East Neck Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00339563) initiated on [DATE] and completed on [DATE], the facility did not ensure each resident transferred to the hospital and discharged from the facility had documentation in the medical record of the attempts made by the facility to meet the needs of the resident before the resident was discharged to the hospital. This was identified for one (Resident #413) of three residents reviewed for death and the facility did not ensure each resident had documentation from a Physician of the necessity to transfer or discharge the resident. This was identified for two (Resident #413 and #414) of three residents reviewed for death. Specifically, Resident #413 suffered a cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping) in the facility and attempts of cardiopulmonary resuscitation and the use of an automated external defibrillator were not documented in the resident's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical and nursing needs was implemented as identified in the comprehensive assessment. This was identified for one (Resident #71) of five residents reviewed for Respiratory Care. Specifically, Resident #71 had a physician's order to drain fluids from the abdominal cavity on the 7:00 PM - 7:00 AM shift via a Peritoneal (abdominal) Pleurex catheter (a thin, flexible tube that is inserted into the abdominal cavity to drain fluid) due to the diagnosis of Ascitis (a condition where fluid builds up in the abdomen between the lining of the abdomen and the abdominal organs). A review of the resident's medical record from 7/1/2024 to 7/12/2024 and from 8/1/2024 to 8/3/2024 revealed no documented evidence that the abdominal fluid was drained as per…

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 during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #116) of two residents reviewed for Communication. Specifically, Resident #116's comprehensive care plan for Communication documented that the resident was hard of hearing in the left ear. The comprehensive care plan was not updated to indicate the resident used a hearing aid and preferred keeping the hearing aid at the bedside. The finding is: The facility's policy titled Care Planning Process, effective 7/2022 documented the facility shall have a care planning process that is person-centered, which includes integrating assessment findings in care planning, providing services to attain or maintain the resident's highest physical, mental, and psychosocial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #5) of five residents reviewed for pressure ulcers and one (Resident #132) of two residents reviewed for activities of daily living. Specifically, 1) on 8/7/2024, Resident #5's fingernails on both hands were observed to be long and dirty, with a brown substance under the nails and 2) on 8/2/2024, Resident #132's right palm was observed with dark crusty flakes and a musty odor was detected coming from their right hand. The findings are: The facility's policy titled Activities of Daily Living, effective 11/2018, documented the facility will provide the necessary care and services based on the comprehensive assessment of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) The facility's policy and procedure titled, Air Mattress last revised in 10/2023 documented that the selection of the air mattress will be based on the individual's specific needs, including mobility levels, weight, and any pre-existing medical condition. The Wound Care Coordinator will conduct a monthly audit of the resident's weight and assessment of the staff's knowledge of operating the equipment. The operation manual for the low air loss alternating pressure relief air mattress documented instructions that included determining the patient's weight and setting the control knob to that weight setting on the control unit. -Resident #94 was admitted with diagnoses including End Stage Renal Disease, Acute Respiratory Failure, and Type 2 Diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #94 had moderately impaired cognition. Resident #94 had one Stage 4 (defined as full-thickness tissue loss with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00333364) initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease of range of motion. This was identified for one (Resident #132) of three residents reviewed for positioning and mobility. Specifically, Resident #132 had a physician's order for right hand Therapy Carrot (a nonsurgical device that helps position contracted hands) to be worn at all times. On 8/1/2024 and 8/2/2024 the resident was observed not wearing the right-hand Therapy Carrot as ordered by the Physician. The finding is: The facility's policy for Application and Management of Splint/Brace/Immobilizer dated 11/2017 documented the nursing staff is responsible for following the wearing schedule for the device and must complete a skin inspection every shift at a minimum unless ordered otherwise.