Nyack Ridge Rehabilitation And Nursing Center

Based on record review and interviews during the Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure that a complete preadmission screening for individuals with a mental disorder was conducted. This was evident for 1 of 30 residents (Resident #86) reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, the SCREEN DOH 695 form was incomplete and a determination of a resident's need for Level II services had not been documented. Answers to items 27, 28, 29 and 30 were not documented. The findings are: Resident # 86 was admitted from acute care hospital with diagnoses and conditions including but not limited to bipolar disorder, schizoaffective disorder and parkinsonism. The Policy on Resident Assessment -Coordination with PASRR Program dated 4/2024 documented the facility coordinates assessment with the preadmission screening and resident review (PASRR) program to ensure that individuals with serious mental illness and or individuals with intellectual disability/developmental disability, who apply or reside in Medicaid certified beds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent new ulcers from developing for 1 of 5 residents (Resident #25) reviewed for Pressure Ulcers. Specifically, Resident #25 did not receive pressure relieving devices to promote pressure ulcer healing in accordance with the Physician Order. The findings are: The facility policy titled Pressure Injury Assessment, Management, and Intervention dated 7/5/2024 documented pressure injury interventions included meticulous skin care, relieving pressure using positioning pillows, nutritional support, and care planning. Resident #25 had diagnoses of schizophrenia, pressure injuries, and chronic obstructive pulmonary disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #25 had a significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure a resident remained free of accident hazards. This was evident for 1 (Resident #44) of 5 residents reviewed for accidents. Specifically, Resident #44 was fed a mechanically altered diet by unqualified and unsupervised staff. The findings are: The facility policy titled Activities of Daily Living dated 4/2024 documented appropriate care and services will be provided for residents including support and assistance with dining. The facility policy titled Nutritional assessment dated 9/2024 documented as part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process to help define meaningful interventions for a resident at risk for or with impaired nutrition. The facility Job Description for Transport Aide documented the Transportation Aide was responsible for the safe and timely transportation of residents to and from…

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

Based on observation, interview, and record review conducted during the Recertification Survey from 1/6-1/14/2025, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 of 3 residents (Resident #46 and Resident #107) reviewed for Respiratory Care. Specifically, 1) Resident #46 was provided oxygen 3 liters via nasal cannula with a physician order for 2 liters; and 2) Resident #107 was provided oxygen 3 liters via nasal cannula with a physician order for oxygen 2 liters. In addition, the nasal cannula and humidified water bottle for Resident #107 was not dated. The Findings include: The Facility Policy titled Oxygen Administration updated July 2024 documented that the purpose is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Adjust the oxygen delivery device so that it is comfortable for the resident…

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

Based on interviews and review of the facility's records during the Recertification survey from 1/6/2025 through 1/14/2025, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, six of six randomly selected Certified Nurse Aides (#29, #30, #31, #32, #33, and #34) did not have a performance review documented at least once every 12 months. Findings include: Review of records provided by the facility on 1/7/2025 revealed Certified Nurse Aides #29, #30, #31, #32, #33, and #34 had been working at the facility for more than one year, their hire dates ranged from 2000 through 2018. During an interview on 1/7/2025 at 5:07 PM, the Human Resources/ Staffing Coordinator stated the Certified Nurse Aides' performance evaluations were not completed and they had a recent discussion with the Director of Nursing. During an interview on 1/08/25 at 11:00 AM, the Nurse Educator stated they conducted the mandatory in-services for the staff on the units and in the classroom. They stated the annual performance evaluations for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conduced during the Recertification survey from 1/6/2025 to 1/14/2025, the facility did not ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. This was evident for 1 (Resident #30) of 2 residents reviewed for Dementia Care and 1 (Resident #122) of 1 resident(s) reviewed for Activities. Specifically, 1) treatment of Resident #30's dementia and related behaviors did not include a person-centered individualized approach or meaningful activities to address the resident's customary routines and preferences, and 2) there was no evidence Resident #122's plan of care included meaningful activities that enhanced the resident's wellbeing. The findings are: The facility policy titled Dementia Care of Resident dated 2/2024 documented restlessness in people with dementia gets worse at the end of the day. Increase daytime activities,…

