (a group of genetic diseases that cause progressive weakness and breakdown of the body's muscles), chronic respiratory failure with hypoxia(a…

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

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (1) (Resident #171) of one (1) resident reviewed for range of motion. Specifically, for Resident #171, a hand carrot (a device used to address hand contractures) was not applied to the resident's left hand to help prevent contracture. This is evidenced by: Resident #171 was admitted to the facility with a diagnoses of hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (a condition where brain tissue dies due to lack of blood supply), pressure ulcer of buttock, stage 3 (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and muscle wasting and atrophy (decrease in size and strength of muscle tissue). The Minimum Data Set (an assessment tool) dated 4/08/2025 documented the resident had moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews conducted during the recertification and abbreviated survey (Case #s NY00350771 and NY00350999), the facility did not ensure that residents were as free from accidents and hazards as possible for three (3) (Resident #s 143, 158, and 192) of nine (9) residents reviewed for accident hazards. Specifically, (a.) for Resident #143, the corridor door to the resident's room was ajar and was unable to be freely closed or opened; (b.) for Resident #158 there was no adequate supervision to prevent an elopement on two different occasions 8/10/2024 and 8/19/2024 when the resident had been identified as an elopement risk from admission; (c.) Resident # 192 was not provided adequate supervision on 8/08/2024, when the resident eloped (left the facility without staff's knowledge). Resident #192 who was on 30-minute safety checks due to cognitive impairment, was last seen at 1:30 PM. At 1:42 PM, Resident #192 was found outside by staff and stated they exited the facility through a side exit…

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

Based on record review, and interviews conducted during a recertification survey, the facility did not ensure that residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (1) (Resident #84) of two (2) residents reviewed for dialysis. Specifically, for Resident #84, the facility did not consistently provide ongoing monitoring for complications after dialysis treatments provided at a certified dialysis facility and did not consistently review the resident's dialysis communication book to provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. This is evidenced by: Resident #84: Resident #84 was admitted to the facility with the diagnoses of end-stage renal disease (irreversible stage of chronic kidney disease, where the kidneys are functioning at a severely diminished capacity, requiring dialysis or kidney transplantation for survival), Type 2 diabetes (a chronic condition where 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 the recertification survey, the facility did not ensure a resident received behavioral health services to attain their highest practicable well-being, in accordance with the comprehensive assessment and plan of care for one (1) (Resident #120) of seven (7) residents reviewed for Behavioral/Emotional Status. Specifically, Resident #120 was diagnosed with a mental illness, received antipsychotic medication, and did not receive psychiatry follow up as ordered. This is evidenced by: Resident #120: Resident #120 was admitted to the facility with the diagnoses of schizophrenia (a chronic brain disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a serious mental illness characterized by persistent feelings of sadness, loss of interest, and difficulty functioning in daily life), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 5/8/2025 documented the resident could be…

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

Based on record review and interviews conducted during the recertification survey, the facility did not ensure that residents were free of unnecessary medications for one (1) (Resident #104) out of Five (5) residents reviewed. Specifically, Resident #104's medication of Trazodone (an antidepressant) did not include a correct diagnosis for the intended use. This is evidenced by: Resident #104 was admitted to the facility with the diagnoses of Alzheimer's disease (a progressive brain disorder that gradually destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (a decline in mental ability severe enough to interfere with daily life), and dysphagia (difficulty swallowing). The Minimum Data Set (an assessment tool) dated 5/16/2025 documented that the resident was usually understood, could understand others, and had moderate cognitive impairment. A review of the Policy and Procedure titled, Medication Therapy dated 01/2025, documented that each resident's medication regimen shall include only those medications necessary to treat existing…

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, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was leaking waste. This is evidenced by: During observations on 6/08/2025 at 4:19 PM, a black and white oily substance was dripping from the bottom of the trash compactor, puddles of the oily black and white substance were found on the ground below the compactor, and a pungent composting odor was detected in the area around the compactor. During an interview on 6/09/2025 at 1:02 PM, Administrator #1 stated that they would investigate the cause of the compactor leak, replace the compactor if necessary, and clean the grounds below the compactor. New York Codes Rules and Regulations Title 10 415.14(h)

