Comprehensive Rehabilitation and Nursing Center at

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Standard survey completed on 12/6/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #30) of one resident reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #30's left and right palm guards (assistive device that positions the fingers away from the palm) were worn as recommended by occupational therapy. In addition, there was inconsistent documentation that range of motion exercises were provided to the resident per their care plan. The finding is: The policy and procedure titled Range of Motion and Ambulation revised 9/15/2020, documented that every effort would be made to ensure that residents do not lose range of motion, ability to walk or activities of daily living abilities unless the loss is unavoidable. Certified nursing assistants…

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 12/6/24 the facility did not ensure that residents with an indwelling foley catheter (tube inserted into the bladder to drain urine) received the appropriate care for one (Resident #45) of two residents reviewed. Specifically, staff did not maintain proper infection control practices for a resident with a foley catheter. The finding is: The policy and procedure titled Indwelling Catheter Care dated 2/2019, documented to keep the drainage tubing/catheter junction closed. Ensure the catheter is properly secured to upper thigh with securement device. 1. Resident #45 had diagnoses that included obstructive and reflux uropathy (obstruction in urinary tract), history of urinary infections and dementia. The Minimum Data Set (a resident assessment tool) dated 11/20/24 documented Resident #45 had moderate cognitive impairment, required substantial/max assistance with toileting and had an indwelling urinary catheter. 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 observations, record review and interviews during a Standard survey completed 12/6/24, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight for one (Resident #65) of two residents reviewed. Specifically, Resident #65 had a significant weight loss and there was a lack of meal and nourishment acceptance being documented or recorded. In addition, the medical provider was not made aware of the significant weight loss. The finding is: 1. Resident #65 had diagnoses that included dementia, protein-calorie malnutrition, and macular degeneration left eye (loss of the central field of vision because of deposits of the retina). The Minimum Data Set, dated [DATE] documented Resident #65 had severe cognitive impairment, required supervision/touch assist for eating, weight was 105 pounds and weight loss marked no or unknown. Additionally, Resident #65 was on a therapeutic diet. During breakfast and lunch meal observations on 12/5/24 at 9:11 AM and 12:53 PM, Resident #65…

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 Standard survey completed 12/6/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being either unlabeled or outdated in the refrigerator. The findings are: The undated facility policy and procedure titled Food Storage Refrigerator/ Freezer documented purpose is to ensure foods are stored properly to minimize spoilage and contamination, and to ensure taste and quality of food. All refrigerated foods should be labeled/ dated and discarded after three (3) days. The facility policy and procedure titled Food Safety Requirements Policy - use and storage of food and beverage brought in for resident's food procurement dated 11/2017 documented the policy is to provide safe and sanitary storage, handling, and consumption of all food. This includes the storage, preparation, distribution, and serving food in accordance with professional standards for food safety. The food service…

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 Standard survey completed 12/6/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for two (Resident #10 and #43) of four residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) during care. Specifically, Resident #10 had chronic pressure ulcers (injury to the skin and tissues from prolong pressure to the area) and the Certified Nurse Aides did not wear proper personal protective equipment during morning care. Additionally, Resident #42 had an ileostomy (a surgical operation in which a piece of the intestine is diverted to an opening in the stomach wall) and the nurse did not wear proper personal protective equipment during care. The findings are: Review of the policy and procedure titled Enhanced Barrier Precautions dated 4/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a Complaint Investigation (Complaint #NY00321583) during an Abbreviated survey completed on 8/14/23, the facility did not maintain complete and accurately documented medical records for three (Resident #1, #2, and #3) of three residents reviewed. Specifically, the bowel and bladder (B&B) elimination task was not documented as completed daily and/ or each shift. The findings are: The policy and procedure titled Bowel Management dated 7/2017 documented if no bowel movement (BM) for 2 days (6 shift), give Milk of Magnesia (MOM- a laxative used to treat constipation) 30 cc (cubic centimeters) at bedtime and monitor BM. If no BM by the following shift (7 shift), give one Dulcolax suppository (laxative stimulant to relieve occasional constipation) rectally and monitor BM. If no BM by next shift (8 shift), give fleet enema (liquid medicine used to help you have a bowel movement) at bedtime. Per physician's order. If steps 1-3 are not successful, contact Physician…

