Eddy Village Green

Inspectors wroteBased on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift was displayed on one (1) resident unit, and not accessible to residents and visitors on the other resident units of the facility. This is evidenced by: During an observation from 3/25/2025 through 4/03/2025, the doorway to the administration suite was labeled with a sign documenting that no one was allowed in the building except staff. [...]

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 two (2) (House 21 and House 24) of 8 medication carts reviewed, and 8 (Houses 1, 2, 3, 4, 19, 21, 22, 24) of 8 medication rooms reviewed. Specifically, (a.) opened medications had no open and or expiration dates; (b.) one active medication had expired; (c.) medication rooms were left open and unattended; (d.) unlicensed staff had key/access code to medication rooms. This is evidenced by: The facility's Policy and Procedure Titled, Medication Administration effective [DATE] documented, each patient/resident/elder would receive medications according to provider orders and accepted professional standards. Under General Considerations, Responsibility and Procedure: [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect, cared for in a manner, and in an environment that promotes maintenance or enhancement of their quality of life for three (3) (Resident #s 110, 136 and 145) of 36 residents reviewed for dignity. Specifically, (a.) Resident #110 was administered medications in a common area with other residents and individuals present without resident's permission; (b.) Certified Nurse Aide stood over the dining room table instead of sitting with resident, while assisting Resident #136 with their meal; (c.) Resident #145 was served meals at dining room table with the use of plastic utensils. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure assessments were coordinated with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid for eight (8) (Resident #s 16, 22, 65, 70, 115, 130, 145, and 166) of 36 residents reviewed. Specifically, (a) Resident # ' s 22, 65, 70, and 145 received new diagnoses of mental illness and no Level I screening was done to determine if a Level II screen needed to be done and (b) Resident # ' s 16, 22, 115, 130, and 166 were admitted with diagnoses of mental illness and Level I screen was not accurately completed to indicate the need for Level II. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview conducted 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 three (3) (Resident #s 16, 22, and 25) of 36 residents reviewed. Specifically, (a.) Resident #22 was unable to make their needs known, and there were several dates with no documented activities. (b.) For Resident #s 16 and 25, there were no consistent activities planned to meet the resident's needs and/or preferences. This is evidenced by: The facility Policy and Procedure titled, Activities, effective 10/15/2021, documented: [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification and abbreviated (Case #NY00347510) survey, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents, and did not ensure that the resident environment remained as free of accident hazards as is possible. This was evident for one (1) (Residents #146) of the 36 residents reviewed, and for House #s 10, 16, and 21. Specifically, (a.) Resident #146, who had a prior incident of being found outside of the home unsupervised, was found to have an electronic monitoring device alarm on their walker that was not functioning as it should. There was no documented evidence that the electronic monitoring device was checked daily for placement and function to prevent further accidents. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case #NY00368845), 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, (1) an analysis of the actual staffing schedule showed that on multiple occasions from 3/25/2025 through 4/02/2025, the facility was below the minimum levels required; (2) staff reported a lack of sufficient staffing; and (3) residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and long wait times for care to be provided. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for five (5) (Resident #s 53, 89, 145, 161, and 166) of nine (9) residents reviewed for unnecessary medications. Specifically, for Resident #s 53, 89, 145, 161, and 166, as needed psychotropic medication orders did not include end dates. This is evidenced by: The Policy and Procedure titled, Psychotropic Medication Management, effective 3/06/2024, documented as needed orders for anti-psychotic and anti-anxiety medications were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety for four (4) of 16 resident central kitchens. Specifically, (a.) bulk food items were not labeled for their contents; (b.) bulk food items and outside items were not date-labeled after opening or labeled with an expiration date; (c.) appliances were not cleaned and had dirt, grime, and unknown substances within them; and (d.) chicken was improperly being thawed. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure residents could safely self-administer medication when clinically appropriate for one (1) (Resident #84) of one (1) resident reviewed for medication administration. Specifically, Resident #84 was observed with a medicine cup of pills while eating breakfast in the dining area on 3/26/2025 and independently taking the pills. There was no documented evidence that Resident #84 was assessed to determine their ability to safely self-administer medications, or physician orders for self-administration of medications. This is evidenced by: [...]

Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not ensure that it made prompt efforts to resolve a grievance and to keep the resident appropriately apprised of progress towards resolution for one (1) (Resident #28) of 36 residents reviewed. Specifically, Resident #28 and their representative did not receive prompt resolution when a grievance was filed regarding missing hearing aids on 2/19/2025. The facility did not follow up with this grievance until 4/01/2025. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that one (1) (Resident # 130) of four (4) residents reviewed for hospitalization received notice of the bed-hold policy and return prior to or within 24 hours of an emergency transfer. Specifically, Resident #130 was not given written notice of the bed hold policy prior to or within 24 hours of transfer to the hospital on 1/18/2025. This is evidenced by: The Facility's Policy and Procedure titled Bed Hold Policy, effective 6/27/2023 documented facility support the resident's right to retain their bed when they are hospitalized or take a therapeutic leave. The policy promotes continuity of care and ongoing psychosocial support for residents. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (2) (Resident #s 28 and 89) of three (3) residents reviewed. Specifically, (a.) Resident #28 order for continuous oxygen was not administered. The oxygen nasal cannula was placed on the resident, but the oxygen concentrator was off, therefore not delivering oxygen to the resident; (b.) Resident #89's order for 2 liters of oxygen were not followed consistently. This is evidenced by: The facility Policy and Procedure titled, Oxygen Management, effective 5/13/2024 documented, it was policy to administer oxygen per provider order in a safe manner. Responsibility of Licensed Nursing Staff: Procedure: (1) Review orders; [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #54) of the 36 residents reviewed. Specifically, for Resident #54, the physician's ordered alcohol administration was not documented in the Medical Administration Record. This is evidenced by: [...]

