Comprehensive Rehabilitation and Nursing Center at

Inspectors wroteBased on observation, record review and interviews conducted during survey, the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accident/hazards for one (Resident #2) of seven residents reviewed for accidents. Specifically, on 04/21/2026 at 8:14 PM, Resident #2, who had moderate cognitive impairment, exited the facility through the front doors after being let out by Licensed Practical Nurse #2 and left unsupervised. Two hours later, Resident #2 was located approximately 0.3 miles away from the facility by a staff member. This resulted in no actual harm that was Immediate Jeopardy and Substandard Quality of Care with the likelihood of serious harm, serious impairment, serious injury or death to Resident #2's health and safety.

Inspectors wroteBased on interview, and record review conducted during a survey 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 if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for two (Resident #5 and Resident #6) of ten residents reviewed for abuse. Specifically, allegations of physical abuse and sexual abuse were not reported to the New York State Department of Health as required.

Inspectors wroteBased on interview, and record review conducted during the survey the facility failed to have evidence that all alleged violations were thoroughly investigated for three (Resident #3, #4 and #5) of ten residents reviewed for abuse . Specifically, the facility investigations were not thoroughly investigated. Issues included lack of interviews/witness statements from staff regarding a staff to resident verbal abuse allegation and lacked provider and family notifications (#3); lacked statements from staff regarding missing personal items (wallet and credit cards) (#4) and lacked a documented investigation and statements into a sexual abuse allegation (#5).

Inspectors wroteBased on observation, interviews and record review conducted during survey, the facility failed to ensure that a resident received adequate supervision to prevent accidents for one (Resident #1) of two residents reviewed for accidents. Specifically, at 2:59 AM on 09/22/2025, Resident #1 who had severe cognitive impairment, wore a wander/elopement alarm and was at high risk for elopement, exited the facility undetected through delayed egress equipped (security device that restricts exit by sounding an alarm and delays a door from opening for 15-30 seconds) front doors without the staff knowledge. The system was re-engaged by Certified Nurse Aide #1 who failed to visually check the surrounding areas and go outside to verify that no residents had exited the building. Resident #1 was located 30 minutes later by emergency services; [...]

Inspectors wroteBased on observations, interviews, and record review completed during a survey, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, a project to replace the facility's roof began and was interrupted from being completed during and due to inclement seasonal weather. The issues involved various ceiling tiles that were missing or stained throughout the facility; buckets and receptacles, and buckets and receptacles containing standing water and drain hoses from ceilings were stored in corridors and a resident room bathroom; tarps with drain hoses were hung from the corridor's ceiling assemblies; floor tiles were not level to the floor's surface, and ceiling's had missing plaster and peeling paint. [...]

Inspectors wroteBased on interview and record review the facility did not follow the required transfer or discharge process for three (3) of three (3) residents (Residents #3, #4, and #5) reviewed for Transfer or Discharge Process. Specifically, the facility did not notify the residents and the residents' representatives in writing and did not send a copy of the notice to the representative of the Office of the State Long-Term Care Ombudsman at least 30 days before the resident was transferred or discharged .

Inspectors wroteBased on interview and record review conducted during an Abbreviated survey (Complaint #2693403), the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) (Resident #1) of three (3) residents reviewed for physician orders. Specifically, Resident #1 had an order for compression for leg edema (swelling caused by excess fluid accumulation) that was not entered into the electronic medical record or implemented. The finding is: The policy titled Physician Notification dated 12/10/2024 documented that nurses are to record any new orders in the resident's medical record. [...]

Inspectors wroteBased on observation, interview, and record review during a Complaint investigation (#NY00372469), the facility did not ensure a resident's right to be free from misappropriation of resident property for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1's bank/credit card was reported missing and had fraudulent charges made by a staff member. The finding is:The policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 01/20/2025 documented misappropriation of resident property included theft, unauthorized use or removal of a resident's personal property including but not limited to money, and other possessions and articles belonging to the resident regardless of monetary value. Resident #1 had diagnoses including chronic obstructive pulmonary disease, atrial fibrillation (irregular heart rate), and general anxiety disorder. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Complaint investigation (#NY00372469) the facility did not have evidence that all alleged violations of misappropriation were thoroughly investigated, that the results of all investigations were reported to the state agency within 5 working days of the incident, and that corrective actions were taken for the verified alleged violation for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility did not complete an investigation of an alleged theft of Resident #1's credit card, did not report the results within 5 working days of the incident, and did not take corrective actions when the allegation was verified. In addition, the facility did not ensure their policy for abuse investigation and reporting was current. [...]