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 Standard survey completed 4/21/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: metal frame holding ceiling tiles were curling/ peeling white paint, hoods over the ovens had a copious amount of grease stains flowing down the back of hood and wall, hand washing sinks had no soap and paper towel dispensers, one hand sink was broken with water not draining, chest freezer in basement had broken seal with ice build-up inside around the seal area, reach in refrigerator in basement was freezing items, sticky fly tape hanging from pipe in dry storage with dead flies on it, and foods either unlabeled or outdated in the refrigerators In addition, two (Unit 1/2 and Unit 5) of three unit nourishment kitchen refrigerators contained unlabeled, undated, and outdated foods. Unit 5 freezer had a 1 to 2-inch ice build-up, outside 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 observation and interview during the Standard survey started on 4/17/23 and completed on 4/21/23, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included a sewer pipe was open and unsealed, a pit containing a sewer pipe was partially full of standing water, a toilet waste line was open and unsealed, and drains leaked from First Floor into the Basement. This affected one (First Floor) of one resident use floor and one of one Basement. The findings are: 1. Observation in the Basement A Wing on 4/18/23 at 12:25 PM revealed the building's main sewer pipe ran horizontally below Storage Room #A11 inside of a four-foot-long by four-foot-wide by five-foot-deep concrete pit. A ten-inch-wide section of the sewer pipe was open and unsealed. Continued observation through the open, unsealed section of the pipe revealed liquid was flowing through the pipe. The pit contained dark standing liquid of unknown depth. Additional observation revealed the vertical four-inch diameter PVC (polyvinyl chloride - 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 Based on observation, interview, and record review conducted during a Complaint investigation (#NY00314500) during the Standard survey completed 4/21/23, the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the facility did not maintain the resident call bell system in working order for three (Unit 2, Unit 5, Unit 6) of three resident care units. The findings are but not limited to: 1. The following observations and interviews were made on Unit 2: During an interview on 4/18/23 at 8:40 AM, the resident residing in #210D (door) stated the call bell had stopped working yesterday or the day before, and they can't call to get their oxygen tank replaced. The surveyor reported the non- functioning call bell concern to the floor nurse, who was not aware, and stated they would get a tap bell for the resident. 4/19/23 at 9:57 AM the call bell in room [ROOM…

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 complaint investigations (Complaint NY00314500 and NY00308655) during the Standard survey completed on 4/21/23,the facility did provide a safe, clean, comfortable, and homelike environment. The facility did not ensure that housekeeping and maintenance services were adequate, to maintain a sanitary, orderly, and comfortable interior. Specifically, two (Units 5 and 6) of four resident units reviewed for the environment had issues as follows; unlabeled resident urinals and graduated cylinders in shared bathrooms; fall mat in disrepair; brown liquid splatters with drips on a wall; hand rail in resident shower room loose and broken; a rusty commode; a fly paper strips (fly-killing device made of paper coated with a sweetly fragrant, but extremely sticky and sometimes poisonous substance that traps flies and other flying insects when they land upon it) in resident rooms and in a nourishment room; a shower chair in disrepair; and dried brown stains 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.

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint # NY00314500) during the Standard survey completed on 4/21/23, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, one (Resident #46) of four residents reviewed for pressure ulcers did not have a comprehensive care plan developed for a resident with multiple pressure ulcers with measurable goals and interventions. The finding is: 1. Resident #46 had diagnoses included type 2 diabetes mellitus with diabetic neuropathy (disorder affecting nervous system), unspecified open wound left foot, and anemia due to stage 4 chronic kidney disease. The Minimum Data Set (MDS- a resident assessment tool) dated 2/10/23 documented Resident #46 had moderate cognitive impairment. The resident was a risk for developing pressure ulcers and had one unhealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Standard survey completed on 4/21/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #63, #65 and #78) of eleven residents reviewed. Specifically, Resident #63 had multiple long ¼ inch whiskers on their chin, Resident #65 had unkempt, oily disheveled hair, had not received hair washing for greater than 2 months and wanted their hair washed; and Resident #78 had long fingernails greater than ¼ inch beyond their fingertips. The findings are: The facility policy and procedure (P&P) titled Routine Care (AM/PM) dated 2/2015, documented routine care rendered by the nursing staff included attention to the physical preference to the patient/resident in the assessment, planning and provision of care. Total bath (bed, shower or tub) washes the resident in sequence (face, chest, abdomen, arms, hands,…

