East Side Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a survey, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (1) (third floor) of three (3) resident use floors. Specifically, ceiling tiles were stained and there was evidence of roof leaks in resident rooms and common areas. This involved Resident #84. The finding is: The policy titled Resident Rights dated 12/19/2022, documented that the facility shall protect and promote the rights of each resident. The policy documented resident rights shall include, but not be limited to, the resident's right to a dignified existence, self-determination, and be treated in a respectful manner that supports his/her dignity in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life.During an interview and observation on 01/27/2026 at 12:58 PM, Resident #84 stated their ceiling leaks and the window leaks; it 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 observations, interviews and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #80) of three (3) residents reviewed for skin conditions. Specifically, Resident #80's arterial ulcer treatment was not completed in accordance with the physician's order. Additionally, there was no documented evidence that a provider was notified Resident #80 was refusing the ordered treatment or it was not being completed as ordered between 01/23/2026- 01/27/2026.The findings are: The policy titled Wound Treatment dated 12/19/2022 documented all residents requiring wound care should receive treatment by a licensed nurse and dressings should be changed per the physician order and documented on the Treatment Administration Record. Resident #80 had diagnoses that included a history of osteomyelitis (infection in a bone), arterial ulcers (painful deep wounds), and dementia. The Minimum Data Set (a resident assessment tool) dated 12/04/2025…

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 survey, the facility did not ensure each resident received food prepared in a form designed to meet individual needs for one (1) (Resident #43) of three (3) residents reviewed. Specifically, Resident #43 was ordered a mechanically altered diet (a diet that consists of easy to chew and swallow foods) of ground meat and was not provided ground consistency meat during a meal observation. The finding is: The policy titled Tray Pass, dated 12/19/2022, documented the purpose of the policy was to ensure residents receive the correct meals safely, timely and in accordance with the physician diet orders. The meal trays were to be checked against the diet roster prior to delivery. Nursing or designated staff verify resident identity and correct diet at the time of tray pass. The policy documented any incorrect trays are addressed immediately and report to dietary and nursing. The policy titled Altered Diets, dated 12/19/2022, documented that residents who require mechanically altered diet will receive meals modified in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Standard Survey completed on 11/20/23, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for two (Residents #8 and #26) of 2 residents reviewed. Specifically, residents were not provided a choice to take a tub bath because there was not a functioning tub bath in the facility. The findings are: The facility's policy and procedure (P&P) titled Resident Preference and Care Planning and Care Area Assessments - C.A.A. dated 10/3/17 documented all residents will have an interdisciplinary care plan developed that shall include measurable goals and timetables to meet each individual's medical, physical, mental, and psychosocial needs as well as review and implement resident wishes/choices and goals. The facility's P&P titled Comprehensive Care Plan dated 12/19/22 documented the resident has the right to participate in the development 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 interviews and record reviews conducted during a Recertification Survey completed 11/20/23, the facility did not ensure they consulted with the resident's physician when medications were not administered as ordered for one (Resident #4) of two residents reviewed for notification. Specifically, the physician was not notified when the resident's insulin was being administered late multiple days on the evening shift. The findings are: The policy and procedure Medication Administration - General dated 10/29/12 documented all medications must be given at the right time and signed for after administration on the Medication Administration Record (MAR). 1.Resident #4 had diagnoses including diabetes mellitus type II, transient cerebral ischemic attack (TIA, temporary impairment of blood flow to the brain), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 8/14/23, documented Resident #4 was cognitively intact and received insulin injections. Resident #4's physician orders dated 9/26/23 documented Levemir (insulin) FlexPen inject 28 units subcutaneous (SQ)…

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 Standard survey completed 11/20/23, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #72) of three residents reviewed for ADLs. Specifically, Resident #72 was observed with long dirty (dark debris) fingernails, had unkempt facial hair, and was not shaved or offered to be shaved during morning care. The finding is: The policy and procedure (P&P) titled Shaving Residents - Male and Female dated 11/14/11 documented it shall be the policy of this facility that residents shall have facial hair removed on a regular basis and/or per their request. The P&P titled Nail Care - Routine and Diabetic dated 2/14/13 documented it shall be the policy of this facility that resident nails will be kept neat, clean, and smooth to assist in injury prevention and to maintain proper hygiene. The P&P titled AM…

