Woodbury Heights Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure a system of records and accounts of all controlled drugs were maintained, and the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for three (Resident #207, Resident #301, and Resident #340) of three residents reviewed during the medication storage task and 2) one (Woodcrest 2 Unit) of nine units observed during the medication storage task. Specifically, 1) Resident #207 and Resident #301 Controlled Substance Disposition Record were not accurately reconciled after the medications were administered to the residents. -A Blister Pack containing 12 Marinol 10 milligram capsules (Scheduled III drug) was observed stored in the locked box in the medication refrigerator; however, there was no Controlled Substance Disposition Record maintained for 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 the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure all drugs and biologicals used in the facility were maintained and stored under proper temperature control. This was identified during a Medication Storage and Labeling Task on one ([NAME] 2 Unit) of nine Nursing Units observed. Specifically, [NAME] 2 Nursing Unit medication refrigerator temperature was observed to be at 60 degrees Fahrenheit. There were two unused/unopened Insulin injection pens and a box of Trulicity (used for Diabetes) injection pens observed stored in the medication refrigerator. Both unopened medications were supposed to be stored in the refrigerator at a temperature between 36 degrees Fahrenheit to 46 degrees Fahrenheit as per the manufacturer's recommendations. The finding is: The facility's Storage of Medication Requiring Refrigeration policy and procedure revised on 7/24/2024 documented that the facility will ensure all…

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 staff interviews during the Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure laboratory services were obtained in a timely fashion to meet the needs of each resident. This was identified for one (Resident #108) of five residents reviewed for Unnecessary Medications. Specifically, a Lipid Profile (a blood test to determine different types of fat in the blood) was ordered for Resident #108 in response to a pharmacist medication regimen review. The blood test was ordered in the electronic medical record on 9/27/2024 and 10/11/2024 but was not communicated to the laboratory and therefore was not done. The finding is: The facility's policy titled Diagnostic Tests and Results, dated 3/22/2022 documented it is the policy of the facility to identify diagnostic tests and results that are needed for the management of resident's care and delineate the timeframe in which the tests and results are expected to be performed or available. Further, the facility will ensure that the results of these tests are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review during a Recertification Survey initiated on 10/16/2024 and completed on 10/23/2024, the facility did not ensure that medical records were maintained for each resident that were complete and accurately documented in accordance with accepted professional standards of practice. This was identified for one (Resident #184) of one resident reviewed for Respiratory Care. Specifically, Resident #184 was observed receiving oxygen therapy via a nasal cannula on 10/16/2024, 10/17/2024, and 10/21/2024 as per their Physician's order; however, there was no documented evidence that the resident was administered oxygen therapy on 10/16/2024, 10/17/2024, and 10/21/2024. The finding is: The facility policy titled Medication and Treatment Administration Record dated 4/2008 and last revised 5/2023 documented unit licensed nurses are provided with a resident medication profile to ensure medications and treatments are given as ordered. The licensed nurses must adhere to policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during a complaint investigation survey NY00337265, the facility did not ensure each resident was free from misappropriation of the resident's property and exploitation. This was identified for one (Resident #1) of three residents reviewed. Specifically, Resident #1's bank card was used by Licensed Practical Nurse #1 to withdraw money totaling 1,000 dollars without the resident's authorization. The findings are: The Facility Policy and Procedure titled Abuse Prohibition and Prevention: Misappropriation of Resident Property, dated 9/1/2016 and last revised on 10/24/2022, defined misappropriation of resident property as the theft, unauthorized use or removal, embezzlement, or intentional destruction of the Resident's personal property, including but not limited to money, clothing, and other possessions belong to the resident, without regard to monetary value. The Facility's Non-Fraternization Policy documented that fraternizing among the employees 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 staff interview and facility document review, the QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvement) committee failed to monitor interventions and implement an appropriate plan of action for an identified quality deficiency regarding smoking noncompliance. This failure resulted in non-compliance in regulations related to smoking safety and noncompliance during an abbreviated survey. Findings included: The policy entitled Quality Assurance and Performance Improvement dated 05/03/2023 documented The facility will develop, implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement program that focuses on indicators of the outcomes of care and quality of life. On 02/29/2024 at 4:06 PM an Immediate Jeopardy was called regarding smoking noncompliance for one resident (Resident #1). An extended survey was completed on 03/04/2024. The Quality Assurance and Performance Improvement committee notes dated 06/01/2023 and 08/30/2023 documented Random Administrative Supervision at Smoking Sessions…

