Tolstoy Foundation Rehabilitation And Nrsg Center

Based on observations, record review and interviews conducted during the recertification and extended survey from 08/21/2025 to 09/02/2025, the facility did not ensure the labeling of medications in accordance with currently accepted principles and the facility did not ensure all drugs and biologicals were stored in a locked compartment. Specifically, 1) an open Insulin pen was found in a medication cart without an open date. The manufacturer recommendation is to date the insulin pen when opened. After opening the medication is considered viable for 28 days. 2) a medication cart was observed unattended and un-locked. Findings include:The Nursing/medication storage policy dated 01/24/ 2025, documented all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel.The Nursing/medication administration policy dated 10/2024, documented that it is the responsibility of the licensed professional nurse to be aware of the drugs classification, action, correct dosage, side effects, and any specific manufacturer recommendations.1)…

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

Based on observation, interview, and record review during a recertification survey the facility did not ensure they maintained an infection prevention and control program designed to provide a sanitary environment and to help prevent development and transmission of infection for two (2) of seven (7) residents reviewed for infection control. Specifically, (1) Certified Nurse Aide #26 was observed touching dresser drawers in Resident #65's room who was on contact precautions. Additionally, there was no contact precaution sign posted outside Resident #65's room and no personal protective equipment bin outside the room/garbage bin for discarding personal protective equipment by or inside the room (2) Certified Nurse Aide # 8 and Certified Nurse Aide # 4 did not wear a gown when providing incontinence care for Resident #23 who was on enhanced barrier precautions and (3) the facility did not ensure a complete infection surveillance plan was implemented for the identification, containment, and prevention of infection.The findings are: The undated policy and procedure titled “Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews during an abbreviated survey (NY00374955/724315, NY00364233/724313), the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, Resident #4, Resident #5) reviewed for care planning. Specifically, (1) Resident #1 was identified as a high risk for fall on admission and there was no documented evidence of a fall risk care plan being initiated. Resident #1 sustained a fall on 3/5/2025 when they attempted to self-transfer from the bed to a chair and slid down to the floor; (2) on 12/10/2024 Resident #4 reported that their roommate Resident #5 had hit them after they engaged in a verbal disagreement. Resident #4 stated Resident #5 rolled over to them in their wheelchair and struck them two times on their left chest/neck area. Resident #5's room was subsequently changed 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 record review and interviews during an abbreviated survey (NY00364233/724313), the facility did not ensure the resident right to be free from abuse for 1 of 3 residents (Resident #4) reviewed for abuse. Specifically, on 12/10/2024 Resident #4 reported that their roommate Resident #5 hit them during a verbal altercation. Resident #4 stated Resident #5 propelled their wheelchair over to their side of the room and struck them two times on their left chest/neck area.The findings are:The facility Abuse Prohibition Protocol policy last reviewed January 2024 documented all residents have the right to be free from physical and mental abuse. The facilities undated Assaultive Resident (Resident to Resident Altercation) policy documented the residents of the long-term care facility are protected from any physical and mental mistreatment from other residents. Resident to resident altercations is reported immediately to the charge nurse and supervisor. An individualized plan for monitoring resident behavior is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00347972) the facility did not ensure that the resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 1 out of 3 residents (Resident #3) reviewed for restraints. Specifically, on 7/10/2024 Resident #3 who was moderately cognitively impaired and needed moderate assistance for bed mobility was found in bed with their floor mats propped up against their bed and held in place with two wooden night tables preventing the resident moving out the bed. The investigation revealed Certified Nurse Aide #1 was responsible and that Certified Nurse Aide #1 believed that placing the mats that way will prevent Resident #3 from rolling out of bed. There was no documented physician need/order for restraints.The findings are:The facility Restraint-Free Environment policy last reviewed June 2021 documented the purpose is to ensure that Residents live in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00347972/724229, NY00364233/724313), the facility did not ensure an allegation involving abuse was reported immediately, but no later than two hours after the allegation is made if the events that cause the allegation involve abuse and to report the results of all investigations to the New York State Department of Health within 5 working days of the incident for 2 out of 3 residents (Resident #3, Resident #4) reviewed for abuse. Specifically, (1) on 7/10/2024 Resident #3 was found in bed with their floor mats propped up against their bed and held in place with two wooden night tables preventing the resident from exiting. The investigation revealed Certified Nurse Aide #1 who was responsible. The facility did not report the incident to the New York State Department of Health until 7/11/2024 and the 5-day investigative conclusion was not submitted to the New York State Department of Health until 7/17/2025; (2) on 12/10/2024 Resident #4 reported…