Based on observations, record review and staff interviews conducted during the Recertification and abbreviated Survey (Case #s NY00350999 and NY00371608), the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit. This was identified for six (6) (Unit1, 2, 3, 4, 5 and Unit 6) of six (6) Units reviewed during the Sufficient Staffing Task. Specifically, (a.) the Facility Assessment, last updated on 1/07/2025, did not include a breakdown of the staffing needs for each resident unit; (b.) Unit 2 and Unit 3 were incorrectly identified in the Facility Assessment. Unit #2 was identified as the Rehabilitation Unit and Short-term care unit. Unit #3 was identified as a Long-term care unit; (c.) Behavioral health and elopement concerns were not identified within the facility that would require extra staffing and education for de-escalation that would heighten the likelihood of resident-to-resident abuse. This is evident by: Cross-referenced to F725: Sufficient Nursing Staff, F600: Abuse, F-689 Accidents and F-676 Activities of Daily Living…

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# NY00338151), the facility did not ensure pain management was provided to residents who required such services, consistent with professional standards of practice and the resident's goals and preferences for 1 (Resident #9) of 3 residents reviewed. Specifically, Licensed Practical Nurse #2 did not notify Registered Nurse Supervisor #1 in a timely manner on 3/31/2024, when Resident #9 was in pain and their scheduled Oxycodone (narcotic pain medication) was not available at 12:00 PM. The resident received the medication at 3:15 PM, over 3 hours past the scheduled time. This is evidenced by: Resident #9: Resident #9 was admitted to the facility with diagnoses of inflammatory spondylopathies, sacral and sacrococcygeal region (bone inflammation in the sacrum or coccyx); hidradenitis suppurativa (also known as acne inversa; a condition that causes small, painful lumps to form under the skin that usually develops in areas where the skin rubs together, such as the buttocks); and chronic pain syndrome. The Minimum Data…

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 during the recertification and abbreviated survey (Case #NY00341467), the facility did not ensure each resident was treated with respect, dignity, and cared for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 5 (Residents #s 26, 66, 71, 108, and 180) of 37 residents observed in 4 of 6 dining rooms reviewed for respect and dignity. Specifically, Resident #s 26, 66, 71,108, and 180 were served with disposable utensils during meals. This is evidenced by: A facility policy titled, Food and Nutrition Services and dated 1/2024, documented residents were provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, taking in consideration the preferences of each resident. Additionally, the policy stated, a resident-centered diet and nutrition plan would be based on an assessment of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews during a recertification survey, the facility did not ensure a comprehensive person-centered care plan was developed and implemented for each resident consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Residents #108, 118 and 376) of 37 residents reviewed for comprehensive care plans. Specifically, for (a)Resident #108, a comprehensive care plan addressing oxygen use was not developed; for (b) Resident #118, a care plan to address the diagnosis of post-traumatic stress syndrome and a trauma informed comprehensive care plan were not developed; and for (c) Resident #376, a person-centered care plan to meet their psychosocial needs related to their history of depression as documented in the facility medical provider's admission history and physical was not developed. This is evidenced by: 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 observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs by the interdisciplinary team after each assessment for 3 (Residents #64, 75, and 200) of 37 residents reviewed for care plans. Specifically, (a) Resident #64 was identified as high risk for falls on admission and fell (witnessed) on 7/01/2023 while ambulating without a walker. The comprehensive Care Plan for Falls was not revised to include interventions initiated or implemented to prevent further accidents following the fall. Subsequently, on 9/26/2023, Resident #64 fell and sustained a cervical 1 vertebrae fracture (broken neck); (b) for Resident #75, the facility did not include the resident in care planning and did not hold a care plan meeting during the comprehensive assessment; and (c) for Resident #200, the comprehensive care plan was not revised after enteral feedings were…

