Livingston Hills Nursing and Rehabilitation Center

Inspectors wroteBased on record review and interview during a survey, the facility failed to ensure medical records on each resident were complete and accurately documented for seven (Residents #s 1,2,3,4,5,6 and 7) of seven residents reviewed. Specifically, Certified Nurse Aides tasks were not documented daily during February 2026. This lack of accurate record keeping made it difficult for other staff to know which tasks were completed for residents and what level of assistance was provided.

Inspectors wroteBased on observation, record review, and interviews conducted during recertification surveys, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility. Specifically, seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they were not able to get money from their resident funds account because the money in the cash box at the reception desk would be empty, even if the arrangements for withdrawal were made in advance. This is evidenced by:The Facility's Policy titled, Resident Finance dated 9/2024, documented the facility would maintain written records of all financial arrangements with the resident or responsible family member and/or source of payment; [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that residents had the right to send and promptly receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service. Specifically, residents did not receive mail on Saturdays. This impacted all residents within the facility. This is evidenced by: Facility Policy titled, Resident Right-Right to Forms of Communication with Privacy, dated 11/2024, documented residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the residents through a means other than the postal service. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated survey (664249), the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not have the desired staffing levels for Licensed Practical Nurses and Certified Nurse Aides, and Registered Nurses as documented in the Facility Assessment for 13 of 13 days from 7/13/2025 to 7/25/2025. As a result of the insufficient staffing, nursing staff reported that indirect and direct resident care activities were unable to be completed. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility nursing staff did not have documentation of completed annual mandatory educations as listed in the Facility Assessment. This is evidenced by:The Facility assessment dated [DATE] documented Staff Training/Education and Competencies that were necessary to provide the level and types of care needed for the resident population: Resident's rights and facility responsibilities; Abuse, neglect and exploitation; Infection control; [...]

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), (South and East Units) of three (3) medication rooms reviewed, and four (4) (East Unit Cart #1; North Unit Cart #1 and #2; South Unit Cart #1) of six (6) medication carts reviewed. Specifically, (a.) one (1) open bottle of purified protein derivative (PPD) had expired; (b.) one (1) vial of COVID 19 vaccine mRNA Comirnaty had expired; (c.) Jevity tube feed formula was stored in resident's room; (d.) pre-poured medication was found stored in medication cart; (e.) one (1) empty inhaler was found in cart. (f.) two (2) open inhalers had no open and or expiration date; [...]

Inspectors wroteBased on observation and interviews conducted during the recertification and abbreviated survey (Case #664249), the facility did not ensure that posted menu items were served, that notification was provided when menu items were substituted and that individual food preferences were honored for five (5) (Resident #'s 11, 14, 40, 47, and 97) of five (5) residents reviewed. Specifically, residents were not served posted menu items, food preferences, or food items that were listed on the meal tray tickets. Additionally, residents were not notified of menu substitutions.this is evidenced by:The Facility Policy titled; Food and Nutrition revised 04/2024 documented that it was the policy of the facility to ensure that facility staff support the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification and abbreviated survey (Case # 664249), the facility did not ensure that food and drink were palatable and attractive for seven (7) (Resident #s 6, 14, 19, 40, 47, 87, and 97) of seven (7) residents reviewed for palatable and attractive food and drink. Specifically, Resident #s 6, 14, 19, 40, 47, 87, and 97 complained of food being cold, unattractive, and not palatable. This is evidenced by: Facility Policy titled, Food Safety Requirements Policy, last revised 5/01/2025, documented that it was the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. Additionally, the facility procures food from sources approved or considered satisfactory by federal, state or local authorities. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received, and the facility provided food that accommodated resident allergies, intolerances, and preferences, and appealing options of similar nutritive value to residents who choose not to eat food that was initially served or who requested a different meal choice. Specifically, seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they were not able to get substitutions or an alternative menu option. This is evidenced by: A facility policy titled Food and Nutrition Services, date revised 4/2024, documented that it was the policy of the facility to ensure that facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (Case # 664249), the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for six (6) (Resident #'s 2, 3, 16, 44, 77, and 97) of the 30 residents reviewed. Specifically, (a.) Resident #2 was observed to be unkempt and in need of assistance to perform activities of daily living, there was no documented evidence of care provided; (b.) Resident #3 medications and monitoring of behaviors were not documented as completed; (c.) Resident #16 did not have weekly skin checks and showers documented as completed; (d.) Resident #44 did not have weekly skin checks and showers documented as completed; [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not ensure the Quality Assurance and Performance Improvement committee developed and implemented appropriate plans of action to correct identified quality deficiencies as well as opportunities for improvement. Specifically, the facility had repeat deficiencies in the areas of Baseline Care Plan (F655), Develop/Implement Comprehensive Care Plan (F656), Care Plan Timing and Revision (657), staffing (F725), Competent Nursing Staff (726), and Label/store/Drugs and Biologicals (F761). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (Case #664249), the facility did not maintain a pest-free environment and an effective pest control program on two (2) of two (2) resident units. Specifically, insect infestation was found in resident rooms, the main kitchen, and staff areas. This is evidenced by:During observations on 7/21/2025 through 7/30/2025 between 8:00 AM and 5:00 PM fly activity was always identified in the below locations throughout the duration of the survey at various intensities noted in the North Unit activity room which was provided to the team as the survey team meeting area. During initial interviews on 7/21/2025 at 10:58 AM, flies were noted to be in the room of Resident #10. During an interview on 7/21/2025 at 12:22 PM, flies were noted to be in the office of Regional Nursing Coordinator #1. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure residents were aware of the grievance process. Specifically, (1.) residents on South Unit did not have the option to file a grievance anonymously; and (2.) seven (7) out of eight (8) residents at a surveyor led Resident Council meeting reported they did not know the process by which to file a grievance. This is evidenced by:Facility Policy titled, Grievance Reporting and Response, last revised 7/01/2022 documented it was the policy of the facility to investigate and respond to all resident grievances in a timely manner. The procedure to file a grievance included filling out a grievance form and giving it to the Director of Social Services or put it in the grievance box located by the social work office. [...]

