Williamsville Suburban, L L C

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review conducted during a Complaint investigation (Complaint #NY00353284, #NY00329150) during the standard survey completed on 10/28/24, the facility did not ensure that there was sufficient nursing staff on a 24-hour basis to provide care for all residents. Specifically, one of one facility reviewed for sufficient staffing the facility did not meet their assessed minimum staffing levels for Certified Nurse Aides on 8/24/2024, 9/8/2024, 9/16/2024, 9/22/24, 10/5/2024, 10/6/2024, and 10/20/2024 to meet the needs of the residents. The finding is: Refer to F 677 Activities of daily living care for dependent residents. The policy and procedure titled Nursing Department Staffing dated 2/17/2021 documented the facility provides adequate staffing to meet needed care and services for our resident population. It documented that Certified Nurse Aides are available on each shift to provide the needed care and services of each resident as outlined in the resident's comprehensive…

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

Based on interview and record review conducted during a Standard survey completed on 10/28/24, the facility did not implement an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one of one infection control program reviewed. Specifically, the facility did not provide documentation showing that antibiotics were being monitored and tracked to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This involved Resident #84. The finding is: The policy and procedure titled Antibiotic Stewardship - Review & Surveillance of Antibiotic Use & Outcomes, dated 8/2018, documented that Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form, and all clinical infections treated with antibiotics will undergo review by the Infection Preventionist. All Antibiotic starts will be reviewed by the Infection Preventionist within 48 hours to determine if continued therapy is justified, justified with needed…

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 10/28/24, the facility did not establish and 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 infections for one (Resident #84) of three residents reviewed for infection control practices during care. Specifically, Certified Nurse Aide's #2, 4, 5, and 6 did not wear appropriate personal protective equipment (PPE) during care activities for a resident on enhanced barrier precautions who had an indwelling catheter (tube inserted into the bladder to drain urine) and a stage IV pressure ulcer. The findings are: The undated policy and procedure titled Enhanced Barrier Precautions documented enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. Enhanced Barrier Precautions employ targeted gown and glove use during high contact resident…

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

Based on interview and record review conducted during a Complaint investigation (#NY00332426) during a standard survey completed on 10/28/24, the facility did not ensure that all alleged violations involving abuse, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator and the State Survey Agency for one (Resident #62) of five residents reviewed. Specifically Resident #62 was found to have an injury of unknown source to their forehead, and it was not reported within the required timeframe. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents, reviewed 2/29/24, documented that if abuse is suspected, personnel will report their observation to their supervisor immediately and without delay, and the Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulations. 1. Resident #62 had diagnoses including unspecified dementia, status post fractured hip, and disorientation (a mental state of confusion…

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 10/28/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Residents #71 and #127) of five residents reviewed. Specifically, issues involved unkempt long, dirty, jagged fingernails (#71, #127). In addition, Resident #71 had presence of unwanted facial hair. Additionally, the 3rd floor Bath & Shower Sheet dated 10/23/24 for #71 was inaccurately documented, that care had been provided. The findings are: The policy and procedure titled Activities of Daily Living created 2/13/23 documented a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming and personal hygiene. The policy and procedure titled Care of Fingernails issued 6/26/18 documented nail care was to include daily cleaning and regular trimming 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 the Standard survey completed on 10/28/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #84) of one resident reviewed. Specifically, Resident #84 was symptomatic for a urinary tract infection, and the foley catheter drainage bag was not draining to gravity below their bladder. The finding is: The policy and procedure titled Catheter Care: Urinary revised on 4/30/24 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. The position of the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Resident #84 had diagnoses which included anxiety, stage IV pressure ulcer (most severe type of pressure ulcer and involves full-thickness tissue loss that exposes bone, tendon, or muscle), and urinary…

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 10/28/24, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs for one (A Wing North Building) of three medication rooms observed for medication storage. Specifically, three bottles of liquid Lorazepam (a Schedule IV controlled substance-sedative/antianxiety medication) were stored in a removable locked box inside a small refrigerator that was not permanently affixed, which was located in a room with an unlockable door. This involved Resident #32. The finding is: The policy and procedure titled Controlled Substances with effective date 12/1/17 documented that refrigerated controlled substances must be stored in a refrigerator that has a locked, affixed narcotic box inside of the refrigerator with a separate lock on the outside of the refrigerator. The refrigerator must be affixed to the floor or wall. The refrigerator and interior narcotic container must remain locked at all times. During a medication storage 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.