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 a Recertification survey from 1/6-[DATE], the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards, labeling, expiration date, and storage of medication at proper temperatures. Specifically, expired feedings, supplies, and test kits, open unlabeled medications, and a medication storage refrigerator temperature above the acceptable range, were found in one of one medication storage rooms (Second Floor Unit) examined for medication storage. The findings are: The Facility Policy titled Storage of Medication updated 12/2023 documented that drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During observations on [DATE] at 1:38 PM in the second floor unit medication storage room, the following…

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 on 1/6/2025 to 1/14/2025 the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. This was evident for 2 (Resident #69 and #25) of 5 residents reviewed for pressure injuries and 1 of 2 residents (Resident #121) reviewed for urinary tract infections. Specifically, 1) Resident #69 was on enhanced barrier precautions and a certified nurse aide was observed providing care without proper personal protective equipment; 2) Resident #121 had a history of urinary tract infections and their catheter bag was observed lying directly on the floor; and 3) the Wound Care Nurse did not perform handwashing or don a gown while performing wound care on Resident #25. Findings include: 1) Resident #69 was admitted with diagnoses including Diabetes Mellitus, Nutritional Anemia, and a Stage 3 pressure ulcer. The Minimum Data Set (an…

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

Based on record review and interviews conducted during a Recertification survey from 1/6/2025 to 1/14/2025, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide documentation as requested on 1/10/2025 of tracking antibiotic use which included appropriate use of antibiotics, results of laboratory tests and duration of antibiotic treatment for November 2024, December 2024, and January 2025. The findings are: The Policy on Antibiotic Stewardship updated in 2024 documented the purpose of Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C & S) is ordered laboratory results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. During an interview on 1/10/2025 at 1:08 PM, the Infection Control Preventionist stated it was their responsibility to track…

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

Based on observations, interviews and record reviews conducted during the Recertification survey 1/6/25 to 1/14/25 the facility did not maintain an effective pest control program so that the facility was free of pasts. Specifically, the facility kitchen was observed to have live and dead roaches. Findings are: The facility policy and procedure titled Pest Control updated December, 2024 documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a kitchen observation on 1/8/25 at 11:37 AM, with the Food Service Director, one live roach was crawling on the wall and one dead roach was found on the floor next to the kitchen tray line. During an interview on 1/8/25 at 11:39 AM Food Service Director stated that they could recognize a roach on the floor. They stated that the facility had bi-weekly pest control treatments. Review of the Pest Management Service Inspection Reports from 10/13/24 to 12/26/24 documented on 12/12/24 unable to service kitchen, kitchen was closed and locked, on 12/26/24 service observed…

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

Based on interviews and record review during the Recertification and abbreviated (NY00339429) surveys from 1/6-1/14/2025, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 30 residents reviewed for quality of care (Resident #107). Specifically, Resident #107 did not receive their eye drops as ordered by the physician after and prior to their cataract surgeries. Findings include: Resident #107 had diagnoses including Dry Eye Syndrome, Edema (swelling) of unspecified eye, and Diabetic Cataracts. The Quarterly Minimum Data Set (assessment tool) dated 10/25/24 documented the resident had intact cognition, moderately impaired vision, and no behaviors. A nursing note dated 4/1/24 at 1:13 PM, documented the resident would have cataract surgery on 4/10/24 on the right eye. Post operative orders included prednisolone drops 4 times a day for 4 weeks, then 3 times a day for 1 week, then 2 times a day for 1 week, then 1 time a day for 1 week. The first follow-up appointment was scheduled for 4/11/24. 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 an abbreviated survey (NY00339416), the facility did not ensure that for 1 (Resident #1) of 3 residents reviewed, all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury, to the Administrator of the facility and to other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction. Specifically, on 3/28/2024, the Director of Nursing and the Administrator were informed of an alleged abuse incidence that occurred between Resident #1 and the facility Podiatrist. There was no documented evidence that the incident was reported to the New York State Department of Health. Findings include: Review 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 record review and interview conducted during an abbreviated survey (NY00339416), the facility did not ensure that an allegation of abuse was thoroughly investigated for 1 (Resident #1) out of 3 residents reviewed for abuse. Specifically, on 3/28/2024 the Director of Nursing and the Administrator were informed of an alleged abuse incidence that occurred between Resident #1 and the facility Podiatrist. There was no documented evidence that an accident/incident report was completed, there was no documented skin assessment from the Registered Nurse, there was documented interviews of other residents seen by the Podiatrist on the day of the incident, and the complainant was not interviewed until the next day. Findings include: Review of the Accident/Incidents reporting policy and procedure dated 6/12/08 documented that the supervisor must be notified, and the licensed nurse complete the report documenting the facts. The licensed nurse will document in the nurses notes the facts and the sequence of events as…

