Hudson Hill Center For Rehabilitation & Nursing

Based on record review and interviews during an abbreviated survey (NY00372408), the facility did not ensure that all alleged violations are thoroughly investigated for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, on 1/5/2025 Resident #1 obtained hot liquid from the hot liquid cart on the unit and carried the hot liquid to another resident's room unwitnessed/undetected by staff. Resident #1 immersed their feet in the hot liquid for 25 to 30 minutes and sustained second and third- degree burns to both feet. The accident/incident report documentation was noted to be inconsistent with the summary of events reported by Resident #1 and the witnesses to the incident on 1/5/2025. Additionally there was no documented evidence of statements from Certified Nurse Aide #1 and Resident #2, who were witnesses to the incident that occurred on 1/5/2025. The Findings are: The Facility undated Accidents and Incidents-Investigating and Reporting policy documented the following data as applicable, shall be included on the Report of Incident/Accident form: the date and time 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 record review and interviews during a partial extended survey, the facility administrator did not ensure they used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 1/5/2025 a resident obtained hot water from the hot liquid cart and sustained second- and third-degree burns. The Administrator did not initiate any policy changes or protocol updates to prevent reoccurrence of such incidents or provide any documentation to support review of the incident details. In addition, the Administrator also did not provide any documented evidence of action plans or performance improvement plans implemented for identified areas of deficiencies discussed in Quality Assurance and Performance Improvement meetings held on 2/3/2025, 2/12/2025 and 2/27/2025. The findings are: The facility Quality and Performance Improvement policy dated documented the Quality Assurance and Improvement program includes the establishment of a Quality Assessment and Assurance committee and 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 record review and interviews conducted during a partial extended survey (NY00372408), the facility did not ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, on 1/5/2025 a resident obtained hot water from the hot liquid cart and sustained second- and third-degree burns. There were no documented evidence of any good faith attempts by the committee to identify and correct the deficiencies brought about by the 1/5/2025 incident. The findings are: The facility undated Quality Assurance and Improvement policy documented it is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Improvement program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. The Quality Assurance and Improvement program includes the establishment of a Quality Assessment and Assurance committee and a written…

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

Based on interview and record review during the recertification survey from 12/11/2024 to 12/18/2024, the facility did not ensure residents had the right to privacy when sending and receiving mail. This was evident for 15 (Resident #s 150, 202, 248, 246, 370, 126, 146, 185, 15, 181, 133, 22, 205, 162, and 51) of 15 resident in attendance at the Resident Council Meeting. Specifically, Resident #s 150, 202, 248, 246, 370, 126, 146, 185, 15, 181, 133, 22, 205, 162, and 51 reported they did not have the right to personal privacy because the facility staff opened residents' mail delivered to the facility before allowing the mail to be distributed to the resident. The findings are: The facility policy titled Mail dated 05/2024 documented residents were allowed to communicate privately with individuals of their choice and may send and receive personal mail unopened unless otherwise advised by the attending physician and documented in the residents' medical records. The facility policy titled Resident Rights dated 6/2024 documented federal and state laws guarantee the resident's right to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey from 12/11/2024 to 12/18/2024, the facility did not ensure an admission policy was established and implemented that did not require a resident representative to pay for facility care without incurring personal financial liability, and did not require residents to waive their rights and facility liability for losses of personal property. This was evident for 11 out of 11 residents reviewed for Admission. Specifically, 1) Resident #s 162, 268, 229, 90, 259, 175, 194, 108, 212, 211, and 182 were provided admission Agreements that identified the facility as a non smoking facility, required the Resident Representative to assume all responsibility for the resident, hold the facility harmless for injury, death, and loss of property, and required the Resident Representative to be personally liable for payment of charges incurred by the resident. Additionally,the admission Agreement documented residents and 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 record review and interview conducted during the recertification and abbreviated (NY00336283) survey from 12/11/2024 to 12/18/2024, the facility did not ensure that Minimum Data Set 3.0 Assessments accurately reflected the residents' status. This was evident for 1 (Resident #276) of 10 residents reviewed for Pressure Ulcers, 1 (Resident #217) of 6 residents reviewed for Accidents, and 1 (Resident #320) of 5 residents reviewed for Discharge. Specifically, 1) the Minimum Data Set 3.0 assessment inaccurately documented that Resident #276's facility acquired pressure ulcer and facility acquired deep tissue injury were present on admission 2) the Minimum Data Set 3.0 assessments did not identify Resident #217 as an active smoker, and 3) Resident #320 had a facility-initiated discharge to the community and the Discharge Minimum Data Set 3.0 assessment inaccurately documented the resident was discharged to a short-term general hospital. The findings are: The undated facility policy, Minimum Data Set guideline for completion documented the facility will ensure accurate and timely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00336283) surveys from 12/11/24 to 12/18/24, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for 2 of 10 residents (Residents #276 and #115) reviewed for Pressure Ulcers. Specifically, 1) for Resident #276 at risk for skin breakdown there was no documented evidence that preventative measures as per care plan and the use of heel booties as per the 1/30/24 physician order were implemented prior to the development of a 2/9/24 left heel pressure ulcer and 3/1/24 left dorsal foot deep tissue injury and 2) Resident #115's air mattress pressure was not inflated according to the Resident's weight. The findings are: The Policy and Procedure titled Pressure Injury Prevention and Management dated 5/2024 documented a resident who enters the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview during the recertification survey from 12/11/24 to 12/18/2024, the facility did not ensure each resident received necessary respiratory care in accordance with professional standards of practice and as ordered by the practitioner for 3 (Resident #168, Resident #194, and Resident #69) of 6 residents reviewed for respiratory care. Specifically, 1) Resident #168 was observed tracheostomy self-suctioning without a physician order, 2) Resident #194 with a physician order for 3 and/or 5 liters of continuous oxygen was observed receiving 7 and/or 8 liters of oxygen and 3) for Resident #69 there was no documented evidence to indicate the oxygen tubing/cannula were being changed. The findings are: The policy and procedure titled Oxygen Administration with a 5/2024 revision date documented, the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure, oxygen therapy is administered by way…

