Delmar Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interview conducted during a survey, the facility did not ensure licensed nurses and Certified Nurse Aides had the specific competencies and skills necessary to care for resident's need. Specifically, (a.) Resident #63's herpes zoster eye disease (shingles of the eyelid) was resolved and their order for Enhanced Barrier Precautions was discontinued instead of contact precautions; (b.) Licensed Practical Nurse #2 was unaware of medication shortened expiration dates and was not able to demonstrate insulin Kwik pen administration; (c.) Licensed Practical Nurse #1 was unable to identify which resident in a shared room was on Enhanced Barrier Precautions and was unable to verbalize the difference in other types of infection control precautions; and (d.) Infection Control training was not routinely conducted. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a survey, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for two (2) (Resident #'s 92 and 130) of three (3) residents reviewed. Specifically, (a.) Resident #92 was observed slumped over in their wheelchair in a common area for over 45 minutes without any staff interaction; and (b.) Resident #120 was told by staff to soil themselves. Additionally, during a lunch observation in the main dining room, staff were observed talking amongst themselves and using their phones off to the side of the room, while residents were eating. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during a survey, the facility did not ensure that as needed psychoactive medications had an end date for one (1) (Resident #10) of five (5) residents reviewed for unnecessary medications. Specifically, for Resident #10, there was no end date to an order for lorazepam (a psychoactive medication). This is evidenced by: The policy and procedure titled Psychotropic Medications, reviewed 12/2025, stated as needed orders for psychotropic medications including anti-psychotic, anti-anxiety, anti-depressant, and hypnotic medications, are limited to 14 days. Resident #10 was admitted with the diagnoses of schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), chronic kidney disease (when the kidneys stop filtering waste from the blood), and iron deficiency anemia (when there is not enough iron in the body). [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility did not ensure that comprehensive care plans were developed and implemented for residents according to professional standards for three (3) residents (Resident #'s 2, 6, and 111) of 23 residents reviewed. Specifically, (a.) Resident #2's care plan for impaired cognition did not have person-centered interventions and the interventions listed were not included on the resident's Kardex; (b.) Resident #6 did not include person-centered approaches/interventions to managing the resident's disruptive behavior; and (c.) Resident #111 did not have a care plan that indicated the resident was at risk for aspiration, although the resident had a history of aspiration pneumonia. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a survey, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (3) (Resident #'s 4, 111, and 130) of four (4) residents reviewed. Specifically, (a.) Resident #4 was not provided with feeding assistance as indicated per the resident's plan of care, (b.) Resident #111 was not assisted out of bed for meals and positioned upright for meals as indicated in their care plan and staff did not know interventions listed in the resident's care plan for feeding Resident #111 who had a history of aspiration (accidental breathing of food, liquid, or foreign material into the airway on lungs, rather than the stomach, often caused by swallowing difficulties); [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for two (2) (Resident #'s 68 and 92) of two (2) residents reviewed. Specifically, Resident #68 was not consistently offered or provided with activities that were meaningful to them and met their interests and preferences; and Resident #92 did not attend any activities, nor were one-to-one activities documented as provided. This is evidenced by: The policy titled Activities revised 1/2026, documented it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a survey, the facility did not ensure that each resident received the necessary respiratory care and services that followed professional standards of practice, for one (1) (Resident #43) of one (1) resident reviewed for oxygen administration. Specifically, Resident #43 supplemental portable oxygen tank was noted to be in the red empty zone on 3/4/2026, 3/7/2026 and 3/8/2026. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure that as needed psychoactive medications had an end date for one (1) (Resident #10) of five (5) residents reviewed for unnecessary medications. Specifically, for Resident #10, there was no end date to an order for an as needed narcotic medications. This is evidenced by: The policy and procedure titled Psychotropic Medications, reviewed 12/2025, stated as needed orders for psychotropic medications including anti-psychotic, anti-anxiety, anti-depressant, and hypnotic medications, are limited to 14 days. Resident #10 was admitted with the diagnoses of schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), chronic kidney disease (when the kidneys stop filtering waste from the blood), and iron deficiency anemia (when there isn't enough iron in the body). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (Sunflower Unit Cart A and [NAME] unit cart B) of three (3) medication carts reviewed, and one (1) (Sunflower/Daffodil AD unit) of two (2) medication rooms reviewed. Specifically, three (3) bottles of eye drops; two (2) inhalers; one (1) Lantus insulin pen (1) one Lidocaine vial one; one (1) liraglutide insulin pen; one (1) NovoLog insulin kwik pen all had no open and, or expiration dates. One (1) outer lock of a narcotic lock box was left open; and one (1) narcotic lock box outer lock was broken leaving the door ajar. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during survey, the facility did not ensure it established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) residents (Residents #63, #82, #106, #10, and #113) reviewed. Specifically, (a.) staff failed to follow posted Contact Precaution and Enhanced Barrier Precaution signage; (b.) staff failed to perform appropriate hand hygiene; and (c.) staff failed to demonstrate knowledge of the differences between Contact Precautions and Enhanced Barrier Precautions. This had the potential to affect residents requiring infection control precautions. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification and abbreviated survey (Case #s NY00358820 and NY00359065), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's staffing minimum staffing levels were not met each day from 1/12/2025 through 1/17/2025 per facility assessment and New York State Nursing Home Minimum Staffing and Direct Resident Care. This is evidenced by: Upon entrance to the facility on 1/12/2024 there were 118 residents residing on 3 units. Nursing Homes are required by New York State Public Health Law and Regulations to meet minimum staffing standards. [...]

