Jewish Home of Central New York

Inspectors wroteBased on record review and interviews (iQIES #3004417), the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (1) of three (3) residents (Resident #1). Specifically, Resident #1 had a physician order for pudding thick liquids, was care planned to receive pudding thick liquids and was served thin liquids for dinner on 05/01/2026. Staff did not follow the facility process for checking meal trays against the meal ticket prior to serving and the certified nurse aide provided thin liquids instead of pudding thick liquids to the resident without verification. This resulted in no actual harm with potential for more than minimal harm past non-compliance for Resident #1.

Inspectors wroteBased on observations and interviews, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one (1) of one (1) main kitchen. Specifically, the main kitchen had unlabeled/undated prepared and leftover food; dishes and utensils were not sanitized appropriately; and refrigerators were unclean and in poor repair.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for three (3) of eight (8) residents (Residents #79, #68, and #32) reviewed. Specifically, Resident #79 had unclean and untrimmed fingernails and was not assisted with removing unwanted facial hair; Resident #68 was not provided with assistance during meals as planned; and Resident #32 had soiled clothing with food debris.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (2) of four (4) residents (Residents #6 and #66) reviewed. Specifically, Resident #6 did not have person-centered interventions in their dementia care plan, and the care plan was not updated to reflect current behavioral symptoms; and Resident #66 did not have interventions included in their dementia care plan regarding their cognitive decline and psychotropic (antipsychotics) medication usage.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional standards for two (2) of three (3) medication carts (Terrace Lane and Terrace Ridge); one (1) of two (2) medication rooms (Second floor); and one (1) of two (2) narcotic count sheets (used to reconcile controlled medications). Specifically, the Terrace Lane Medication cart had one (1) unlabeled insulin pen and two (2) bottles of vitamins without expiration dates; the Terrace Ridge Medication cart had had three (3) tubes of unlabeled cream and was unlocked and unsupervised; and the narcotic count sheet for Second floor medication room was illegible.

Inspectors wroteBased on observations and interviews the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for three (3) of three (3) test trays (one lunch tray on 03/06/2026 and two breakfast trays on 03/10/2026). Specifically, the lunch tray and breakfast trays included hot foods served below 110 degrees Fahrenheit and cold foods served above 60 degrees Fahrenheit and were not palatable.

Inspectors wroteBased on observations and interviews the facility failed to ensure a clean, comfortable, and homelike environment for one (1) of three (3) resident units (Terrace, Memory care unit). Specifically, the Terrace unit had a strong urine odor, unclean surfaces including stained and sticky floors, and unclean chairs.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to provide ongoing programs to support each resident in their choice of activities, for one (1) of one (1) Resident (Resident #20) reviewed. Specifically, Resident #20 was not provided with activities, or invited to activities that were of interest and preference.

Inspectors wroteBased on record reviews and interviews during the recertification survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #120) reviewed. Specifically, Resident #120 was admitted with wounds and did not have admission orders for wound care, a timely assessment by a wound care provider, and their outside wound care clinic appointment was canceled by the facility.

Inspectors wroteBased on observations and interviews the facility failed to ensure garbage and refuse was disposed of properly for one (1) of one (1) trash compactor. Specifically, there was food debris, food wrappers, milk cartons, used gloves, and dirty utensils, strewn about on the ground surrounding the trash compactor.

Inspectors wroteBased on record review and interview during the abbreviated survey (iQIES #734057), the facility did not ensure residents received proper foot care and treatment in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for one (1) of three (3) residents (Resident #3). Specifically, Resident #3 was recommended for routine podiatry care by a wound care provider and there was no documented evidence of podiatry care in the resident's record for eight (8) months.

Inspectors wroteBased on record review, observation, and interview during the recertification survey and abbreviated (NY00311928 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (Terrace floor unit, first floor unit, and second floor unit) reviewed. Specifically, the Terrace floor unit had unclean resident wheelchairs, damaged and sticky flooring, and damaged countertops; the first floor unit had sticky floors in the dining room; and the second floor unit had a resident room with a damaged commode, a spa room with a water damaged cabinet, cigarettes and loose tobacco were kept in the second floor unit kitchenette, and the noise level in the dining room was loud during meal service. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00311928 and NY00320383) surveys conducted 5/16/2024-5/23/2024, 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 of 8 residents (Residents #31, #95 #103) reviewed. Specifically, Resident #31 was not assisted with showering, washing their hair, and removing facial hair; Resident #95 was not assisted with nail care; and Resident #103 was not assisted with toileting.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 4 of 4 residents (Residents #26, #41, #109 and #119) reviewed. Specifically, Residents #26, #41, #109 and #119 were not offered meaningful activities of their choosing as care planned.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, did not review the risks and benefits of bed rails with the resident or resident representative, and did not obtain informed consent prior to the installation of bed rails for 4 of 4 residents (Resident #48, #59, #109, and #119) reviewed. Specifically: - Resident #109 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed rail installation. Additionally, the resident's enabler bar was not removed timely, and the resident was found with their arm between the enabler bar and the mattress. [...]