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews during the Recertification Survey initiated on 8/01/2024 and completed on 8/08/2024, the facility did not ensure that each resident's receives adequate supervision and the resident's environment remained as free of accident hazards as possible to prevent accidents. This was identified for one (Resident #28) of seven residents reviewed for accidents. Specifically, Resident #28 was observed on 8/1/2024 with an Albuterol inhaler on their overbed table. There was no staff present in the vicinity. Additionally, Resident #28 did not have a physician's order for the use of the Albuterol inhaler or an order to self-administer medications. The finding is: Resident #28 was admitted to the facility with diagnoses including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #28 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 8/01/2024, and completed on 8/08/2024 the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for two (Resident #42 and Resident #71) of five residents reviewed for Respiratory Care. Specifically, 1) Resident #42 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 and 8/7/2024. 2) Resident #71 had a physician's order for oxygen to be administered at 2 liters per minute via a nasal cannula. The resident was observed receiving an inaccurate amount of oxygen on 8/1/2024 at 10:30 AM and 2:34 PM. This is a repeat deficiency. The findings are: The facility's policy titled Oxygen Therapy dated 6/2017, documented the physician's order specifies the concentration, type, and duration of the (oxygen)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not ensure that outside professional services were furnished timely. This was identified for one (Resident #222) of one resident reviewed for Dignity and for one (Resident #150) of five residents reviewed for Unnecessary Medications. Specifically, 1) Resident #222 was readmitted from the hospital on 7/13/2024 with a diagnosis of Traumatic Subarachnoid Hematoma (brain bleed). The hospital discharging physician recommended a follow-up with a Neurosurgeon within a week. The recommended consult was not completed as of 8/7/2024 when it was brought to the facility's attention by the Surveyor. 2) Resident #150 was admitted to the facility in November 2023. A physician's order dated 11/14/2023 documented that the resident was to be seen by the Psychiatrist for the Initial Evaluation. The Psychiatry consult/evaluation was not completed until 8/6/2024 when it was brought to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024, the facility did not ensure medical records for each resident were complete and accurately documented. This was identified for one (Resident #90) of three residents reviewed for Choices. Specifically, Resident #90 had a physician's order for a finger stick blood glucose monitoring every morning. The Medication Administration Record did not include the finger stick blood glucose level results and the Vital Signs record had inconsistent documentation of the finger stick blood glucose level results. The finding is: The policy titled Blood Glucose Monitoring dated 7/2013 documented findings (of finger stick blood glucose levels) shall be documented in the medical chart. Resident #90 was admitted with diagnoses including Spinal Stenosis, Dementia, and Type two Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score…

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 during the Recertification Survey initiated on 8/1/2024 and completed on 8/8/2024 the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infections was maintained. This was identified for one (Resident #6) of five residents reviewed for Pressure Ulcers. Specifically, during a dressing change observation of Resident #6's sacral wound, Registered Nurse #15 did not change their gloves and did not wash their hands after cleansing the sacral wound and before applying the treatment. The finding is: The facility's Hand Washing Protocol dated 11/2017 documented to perform hand hygiene before and after each resident/patient contact. The facility's Clean Dressing Change policy and procedure dated 5/2024 documented to cleanse the wound while maintaining an aseptic technique, pat dry with a clean gauze, and then perform hand hygiene. [NAME] (put on) clean gloves before applying a dressing 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 observations, interviews, and record review during the recertification Survey and Abbreviated Survey (NY 00332930) initiated on 8/01/2024 and completed on 8/08/2024, the facility did not provide a safe, functional, sanitary, and comfortable environment. This was identified for two (Resident #131, Resident #5) of three residents reviewed for Environment. Specifically, the toilets that were mounted to the walls in Resident #131 and Resident #5's bathroom did not have appropriate support and reinforcement. The toilets were observed with wooden blocks underneath the toilet to provide support and reinforcement. The findings are: The facility policy titled Room and Unit Maintenance dated 9/2021 documented to maintain rooms and units within the facility in a manner that provides a safe, homelike environment. -Resident #131 was admitted with diagnoses of Morbid Obesity, Type Two Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00292215) initiated on 12/12/2022 and completed on 12/16/2022, the facility did not develop and implement a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This was identified for one (Resident #399) of one resident reviewed for Tube Feeding. Specifically, Resident #399 was admitted to the facility on [DATE] and the baseline care plan developed for the Gastrostomy (G) tube did not include use of an abdominal binder. A baseline care plan for the use of the abdominal binder was not developed until 3/3/2022. The finding is: The policy titled: Baseline Care Plan, effective date 11/2016, documented that the facility will develop and implement a baseline care plan within 48 hours of a resident's admission, which include, but is not limited to,…