Inspectors wroteFACILITY Sufficient and Competent Nurse Staffing 01/13/25 11:37 AM [NAME] O2 cannula not in nose. 2.5L NC on concentrator. Problems at nighttime getting help. + cough. Usually takes 10-15 minutes to get help. Only one person works at night. 01/17/25 11:23 AM Interview with Deprincess Golden Staffing coordinator Given numbers on PBJ that were less than 8h in the building. 7/4 7.5h - looked at punch sheets and stated that the RN was present for 7:05 to 3:04. Asked if took a lunch break would that be a 7.5h day. Couldn't confirm that was the situation for that day. 7/14 confirmed there was no RN on that day. 9/20 stated the DON was in the building at the time for full 8h and another RN was here 6.75 The staff are not allowed to clock in 7 minutes before shift start or 7 minutes before time to leave. Puts her schedule in place months in advance and gives it to upper management for review. [...]

Inspectors wroteResident # 364 Resident #364 was admitted to the facility with diagnoses of unspecified fall, influenza virus A and other acidosis (a condition where the body has too much acid in body fluids). A Minimum Data Set, dated [DATE] documented Resident #364 was cognitively intact, could be understood, and understand others. During an observation on 1/13/2025 at 1:41 PM, Resident #364 had a urinary catheter in place connected to a bed bag. The urinary catheter bag was observed uncovered and lying on the floor. A care plan titled risk for Multiple Drug-Resistant Organisms (MDRO) colonization/ infection related to indwelling urinary catheter dated 1/08/2025 documented goal of Resident #364 would remain free of Multiple Drug -Resistant Organism infection/colonization. Interventions included: Educate Resident, family and visitors on Enhanced Barrier Precautions; Enhanced barrier precautions: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 4 (Resident #s 13, 17, 62, and 364) of 40 residents reviewed. Specifically, [a.] Resident #13 was unable to attend activities of their choice as their wheelchair was not able to fit through the interior doorways to the activities room, which caused the resident to feel excluded, [b.] Resident #17 expressed feeling like a burden and was uncomfortable asking for help because of staff ' s unprofessionalism, [c.] Resident #62, was observed on 1/13/2025 at 11:40 AM with matted, greasy hair, fully clothed, and was malodorous. [...]

Inspectors wroteBased on observations, record reviews, and interviews during a recertification survey, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for 2 (Residents #s 13 and 22) of 2 residents reviewed for self-administration of medication. Specifically, (a.) Resident #13 was observed with their prescribed Albuterol inhaler and Trelegy inhalers on their overbed table and; (b.) Resident #22 was noted to have an Albuterol sulfate hydrofluoroalkane (HFA) inhaler on their overbed table. There was no documented evidence that Resident #s 13 and 22 were assessed to determine their ability to safely self-administer medications, and there was no physician order for self-administration of medications. This is evidenced by: [...]