Inspectors wroteThis is evidenced by:The policy and procedure titled, Comprehensive Care Plans, last revised 5/2024, documented interdisciplinary comprehensive care plans would identify problems and needs, reflecting the resident's strengths, limitations, and goals. Resident #2Resident #2 was admitted to the facility with the diagnoses of dementia, major depressive disorder, and atrial fibrillation (irregular heartbeat). The Minimum Data Set (an assessment tool) dated 7/02/2025, documented the resident was able to understand others, be understood, and was severely cognitively impaired. During a general observation of the unit on 7/21/2025 at 10:52 AM, Resident #2 was still in bed, still sleeping, and did not appear to have been gotten up or cleaned up for the day. The resident was noted to have floor mats next to their bed, call bell on the floor. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case #664249), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for six (6) (Resident #s 2, 47, 50, 71, 77, and 97) of ten (10) residents reviewed. Specifically, (a.) Resident #2 was observed to be unkempt and in need of assistance to perform activities of daily living; (b.) Resident #47 did not receive twice weekly showers as per the resident's plan of care; (c.) Resident #50 was observed on 7/22/2025 at 1:41 PM, 7/24/2025 at 1:10 PM, 7/28/2025 at 10:00 AM, and 7/29/2025 at 11:22 AM, in their room with door closed, temperature warm and sweltering, disheveled appearance, clothing soiled, unshaven, hair unkempt with strong urine odor; [...]

Inspectors wroteBased on observation, record review, and interviews 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 for three (3) (Resident #'s 34, 50, and 71) of four (4) residents reviewed. Specifically, Resident #'s 34, 50, and 71 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by:The Facility Policy titled; Activity Programs, last revised 5/2024, documented (a.) activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs; [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5 percent for Four (4) (Resident #33, 36, 76, and 11) of four (4) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 84 percent. This is evidenced by:The Facility's Policy and Procedure titled; Administering medications, effective 1/2024, documented a licensed nurse will be responsible for passing medications to residents in accordance with techniques approved for use in the facility, in compliance with New York State Codes, rules and regulations ad with other applicable Federal and State Laws. Medications will be administered using the six rights of medication administration: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate for three (3) (Residents #'s 10, 29, and 47) of three (3) residents reviewed for self-administration of medication. Specifically, (a.) Resident #'s 10 and 29 were observed with unprescribed medications on their nightstands; and (b.) Resident #47 was noted to have discontinued Clindamycin Phosphate cream in their nightstand. There was no documented evidence that Resident #'s 10, 29, and 47 were assessed by an interdisciplinary team to determine their ability to safely self-administer medications, and there was no physician order for self-administration of medications. [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that residents had the right to be treated with respect and dignity to retain and use personal possession, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents for one (1) (Resident #14) of five (5) residents reviewed for personal property. Specifically, (a.) for Resident #14 was observed at nurses' station, in a common area, wearing a hospital gown. Resident #14 stated they were wearing a hospital gown because their clothing was not returned to them from the off-site laundry facility. This is evidenced by: The Facility's Policy titled; [...]