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 (NY00374955/724315), the facility did not ensure a thorough investigation was completed for 1 out of 3 residents (Resident #1) reviewed for falls. Specifically, on 3/5/2025 Resident #1 had a fall while attempting to transfer themself from the bed to a chair. The accident/incident report submitted by the facility was incomplete with no investigative summary and no staff statements were obtained. The findings are:The facility Accident/Incident Reports and Investigations policy last revised January 2024 documented an accident/incident report shall be initiated for any outward event at the time of that event. An investigation will be initiated to analyze the event in order to prevent reoccurrence. An outward event is considered any unusual circumstance that occurs involving the safety and well-being of a Resident, such as falls. Registered Nurses assess the situation and initiate the accident/incident form and investigation. An investigation includes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00370834/724309) the facility did not ensure the comprehensive care plan was reviewed, updated, and revised for 1 out of 3 residents reviewed (Resident #2) for care planning. Specifically, Resident #2 had a Stage 2 pressure ulcer to their sacrum and bilateral buttocks. The pressure ulcer worsened to a Stage 4 pressure ulcer. The actual skin impairment care plan had no documentation of the sacral pressure ulcer, measurements, treatments ordered and there were no updates of wound progression and physician findings when physician finding reports were submitted to the facility.The findings are:The facility Development and Implementation of Resident Care Plans policy last reviewed January 10, 2024 documented the purpose is to establish guidelines for the development, implementation, and review of individualized care plans for the residents to ensure high quality, person-centered care. The facility is committed to creating and maintaining…

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 (NY00374955), the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 out 3 residents (Resident #1) reviewed for pressure ulcers. Specifically, Resident #1 admitted to the facility on [DATE] was noted to have a Stage 2 pressure ulcer to their intergluteal medial cleft on their admission skin check. There was no documented evidence that the Physician was informed of Resident #1's Stage 2 pressure ulcer or of any treatments being ordered for the pressure ulcer. The findings are:The facility Prevention and Treatment of Pressure Ulcers policy last revised January 2024 documented it is the policy of the facility to prevent, care for, and provide treatment for decubiti. The Physician must be notified of any wounds or pressure ulcers at the time of assessment. Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00346485), the facility did not ensure residents were free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, on 6/26/2024 a visitor to the facility reported that while walking down the hallway they witnessed Certified Nurse Assistant #1 punching Resident #1 in their head, in the resident's room. Findings include: The facility abuse policy last revised January 2024 documented all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of their property. Physical abuse includes hitting, slapping, pinching, and kicking. A Quarterly Minimum Data Set, dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 00/15, associated with severe cognition impairment.re impairment, 08-12 moderate impairment and 13-15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00346485) , the facility did not ensure allegations of abuse were thoroughly investigated for 1 out of 3 (Resident #1) residents reviewed for abuse. Specifically, a visitor in the facility reported they witnessed Certified Nurse Assistant #1 punching Resident #1 in the head on 6/26/2024, there was no written statement obtained from Certified Nurse Assistant #1. There was also no documented evidence of Resident #1 being assessed by a Medical Physician, a Nurse Practitioner, or Registered Nursing staff. In addition, the residents Certified Nurse Assistant #1 cared for were not interviewed or assessed to rule out abuse. Findings include: The facility abuse policy last updated January 2024 documented that for the investigation of actual or suspected (including alleged) cases upon notification of abuse or potential abuse, the Director of Nursing/designee shall immediately commence an investigation including interviewing, with written, signed…