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/24, the facility did not provide or obtain dental services to meet the resident's needs for one (Resident #84) of one resident reviewed. Specifically, there was no follow up to recommendations for a crown for a chipped tooth. In addition, the care plan was not revised to include Resident #84's chipped tooth. The finding is: The policy and procedure titled Dental Services with a revised date 1/28/20 documented routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The Director of Nursing, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services and coordinate appointments with Medical Records/Unit Clerks. Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary whenever an outside appointment is requested. The Medical Records…

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 # NY00321134), the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for three (Residents #1, #2, and #3) of six residents reviewed for care planning. Specifically, Residents #1, #2 and #3 were care planned for the use of a stop sign across their room door to deter other residents from entering and they were not provided with one. The findings are: The policy and procedure titled Comprehensive Care Plans with a revision date of 2/1/2018 documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to reflect the resident's expressed wishes regarding care and treatment goals. 1. Resident #1 had diagnoses including anxiety, depression, and diabetes mellitus (high blood sugar). The Minimum Data Set (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 (#NY00331620), the facility did not ensure that all alleged allegations of abuse, were thoroughly investigated for two (Resident #1 & 2) of three residents reviewed. Specifically, the facility did not complete a thorough and accurate investigation into resident-to-resident abuse to include conducting interviews with witnesses and other pertinent staff. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents dated 4/19 documented the Administrator/Director of Nursing (DON/designee will conduct an investigation. Witness reports will be in writing. Witnesses will be required to sign and date such reports. The individual conducting the investigation shall follow the procedure for reporting and investigation when an incident of resident abuse is alleged or suspected. The following should be reported by individuals/employees which include the following: The name of the resident involved,…

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 an Abbreviated survey (Compliant #NY00289521) completed on 1/24/24, it was determined that the facility did not ensure that that residents receive treatment and care in accordance with professional standards of practice. Specifically, one of three residents (Resident #1) reviewed for delay of treatment had complained of left hip pain on 1/9/22 and was not sent to the hospital for a confirmation of a broken hip until 1/12/22. The finding is: The policy and procedure titled Laboratory and Diagnostic Test Results - Clinical Protocol dated 2/1/2017 documented that all laboratory and diagnostic tests will be scheduled, collected, and tracked timely to ensure the physician receives timely reports to ensure there is no delay when notifying the physician whenever abnormal findings are identified. Resident #1 was admitted to the facility with diagnoses of stroke and dementia. The Minimum Data Set (a resident assessment tool) dated 1/22/22 documented Resident #1 was severely cognitively impaired, was understood and usually understands.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during a Recertification survey and complaint investigation (#NY00306577) completed on 3/17/23, it was determined that the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for five (North Building: Units B, C, and D & South Building 2nd and 3rd Floor) of five resident units and one laundry room in the North building. Specifically, the issues involved soiled floors, walls, furniture, and doors; garbage on the floors; window blinds in disrepair; stained privacy curtains; personal care supplies directly on the floor; dusty vents and heaters; rusty toilet paper holders; stained ceiling tiles and urine odors. Additionally, the laundry room had piles of visibly soiled linens on the floor next to and in front of washing machines; visibly soiled incontinent wipes on the floor in front of dryers; standing water on the floor, and soiled incontinent briefs on the floor between 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.

Based on observation, interview, and record review conducted during a Standard survey completed 3/17/23, the facility did not provide food and drink that was palatable, and at a safe and appetizing temperature for five (South building: 2nd floor, 3rd floor and North building: B Unit, C Unit and D unit) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents' #62, #77, #89, #128, #155 and #166 were involved. The findings are: The policy and procedure titled Food Preparation and Service dated 6/26/18 documented the food service employees shall prepare and serve food in a manner that complies with safe food handling practices. The danger zone for food temperatures is between 41 degrees (°) and 135° Fahrenheit (F). This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained at 40°F or below or at 136°F or…

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 started 3/12/23 and completed 3/17/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (South) of two kitchens. Specifically, the South kitchen had issues with soiled floors, walls, and storage shelves. The dish-room walls and ceiling were soiled with dried food debris, and thick dust hanging from the light fixture. The kitchen commercial hood and mobile heated dish dispenser had a build-up of grease and dust. The walk-in freezer's floor was soiled with spilled frozen food products, there was no thermometer, and had undated/outdated/unlabeled food. The stand-up and walk in cooler had undated/outdate/unlabeled food items. Dietary staff were not wearing face masks positioned appropriately and dietary staff with facial hair were not wearing beard nets. Two (Second Floor, Third Floor) of two nourishment room refrigerators in the South…

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 the facility did not ensure the Binding Arbitration Agreement was explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; and the resident or his or her representative acknowledges that he or she understands the agreement five (Resident #100, #238, #387, #388 and #389) of five residents reviewed. Specifically, the residents did not understand what an Arbitration Agreement was and did not recall the facility explaining what an Arbitration Agreement was. The findings are: The policy and procedure (P&P) titled Arbitration Agreements with revision date 10/22/22 documented the facility informs residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. The facility must ensure that the agreement is explained to the resident 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 interview and record review the facility did not ensure the Binding Arbitration Agreement provides for the selection of a neutral arbitrator agreed upon by both parties and the agreement provides for the selection of a venue that is convenient to both parties. Specifically, five (Resident #100, #238, #387, #388 and #389) of five resident's Binding Arbitration Agreements were reviewed and there is no documented evidence the agreement addresses the selection of a neutral Arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties. Refer to F 847 E The finding is: The policy and procedure (P&P) titled Arbitration Agreements with revision date 10/22/22 revealed there was no documented evidence the Binding Arbitration Agreement provides for a selection of a neutral Arbitrator agreed upon by both parties and a venue that was convenient to both parties. The facility's Binding Arbitration Agreement dated 8/21/19 revealed there was no documented evidence the Binding Arbitration Agreement provides for a selection of a neutral Arbitrator…