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 recertification survey from 12/11/2024 to 12/18/2024, the facility did not ensure residents and their representatives were explicitly informed of their right not to sign an arbitration agreement as a condition of admission to the facility. This was evident for 2 of 3 (Residents 211, and 182) residents reviewed for Arbitration. Specifically, facility admission Agreements for Resident #211, and #182 included language that the resident and/or resident representative signature was applicable to a Binding Arbitration Agreement (an attached document included in the admission Packet). The findings are: The facility admission Packet included an admission Agreement and a list of Attachments that included a Binding Arbitration Agreement. The admission Agreement documented the Attachments, Policies, and Notices here to and for which my signature is applicable include: . Attachment 16 - Binding Arbitration Agreement. admission Packets for Resident #211 signed by the resident and undated, and #182 signed by the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00356093) surveys from 12/11/2024 to 12/18/2024, the facility did not ensure an effective pest control program was maintained to ensure the facility was free of pests. This was evident for 3 (2nd, 4th, and 6th Floors) of 5 resident floors reviewed for environment. Specifically, a 2nd floor Resident reported seeing roaches in their room, and roaches were observed on the 4th and 6th Floors. The findings are: The facility policy titled Pest Control dated 6/2024 documented a written agreement with a qualified outside pest service will be maintained to provide comprehensive pest control services utilizing a variety of methods to eradicate and contain household pests, including roaches. There was no documented evidence of a valid Pest Management Contract. The Facility Survey Report and the Facility Assessment, both dated 12/11/2024, did not identify a third-party contractual agreement with a pest control company…