Inspectors wroteBased on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment and effective housekeeping and maintenance services were maintained for 5 (Units A, B, C, D, and G) of 5 resident units. Specifically, for all units, the handrails throughout the unit were scuffed, nicked, and scraped, exposing the untreated wood; for Unit A, there was not sufficient hot water to the resident's rooms; for Units B, C, D, and G, the bathrooms were not fully cleaned, tidy, and lights in residents bathroom not working. This is evidenced by: The undated Policy &Procedure, titled Maintenance/Housekeeping Work Order Policy, documented that it was the facility's policy to ensure all areas maintained a clean, comfortable, and well-functioning environment. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a recertification survey, the facility did not ensure residents had the right to voice grievances without discrimination or reprisal and without fear of discrimination or reprisal. Specifically, residents were not provided information on how to file a grievance or complaint anonymously. This is evidenced by: The facility Policy titled, Grievances, created 3/2016 with a current revision date of 7/02/2024, documented policy implementation included upon admission, the resident and/or resident representative are provided with information on how to file a grievance. Grievances may be submitted orally, in writing, and anonymously. Written grievances should be signed by the resident and/or representative whenever possible. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 resident (Resident #40) of 40 residents [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident had an appropriate and safe discharge for 1(Resident #362) of 3 residents reviewed for discharge. Specifically, Resident #392 did not feel they were discharged appropriately, did not have a discharge planning meeting with Social Work and did not receive adequate discharge education or written notice of their rights to appeal the decision. This is evidenced by: Resident # 362 was admitted to the facility with diagnoses of fracture of one femur, repaired (broken hip repaired surgically), polysubstance abuse (drug and alcohol abuse) and unspecified osteoarthritis (arthritis of the bones and joints). The Minimum Data Set (an assessment tool) dated 1/14/2025 documented resident was cognitively intact, could be understood by and could understand others. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 7 (Resident #s 6, 17, 22, 24, 40, 60, and 92) of 40 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was incomplete for Residents #s 6, 17, 22, 24, 40, 60, and 92). This is evidenced by: The Policy and Procedure titled, Preadmission Screening and Resident Review (PASARR)/Screens, revised 12/2019, documented the Admissions department would obtain a completed Level 1 Screen for all admissions prior to being accepted to and arriving at the facility. [...]

Inspectors wroteBased on record review and interview during the recertification survey and an abbreviated survey (Case #NY00358820), the facility did not ensure the development and implementation of comprehensive person-centered care plans that included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs for 7 (Resident #s 14, 27, 38, 40, 211, 362, and 364) of 40 residents reviewed. [...]

Inspectors wroteBased on record review and interview during the recertification and an abbreviated survey (Case #NY00364136), the facility did not ensure comprehensive care plans were reviewed and revised based on changing goals, preferences, and needs for 1 (Resident #s 6) of 40 residents reviewed. Specifically, the facility did not ensure Resident #6's comprehensive care plan was reviewed and revised when the resident fell and was assessed on 10/01/2024, 10/05/2024, 10/07/2024, 10/16/2024, 10/20/2024, 11/01/2024, 12/09/2024, and 12/11/2024. This is evidenced by: The Policy and Procedure titled, Care Plans-Comprehensive, revised 10/2019, documented assessments of residents were ongoing, and care plans were revised as information about the residents and the residents' conditions change. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (Resident #s 22, and 75) of 40 residents reviewed. Specifically, Resident #s 22 and 75 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. Additionally, Resident #22 requested supplies for an activity that was not provided. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey and an abbreviated survey (Case #NY00358820), the facility did not ensure residents receive treatment and care in accordance with professional standards of practice for 2 (Resident #s 34 and 211) of 40 residents reviewed for. [...]

Inspectors wroteBased on observations, record review and staff interviews during the recertification survey, the facility did not ensure that it maintained acceptable parameters of nutritional status, maintain usual body weight or desirable body weight range and electrolyte balance related to resident preferences for ordered diet; and maintain the physician ordered therapeutic diet, and offered sufficient fluid intake to maintain proper hydration and health for 2 (Resident #s 51, and 364) of 40 reviewed. Specifically, for (a.) Resident #51 the facility did not ensure that the resident was tolerating tube feedings without symptoms or nausea or vomiting, monitoring the resident's weights for significant changes, or addressing the significant weight change; [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey, the facility did not ensure that residents who required respiratory care were provided such care in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences for 2 (Resident #'s 13 and 22) of 40 residents reviewed. Specifically, Resident #s 13 and 22 oxygen therapy were not administered as ordered by the physician. This is evidenced by: The Policy and Procedure titled Oxygen Therapy, last revised 09/2022, documented the administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. However, oxygen should be regarded as a drug and therefore requires prescribing in all but emergency situations. [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight consecutive hours per day on multiple dates from July 4, 2024, to September 28, 2024. This is evidenced by: The facility assessment dated 1/2025 documented that the staffing plan was based on the resident population and their needs for care and support. The staffing plan documented the following daily staffing needs: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 1 (Resident #5) of 7 residents observed during a medication pass for a total of 27 observations. This resulted in a medication error rate of 22.22%. This is evidenced by: The facility's Policy and Procedure titled, Medication Administration revised 12/2019, documented medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label three (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 3 of 3 medication carts (Unit G, Cart 2; Unit C, Cart 2; Unit D, Cart 1) and 2 of 2 medication rooms (Unit G and Unit B units) reviewed. Specifically, (a.) opened medications had no open and or expiration dates (b.) 1 open vial of insulin had an expired date: (c.) discontinued medications were stored in medication carts and refrigerator; (d.) 2 narcotic boxes were not double locked; (e.) and personal items were stored in medication carts and medication room. This is evidenced by: [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in 3 (A/D, B/C, and G units) of 3 resident unit nutrition rooms and the main kitchen. Specifically, the area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During the initial inspection in the main kitchen on 1/13/2025 at 11:20 AM, the following observations were made: The rolling toaster appliance had a large amount of buildup and debris on the device. The meat slicer had dirt and debris on and under the device. Cooler #1 had a broken seal with dirt and debris in the seal. Cooler #3 had a broken seal around the lid not allowing proper sealing. The top of the Accutemp steamer had dirt and debris on the equipment. [...]