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

Based on record reviews and interviews during the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months. Specifically, performance appraisals were not documented every 12 months for 5 of 5 certified nurse aides (Staff #2, #4, #8, #10, #11) records reviewed. The findings are: On 06/04/24 at 11:11 AM during an interview with the Director of Human Resources, they stated that about one month ago, they started a project of updating performance appraisals for all employees and during the morning meeting, department heads were advised to complete performance appraisals. The Director of Human Resources stated the Nursing Department has not completed the performance appraisals for any nurse aides. On 6/4/24 at 11:15 AM, performance appraisals were requested from the Director of Human Resources. On 6/4/24 at 11:29 AM, the Director of Human Resources stated they could not find any recent performance appraisals for the selected nurse aides (Staff #2, #4, #8, #10, or #11). Facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey from 5/28/24-6/4/24, the facility did not properly establish and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) The facility did not ensure cleans linens were transported throughout facility in a clean manor, or that hand hygiene was practice after handling dirty linens. 2) The facility did not have a current Water Management Plan in place; 3) Contact Precautions were not implemented for a resident with Clostridium Difficile infection (Resident#280) and staff were observed breaching infection control precautions. The findings are: The facility policy and procedure titled Infection Control Program dated 1/10/2024, documented the Infection Control and Prevention program aims to provide a clean, safe environment for the patients, nursing staff, medical staff ancillary staff visitors and the surrounding community by monitoring, controlling and preventing…

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

Based on interview and record review during the recertification survey conducted 05/28/24-6/04/24, the facility did not ensure each staff was screened, offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 3 of 10 staff reviewed for COVID-19 vaccines. Specifically, there was no documented evidence of immunization records for Staff #13, #14, and #15. Findings include: During the recertification survey the facility was asked to provide the vaccination status for flu, pneumococcal and COVID-19 vaccines. There was no documented evidence the facility had documentation of screening, education offering or current COVID19 status. During an interview with the Assistant Director of Nursing on 6/4/24 at 11:37 AM they stated they have tried everything to get the staff to be on board with COVID-19 vaccinations, but most employees did not want the vaccine. They stated they got the vaccine records from Human Resources and reviewed them on hire but did not know what happened in this case and was not aware the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during a recertification survey from 5/28/24 through 6/4/24, the facility did not ensure residents had the right to a dignified experience for 2 of 9 residents (Residents #328, and #46) reviewed for dining. Specifically, certified nurse aides were observed standing over Residents #328 and #36 while assisting the residents with their meals. The findings include: The facility's policy titled: Resident Feeding Program revised January 2020. Stated the feeding program was designed to assist the residents to regain lost feeding skill ability, restore self-esteem and promote a higher level of physical, social, and emotional wellbeing. 1. Resident # 328 was admitted to the facility with diagnoses including dementia, Parkinson's disease, and aspiration pneumonia. The Minimum Data Set, dated [DATE] (an assessment tool) documented that Resident #328 had severely impaired cognition and required extensive assistance with eating. The nutrition care plan dated 5/24/24…

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 survey from [DATE] through [DATE], it was determined for 1 of 3 residents reviewed for advance directives, the facility did not ensure residents had the right to formulate advance directives. Specifically, there was no documented evidence that Resident #334 had a physician's order for advanced directives. The findings include: Resident #334 was admitted to the facility on [DATE] with diagnoses including anemia, malignant neoplasm of prostrate, and occlusion and stenosis precerebral arteries. The admission Minimum Data Set (resident assessment tool) dated [DATE] documented the resident had moderately impaired cognition. On [DATE] at 08:58 AM, a record review revealed Resident #334 had no advanced directives located in electric medical records and had no hard copy of medical orders for life sustaining treatment (MOLST). On [DATE] at 9:22 AM during an interview, Staff #1 (Registered Nurse Unit Supervisor) stated Resident #334 did not have any…