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 an abbreviated survey (NY00339416), the facility did not ensure in accordance with accepted professional standards and practices that a resident's medical records was accurately completed and contained a record of the assessment performed for 1(Resident #1) of 3 residents reviewed. Specifically, on 3/28/2024, Resident #1 had an incident of alleged abuse during a podiatry toenail trimming consult overheard by staff (the Wound Doctor and the Registered Nurse Wound Care Nurse-Staff #4 and the Certified Nurse Aide-Staff #1). There was no documented assessment in the electronic medical record of Resident #1. Findings include: Review of the Accident/Incidents reporting policy and procedure dated 6/12/08 documented that the supervisor must be notified, and the licensed nurse complete the report documenting the facts. The licensed nurse will document in the nurses notes the facts and the sequence of events as they occurred. Resident #1 was admitted with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility provided pharmaceutical services to assure accurate acquiring, receiving and administration of medications to meet the needs of each resident. Specifically, 1. expired and undated and/or discontinued medications were found on 2 of 3 medication carts and in 1 of 1 medication rooms 2. 1 of 3 medication carts were not kept locked or under direct observation of authorized staff in an area where residents could access them and 3. A blister pack of medications for Resident #81 was left on the medication cart unattended in the hallway on the A unit. The findings are: 1. During an observation of the 2nd floor medication room on [DATE] at 11:02 AM an opened bottle of Vancomycin had a pharmacy date [DATE] and a pharmacy label indicating it had been prescribed for Resident #41, and dosage/instructions 50 mg/ml, 2.5 ml (125 mg) by mouth 6x daily for 3 days. There was no opened date 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 observations, interview and record review during the Recertification and Extended surveys from 09/13/2023 through 09/25/2023, the facility did not ensure each resident had the right to a dignified dining experience for 3 of 11 residents (Residents # 146, # 88, and # 89 ) Specifically, 1. Resident # 146 was served their meal 15 minutes after their tablemate's had received their meals, 2. Residents #88 and #89 were referred to as 'feeders' by the Assistant Director of Nursing (ADON) in the 3rd floor dining room in the presence of residents. Findings include: 1. Resident #146 was admitted to the facility with diagnoses including but not limited to Atrial Fibrillation, Coronary Artery Disease, and Malnutrition. The 8/27/2023 admission Minimum Data Set (MDS) documented Resident #146 had a Brief Interview of Mental Status (BIMS) score of 7/10 (severely impaired cognition), received supervision with eating, and had no functional limitation in range of motion. The 6/28/2023 activities of daily living (ADL) care plan interventions included supervision with set up help only. During…