Inspectors wroteBased on observation during the recertification survey, the facility did not dispose of garbage and refuse properly for 2 of 3 trash bins. Specifically, 2 trash bins were not pest and rodent-proof with trash bin doors not fully closed, and the drain plug was not secured. This is evidenced as follows: During an inspection on 1/15/2025 at 12:48 PM, garbage waste was found around the dumpsters. the right dumpster did not have a drain plug, and the left dumpster side door was open. During an interview on 1/23/2025 at 10:35 AM, Director of Maintenance #1 stated they were responsible for the dumpsters and the area. They stated the left dumpster was for the adult apartment facility, but it was still their responsibility. They stated that they would clean up the area daily but refuse still litters the ground around the dumpsters throughout the day. [...]

Inspectors wroteBased on observation, resident and staff interviews, review of facility policies and procedures, staffing records, resident records, accident and incident reports, and the facility's maintenance records, during the recertification survey, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements, which affected or potentially affected all residents in the facility. These failed practices directly impacted 39 of 39 residents sampled (Resident #s 3, 6,13, 14, 17, 22, 24, 27, 34, 38, 39, 40, 42, 46, 51, 52, 56, 58, 60, 62, 68, 75, 92, 97, 102, 103, 107, 108, 109, 160, 210, 211, 212, 213, 218, 260, 261, 362, 364). [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure in accordance with accepted professional standards and practices, it maintained medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #34) of 40 residents reviewed. Specifically, Resident 34's Treatment Administration Record was not accurately documented on 1/12/2025. This is evidenced by: Cross-referenced to: F684: Quality of Care Resident #34 was admitted to the facility with diagnoses of disruption or dehiscence (splitting open) of internal surgical wound of abdominal wall muscle, surgical aftercare following surgery on the digestive system, and personal history of malignant neoplasm (cancer) of the large intestine. [...]

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to maintain a quality assurance committee that met with the participation of all required members, including the director of nursing, Medical Director or designee, Administrator, and Infection Preventionist. The failure to meet to coordinate and evaluate the need for performance improvement projects had the potential to affect all residents of the facility. This is evidenced by: A review of the facility's undated Quality Assurance and Performance Improvement Plan, revealed that the Quality Assurance and Performance Improvement Plan provides leadership through its committee. [...]

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not designate one or more individual(s) as Infection Preventionist (s) responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have designated individual as their Infection Control Preventionist from October 4th 2024 to January 2025. This is evidenced by: Cross referenced to: F880 Infection Control The Policy and Procedure titled C-IC-14 Antibiotic Stewardship created 10/2017 and revised 7/25/2024, documented under Accountability: The facility Infection Preventionist has oversight of the Antibiotic Stewardship , with input, review, guidance, and actions taken by the facility's Medical Director, Consultant Pharmacist, Director of Nurses, Administrator, and other facility leaders as appropriate; [...]

Inspectors wroteBased on observation and interviews conducted during a recertification survey, the facility did not ensure results of the most recent Federal/State survey were posted in a place readily accessible to residents. Specifically, survey results were posted in a place that was not frequented by most residents, visitors, or other individuals; was not in a location that would allow individuals to examine the survey results without having to ask and to maintain privacy to review the results; and there was no documentation on resident units notifying residents of the location of the survey results. This was evidenced by: During the resident council meeting on 1/14/2025 at 11:07 AM, 4 of 4 residents in attendance verbalized they did not know where the facility had the Department of Health Survey results located. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the resident's right to be free from abuse and neglect for 1 (Resident #40) of 40 residents reviewed for abuse and neglect. Specifically for Resident #40, a Certified Nurse Aide did not follow the resident's comprehensive care plan when giving personal care, during which the resident fell from their bed and sustained a broken leg on 10/01/2024. This is evidenced by: A policy titled, Abuse Policy, revised 12/2022, documented that the facility prohibited the mistreatment, neglect, and abuse of residents/patients and misappropriation of the resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. [...]