Inspectors wroteBased on observation, interview, and record review during a Complaint investigation (Complaint #NY00374344- 635063) the facility did not ensure physician orders for the resident's immediate care were in place on admission for one (1) (Resident #7) of three (3) residents reviewed for admission orders. Specifically, Resident #7 was re-admitted to the facility on [DATE] and their admission medication orders were not entered into the electronic medical record and implemented until 09/10/2025. The finding is:The policy and procedure titled Electronic Physician Orders (Create, Confirm, Processing Orders) dated 08/28/2024, documented Admission/readmission orders for the care of a resident are received from a Licensed Physician/Nurse Practitioner/Physician Assistant upon admission/readmission of a resident to the facility. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey, completed on 12/6/24, the facility did not ensure information on how to file a grievance or complaint was available to the residents and that they had an established grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights. Specifically, Resident Council was unaware of the process and policy on how to file a grievance or a compliant. The facility did not have a policy to ensure prompt resolution of all grievances regarding resident rights that included all required information.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification survey completed on 12/6/24, the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance and had repeated deficiencies from the previous Recertification Survey 4/21/23 and Post Survey Revisit 7/12/23. In addition to identified systematic problems regarding grievances and functional/usable bathtubs.

Inspectors wroteBased on interview, and record review conducted during the Standard Survey completed on 12/6/24, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for six (Residents #10, #25, #36, #41, #43, and #65) of 28 residents reviewed for care planning. Specifically, Resident #10 did not have a care plan developed for skin integrity and had pressure ulcers; Resident #25 did not have a care plan developed for dentures; Residents #36 and #41 did not have a care plan developed for an alleged resident-to-resident altercation; Resident #43 did not have a care plan developed for skin care and incision care with treatments ordered, depression, cardiac, vision, dry nasal passages and supplements with medications ordered, and discharge planning; [...]

Inspectors wroteBased on observation, interview and record review conducted during the standard survey, completed on 12/6/24, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (Residents #10 and #25) of six residents reviewed. Specifically, Resident #25 had visible food residue in their top and bottom dentures on multiple observations; Resident #10 had visible chin hair and long nails with brown debris underneath on multiple observations.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 12/6/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #30) of one resident reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #30's left and right palm guards (assistive device that positions the fingers away from the palm) were worn as recommended by occupational therapy. In addition, there was inconsistent documentation that range of motion exercises were provided to the resident per their care plan. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed 12/6/24 the facility did not ensure that residents with an indwelling foley catheter (tube inserted into the bladder to drain urine) received the appropriate care for one (Resident #45) of two residents reviewed. Specifically, staff did not maintain proper infection control practices for a resident with a foley catheter. The finding is: The policy and procedure titled Indwelling Catheter Care dated 2/2019, documented to keep the drainage tubing/catheter junction closed. Ensure the catheter is properly secured to upper thigh with securement device. 1. Resident #45 had diagnoses that included obstructive and reflux uropathy (obstruction in urinary tract), history of urinary infections and dementia. [...]

Inspectors wroteBased on observations, record review and interviews during a Standard survey completed 12/6/24, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight for one (Resident #65) of two residents reviewed. Specifically, Resident #65 had a significant weight loss and there was a lack of meal and nourishment acceptance being documented or recorded. In addition, the medical provider was not made aware of the significant weight loss. The finding is: 1. Resident #65 had diagnoses that included dementia, protein-calorie malnutrition, and macular degeneration left eye (loss of the central field of vision because of deposits of the retina). The Minimum Data Set, dated [DATE] documented Resident #65 had severe cognitive impairment, required supervision/touch assist for eating, weight was 105 pounds and weight loss marked no or unknown. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 12/6/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being either unlabeled or outdated in the refrigerator.

