Andrus on Hudson

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 6/25/25 to 7/2/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the annual water sampling report for the year 2025 was missing and not provided at time of survey.

Inspectors wroteBased on observation, record review and interviews during the recertification survey conducted from 6/25/25 to 7/2/25, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services for 1 of 3 residents (Resident #163) reviewed for Activities of Daily Living. Specifically, Resident #163 required substantial/maximal assistance with showers/bathing and supervision with personal hygiene; they were observed during multiple observations with fingernails that were long and dirty.

Inspectors wroteBased on observation, record review and interviews during the recertification survey conducted from 6/25/25 to 7/2/25, the facility did not ensure that 1 of 4 residents (Resident #78) reviewed for Nutrition was monitored for nutritional status. Specifically, for Resident #78, a weight was struck out on 6/9/25, a re-weight which was requested on June 16, 2025, was not documented until June 20, 2025, the facility did not assure the resident was assessed and evaluated for poor oral intake in May and June 2025, and new interventions related to nutritional status were not implemented after weight loss was documented on June 20, 2025.

Inspectors wroteBased on interview and record review during the recertification survey from 06/25/25 through 07/02/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#1, #2, #3, #4, #5) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on observation and interview conducted during the recertification and abbreviated (NY00378520) surveys from 6/25/25 to 7/2/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, when a test tray was sampled the tuna salad was not cold to taste, and yogurt was held at 58 degrees Fahrenheit in the kitchen during an observation of the lunch meal service.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00332256), the facility did not ensure residents right to be free from abuse for 1 of 3 sampled residents (Resident #1). Specifically, on 1/14/2024 a Certified Nursing Assistant (Staff #1) was observed on the facility Closed-Circuit Television footage, roughly and inappropriately handing Resident #1 by pulling them from behind, lifting them off their feet from behind, carrying them a few steps, and swinging them into their room.

Inspectors wroteBased on observation, interviews and record reviews conducted during an Abbreviated Survey (NY00326823), the facility did not ensure that a resident's care plan was revised with specific interventions/instructions needed to provide effective and person-centered care for 1 of 4 residents (Resident #3) reviewed. Specifically, Resident #3 fell out of the Hoyer lift on 10/22/2023 during a two person assist transfer, allegedly due to a sudden jerking movement. Resident #3 sustained right forehead superficial laceration, upper arm abrasion and a right wrist skin tear and transferred to the hospital. Resident #3's care plan was not updated with interventions to monitor for sudden movements during transfers or to anticipate unsafe movements.

Inspectors wroteBased on observations, interviews and record review conducted during an abbreviated survey (NY00328308, NY00317607) the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 4 residents (Resident #1 and Resident #2) reviewed. Specifically, Staff #1(Certified Nursing Aide) was scheduled for monitoring/supervision of residents in the rotunda. Staff #1 left her post without informing the nurse. Resident #1 fell forward out of their wheelchair while sitting in the rotunda with no supervision. Resident #1 sustained a hematoma with lacerations to the forehead and a cut to the bridge of the nose. Resident #1 was transferred to the hospital for further medical evaluation. Resident #2 who was under the supervision of Staff #2(Certified Nurse Aide) fell out of their wheelchair when the wheelchair rolled backwards while outside getting some fresh air. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 03/09/2023 to 03/17/2023, the facility failed to revise a comprehensive care plan for 1 of 4 residents (Resident #52) reviewed for position/mobility. Specifically, Resident #52's care plan failed to address the use of wheelchair elevating leg rests and calf and/or foot board as ordered.

Inspectors wroteBased observation, record review, and interview conducted during the recertification survey from 03/08/2023 to 03/17/2023, the facility failed to ensure that residents received care and treatment in accordance with professional standards for one of four residents (Resident #52) reviewed for positioning and mobility. Specifically, Resident #52 was not provided positioning devices for their wheelchair as ordered.

Inspectors wroteBased on observation, interview and record review conducted during the recertification and abbreviated surveys (NY00286859,NY00293521), the facility did not ensure that residents were adequately supervised and the environment remained free from accident hazards for 2 of 3 residents (Resident #63 and #58) reviewed for accidents. Specifically, observation revealed that a closet door in room [ROOM NUMBER]A which had previously fallen on Resident #63 was broken and not on the track. Resident #58 was identified at risk for elopement and exited the building undetected.