Inspectors wroteBased on observation and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 3 medication carts (second floor Ridge cart), and 1 of 2 medication rooms (first floor) reviewed. Specifically, the second floor Ridge medication cart was unlocked and unattended; and the first floor medication room had 3 bottles of alcoholic beverages stored in a brown paper box on the floor.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/24, the facility did not establish and maintain an infection prevention and 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 8 staff (Certified Nurse Aides #10, #11, #13, #20 and #21; Licensed Practical Nurses #8 and #18, and the Assistant Director of Nursing) observed; and for 1 of 2 residents (Resident #4) reviewed. Specifically, - Licensed Practical Nurse #8 did not perform hand hygiene or wear gloves when administering medication via a gastrostomy tube (feeding tube) to Resident #44 who was on enhanced barrier precautions. [...]

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 3 nursing floors (first and second floors). Specifically, there was evidence of drain flies and fruit flies on the first and second floors.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for 13 of 13 residents (Residents #59 and 12 anonymous residents) reviewed. Specifically, Certified Nurse Aide #36 was observed speaking loudly near the main dining room about Resident #59's urinary drainage device; and multiple staff were observed using their personal communication devices in care areas during working hours.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #48) reviewed. Specifically, Resident #48 did not have the capacity to make medical decisions and their health care proxy (person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident developed a wound which required treatment.

Inspectors wroteBased on record review and interview during the recertification and abbreviated (NY00326481 and NY00334060) surveys conducted 5/16/2023-5/23/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 2 of 3 residents (Resident #48 and 119) reviewed. Specifically, Resident #48 had an unwitnessed fall that was not investigated; and Resident #119 had injuries of unknown origin that were not thoroughly investigated.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 of resident (Resident #52) reviewed. Specifically, Resident #52 did not have resident-specific interventions for the use of an indwelling urinary catheter (a tube placed in the bladder to drain urine).

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00320383 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 6 residents (Resident #48) reviewed. Specifically, Resident #48 developed moisture associated skin damage (open areas resulting from moisture on the skin) on 2 occasions when incontinence care was not provided routinely or as planned.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00320383 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not post daily, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, accessible to residents and visitors for 4 of 6 days reviewed. Specifically, the current daily resident census was not documented, and the licensed nurse staffing was not divided into licensed practical nurses and registered nurses for each shift in a 24-hour period.

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure planned menus were followed for 2 of 2 residents (Resident #23 and #117) reviewed. Specifically, Residents #117and #23 did not receive menu items as planned per their individual meal tickets.

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch meals on 5/17/2024 and 5/20/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures for lunch on 5/17/2024 and 5/20/2024.

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen, and 1 of 3 unit kitchenettes (Terrace unit kitchenette). Specifically, in the main kitchen the ventilation hood system was missing a grease trap, there were multiple stained ceiling tiles, there was a hole in one of the kitchen walls with exposed wiring, the meat side of the freezer floor was in disrepair, and there was expired and undated food; and the Terrace unit kitchenette had expired and undated food.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure resident call systems were accessible to call for staff assistance for 2 of 2 residents (Residents #15 and #56) reviewed. Specifically, Resident #15 was observed with their call light out of reach, and Resident #56 was left alone in the shower room without access to the call light.

Inspectors wroteBased on observation, record review, and interview during the abbreviated survey (NY00322111), the facility failed to ensure each resident had the right to be free from neglect for 1 of 4 residents reviewed (Resident #4). Specifically, on [DATE], the resident was not provided with services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveillance video of the nursing unit from [DATE] at approximately 7:38 PM, revealed a resident falling backwards off a partition (separating the dining room from the hallway) that was approximately 27 inches in height and hitting their upper back on the floor in the hallway. [...]