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed 12/6/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for two (Resident #10 and #43) of four residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) during care. Specifically, Resident #10 had chronic pressure ulcers (injury to the skin and tissues from prolong pressure to the area) and the Certified Nurse Aides did not wear proper personal protective equipment during morning care. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Standard survey completed on 12/6/24, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Resident #64) of one resident reviewed. Specifically, Resident #64 was not provided with a tub bath per their preference as the facility did not have a functioning tub. The finding is: The policy and procedure titled Comprehensive Care Planning & Baseline dated 6/2021, documented a care plan will be individualized for each resident using a person-centered approach. Your Rights as a Nursing Home Resident in New York State dated 2022 documented, you have the right to self-determination includes but not limited to; [...]

Inspectors wroteBased on observations, interviews and record review conducted during a standard survey, completed on 12/6/24, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, 2 (Units 1 and 5) of 4 units reviewed for environment had issues with brown stained ceiling tiles in halls and resident rooms. Unit 5 the baseboards in the halls were dirty with visible dark debris, and the shower room had a strong fecal odor, soiled wet linens on the floor, and soiled shower curtain.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 12/6/24, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, one (Employee #3, Housekeeping Aide) of eight employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, was not reviewed through the New York State Nurse Aide Registry prior to their employment as required. The finding is: The undated policy and procedure titled New York State Nurse Aide Registry Check documented all individuals hired to work at the facility will undergo a review of qualifications, performance and will be checked against the New York State Aide Registry. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during an Abbreviated Partial Extended survey (Complaint #NY00345600), the facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for seven (Resident #1, #2, #3, #4, #5, #6, and #7) of seven residents reviewed. Specifically, on 6/18/2024 at 4:30 AM, staff returned Resident #1 to the facility after they were found outside. The facility failed to initiate safety interventions after Resident #1 eloped to prevent recurrence. Subsequently, at 6:30 AM facility staff were unable to locate Resident #1 and local authorities were called. Resident #1 was returned to the facility at 4:00 PM by their Health Care Proxy. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 4/21/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: [...]

Inspectors wroteBased on observation and interview during the Standard survey started on 4/17/23 and completed on 4/21/23, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included a sewer pipe was open and unsealed, a pit containing a sewer pipe was partially full of standing water, a toilet waste line was open and unsealed, and drains leaked from First Floor into the Basement. This affected one (First Floor) of one resident use floor and one of one Basement.

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00314500) during the Standard survey completed 4/21/23, the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the facility did not maintain the resident call bell system in working order for three (Unit 2, Unit 5, Unit 6) of three resident care units.