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 conducted during a complaint investigation, Complaint # NY00332067 initiated on 2/8/2024 and completed on 2/12/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the New York State Department of Health. This was identified for one (Resident #1) of three residents reviewed for Abuse. Specifically, the facility did not report an allegation of physical abuse to the New York State Department of Health within 24 hours when Resident #1 complained that Certified Nursing Aide #1 handled the resident roughly during care and it was reported to the nursing supervisor. The resident stated Certified Nursing Assistant #1 grabbed the resident's left arm, twisted, and pushed to turn the resident. The findings are: The facility's policy titled, Abuse Prohibition and Prevention Accident Investigation Report dated 11/16/2023 documented that if there is belief or suspicion of abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews during the Recertification and Abbreviated surveys (NY00304799 and NY00320391) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure nursing services are provided by sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. Additionally, the facility did not provide services by sufficient number of licensed nurses and nurse aides (assistants) on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Specifically, 1) 10 of 10 Residents in the Resident Council meeting held on 8/2/2023 reported chronic understaffing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was not effectively administered to ensure sufficient staffing was provided to promote the highest practicable physical mental and psychosocial well-being of each resident. The Facility Assessment did not include the overall number of facility staff needed to ensure that each resident's needs were being met. Additionally, the Administrator did not monitor and enhance the quality of care and services by repeating the same deficiencies including: F656 Develop/Implement Comprehensive Care Plan, F658 Services Provided meet Professional Standards, F689 Free of Accident Hazards/Supervision/Devices and F840 Use of Outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure sufficient number of qualified staff required to meet each resident's needs. The facility assessment did not consider a review of individual staff assignment and systems for coordination and continuity of care for resident's within and across these staff assignments. Additionally, the facility assessment did not include the need for the respiratory care clinicians on the ventilator unit. The finding is: Review of the Facility assessment dated [DATE], in its entirety, revealed that there was no overall number of facility staff needed included in the assessment to ensure that each resident's needs were being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident is treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (Resident #224) of one resident reviewed for resident rights. Specifically, during a lunch meal observation on 8/1/2023 at time 1:05 PM Registered Nurse (RN) #13 was observed standing over Resident #224 while feeding the resident. The finding is: The facility's policy titled Assisting with Feeding dated 10/26/2022 documented to provide assistance with feeding to residents who require it as part of their care plan in the nursing home. This policy aims to ensure that residents receive proper nutrition and hydration, maintain their overall health, and experience a comfortable dining experience. Staff will respect residents' preferences and dignity while assisting with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00309550) initiated on [DATE] and completed on [DATE], the facility did not ensure that residents and/or their Designated Representatives participated in the development and implementation of his or her person-centered plan of care. This was identified for one (Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that Resident #43 had a Comprehensive Care Plan (CCP) meeting held since [DATE]. Additionally, there was no documented evidence that the resident's Health Care Proxy (HCP)/Designated Representative was invited to a CCP meeting since [DATE]. The finding is: The facility's policy titled, Care Plan Scheduling and Meeting dated [DATE] documented to provide each resident with an individualized interdisciplinary plan of care. Scheduling of the CCP Review and Meetings will be generated by the Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00310476 and NY00309550) initiated on [DATE] and completed on [DATE], the facility did not immediately consult with the resident's Physician and/or notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for two (Resident #738 and Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that 1A) Resident #738's Designated Representative was informed when the resident developed a Stage 3 pressure ulcer to their left shoulder on [DATE], 1B) Resident #738's Physician was not notified when the Licensed Practical Nurse (LPN) #7 identified a significant change in Resident #738's condition from [DATE] to [DATE], and 2) Resident #43's Designated Representative was informed when the resident became positive for COVID-19 infection…