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 the recertification and abbreviated surveys (#NY00341484) from 5/28/24 to 6/4/24, the facility did not ensure an allegation of abuse was reported to the New York State Department of Health within 2 hours of becoming aware of the allegation for 1 (Resident #70) of 2 residents reviewed for abuse. Specifically, the facility did not ensure an allegation of sexual abuse involving Resident #70 was reported within 2 hours of becoming aware of the allegation on 5/6/24 and was not reported until 5/7/24. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis, cerebrovascular accident, dementia reflux and hypertension. The resident's Minimum Data Set (an assessment tool) dated 3/18/24 documented the resident had intact cognition and was dependent on staff for Activities of Daily Living, ambulated with supervision and was incontinent of bowel and bladder. An Incident and Accident report dated 5/7/24 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 conducted during the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 2 of 3 residents (Residents #18 and #24) reviewed for hospitalization. Specifically, Resident #18 and Resident #24 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident representatives and that notification was sent to the Ombudsman. Findings include: The facility policy, 'Notice of Discharge / Transfer', revised February 2018 documented that the facility must issue a valid Notice of Discharge/Transfer to any resident prior to discharge for any reason and to their designated representative, family and/or legal representative and ombudsman. 1. Resident #18…

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 the recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that residents or resident's representatives were notified in writing of the facility policy for bed hold for 2 of 3 residents (Residents #18 and #24) reviewed for hospitalization. Specifically, the residents were transferred to the hospital and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the residents or their representatives. The findings are: Resident #18 was admitted with diagnoses which included diabetes mellitus, chronic kidney disease stage 3, and protein calorie malnutrition. The Minimum Data Set Significant Change (resident assessment tool) dated 2/19/24 documented Resident #18 had intact cognition. The Minimum Data Set discharge date d 3/19/24 documented discharge, return anticipated. The Nurse's notes dated 3/19/24 documented Resident #18 was transferred to the hospital and was admitted . Documentation could not…

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 from 5/28/24 through 6/4/24, the facility did not ensure the Minimum Data Set 3.0 comprehensive assessment was completed in a timely manner. Specifically, for 1 of 1 resident (Resident #30), the Minimum Data Set admission assessment was not completed within 14 calendar days from admission and/or by the required Assessment Reference Date. The findings include: The facility policy, 'Policy for Minimum Data Set (MDS) Completion' revised January 2024, documented the Resident Assessment Instrument (RAI) is used, in accordance with federal and state regulations for ensuring optimal care planning and quality of the resident's care. In addition, the assessment coordinator is responsible for ensuring the Interdisciplinary Team complete timely residents' assessments and reviews in accordance with CMS RAI Version 3.0 Manual, Chapter 2 assessment schedules: 1. admission within 14 days of residents' admission to the facility. 2. Quarterly…

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 from 5/28/24 to 6/4/24, the facility did not ensure that each resident's screen for a mental disorder or intellectual disability was signed and included the required digital ID. This was evident for 3 of 25 residents reviewed. Specially, Residents #18, #35 and #46 did not have the required signatures and digital IDs documented on their pre-admission screening and resident review assessment prior to their admission to the facility. The findings are: The facility policy,' Pre-admission Screen & Annual Resident Review (PASRR)' dated January 2024 documented that all Residents must have a PASRR Screen upon admission to the facility and thereafter when there is a significant change that has a bearing on the Resident's specialized service needs. The screen assesses Residents for mental illness, dementia and mental retardation. 1. Resident #18 was admitted with diagnoses which included diabetes mellitus, chronic kidney disease stage 3, and protein calorie malnutrition. Resident #18 electronic medical record…

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 from 5/28/24 to 6/4/24, it was determined for 1 of 6 residents (Resident #280) reviewed for Pressure Ulcers, the facility did not ensure a Baseline Care Plan was developed and implemented for a newly admitted resident that included the instructions needed to provide effective care within 48 hours of a resident's admission and that a summary of the Baseline Care Plan was provided to the resident. Specifically, Resident #280's baseline care plan was not developed. Findings include: The facility policy and procedure Resident's Baseline Care Plan revised January 2024 documented it is the policy of the facility to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and to comply with CMS regulations F483.21(a). Resident #280 was admitted with diagnoses which included Pressure Ulcer of Sacral Region Unstageable, Local Infection of the Skin…

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 from 5/28/24 to 6/4/24, 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 was the Assistant Director of Nursing and did not have documented evidence of completed specialized training in infection prevention and control until 05/29/24. The findings are: During the annual survey Entrance Conference on 5/28/24, the Assistant Director of Nursing (DON) was identified as the Infection Preventionist but did not present a certificate of course completion until 5/29/24. Upon review, the Infection Preventionist had 5 outstanding modules to complete in the program including Antibiotic Stewardship and Occupational Health. During an interview with the Infection Preventionist on 6/4/24 at 11:37 AM they stated they had been in the role since the March 2024 but did not finish the Centers for Disease Control training course. They finished the course and presented the certificate…

