Yonkers Gardens Center For Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during the recertification and abbreviated (2584489) survey from 02/05/2026 to 02/12/2026, the facility did not ensure that alleged violations involving abuse, mistreatment, or neglect were thoroughly investigated for one (1) of five (5) residents. (Resident #140) reviewed for abuse. Specifically, for Resident #140 there was no documented evidence the facility conducted a complete and thorough investigation, including statements, after Resident #140's family member reported the resident was beaten in the shower by certified nurse aides. The findings include: The facility policy and procedure on Abuse Prevention, revised 12/2025, were documented to provide a proactive and systematic approach to protecting residents' rights from harm related to abuse, neglect, or misappropriation of property. The facility protected residents' rights to be free from physical abuse and ensured that residents were not subjected to abuse by anyone, including but not limited…

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 survey 02/05/2026 - 0212/2026 the facility did not ensure a significant change Minimum Data Set assessment was completed within the 14-day requirement for one (1) of six (6) residents (Resident #2) reviewed for Nutrition. Specifically, a significant change Minimum Data Set was not initiated within 14 days for Resident #2 who had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, a decline in activities of daily living, a decline in cognition and a decline in urinary continence. The findings include:The October 2025 policy and procedure titled Minimum Data Set documented ensure accurate and timely completion of the Minimum Data Set in accordance with the State and Federal Operation Manuals. Assessments will be completed by members of the interdisciplinary team in accordance with the completion date as determined by the Minimum Data Set Director. For comprehensive assessments that require completion of Care Area Assessments all disciplines will be required to complete 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 interview conducted during the Recertification Survey from 2/05/2026 to 2/12/2026, the facility did not ensure Minimum Data Set Assessments were submitted within 14 days after the facility completed the resident's assessment for two (2) of two (2) (Resident #83 and #96) residents reviewed for Minimum Data Set. Specifically, Resident #83 and #96's Minimum Data Set Assessments were completed on 10/07/2025, and were not transmitted until 02/09/2026. The findings include:Minimum Data Set Policy and Procedure dated October 2025, documented it was the policy for timely completion of the Minimum Data Set in accordance with the State and Federal Operation Manuals.Review of the submissions revealed:- Resident # 83 Discharge Minimum Data Set 3.0, with an assessment reference date of 09/22/2025 and completion date of 10/07/2025, was transmitted on 02/09/2026.- Resident #96 Discharge Minimum Data Set 3.0, with an assessment reference date of 09/26/2025 and completion date of 10/07/2025, was transmitted on 02/09/2026.During the interview on 02/10/2026 at 10:10 AM, 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 interview conducted during the Recertification Survey from 02/05/2026 to 02/12/2026, the facility did not ensure that the Minimum Data Set assessment accurately reflects the resident's status for (1) one of (3) three residents (Resident # 46) reviewed for Smoking. Specifically, the 12/10/2025 Minimum Data Set assessment was not accurately coded to reflect Resident #46's use of tobacco. The findings include:The October 2025 policy and procedure titled Minimum Data Set documented ensure accurate and timely completion of the Minimum Data Set in accordance with the State and Federal Operation Manuals. The assessments will be completed by members of the interdisciplinary team in accordance with the completion date as determined by the Minimum Data Set Director. For comprehensive assessments that require completion of Care Area Assessments all disciplines will be required to complete the Minimum Data Set as assigned.Resident #46 was admitted with diagnoses that included but were not limited to opioid dependence, acute kidney failure and obesity.The 12/04/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure each resident received adequate supervision to prevent accidents. This was evident for one (Resident #19) of three residents reviewed for smoking. Specifically, Resident #19 was not reassessed for their ability to smoke safely and care plan interventions to prevent future noncompliance were not developed and implemented following the resident's noncompliance with facility smoking rules. The findings are:The facility policy titled Smoking dated 05/2025 documented smoking restrictions shall be strictly enforced in all nonsmoking areas. The staff should consult the Director of Nursing and Physician to determine restrictions on a resident's smoking privileges.Resident #19 had diagnoses of adjustment disorder, post-traumatic stress disorder, and nicotine dependence. The comprehensive Minimum Data Set 3.0 assessment dated [DATE] documented Resident #19 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 interviews conducted during the recertification survey from 02/05/2026 to 02/12/2026, the facility did not ensure a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for one (1) of one (1) residents reviewed for respiratory care. Specifically, Resident #92 had a physician order for oxygen via nasal canula at 4 liters per minute, and was observed receiving oxygen via nasal cannula at a rate of 2 liters per minute. The findings include:Resident #92 had diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, and Asthma.The Quarterly Minimum Data Set, dated [DATE] documented Resident #92's cognition was intact, the resident required supervision or touching assistance with activities of daily living, and the resident used oxygen.The physician order dated 08/26/2025 documented continuous oxygen at 4 liters via nasal canula. The Oxygen Therapy Care Plan dated 01/26/26 documented oxygen at…