Inspectors wroteThis is evidenced by:The Facility Policy titled, Resident Right- Right to Survey Results/Advocate Agency Information, last reviewed 11/2024, documented it was the policy of the facility to inform residents of survey results and advocate agencies in such manner to acknowledge and respect resident rights. The facility will post in a place readily accessible to residents, family members, and legal representatives of residents the results of the most recent survey of the facility. The facility will post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. During a surveyor led Resident Council Meeting on 7/22/2025 at 10:32 AM, eight (8) of eight (8) anonymous residents present stated they did not know where survey results were located for them to read. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure a base line care plan was developed and implemented for each resident within 48 hours of admission for one (10 (Resident #114) of 30 residents reviewed for baseline care plans. Specifically, for Resident # 114, a baseline care plan was not developed within 48 hours of admission. [...]

Inspectors wroteBased on record review and interviews conductedion during the recertification survey, the facility did not ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident for two (2) (Resident #'s 16, and 47) of 30 residents reviewed. Specifically, (a.) for Resident #16, there was no documented evidence that the Comprehensive Care Plan for Psychotropic Drug Use was reviewed and revised after a psychotropic medication change occurred on 7/03/2025; and (b.) Resident #47's Comprehensive Care Plan for Physical Therapy was not reviewed and revised after each assessment or after they discharged from physical therapy services on 7/15/2025. This is evidenced by:The Facility Policy titled; [...]

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that the residents received the necessary care and services to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) (Resident #37) of 30 residents reviewed. Specifically, for Resident #37, the resident's room was bare of home-like touches and furniture with no care-planned reason or physician order. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards for one (1) (Resident #16) of 30 residents reviewed. Specifically, for Resident #16, a large bruise was not reported and assessed in a timely manner. This is evidenced by:Resident #16 was admitted to the facility with the diagnoses malignant neoplasm of kidney (cancerous tumor characterized by uncontrolled cell growth that can invade nearby tissues and spread to other parts of the body), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure (a condition where the heart can't pump enough blood to meet the body's needs). [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (1) (Resident #4) of two (2) residents reviewed for range of motion. Specifically, for Resident #4, a washcloth roll was not applied to the resident's left hand for contracture management as indicated by physician orders. This is evidenced by:The facility's Policy titled; Physical Rehabilitation Department Issuing and Use of Splints, undated, documented the Physical Rehabilitation Department staff were responsible for the evaluation and determination of appropriate splinting devices with assistance from Orthotist when necessary. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that resident environments were as free from accidents hazards as is possible for one (1) (Resident #10) of nine (9) residents reviewed for accidents hazards. Specifically, Resident #10 resided in a semi-private room and two (2) disposable razors, and an unlabeled electric razor were observed in the resident's shared bathroom. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice, for one (1) (Resident #s 43) of two (2) residents reviewed for dialysis. Specifically, nursing did not consistently complete, reviewed, and logged dialysis communication sheets for Resident #43 between 4/08/2025 and 7/21/2025. This is evidenced by:The Facility's Policy and Procedure titled Care of Residents Receiving Hemodialysis, revised 9/2023, documented: Before Dialysis: Locate resident's dialysis Communication Book and enter pre-treatment information per the form fields. Include any relevant continuity of care information and vital signs. Ensure resident receives Activity of Daily Living and hygienic care well prior to departure time; [...]

Inspectors wroteBased on an observation, record review, and interviews 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, daily nurse staffing levels for staff working in the facility on each shift was not posted in the facility on July 21, 2025, through July 25,2025, and July 28, 2025, through July 29, 2025. This is evidenced by:Facility Policy titled, Posted Nurse Staffing Information, last revised 09/2024, documented it was the policy of the facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. The nursing staffing sheet would be posted on a daily basis at the beginning of each shift. [...]

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (Complaint #NY00342787, #NY00355908, and #NY00348307) completed on [DATE], the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented for three (3) (Resident #3, #4, and #5) of three (3) reviewed for medical records. Specifically, the facility transitioned to another electronic medical record company [DATE] and the facility did not have access to resident medical information for any residents that are current, discharged or expired prior to [DATE]. This is evidenced by: The facility policy titled Resident Medical Record dated 5/2025 documented the following: it is the policy of the facility to maintain Medical Records in accordance with State and Federal regulations. [...]

