Casa Promesa

Inspectors wroteBased on observation, record review, and interviews during an Abbreviated Survey (NY00380952), the facility failed to ensure that a resident, identified as an elopement risk based on a history of previous elopement attempts, received adequate supervision to prevent elopement from the facility. This was evident for one (1) of eight (8) residents sampled (Resident #1). Specifically, on 05/16/2025 at 10:12 AM, Resident #1, who was assessed as cognitively impaired and at risk for elopement, who had a Wander Alert Device on their left ankle, exited the building undetected. Interview revealed Security Guard #1 heard a beeping sound and was not aware that it was the Wander Alert Alarm. Security Guard #1 did not investigate the beeping sound, did not identify if a resident exited the facility, did not search the lobby, and did not notify any staff. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00355130, NY00355122) Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that each resident's comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect a change in resident's status. This was evident in 4 (Residents #42, #51, #50, #61) of 20 total sampled residents. Specifically, the comprehensive care plans for Residents #42, #51, #50, and #61 were not reviewed and revised following their involvement in a resident to resident altercation.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident in 2 (3rd and 4th Floor) of 3 units. Specifically, 1.) Expired Heparin lock flush syringes were stored in the medication room. 2.) Food items were stored together with the intravenous bags in the medication room.

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the Kitchen Task. Specifically, there were multiple cans of expired beef stew in the emergency food storage and expired frozen omelets stored past the expiration date in the kitchen freezer.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident for 1 (Resident #43) of 2 residents reviewed for choices out of 20 total sampled residents. Specifically, Resident #43's choice to refuse care was not respected.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 12/04/2024 to 12/09/2024, the facility did not ensure residents received necessary respiratory care consistent with professional standards of practice. This was evident for 1 (Resident #36) of 4 residents reviewed for Respiratory Care out of 20 total sampled residents. Specifically, Resident #36 received oxygen at a flow rate that was not consistent with physician's order and there was no documented evidence that oxygen tubing was being changed.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the Infection Preventionist had completed specialized infection prevention and control training. This was evident during the review of the Infection Control Task. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the assessment accurately reflected each resident's status. This was evident in 4 (Residents #1, #36, #42, and #54) of 20 total sampled residents. Specifically, 1.) Resident #1, #36, and #42's antiviral medication use was inaccurately documented in the Minimum Data Set assessment, and 2.) Resident #54's assessment inaccurately documented that the Resident had diagnosis of Dementia.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/04/2024 to 12/09/2024, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. This was evident for 2 (Residents #24 and #36) of 3 residents reviewed for Beneficiary Protection Notification Rights, out of 20 total sampled residents. Specifically, the facility did not provide residents with Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS-10055) at the termination of their Medicare Part A benefits. The residents remained in the facility.

Inspectors wroteBased on record review and staff interview during the Abbreviated Complaint survey (NY00345861) conducted between 11/25/2024 and 11/26/2024, the facility did not ensure that all alleged violations involving abuse were reported immediately but not later than 2 hours after the allegation was made. This was evident for 1 resident investigated for Abuse out of 10 complaints investigated. (Resident #15). Specifically, the facility did not report an allegation of Resident Verbal or Mental Abuse to the New York State Department of Health within 2 hours after the allegation was made.

Inspectors wroteBased on observations, record review and interview conducted during the recertification survey from 9/10/23 to 9/15/23, the facility did not ensure that the results of the most recent survey report and any plan of correction in effect were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for all residents, including 10 of 10 attendees of the Resident Council Meeting. Specifically, the results of the most recent state survey were not posted.

Inspectors wroteBased on interview and record review during the Recertification Survey, the facility did not ensure each resident was screened for a mental disorder or intellectual disability prior to admission for 4(Resident #s 2,3,12 and 34) of 20 residents reviewed for DOH-695 (Department of Health) Pre-admission Screening and Record Review (PASRR, a federal requirement to ensure that residents were not inappropriately placed in a skilled nursing facility). Specifically, there was no documentation the facility reviewed and maintained DOH-695 PASRR screens prior to admission to the facility for Resident #s 2,3,12 and 34.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification Survey 9/10/23 - 9/15/23, the facility did not ensure adequate supervision was provided and equipment was available to prevent accidents. This was evident for 1 (Unit 2) of 3 units and the Main Dining Room observed for Dining. Specifically, the facility did not have suction equipment accessible in the Unit 2 common dining area, and there was no nurse staffing providing supervision during meal service on Unit 2 and in the Main Dining Room.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 09/10/2023 to 09/15/2023, the facility did not ensure sufficient nursing staff to provide nursing or related services to assure resident safety and to attain or maintain highest practicable well-being of each resident. This was evident for 3 of 3 resident units (Unit 1, 2, and 3). Specifically: 1) During meal observations, there was no Licensed Professional Nurse or Certified Nursing Assistant available to monitor the residents in the common dining areas. 2) Actual nurse staffing was less than projected staffing on multiple occasions, based on the Facility Assessment Tool document submitted to the survey team.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey on 09/10/23 - 09/15/23, the facility did not ensure that a resident's room was adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. This was evident for 2 (Resident #12 and Resident #62) of 20 sampled residents. Specifically, the emergency call device located in Resident #12's bathroom was not working on multiple observations during the survey. The emergency call device in Resident #62's bathroom was missing a pull cord.