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 Survey and Abbreviated survey (2650146) from 02/05/2026 to 02/12/2026, the facility did not ensure medications were available to meet the needs of each resident for one (1) of three (3) residents reviewed for pain management. Specifically, when Resident #205 was re-admitted to the facility, Methadone was unavailable for timely administration.Findings include:The facility policy and procedure, Methadone Use last reviewed on 12/2025, documented when methadone is prescribed for narcotic addiction only: the resident is certified as a patient of an identified Opioid Treatment Program which will supply the methadone, prior to admission to the facility.Resident #205 was admitted to the facility with diagnoses including opioid abuse with unspecified opioid-induced disorder, anxiety disorder and obstructive uropathy,The Minimum Data Set (resident assessment) dated 10/12/2025 documented Resident #205 was cognitively intact and received opioid medication 7 of 7 days. The 10/6/2025 Physician Order documented Methadone…

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 conducted during the recertification and abbreviated surveys (2669870), the facility did not ensure a Quality Assurance and Performance Improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. Specifically, the facility was aware of ongoing sightings of roaches and mice (see F925) and there was no evidence a QAPI plan was in place to to address pest control. The findings include:The Facility Quality Assurance and Performance Improvement Policy, last revised in March 2025, documented establishing a QAPI committee/subcommittee that works in tandem with the facility leadership and the Quality Assessment & Assurance committee.A review of the 2025 Quarterly Meeting Attendance Sheets titled Quality Assurance and Performance Improvement Employee Sign in Sheets for 4/8/2025, 7/23/2025 and 11/12/25 documented topics for discussion.The 4/8/2025 topics/agenda included Quality Assurance and Performance Improvement for Plan of Correction on staffing, dignity, maintenance repairs,…

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 survey from 2/5/2026 to 2/12/2026, the facility did not ensure the Quality Assurance & Performance Improvement Committee consisted at a minimum of the Infection Control Practitioner, the Medical Director, the Administrator and the Director of Nursing. Specifically, the Infection Control Practitioner did not participate in Quality Assurance & Performance Improvement meetings for three (03) out of the three (03) quarterly meetings in 2025. The findings include:The Facility Quality Assurance and Performance Improvement Policy, last revised in March 2025, documented establishing a QAPI committee/subcommittee that works in tandem with the facility leadership and the Quality Assessment & Assurance committee.A review of the Quality Assurance and Performance Improvement Committee members documented the Administrator, Director of Nursing, Director of Social Services, Minimum Data Set Coordinator, Medical Director, Infection Preventionist, and two (02) Registered Nurse Unit Managers.A review of the 2025 Quarterly…

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 abbreviated surveys (NY00378486, NY00339264 and NY00343082), the facility did not ensure that the resident environment remained free of accident hazards and that each resident received adequate supervision for three (3) of three (3) residents (Residents #1 and #2 and #3) reviewed for elopement. Specifically, 1) on 4/20/2025 at approximately 7:00 PM Resident #1 walked unsupervised through the facility's alarmed rear exit patio door through the tunnel to the hospital emergency department, was evaluated and returned to the facility on 4/20/2025 at 11:00 PM in stable condition, and 2) on 04/14/2024 sometime after 7:10 PM Resident #2 exited the facility unsupervised and ambulated to a friend's house, the resident was picked up by facility staff and evaluated at the emergency room and returned to the facility on [DATE] at 11:50 PM in stable condition, and 3) Resident #3 was last seen at the facility on 05/22/2024 at 4:00 PM and was not found until 05/23/2024 by the police.…