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (Complaint #NY00342787, #NY00355908, and #NY00348307) completed on 7/14/2025, the facility did not effectively communicate and implement the standards of its compliance and ethics program that is likely to be effective in preventing care violations and promoting quality of care. Specifically, at a minimum, the facility did not implement the standards of its compliance and ethics program-resident medical records dated prior to November 2024 were not accessible. A risk area of record retention is associated with the delivery of health care to nursing facility residents. This could place all residents at risk of diminished quality of care. This is evidenced by: The facility policy titled, Compliance and Ethics Program, undated, identified as current by Administrator #1 documented the following: [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated Survey (Compliant #NY00378346) completed on 7/14/2025, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #1) of one (1) resident reviewed for infection control practices. Specifically, Resident #1 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment while providing wound care and did not change gloves and wash hands according to standards of practice. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews conducted during an Abbreviated Survey (Compliant #NY00378346) completed on 7/14/2025, the facility did not ensure an effective training program for all new and existing staff was developed, implemented and maintained based on the facility assessment for two (2) of two (2) staff (Licensed Practical Nurses #1 and #3) reviewed. Specifically, there was no documented evidence Licensed Practical Nurses #1 and #3 had peripheral intravenous training and competencies and they administered antibiotics via peripheral intravenous to Resident #2. This is evidenced by: The Facility Assessment Tool completed 4/23/2025, documented the following: Medication awareness of any medications that residents need, by route including intravenous) peripheral or central lines). [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, it was determined that the governing body did not implement policies regarding the management and operation of the facility. Specifically, the facility did not ensure professional staff were licensed, certified, or registered in accordance with applicable Federal and State laws for a full-time, onsite Administrator. The facility did not appoint a licensed and currently registered Nursing Home Administrator to provide onsite, full time oversight prior to expiration of New York State Department of Health Unlicensed Acting Administrator approvals. Additionally during the recertification survey, there was no Nursing Home Administrator onsite. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00317289, NY00325414, NY00334048, NY00335064, NY00336444, and NY00336400), the facility did not ensure a quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additionally, the facility did not develop written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. Specifically, the facility had repeat deficiencies in the areas of safe/clean/comfortable/homelike environment (F-584), food procurement, store/prepare/serve-sanity (F-812), and infection control (F-880); [...]

Inspectors wroteBased on observations, record reviews and interviews during recertification survey, the facility did not protect and promote the rights of the resident; did not provide equal access to quality care regardless of diagnosis or severity of condition; and did not ensure residents had the right to be free of interference from the facility in exercising their right to wear clothing for 3 of 3 residents (Resident #'s 61, 63 and 89) reviewed for resident rights and exercise of rights. Specifically, (a) Resident #61 did not have access to their clothing, and staff who were interviewed stated it was difficult to find clothing that fit Resident #61. (b) For over an hour, Resident #63 was viewable from the hallway wearing a hospital gown with their back and buttocks exposed without any underclothes or briefs on. [...]

Inspectors wroteBased on observations, record reviews and interviews during recertification survey, the facility did not ensure that the facility did not exercise reasonable care for the protection of the resident's property from loss or theft for 4 (Residents #1, 34, 73, and 108) of 4 residents reviewed for missing property. Specifically, Residents #1, 34, 73, and 108 personal belongings sent out for laundering were not returned to the residents timely. This is evidenced by: A facility policy titled, Personal Property Theft and Loss Risk and dated October 2023, documented the facility provided for the reasonable safekeeping of personal property and funds for residents in the facility per state and federal requirements. The policy further documented that the facility provided labeling of the resident's clothing and personal property. [...]

Inspectors wroteBased on observations, record reviews and interviews during recertification survey, the facility did not ensure that grievances were resolved in a timely manner for 3 (Residents #1, 34, and 73) or 3 residents reviewed. Specifically, resident's concerns were not documented and resolved through the facility grievance process. This is evidenced by: A facility policy titled, Grievance Reporting and Response and dated 10/01/2022, documented that to make a complaint or a recommendation, fill out a grievance form and put it in one of the grievances boxes located by the Social Work office and on each unit. Forms would be collected and brought to the attention of the Administrator and/or Director of Nursing Services for review and resolution by the appropriate party. Grievances could also be filed verbally with the Director of Social Work or the Administrator. [...]

Inspectors wroteBased on observations, record reviews and interviews during recertification survey, the facility did not ensure to develop or implement a comprehensive person-centered care plan for each resident for 3 (Residents #1, #23, #63) of 3 residents reviewed for comprehensive person-centered care plans. Specifically, for Resident #s 1 and 23, a care plan was not developed, or interventions implemented for use of anticoagulants (blood thinners). For Resident #63, care plan did not document physician's supervision for significant weight loss or interventions implemented. This is evidenced by: A facility policy titled Comprehensive Care Plans dated 9/2023, documented that every resident would have an Interdisciplinary Care Plan, with the Interim/baseline Interdisciplinary Care Plan initiated within 48 hours of admission. [...]

Inspectors wroteBased on observations, record reviews and interviews during the recertification survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility did not perform the appropriate competency evaluations for the licensed nursing staff to measure the pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles or occupational functions successfully. This is evidenced by: Resident #73 was admitted with diagnoses of atherosclerotic heart disease, cachexia, and severe protein-calorie malnutrition. [...]