Inspectors wroteBased on observations interviews and record review during a recertification survey (3/8/23-3/17/23), the facility did not ensure that professional standards for food safety and prevention of food borne illness were followed. Specifically, wait staff #1 did not perform hand hygiene between serving residents while passing out food during a lunch meal to prevent cross contamination and infection.

Inspectors wroteBased on observations, interviews and record review during a recertification survey from 3/8/23 to 3/18/2023 the facility did not ensure that Infection Control practices and procedures were maintained. Specifically, 1) Housekeeping staff #1 did not properly distribute clean laundry to residents in a manner that would prevent the spread of infection, 2) Certified Nursing Assistant (CNA) #4 handled linen on a clean linen cart while wearing dirty gloves and 3) the front desk concierge did not handle COVID19 test specimens and maintain the COVID19 testing area in a clean and sanitary manner to prevent the development and transmission of communicable disease and illness.

Inspectors wrote3. Resident #62 was admitted on [DATE] with diagnoses including but not limited to: Benign Prostatic Hypertrophy (BPH), Urinary Tract Infection (UTI), elevated Prostate Specific Antigen (PSA), Diabetes Mellitus (DM) and Depression. Record review revealed that the resident was hospitalized [DATE] and re-admitted [DATE]. Primary Medical Doctor (PMD) note dated 4/10/19 documented the resident was admitted to the hospital for hypotension, found to have UTI, and treated with antibiotics. A comprehensive 14-day Minimum Data Set (MDS: an assessment tool) dated 4/23/19 documented a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact; received extensive assistance of one person for toilet use; was always incontinent of bowel and bladder; and had a diagnosis of UTI within the last 30 days. [...]

Inspectors wroteBased on observation and interview conducted during the recertification survey, it cannot be ensured that the facility practiced proper storage of foods in accordance with professional standards for food safety. Specifically, undated, outdated, and/or expired foods were stored in two refrigerated units. This was observed on both the initial tour and a follow up observation of the kitchen.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, it cannot be ensured that the facility provided the appropriate treatment and services to maintain or improve abilities to complete Activities of Daily Living (ADLs) for 4 of 4 residents (#14, #26, #57 and #135) reviewed for Activities of Daily Living. Specifically, the facility did not ensure that Resident #14 was evaluated for decline in mobility and elimination as identified on the Resident Assessment; Resident #26 received adequate fingernail grooming as her fingernails were very long, thick, and fungal looking; Resident #57 did not remain in bed for long periods of time, without her prescribed stump shrinkers. (stump shrinkers are typically used to reduce or control swelling and phantom pain in the residual limb of amputee patients); [...]

Inspectors wroteBased on observation, record review, and interview conducted during a recent recertification survey, the facility did not provide the necessary care and services for 1 of 1 resident (#57) reviewed for Activities of Daily Living. Specifically, the facility did not ensure that Resident who had bilateral below knee amputation was utilizing the custom-made prosthesis to enhance the resident's mobility and ambulation or stump shrinkers to prevent lower extremity edema.

Inspectors wroteBased on observation, interview and record review conducted during a recent recertification survey, it could not be ensured that a resident received the necessary treatments to meet the resident's foot care needs. Specifically, 1 of 1 resident (Resident #185) reviewed for quality of care did not receive the treatment that was recommended by a Podiatrist.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it cannot be ensured that the facility's staff provided ongoing monitoring of a resident for medication effect, side effects, adverse reaction, or any associated behavioral effects of the medication. Specifically, 1of 5 residents (Resident #106) reviewed for unnecessary medication revealed no evidence of ongoing monitoring for the use of an antipsychotic medication used to treat Hiccups.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, it could not be ensured that the facility provided necessary dental services in a timely manner for 1 of 1 residents (resident #57) reviewed for dental services. Specifically, Resident #57 needed an adjustment to full upper and full lower dentures which was not completed or scheduled.