Inspectors wroteBased on observation, record review, and interview during the abbreviated survey (NY00322111), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated; did not ensure residents were protected while the investigation was in process and did not ensure incidents were reported to the New York State Department of Health (NYS DOH) when required for 1 of 4 residents reviewed (Resident #4). Specifically, Resident #4 was found on the floor by staff on [DATE] and remained on the floor without a registered nurse (RN) assessment for approximately two and a half hours and when the resident was assisted off the floor, they expired shortly thereafter. The facility's investigation was not thorough and complete as it did not: [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00322111) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #4) reviewed. Specifically, Resident #4 had medical orders including: - a one-time dose of 200 milligrams (mg) of Seroquel (antipsychotic medication) and was administered the one-time dose in addition to the routine dose of 150 mg Seroquel on 6 consecutive days. - Finger sticks (blood glucose monitoring) before meals and at bedtime and call the medical provider if the result was less than 70 milligrams/deciliter (mg/dl). The resident had a fingerstick of 64 mg/dl and there was no documented evidence the medical provider was notified. [...]

Inspectors wroteBased on record review, and interview during the abbreviated survey (NY00322111), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #4). Specifically, facility Administration, including the Director of Nursing (DON) did not ensure residents were free from neglect, did not complete a thorough investigation into resident neglect, did not ensure staff were removed from having access to residents while neglect investigations were pending, and did not report neglect as required to the New York State Department of Health (NYS DOH).

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00277399 and NY00257605) surveys conducted from 3/1/22-3/8/22, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents reviewed (Resident #79). Specifically, Resident #79 was admitted and assessed as mild risk for developing pressure ulcers and had a deep tissue injury (DTI, deep red, maroon, purple discoloration) to their coccyx (tailbone) that was not routinely monitored and developed into a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This resulted in harm to Resident #79 that was not immediate jeopardy.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 nursing units (Terrace Unit, Unit 1, and Unit 2) and for 2 of 2 residents (Residents #10 and 63) reviewed. Specifically, the Terrace Unit had unclean rolling window shades in the dining room and a torn fall mat in resident room [ROOM NUMBER]; Unit 1 had a damaged ceiling in the Ridge shower room and loose handrails; and Unit 2 had a damaged section of wall in resident room [ROOM NUMBER]. Additionally, Resident #10 had an unclean wheelchair and Resident #63 had an unclean scoot chair.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, there were damaged sinks, unclean/soiled floors, unclean soiled deep fryers, unused lids, and containers stored on an unclean shelf, improperly stored food scoops, missing ceiling tiles, and uneven floor surfaces.

Inspectors wroteBased on observation and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction with respect to the facility. Specifically, the facility did not post the survey results and plan of correction from the most recent Life Safety Code Federal survey conducted on 9/11/19.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure that when a restraint was indicated, the least restrictive alternative for the least amount of time was used and included ongoing re-evaluation of the need for the restraint for 1 of 2 residents (Resident #48) reviewed. Specifically, Resident #48 had an alarming wheelchair seat belt that was not assessed to determine if it was the least restrictive device, and a plan was not implemented to ensure the device was used for the least amount of time.

Inspectors wroteBased on record review and interview during the recertification survey conducted 3/1-3/8/22, the facility failed to ensure, to the extent practicable, the participation of the resident and the resident's representative in the development of the comprehensive care plan for 1 of 2 residents (Resident #50) reviewed. Specifically, Resident #50 was not invited and did not attend their comprehensive care plan meetings.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to 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 2 of 4 residents (Residents #100 and 253) reviewed. Specifically, Resident #100 did not receive toileting assistance; and Resident #253 was not assisted with care timely and did not have a care plan to address behavioral symptoms when requesting care.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00257605) surveys conducted 3/1/22-3/8/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #97) reviewed. Specifically, Resident #97 had a significant weight loss without timely nutritional assessments and interventions, and weekly weights were not consistently obtained as ordered.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00281008) surveys conducted 3/1/22-3/8/22, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 staff (registered nurse [RN] Unit Manager #21, receptionist #31, security guard #27, and activity aide #30) observed. Specifically, RN Unit Manager #21, receptionist #31, and security guard #27 were observed wearing masks inappropriately and security guard #27 and activity aide #30 wore masks of unsuitable materials.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00281008) surveys conducted 3/1/22-3/8/22, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19 for 3 of 11 staff (security guards #27, 28, and 29) reviewed. Specifically, the facility did not maintain documentation of COVID-19 vaccination status for 3 contract staff, security guards #27, 28, and 29, and did not implement a contingency plan to address non-vaccinated employees.