Inspectors wroteBased on record review and interview during the post-survey revisit and abbreviated survey (Case # NY00376983), the facility did not have evidence that all alleged violations were thoroughly investigated for 1 (Resident #365) of 4 residents reviewed. Specifically, the facility did not have evidence of thorough investigation when Resident #365 reported they injured their hand on the front door when they were coming back into the facility at 11:00 PM on 3/25/2025. This is evidenced by: Cross-reference to F689: Free of Accident Hazards/Supervision/Devices Resident #365 Resident #365 was admitted to the facility with diagnoses of type 2 diabetes mellitus (chronic metabolic disease characterized by persistently high blood sugar levels) without complications, nicotine dependence - cigarettes, and schizophrenia (a serious mental condition that effects how people think, feel, and behave). [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure written notice specifying the duration of the bed-hold policy, was provided to the resident and the representative at the time of transfer for hospitalization for 1 (Resident #22) of 1 resident reviewed for hospitalization. Specifically, for Resident #22, the resident and the resident's representative were not notified in writing of the bed hold policy when the resident was admitted to the hospital on [DATE]. This is evidenced by: The facility policy titled, Discharge - Transfer/Discharge Process, date created 11/2017, last revised 10/10/2024, documented the facility would coordinate a safe transfer or discharge for residents leaving the facility. [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey, the facility did not ensure each resident had an environment that was as free of accident hazards as was possible to prevent accidents for 1 (Resident #13) of 1 resident reviewed for accident hazards. Specifically, Resident #13 who shared a room with another resident was observed with medications in their room not supervised. This is evidenced by: Resident #13 was admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia (when the body cannot exchange oxygen and carbon dioxide), type 2 diabetes mellitus without complications, and chronic obstructive pulmonary disease with (acute) exacerbation. The Minimum Data Set (an assessment tool) dated 11/12/2024 documented the resident was cognitively intact, could be understood and understand others. [...]