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 a recertification survey, the facility did not ensure that drug records were in order; and that an account of all controlled drugs was maintained and periodically reconciled on 2 (Units #s 5 and 6) of 6 units reviewed. Specifically, the shift-to-shift staff signature form for controlled drugs (untitled) on Units # 5 and Unit #6, did not consistently include the signatures of staff members at each shift change, validating the correct narcotic count. This is evidenced by: A review of the Controlled Substances policy dated 1/2024 documented that nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make sure they counted together documenting and reporting any discrepancies to the Director of Nursing Services. A review of the Administering Medications policy dated 1/2024 documented the individual administering the medication must sign the resident's electronic administration record after giving the resident medication and before administering the…

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

Based on observation, record review, and 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 6 out of 6 medication carts and 2 of 3 medication storage rooms reviewed. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) controlled substances were not kept secured in a double locked cabinet; (c.) multiple loose pills were found in medication cart, and (d.) medications were found pre-poured on one medication cart. This is evidenced by: The facility's Medication Administration Policy and Procedure, revised 01/2024, documented The expiration / beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened should be recorded on the container. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record may be flagged. After completing the medication pass, the nurse would return to the missed…

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 during recertification survey, the facility did not ensure that food and drink were palatable and attractive for 10 (Resident #s 26, 53, 59, 71, 75, 86, 107, 108, 111, and 161) of 37 residents reviewed for palatable and attractive food and drink. Specifically, residents complained of food being cold, unattractive, and not palatable in general during resident council meeting. Additionally, 3 floors (2, 3, and 4) of 6 floors served food that was not palatable and was not at appetizing temperature. This is evidenced by: A facility policy titled Food and Nutrition Services dated 1/2024, documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Resident #71 was admitted with diagnoses of sepsis (a serious condition resulting from infection that can cause multiple organ failure), chronic…

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 staff interview during the recertification survey, the facility did not prepare and store food in accordance with professional standards for food service safety in the main kitchen and 1 of 6 kitchenettes. Specifically, ground chicken was not cooled safely, and the Unit #1 kitchenette was not clean. This is evidenced by: The document titled (Hazard Analysis Critical Control Points) HACCP Cooling Step by Step Process and dated 6/03/2020 and the document titled Temperatures Cooking and Cooling and dated 4/2024 both documented the cooked food was to be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours then to 41 degrees Fahrenheit within 4 hours. During observations on 6/20/2024 at 10:54 AM, ground chicken in hotel pan found in the walk-in refrigerator was 52 degrees Fahrenheit. During an interview on 6/20/2024 11:24 AM, Assistant Director of Food Service #1 stated the chicken was ground and placed in the walk-in refrigerator at 7:00 AM this morning. During an interview on 6/20/2024 at 11:26 AM, Chef #1 stated the chicken was cooked 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 survey, the facility did not ensure food brought for residents by family or visitors (food) was stored safely and in a way that is either separate or easily distinguishable from facility food on 3 of 6 resident units. Specifically, resident and personal food stored in the resident unit kitchenette refrigerators was not properly labeled. This is evidenced by: During an observations on 6/20/2024 at 12:43 PM, in the Unit #1 kitchenette refrigerator, deli sandwiches labeled with the name of Resident #109 and their room number was not dated. During an interview on 6/20/2024 at 12:44 PM, Registered Nurse Unit Manager #1 stated the food brought in for Resident #109 should have been dated by the nursing staff. During an observations on 6/20/2024 at 2:55 PM, in the Unit #6 kitchenette refrigerator, lactose-free milk and orange tonic were not labeled. During an interview on 6/20/2024 at 2:57 PM, Licensed Practical Nurse #1 stated that the milk and orange tonic were brought in by family members for a resident on the…