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 3/17/23, 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 two (Residents #153 and #155) of 8 residents reviewed. Specifically, Residents #153 and #155 had unkempt (long/jagged/dirty) fingernails. Additionally, Resident #155 was unkempt had oily disheveled hair and the presence of unwanted facial hair. The findings are: The policy and procedure (P&P) titled Activities of Daily Living (ADLs) Maintain Abilities dated 2/13/2018 documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following ADLs: Hygiene - bathing, dressing, grooming and oral care. A resident who is unable to carry out ADLS will receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the Standard survey completed on 3/17/23, the facility did not ensure that the residents' environment remains as free from accident hazards as is possible. Specifically, three (First Floor, Second Floor, Third Floor) of three resident use floors in one (South Building) of two buildings had issues with water temperatures exceeding 120 degrees Fahrenheit (°F). This involves Resident #86. The findings are: The facility policy and procedure titled, Water Temperatures, Safety of, issued 11/9/16, documented tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/ shower areas shall be set to temperatures of no more than 120 °F. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. During an observation on 3/12/23 at 10:30 AM, the hot water…

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

Based on interview and record review conducted during a Standard survey completed on 3/17/23, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice for one (Resident #166) of one resident reviewed. Specifically, Resident #166 did not receive ongoing monitoring of vital signs upon return to the facility after dialysis. The finding is: The facility policy and procedure (P&P) titled Care of a Resident with End-Stage Renal Disease revised 9/5/18, documented to monitor for vital signs (VS) especially blood pressure (BP) before and after the dialysis session and as needed. Additionally, the nurse will document pertinent information in the progress notes, 24-hour report and care plan when indicated. The facility P&P titled Dialysis revised 1/19/19, documented post dialysis monitoring: licensed nurse to obtain blood pressure and pulse. 1. Resident #166 was admitted to the facility with diagnoses including end-stage renal disease (ESRD), type 2 diabetes mellitus, and morbid obesity. The Minimum Data Set (MDS- 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 and interview during the Standard survey completed on 5/6/21, the facility did not maintain all essential mechanical, electrical, and patient care equipment in safe, operating condition. Specifically, the plumbing system on one (North Building A Wing) of six resident units had open and unsealed toilet and sink waste lines. The findings are: 1) Observations in the North Building A Wing on 4/29/21 from 2:05 PM until 3:30 PM revealed this 36-bed unit was vacant. a. Observation in the North Building A Wing on 4/29/21 at 2:27 PM revealed the bathroom sink in Resident room [ROOM NUMBER] had an unsealed waste line, with a rag placed at the end of the line. b. Observation in the North Building A Wing on 4/29/21 at 3:28 PM revealed the bathroom toilet in Resident room [ROOM NUMBER] had an unsealed waste line, with a rag covering it. During an interview on 5/4/21 at 2:45 PM, the Maintenance Director stated the sink and toilet were removed from the vacant A Wing to be used elsewhere in the building,…

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 5/6/21, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to appropriate officials (including the State Survey Agency) for one (Resident #60) of four residents reviewed for alleged abuse. Specifically, an alleged incident of sexual abuse was not reported timely to the New York State Department of Health (NYS DOH) within the two-hour timeframe as required. The finding is: Review of the facility policy and procedure (P&P) titled Abuse Prohibition Program revised 11/20/2017 documented facility it is the responsibility of our employees to promptly report any incident or suspected incident of neglect or resident abuse. All alleged violations and results of all investigations shall be reported immediately to the Administrator of the facility and to other officials in accordance with New York State…

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 5/6/21, the facility did not provide food and drink that was palatable, attractive, and served at a safe and appetizing temperature. One (North Building) of two resident units reviewed for food temperatures during the lunch meal on 5/4/21 had issues involving items that were not palatable and not served at appetizing temperatures. Residents #3, 36, 55, 83, 121, 135 and 143 were involved. Review of an undated facility policy and procedure entitled Meal Distribution Policy revealed food is to be transported to the dining locations in a manner that ensures proper temperature maintenance (through the use of a traveling Cambrio (meal cart), which protects against contamination by being covered prior to being placed in the traveling Cambrio) and are delivered in a timely and accurate manner. All items will be transported promptly for appropriate temperature maintenance from the South Kitchen to the North dining room by way of A Wing entrance. Proper food handling techniques to prevent…

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.