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

Based on record reviews and interviews conducted during a recertification survey from 5/28/24 to 6/4/24, the facility did not ensure that the certified nurse aides were provided the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 2 of 5 certified nurse aides (Staff # 8 and #11), reviewed for Nurse Aide training, were provided 12 hours of mandatory training. The findings are: On 6/4/24 at 11:41 AM during an interview with the MDS Nurse/Staff Educator, they stated they are responsible for documentation of the nurse aide mandatory in-services. On 6/4/24 at 11:45 AM, nurse aide mandatory in-service documentation was requested from the MDS Nurse/Staff Educator. Review of the facility annual in-service training records revealed that the training documentation for Staff #8 and Staff #11 could not be located. On 6/4/24 at 12:13 PM, the MDS Nurse/Staff Educator stated they could not locate the 'Mandatory In-Service Sign-Off Sheets 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 record reviews and interviews during the recertification and abbreviated surveys(NY00308566) from 5/28/24 to 6/4/24, the facility did not ensure that a resident's representative was immediately notified of the presence of an unstageable sacral pressure ulcer. This was evident for 1 of 6 residents (Resident #229) reviewed for pressure ulcers. Specifically, Resident #229's representative was not made aware the resident developed a pressure ulcer in the facility. Findings include: Resident #229 was admitted with diagnoses which included urinary tract infection, metabolic encephalopathy, and a history of brain tumor. The admission Minimum Date Set ( an assessment tool) dated 10/31/22, documented modified independence for decision making. The resident required limited assistance with eating, and was dependent with all other areas of activities of daily living. No pressure ulcer was documented on the admission assessment. A review of the Care Plan, Potential for Skin Breakdown dated 11/8/2022, documented an intervention to inform resident/family of any new areas of skin…

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.

3. Resident #70 was admitted to the facility with diagnoses which included amyotrophic lateral sclerosis (nervous system disease), cerebrovascular accident, and dementia. The resident's Minimum Data Set (an assessment tool) dated 3/18/24 documented the resident has intact cognition and is dependent on staff for Activities of Daily Living, ambulates with supervision and is incontinent of bowel and bladder. An Incident and Accident (I&A) report dated 5/7/24 documented the facility Administrator visited the resident on 5/6/24 to encourage them to take a shower. The resident informed the Administrator that They were not taking any more showers because the last time three women pulled off my clothes and dragged me down the hallway naked to take a shower. One of the women squeezed my genitals in the shower 12 times. Resident #70 electronic medical record did not document a plan of care with resident centered goals and interventions to address the resident's activities of daily living which would include showers, dressing and eating. Additionally, there was no plan of care in Resident #70…

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, the facility did not ensure that the residents' call bell system was functioning to enable residents to call for assistance if needed, or for anyone to use in case of an emergency. Specifically, during environmental rounds, 4 of 4 residents (Residents #31, #34, #48, and #78) occupied rooms and bathrooms call bells were observed in non-functioning status. Additionally, one emergency bathroom call bell was partially detached from the wall. The findings are: The facility's Policy/Procedure regarding call light, revised 5/2021, indicated licensed nurse and nursing assistant are responsible for the call light system. The purpose included prompt response to a resident's call for assistance and to assure resident's bedside, and bathroom call light system is in proper working order. Further instructions in the Policy stated that all nursing personnel must be aware of call lights at all times. All call lights must be answered…

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 F582 Based on the interview and record review conducted during the Recertification and Abbreviated Survey, the facility did not ensure that the beneficiary protection notice was reviewed with all residents and/or resident representatives. Specifically, there was no documented evidence that a beneficiary protection notice had been reviewed with 1 of 3 resident/representative reviewed for Advance Directives (Resident # 33). Resident #33 was admitted to facility 3/02/2021 with diagnoses including but not limited to Dementia and Depression. Resident # 33 was discharged [DATE], The resident had a (Brief Interview of Mental Status) BIMS score of 07/10 (severe cognitive impairment) Review of the resident record revealed the facility did not have a signed beneficiary protection notice to indicate it had been given to and/or reviewed with the resident and/or representative. An interview on 06/15/21 at 12:30 PM Social Worker #1 (SW) stated when a resident is taken off skilled services, an occupational therapist, physical…