Inspectors wroteBased on observation, record review, and interview conducted during complaint investigations (Complaint NY00314500 and NY00308655) during the Standard survey completed on 4/21/23,the facility did provide a safe, clean, comfortable, and homelike environment. The facility did not ensure that housekeeping and maintenance services were adequate, to maintain a sanitary, orderly, and comfortable interior. Specifically, two (Units 5 and 6) of four resident units reviewed for the environment had issues as follows; unlabeled resident urinals and graduated cylinders in shared bathrooms; fall mat in disrepair; brown liquid splatters with drips on a wall; hand rail in resident shower room loose and broken; a rusty commode; [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (Complaint # NY00314500) during the Standard survey completed on 4/21/23, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, one (Resident #46) of four residents reviewed for pressure ulcers did not have a comprehensive care plan developed for a resident with multiple pressure ulcers with measurable goals and interventions. The finding is: 1. Resident #46 had diagnoses included type 2 diabetes mellitus with diabetic neuropathy (disorder affecting nervous system), unspecified open wound left foot, and anemia due to stage 4 chronic kidney disease. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 4/21/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #63, #65 and #78) of eleven residents reviewed. Specifically, Resident #63 had multiple long ¼ inch whiskers on their chin, Resident #65 had unkempt, oily disheveled hair, had not received hair washing for greater than 2 months and wanted their hair washed; and Resident #78 had long fingernails greater than ¼ inch beyond their fingertips.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/21/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community for one (Resident #78) of one resident reviewed for activities. Specifically, Resident #78 was not in attendance of activities according to their preference and comprehensive assessment due to the lack of being not gotten up and out of bed and not being asked if they wanted to attend activities. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/21/23, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #404) of two residents reviewed. Specifically, the facility did not ensure Resident #404 had a call device to request assistance and the resident fell on the floor in their room which resulted in bruising to their left forehead. The finding is: 1. Resident #404 had diagnoses including anxiety disorder, Parkinson's Disease, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS, a resident assessment tool) dated 3/24/23 documented Resident #404 was cognitively intact, understood, and understands. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 4/21/23, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing (DON), and these reports must be acted upon for one (Resident #34) of five residents reviewed for drug regimen reviews. Specifically, Resident #34 was ordered Haldol (antipsychotic medication) prn (as needed) for agitation from 1/30/23 to 2/28/23. The Consultant Pharmacist did not identify and recommend the discontinuation of the prn antipsychotic medication after 14 days. The finding is: 1. Resident #34 had diagnoses including bipolar disorder, major depressive disorder, and schizophrenia. The Minimum Data Set (MDS- a resident assessment tool) dated 1/8/23 documented Resident #34 was understood, understands and cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed 4/21/23, the facility did not store all drugs and biologicals in locked compartments and under proper temperature for one of one floor used by residents and one (Unit 6) of two medication storage rooms. Specifically, a box of medications that contained 61 medications for 20 residents was left unattended, unsecured on the floor outside an office in the hallway where residents, staff and visitors had access. This involved Resident #'s 7, 16, 62, 82, 84, 88, 92, 104, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, and 216. In addition, the medication Retacrit (epoetin, injectable medication used to treat anemia) was not stored in the refrigerator as required upon receiving from the pharmacy (#405).

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 4/21/23 the facility did not dispose of garbage and refuse properly for two of two dumpsters. Specifically, waste was not properly contained within dumpsters and the lids on the top were not closed shut. There were open bags of garbage and debris on the ground surrounding the dumpster with birds and squirrels picking at the garbage. The finding is: The policy and procedure (P/P) titled Sewage disposal- Medical Waste Disposal- Dumpster Maintenance and Holding of Waste last revised 12/1/2019 documented the dumpster and surrounding area shall be clear and free of debris. Individuals disposing of refuse will ensure all refuse ends inside the dumpster, the dumpster lids are properly closed and the dumpster sliding doors are properly closed. [...]

Inspectors wroteBased on interview and record review conducted during the Onsite Post Survey Revisit completed on 7/12/23, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the QAPI Committee did not have documentation of audits or documentation of review of audits to ensure deficiencies identified during the Recertification Survey completed on 4/21/23, were corrected, and the facility did not institute and follow corrective actions that were to put in place to ensure that the following deficiencies would not reoccur.

Inspectors wroteBased on observation, interview and record review during the Standard survey completed on 4/21/23, the facility did not maintain 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 infection for two (Residents #78 and 82) of three residents reviewed for transmission-based precautions and incontinence care. Specifically, transmission-based precautions were not implemented for an active infection or reflected on the care plan (Resident #82) and staff did not perform adequate hand hygiene while providing fecal incontinence care (Resident #78).

Inspectors wroteBased on observation, interview, and record review during the Standard survey started on 4/17/23 and completed on 4/21/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected one (First Floor) of one resident use floor and one of one Basement.

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 4/21/23, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries at the termination of Medicare coverage for three (Residents #82, 454, and 455) of three residents reviewed. Specifically, the facility did not provide a Notice of Medicare Non-Coverage (NOMNC) to the residents and/or their responsible party (RP).