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

Based on record review and interview conducted during a recertification survey from 12/11/24 to 12/18/24, the facility did not ensure Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services to ensure safe delivery of care including dementia management and resident abuse prevention training. Specifically, the facility was unable to provide documentation that 5 of 5 Certified Nurse Aides (#22, #24, #25, #26, and #27), were provided dementia management training. Additionally, the facility was unable to provide documentation that Certified Nurse Aide (#27) completed12 hours in-service training, and abuse prevention training. The findings are: The Policy titled Inservice Training with a May 24 review date documented all personnel are required to attend regularly scheduled in-service training classes. The Facility Assessment with a 12/11/24 updated on date documented required in-service training for nurse aides must be sufficient to ensure continuing competence of nurse aides but must be no less than 12 hours per year. It also documented dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey from 12/11/24 to 12/18/24, the facility did not ensure the resident's right to manage their financial affairs and a resident provided written authorization prior to depositing the resident's funds with the facility 1 (Resident #162) of 2 residents reviewed for personal funds. Specifically, the facility did not inform Resident #162 upon receipt of the resident's tax refund checks in the mail and did not obtain written authorization from Resident #162 prior to depositing the tax refund checks in a facility's operating account. The findings are: The facility policy titled Privacy and Confidentiality dated 5/2024 documented personal privacy and confidentiality of each resident is maintained. The facility policy titled Personal Needs Accounts/Resident Fund Account dated 5/2024 documented all residents were offered a personal needs account, and monies deposited to a personal needs account would be held in an interest-bearing account…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey from 12/11/2024 to 12/18/2024, the facility did not ensure a resident's right to be free of misappropriation of their property. This was evident for 1 (Resident #162) of 2 residents reviewed for personal funds. Specifically, tax return checks mailed to Resident #162 were taken by the facility Business Office without the resident's knowledge or consent and deposited into the facility's bank account. The findings are: The undated facility policy titled Prevention/Identification and Reporting of Patient Abuse documented misappropriation of resident's property was defined as wrongful temporary or permanent use of a resident's money without the resident's consent. The facility policy titled Personal Needs Accounts/Resident Fund Account dated 5/2024 documented all residents have the option to open a Personal Needs Account at any time during their stay, funded by the patient, and intended strictly for their personal use. Resident #162 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, interview, and record review conducted during the recertification and abbreviated (NY00354189) surveys from 12/11/2024 to 12/18/2024, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency. Specifically, a resident-to-resident altercation involving Resident #42 and Resident #273 on 9/12/24 at 2:50 PM was not reported to the State Survey Agency until 9/12/24 at 6:17 PM. The findings are: The facility policy titled Abuse, Neglect, Exploitation Prevention & Elderly Justice Act updated 01//2024 documented the New York State Department of Health/Nursing Home Complaint Hotline was to be called to report any physical altercations, alleged abuse. neglect and/or mistreatment and injury of unknown origin. Calls must be placed within indicated time frame to prevent the facility being cited for non-compliance with Reporting. The Elder Justice Act requires nursing homes to report…

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 recertification and abbreviated (NY00352882) survey from 12/11/2024 to 12/18/2024, the facility did not ensure a resident's representative was notified in writing of a resident's facility initiated discharge. This was evident for 1 (Resident #255) of 5 residents reviewed for Discharge. Specifically, Resident #255 received a Notice of discharge on [DATE] and there was no documented evidence that a copy of the discharge notice was not sent to the resident representative. The findings are: The facility policy titled Transfer or Discharge Notice dated 6/2024 documented the resident and/or representative will be notified in writing of the reason for the resident's transfer or discharge. Resident #255 had diagnoses of medically complex conditions and depression. The Quarterly Minimum Data Set assessment dated [DATE] documented esident #255 was cognitively intact, required supervision for transfers, ambulationg, resident/family were involved in…

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

Based on record review and interview conducted during the recertification and abbreviated survey (NY 00344069) from 12/11/24 to 12/18/24, the facility did not ensure each resident was provided with the necessary care and services to ensure the resident's ability to communicate their needs to staff was available. This was evident for 1 of 2 residents (Resident #275) reviewed for communication. Specifically, Resident #275 who spoke Spanish as their primary language was not provided with a Spanish translator as indicated in the resident's Care Plan. Additionally, the staff did not know how to access a translation device or services. The findings are: The policy titled Communication/Language documented make every effort to provide interpretive services for residents whose primary language is other than English. The facility staff will strive to ensure meaningful language access and communication services are available for all limited English proficient persons. Resources available for language access service during hours of facility operation, include the following: a)Language Access…

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 (NY00348967), the facility did not provide person-centered care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being for one of six residents (Resident #271) reviewed for Accidents. Specifically for Resident # 271 with a history of pneumonitis due to inhalation of food/vomit and dysphagia the facility did not develop and/or implement a plan to address the resident's individual needs and minimize risk of potential choking hazards as per 3/25/24 hospital visit summary swallowing recommendations for a soft, bite-sized diet texture, mildly thick liquids with no straw, and intermittent supervision to monitor for aspiration and after Resident #271 verbalized a 6/28/24 request for chopped texture proteins due to difficulty with chewing chicken and beef. Additionally, the facility did not thoroughly investigate an incident to rule out choking after Resident #271 was found…

