Martine Center For Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00367889/591527, NY00333553/591524, NY00349962/591497) 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 5 residents (Resident #1, #2, #5) reviewed for care planning. Specifically, 1) Resident #1 had an unwitnessed fall on 01/1/2025 and sustained skin tears to both arms. Resident #1 had no documented fall risk or actual fall care plan initiated before or after the incident. 2) Resident #2 was noted to have eschar to their left heel on 02/11/2024. Resident #2's pressure injury care plan had not updated with the presence of the left heel eschar, measurements and/or tracking. 3)After a meeting with Resident #5's representatives on 04/18/2025, it was determined the resident would have a two person assist for all cares. Review of Resident #5's self-care care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00367889-591527, NY00367906-591522), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for safety and supervision. Specifically, on 01/01/2025 Resident #1 told Certified Nurse Aide #1 that they needed to get out of bed otherwise they were going to jump out. Certified Nurse Aide #1 left the resident alone in their room after the resident made the statement. When Certified Nurse Aide #1 returned to Resident #1's room, the resident was on the floor. Resident #1 sustained skin tears to both upper extremities.The findings are:The facility Safety and Supervision of Residents policy last reviewed 01/2024 documented the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during an abbreviated survey (NY00362050), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately but no later than 2 hours to the New York State Department of Health (NYS DOH). This was evident for 1 of 3 residents (Residents #1) reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/21/2024 left the facility undetected by facility staff on 11/26/2024. The Facility staff did not realize Resident #1 was not in the facility until dinner time (approximately 5:30pm-6pm) and did not report the incident to State Agency Department until 11/27/2024. The findings are: The Facility Policy on Accident-Incidents created 11/2013 documented that it is the facility policy to monitor and evaluate all occurrences of accidents or incidents or adverse event occurring on the facility premises which is not consistent with the routine operation of the facility or care of a particular…

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 an abbreviated survey (NY00362050), the facility did not ensure that residents were provided adequate supervision/monitoring to prevent elopement. This was evident for 1 of 3 (Resident #1) residents reviewed for accidents. Specifically, Resident #1 who was identified to be at risk for elopement on 10/12/2024 exited the facility through the front door on 11/26/2024 at approximately 11:30 am undetected by facility staff. The resident was found on 12/2/2024 by Los Angeles Police Department who called the facility to report that the resident was brought to Los Angeles Police Department General Psych for evaluation. The findings are: The Facility Policy on Elopement Prevention created on 7/2024 documented the facility maintains a process to identify residents at risk for elopement, implement preventative strategies for those identified as an elopement risk and conduct a missing resident procedure when necessary. Interventions that may be implemented 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 an abbreviated survey (NY00362050), the facility did not ensure Certified Nurse Aide performance appraisals were completed at least once every 12 months for 2 of 3 Certified Nurse Aides record reviewed. Specifically, performance appraisals were not documented every 12 months for Certified Nurse Aide #2 and #3. The Findings are: The Facility Policy on Employee Evaluations created 9/2019 documented the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at least annually. The completed performance evaluation will be placed in the employee's personnel record. Review of Facility Personnel Records revealed Certified Nurse Aide #2 was hired 7/1/2022. There was no documented evidence of any annual performance evaluation since date of hire. Review of Facility Personnel Records revealed Certified Nurse Aide #3 was hired 6/20/2017 and performance evaluation was conducted 9/5/2018. There was no documented evidence that an annual performance evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00352478), the facility did not ensure the Minimum Data Set assessment accurately reflected the resident's status for 1 out of 3 residents reviewed for assessments. Specifically, Resident #1's Quarterly Minimum Data Set assessment dated [DATE] coded the resident as dependent for all cares with 2-person assistance. The Quarterly Minimum Data Set, dated [DATE] coded the resident as dependent but requiring a 1 person assist which is not indicative of dependence for care. In addition, staff interview revealed a discrepancy on Resident #1's required assistance with bed mobility and the Certified Nurse Assistant Task Instructions/Accountability did not accurately reflect required assistance for Resident#1. Findings include: The facility Minimum Data Set 3.0 policy dated 5/2017 documented the Resident Assessment Instrument process and requirement procedure are as follows: the assessment accurately reflects the resident's status, the assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey (NY00352478, NY00350699), 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 1 out of 3 residents reviewed for activities of daily living. Specifically, there was no documented evidence that a comprehensive care plan was initiated after the Quarterly Minimum Data Set assessment dated [DATE], that documented that the resident was dependent for all cares. In addition, the care plan did not accurately reflect the required assistance for a resident dependent for all cares on the Certified Nurse Assistant Task Instructions/Accountability. Resident #1 fell out of bed while Certified Assistant #1 was providing cares alone without rails and sustained lacerations to the forehead, and right nares and possible cervical fracture. The findings are: The facility Care Plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey ( NY00350699), the facility did not ensure that a comprehensive person-centered care plan was reviewed and revised for 1 out of 3 residents (Resident #2) reviewed for care planning. Specifically, Resident #2 had a self-reported fall on 7/24/2024 and their actual fall care plan was not updated to reflect it. Findings include: The facility Care Plan Comprehensive policy dated 10/2015 and last revised 10/2019 documented the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of the resident are ongoing and care plans are revised as information about the residents and resident's condition change, when the resident has been readmitted to the facility from the hospital and at least quarterly with scheduled Minimum Data Sets. Resident #2 initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnosis including but not limited to Metabolic…

