Highfield Gardens Care Center of Great Neck

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025, the facility did not ensure each resident was served food and drink that was palatable, attractive, and at a safe and appetizing temperature. This was identified for ten (Resident #83, Resident #111, Resident # 33, Resident # 52, Resident #53, Resident #20, Resident #18, Resident #164, Resident #118, and Resident #171) of ten residents during the Resident Council meeting. Specifically, during the Resident Council meeting held on 1/29/2025, ten of the ten residents in attendance complained of hot food being served at cold temperatures. On 1/30/2025, during the lunch meal service, one (Unit 3 North) of three units' meal temperatures for the hot food items were recorded below 135 degrees Fahrenheit. The finding is: [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not distribute and serve food in accordance with professional standards for food service safety. This was identified during the Kitchen and Dining task. Specifically, 1) during the kitchen observation on 1/28/2025, the rinse temperature of the high-temperature dishmachine was observed to be below 180 degrees Fahrenheit. The manufacturer's temperature recommendation for the rinse cycle was 180 degrees Fahrenheit and above. Additionally, the facility did not monitor the rinse and wash cycle temperatures of the dishmachine. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025 the facility did not maintain an effective pest control program. This was identified for two (Unit 2 South and Unit 3 North) of five units observed during the Environmental Task. Specifically, a cockroach was observed at the 2 South nursing station on 1/28/2025. Additionally, all residents (10 of 10) in the resident council meeting confirmed the sighting of cockroaches throughout the facility and had concerns about pest control. The finding is: A facility policy titled, Pest Control, dated July 2018 documented it is the responsibility of the Maintenance Department to coordinate the control of pests with a company engaged in the business of providing Pest Control Services. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025, the facility did not ensure that accurate preadmission screening for individuals with a mental disorder and individuals with intellectual disability was accurately conducted. This was identified for one (Resident #69) of 37 residents reviewed for Pre-admission Screening and Resident Review (PASRR). Specifically, Resident #69 did not have a complete Level 1 screen and was missing the screener identification number. The finding is: The facility's policy and procedure titled Pre-admission Screening and Resident Review (PASRR) last revised on 11/16/2023 documented that the admission department/designee will obtain a Screen and Level I Referral prior to a resident's admission to the facility. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, initiated on 1/28/2025 and completed on 2/3/2025, the facility did not ensure that it implemented a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #337) of three residents reviewed for Pressure Ulcers. Specifically, Resident #337 had a physician's order to wear bilateral (both extremities) heel booties at all times. During multiple observations, the resident was not wearing the physician-ordered heel booties. The finding is: The facility's policy, titled Care Planning Process and Care Conference, dated 7/2023, documented the care plan is a working tool that provides a profile of the needs of the individual resident; [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025 the facility did not ensure each resident received care, consistent with professional standards of practice to prevent pressure ulcers from developing, promote healing, and prevent infections. This was identified for two (Resident #26 and Resident #38) of three residents reviewed for Pressure Ulcers. Specifically, 1) Resident #26 had a physician's order for an Air Mattress. The facility did not provide the resident with an air mattress as per the physician's orders. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025, the facility did not ensure that all medications and biologicals were stored properly and labeled in accordance with currently accepted principles. This was identified for one (Resident #35) of seven residents reviewed for Accidents. Specifically, one inhaler of Albuterol Sulfate was observed in Resident #35's room on their nightstand without a nurse in the vicinity. The Albuterol Sulfate inhaler was not labeled with Resident #35's name. The finding is: Resident #35 was admitted with diagnoses that included Asthma, Type 2 Diabetes Mellitus, and Hypertension. A Quarterly Minimum Data Set assessment dated [DATE] documented Resident #35 had a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/28/2025 and completed on 2/3/2025, the facility did not ensure its Facility Assessment included the facility's resources of nursing staff who provided services under contract. This was identified during the Sufficient Staffing Task. Specifically, the Facility Assessment, last reviewed in January 2025, did not indicate the use of staffing agencies to meet the staffing needs of the facility. The finding is: The facility's policy titled Facility Assessment reviewed and revised on 7/3/2024, documented the facility will conduct and document a facility-wide assessment to evaluate the resident population and identify the resources needed to provide necessary care required during day-to-day operations, (including nights and weekends) and emergency services. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/3/2023 and completed on 4/11/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial tour of the kitchen on 4/3/2023. Specifically, 12 unopened boxes of food including raw chicken drumsticks, raw fresh ground beef, and cooked turkey breast were observed placed on the patio outside the front entrance of the facility. These boxes of food were observed to be left during multiple observations between 11:16 AM and 2:06 PM when the outside temperature was between 50 to 53 degrees Fahrenheit. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 4/3/2023 and completed on 4/11/2023, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for two (Resident #156 and Resident #142) of five residents reviewed for Nutrition. Specifically, 1) Resident #156 had a 7% significant weight loss in eight days, identified in June 2022, which was not addressed by the Registered Dietitian (RD). 2) Resident #142 was identified with a significant weight loss of 12.7 pounds (lbs) from 3/14/2023 to 3/28/2023; however, there was no dietary assessment nor dietary interventions put in place until 4/3/2023.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 4/3/2023 and completed on 4/11/2023 the facility did not ensure that each resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences. This was identified for one (Resident #176) of four residents reviewed for Respiratory Care. Specifically, Resident #176 had an order for continuous oxygen administration within a range of 2-4 liters per minutes (lpm); however, the resident was observed without supplemental oxygen administration on multiple occasions. There were no physician's orders or parameters established regarding when to administer 2 liters oxygen, 3 liters of oxygen, or 4 liters of oxygen. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 4/3/2023 and completed on 4/11/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one(Resident #156) of five residents reviewed for Nutrition. Specifically, Resident #156 had a 7% significant weight loss in eight days, identified in June 2022; and a 5.8% significant weight loss in 30 days/8% significant weight loss in 90 days, identified in September 2022. The significant weight loss was not addressed by their Primary Care Physician (PCP). The finding is: The facility's policy titled, Weight Policy and Procedure last reviewed in 4/2023 documented that the RD would review the medical record of residents with significant weight changes (i.e. [...]