Inspectors wroteBased on observations, record reviews and interviews during recertification survey, the facility did not ensure that the drug regimen of each resident were reviewed at least once a month by a licensed pharmacist for 4 (Resident #'s 23, 78, 30, 67) of 4 residents reviewed. This is evidenced by: Resident #23 was admitted to the facility with diagnoses of fatty liver, fibromyalgia (a chronic condition where there is heightened pain and widespread pain), and unspecified mood disorder. The Minimum Data Set (an assessment tool) dated 4/12/2024, documented the resident was cognitively intact, could be understood and could understand others. Resident #78 was admitted to the facility with diagnoses of chronic systolic congestive heart failure, acquired deformity of right lower leg and major depressive disorder severe with psychotic symptoms. [...]

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not maintain drugs and biologicals, labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration date when applicable for 3 of 3 units reviewed. Specifically: (1) urine was stored in the same refrigerator with multiple insulin pens and insulin vials; (2) purified protein derivative solution stored in the refrigerator with no open date was expired on 3/2024; (3) eye drops, ear drops, Vitamin D, and insulin pens in the medication cart opened did not have expiration dates. Additionally, the controlled substance cabinet inside lock was broken. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective 1/2024 documented section 1. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey from 05/13/2024 to 05/23/2024, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and one (1) of 3 kitchenettes. Specifically, dented cans were with the common stock, the food temperature thermometer was out of calibration, and kitchen and kitchenette equipment were not clean and/or in good repair. This is evidenced by: During observations in the main kitchen and unit kitchenettes on 05/13/2024 from 11:05 AM through 12:02 PM: • One #10-sized can mashed potatoes found in the common stock had a V-shaped dent in top seam of the can. • Two #10-sized cans of red pepper strips found in the common stock had metal touching metal at top seam of the can. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure residents have the right to and the facility must promote and facilitate resident self-determination through support of resident choice, and that the resident had a right to make choices about aspects of their life in the facility that are significant to the resident for 1 (Resident #80) of 1 resident reviewed Specifically, Resident #80 did not get out of bed due to facility not having the appropriate wheelchair. This is evidenced by: The facility's Policy and Procedure titled, Resident Rights and effective 8/2022, documented Resident of [NAME] Hills had the Right (including but not limited) to: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (medical interventions in the event of a life-threatening episode) that would be honored for 1 (Residents #316) of 1 resident reviewed. Specifically, Resident #316's advance directive (code status) identifiers were not consistently documented to reflect Medical Orders for Life-Sustaining Treatment orders that could be easily identified by for all staff. This is evidenced by: Resident # 316 was admitted to the facility with the diagnoses of unspecified dementia, without behavior disturbances, early onset of Alzheimer's disease, and type 2 diabetes. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure Significant Change Minimum Data Set assessment was completed for a 1 (Resident #36) of 1 resident reviewed for significant changes in health status. Specifically, Resident #36 experienced a change in respiratory status, was sent to the hospital on 4/18/2024 and returned on 4/19/2024 with diagnosis of respiratory bronchiolitis interstitial lung disease requiring oxygen and inhaler use. This is evidenced by: Resident #36: The resident was admitted to the facility on with the diagnoses of chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could understand others, and could make themselves understood. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #s NY00317289 and NY00325414), the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission for 1 resident (Resident #115) of 3 residents reviewed for baseline care plans. Specifically, Resident #115 baseline care plan was not completed by staff and signed by the resident within 48 hours of their admission to the facility. This is evidenced by: The Policy and Procedure titled, Comprehensive Care Plans and dated 9/2023, documented every resident will have an Interdisciplinary Care Plan, with the Interim/baseline Interdisciplinary Care Plan initiated within 48 hours of admission. [...]

Inspectors wroteBased on record review and interviews conducted 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 #'67) of 1 resident reviewed. Specifically, for Resident #67's\ Comprehensive Care Plan for psychotropic medications was not reviewed and revised after medication changes. This is evidenced by: Resident # 67 was admitted to the facility with diagnoses of unspecified dementia with agitation, major depressive disorder, and hypertension. The Minimum Data Set (an assessment tool) dated 6/13/2023 documented the resident had moderate cognitive impairment, could understand others, and could make self-understood. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure to complete a comprehensive assessment of a resident, to receive treatment and care in accordance with professional standards of practice for 1 (Resident #89) of 1 resident reviewed Specifically, Resident #89's standing order for compression stockings was not carried out and staff stated compression stockings were never placed because the resident would take them off. This is evidenced by: Resident #89 was admitted with diagnoses of Alzheimer's Disease (a disorder of brain causing dementia, impaired ability to think or make decisions), Atherosclerotic Heart Disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), and depression. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided a residential environment that was as free from accident hazards as possible, and that each resident received adequate supervision to prevent accidents for 1 (Resident #36) of 1 resident reviewed for accident hazards. Specifically, Resident #36 was observed using tobacco in their room without supervision; approach was utilized to communicate observed hazards related to the accessibility of the resident's use of tobacco supplies, and the facility did not develop and implement an individualized care plan to address the resident's potential or actual non-compliance with the facility's smoking policy. This is evidenced by: Resident #36: [...]