Inspectors wroteBased on observation, record review, and interview completed during the Standard survey completed 8/27/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, one (Resident #58) of two residents reviewed for range of motion (ROM-normal range of motion for a joint) services was not provided with an air carrot (assistive device that positions the fingers away from the palm) to their right hand, and pillows for leg positioning as recommended by Occupational Therapy (OT) and Physical Therapy (PT). The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Complaint # NY00253925) completed during the Standard survey on 8/27/21, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #15) of one resident reviewed. Specifically, Resident #15 eloped while out at an appointment at a local hospital on 3/12/20. The finding is: Review of the policy and procedure titled, Wander/Elopement Risk Assessment dated 11/2004 documented once a resident has been identified as being at risk for elopement and preventative interventions have been implemented appropriate documentation from all departments will be checked and be kept in the resident's permanent record. Modes of communication include but are not limited to (a) Resident's care plan; (b) Elopement list; [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 8/27/21, the facility did not ensure residents who use psychotropic drugs received gradual dose reductions (GDR) in an effort to discontinue these drugs for one (Resident #62) of five residents reviewed for antipsychotic medications. Specifically, there was a lack of documented targeted behaviors and ongoing behaviors to support the use of antipsychotic medication and lack of attempted GDRs as required. Additionally, the resident lacked a comprehensive care plan for antipsychotic medication use. The finding is: The facility policy and procedure (P&P) titled, Monitoring of Psychotherapeutic Medications revised on 9/10, documented residents receiving a psychotherapeutic medication will be observed for therapeutic response to the medication. [...]

Inspectors wroteBased on observation and interview during the Standard survey completed on 8/27/21, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included open and uncapped sewer plumbing, a consistent floor drain leak from First Floor into Basement, and shower plumbing devices and hoses that did not have vacuum breakers installed to prevent backflow. This affected one (Unit 6) of three resident units, one of one Main Kitchen, and one of one Basement.

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated Survey (Complaint NY#00263124) completed on 8/27/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident 58) of 21 reviewed for plan of care (POC). Specifically, the facility did not ensure Resident #58 had their abdominal (ABD) binder on as they have a history of dislodging their percutaneous endoscopic gastrostomy tube (PEG/ G-tube- feeding tube inserted into the stomach) and were not wearing heel booties, at all times (AAT), per doctors' orders plan of care.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/27/21, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for one (Resident #29) of two residents reviewed for incontinence care. Specifically, the Certified Nurse Aide (CNA) provided incomplete AM (morning) and incontinence care. The finding is: 1. Resident #29 had diagnoses which include major depressive disorder, peripheral vascular disease (poor circulation) and sacral (area between base of spine and tailbone) pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/27/21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #34) of one resident reviewed for respiratory care. Specifically, oxygen (O2) was not administered in accordance with the physician's order, oxygen concentrator filter was dirty and covered with white debris, and the oxygen tubing was not dated and documented when changed. The finding is: The facility's undated policy and procedure (P&P) titled Oxygen Supplies and Concentrator documented that the facility will maintain an adequate supply of oxygen concentrators, nebulizers, tanks, and supplies. The policy did not include the care and maintenance of the concentrator and tubing. 1. [...]

Inspectors wroteBased on observation and interview during the Standard survey completed on 8/27/21, the facility did not dispose of garbage and refuse properly. Specifically, waste was not properly contained outside of the facility in closed dumpsters, and torn bags of garbage and loose debris were observed on the ground behind the dumpsters, which created potential feeding and harborage areas for pests. The finding is: Observation on 8/23/21 at 9:40 AM revealed two cardboard dumpsters and two garbage dumpsters were located behind the facility. Further observation revealed one torn garbage bag on the ground outside of the garbage dumpsters, and garbage items from this torn bag, which included food debris and dirty food plates, were strewn around the surrounding grass in a 20-foot diameter area. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/27/21, the facility did not maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19 for one (Resident #289) of three residents reviewed for transmission based precautions (TBP). Specifically, the facility did not ensure a newly admitted , unvaccinated resident was placed on TBP (including appropriate room signage) and staff did not wear required Personal Protective Equipment (PPE) when in direct contact with the resident. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/27/21, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; and the facility shall exercise reasonable care for the protection of the resident's property from loss or theft. Specifically, two (Units 5 and 6) of two units reviewed for the environment had issues with soiled wheelchairs and privacy curtains, cobwebs, chipped toilet seats and the garbage in the Unit 6 shower room/bathroom was overflowing with soiled paper towels, used gloves and soiled incontinence briefs. This involved Resident's #5,19,63, and 52. Additionally, two (Resident's #19, 34) of three residents reviewed for personal property had issues with missing personal items. [...]