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 (NY00367662), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health within 2 hours of occurrence. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, on 1/5/2025 at 1:30 PM, Resident #1 was found in bed with Resident #2 who was severely cognitively impaired Resident #1 was half naked on top of Resident #2 with their mouth on Resident #2's genital area. Administration was made aware of this event on 1/5/2025 at 1:43PM. The facility did not report the incident to the New York State Department of Health until 1/5/2025 at 4:10PM. The Findings are: The Facility's Abuse policy revised 5/2024 documented that the resident has the right to be free from verbal, sexual, physical and mental abuse. The facility promotes any effort to prevent abuse. The facility will report any Incident and/or violation where Abuse, Neglect, mistreatment, or misappropriation of property is suspected to the New York State Department of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the abbreviated survey (NY00367662) it was determined for 1 of 3 residents reviewed for abuse (Resident #1), the facility did not ensure a sexual abuse was thoroughly investigated and ensure residents safety during the investigation. Specifically, Resident #1 was found half naked on top of Resident #2 with their mouth on Resident #2's genital area. The facility did not conduct a thorough investigation, did not assess both residents and did not send both residents to the hospital for medical evaluation. Findings include: The facility's Abuse policy revised on 5/2024 documented that the resident has the right to be free from verbal, sexual, physical and mental abuse. The facility promotes any effort to prevent abuse. The facility's policy titled Accident and Incidents - Investigating and Reporting revised on 05/2024 documented all accidents or incidents involving residents shall be investigated and reported to the Administrator. A head-to-toe assessment shall…

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 abbreviated survey (NY00367662), the facility did not review and revise the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, Resident #1 had a history of sexually inappropriate behaviors towards other residents on 9/20/2024 and 12/23/2024 and there was no documented evidence the facility revised care plans or implemented interventions and/or physician orders to prevent the resident from abusing other residents. The findings include: The facility policy titled Comprehensive Care Plan revised on 09/2024 documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. Resident #1 had diagnoses which included Cerebral Infarction, Vascular Dementia. The 6/18/24…

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 and interviews during an abbreviated survey (NY00337354), the facility did not ensure the resident's right to a dignified existence. This was evident for 5 out of 6 residents (Resident #4, #12, #13, #14, #15) reviewed for dignity. Specifically, (1) During an observation on 12/13/2024, the 6th floor unit hallway had 4 residents (Resident #4, #12, #13, #14) dressed in hospital gowns; (2) During an observation on 12/13/2024 on the 5th floor dining room, Registered Nurse #1 was standing over Resident #15 while assisting them with their meal. The findings are: The Facility Resident's Rights Policy last reviewed 5/2024 documented the purpose was to provide general guidelines for resident rights while caring for the resident. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on residents' rights including resident dignity and respect. During an observation on the 6th floor on 12/13/2024 between12:34 PM to 12:54 PM, Residents were noted 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 record review and interview during an abbreviated survey ((NY00337504, NY00353121), the facility did not ensure residents right to be free from abuse. This was evident for 6 out of 9 residents (Resident #3, #4, #5, #7, #8, #9). Specifically, (1) on 3/28/2024 Resident #2 hit Resident #5 with their walker after a verbal altercation in the hallway. Resident #5 sustained bruising to their left hand and chest area. (2) On 5/2/2024, Resident #2 and Resident #4 who resided in the same room engaged in a physical altercation. Resident #4 sustained a laceration to their chin and Resident #2 sustained a laceration to their left eyebrow. On 8/23/2024, Resident #2 was witnessed by staff hitting Resident #4 in the arm, while they were in the hallway without being provoked. Resident #4's room was changed after the 5/2/2024 incident, but they remained on the same unit as Resident #2 which increased the chance for another incident to occur; (3) On 11/2/2024, Resident #2 engaged in a physical altercation with 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 record review and interviews conducted during an abbreviated survey (NY00337504, NY00353121) the facility did not ensure the report of the results of their investigation was submitted to the New York State Department of Health in accordance with State law within 5 working days of the incident for 2 of 3 residents (Resident #2, #6) reviewed for abuse. Specifically, (1) Resident # 2 was witnessed hitting Resident #5 on their left hand with their walker on 3/28/2024. The 5-day investigative conclusion report was not submitted to the New York State Department of Health until 4/11/2024. 2)On 5/2/2024 Resident #2 engaged in a physical altercation with Resident #4 and resulted in injury to both residents. There was no documented evidence that a 5-day investigative conclusion report was submitted to the New York State department of Health. 3) On 11/2/2024 Resident #2 and Resident #3were engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial…