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 a recertification survey the facility did not ensure a thorough and complete investigation was conducted for 1 of 6 residents (Residents #129) reviewed for accidents. Specifically an 8/26/2023 and 9/3/2023 xray reports revealed Resident # 129 had a healing humeral neck fracture and the facility did not ensure that an investigation into the fracture was completed to determine root cause. Findings include: The facility Accident-Occurrence Investigation policy and procedure with a revision date of 12/2022 documented the RN/Clinical Care Manager initiates occurrence investigation report, obtains statements from all staff, residents, visitors present at the time of the accident by the end of the shift, obtains statements until the determination can be made as to the time of the accident. Notifies the regulatroy agency regarding injuries of unknown origin Resident #129 was admitted with diagnoses including but not limited to Arthritis, Non Alzheimer Dementia, and Malnutrition. The 6/24/2023 Quarterly Minimum Data Set (MDS) documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey (9/13/2023-9/25/2023), the facility did not ensure it developed a discharge summary for 2 of 3 (Resident #156, #157) residents reviewed for discharge. Specifically, there was no evidence that discharge summaries which included a recapitulation of the residents' stay detailing the resident's clinical status, course of treatment, reconciliation of the residents' post discharge medications and post discharge needs, were completed to ensure a safe and effective transition of care. The findings are: Resident #156 was admitted with diagnoses including Hypertension, Paranoid Schizophrenia, and Cellulitis. The 7/5/2023 Minimum Data Set (MDS) documented the resident was cognitively impaired, had a Brief Interview for Mental Status (BIMS) score of 0/15 and required extensive assist with transferring, bed mobility, toileting and eating. Review of Resident #156's record revealed the resident was discharged [DATE] but there was no discharge…

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

Based on observations, interviews, and record reviews conducted during recertification and abbreviated surveys (NY 00323895) from 09/13/2023 through 09/25/2023 it was determined the facility did not ensure that the residents received treatment and care in accordance with professional standards of practice in order to meet the resident's physical, mental and psychosocial needs for one (Resident #129) of six residents reviewed for accidents, one (Resident #150) reviewed for medication error and/or storage, and one (Resident #119) of two residents reviewed for positioning and mobility. Specifically, 1. the facility did not ensure timely orthopedic follow-up for Resident # 129 after xray reports revealed a healing right humeral neck fracture and as per physiatrist recommendation, 2. Resident #150 was administered discontinued Lorazepam without a physician order, and 3. Resident #119 was not referred for a rehabilitation screen for wheelchair positioning despite multiple observations of their legs hanging off the side of their wheelchair footrest. Findings include 1. Resident # 129 was…

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

Based on observation, record review, and interview during the recertification survey conducted 9/13/2023-9/25/2023, the facility did not 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 1 of 7 residents (R) #9. Specifically, Resident #9 exhibited periods of worsening irritability and agitation, and had a physician order for a psychological evaluation that was not completed timely. Findings include: Resident # 9 was admitted to the facility with the following diagnoses Major Depressive Disorder Recurrent Mild, Anxiety Disorder, and Schizophrenia Unspecified. The 12/14/2022 Psychotropic Drug Use Care Plan documented the resident was noted to have the following diagnoses and corresponding medications: Schizophrenia: Quetiapine 100 mg tablet - give 1 tablet (100 mg) by oral route 2 times per day, Anxiety state: Buspirone 15 mg tablet 1 tablet by mouth 3 times a day, Depression: sertraline 100 mg tablet - give 1…

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

Based on record review, and interview conducted during the recertification survey and abbreviated survey (NY00323895) the facility did not ensure that each resident (Resident #150) reviewed for medication error and/or storage had a drug regime that was free of unnecessary medications. Specifically the issue involved the administration of and lack of a documented indication for the continued use of an as needed (PRN) antipsychotic medication without a physician order. Findings include Resident # 150 was admitted to the facility with diagnoses including but not limited to Hypertension, Seizure Disorder, and Malnutrition. The 8/12/2023 admission orders documented Lorazepam 0.5 mg 1 tab orally every 4 hours as needed (PRN) x 14 days. The 8/12/2023 psychotropic drug use interventions documented assess need for psychotropic medication, obtain psychiatry consult follow up as necessary and establish an appropriate medication use. The 8/15/2023 behavior symptoms care plan documented refer for psychiatry consult, notify and report changes in behavioral changes to the Medical Doctor (MD). The…