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, the facility did not ensure that an injury of unknown origin was investigated. Specifically, Resident #30 was observed with ecchymosis to the left cheek. Record review revealed that Nursing was aware of the ecchymosis, and the ecchymosis was not investigated to ascertain the cause of the injury and/or prevent potential abuse. The findings are: An undated facility policy and procedure titled Accident/Incident Reports and Investigations documented that an Accident/Incident Report shall be initiated for any untoward event at the time of that event. An investigation will be initiated to determine if abuse, neglect, or mistreatment can be ruled out, and to analyze the event in order to prevent recurrence. An untoward event is considered any unusual circumstance that occurs involving the safety and well-being of a Resident. Examples of untoward events included Injury of unknown origin. Procedures included: the Registered Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that person-centered care plans with measurable goals and interventions were developed for a resident who is dependant on oxygen therapy and for a resident with skin bruising issues. Specifically; (1) One resident (Resident #31) reviewed for respiratory care, Actual Impaired Oxygen Care Plan was initiated for conditions such Shortness of Breath (SOB), and Chronic Obstructive Pulmonary Disease (COPD). The care plan had no measurable goals and interventions to address the resident's respiratory needs; and (2) One of 3 Residents (Resident #48) reviewed for skin conditions had no skin care plan in place to address the resident's skin bruising issues. The findings are: 1. Resident #31 is an [AGE] year-old who was initially admitted to the facility on [DATE]. Diagnoses included but not limited to Dementia, Shortness of Breath (SOB), Chronic Obstructive Pulmonary Disease (COPD) and Anxiety. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that each resident's person-centered Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's current health status. This was evident for 1 of 5 residents (#30) reviewed for Accidents. Specifically, Resident #30 was identified with ecchymoses to the left cheek and the Incident/Accident care plan was not reviewed and revised to address this change in skin status and new interventions to protect from further ecchymoses. The findings are: Resident #30 was on admitted on [DATE] with diagnoses including but not limited to acute upper respiratory infection, urinary tract infection, and Alzheimer's disease. An annual Minimum Data Set (MDS: a resident assessment and screening tool) dated 6/12/2020 documented the resident had severely impaired cognition for decision making, was dependent upon staff with assist of one staff for all activities of daily living (ADL's), had active…

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, the facility did not ensure that medications and biologicals were stored and labeled according to current acceptable professional standard of practice regarding storage of multi-dose insulin injection, and the recommended refrigerator temperature range. Specifically, (1) An unopened multi-dose Aspart Flex Pen Insulin (Novolog Flex Pen Insulin) assigned to Resident #26 was observed in a medication cart without a pharmacy dispensed date or instructions; (2) The above multi-dose Aspart Flex Pen Insulin for Resident #26 and a multi-dose Lantus Solostar Insulin Pen for Resident #36 were stored together in a plastic bag in the same medication cart; (3) The medication refrigerator temperature was not maintained at the proper recommended temperature range between 36 to 46 degrees Fahrenheit (F); (4) Four multi-dose Novolin 70/30 Flex pen Insulin and four Bydureon BCise Non- Insulin injection assigned to Resident #3, three…

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, the facility did not ensure that facility staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) Hand hygiene was not observed for 4 of 4 residents (Residents #26, #9, #54, and #47) randomly observed during a lunch meal observation; (2) Cross contamination of wounds and wound supplies, was observed; and (3) Removal of soiled gloves and hand hygiene were not observed during wound care procedures for 3 of 4 residents (Residents #31, #34 and #38) reviewed for pressure ulcer. This was evident on one of two units (Lower Level). The findings are: 1. During a lunch meal observation on the on 6/8/2021 at 12:13 PM, Certified Nursing Assistance (CNA #1) was observed with bare hands transporting and repositioning Resident #26, in his/her wheelchair, in the resident's room, for preparation of the resident's lunch meal. CNA #1 bare hands touched 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.