Inspectors wroteBased on record review and interview conducted during the recertification and abbreviated (Case #NY00358717) survey, the facility did not ensure that residents were free from neglect for four (4) (Resident #s 16, 25, 99, and 115) of five (5) residents reviewed for neglect. Specifically, Residents #s 16, 25, 99, and 115 were not provided toileting care by staff on evening and night shift of 10/27/2024. Some of these residents were left overnight in the same clothes they had been dressed in the day before, and some with their incontinence garment, clothes, and bedding saturated with urine. This is evidenced by: [...]

Inspectors wroteBased on record review and interview conducted during an abbreviated survey (NY00373673), the facility did not ensure the environment remained as free of accident hazards as possible for 1 (Resident #1) of 1 resident reviewed for accident hazards. Specifically, for Resident #1 the facility did not ensure the resident's bed was positioned away from the heating unit resulting in a second degree burn to the resident's arm. This is evidenced by: Resident #1 was admitted to the facility with diagnoses of Alzheimer's Disease (a degenerative neurological disease-causing memory loss), peripheral vascular disease (disorder of the blood vessels), and psychotic disorder with delusions (mental health condition in which a person can't tell what's real from what's imagined). [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #'s NY00370986, NY00359919, NY00359950, and NY00360114), the facility failed to ensure the residents' right to be free from abuse and neglect for four (4) (Resident #'s 1, 2, 3, and 4) of four (4) residents reviewed for abuse and neglect, which included physical, verbal and mental abuse. Specifically, (1.) Video footage documented Resident #1 was pushed to the floor on 2/02/2025 at 5:03 PM by Shahbaz (Certified Nurse Aide) #1, transferred off the floor by Licensed Practical Nurse #1 without an assessment by a Registered Nurse, and suffered a broken hip. (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off the toilet and subsequently fell and suffered an injury to their right shoulder. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00370986, NY00359919, NY00359950, and NY00360114), the facility failed to ensure all allegations of abuse were thoroughly investigated for three (3) (Resident #'s 1, 2, and 3) of four (4) residents reviewed for abuse investigation. Specifically, (1.) video surveillance footage revealed Shahbaz (Certified Nurse Aide) #1 pushed Resident #1 to the floor on 2/02/2025 at 5:03 PM. There was no documented evidence the facility initiated an investigation on 2/02/2025 (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off of the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00370986, NY00359919, NY00359950, and NY00360114), 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 4 [...]

Inspectors wroteBased on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, automatic dishwashing machines (dish machine) in 6 (six) of 13 Houses inspected were not operating within the manufacturer's specifications; the concentration of chemical sanitizing rinse (QAC) was less than that required by the manufacturer in 1 of 13 Houses inspected; cabinetry was in disrepair in Houses 4, 6, and 8; and cabinetry and floors in Houses 3, 14, 19, and 21 required cleaning. This is evidenced as follows: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey on 4/24/2022 through 4/28/2022, the facility did not ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices for 5 (Resident #'s 9, 30, 80, 113, and #125) of 28 residents reviewed. Specifically, the facility did not ensure the electronic medication administration record (EMAR) accurately reflected that residents received their medications as ordered by the physician. This was evidenced by: The Policy and Procedure (P&P) titled Medication Administration/Documentation System dated 04/2014, documented the medication nurse immediately signs for all medications given by checking the Y box on the computer screen. The P&P documented Be sure to hit the SAVE button when all medications have been accepted by the resident. Resident #30: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not ensure medical records were maintained on each resident that were complete, accurately documented, readily accessible and systematically organized for 5 (Resident #s 45, 54, 55, 128, 141, and 165) of 35 residents reviewed. Specifically for Resident #s 45, 54, 128, 141 and 165 the facility did not ensure activity participation records were documented in accordance with professional standards, and for Resident #55, the facility did not ensure documentation of a physician order for an indwelling catheter. The Policy and Procedure (P&P) titled Activities and dated 7/19/19 documented activities and recreation in the house should resemble the patterns and types of activities commonly found in the home and outside of the home. [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs for 6 (Resident #'s 1, 9, 10, 48, 148, and 170) of 35 residents reviewed for comprehensive care plans. Specifically, for Resident #1, the facility did not ensure the CCP addressed the resident refusal a physician ordered treatment for edema; for Resident #9, the facility did not ensure a comprehensive care plan was developed to address the resident's behaviors that put him at risk to be victimized; for Resident #10, did not ensure a CCP for psychotropic medications had individualized, person-centered interventions; [...]

Inspectors wroteBased on observation and staff interview during the recertification survey the environment was not free from accident hazards over which the facility has control. Specifically, wardrobes in resident rooms were not secured to the walls. This is evidenced as follows. A selection of resident rooms was inspected on 10/07/2019 at 9:15 AM. Wardrobes were observed in resident rooms in all 16 resident houses that were free-standing and toppled over when tested with normal body weight. The Facilities Manager stated in an interview on 10/07/2019 at 2:15 PM that he understands that the unsecured wardrobes in resident rooms could cause an accident, and he will secure all the wardrobes to the wall. 10 NYCRR 415.12(h)(1)

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #65) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #65, the facility did not ensure a PRN antianxiety medication (Ativan) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #65: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. This is evidenced by: A Policy and Procedure (P&P) titled Food Brought to Residents from the Outside dated 4/2018, did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. [...]