Inspectors wroteBased on observations, record reviews, and interviews during recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, which was any drug used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences which indicated the dose should be reduced or discontinued for 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Specifically, Resident #27's physician order for Estrace (a vaginal cream) did not include an indication for use in accordance with professional standards. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents were free of any significant medication errors for 1 (Resident #s 62) of 40 residents reviewed. Specifically, Resident #62 was not given Alprazolam (used to treat anxiety) at the prescribed therapeutic times. Additionally, there was no documented evidence that physician was notified, and that Resident #62 was monitored for side effects. This is evidenced by: Resident # 62 was admitted to the facility with diagnoses of pubic ramus fracture (a fracture of the pubic bone), primary osteoarthritis (arthritis of the bones and joints), left shoulder, and muscle weakness. The Minimum Data Set (an assessment) dated 12/24/2024 documented the resident had intact cognition, could be understood, and understand others. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey, the facility did not ensure safe and sanitary storage of foods brought to residents by families and other visitors to prevent food-borne illness for 1 (Resident #52) of 1 resident reviewed for outside food. Specifically, Resident #52's food brought from outside was not labeled and discarded per the facility policy. This is evidenced by: Resident #52 was admitted to the facility with the diagnoses of unilateral inguinal hernia with obstruction (when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles causing pain and obstruction to the intestine), hepatomegaly (a condition where the liver is larger than normal), and type 2 diabetes mellitus (a chronic disease that occurs when the body can't use insulin properly, resulting in high blood sugar levels). [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case #s NY00319982 and NY00331306), the facility did not ensure that all alleged violations involving abuse, including injuries of unknown source 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 the State Agency for 2 (Resident #s 1 and 3) of 3 residents reviewed. Specifically, for Resident #1, allegation of verbal abuse by Certified Nurse Aide #1 on 1/12/2024 was not reported to the Administrator and to the State Agency within 2 hours after the allegation was made. The Administrator was made aware of the allegation on 1/15/2024. The facility did not report to the New York State Department of Health until 1/18/2024. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00319982 and NY00331306), the facility did not ensure that in response to an allegation of abuse, that it had evidence that all alleged violations were thoroughly investigated for 2 (Resident #s 1 and 3) of 3 residents reviewed. Specifically, the facility did not have evidence of a thorough investigation for 1) Resident #1, when staff witnessed an allegation of verbal abuse on 1/12/2024. The investigation was not started until 1/15/2024, and 2) Resident #3, when the resident reported an allegation of physical abuse on 1/09/2024. The investigation was not started until 1/26/2024, during the abbreviated survey. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case# NY00319982), the facility did not ensure each resident was treated with respect, dignity, and care for 1 (Resident #1) of 3 residents reviewed. Resident #1, who had post-traumatic stress disorder, became angry while waiting for care on 1/12/2024. Resident #1 approached Certified Nurse Aide #1 about their care needs, and the aide responded to the resident in an undignified manner. During an interview on 1/23/2024 at 12:02 PM, Resident #1 stated they confronted Certified Nurse Aide #1 about their care needs and there was an argument. They stated they felt damaged, verbally abused, and betrayed at the time of the incident. This is evidenced by: Refer to F609 Resident #1: [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case# NY00331306), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice for 1 (Resident #3) of 3 residents reviewed. Specifically, while at a medical consult on 1/10/2024, Resident #3 showed the clinician an injury on their left forearm. Skin evaluations were not done or documented from 1/10/2024 through 1/24/2024. The injury was not identified by the facility until the time of the survey. This is evidenced by: Refer to F610 Resident #3: Resident #3 was admitted to the facility with diagnoses of chronic kidney disease stage 3, diabetes with diabetic neuropathy (nerve damage caused by diabetes), and dementia without behavioral disturbance. [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case# NY00319982), the facility did not ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not provide adequate supervision of Resident #1 during medication administration of Oxycodone (narcotic pain medication). As a result, Resident #1 had possession of ten (10) Oxycodone pills that the resident kept in the top drawer of their unsecured nightstand. During interview on 1/23/2024, Resident #1 stated they were saving them to prove to the New York State Department of Health, the nurses were not administering their medication correctly. This is evidenced by: Refer to F760 Resident #1: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case# NY00319982), the facility did not ensure residents are free of any significant medication error for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1 received prescribed Oxycodone (narcotic pain medication) on 1/21/2024, as ordered by the physician. This is evidenced by: Refer to F689 Resident #1: Resident #1 was admitted to the facility with diagnoses of paraplegia (paralysis of the lower body), acquired absence of right and left leg above the knee, and post-traumatic stress disorder. The Minimum Data Set (an assessment tool) dated 1/7/2024, documented the resident was cognitively intact. The Policy and Procedure titled Medication Administration last revised 12/2019, documented medications would be administered in a safe and timely manner, and as prescribed. [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case# NY00331306), the facility did not ensure in accordance with State and Federal laws, that all drugs were stored in locked compartments. Specifically, the facility did not ensure that all medications were secured and inaccessible for Resident #3, when the surveyor observed a bottle of aspirin on the resident's nightstand during interview of the resident on 1/23/2024 at 12:28 PM. The resident stated they noticed the bottle of aspirin there earlier but did not know where it came from or what to do with it. This is evidenced by: Resident #3: Resident #3 was admitted to the facility with diagnoses of chronic kidney disease stage 3, diabetes with diabetic neuropathy (nerve damage caused by diabetes), and dementia without behavioral disturbance. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case# NY00331399), the facility did not ensure laboratory services were provided timely to meet the needs of the residents for 1 (Resident #2) of 3 residents reviewed. Specifically, Resident #2 was ordered to have a laboratory test completed on 12/25/2023. The test was not completed as ordered and Physician Assistant #1 was not notified. Subsequently, the test was not done until 12/29/2023. This is evidenced by: Refer to F773 Resident #2 Resident #2 was admitted to the facility with diagnoses of surgical aftercare for fracture of part of neck of right femur (hip fracture), diffuse large B-cell lymphoma (fast-growing blood cancer and the most common form of non-Hodgkin lymphoma), and diastolic (congestive) heart failure. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case# NY00331399), the facility did not promptly notify the physician assistant of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #2) of 3 residents reviewed. Specifically, the facility did not ensure it promptly notified Physician Assistant #1or the on-call provider of an abnormal laboratory result for Resident #2 on 12/29/2023 at 8:23 PM. Physician Assistant #1 was not made aware of the result until they were in the facility on 1/2/2024. This is evidenced by: Refer to F770 Residnet #2: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case# NY00331399), the facility did not ensure in accordance with accepted professional standards and practices, it maintained medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #2) of 3 residents reviewed. Specifically, for Resident #2, the facility did not ensure A) a documented assessment of the resident's condition, when there was a change in physical condition on 12/31/2023, B) documentation the physician was notified of the resident's condition on 12/31/2023, and orders given, C) documentation of the resident's response to the ordered treatment given on 12/31/2023 and ongoing monitoring of the resident's condition and D) documentation of the resident's condition on 1/1/2024. The resident was sent to the hospital on 1/2/2024. [...]

Inspectors wroteBased on observations and interviews during an abbreviated survey (Case # NY00289386), the facility did not ensure a safe, clean, comfortable homelike environment for three (3) out of five (5) units. Specifically, the facility did not ensure that resident rooms were clean and sanitary and that holes in the walls and areas of the facility that were in disrepair were repaired. This was evidenced by: Facility Policy and Procedure titled, Maintenance/Housekeeping Work Order Policy, undated, read in pertinent part that the facility was to assure all areas of the facility maintained a clean, comfortable, and well-functioning environment. Upon noticing any problem with this standard, all employees were required to complete a Maintenance/Housekeeping Work Order. The date, time, location, request description and person requesting would be written/listed on the order. [...]