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 initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was identified for one (Resident #105) of three residents reviewed for Choices. Specifically, Resident #105 had documented Physician's Orders on 6/6/2022, 8/16/2022, and 10/22/2022 to have a bilateral breast mammogram which was never completed. The finding is: The facility's policy titled: Laboratory, Radiology and Other Diagnostic Services, last revised in August 2018, documented to provide, or obtain radiology and other diagnostic services only when ordered by a medical provider. Resident #105 has diagnoses which include Peripheral Vascular Disease and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) The facility policy entitled, Laboratory, Radiology and other diagnostic services, dated 8/2018 documented that the facility will provide radiology services only when ordered by a medical provider. The licensed nurse must ensure to pick up orders made by the Physician/Physician extenders. A stat order must be transcribed as soon as the nurse is made aware of the request. The licensed nurse will ensure to properly fill out the requisition form and must call the appropriate service provider immediately. A follow up call must be made by the licensed nurse to the appropriate service provider to ensure that stat order was received and acknowledged. The licensed nurse must document in the medical record any communication made with the appropriate provider. Resident #186 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #186 had a Brief Interview for Mental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that a resident who needs respiratory care, is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #57) of four residents reviewed for Respiratory Care. Specifically, Resident #57 had a diagnosis of Chronic Obstructive Pulmonary Disease and was observed receiving four liters of oxygen via a nasal cannula without a Physician's order. The finding is: Resident #57 was admitted with diagnoses that include Pneumonia, Chronic Obstructive Pulmonary Disease and Congested Heart Failure. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident had no behavioral symptoms. The MDS documented the resident received oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that Radiology services to meet the resident's needs were provided timely as ordered by a Physician. This was identified for one (Resident #105) of three residents reviewed for Choices. Specifically, 1) Resident #105 had documented Physician's Orders dated 6/6/2022, 8/16/2022, and 10/22/2022 to have a bilateral breast mammogram which was never completed; and 2) as a result of the mammogram not being completed, a Physician's order for bilateral breast ultrasound due to breast pain and to rule out breast mass was obtained on 10/27/2022. The bilateral breast ultrasound was not performed until 5 days later on 11/1/2022. The findings are: The facility's policy titled: Laboratory, Radiology and Other Diagnostic Services, last revised on August 2018, documented to provide or obtain radiology and other diagnostic services only when ordered by a medical provider.…

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 the Recertification Survey initiated on 12/12/2022 and completed on 12/16/2022, the facility did not ensure that radiology services were obtained only when ordered by a Physician, Physician Assistant, or Nurse Practitioner. This was identified for one (Resident #186) of six residents reviewed for respiratory care. Specifically, Resident #186 received radiology services of an abdominal and chest x-ray without a Physician/Physician Assistant/Nurse Practitioner's order. The finding is: The facility policy entitled Laboratory, Radiology, and other diagnostic services dated 8/2018 documented that the facility will provide radiology services only when ordered by a medical provider. The licensed nurse must ensure to pick up orders made by the Physician/Physician extenders. A stat order must be transcribed as soon as the nurse is made aware of the request. The licensed nurse will ensure to properly fill out the requisition form and must call the appropriate service provider…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification initiated on 12/12/2022 and completed on 12/16/22 the facility failed to maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and COVID-19 infection. This was identified on 1 of 5 units. Specifically, 1) On the Legrange Unit, a Transmission Based Precautions (TBP) sign was not observed for a resident who was COVID-19 positive; 2) a Certified Nursing Assistant (CNA #5) did not utilize appropriate Personal Protective Equipment (PPE) when entering a COVID-19 positive resident's room and did not discard all of the used PPE prior to leaving the COVID-19 positive resident's room. The finding is: The facility policy titled Cohorting for COVID-19 last updated 9/10/2021 documented that for positive cohorts full PPE is required, including gloves, gown, N-95 mask, and eye protection. The policy further documents Transmission-Based Signage for Droplet 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.