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 recertification and abbreviated (NY 00348067) survey from 12/11/2024 to 12/18/2024, the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for 1 (Resident #271) of 6 residents reviewed for Accidents. Specifically, Medical Doctor #1 did not review and document a hospital Speech Pathology dysphagia diagnosis and diet texture recommendations for Resident #271 and did not review a Dietician note documenting Resident #271 had difficulty eating a regular texture diet. The findings are: The facility policy titled Aspiration Precaution dated 5/2024 documented the interdisciplinary team will collaborate and develop a personalized care plan documenting the resident's dietary recommendations and supervision needs. Resident #271 had diagnoses of cerebral infarction with left hemiplegia and hemiparesis, aphasia, and dysarthria. The Minimum Data Set 3.0 assessment…

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

Based on interview and record review conducted during a recertification survey conducted from 12/11/24 to 12/18/24, the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (Resident #220) of four residents reviewed for mental health services. Specifically, a psychology consult for Resident #220 was not conducted as per physician order. The findings are: The Policy titled Consultations, dated 5/24. documented medical consultations services provided in the facility are completed by the medical staff that has been approved by the credentialing process outline in the medical staff by-laws. Resident #220 was admitted with diagnoses including acute stress reaction, uncomplicated alcohol dependence, uncomplicated cocaine abuse. The Care Plan (dated 8/9/23 and revised 9/23/24) titled Recent Right Leg Amputation (accident or injury) documented encourage expression of fears, negative feelings, and grief over the loss of body part. Help the amputee cope…

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 interview conducted during the recertification survey from 12/11/24 to 12/18/24, the facility did not ensure all drugs and/or biologicals in 1 of 3 medication storage rooms and 1 of 6 medication carts were labeled and stored in accordance with professional standards. Specifically, an insulin pen, (Lantus Solostar 100 units) for Resident #93 with a use by date of 11/6/24 remained in the refrigerator on unit 4 and a controlled medication (Phenobarbital) remained in the locked drawer of the moveable medication cart on unit 4. The findings are: The policy titled Medication Storage in the Facility with a revision date of June 24 documented outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy if a current order exists. Controlled medications following the medication pass are returned to the double locked cabinet, in a timely manner.…

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

Based on observation, interview, and record review during the recertification and abbreviated surveys from 12/11/24 to 12/18/24, the facility did not ensure residents had the right to a dignified experience for 1 of 1 resident (Resident #90) reviewed for dignity. Specifically, the fitted mattress sheet on Resident #90's bed was observed stained and not changed for six days. The findings include: The policy titled Rights/Dignity Resident dated 6/24 documented promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in recognition of a person-centered care approach. 1)Resident #90 was admitted with diagnoses including neuromuscular dysfunction of bladder, unspecified retention of urine, and acquired absence of kidney. The Annual Minimum Data Set (resident assessment) dated 10/23/24 documented Resident #90 was cognitively intact. The care plan titled Resident is Dependent on staff daily for Activities of Daily Living needs, revised 10/15/24, documented needs will be met by staff as evidenced by being well…

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

Based on record review and interviews conducted during an abbreviated survey (NY00347152), the facility did not ensure residents were free from abuse neglect/misappropriation of property and exploitation and that non dialysis residents were protected for 1 (Resident #3) of 3 residents reviewed. Specifically, (1) on 7/2/2024 during a discharge planning meeting with the facility social worker, Resident #1 alleged that the dialysis transportation worker withdrew a total amount of $5,900 from their cash app account. The incident was reported to Law enforcement on 7/3/2024. The facility did not ensure the transportation worker did not have access to resdientst who were not on dialysis. The findings are: The Policy and procedure titled Abuse, Neglect, Mistreatment & Exploitation Prevention & Elder Justice Act last reviewed 02/06/24 documented, .It is our policy to ensure that residents are free of verbal, neglect and misappropriation of property Resident #3 had diagnoses including but not limited to Congestive Heart Failure, Cerebral Infraction, and Ataxia following other Cerebrovascular…

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

Based on record review and interviews conducted during an abbreviated survey (NY00347152), the facility did not ensure residents rights to be free from abuse/misappropriation of property for 1 (Resident #3) of 3 residents reviewed for abuse. Specifically, on 7/2/24 during a discharge planning meeting with the facility social worker, Resident #3 alleged that the dialysis transportation worker withdrew a total amount of $5,900 from their cash app account. The incident was reported to Law enforcement on 7/3/24; (2) There was no documented evidence that other residents who were transported by the dialysis transportation worker were interviewed after the incident. The Findings are: The policy and procedure titled Abuse, Neglect, Mistreatment & Exploitation Prevention & Elder Justice Act last reviewed 02/06/24 documented, It is our policy to ensure that residents are free of verbal, neglect and misappropriation of property Resident #3 had diagnoses including but not limited to Congestive Heart Failure, Cerebral Infraction, and Ataxia following other Cerebrovascular Disease. 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.