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 interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on two of three nursing units in the Woodcrest Building. Specifically, on 8/4/2023 on the Woodcrest 1 unit there was an upholstered couch used by residents in the common area that was soiled and stained; and on Woodcrest 3 unit there were two upholstered chairs used by residents in the common area that were soiled and stained. The finding is: The facility's policy titled, Cleaning Furnishings, dated 6/1/2022, documented to create a clean and hygienic environment for residents, staff, and visitors, promoting infection prevention and overall well-being. Nursing home staff will conduct routine cleaning of all furnishings in common areas, resident rooms, and other designated spaces, as per the established cleaning schedule. Routine cleaning will include dusting, vacuuming, and spot-cleaning of stains to maintain 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 initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that all residents were free from physical restraints imposed for the purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was identified for one (Resident #455) of one resident reviewed for restraints. Specifically, Resident #455 was observed in their bed with the right side of the bed placed against the wall. On the left side of the bed three pillows were observed folded in half and wedged between the mattress and bed frame which caused the mattress to curve upward and prevented the resident for exiting the bed. There was not a physician's order or an assessment for the use of pillows to prevent the resident from exiting the bed. The finding is: The facility's policy titled Restraints dated 1/25/2008 and last reviewed 4/2015 documented that the facility shall promote and encourage 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 observations, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was identified for one (Resident #91) of one resident reviewed for Dialysis. Specifically, there was no Dialysis or Renal care plan created for Resident #91, who received bedside dialysis in the facility. The finding is: The facility's policy titled Comprehensive Care Plan, dated 2/1/2021, documented residents of the facility will have a Comprehensive Care Plan (CCP) completed in accordance with Federal and State requirements. The CCP will include the resident's problems, strengths, and needs. An individual CCP will be developed for each problem, strength, or need, measurable objectives, and timetables in order to meet the resident's physical, mental and psychosocial needs that are identified from the Resident's…

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, record review, and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that services were provided or arranged by the facility, as outlined by the comprehensive care plan, to meet professional standards of quality. This was identified for two (Resident #91 and #422) of 27 residents observed during the initial tour on Seacliff 1 unit. Specifically, Resident #91's and #422's tube feeding bottles were not labeled with the resident name, date, or start time. The findings are: 1) Resident #422 was admitted with diagnoses including Multiple Sclerosis, Respiratory Failure, and Epilepsy. The 7/2/2023 annual MDS assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had moderately impaired cognitive skills for daily decision making. The resident was also non-verbal and ventilator dependent. The Physician's order as of 8/1/2023 documented to administer Jevity 1.5, 65 milliliter (ml) per hour, start time 4 PM, 1500 ml per 24 hours. On 8/1/2023 at 10:08 AM 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 observation, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain grooming, and personal hygiene for one (Resident#343) of eight residents reviewed for ADLs. Specifically, on 8/1/2023 Resident #343 was observed lying in bed in a hospital gown with a towel over their chest and abdomen. Coffee had spilled onto the towel, the resident's call bell was behind the resident on the head board and the resident's fingernails were observed to be long, untrimmed, and dirty on both hands. The finding is: The facility's policy titled Activities of Daily Living - General, dated 5/1/2021, documented to ensure residents receive all necessary care including activities of daily living. This policy aims to promote resident independence, dignity, and well-being while ensuring their safety and comfort. This policy applies to all residents in the nursing home who require assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for 1) one (Resident #318) of three residents reviewed for skin conditions and 2) for one (Resident #455) of one resident reviewed for Restraints. Specifically, 1) Resident #318 did not receive the physician ordered wound treatment to the resident's bilateral legs on 8/6/2023. 2) Resident #455 with diagnoses including crushing injury of the head and traumatic hemorrhage of the cerebrum (brain), had a physician's order to utilize a helmet at all times and on six occasions Resident #455 was observed without wearing the helmet. Additionally, the physician's order was discontinued on 8/3/2023 by Licensed Practical Nurse (LPN) #8 without notifying the resident's…