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

Based on observation, interview and record review conducted during the recertification survey completed on 9/25/2023 the facility did not ensure for 1 of 5 residents reviewed for food, (Resident # 77) received menu items and preferences listed on the meal tray tickets. Specifically, the preference to receive their meal tray early was not honored. Additionally, food and drink items listed on the meal tray ticket for Resident # 77 were not provided according to the resident's personal preference. The findings are: The resident was admitted with diagnoses including but not limited to Neuropathy, Osteoarthritis, and Chronic Urinary Retention. The 7/3/2023 Quarterly Minimum Data Set (MDS) documented Resident #77 was cognitively intact, required extensive assistance for eating and was on a therapeutic diet. The 2/6/2023 Nutrition Care Plan documented Resident #77 preferred their tray early, and received prune juice and milk shakes three times a day with meals During observation on 09/13/2023 at 1:20 PM the meal tray ticket documented no rice, and serve first, the resident's tray had rice…

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

Based on interviews and record review Recertification and Extended surveys from 09/13/2023 through 09/25/2023, the facility did not ensure that the facility wide assessment was updated annually to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The findings are: The Facility Assessment reviewed covered the period from 7/5/2021-7/5/2022. and revealed the last date the assessment was updated was 07/05/2021. The Facility Assessment reviewed covered the period from 7/5/2021-7/5/2022. During an interview with the Supervising Administrator on 09/25/2023 at 11:00 AM they stated that the Administrator was responsible for making sure the Facility Assessment was updated annually because it is an important tool which assesses the needs of the facility to care for the residents. The Supervising Administrator did not know why the Facility Assessment had not been updated in over a year. 415.26

Based on record review, and interviews conducted during the Recertification and Extended survey from 09/13/2023 through 09/25/2023, the facility did not ensure the they explicitly granted the resident or the residents representative the right to rescind the arbitration agreement within 30 calendar days of signing it for 3 (Resident #1, #211, and #212) of 3 sampled residents. Specifically, Resident #1, #211, and #212's Binding Arbitration Agreements were reviewed, and there was no documented evidence the agreements gave the resident and/or representative the right to rescind the agreement within 30 calendar days of signing the agreement. The findings are: The Facility admission Agreement with revision date 7/2018 for Residents #1, #211 and #212 in Arbitration Agreement. There was no documented evidence noting the resident and/or their representative were given an option to rescind the agreement within 30 days of signing the agreement. During an interview with the Director of Admissions 09/19/2023 at 02:05 PM, they stated Arbitration Agreements are optional, and they were responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the Recertification Survey, it was determined that for one resident (# 408) of two reviewed for urinary catheters, the facility did not ensure staff maintained and complied with infection control interventions to prevent the transmission and development of infection and disease. Specifically, the foley catheter tubing and foley catheter drainage bag for Resident #408 were observed touching the floor. The findings are: Review of the facility's policy, Urinary Catheter Care, effective 9/2019, and last reviewed 7/6/2023 documented its purpose was to prevent urinary tract infections and directed that staff review the resident's care plan to assess for any special needs of the resident, and that the catheter tubing and drainage bag are to be kept off the floor. Resident #408 was admitted with diagnoses including but not limited to Alzheimer's disease, Diabetes Mellitus Type 2, and Neurogenic bladder. The admission nursing assessment dated [DATE]…

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

Based on record review and interviews during the Recertification and Extended surveys from 09/13/2023 through 09/25/2023, the facility did not ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control prior to assuming the role. Specifically, the facility's designated IP, did not have documented evidence of having completed specialized training in infection prevention and control prior to 09/22/2023. The findings are: During the Entrance Conference on 9/13/2023 at 09:48 AM, the Director of Nursing (DON) identified the Infection Preventionist (IP). On 09/14/2023 at 02:00 PM, the Centers for Disease Control (CDC) Infection Preventionist Certificate was not provided on request. The Infection Preventionist's job offer letter documented they started work on 12/6/2022 and their job title was documented as Infection Control and was signed by the IP and the previous Administrator. The 12/2022 'Infection Control Nurse: job description' documented that the qualifications/specialized training of the infection preventionist are to have…

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.