Inspectors wroteBased on observations and interviews during an abbreviated survey (Case # NY00291257, NY00298722, NY00293839), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 3 (Residents #5, #11, #17) of 7 residents reviewed for activities of daily living care. Specifically, the facility did not ensure that Resident #5's used incontinence brief was not properly discarded and that their dentures were cleaned regularly and stored in a sanitary way, that Resident #11 was regularly transferred from their bed in order to receive a full shower and that Resident #17 received bi-weekly showers in accordance with their plan of care. Resident #5's used incontinence brief was not properly discarded and that their dentures were cleaned regularly and stored in a sanitary way. This was evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews during abbreviated survey (Case #NY00324950), the facility did not store, prepare, distribute, or serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, (1) the dishwashing machine final rinse water pressure was too high; (2) areas were soiled with food particles and/or dirt; (3) walls contained holes and were broken; (4) the kitchen door and wall behind the preparation sink were peeling; and (5) the preparation sink faucet was leaking. This was evidenced as follows: During observations of the main kitchen on 11/15/2023 at 9:50 AM: 1) The automatic dishwashing machine final rinse water pressure was 60 pounds per square inch (psi); the gauge on dishwashing machine states final rinse is to be 15-25 pounds per square inch. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00297761), the facility did not ensure a comprehensive, person-centered care plan was developed and implemented that included measurable objectives and services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) resident (Resident #3) of 17 sampled residents. Specifically, the facility did not ensure that Resident #3's care plan included support required by the resident to complete activities of daily living and care required to attain or maintain their highest practical physical wellbeing. This was evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review conducted during an abbreviated survey (Case #NY00293839), the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. Specifically, Resident #1, who was admitted to the facility without pressure ulcers, developed a pressure ulcer on their buttocks 5 days after admission. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00297761), the facility did not ensure that dentures were replaced for one (1) resident (Resident #3) of two (2) residents reviewed for dental services. Specifically, when Resident #3's lower denture went missing at the facility, the facility referred the resident to dental services for replacement of the denture, however, the facility did not follow through with replacing the denture and the resident never received the replacement denture nor did the facility reimburse the cost for the denture to be replaced. Cross referenced to F677: ADL care for dependent residents; see Resident #5 Cross referenced to F656: Comprehensive Care Plan This was evidenced by: The Policy and Procedure, last revised July 2019, read in pertinent part that the facility is responsible for managing resident's dentures. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case# NY00289722), the facility did not ensure that the facility assessment addressed the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Specifically, the facility assessment did not address the care and equipment needed to care for bariatric care residents. This was evidenced by: The Policy and Procedure titled, Facility Assessment and last revised January 2020 read, in pertinent part, the following: a facility assessment would be conducted annually to determine and update the facility's capacity to meet the needs of and competently care for faciliy residents during day-to-day operations. [...]

Inspectors wroteBased on observations and interviews during an abbreviated survey (Case # NY00289722, NY00289386), the facility did not ensure to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not ensure (1) Resident #5's dentures were clean and stored in a sanitary way; (2) resident bathrooms were clean and sanitary; (3) toothbrushes were stored in a sanitary way; and (4) toothbrushes were discarded when they became visibly dirty/soiled. This was evidenced by: [...]

Inspectors wroteBased on observation and staff interviews during a recertification survey, the facility did not ensure a safe comfortable home like environment was provided and effective housekeeping and maintenance services were maintained for 5 of 5 residents units. Specifically, for Unit A, the facility did not ensure doors and handrails throughout the Unit were not scraped and walls in rooms were not patched, unfinished, and unpainted, the main shower room floor was not dirty and dusty and that equipment stored there was not soiled, and did not ensure personal care products and equipment were labeled with residents' names in shared bathrooms; [...]

Inspectors wroteBased on observation and interview during the recertification survey on 1/25/2023 through 2/03/2023, the facility did not ensure the resident environment remained as free of accident hazards as was possible. Specifically, the facility did not ensure resident room wardrobes were secured and as a result could topple over on 5 (A/D unit, B/C Unit, and G Unit) of 5 resident units. This is evidenced by: During observations on 1/26/2023 from 9:30 AM to 10:30 AM, the wardrobes in resident rooms were not attached to the wall and could topple on the following units and their room #s: -A Unit: 13, 17 -D Unit: 20, 21, 22, 25, 26, 30, 31, 36, 38 -B Unit: 39, 40, 41, 52, 54, 55 -C Unit: 59, 60, 66, 67, 69, 73 -G Unit: 101, 103, 104, 106, 107, 108, 109, 113 During an interview on 1/26/2023 at 10:50 AM, the Director of Maintenance stated they were not aware wardrobes were not attached to the walls. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not prepare and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 nourishment rooms. Specifically, the components of the automatic dishwashing machine required repair, dishware was not protected from contamination, and equipment, fixtures, and floors required cleaning and repair. This is evidenced as follows: During observations on 01/25/23 at 9:30 AM, in the main kitchen, the automatic dishwashing machine (machine) final rinse registered zero degrees Fahrenheit (F) while tableware was being washed. The operating instruction on the dishwashing machine state that the final rinse temperature is to be 180 F. After a second attempt, the dial did not move to register a temperature for a wash or a rinse. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey the facility did not ensure it established and maintained an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically: the facility did not ensure proper hand hygiene was performed, during a dressing change to prevent contamination of a resident's wound. Additionally, the facility did not ensure proper use of personal protective equipment was maintained to prevent the spread of infectious disease: This was determined by: Finding #1 The facility did not ensure proper hand hygiene was performed, during a dressing change. A document titled: Wound Care Policy last revised 10/2021 documented the following: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. [...]