Inspectors wroteBased on observations, record reviews and interviews during recertification survey, the facility did not ensure that resident care was supervised by a physician for their immediate need for 1 (Resident #63) of 1 resident reviewed for physician care. Specifically, Resident #63 had a significant amount of weight loss and did not receive adequate medical supervision to intervene. This is evidenced by: Resident #63 was admitted with diagnoses of traumatic subdural hemorrhage, urinary calculus, and scoliosis. The Minimum Data Set (an assessment tool) dated 4/11/2024, documented that the resident had significant cognitive impairment, could sometimes be understood and sometimes understand others. [...]

Inspectors wroteBased on observations, record reviews, and interviews during recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, which was any drug used in excessive dose, for excessive duration, without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences which indicated the dose should be reduced or discontinued for 1 (Resident #78) of 4 resident reviewed for unnecessary medications. Specifically, Resident #78's physician order for Abilify (antipsychotic medication) did not include an indication for use in accordance with professional standards. This is evidenced by: Resident #78 was admitted to the facility with diagnoses of chronic systolic congestive heart failure, acquired deformity of right lower leg and major depressive disorder severe with psychotic symptoms. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, one (1) of 3 dumpsters was leaking waste and the dumpster area was not clean. This is evidenced by:. During observations on 05/13/2024 at 11:56 AM, the front dumpster was leaking a black oily liquid from the bottom, and a build-up of brown leaves was found on the ground around the back dumpster. During an interview on 05/14/2024 at 2:01 PM, Corporate Director of Maintenance #1 stated that the leaking dumpster would be replaced. During an interview on 05/20/2024 at 10:55 AM, Assistant Administrator #1 stated that the leaky dumpster had been replaced, and the area around the dumpsters would be cleaned that day. 10 New York Codes, Rules and Regulations 415.14(h)

Inspectors wroteBased on observation, record review, and staff interviews during the recertification survey, the facility did not ensure infection control practices in accordance with professional standards of care for 1 (Resident #24) of 1 resident reviewed. Specifically, Resident #24 peripheral inserted central catheter dressing changes were not done per physician orders to prevent infection. This is evidenced by: The Facility's Peripheral Inserted Central Catheter Insertion and care Policy and Procedure effective 1/17/2019, documented general guidelines to include: 1. Dressings must stay clean, dry, and intact. 2. Change transparent semi-permeable membrane dressings at least every 5-7 days and as needed (when wet, soiled, or not intact). The following information should be recorded in the resident's medical record: 1. Date and time dressing was changed. 2. [...]

Inspectors wroteBased on observations, record review, and interviews during an abbreviated survey (Case # NY00325764), the facility failed to ensure the resident environment remained as free of accident hazards as possible for 7 (Resident #'s 2, 3, 20, 21, 22, 25, and 26) of 7 residents reviewed. Specifically, the facility (A) failed to provide meals to Resident #'s 2, 20, 21, 22, 25 and 26 who required a modified diet (provides foods that have a texture that is easier to eat), with meal items that were consistent with the physician ordered food texture, and (B) did not ensure that kitchen and nursing staff knew how to properly and consistently prepare and identify modified diets that were safe for residents. Subsequently, this put all residents with modified diets at risk for choking. [...]

Inspectors wroteBased on observations, record review and interviews During an abbreviated survey (Case #'s NY00325764, NY00324136, and NY00321074) the facility did not maintain sufficient nursing staff to ensure that residents received care and services as determined by assessment of resident needs and plans of care and in accordance with the facility assessment. Specifically, there was not sufficient nursing staff to meet the residents' needs including activities of daily living in accordance with individual plans of care and the facility assessment for 3 of 3 care units at the facility. [...]

Inspectors wroteBased on record reviews and interview during an Abbreviated survey (Case #NY00325764), the facility did not ensure that the facility assessment addressed the care required by the resident population considering the types of disabilities, overall acuity, and other pertinent facts within the population. Specifically, the facility assessment did not account for the total resident population and their care needs. This has the potential to affect all residents. This is evidenced by: Cross-referenced to F725: Sufficient Nursing Staff, F677: [...]