Inspectors wroteBased on observation, record review and staff interview the facility did not ensure a safe, clean, comfortable, and homelike environment was provided or exercise reasonable care for the protection of the resident's personal property from loss or theft. This was evident for 2 of 20 sampled residents (Resident #3 and Resident #12). Specifically, Resident #3 had a fanny pack taken from their room, and Resident #12's room was observed with missing wall paint, a rusty door, missing wall plaster, dirty floors, and other concerns.

Inspectors wroteBased on observation, record review and interview during the Recertification/Complaint survey, the facility did not ensure that drug records are in order and that an account of all controlled drugs is maintained as per standard of practice. Specifically recount and reconciliation of Narcotics and Controlled Medications were observed not being done by two (2) Licensed Nurses. This was evident for 1 of the 3 units observed for medication storage and labelling.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure that food was stored according to professional standards for food safety. This was evident for 1 (2nd Floor) of 3 units. Specifically, the pantry refrigerator on the 2nd Floor was used to store staff food items, contained undated resident food, contained unlabeled, undated, and uncovered bowls of ice, and was not within acceptable temperature range.

Inspectors wrote42 CFR 483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. 10NYCRR 415.29 Physical environment. The nursing home shall be designed, constructed, equipped, and maintained to provide a safe, health, functional, sanitary, and comfortable environment for residents, personnel, and the public. Based on staff interview and document review conducted during the Life Safety Code recertification survey, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Reference is made to the following: 1. It could not be verified that the building's backflow devices on the domestic water supply and Sprinkler system (devices that stop the undesirable reversal of flow of liquids, gases, or suspended solids into the potable water supply) were inspected annually. The finding is: [...]

Inspectors wroteBased on observation, record review and staff interview the facility did not ensure prompt efforts were made to resolve a resident's grievance. This was evident for 1 (Resident #3) of 20 sampled residents. Specifically, the facility did not complete their investigation and respond to Resident #3's grievance that a fanny pack was taken from their room. The finding is: The facility policy titled Grievance/Complaint dated 11/01 documented residents are encouraged to verbalize any grievances or complaints without retaliation. Designated staff are assigned to intervene in resolving the issues. Resolution should be attempted immediately but should not take longer than fourteen days. Procedure # 2 documented, the resident /Significant other has the right to present a grievance or complaint directly to administration or to any other staff member. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification and Complaint (#NY00269873) survey, the facility did not ensure that there was sufficient staff available to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This was evident for 1 of 2 residents reviewed out of a sample of 25 residents (Resident #52). Specifically, there was no documented evidence the facility provided Resident #52 with assistance to with Activities of Daily Living (ADL) to be showered in October 2021 and November 2021 due to insufficient staff.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification, the facility did not ensure infection control practices were maintained. This was evident for 4 of 4 residents observed for blood glucose monitoring (Resident #22, #21, #10, #57) and 5 of 10 employees reviewed for influenza vaccination (Employees #3, #6, #8, #9, #10). Specifically, 1) a Licensed Practical Nurse (LPN) was observed not sanitizing a glucometer in between blood glucose readings for Resident #22, #21, #10, and #57; and 2) there was no documented evidence Employees #3, #6, #8, #9, #10 received the influenza vaccine for the 2020/2021 flu season.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure the Minimum Data Set 3.0 (MDS) Assessments accurately reflected residents' status. This was evident for 2 of 35 residents reviewed (Resident #29 and Resident #67). Specifically, 1) the MDS for Resident #29 did not document the dialysis treatment; and 2) the MDS for Resident #67 did not document tracheostomy care.

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure residents were invited to participate in comprehensive care plan (CCP) meetings with the interdisciplinary team (IDT). This was evident for 2 of 25 residents reviewed (Resident #29 and Resident #71). Specifically, 1) Resident #29 was not invited to attend CCP meetings with the IDT; and 2) Resident #71 was not invited to attend CCP meetings with the IDT.

Inspectors wroteBased on observations, interviews, and record review conducted during a recertification survey, the facility did not ensure actual nursing staffing data was posted accurately and was not posted in a prominent place in view of all visitors and residents. This was evident during observations of the facility lobby and 2 of 3 residential units (lobby, 3rd floor, 4th floor). Specifically, 1) the lobby and 4th floor of the facility were observed with no daily staffing nursing; and 2) nursing staffing data observed on the 3rd floor did not reflect actual staffing.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 of 6 medication carts reviewed (Unit 2) and 2 of 4 residents reviewed out of a sample of 25 residents (Resident #8 and Resident #65). Specifically, 1) Resident #8 was administered Clonazepam 0.5 mg without accurate reconciliation on the facility's Controlled Substance Records/Narcotic Sheets (CSRNS); and 2) Resident #65 was administered Oxycodone-Acetaminophen 10-325mg without accurate reconciliation on the CSRNS.