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 Standard survey completed on 4/21/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community for one (Resident #78) of one resident reviewed for activities. Specifically, Resident #78 was not in attendance of activities according to their preference and comprehensive assessment due to the lack of being not gotten up and out of bed and not being asked if they wanted to attend activities. The finding is: The facility undated policy and procedure (P/P) titled Activities Protocol identified as current by the Administrator, documented the facility will provide…

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 Standard survey completed on 4/21/23, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #404) of two residents reviewed. Specifically, the facility did not ensure Resident #404 had a call device to request assistance and the resident fell on the floor in their room which resulted in bruising to their left forehead. The finding is: 1. Resident #404 had diagnoses including anxiety disorder, Parkinson's Disease, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS, a resident assessment tool) dated 3/24/23 documented Resident #404 was cognitively intact, understood, and understands. The resident required extensive assist of one with bed mobility and supervision of one assist for transfers. The Comprehensive Care Plan (CCP) initiated on 3/31/23 documented Resident #404 is at risk for falls related to deconditioning,…

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 4/21/23, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing (DON), and these reports must be acted upon for one (Resident #34) of five residents reviewed for drug regimen reviews. Specifically, Resident #34 was ordered Haldol (antipsychotic medication) prn (as needed) for agitation from 1/30/23 to 2/28/23. The Consultant Pharmacist did not identify and recommend the discontinuation of the prn antipsychotic medication after 14 days. The finding is: 1.Resident #34 had diagnoses including bipolar disorder, major depressive disorder, and schizophrenia. The Minimum Data Set (MDS- a resident assessment tool) dated 1/8/23 documented Resident #34 was understood, understands and cognitively intact. Antipsychotic medication was being used over the past seven days. The untitled comprehensive care plan dated 7/2/19, documented Resident #34 used psychotropic medications related to behavior management…

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 Standard survey completed 4/21/23, the facility did not store all drugs and biologicals in locked compartments and under proper temperature for one of one floor used by residents and one (Unit 6) of two medication storage rooms. Specifically, a box of medications that contained 61 medications for 20 residents was left unattended, unsecured on the floor outside an office in the hallway where residents, staff and visitors had access. This involved Resident #'s 7, 16, 62, 82, 84, 88, 92, 104, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, and 216. In addition, the medication Retacrit (epoetin, injectable medication used to treat anemia) was not stored in the refrigerator as required upon receiving from the pharmacy (#405). The findings are: The policy and procedure (P/P) titled Medication Storage dated 2/2015 documented medications are stored safely, securely, and properly, following manufacturer's recommendations or those of the…

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

Based on observation, interview and record review conducted during the Standard survey completed on 4/21/23 the facility did not dispose of garbage and refuse properly for two of two dumpsters. Specifically, waste was not properly contained within dumpsters and the lids on the top were not closed shut. There were open bags of garbage and debris on the ground surrounding the dumpster with birds and squirrels picking at the garbage. The finding is: The policy and procedure (P/P) titled Sewage disposal- Medical Waste Disposal- Dumpster Maintenance and Holding of Waste last revised 12/1/2019 documented the dumpster and surrounding area shall be clear and free of debris. Individuals disposing of refuse will ensure all refuse ends inside the dumpster, the dumpster lids are properly closed and the dumpster sliding doors are properly closed. The environmental team shall be responsible for ensuring the surrounding area is clear from debris-in the event the items are too large the maintenance team shall assist in removing items properly. Observation on the exterior of the building on 4/17/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during the Onsite Post Survey Revisit completed on 7/12/23, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the QAPI Committee did not have documentation of audits or documentation of review of audits to ensure deficiencies identified during the Recertification Survey completed on 4/21/23, were corrected, and the facility did not institute and follow corrective actions that were to put in place to ensure that the following deficiencies would not reoccur. The findings are: Refer to: F 812- Food Procurement, Store/Prepare/Serve - Sanitary - Scope and Severity D F 908- Essential Equipment, Safe Operating Condition - Scope and Severity D K 200- Means of Egress Requirements - Other - Scope and Severity D K 222- Egress Doors…