Based on record review and interviews conducted during an abbreviated survey (NY00326265), the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 2 of 3 Residents (Resident #1, #4) reviewed for quality of care. Specifically, the facility did not ensure a timely gynecological appointment for Resident #1 who had episodes of vaginal bleeding and a pelvic ultrasound result with a service date 3/20/23 showed enlarged extremely heterogeneous lobulated uterus most likely due to multiple fibroids. Resident was transferred to the hospital on 6/20/2023 for vaginal bleeding; 2) Resident #4 was admitted to the facility with intravenous antibiotic for infection on 6/6/2023. Resident #4's intravenous antibiotic infusion did not begin until 6/9/2023 after the resident's family representative brought it to the attention of facility staff. Findings include: The facility undated policy on Quality of Care documented the facility will ensure it identifies and provides the needed care and services that are person…

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 conducted during the Recertification Survey from 8/30/23-9/8/23, the facility did not ensure that residents or residents' representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood, and the facility did not notify the Ombudsman for 6 of 6 residents (Residents # 2, 79, 222, 68, 97, and 215) reviewed for hospitalization. Specifically, the residents were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the residents' representatives and that notification was sent to the Ombudsman. The findings are: 1. Resident # 2 was admitted to the facility with diagnoses which included coronary artery disease, diabetes mellitus, and seizures. The Minimum Data Set (MDS-a resident assessment tool) admission assessment dated [DATE] documented Resident #2 had intact cognition and required assistance with activities of daily…

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 from 8/30/23-9/8/23, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy for 6 of 6 residents (Residents # 2, 79, 222, 68, 97, and 215) reviewed for hospitalization. Specifically, the residents were transferred to the hospital and the facility was unable to provide evidence that written notice of the facility Bed Hold Policy was given to the residents or their representatives. The findings are: The facility policy, 'Bed Reservation (Bed-Hold) and Return', effective date 1/04/23, reviewed 8/31/23, documented that the facility will provide information regarding its bed reservation policy to the resident/resident's representative at the time of transfer. 1. Resident # 2 was admitted to the facility with diagnoses which included coronary artery disease, diabetes mellitus, and seizures. The Minimum Data Set (MDS-a resident assessment tool) admission assessment 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 observations, interviews, and record review during the Recertification Survey from 8/30/23 to 9/8/23, the facility did not ensure residents had the right to a dignified existence for 3 of 6 residents observed for dining. Specifically, Residents #132, #109, #79, were observed being fed by staff while staff were standing over the residents. The findings are: The facility policy for Assistance with Meals dated 3/2023, documented, Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. For example, not standing over Residents while assisting them with meals. 1. Resident #132 was admitted with diagnoses of hypokalemia, dementia, and Diabetes Mellitus II. The Minimum Data Set (MDS, an assessment tool) dated 7/28/23 documented the resident required extensive assistance with eating. During an observation on 8/30/23 at 12:36 PM in the second-floor dining area, Certified Nurse Aide (CNA) #5 was observed standing over Resident #132 and looking around while feeding them.…

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 a recertification survey and abbreviated surveys (NY 00320148), the facility failed to protect residents right to be free from abuse and psychological harm. The facility did not ensure that each resident was protected from resident-to-resident altercations for 1 of 4 residents (Resident #68) reviewed for behavior resulting in 4 other residents being assaulted (Residents #108, #153, #335, and #80). Specifically, Resident #68 had physical altercations with 4 other residents and interventions were not put in place to prevent recurrence. (1) On 11/8/22 Resident #68 slapped Resident #108 in the face; (2) On 6/15/23 Resident #68 went to Resident #153's room on another unit, Resident #68 had Resident #153 in a head lock, and Resident #153 had a minor scratch; (3) On 6/21/23 Resident #68 was arguing with Resident #335 and hit Resident #335 in the face; and (4) On 7/14/23 Resident #68 punched Resident #80 on the left jaw. The Findings are: The Facility's Policy titled Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Residents'…