Inspectors wroteBased on record review and staff interview. during the Recertification Survey initiated on 4/3/2023 and completed on 4/11/2023, the facility did not ensure that residents were seen by a Physician at least once every 30 days for the first 90 days after being admitted to the facility. This was identified for one (Resident #156) of five residents reviewed for Nutrition. Specifically, Resident #156 was admitted to the facility on [DATE] and there was no documented evidence in their Electronic Medical Record (EMR) the resident was seen by a Physician timely at least once every 30 days for the first 90 days after admission. The finding is: [...]

Inspectors wroteBased on observations and interviews during the Recertification Survey, the facility did not ensure that food was served in accordance with professional standards for foodservice safety on two of 5 nursing units. Specifically, during observations of meal service for two residents (Resident #14 and Resident #78), two Certified Nursing Assistants (CNA #1 and #2) were observed handling the resident food with their bare hands. The finding is: The facility's policy dated 3/26/2020, titled Dining and Meal Service, documented that nursing staff will wash or sanitize hands between assisting residents with meals. On 9/10/20 at 8:47 AM during breakfast observation on the 2 North unit hallway, CNA #1 was observed spreading margarine on a bagel that he was preparing for Resident #14. CNA#1 was handling the bagel with bare hands. [...]

Inspectors wroteBased on observations, and interviews during the Recertification Survey, completed on 9/15/2020, the facility did not ensure that an infection prevention and control program was maintained to help prevent the development and transmission of communicable diseases and infections on 1 of 5 nursing units. Specifically, a Licensed Practical Nurse (LPN #1) on the 3 South nursing unit was observed wearing a facial mask below his nose and was less than 6 feet apart with Resident #78 who did not have a mask on. The finding is: Review of the Health Advisory from NYSDOH Bureau of Healthcare Associated Infections (BHAI): Memorandum dated March 13, 2020, to all Nursing Homes and Adult Care Facilities, provided: All HCP (health care personnel) and other facility staff shall wear a face mask while within six feet of residents. Extended wear of face masks is allowed; [...]