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

Based on record review and interview during an abbreviated survey (NY00334737) the facility did not ensure sufficient nursing staff to attain or maintain the well-being of each resident as determined by the facility staffing grid as necessary to meet the needs of the residents for 35-40 residents on the 3rd floor Dementia Unit. Specifically, review of the facility scheduled data sheets for January 2024, February 2024 and March 2024 revealed staffing was not adequate across various shifts based on the unit needs and Provider Average Ratio (PAR) levels documented on the staffing grid. The findings are: The facility Staffing policy last revised 5/2024 documented the facility must have sufficient nursing staff with the appropriate competencies and skill sets to: provide nursing and related services to assure resident safety. Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. As…

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 and interviews during an abbreviated survey (NY00337354, NY00334737), the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, on every unit in the facility there were multiple areas of chipped paint, scuff marks, visible dirt and stains on the walls and floors, base boards chipped and coming off the wall, holes in the walls, chipped tiles, caving ceiling tiles and foul odors. The findings are: The facility Resident Environmental Quality policy last revised 10/2024 documented it is the policy of the facility to be designed, constructed, and maintained to provide a safe, functional, sanitary, and comfortable environment for resident's staff and the public. During rounds on the units on 12/13/2024 from 12:34pm to 2:41pm the following was observed: On the 2nd floor there was chipped paint on the walls along the hallway. On the 3rd floor there was a light bulb out on the high side hallway, the walls were dirty 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 record review and interview during an abbreviated survey (NY00337354) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 out of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 who was dependent on staff for all cares including rolling left to right acquired a Stage 3 pressure ulcer to their left hip during their stay at the facility. There was no documented physician order for turning and repositioning, and the certified nurse accountability form did not show that staff were consistently providing this care to the resident. The findings are: The facility Activities of Daily Living Total Care Policy last reviewed July 2024 documented the purpose is to establish guidelines for providing comprehensive assistance with Activities of Daily Living to residents. It aims to ensure that each individual's basic needs are met while promoting dignity, independence, and comfort. Resident #1 was admitted…

