Essex Center for Rehabilitation and Healthcare

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment on resident unit #s 1, 2, and 3 and the lobby/administrative areas. Specifically, floors and windows were not clean, and walls were not in good repair. This is evidenced by: During observations on 11/07/2024 at 10:38 AM through 11:40 AM, the floors in the following areas were soiled with dirt or were soiled dirt and cobwebs next to walls and in corners: • Meeting Room. • Ice Machine room. • Director of Nursing office. • Medical Records office. • Activities room. • Main Dining Room. • Unit #1 Dirty Utility room. • Unit #3 short hall foyer, long hall foyer, janitor closet & floor sink, electrical closet, and Clean Utility room. • Resident room #s: [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen and 3 of 3 nourishment kitchenettes. Specifically, surfaces were soiled with food particles, and/or dirt, equipment was not in good repair, thermometers were not in calibration, and the facility did not have the correct test kit to check the concentration of sanitizing solution used to manually sanitize food contact surfaces. This was evidenced by: All observations were on 11/04/2024 from 12:05 PM through 1:10 PM. In the main kitchen: • One of 3 food temperature thermometers was not in calibration at 37 degrees Fahrenheit when tested in the standard ice bath method. [...]

Inspectors wroteBased on medical record review and interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay for 2 (Resident #s 56 and 74) of 3 resident records reviewed). Specifically, residents who remained in the facility and after receiving covered rehabilitative services were not provided with the Advance Beneficiary Notice of Noncoverage form for Medicare Part A and received timely notification (2-day notification) of the termination of Medicare Part A services with the required Notice of Medicare Non-Coverage form. This is evidenced by: [...]

Inspectors wroteBased on observation and interview during the recertification survey, the environment was not free from accident hazards over which the facility had control. Specifically, dangerous tools were left unattended in resident areas on unit 3. This is evidenced by: During observations on 11/06/2024 at 8:05 AM through 8:15 AM, an unattended maintenance tool cart with open access to tools such as screwdrivers was found on Unit #3 in the corridor by the library; a six-inch broad fixed blade knife was on the unenclosed middle tier shelf of the cart. There was no documented evidence in the facility Incident and Accident reports of residents having facility tools or getting tools off the facility tool carts for the past 6-months. The undated document titled Maintenance Assistant documented that maintenance staff were trained to place tools in storage upon leaving work areas. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the waste contained in dumpsters was not covered. This is evidenced by: During observations on 11/04/2024 at 1:21 PM, three of the 4 garbage dumpsters were not closed, and garbage was found within. During an interview on 11/04/2024 at 1: 29 PM, Administrator #1 stated that they would speak with staff about keeping the dumpsters closed after filling them. 10 New York Codes, Rules, and Regulations 415.14(h)

Inspectors wroteBased on observation, record review, and interview during a recertification survey and abbreviated survey (Case #NY00351614), the facility did not ensure it protected the resident's right to be free from abuse and neglect for one (Resident #68) of three residents reviewed. Specifically, the facility investigation determined the likely cause of the resident's elopement on 8/15/2024 was, they were placed in the locked utility room by a terminated employee. This is evidenced by: The Facility's Policy titled, Abuse last reviewed 6/01/2024 documented the following: the facility prohibits the mistreatment, neglect, abuse, and misappropriation of resident property by anyone. Resident #68 was admitted to the facility with diagnoses of dementia with behaviors, chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), and. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #84) of 20 residents reviewed. Specifically, for Resident #84, the facility did not ensure an interdisciplinary care plan meeting was held to review the comprehensive care plan. Resident #84 was admitted to the facility with the diagnoses of cerebral infarction (stroke), gastro-esophageal reflux disease and hemiplegia and hemiparesis following cerebral infarction (paralysis on one side after stroke). The Minimum Data Set (an assessment tool) dated 9/27/2024 documented the resident was usually understood, could usually understand others, and had a mild cognitive impairment. [...]