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

Based on observation, record review, and interviews during a Recertification and abbreviated survey (Case #NY00335134), the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for 1 (Resident #35) of 1 resident reviewed for medication administration. Specifically, Resident #35 was observed with a cup containing 7 pills and a cup of medicine mixed in water at their bedside, without being evaluated as to whether they could safely self-administer their medication. This is evidenced by: Resident #35 was admitted to the facility with diagnoses of chronic diastolic congestive heart failure (heart does not pump blood well enough to give the body a normal supply), morbid obesity ( weight is more than 80 to 100 pounds above ideal body weight), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The Minimum Data Set (an assessment tool) dated 4/11/2024, documented the resident was cognitively intact,…

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 a recertification and abbreviated survey (Case # NY00333003) , the facility did not ensure that a Level II PASRR (Preadmission Screening and Resident Review) assessment was conducted prior to admission for 1 (Resident # 179) of 37 residents reviewed with a diagnosis of mental illness/intellectual disability. Specifically, Resident #179's preadmission Screen and the Resident Review form was not completed prior to admission on [DATE]. This is evidenced by: Per federal regulations, a Level II PASRR (Preadmission Screening and Resident Review) assessment must be completed for all individuals who are known or suspected of having an intellectual and/or developmental disability prior to skilled nursing facility admission. Federal regulations also stated that the state intellectual and/or developmental disability authority had an average of 7-9 working days to complete the Level II PASRR (Preadmission Screening and Resident Review) assessment.…

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 survey, the facility did not ensure resident with a percutaneous endoscopic gastrostomy tube (a tube placed in the stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate) received the appropriate treatment and services to prevent complications for 1 (Residents # 200) of 1 resident reviewed for tube feeding. Specifically for Resident #200 care and maintenance of the percutaneous endoscopic gastrostomy tube was not provided after enteral feedings were discontinued on 5/02/2024. This is evidenced by: Resident #200 was admitted to the facility with diagnoses of dysphagia following cerebral infarction (stroke), metabolic encephalopathy (brain dysfunctions due to problems with metabolism), and gastrostomy status (feeding tube). The Minimum Data Set (an assessment tool) dated 4/30/2024 documented resident had moderate cognitive impairment, could be understood, could understand others, 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 a recertification survey and abbreviated surveys (Case #NY00337074), the facility did not ensure parenteral fluids (delivery of fluid or nutrition through an intravenous (into a vein) route) was administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #224) of 1 resident reviewed for parenteral fluids. Specifically, Resident #224's Medical Doctor orders were not followed when their total parenteral nutrition was not started at 5:00 PM on 03/08/2024 stopped on 03/09/2024 at 9:00 AM as ordered. This is evidenced by: Resident #224 was admitted to the facility with diagnoses of pneumonia, severe malnutrition, and a stroke. The Minimum Data Set (an assessment tool) dated 1/14/2024, documented the resident was cognitively intact, could be understood, and could understand others. The Policy and Procedure titled, Total Parenteral Nutrition dated January 2024, documented Nursing would confirm a physician order was in place that included frequency. The Comprehensive Care Plan 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.

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure that a resident who needs required respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences were provided by a qualified professional for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function for 2 (Resident #108 and 473) of 3 residents reviewed for respiratory care. Specifically, for (a) Resident #108 was not provided with oxygen at 4 liters per minutes via nasal cannula every shift as ordered by the physician and interventions for resident's oxygen use were not implemente; and (b) Resident # 473 did not have a physician's order for oxygen administration, however Resident # 473 received oxygen for at least the 5 days prior to the oxygen order being written in the resident's medical chart. This is evidenced by: The Policy and Procedure titled…

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, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 (Resident #75) of 2 residents reviewed for dialysis care. Specifically, for Resident #75, was not monitored for complications before and after dialysis treatments were not completed consistently completed and communicated to the dialysis center through the dialysis communications log. This is evidenced by: Resident #75 was admitted to the facility with the diagnoses of chronic systolic (congestive) heart failure (condition where the heart can't pump enough blood to satisfy the normal needed supply), end stage renal failure) final stage of kidney disease, when the kidneys no longer co0mplete their function) and type 2 diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels ), cerebral infarction (stroke), metabolic encephalopathy, and gastrostomy status (feeding tube). The Minimum Data Set (an assessment tool) dated…