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 an abbreviated survey (NY00337354, NY00337504, NY00353121, NY00334737), the facility did not ensure a facility-wide assessment was conducted to determine what resources are necessary to care for its residents competently. Specifically, the Facility Assessment did not identify individual staff assignments, systems for coordination, and continuity of care necessary to care for residents during both day-to-day operations including nights and weekends. Findings include: The Facility Assessment provided was last updated 11/7/2024 and last reviewed with the quality assurance and improvement committee on 9/18/2023. The staffing plan documented an example of the evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff is available to meet each residents needs. The table listed the position of staff by title, as well as the total number needed or average or range by position. Review of the Facility Assessment on 12/19/2024 revealed the assessment did not include the staffing plan, the requirements of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated survey (NY00331536 and NY00330044), the facility did not ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated. This was evident for 4 of 4 residents (Residents #1, #2, #3, #4, #5) reviewed for Abuse. Specifically, (1) Resident #2 was accused of alleged inappropriate touching by Resident #1 on 1/13/2024 and the facility failed to call 911 or notify local law enforcement. Local law enforcement was notified of the sexual abuse allegation on 1/14/2024 by the hospital emergency room staff when Resident #1 reported the allegation to hospital staff; (2) Facility progress note documented Resident #2's aggressive physical/verbal/sexual behaviors towards staff and residents on 12/19/2023, 12/20/2023 and 1/12/2024. There was no documented evidence that the incidents were investigated by the facility; (3) the facility failed to investigate an allegation of resident-to-resident sexual abuse involving Resident #3 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 interviews and record review conducted during an abbreviated survey(s) (NY00331536, NY00330044 and NY00332489) the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents and staff complained about short staffing, and how it delayed care to many of the residents 2) Observations of 1 CNA for an entire nursing unit who was also assigned provide continuous monitoring of Resident # (), and 3) analysis of the actual staffing schedule for 2/2/0224 showed the facility was below the minimum levels documented on the Facility Assessment. The findings are: The Facility Assessment, last revised January 24, 2024, documented the facility's staffing plan to ensure sufficient staff to meet the needs of residents at any given time on units 2,3,4,5, and 6 calls for the following staffing plan: 7:00AM-3:00pm shift: 2 registered nurses and 5 certified nursing assistants per floor 3:00PM-11:00PM: 1 licensed practical nurse and 3 certified nursing assistants per floor 11:00PM-7:30 AM: 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview during an abbreviated survey/s (#NY00331536, NY00330044, and NY00332489), the facility did not ensure each resident was provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 3 of 3 residents (Resident #2, Resident #4, and Resident #5) reviewed for abuse . Specifically, 1 )Resident #2 displayed sexually aggressive behaviors beginning in December 2023 and a plan was not developed or implemented to prevent recurrence until after an alleged incident of sexual abuse of Resident #1 that occurred on 1/13/2023; 2) Resident #5 suffered a known substance use disorder and no plan or interventions were put in place to prevent multiple hospitalizations for suspected overdoses during their stay in the facility; and 3) Resident # 4 exhibited a behavioral disturbance, and a plan was not developed or implemented 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 record review and interviews conducted during an abbreviated survey and extended survey (NY00332489), the facility did not ensure that all nursing staff were in-serviced in behavioral health care needs of residents. Specifically, the facility was unable to provide documented evidence that they provided nursing staff education on behavioral health between1/1/23 and 12/31/23. The findings are: A request was made for the Policy and Procedure related to In-services and Staff Education but was not received prior to the exit date of 2/7/2024. A Facility Assessment last updated on 1/24/24 documented that the facility had a capacity of 200 residents. The facility assessment documented common diagnoses of residents included but were not limited to psychiatric/mood disorder and offered mental health and behavior services to residents. The facility assessment documented that nursing staff received training and competencies upon hiring and then annually. It further documented that the facility ' s behavioral health…

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 abbreviated survey (NY00331536, NY0033004, NY00332489), the facility did not ensure that residents were free from abuse, neglect, and exploitation for 2 of 4 (Residents #1 and #2) reviewed for abuse. Specifically, (1) Resident #2 had multiple documented incidents of sexual/physical and verbal aggression towards staff on 12/19/2023,12/20/2023,1/12/2024 and no new interventions were put in place to prevent further reoccurrence; (2) On 1/13/2024, Resident #1 reported to their assigned Certified Nursing Assistant (Staff # 21) that they were inappropriately touched by another resident (Resident #2). Resident #2's hat was found on Resident #1's bed and Resident #2's sweater was found on the ground next to the bed. Resident #1and #2 were assessed and transferred to the Emergency Room. Resident #1 was transferred from the emergency room to a hospital for further evaluation. The facility did not notify local law enforcement. Resident #2 was arrested for alleged…