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 a complaint investigation (#NY00315321) completed on 8/2/23, the facility did not ensure residents had the right to be free from sexual abuse for one (Resident #1) of four residents reviewed. Specifically, the facility did not ensure Resident #2 did not engage in non-consensual sexual contact with Resident #1. The finding is: The policy and procedure (P&P) titled Resident Abuse Prohibition revised on 3/1/18, documented sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. 1. Resident #1 had diagnoses that included depression, anxiety, and diabetes mellitus (high blood sugar levels). The Minimum Data Set (MDS - a resident assessment tool) dated 3/18/23 documented Resident #1 was understood, understands, and had moderate cognitive impairment. During an observation/interview on 8/2/23 at 10:19 AM, Resident #1 was well-kempt with a guarded, flat affect. Resident #1 stated they felt safe at the facility. The undated Facility Investigation and Findings documented that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review completed during the Standard survey completed on 1/28/22, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury for three (Resident #4, #34, #226) of seven residents reviewed for alleged abuse. Specifically, a bruise of unknown origin (Resident #226) and an allegation of resident-to-resident abuse (Resident #4 and #34) were not reported to the New York State Department of Health (NYSDOH) within the two-hour timeframe as required. The findings are: The facility policy and procedure (P&P) titled Resident Abuse Prohibition revised 3/1/18 documented to prohibit resident abuse. Upon the receipt of a complaint, if there is reasonable case to believe abuse has occurred, Administration will 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 interview and record review conducted during the Standard Survey completed on 1/28/22, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #226) of seven residents reviewed for abuse. Specifically, there was a lack of a thorough investigation to include the previous shifts staff members statements according to facility practices to rule out abuse, neglect or mistreatment when a bruise of unknown origin was identified above the resident's right eyebrow. The finding is: Review of a facility policy and procedure (P&P) titled Accident/Incidents revised date 7/31/2017 documented, all accidents, potential accidents, incidents, reported abuse, suspected abuse, unexplained bruising shall be investigated and reported to the administration as indicated (see P&P Abuse Prohibition). The supervisor needs to immediately start an investigation as to what happened and the cause, making sure all staff scheduled on the unit complete the staff observation sheet. The supervisor will also fill out…

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 Standard survey completed on 1/28/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, one (Resident #36) of one resident reviewed for quality of care of prosthetic eye did not receive eye care as ordered by the physician and was inaccurately documented in the treatment record. The facility policy and procedure (P&P) titled Maintenance of Prosthetic Eye dated 2/4/21 documented that routine cleaning of prosthetic eye is to be performed in effort to maintain comfort, reduce secretions, extended life of prosthetic eye and aide in the prevention of conjunctivitis (eye infection). Any licensed nursing staff is able to perform maintenance of prosthetic eye. All residents possessing a prosthetic eye shall have it removed, cleansed and inserted once monthly unless otherwise specified by a doctor. Equipment included: Sterile water, clean gloves, baby shampoo, prosthetic eye suction…

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 Standard survey completed on 1/28/22, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three, (Resident #47, #56, & #224) of four residents observed for pressure ulcers. Specifically, there was a lack of treatment initiation for residents with pressure ulcers (#47, #224), treatments were not completed as recommended by the Wound Consultant Physician (#56), a wound culture was not obtained as ordered (#224), and pressure reducing devices were not provided as recommended by the Wound Consultant Physician (Resident #56 & 224). The findings are: The facility policy and procedure (P&P) titled Pressure Ulcer Prevention and Treatment Protocol revised July 2013 documented any resident entering the facility without pressure ulcers will remain free from pressure…

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 conducted during a Standard survey completed on 1/28/22, it was determined that the facility did not arrange for the provision for physician services 24 hours a day, in case of emergency. Specifically, one (Resident #124) of one resident reviewed for hospitalization the facility did not ensure the provider responded promptly to notification for resident with critically high and high laboratory values. The finding is: 1. Resident #124 had diagnoses of dementia, aphasia (the inability to communicate) and chronic kidney disease. The Minimum Data Set (MDS - a resident assessment tool) dated 10/17/21 documented Resident #124 was moderately cognitively impaired, understands and was understood. An undated facility document titled Team Health documented that staff are to call the on call medical provider between the hours of 8:00 AM and 5:00 PM and to use option #2 unless it is a code situation then staff are to press option #1. Additionally, staff are to contact the Medical Director after hours. A review of chronological nursing progress notes 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.