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, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure the resident environment remained as free of accident hazards as is possible. This was identified for one (Resident #39) of four residents observed for medication administration. Specifically, during the medication pass observation conducted on 8/2/2023 Resident #39 was observed with a bottle of Tylenol PM (pain medication also used to assist with sleeping), antacid tablets, and a tube of Icy-Hot pain cream at the resident's bedside. There was no Physician's order for the Tylenol PM, antacid tablets, or tube of Icy-Hot pain cream and the resident was not assessed to self-medicate. The finding is: The facility's policy titled, Preventing Accidents, dated 6/24/2022, documented staff will provide appropriate supervision and monitoring of residents, especially those at higher risk of accidents due to cognitive impairment or mobility issues. Staff will closely observe residents during activities and assist as needed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that medications were administered within one hour of the ordered administration time. This was identified for 1) one of three units in the [NAME] building on 8/1/2023; 2) one of three units in the Sagamore building on 8/6/2023; and 3) the facility did not ensure that an account of controlled drugs was maintained on each unit for one of three units in the Woodcrest building. Specifically, 1) on 8/1/2023 on the Woodcrest 3 unit during the 7:00 AM-3:00 PM shift, 13 residents ( Resident #200, #358, #120, #341, #45, #639, #319, #210, #366, #241, #387, #303, #169) did not get there 9 AM medications within one hour of the physician-ordered administration time; 2) Five (Resident #4, #261, #379, #426, and #442) of 30 residents on Sagamore 2 unit received medications beyond one hour of the scheduled administration time on 8/6/2023 during the 7:00 AM-3:00 PM…

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 during the Recertification Survey and Abbreviated Survey (NY 00299549) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident was free from any significant medication errors. This was identified for one (Resident #638) of one resident reviewed for significant medication errors. Specifically, on 7/18/2022 Resident #638 received two doses of Ambien (hypnotic for sleep which is a controlled substance), 10 milligrams each, for a total of 20 mg. The physician order documented a maximum daily dosage of one tablet (10 mg). The finding is: The facility's policy, titled Medication Administration, dated 5/14/2020, documented to promote medication safety, prevent medication errors, and to ensure that residents receive their prescribed medications in a timely and appropriate manner. Medication administration will be conducted according to each resident's individualized care plan and physician's orders. Medication administration times will be strictly adhered to, and medications will be administered at the prescribed…

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 staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each controlled-substance storage box was separately locked as per the state and federal guidelines. This was identified for one of two medication carts on Seacliff 1 unit on 8/8/2023. Specifically, on 8/8/2023, a controlled substance box in a medication cart on Seacliff 1 unit did not have a lock. The unlocked box was observed with narcotic controlled substances. The finding is: The facility's policy, titled Medication Storage, dated 5/1/2021, documented all controlled substances, as defined by federal and state regulations, will be stored in a double-locked area within the medication cart or cabinet. The double locking will include both a locked drawer or compartment and a lock securing the medication cart or cabinet itself. On 8/8/2023 at 2:07 PM on Seacliff 1 unit a medication cart was observed with Licensed Practical Nurse (LPN) #1. The narcotic box (controlled substance storage box) within the medication cart did not have…

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 during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure outside services were provided to resident timely as per their Physician's orders. This was identified for one (Resident #97) of one resident reviewed for Psychotropic Medication Side Effects. Specifically, Resident #97, with a medical diagnosis of Parkinson's Disease was on a psychotropic medication, Zyprexa, as per their Physician's orders. A Physician's order for a Neurology consult due to increased shakiness was put in place on 5/12/2023. The resident has not been seen by the Neurologist as of 8/10/2023. The finding is: The facility's policy titled, Consults dated 2/21/2021 documented to provide residents with consultation services in accordance with their plan of care and as ordered by a physician. The physician will order the consult. The nurse generates the Consultation Request form. If the facility has the consultant in-house, the consult request will be sent directly to the consultant for review and scheduling. Once completed,…