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

Based on record review and interviews during a recertification survey, the facility did not ensure to it provided medically related social services to attain or maintain the highest practicable, mental, and psychosocial well-being of each resident for 1 (Resident #376) of 37 residents reviewed for medically related Social Services. Specifically, Resident #376 who had a documented history of depression was not assessed by a Social Worker when they were admitted to the facility. This is evidenced by: Resident #376 was admitted to the facility with diagnoses of a fractured neck, fractured back, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 6/10/2024, documented the resident had moderate cognitive impairment, could be understood, and could understand others. The Policy and Procedure titled, Care Planning-Interdisciplinary Team dated January 2024, documented the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan…

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# NY00333575), the facility did not ensure it treated each resident with respect and dignity and care for 2 (Resident #s 2 and 6) of 10 residents reviewed. Specifically, Resident #2, who had severe cognitive impairment, and was asking where their room was, was spoken to in a disrespectful and undignified manner by Certified Nurse Aide #8 on 2/10/2024. For Resident #6, they stated during interview on 4/2/2024 at 9:41 AM, they felt scared when they overheard a loud verbal altercation between Certified Nurse Aide #8 and Licensed Practical Nurse #4, during the night shift on 2/6/2024. This is evidenced by: Refer to F609. The Policy and Procedure titled, Resident Rights, reviewed 1/2024, documented employees would treat all residents with kindness, respect, and dignity. It documented federal and state laws guaranteed certain basic rights to all residents of the facility. These rights included: a dignified experience; be treated with respect,…

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# NY00333575), 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 Agency for 1 (Resident #2) of 3 residents reviewed. Specifically, on 2/10/2024, the facility did not ensure an allegation of verbal abuse by Certified Nurse Aide #8 towards Resident #2 was reported to the Administrator and to the State Agency within 2 hours after the allegation was made. On 2/14/2024, Resident #12 reported to Licensed Practical Nurse Manager #3 that during the 11:00 PM - 7:00 AM shift on 2/9/2024 or 2/10/2024, Resident #12 heard Certified Nurse Aide #8 yelling and cursing at Resident #2 for about 10 to 15 minutes. The Administrator was first made aware on 2/14/2024 at 3:34 PM. The allegation was reported to the New York State Department of Health on…

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

Based on record review and interviews during an abbreviated survey (Case #NY00309238), the facility did not provide needed care and services that are resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one (1) resident (Resident #2) out of seventeen (17) sampled residents. Specifically, the facility did not ensure results were obtained and reviewed after a urine analysis was ordered and urine sample obtained for Resident #2. The findings include: The Policy and Procedure (P&P) titled, Lab and Diagnostic Test Results, last revised January 2023, read in pertinent part, The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange tests. The laboratory, diagnostic radiology provider or other testing source will report test results to the facility via telephone, fax or electronic medical record (EMR) integration. Nursing staff are expected to review all results and relay results to the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility record review during an abbreviated survey (Case #NY00317263), the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (Resident #11) of 2 residents reviewed for possible elopement and Wanderguard placement. Specifically for Resident #11, the facility did not follow their process to prevent accidents and elopement on [DATE] when Resident #11, who was severely cognitively impaired, left the building undetected. Resident #11: Resident #11 was admitted to the facility on [DATE] with diagnoses of violent behavior, unspecified Schizophrenia, and unspecified anxiety disorder. The Minimum Data Set (MDS- an assessment tool) dated [DATE], documented that the resident had severely impaired cognition, and could be understood by others. The policy and procedure titled Wandering, Unsafe Resident, dated 1/2023, documented the facility's process was for the facility to identify residents who are at risk for harm of unsafe wandering…

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.