Inspectors wroteBased on observation and interview during a post survey revisit on 8/16/2024, the facility did not maintain an effective pest control program on (3) of 3 units. Specifically, house flies were noted on the A) North, B) East, and C) South residential units, in the hallways and in resident rooms. This is evidenced by: House flies were noted on the North unit: During observation of the North unit on 8/8/2024 at 9:35 AM, Resident #3 was in the hall and told the surveyor they wanted to talk to them. At 9:38 AM, the surveyor entered Resident #3's room and a house fly landed on the surveyor's head and the surveyor then swatted flies away from them with their clipboard. Resident #3 stated that every resident room had flies, according to what they heard from the other residents. They stated the facility was aware of the flies and gave residents fly swatters and showed the surveyor the fly swatter. [...]

Inspectors wroteBased on observations and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure each resident was treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of their quality of life. Specifically, (A) three residents (Resident #'s 1, 4 and 8) did not receive regular, timely assistance to carry out activities of daily living, which impacted their right to be treated in a dignified way; residents reported feeling their dignity was impacted by lack of showers and not receiving care in a timely fashion; (B) Resident #11 reported that loud sounding call bell alarms would be going off constantly on their unit, which impacted their ability to sleep; and (C) residents were served with plastic utensils rather than silverware. This was evident for 45 residents (Resident #'s 1, 4, 11, 8; [...]

Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure a safe, clean, comfortable, home-like environment for 3 of 3 resident care units. Specifically, the facility did not ensure that the resident rooms and common spaces were clean and sanitary and that areas of disrepair were repaired. This is evidenced by: Cross-referenced to: F550: Resident Rights The Policy and Procedure titled, Housekeeping and Sanitation, last reviewed 8/03/2023, read in part, in order to prevent and control the spread of disease, it was the objective of the housekeeping department to maintain a clean, sanitary, clutter free, and safe environment for residents, visitors, and staff. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #'s NY00325764, NY00333406, and NY00333793) the facility did not ensure residents were free from abuse. Specifically, the facility did not implement effective interventions to manage aggressive behaviors exhibited by Resident #3 and resulted in two incidents of resident-to-resident altercations that resulted in Resident #3 being punched by Resident #6 and in a separate incident where Resident #3 hit Resident #18. Prior to both incidents occurring, the resident was named in the complaint for having aggressive behaviors and altercations with other residents. This is evidenced by: [...]

Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (Case #NY00325724) the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #'s 1, 4, 5, 6 and, 8) of 5 residents reviewed for activities of daily living. Specifically, Resident #'s 1, 4, 5, 6 and 8 did not receive required assistance to perform activities of daily living as determined by assessment of the residents' needs and individual plans of care. This is evidenced by: Cross-referenced to: F550: Resident Rights, F692: Nutrition/ Hydration Status Maintenance, F725: Sufficient Nursing Staffing, F838: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00325764), the facility did not provide needed care and services in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 3 (Resident #'s 2, 30 and 31) of 3 sampled residents reviewed for nursing assessments after an accident/incident. Specifically, Residents #'s 2, 30 and 31 were not assessed by a Registered Nurse after accidents/incidents that were unwitnessed and/or when the residents observed with injuries. This is evidenced by: Cross referenced to: F689: Accident Hazards, F725: Sufficient Nursing Staff According to New York State Education Law §6902, Licensed Practical Nurses typically provide the following services: [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (Case #'s NY00325764 and NY00324136), the facility did not ensure the provision of nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment, therapeutic diet and preferences for 2 (Residents #4 and #5) of 3 sampled residents reviewed for weight loss. Specifically, the facility did not ensure that Residents #4 and #5, who were dependent on staff for meal assistance, regularly received meal assistance, were regularly monitored for meal intake, were provided with adaptive feeding equipment and that they received their full, correct meal orders. This is evidenced by: Cross-referenced to: F689: Accidents/Hazards, F677: Activities of Daily Living for Dependent Residents and F725: Sufficient Nursing Staff. [...]

Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (Case #NY00325764), the facility did not ensure to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of communicable infections for 3 of 3 care units. Specifically, the facility did not ensure that staff appropriately used and discarded of personal protective equipment and that the resident environment was sanitary. This is evidenced by: Cross-referenced to F584: Safe/clean/comfortable homelike environment. [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure a resident was assessed by the interdisciplinary to determine a resident's ability to safely administer their own medications if clinically appropriate for one 1 (Resident #7) out of 3 residents reviewed for medication administration. Specifically, Resident # 7 was observed with medications in their room and self-administered those medications without being evaluated as to whether they could safely do so. This is evidenced by: The Policy and Procedure titled, Activities of Daily Living, last revised October 2023, read in part, that Residents who expressed a wish to self-administer medications would be assessed by nursing and by rehabilitation services for ability to do so safely. [...]