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 (NY00352478, NY00350699), the facility did not ensure the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance to prevent accidents for 1 out of 3 residents reviewed for accidents. Specifically, on 8/21/2024, Resident #1 who had been identified as totally dependent with cares (helper completes all activities for the resident, resident does not use any of their own strength for any part of the activity), fell off the bed when Certified Nursing Assistant #1 was providing care by themself. Resident #1 sustained an unstable cervical spine C4-C5 fracture and possible left femoral neck fracture with deep forehead lacerations 4.5cm long and 0.1cm depth across forehead, swollen upper lip and gums and right nares. Resident #1's care plan documented resident required 1 person assist. Resident was transferred to the hospital for further medical evaluation. Findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure housekeeping and maintenance services were provided to maintain a clean, comfortable, and homelike environment on 3 of 6 units. Specifically, observations included loose toilet seat/commode, spackled walls in halls and rooms in need of paint, broken handrails fixed with tape, walls adorned with various sections displaying black streaks and chipped paint, a hole in a wall, and the pungent smell of urine in multiple rooms. Findings include: 1) Unit 2: During an observation on 11/27/23 at 11:25 AM, on 11/28/2023 at 9:41 AM and 3:00 PM, and on 11/30/2023 at 9:05 AM, Rooms #201 and #218 had an unpleasant smell and the bedsheets were soiled with urine. During an interview on 11/30/23 at 10:05 AM, the Licensed Practical Nurse Unit Manager (LPNUM) #1 stated, there were a lot of residents who required a hoyer lift to get out of bed and it took time to clean their beds. LPNUM #1 stated 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 interviews conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure that resident Minimum Data Set assessments (MDS-an assessment tool) accurately reflected the resident's status. This was evident for 4 of 5 residents (Residents # 138, #5, #77, and #1) reviewed for MDS accuracy. Specifically, 1) the significant change MDS for Resident # 138 did not address that a stage 3 pressure ulcer was present on admission; 2) the MDS for Resident # 5 did not address administration of insulin or antidepressants; 3) the MDS for Resident #77 documented other restraints not used daily, but the resident did not have any documented or observed restraints; and 4) the MDS for Resident #1 documented, 'other restraints not used every day', but the resident did not have any documented or observed restraints. The findings are: A review of the Policy and Procedure, 'MDS 3.0' dated 5/17 documented it is the policy of the facility to follow the guidelines of…

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

Based on observations, record review and interview conducted during the Recertification Survey from 11/27/2023 to 12/5/2023, the facility did not ensure a resident was assessed by the interdisciplinary team to determine the resident's ability to safely administer their own medications if clinically appropriate for 1 of 1 resident (Resident #78) reviewed for self-administration of medications. Specifically, Deep Sea/Fluticasone Propionate nasal sprays and Ventolin/Symbicort inhalers were stored at the resident's bedside intended for the resident to self administer their own medications. Findings include: The facility Policy and Procedure, 'Medication-Self Administration' revised 7/2023, documented residents may request to keep medications at the bedside for self-administration in accordance with resident rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication/s and to keep accurate documentation of these actions. Resident #78 had diagnoses which included Chronic Obstructive Pulmonary Disorder (COPD), Obstructive…