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 Standard survey completed on 4/21/23, the facility did not maintain 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 infection for two (Residents #78 and 82) of three residents reviewed for transmission-based precautions and incontinence care. Specifically, transmission-based precautions were not implemented for an active infection or reflected on the care plan (Resident #82) and staff did not perform adequate hand hygiene while providing fecal incontinence care (Resident #78). The findings are: The facility policy and procedure (P&P) titled Contact Precautions revised 2/16, documented contact precautions shall be observed by all personnel to prevent transmission of infectious agents, including epidemiologically important organisms, which are spread by direct or indirect contact with the resident or 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 completed during the Standard survey completed 8/27/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, one (Resident #58) of two residents reviewed for range of motion (ROM-normal range of motion for a joint) services was not provided with an air carrot (assistive device that positions the fingers away from the palm) to their right hand, and pillows for leg positioning as recommended by Occupational Therapy (OT) and Physical Therapy (PT). The finding is: Review of the facility policy and procedure (P&P) titled Range of Motion and Assistive Devices with Activities of Daily Living revised 11/13/18 documented every effort will be made to ensure that residents do no lose ROM of activities of daily living (ADL) abilities unless the loss is unavoidable. Additionally, it documented the following: -Therapy…

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 an Abbreviated survey (Complaint # NY00253925) completed during the Standard survey on 8/27/21, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #15) of one resident reviewed. Specifically, Resident #15 eloped while out at an appointment at a local hospital on 3/12/20. The finding is: Review of the policy and procedure titled, Wander/Elopement Risk Assessment dated 11/2004 documented once a resident has been identified as being at risk for elopement and preventative interventions have been implemented appropriate documentation from all departments will be checked and be kept in the resident's permanent record. Modes of communication include but are not limited to (a) Resident's care plan; (b) Elopement list; (c) Check in/out logs will be used if and when a resident leaves or returns form the facility to the unit with RP (responsible party). Resident #15 had diagnoses which included schizophrenia, anxiety, multiple substance abuse, aphasia (loss 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 interview and record review conducted during the Standard survey completed on 8/27/21, the facility did not ensure residents who use psychotropic drugs received gradual dose reductions (GDR) in an effort to discontinue these drugs for one (Resident #62) of five residents reviewed for antipsychotic medications. Specifically, there was a lack of documented targeted behaviors and ongoing behaviors to support the use of antipsychotic medication and lack of attempted GDRs as required. Additionally, the resident lacked a comprehensive care plan for antipsychotic medication use. The finding is: The facility policy and procedure (P&P) titled, Monitoring of Psychotherapeutic Medications revised on 9/10, documented residents receiving a psychotherapeutic medication will be observed for therapeutic response to the medication. When a resident starts on a new psychotherapeutic medication the nurse will: document the resident behavior and response; monitor for extra pyramidal effects; notify the physician of resident refusing and/or adverse effects, or omission of the medication. The P&P…