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 an abbreviated survey (NY00332489) it was determined the facility did not ensure that the comprehensive person-centered care plan was implemented to meet the residents needs for safety for 1 of 9 residents reviewed for accidents (Resident #5). Specifically, Resident #5 with a known history of polysubstance abuse had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/2024,1/10/2024, 1/18/2024, 1/23/2024, 1/29/2024, and 2/2/2024 for which Narcan (an opioid reversal agent) had to be administered by facility staff; Resident #5's comprehensive care plan did not address the resident's known substance use disorder, was not updated to reflect the suspected overdoses. No new care plan interventions were put in place to ensure Resident #5's safety and prevent recurrent overdoses. The findings are: The undated facility policy titled, Comprehensive Care Plan documented each resident's comprehensive care plan has been designed to incorporate risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews during an abbreviated survey (#NY00332489, NY00331536, NY00330044), the facility did not ensure that the resident's Primary Care Physician (PCP) comprehensively reviewed the resident's total program of care including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen for 1 of 9 residents (Resident #5) reviewed for accidents. Specifically, Resident #5 Resident #5 had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/24,1/10/24, 1/18/24, 1/23/24, and 1/29/24 for which Narcan (an opioid reversal agent) had to be administered by facility staff. Resident #5's comprehensive care plan was not updated after episodes of overdose or illicit substance. The resident's physician (Physician #2) did not recommend new interventions including recommendations made by hospital after discharge.…

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 abbreviated surveys (NY00331536, NY00330044, and NY00332489) between 01/22/2024 and 02/07/2024, it was determined the facility was not administrated in a manner that enabled 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 200 licensed bed facility did not operate with a full-time social worker from 8/12/2023 to 11/2/2023. The findings are: Refer to the following tag: F850: Qualifications of Social Worker greater than 120 Beds The Facility Survey Report, dated 8/9/2023 included the question: Has your facility ensured that employees and other persons providing residents services in your facility are licensed, registered or certified in accordance with applicable laws? The answer was checked, Yes. Under the heading Director of Social Work, the facility documented they employed a full-time social worker with a master's degree in social work. During an interview on 2/2/2024 at 10:25AM, the director of…

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

Based on record review and interviews conducted during abbreviated surveys (NY00331536, NY00330044, NY00332489), the facility with a licensed bed capacity of 200 beds was operating without a full-time social worker from 8/12/2023 to 11/2/2023. The findings are: A facility policy titled, 'Social Services', dated 2/2022, documented a facility with more than 120 beds will employ a qualified social worker on a full-time basis. The Facility Survey Report, dated 8/9/2023 included the question: Has your facility ensured that employees and other persons providing residents services in your facility are licensed, registered or certified in accordance with applicable laws? The answer was checked, Yes. Under the heading Director of Social Work, the facility documented they employed a full-time social worker with a master's degree in social work. During an interview on 2/2/2024 at 10:05 AM, the facility's Social Work Assistant #1 stated the facility did not have a full-time social worker from 8/12/2023-11/2/2023 and they assumed many responsibilities in the absence of a full-time social worker.…

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, interviews, and record reviews conducted during the Recertification Survey from 8/11/23 to 8/15/23, it was determined the facility did not ensure a resident's care plan was revised to reflect the resident's change in condition for one of one resident (Resident #102) reviewed for Incontinence of Bowel and Bladder. Specifically, when Resident #102 had a decline in continence of bowel and bladder, the care plan was not updated. Findings include: Review of the undated facility policy, Comprehensive Care Plan, revealed that the resident's care plans would be revised as changes in the resident's condition dictates. Resident #102 had diagnoses including Schizophrenia, brain cancer, and obesity. A quarterly Minimum Data Set (MDS, an assessment tool), dated December 09, 2022, documented the resident was always continent of bowel and occasionally incontinent for bladder. An annual MDS dated [DATE], documented the resident was always continent of bowel and frequently incontinent of bladder. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview conducted during a recertification survey and abbreviated survey conducted from 8/9/23-8/15/23(NY00315357) the facility did not provide adequate supervision to prevent elopement for 1 of 5 residents reviewed for accidents. Specifically, Resident #237 left the facility undetected by staff on 4/23/23 and was not found until 4/24/23 when the facility found the resident had been admitted to a hospital. Findings include: The Policy and Procedure titled Elopement Prevention dated 10/2018, documented the facility will utilize all possible measures to maintain the safety and well-being of all residents. The facility will have systems and tools in place to prevent unsafe wandering and or elopement. Resident #237 had diagnoses of Unspecified Dementia with Behavioral Disturbance, and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS, a resident assessment and screening tool) dated 2/10/23 revealed the resident was severely cognitively impaired. The 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.