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 from 11/27/23 to 12/5/23 it was determined that for one of 2 residents (Resident #129) reviewed for choices, the facility did not ensure that each resident had the right to make choices about aspects of life that were significant to them. Specifically, Resident #129's choice of when to get out of bed in the morning was not consistently honored. Findings include: Resident #129 had diagnoses including Dementia, Schizophrenia, and Mood Disturbance. The 8/21/23 annual Minimum Data Set (MDS-an assessment tool) documented Resident #129 had moderately impaired cognition, customary routine and activities including choosing clothing were very important to the resident, and the resident required limited assistance of one person for dressing and transfer. The November 2023 Comprehensive Care Plan (CCP) initiated 3/3/22 for resident preferences directed staff to respect and encourage the resident's preferences and choices. During an interview on 11/28/23 at 9:47 AM, Resident #129 stated they would like to remain in bed later…

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

Based on record review and interview during the Recertification Survey conducted from 11/27/23 to 12/5/23, the facility did not ensure that they provided the appropriate liability and appeal notices to Medicare beneficiaries for 2 of 3 residents (Residents #278 and #600) reviewed for Beneficiary Notification. Specifically, the facility was unable to provide documented evidence that Residents #278, and #600 or their representatives received the Notice of Medicare Non-Coverage (NOMNC) for Medicare Part A at least two calendar days before Medicare covered services ended as required. Findings include: The CMS form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (expiration date 8/31/23) documented the NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Resident # 278's Medicare Part A skilled services began on 10/17/23 with a last covered day of 11/5/23. A CMS 10123 - NOMNC form dated 11/5/23 documented Resident #278 was notified that their last covered…

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 11/27/23 to 12/05/23, the facility did not ensure that the resident or the resident's representative was given a timely written notice of the facility's bed hold policy upon transfer to the hospital for 2 of 2 residents reviewed for hospitalization. Specifically, there was no documented evidence that Residents #144 and #125 and/or their representatives were given a timely written notice of the facility's bed hold policy upon transfer to the hospital. Findings include: The Bed Hold policy dated 12/22 documented the facility would provide to residents and/or their representatives written information regarding the bed hold and return policy of the facility on admission and prior to /at the time of hospitalizations and therapeutic leaves. 1) Resident #144 was admitted with diagnoses including major depressive disorder, esophageal stricture and gastro esophageal reflux. The Quarterly Minimum Data Set (MDS; a resident assessment and…

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

Based on record review and interviews conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure each resident had a person-centered comprehensive care plan implemented to addresses the resident's medical and physical needs for 1 (Resident #60) of 4 residents reviewed for care plan implementation. Specifically, for Resident #60 the facility did not implement proper footwear as planned. Findings include: Resident # 60 was admitted with diagnoses including Dementia, Peripheral Vascular disease, and schizoaffective disorder. The 11/2/23 Minimum Data Set (MDS) documented the resident was moderately cognitively impaired and required set up to partial assistance for all activities of daily living (ADLs). The comprehensive care plan (CCP), updated 11/26/23, documented the resident was care planned at risk for falls, had peripheral vascular disease and needed assistance with ADLs. Interventions included wearing appropriate footwear for movement and to provide constant safety reminders for the risk of falling; to educate the resident on the importance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews conducted during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure they reviewed and revised the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 1 of 1 resident (Resident #11) reviewed for communication. Specifically, Resident #11 communication care plan did not reflect their current communication status. Findings include: The facility comprehensive care plan policy that was last revised 2/2023, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Resident #11 was admitted with diagnoses which included dysarthria (difficulty speaking), hemiplegia and hemiparesis following a cerebrovascular disease (stroke) affecting the right dominant side. The Annual Minimum Data Set (MDS-an assessment tool) dated 8/25/23 documented the resident's cognition was intact; the resident had unclear speech but was usually…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification and Abbreviated surveys (NY00314899 and NY311919) from 11/27/23 to 12/5/23, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Resident #578, reviewed for quality of care. Specifically, 1) Resident #578 refused medications and treatments, and the facility did not inform the health care provider or document in the resident's electronic medical record (EMR); 2) Resident #87's behavior (spitting) was not evaluated to determine if it was contributing to weight loss. 3) Resident #125 was not provided seizure medications as ordered for a total of 34 omissions in March 2023. 4) Resident #329 did not receive Dilaudid as ordered by the medical provider on 5/28/2023 and 5/30/2023 and the medical provider was not notified. Findings include: Policy and Procedure dated 12/20/2019 titled, 'Medication Administration' documented that if a drug 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.