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 and interview during the Standard survey completed on 8/27/21, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included open and uncapped sewer plumbing, a consistent floor drain leak from First Floor into Basement, and shower plumbing devices and hoses that did not have vacuum breakers installed to prevent backflow. This affected one (Unit 6) of three resident units, one of one Main Kitchen, and one of one Basement. The findings are: 1. Observation on the Basement's A Wing on 8/24/21 at 10:32 AM revealed a portion of the building's main sewer pipe ran horizontally below Storage Room #A11 in a four foot long by four foot wide by five-foot-deep pit. Further observation revealed the pit was covered by a large sheet of wood. When the facility's Director of Maintenance lifted the wood, a ten-inch-wide area of the pipe was open and uncapped. Continued observation through the open uncapped area of the pipe revealed liquid was flowing through the pipe. During an interview at the time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during an Abbreviated Survey (Complaint NY#00263124) completed on 8/27/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident 58) of 21 reviewed for plan of care (POC). Specifically, the facility did not ensure Resident #58 had their abdominal (ABD) binder on as they have a history of dislodging their percutaneous endoscopic gastrostomy tube (PEG/ G-tube- feeding tube inserted into the stomach) and were not wearing heel booties, at all times (AAT), per doctors' orders plan of care. The findings are: Resident #58 had diagnoses including cerebral vascular accident (CVA-stroke) with right sided hemiplegia (paralysis of one side of body), diabetes, and hypertension (HTN-high blood pressure). The Minimum Data Set (MDS-a resident assessment tool) dated 7/16/21 documented the resident had severe…

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 Standard survey completed on 8/27/21, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for one (Resident #29) of two residents reviewed for incontinence care. Specifically, the Certified Nurse Aide (CNA) provided incomplete AM (morning) and incontinence care. The finding is: 1. Resident #29 had diagnoses which include major depressive disorder, peripheral vascular disease (poor circulation) and sacral (area between base of spine and tailbone) pressure ulcer. The Minimum Data Set (MDS- a resident assessment tool) dated 6/15/21 documented the resident was cognitively intact, required extensive assistance of one person for personal hygiene, and did not exhibit behaviors or refuse care. The facility policy and procedure (P&P) titled Incontinent Care dated 2/2015 documented to keep the resident who is incontinent clean, dry, and comfortable; equipment included wash…

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 8/27/21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #34) of one resident reviewed for respiratory care. Specifically, oxygen (O2) was not administered in accordance with the physician's order, oxygen concentrator filter was dirty and covered with white debris, and the oxygen tubing was not dated and documented when changed. The finding is: The facility's undated policy and procedure (P&P) titled Oxygen Supplies and Concentrator documented that the facility will maintain an adequate supply of oxygen concentrators, nebulizers, tanks, and supplies. The policy did not include the care and maintenance of the concentrator and tubing. 1. Resident #34 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease (COPD), anxiety disorder and unspecified heart failure. The Minimum Data Set (MDS- a resident assessment tool) dated 6/23/21…

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 and interview during the Standard survey completed on 8/27/21, the facility did not dispose of garbage and refuse properly. Specifically, waste was not properly contained outside of the facility in closed dumpsters, and torn bags of garbage and loose debris were observed on the ground behind the dumpsters, which created potential feeding and harborage areas for pests. The finding is: Observation on 8/23/21 at 9:40 AM revealed two cardboard dumpsters and two garbage dumpsters were located behind the facility. Further observation revealed one torn garbage bag on the ground outside of the garbage dumpsters, and garbage items from this torn bag, which included food debris and dirty food plates, were strewn around the surrounding grass in a 20-foot diameter area. A bee trap was observed hanging on one of the garbage dumpsters and many live bees were observed in the vicinity. On the ground to the right of the garbage dumpsters were an intact garbage bag under a pile of dried brush, a broken tent, a bed frame, three air conditioning units, a vacuum, and several chairs.…

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 Standard survey completed on 8/27/21, the facility did not maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19 for one (Resident #289) of three residents reviewed for transmission based precautions (TBP). Specifically, the facility did not ensure a newly admitted , unvaccinated resident was placed on TBP (including appropriate room signage) and staff did not wear required Personal Protective Equipment (PPE) when in direct contact with the resident. The finding is: CDC (The Centers for Disease Control and Prevention) guidelines titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 3/29/21 documented all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. CDC guidance titled Transmission-Based Precautions…

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.