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 recertification survey from 8/30/2023 to 9/8/2023, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property and includes the screening of prospective employees and residents. Specifically, an employee who was hired on a contingent basis was not provided supervision while working in the facility pending their criminal history record check (CHRC) completion/return. This was identified for 1 of 5 employees reviewed for CHRC. The findings are: Review of CHRC records of five (5) employees hired in the 6 months prior to the survey on 8/30/2023 revealed: 1 of the 5 employees, specifically a Certified Nurse Aide (CNA), was not in compliance with the supervision element of the employees' screening. The employee was hired on 5/17/2023, Form 103 (CHRC) had been submitted by the facility on 5/9/2023, and the CHRC letter of determination was received 5/22/2023. The employee worked without documented supervision on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews conducted during the Recertification Survey from 8/30/2023 to 9/8/2023, the facility did not ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's status. This was evident for 2 of 39 residents (Residents #67 and # 200) reviewed for MDS accuracy. Specifically, 1) for Resident #67, the MDS assessment did not document the resident's most recent weight, therefore the weight loss of more than 10% over 6 months was not reflected. 2) for Resident # 200, the MDS assessment did not reflect the resident having intermittent catheterization. The findings are: A review of the Policy and Procedure Minimum Data Set Completion dated 3/2023 documented it is the policy of the Regency to ensure accurate and timely completion of MDS/CCP for all residents in accordance with Federal and State Operation Manual. 1. Resident #67 was admitted with diagnoses which included Paranoid Schizophrenia, Diabetes Mellitus, and Chronic Obstructive…

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

Based on record review and interviews during a recertification survey and an abbreviated survey (NY 00320148), the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program for 1 of 2 residents, sampled for PASARR. Specifically, Resident #68 had a referral for a PASARR Level II assessment sent via fax to Ascend (an agency that assesses for appropriate placement) on 6/14/23 and there was no documented evidence of any follow up, and the Level II assessment was never completed. The Findings are: Resident #68 was admitted to facility with a 2/28/21 with the following diagnoses and medical conditions: seizure disorder, traumatic brain injury, bipolar and schizophrenia. The quarterly Minimum Data Set (MDS, an assessment tool) dated 8/10/23 documented Resident #68 had severe cognitive deficit and did not document any behaviors. Review of the resident's record revealed: - a PASARR Screen Level I was completed 5/22/23. - a referral for a PASARR Screen Level II assessment was sent via fax to Ascend on 6/14/23. There was no documented…

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 the Recertification Survey from 8/30/2023 to 9/8/2023, the facility did not ensure for 2 of 2 residents (#67 and #174) reviewed for positioning and limited mobility that appropriate treatment and services were provided to improve and/or prevent a further decrease in range of motion (ROM). Specifically, 1) Resident #67 did not have a hand roll to their right hand or a carrot splint to left hand applied as ordered by the physician. 2) Resident # 174 was not wearing bilateral knee braces and bilateral heels were not off loaded as per occupational therapy recommendations and physicians orders. The finding are: 1. Resident #67 had diagnoses which included Paranoid Schizophrenia, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. A review of the quarterly Minimum Data Set (MDS, an assessment tool) dated 8/10/2023 documented the resident had severely impaired cognition, and was totally dependent with bed mobility, transfers, toilet use 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 observations, interviews and record review conducted during the Recertification Survey from 8/30/23 to 9/8/23, the facility did not ensure accurate staffing information was posted in a prominent place readily accessible to residents, staff, and visitors. Specifically, the facility did not post the total and actual hours of licensed and unlicensed staff directly responsible for resident care daily from 8/17/2023 - 8/30/2023. The findings are: The facility policy titled Posting of Daily Staffing Numbers and dated 2/2023 documented the Nursing Staffing levels are posted by the elevator on the first or main floor. The facility Nursing Staffing Information form documented the facility will prominently display in a clearly visible place the number of Licensed and Unlicensed staff for each shift each day, and procedures documented the 11PM-7AM Supervisor would post the above information at the beginning of each day (midnight). During the initial tour of the facility on 8/30/2023 at 9:35 AM, the daily staffing sheet posted on the main floor by the elevator was dated 8/16/2023, 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 observations, interviews, and record review conducted during the recertification survey from 8/30/23 to 9/8/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1) Food contact surfaces were not maintained in a sanitary condition. 2) The three bay sink sanitizer solution was under the minimum required quaternary ammonium sanitizer test range of 150 parts per million (PPM) to ensure the concentration of the sanitizer was strong enough to kill bacteria, viruses, and fungi. 3) Multiple cold foods were not held for service at 41 degrees Fahrenheit (F) or lower. The findings are: 1) A policy and procedure dated 4/19/2013 and revised 2/2023, documented the policy was to ensure cleaning and sanitizing of food areas and kitchen equipment to prevent bacterial growth, and procedures included preparation of sanitizing solution for towels used to clean food areas and kitchen equipment. On 8/31/23 at 3:52 PM Dietary Aide (DA) #1 was observed placing 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 review, and interviews conducted during the recertification survey conducted on 8/30/2023 - 9/8/2023, the facility did not ensure that the trash compactor area was maintained in a sanitary condition to prevent the harborage and feeding of pests, was free from leaks, free of debris, and free of foul odors. Specifically, the ground near the trash compactor was littered with paper and plastic debris, gnats and flies were observed around the trash compactor, and a pool of yellow-ish/green-ish colored liquid with white foam on its surface was observed under the front left wheel of the compactor and was emanating a strong, sour odor. The findings are: The facility's policy and procedure titled Cleaning of Compactor Area noted a revision date of July 2023 and documented Daily the following tasks will be done by housekeeping staff at 7AM, 12PM, and 05PM, and audited by the supervisor. Tasks included Items will be removed where possible, ex. garbage cans, food trucks, carts, etc., and floors will be cleaned., floors will be cleaned by damp mopping, and cleaning…