Based on record reviews and interviews during the Recertification Survey from 11/27/23 to 12/5/23, the facility did not ensure that Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months. Specifically, performance evaluations were not conducted every 12 months for four of five (CNA #11, #10, #2, and #9) records reviewed. The findings are: There was no documented evidence to indicate that CNA #2, #9, #10, and #11 had performance reviews completed at least once every 12 months. The facility provided documentation that CNA #11 was hired 2/24/88, CNA #10 was hired 11/12/12, CNA #2 was hired 10/20/20, and CNA #9 was hired 7/22/21 During an interview on 12/5/23 at 12:27 PM CNA #9 stated about five years ago the facility stopped conducting performance evaluations. During an interview on12/4/23 at 03:56 PM, the Director of Nursing (DON) stated that the facility did not conduct CNA annual performance evaluations, but they do conduct competencies with their CNAS. During an interview on 12/5/23 at 12:14 PM, the Administrator stated that the facility does…

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 from 11/27/23 to 12/5/23, the facility did not ensure that all drugs and biologicals used were stored in accordance with professional standards for 2 of 2 residents reviewed for Medication Storage. Specifically, 1. Resident #78 was observed with medications unsecured and unsupervised, on their bedside table and 2. Resident #174 was observed unsupervised, with medications on their meal tray. Findings include: The Policy and Procedure, 'Medication -Storage' revised 1/2023 documented medications will be stored in a manner that maintains the integrity of the product, ensures safety of the residents, and is in accordance with Department of Health guidelines. The findings are: 1. Resident # 78 was admitted with diagnoses including Chronic Obstructive Pulmonary Disorder (COPD), Obstructive Sleep Apnea, and Hypertension. The Minimum Data Set (MDS-an assessment tool) quarterly assessment dated [DATE] documented the resident 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 observation, record review and interview during the Recertification Survey from 11/29/23 to 12/5/23, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1. A Certified Nurse Aide (CNA) #1 was observed not using Personal Protective Equipment (PPE) or washing their hands appropriately while assisting Resident (# 59) who was on contact precautions. 2. A CNA did not use a barrier when assisting Resident # 131 with eating a sandwich. The findings are: 1. Resident # 59 had diagnosis which included sepsis, atrial fibrillation, and Clostridium Difficile (C- Diff). The quarterly Minimum Data Set (MDS-an assessment tool) date 11/16/23 Resident # 59 had severe cognitive impairment. The Physician order dated 11/22/23 documented Resident # 59 was on contact precautions for C-Diff. During an observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations record reviews and interviews during the Recertification Survey it was determined that the facility did not ensure that based on the comprehensive assessment a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. Specifically, the clinical staff did not provide post operative assessment, care planning and treatment for Resident #72, who returned to the facility after multiple surgeries. (5) Resident #72 is a [AGE] year-old male with admitting diagnoses of schizophrenia, end stage renal disease status post AV graft formation (a surgical procedure to form an access for hemodialysis) and left kidney removal, hypertension, and diabetes. The MDS 9/4/20 indicated the resident is cognitively intact and requires extensive/1-person assist with bed mobility, toileting and dressing. The resident ambulates with a walker. The resident returned from acute care facility on 8/29/20 after having the following surgeries: 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during a recertification survey, the facility did not ensure that appropriate care and services were provided according to professional standards to promote the practicable wellbeing for 4 of 4 residents ((1) #93, (2) #162, (3) #59, (4) #159 reviewed for positioning and mobility. Specifically, residents #59, #93, #159 and #162 were observed with clenched fist without hand rolls or splints in place to prevent contractures. The findings are: (1) Resident #93 is a [AGE] year-old admitted from the hospital on [DATE] with diagnoses of Hypertension, Diabetes Mellitus and Functional Quadriplegia. The Quarterly MDS dated [DATE] documented short term and long-term memory problems. The resident required two-person total dependence for bed mobility, transfer, dressing toilet use and personal hygiene. There was no documented rehab and restorative services. The resident was observed on 09/17/20 at 02:28 PM with limited range of motion and contractures of the upper…