Based on observation, record review and interview conducted during a recertification survey from 8/9/23 to 8/15/23. The facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 residents reviewed for Medication storage. Specifically, Resident #64 had a bottle of unlabeled Mucinex at his bedside. Findings include: The Policy and Procedure titled Medication Administration revised 2/4/2020 documented medications should be administered as ordered by the physician. Only licensed Personnel are assigned responsibility preparing administering and recording medication. Resident #64 was admitted with Malignant Neoplasm of Esophagus, Dysphagia and Muscle wasting. The Quarterly Minimum Data Set (MDS, a resident assessment and screening tool) dated 5/5/23 revealed the resident had intact cognition. The MDS documented Resident #64 had no swallowing disorder and required supervision and set up help only for eating. The Care Plan dated 9/6/2022, documented Resident #64 was at risk for aspiration related…

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 8/9/23 to 8/15/23, the facility did not properly establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) The facility could not provide evidence that a facility risk assessment was conducted annually to identify where waterborne pathogens could grow and spread in the facility water system and 2) the facility did not update the Water Management Plan since July 2017. The findings are: The facility Legionella Water Management Program dated July 2017 documented the purpose of the water management program is to identify areas in the water systems where Legionella bacteria can grow and spread. 1) The facility did not provide any documented evidence that an Environmental Assessment of Water Systems in Healthcare Settings was performed and updated annually to minimize the risk of healthcare facility associated Legionella Species according to best practice standards and regulations. 2) The facility Water Management Program…

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 from 8/9/23 to 8/15/23, the facility did not ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control prior to assuming the role. Specifically, the facility's designated IP who is the Director of Nursing Services (DON), did not have documented evidence of completed specialized training in infection prevention and control until 08/11/23. The findings are: During the annual survey Entrance Conference on 8/09/23 at 9:33 AM, the Director of Nursing (DON) identified themselves as the Infection Preventionist since they started at the facility in October of 2022. When asked for proof of training, they stated they could not find it. On 8/11/23 at 02:30 PM, the DON presented a document titled Training Plan Proof of Completion as of 8/11/23 and included an attached copy of course modules. One of the modules had a completion date of 8/11/23. During an interview with the DON on 8/14/23 at 10:21 AM the DON stated they have a certificate of Proof of Training effective…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey from 8/9/23 to 8/15/23, the facility did not provide a COVID-19 vaccination for 1 (Resident #110) of 5 residents reviewed for COVID-19 vaccination after screening and consent was obtained. Specifically, Resident #110 had consent from 12/7/22 but had not received the vaccine when reviewed as of 8/14/23. Findings include: The facility policy titled COVID-19 Infection Control Policy, dated 2/11/2022, documented the updated COVID-19 vaccination will be offered within 14 days of admission/readmission. Resident #110 was admitted [DATE] and had diagnoses including Dysphagia, Type II Diabetes, and Depression. The Minimum Data Set (MDS, a resident assessment tool) dated 5/10/23, documented the resident had cognitive impairment, required extensive assistance with bed mobility, transfers and toilet use and received a gastrostomy tube feeding. The resident had a Consent for the COVID-19 immunization which was obtained 12/7/22. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during recertification and abbreviated (NY000320651) surveys from 8/9/23 to 8/15/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #73) reviewed for accidents, and for 1 of 1 resident (Resident #125) reviewed for pressure ulcers. Specifically, 1. Resident #73 did not have a plan of care to address skin assessment and treatment for a repair of laceration on their nose and 2. Resident #125 was identified with skin breakdown to the sacrum and there was no corresponding comprehensive care plan with interventions addressing the skin breakdown. The undated facility policy for Comprehensive Care Plan documents an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental 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 observation, record review and interview conducted during the recertification survey, the facility did not ensure that 1 of 3 residents ( Resident #86) received care in a dignified manner. Specifically, during wound care and diaper change the resident's door was left ajar exposing the resident's private areas to public view. The findings are: Resident #86 was admitted with diagnoses including; Benign Prostatic Hypertrophy, Neurogenic Bladder and Diabetes Mellitus. The Minimum Data Set (MDS; a resident assessment and screening tool) of 4/9/19 indicated the resident was mildly cognitively impaired and was dependent on staff for personal hygiene, toileting, and dressing. During the survey the following was observed: 5/21/19 at 9:33 AM- the door to the resident's room was ajar. A nurse was transferring the resident to a wheelchair and she was observed pulling up the resident's diaper and then pulling up the residents' pants. No curtain was drawn for privacy. Later, during the dressing change the nurse left the room and the resident was left lying on his right side facing 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 a recertification survey, the facility did not ensure that residents or their representatives and the ombudsman were provided with written notification of their transfer to the hospital. This was evident for 2 of 2 residents (Resident #45 and Resident #160) reviewed for hospitalizations. The findings are: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses including Hypertension, Quadriplegia and Neurogenic Bladder. The clinical record documented that resident #45 was admitted to the hospital on [DATE] and returned to the facility on 5/3/19 with a diagnosis of Bacteremia. Resident #45 was also admitted to the hospital on [DATE]. He returned to the facility on 5/13/19 with a diagnosis of Artificial Opening Status of Gastronomy Tube. There was no documented evidence that written notification for both hospitalizations on 4/26/19 and 5/11/19 was submitted to the Ombudsman. 2. Resident #160 was admitted to the facility on [DATE] with diagnoses…