Inspectors wroteBased on interview and record review during a recertification survey from 1/25/2023 through 2/3/2023, the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment. Specifically, for 7 of 7 Employee Files reviewed, the facility did not ensure staff participated in general orientation in accordance with the facility assessment. This is evidenced by: The Facility Assessment Portfolio dated January 2023, under the heading Overview of Staff training/education and competencies, documented upon hiring, all facility personnel would participate in general orientation and job specific orientation. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and abbreviated survey (Case #NY00308551) on 1/25/2023 through 2/03/2023, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 3 (Resident #s 9, 12, and #271) of 8 residents reviewed for Activities of Daily Living (ADLs). Specifically, for Resident #'s 12 and #271, the facility did not ensure the residents received showers twice a week in accordance with the comprehensive care plan (CCP) to maintain good personal hygiene and for Resident #9, who could not carry out activities of daily living independently, the facility did not ensure the resident's need to have their hair washed, their facial hair trimmed, and their fingernails cleaned and trimmed to maintain good personal hygiene was addressed. [...]

Inspectors wroteBased on record review and interview during the recertification survey on 1/25/2023 through 2/3/2023, the facility did not ensure irregularities reported by the pharmacist to the attending physician, the facility's medical director and the director of nursing (DON) were acted upon for 1 (Resident # 12) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #12, the facility did not ensure an irregularity identified by the pharmacist during a medication regimen review was reviewed and acted upon by the physician and the DON in a timely manner. This is evidenced by: Resident #12: Resident #12 was admitted to the facility with the diagnoses of type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction and essential (primary) hypertension. [...]

Inspectors wroteBased on record review and interviews during the recertification survey dated 1/25/2023 through 2/3/2023, the facility did not ensure residents were free from significant medication errors for 1 (Resident #12) of 5 residents reviewed. Specifically, for Resident #12, the facility did not ensure a physician ordered medication (Insulin Aspart) was administered in accordance with physician ordered parameters on 62 occasions between October 14, 2022 and January 2023. This is evidenced by: Resident #12: Resident #12 was admitted to the facility with the diagnoses of type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction and essential (primary) hypertension. The Minimum Data Set (MDS - an assessment tool) dated 9/20/2022, documented the resident had intact cognition, could understand others, and could make themselves understood. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure food that accommodated resident allergies, intolerances and preferences for 1 (Resident #12) of 3 residents reviewed. Specifically, for Resident #12, the facility did not ensure Lactaid (lactose-free dairy products) milk and diet hot chocolate documented on the resident's meal ticket were provided on 1/25/2023 and 1/26/2023. This is evidenced by: Resident #12: Resident #12 was admitted to the facility with the diagnoses of type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction and essential (primary) hypertension. The Minimum Data Set (MDS - an assessment tool) dated 9/20/2022, documented the resident had intact cognition, could understand others, and could make themselves understood. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure residents requiring specialized rehabilitative services were provided with services for 1 (Resident #41) of 1 resident reviewed for rehabilitation. Specifically, the facility did not ensure Resident #41 was provided with Physical Therapy (PT) and Occupational Therapy (OT) screens per facility policy, following a referral made on 1/23/23. This was evidenced by: Resident #41: Resident #41 was admitted to the facility with diagnoses of morbid obesity, muscle weakness, and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 1/2/23, documented the resident was able to make themselves understood, understand others, and was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure an effective pest control program was maintained for 2 (Units C and G) of 5 units. Specifically, for Unit C, the facility did not ensure room C 63, the hallway bathroom, and the Unit C hallway were kept free from flies and for Unit G, the facility did not ensure the hallway and hallway bathroom outside of the resident dining room were were kept free from flies. This was evidenced by: The Policy and Procedure (P&P) titled Pest Control, dated 11/2022, documented the facility maintains an ongoing pest control program to ensure the building is kept free of pests and rodents. Unit C: Facility Pest Management Logs dated 9/29/22 documented an inspection for flies in C 63; follow up inspections for flies in room C 63 were not performed between 9/30/22 - 1/20/23. [...]