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (Case #sNY00328017 and NY00340585), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 residents (Resident #s 1, 3, and 7) of 7 residents reviewed for activities of daily living. Specifically, (a) Resident #1's appearance was unkempt, they were wearing only a t-shirt and brief, and their bed had a dried ring of a urine appearing substance on the incontinence pad. (b)Resident #3's fingernails were not clean, and their hair was greasy. (c)Resident #7's hair was greasy, their fingernails were not clean, and the upper right leg of their slacks was soiled. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (Case #s sNY00328017 and NY00340585), the facility did not ensure the resident had a right to a dignified existence for 1 (Resident #1) of 7 residents reviewed for residents' right to a dignified existence. Specifically, Resident #1's colostomy bag was exposed, their upper body was not covered, and breasts were exposed, and the resident's lower body was not appropriately clothed, as they were observed lying on their bed and walking in the hallway with only a brief on. This is evidenced by: The facility's Corporate Compliance Manual updated 7/12/2021, documented residents must be afforded their right to a dignified existence. Resident #1 was admitted to the facility with diagnoses of post-traumatic stress disorder (a mental health condition that's triggered by an event. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #sNY00328017 and NY00340585), the facility did not ensure the resident had a right to personal privacy and confidentiality of their personal and medical records for 2 (Residents #1 and #2) of 2 residents reviewed for the right to personal privacy and confidentiality. Specifically, the facility did not maintain confidentially for Residents #1 and 2 when staff were texting Health Insurance Portability and Accountability Act (HIPAA)-protected information to other staff members using an application on their personal cell phones not sanctioned by the facility. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #sNY00328017 and NY00340585), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency in accordance with State law through established procedures for 2 residents (Resident #1 and #2) of 2 residents reviewed for incident reporting. Specifically, an allegation of sexual abuse that involved 2 residents and alleged to have occurred on 4/27/2024 was not reported to the New York State Department of Health within 2 hours. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure a clean, comfortable, and homelike environment for 2 of 3 resident units (units 1 and 2) reviewed for environment. Specifically, for Unit 1, the facility did not ensure the hallway did not have a strong odor of urine, and the floors of the hallway and main dining area were not dirty on 12/11/22. Specifically, for Unit 1, the facility did not ensure the floors in the hallway and dining area was free from dirt and debris (crumbs, tissues, small colored discs, empty, ripped plastic packaging, and sticky areas) and the hallway and dining area were free from the odor of urine and for Unit 2, the facility did not ensure the floors of the hallway were free from dirt and debris (food crumbs, and shiny/sticky areas) and the hallway and dining area had a strong odor of urine. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 12/11/22 through 12/19/22, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 unit kitchenettes. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications, equipment and floors required cleaning, and the main kitchen refrigerator doors and the Unit 1 kitchenette wall were in disrepair. This is evidenced as follows: [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure 1 (Resident #75) of 2 residents reviewed for advance directives had the right to formulate advance directives. Specifically, Resident #75's the facility did not ensure the residents representative was court appointed under State law to act on the resident's behalf. This is evidenced by: The Policy and Procedure titled Advanced Directives, last revised 2/19, documented appropriate primary decision-makers are a conservator of the resident's person, or agent(s) named in health care proxy. Resident #75 Resident #75 was admitted to the facility with the diagnoses of autistic disorder, dysphagia, and severe intellectual disability. [...]

Inspectors wroteBased on interviews during the recertification survey dated 12/11/22 through 12/19/22, the facility did not notify The New York State Department of Health (NYSDOH) of an occurrence where the health and safety of residents are endangered. Specifically, the facility did not ensure the facility's investigative report was submitted to the NYSDOH no later than 5 days of a fire incident. This is evidenced as follows: A document titled Emergency Prep last updated on 2/2020 documented the following: POLICY: The facility has a designated procedure for fires and explosions that shall be followed if such an emergency arises. Staff receives training at least annually on fire procedures (R.A.C.E.) and the use of fire extinguishers a. All employees are trained to utilize the R.A.C.E. Procedure and notify the Fire Department of the exact circumstances of the situation. b. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and an abbreviated survey (Case #NY00289586), conducted on 12/11/2022 through 12/16/2022, 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 timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #'s 11, 22, and #48) of 22 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #11, the facility did not ensure a CCP required to address urinary incontinence was implemented as goals and interventions changed; for Resident #22, did not ensure a CCP that addressed the resident's right lower leg cellulitis requiring treatment was implemented; [...]

Inspectors wroteBased on observations, interviews and record reviews during a recertification and an abbreviated survey (Case #NY00298692), survey 12/11/2022 through 12/19/2022, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #47) of 5 residents reviewed for ADL's. Specifically, for Resident #47, who required extensive assistance of staff for ADL care, the facility did not ensure the resident was received showers and had their hair washed as documented on the resident's care plan. This is evidenced by: The Policy and Procedure (P&P) titled ADL Support, dated 10/2019 documented, residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean, and wardrobes and walls were not in good repair on 3 of 3 resident units. This is evidenced as follows. The floors were spot checked on 03/05/2020 at 1:45 PM. The floors next to walls, in corners, and at the base of door frames were soiled with dirt and a brown build-up in resident bathroom #'s 5, 24, 26, 118, 119, 120, and #127. Bathroom floor tiles in resident room #'s 119 and #120 were cracked. Walls were heavily scratched and missing paint in resident room #'s 118, 120, and #125. The doors on the wooden wardrobes in resident room #'s 1 and #5 were cracked. [...]

Inspectors wroteBased on observations and interviews during the recertification survey, the facility did not ensure that each resident received, and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for three out of three units. Specifically, on 3/5/20, the facility did not ensure that cold foods were served at a temperature less than 41 degrees Fahrenheit (F) and warm foods were served at a temperature greater than 135 degrees F. Also, did not ensure that the food served was palatable and attractive as determined by the type of food. This was evidenced by: A facility policy titled Food and Nutrition Services; [...]