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 initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside. This was identified 1) one (Resident #343) of eight residents reviewed for Activities of Daily Living (ADL) and 2) one (Resident #259) of three residents reviewed for the communication-sensory care area. Specifically, 1) On 8/1/2023, Resident #343's call light was wrapped over the head of the bed frame while the resident was in bed. The call bell was not in view or within reach of the resident. 2) Resident #259, with diagnoses of Chronic Obstructive Pulmonary Disease and Muscle weakness was observed on three occasions without access to their call bell. The findings are: The facility's policy, titled Call Light, dated 1/10/2023, documented every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that a thorough investigation was conducted for one of three residents reviewed for accidents. Specifically, Resident #471 had two Accidents/Incident (A/I) reports with injuries without an investigation to determine whether the call bell was functioning, was within the resident's reach, and if the call bell was activated prior to the incident. The finding is: The Facility Policy titled Abuse Prevention Program Policy and Procedure dated 12/2017 documented it is the policy of the facility that all reports or allegations of abuse, mistreatment, neglect and/or misappropriation of resident belongings be promptly and thoroughly investigated. Resident # 471 was admitted with diagnosis that include Schizophrenia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed to meet each resident's individualized care needs. This was identified for one (Resident #12) of two residents reviewed for Behavior and for one (Resident #279) of one resident reviewed for Urinary Tract Infections (UTI). Specifically, 1) Resident #12, who had a history of accusatory behavior, did not have a CCP developed addressing the need for a two person approach during care 2) Resident # 279 did not have a CCP developed for the use of an Antibiotic to treat a UTI. The findings are: 1) Resident #12 has diagnoses which include Cerebral Infarction and Hypothyroidism. The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was understood and was able to understand. The resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident 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 observation, record review, and interview during a Recertification Survey completed on 5/24/2021 the facility did not ensure that for one (Resident #360) of four residents reviewed for medication administration, the Licensed Practical Nurse (LPN) #3 followed the Physician's order as written. Specifically, the LPN crushed the medication Clozaril (Antipsychotic) 100 milligrams (mg) two tablets and placed the crushed medication in Resident #360's food without a Physician's order to crush the medication. The finding is: Resident #360 was admitted to the facility with a diagnoses that include Schizophrenia and Anxiety Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also documented that the resident had delusions. The resident received Antipsychotic and Antianxiety medication 7 of 7 days during the look-back period. The Physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure the resident environment remains free of accident hazards. This was identified for 2 of 3 residents reviewed for accidents. Specifically, 1) Resident # 249, who was identified as an elopement risk and wore a wander guard, entered an elevator and was able to reach the facility lobby on 1/23/2021. The elevator door did not function as intended with the use of the wander guard. The Registered Nurse Supervisor (RNS) did not report the elevator door malfunction. Subsequently, on 3/1/2021 Resident #249 entered the elevator and was able to reach the facility lobby again. 2) Resident #36 was using a wheelchair with a broken removable right arm rest which was identified on 5/21/2020 and was not addressed by the facility staff until 5/24/2021. The findings are: 1) The facility policy entitled Wandering Residents Security system dated 12/2004 documented that an elevator alarm system…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that each resident is free from unnecessary medications. This was identified for one (Resident #60) of five residents reviewed for unnecessary medications. Specifically, Resident #60 was prescribed Haldol (an antipsychotic medication), which was increased from 10 milligrams (mg) twice daily to 20 mg twice daily without documented evidence of the justification for the increase of the Haldol. The finding is: Resident #60 has diagnoses that include Dementia superimposed on Schizoaffective Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The resident had no verbal or physical behavior problems identified on the MDS. On 05/17/2021 at 3:50 PM the resident was observed sleeping in bed. The physician's order dated 2/14/2021…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021, the facility did not ensure that outside professional services were furnished in a timely manner for one (Resident #472) of 5 residents reviewed for unnecessary medications. Specifically, Resident #472 had a Physician's order for a Psychiatry consult dated 4/25/2021 and the Psychiatry consult was not completed as of 5/24/2021. The findings is: Resident #472 was admitted on [DATE] and readmitted on [DATE] with diagnosis including Dementia with Behavioral Disturbances. A Progress Notes dated 4/25/2021 at 2:38 PM , written by the Nurse Practitioner (NP) documented the NP was asked to see resident for behavior, and that the resident placed themselves on the ground and was laying on ground refusing to get up. A Nursing Note (NN) dated 04/25/2021 at 5:19 PM documented the resident attempted to kick/punch staff and was removing the suprapubic (hollow flexible tube inserted directly to the bladder to drain the urine)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews during the Recertification Survey completed on 5/24/2021 the facility did not ensure that each resident was offered Influenza and Pneumococcal vaccination and that each resident's medical record documented whether or not the resident received the immunization. This was identified for 1 (Resident # 13) of 5 residents reviewed for Influenza and Pneumococcal immunizations. Specifically, Resident #13's medical record lacked documented evidence of whether the resident received or declined the Influenza and Pneumococcal vaccines. The finding is: The facility's undated policy titled Conducting the Vaccination Program documented within 5 days of Admission/readmission the admitting nurse will complete the admission vaccine assessment, noting the resident's Influenza/Pneumococcal vaccine status. Resident #13 was admitted to the facility with diagnoses including Diabetes Mellitus, Non-Alzheimer's Dementia, and Chronic Kidney Disease. The admission Minimum Data Set (MDS)…

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.