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 a recertification survey, the facility did not ensure the right to participate in the development and implementation of person-centered plans of care, including but not limited to the right to participate in the planning process and attend care planning meetings. This was evident for 2 of 2 residents (Residents #113 and #55) reviewed for care planning. Specifically, resident # 113 has not participated in the planning process and has not participated in a care planning meeting, and resident #55 also has not participated in a care plan meeting. The findings are: Review of the Clinical Operations policy and procedure for comprehensive, person-centered care plans dated 10/2015 and revised 10/2019 documented that each resident's care plan will be consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to participate in the planning process. Resident #113 was admitted on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY [NAME], [NAME] A. (41666) Based on interview and record review conducted during the most recent recertification survey, the facility did not report to the New York State Department of Health (NYS DOH) an unwitnessed fall incident that resulted in a major injury to resident (#158). This was evident for 1 out of 1 resident reviewed for accidents. The findings are: Resident #158 is a [AGE] year-old resident who was admitted to the facility with diagnoses of Hypertension, Schizophrenia Hypothyroidism, and dementia on 10/06/2016. A Quarterly Minimum Data Set (MDS, an assessment tool) dated 07/13/2019 documented a BIMS Score of 7 indicating severe cognitive impairment. The resident did not have a fall history, was ambulatory and required supervision for bed mobility, transfer and eating. A Potential for Fall Care Plan initiated on 10/07/2016 documented a goal that the resident will be free of accidents / injury with the following interventions: bed in lowest position, ensure proper footwear and encourage resident 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 observation, interview and record review during a recertification survey the facility did not ensure that the facility developed and implement a resident centered care plan with measurable objectives for residents in need of positioning devices. Specifically, (1) resident #93 and (2) resident #162 were observed during the initial screening process with bilateral hand contractures with no devices in place. The findings are: (1) Resident #93 is a [AGE] year-old admitted from the hospital on [DATE] with diagnoses of Hypertension (HTN), Diabetes Mellitus and Functional Quadriplegia. The Quarterly MDS dated [DATE] documented short term and long-term memory problem. The resident required two-person total dependence for bed mobility, transfer, dressing toilet use and personal hygiene. There were no documented services provided in Section O (no rehab and no restorative services). The resident was observed on 09/17/20 at 02:28 PM with limited range of motion and contractures of the upper extremities with no…

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 conducted during a Recertification and Abbreviated survey (Complaint # NY00249941) the facility did not ensure that physician's orders and resident's advance directives were reviewed prior to initiating CPR (Cardio Pulimonary Resuscitation). Specifically, the ADN (Assistant Director of Nursing) initiated CPR on Resident #1 who had a MOLST (Medical Orders for Life Sustaining Treatment) form and Physician's Orders that identified the resident's choice for DNR (Do Not Resuscitated). This was evident for 1 out 3 residents reviewed for advance directives. The findings are: The Facility Policy on Emergency Procedure on Cardiopulmonary Resuscitation dated 12/2017 documented that if a resident is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless it is known and verified that a DNR order exist. A Facility Policy on Advance Directives and MOLST NY dated 03/2019 documented that all residents have the…

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

Based on observation, interview and record review during a recertification survey, the facility failed to employ a qualified social worker on a full time basis. Specifically, this facility has a licensed bed capacity of 200. From 04/15/20-08/24/20 it operated without a qualified full time Social Worker (SW) in its employ. The findings are: The Facility Survey Report (FSR) dated 09/16/20 under the heading Social Worker indicates that the facility should have a full-time SW with a master's degree qualification. Review of SW #1's Employee Profile and Time Sheet from 01/18/20 to 08/16/20 revealed a bachelor's degree and documentation of part time employment in the facility. SW#1 resigned effective 09/08/20 documenting resignation from her position as a part time SW in the facility. There was no documented evidence that SW#1 became a full-time employee from 04/15/20 to 09/08/20. Review of SW #2's Employee Profile and Time Sheet from 01/18/2019 to 04/03/20 revealed a master's degree and documentation of full-time employment in the facility. SW#2 resigned effective 04/03/20. Review of SW…

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.