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 during the Recertification Survey from 8/30/23 to 9/8/23, the facility did not ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) Resident #132 had a Foley bag (urinary drainage bag) on the floor. 2) The facility Water Management Plan was not updated. 3) A dirty linen cart was touching and in between two clean linen carts. The findings are: 1) The facility policy titled Infection Control, dated 1/2023 documents the facility will establish and maintain standards and practices of infection control, in accordance with applicable state and city codes and the Guidelines of the Centers for Disease Control (CDC) to prevent the spread of communicable diseases within the facility, among and between residents, staff, visitors and volunteers. Resident #132…

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 conducted during the recertification survey, the facility did not maintain sanitizing equipment in accordance with professional standards for food service safety. Specifically, the low temperature dishwasher final rinse did not maintain the proper concentration of chemical sanitizer. According to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code, the recommendations for Low Temperature Dishwasher (chemical sanitization) are: - Wash - 120 degrees F; and - Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. The findings are: A tour of the kitchen conducted on 6/04/19 between 9:15 and 9:55 am revealed dishwashing in progress. The food service manager (FSM) reported the dishwasher was low temperature and chemical sanitizing. In the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification survey, the facility did not ensure that each resident was invited to participate in the care planning process. Specifically, during an initial pool interview Resident #402 stated that he had only been invited to attend one care plan meeting since admission on [DATE]. This was evident for 1 of 9 residents reviewed for resident rights. The facility Comprehensive Care Plan (CCP) policy effective 1/15/18 documented that the resident has the right to participate in the development, planning and implementation of the CCP as well as the right to be informed of changes to the plan of care and the right to see the care plan including the right to sign the care plan after significant changes. The Social Worker (SW) will inform the resident and or resident representative of the availability of the Resident Plan of Care summary via the care plan meeting. The findings are: Resident #402 was admitted with diagnoses that include; Atrial Fibrillation,…

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 recertification survey, the facility did not ensure that a device to correct visual impairment was provided to a resident in a timely manner. Specifically, 1 of 4 residents (Resident # 64) reviewed for vision did not receive prescribed glasses recommended by the Optometrist. The findings are: Resident # 64 has diagnoses including Hypertension, Glaucoma, and Cataracts. According to the 3/14/19 admission assessment, the resident was able to see large print in newspapers and books, but not regular print. The vision care plan initiated 3/7/19 and updated 5/22/19 documented the resident had impaired vision and used eye glasses. Interventions included, but not limited to, optometry consult according to the physician order, monitor for changes in vision, and notify the physician of any changes. In an interview with the resident on 5/29/19 at 10:47 AM she stated that her eye glasses were missing for three weeks while she was residing on another unit. The resident stated that the staff informed her that they would bring…

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.