Inspectors wroteBased on record review and interviews, 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 were reported immediately, but not later than two (2) hours to the State Survey Agency for 2 of 2 qualifying reportable incident and accident investigations reviewed. Specifically, when Resident #2 was observed with injuries of an unknown origin on 2/01/2024 and 2/18/2024, the facility did not report the incidents to the State Survey Agency. This is evidenced by: Cross-referenced to: F610: [...]

Inspectors wroteBased on record review, and interviews during an abbreviated survey (Case # NY00325764), the facility did not ensure thorough and accurate investigations were conducted after injuries of an unknown origin were for 2 of 2 facility investigations reviewed. Specifically, when Resident #2 was observed to have injuries of an unknown origin during two separate incidents, the facility did not follow their investigative process, did not thoroughly investigate the injuries to rule out abuse, and did not determine when or how the resident injured themself to prevent further injury. This is evidenced by: Cross-referenced to: F609: Reporting, F689: Accident Hazards and F684: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 05/04/23 through 05/10/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment on three (3) of 3 resident units, the lobby and core area, and the service areas. Specifically, on the South Unit, the south-end toilet was soiled with a brown substance; the corridor floors including next to walls and where door frames meet the floor were soiled with dirt; the floors were soiled with dirt in corners and next to walls in resident room #s 203, 205, 206, 212, 216, 217, 218, and 222; the shower A floor tiles were soiled with a black build-up; the bottom of the frames of the overbed tables in room #s 217 and 222 were soiled with drip marks and dust; [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the resident and the resident's representative(s) were notified in writing and in a language and manner they understood and did not send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 (Resident #'s 4, 74, and 116) of 3 residents reviewed for hospitalization. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or resident's representative upon transfer to the hospital for 3 (Resident #'s 4, 74, and 116) of 3 residents reviewed for hospitalization. Specifically, for Resident #4 the facility did not ensure a copy of the bed hold policy was provided to the resident and or/residents representative upon transfer to the hospital, for Resident #74, the facility did not ensure the resident and family received a copy of the bed hold policy upon discharge to hospital, for Resident #116, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or resident's representative upon the resident's transfer to the hospital on 3/23/2023. This was evidenced by: [...]

Inspectors wroteBased on observations and interviews during the recertification and abbreviated survey (Case #s: NY00297245 and NY00311218), the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 units. Specifically, the meal trays tested on [DATE] were not served at palatable and appetizing temperatures on the East, North and South units. Additionally, the facility did not ensure thermal insulated domes were utilized on all resident meal trays where required during meals observed between 5/8/2023 - 5/9/2023. This was evidenced by: The Policy and Procedure (P&P) titled Meal Tray Preparation and Tray Pass undated, documented it is the policy of the Dietary Department to assemble and pass meal trays that are nutritious, appetizing, palatable, and at appropriate temperature.

Inspectors wroteBased on observation and interview during the post survey revisit survey dated 07/13/23, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety for the main kitchen and two (2) of 3 units kitchenettes. Specifically, in the main kitchen, the can opener and holder, mixer, slicer, microwave oven, bulk food containers, drawers, shelf under worktables, walls, and floor in corners and next to walls, and under equipment were soiled with food particles; the South Unit kitchenette and the East Unit kitchenette microwave ovens were soiled with food particles; and the East Unit kitchenette cabinets and walls were soiled with food splatters. This is evidenced as follows: Finding #1 - Main Kitchen: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 05/04/23 through 05/10/23, the facility did not ensure corridors were equipped with firmly secured handrails on each side in the core area. Specifically, the following sections of handrailing was missing in core area: 32-feet, 16-feet, 6- feet, 10-feet, 36-feet, 14-feet, 2-feet, 6-feet, 10-feet, 6-feet, 33-feet, 12-feet, 29-feet, and 8-feet. This is evidenced as follows: During observations on 05/10/23 at 10:05 AM, the following sections of handrailing was missing in core area: 32-feet, 16-feet, 6- feet, 10-feet, 36-feet, 14-feet, 2-feet, 6-feet, 10-feet, 6-feet, 33-feet, 12-feet, 29-feet, and 8-feet. [...]

Inspectors wroteBased on observation, record review and interviews the facility did not ensure an infection control prevention and control program was implemented to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #74) of 1 residents. Specifically, the facility did not ensure Resident 74's urinary catheter drainage bag was kept off the floor in a privacy bag. The Policy and Procedure (P&P) titled Management of Indwelling/Foley Catheters dated 2/2023 stated the collection bag will be kept in a privacy bag both when in and out of bed for infection control and resident dignity. Resident #74 Resident #74 was admitted to the facility with the diagnoses of metabolic encephalopathy, other specified disorders of kidney and ureter, and hydronephrosis with renal and ureteral calculous obstruction. [...]