East Side Nursing Home

Inspectors wroteBased on observation, interviews and record during a survey, the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents for one (1) (Resident #89) of eleven (11) residents reviewed for accidents. Specifically, on 10/10/2025 facility staff (Driver #1 and Transport Aide #1) failed to ensure that Resident #89 was safely secured in the facility's wheelchair transport van when returning from a medical appointment. The resident's wheelchair was secured to the van floor; however, the transport staff did not ensure the resident was wearing the required shoulder and lap belts, which resulted in Resident #89 being thrown from the wheelchair to the front of the van during an abrupt stop. Resident #89 suffered a nasal fracture, abrasions, and had associated pain. [...]

Inspectors wroteBased on observation, interview and record review conducted during a survey, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (1) (third floor) of three (3) resident use floors. Specifically, ceiling tiles were stained and there was evidence of roof leaks in resident rooms and common areas. This involved Resident #84. The finding is: The policy titled Resident Rights dated 12/19/2022, documented that the facility shall protect and promote the rights of each resident. The policy documented resident rights shall include, but not be limited to, the resident's right to a dignified existence, self-determination, and be treated in a respectful manner that supports his/her dignity in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life. [...]

Inspectors wroteBased on observations, interviews and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #80) of three (3) residents reviewed for skin conditions. Specifically, Resident #80's arterial ulcer treatment was not completed in accordance with the physician's order. Additionally, there was no documented evidence that a provider was notified Resident #80 was refusing the ordered treatment or it was not being completed as ordered between 01/23/2026- 01/27/2026.

Inspectors wroteBased on observation, interview and record review conducted during the survey, the facility did not ensure each resident received food prepared in a form designed to meet individual needs for one (1) (Resident #43) of three (3) residents reviewed. Specifically, Resident #43 was ordered a mechanically altered diet (a diet that consists of easy to chew and swallow foods) of ground meat and was not provided ground consistency meat during a meal observation. The finding is: The policy titled Tray Pass, dated 12/19/2022, documented the purpose of the policy was to ensure residents receive the correct meals safely, timely and in accordance with the physician diet orders. The meal trays were to be checked against the diet roster prior to delivery. Nursing or designated staff verify resident identity and correct diet at the time of tray pass. [...]

Inspectors wroteBased on interviews and record review conducted during the survey, the facility did not ensure that newly admitted resident's and/or their representatives were provided with a written summary of a Baseline Care Plan that included the minimum healthcare information necessary to properly care for the immediate needs of the resident (including but not limited to initial goals, admission orders, dietary, therapy and social services) for eight (8) (Residents #7, #9, #32, #40, #57, #64, #80, and #89) of ten (10) residents reviewed. Specifically for all residents identified the facility did not provide the residents or their representative with a written summary of their Baseline Care Plan.

Inspectors wroteBased on observation, record review, and interviews conducted during the Standard Survey completed on 11/20/23, 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 two (Residents #8 and #26) of 2 residents reviewed. Specifically, residents were not provided a choice to take a tub bath because there was not a functioning tub bath in the facility.

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey completed 11/20/23, the facility did not ensure they consulted with the resident's physician when medications were not administered as ordered for one (Resident #4) of two residents reviewed for notification. Specifically, the physician was not notified when the resident's insulin was being administered late multiple days on the evening shift.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed 11/20/23, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #72) of three residents reviewed for ADLs. Specifically, Resident #72 was observed with long dirty (dark debris) fingernails, had unkempt facial hair, and was not shaved or offered to be shaved during morning care. The finding is: The policy and procedure (P&P) titled Shaving Residents - Male and Female dated 11/14/11 documented it shall be the policy of this facility that residents shall have facial hair removed on a regular basis and/or per their request. [...]

Inspectors wroteBased on interview and record review completed during the Standard survey completed on 1/28/22, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury for three (Resident #4, #34, #226) of seven residents reviewed for alleged abuse. Specifically, a bruise of unknown origin (Resident #226) and an allegation of resident-to-resident abuse (Resident #4 and #34) were not reported to the New York State Department of Health (NYSDOH) within the two-hour timeframe as required.

Inspectors wroteBased on interview and record review conducted during the Standard Survey completed on 1/28/22, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #226) of seven residents reviewed for abuse. Specifically, there was a lack of a thorough investigation to include the previous shifts staff members statements according to facility practices to rule out abuse, neglect or mistreatment when a bruise of unknown origin was identified above the resident's right eyebrow. The finding is: Review of a facility policy and procedure (P&P) titled Accident/Incidents revised date 7/31/2017 documented, all accidents, potential accidents, incidents, reported abuse, suspected abuse, unexplained bruising shall be investigated and reported to the administration as indicated (see P&P Abuse Prohibition). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/28/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, one (Resident #36) of one resident reviewed for quality of care of prosthetic eye did not receive eye care as ordered by the physician and was inaccurately documented in the treatment record. The facility policy and procedure (P&P) titled Maintenance of Prosthetic Eye dated 2/4/21 documented that routine cleaning of prosthetic eye is to be performed in effort to maintain comfort, reduce secretions, extended life of prosthetic eye and aide in the prevention of conjunctivitis (eye infection). Any licensed nursing staff is able to perform maintenance of prosthetic eye. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 1/28/22, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three, (Resident #47, #56, & #224) of four residents observed for pressure ulcers. Specifically, there was a lack of treatment initiation for residents with pressure ulcers (#47, #224), treatments were not completed as recommended by the Wound Consultant Physician (#56), a wound culture was not obtained as ordered (#224), and pressure reducing devices were not provided as recommended by the Wound Consultant Physician (Resident #56 & 224).

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 1/28/22, it was determined that the facility did not arrange for the provision for physician services 24 hours a day, in case of emergency. Specifically, one (Resident #124) of one resident reviewed for hospitalization the facility did not ensure the provider responded promptly to notification for resident with critically high and high laboratory values. The finding is: 1. Resident #124 had diagnoses of dementia, aphasia (the inability to communicate) and chronic kidney disease. The Minimum Data Set (MDS - a resident assessment tool) dated 10/17/21 documented Resident #124 was moderately cognitively impaired, understands and was understood. [...]