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

Based on record review and interview conducted during the most recertification survey, the facility did not ensure that two quarterly assessments utilizing the State approved instrument were conducted for 1 of 11 residents (#59) reviewed for resident assessment. The findings are: Resident #59 was admitted in 2013 and had an annual assessment utilizing the State approved instrument, Minimum Data Set (MDS), completed on 7/30/2018. A review of the resident's clinical record revealed that no additional assessments utilizing the MDS were completed until 3/4/19 at which time an annual MDS was done. This resulted in two quarterly assessments not being done between 7/30/18 and 3/4/19. The MDS Nurse responsible for the completion of the resident's assessments was interviewed on 5/21/19 at 10:40 AM and stated she knew they were late in doing 2 quarterly assessments for Resident #59. Additionally, they had completed an annual assessment in March 2019 instead which is more comprehensive. The MDS Coordinator was interviewed on 5/22/19 at 9:43 AM. She stated that quarterly assessments are to be…

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 the comprehensive person-centered care plan was reviewed and revised with measurable objectives, time frames and appropriate interventions for 1 of 5 residents (Resident #86) reviewed for pressure ulcers. Specifically, the care plan 1. did not address the effectiveness of treatment to a left heel pressure injury identified on admission, 2. did not reflect the development and treatment of two new pressure ulcers, and 3. did not initiate new interventions to prevent further skin breakdown. The findings are: Resident #86 was admitted on [DATE] with diagnoses and conditions including chronic viral Hepatitis C, Cerebral infarction and Diabetes Mellitus. The admission Minimum Data Set (MDS; a resident assessment tool) dated 4/5/19 documented the resident was cognitively intact, received total assist of two staff support for transfer, total assist of one staff support for toilet use and personal hygiene,…

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 the environment was free of accident hazards and that each resident received adequate supervision and assistance to prevent accidents. This was evident for 1 resident reviewed for accident hazards. (Resident #153) The findings are: Resident #153 was admitted with diagnoses including; Diabetes Mellitus, Non-Alzheimer's Dementia and Right Above the Knee Amputation. The annual MDS (Minimum Data Set-an assessment tool) dated 1/28/19 documented that the resident is cognitively impaired and is dependent on 1 staff person for toileting, personal hygiene and dressing. Review of the comprehensive care plan initiated on admission revealed the following; Goals: Resident will be without injuries resulting from falls/Resident will have no further falls related to physical performance limitations (i.e. unsteady gait or Orthostatic Hypotension) within the next 90 days. Interventions: Anticipate needs of resident/encourage resident to seek assistance as needed/keep personal…

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.