North Westchester Restorative Therapy & Nrsg Crt

Inspectors wroteBased on record review and interviews during the recertification and abbreviated surveys (677260 / NY00386237), the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (1) one (1) resident (Resident #124) reviewed for change in condition. Specifically, Resident #124's stool sample was not collected as ordered and there was no documented evidence that the Nurse Practitioner or the Physician were made aware that the stool sample had not been collected.

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00375176) the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 2 out of 3 residents (Resident #1, Resident #3) reviewed for medications. Specifically, (1) review of Resident #1's medication administration record for November 2024 revealed their blood pressure medication was not administered on 11/23/2024. There was no documented evidence of any hold parameters for Resident #1's medication and no documented evidence of the Physician being informed of the medication hold. Review of Resident #1's medication administration record for December 2024 revealed the resident refused their asthma medication on 12/11/2024 and their blood pressure medication on 12/12/2024 and 12/13/2024. [...]

Inspectors wroteBased on record review during an abbreviated survey (NY00370400) the facility did not ensure a comprehensive care plan was developed and implemented for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 out of 3 residents (Resident #2) reviewed for care planning. Specifically, Resident #2 who had impairment to one upper extremity and was dependent on staff for toileting, bed mobility and transfers, did not have an at risk for abuse care plan in place. On 1/27/2025 Resident #2 reported to their representative that a certified nurse aide threw a television remote control at them, and it hit them in the face. The facility concluded the allegation was unfounded

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00370400), the facility did not maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices for 1 out of 3 residents (Resident #2) reviewed for documentation. Specifically, on 1/28/2025 Resident #2 reported to their representative that a Certified Nurse Assistant threw a television remote control at them hitting them on the face. Review of Resident #3's medical chart revealed no documented evidence of any nursing or medical assessment completed pertaining to Resident #2's allegation that occurred on 1/27/2025.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00367900), the facility did not ensure a resident with a communicable infection was isolated to prevent further spread of infection for 2 out of 3 (Resident #1, #2) residents reviewed for infection control. Specifically, on [DATE] the facility identified Resident #2 as having a suspected case of Norovirus during a facility outbreak. Resident #2 was the roommate of Resident #1, who did not display any symptoms of the infection on [DATE]. Resident #1 remained in the same room with Resident #2 on the south unit, and Resident #1 subsequently acquired symptoms of the infection on [DATE]. Facility open bed census reviewed revealed available beds on the South unit on [DATE], [DATE] and [DATE]. Resident #1 expired in the facility on [DATE] from acute respiratory failure.

Inspectors wroteBased on record review and interview during an abbreviated survey (NY00349402), the facility did not ensure the resident's legal representative upon written request was provided with a copy of the resident's medical records within 2 working days advance notice to the facility as per Federal regulations for 1 of 3 residents (Resident #3) reviewed for medical records. Specifically, on 5/28/2024 Resident #3's representative requested via email copies of Resident #3's complete medical record and physical therapy records from the facility. Resident #3's representative submitted an Authorization for Release of Health Information form to the facility via email attachment on 6/16/2024. The facility did not provide Resident #3's representative with the copies of the medical records until 7/8/2024.

Inspectors wroteBased on observation, record review and interview during the recertification survey from 7/31/24 to 8/7/24, the facility did not ensure that oxygen equipment was maintained in accordance with professional standards of practice and manufacturer specifications for 1 of 4 residents (Resident #308) reviewed for respiratory care. Specifically, the oxygen concentrator filter was not removed and cleaned on a weekly basis, according to the physician's order and the maintenance policy.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 7/31/24 to 8/07/24, the facility did not ensure for 1 (Residents #48) of 1 residents reviewed for Pharmacy Services and 1 of 4 residents (Resident #261) reviewed for Drugs/Medications, that they provided medications and/or biologicals, as ordered by the prescriber, to meet the needs of the resident. Specifically, 1. Resident #48 had requested Hydromorphone(Dilaudid) on 7/30/24 and it was not given due to being unavailable from the pharmacy and 2. Resident #261 was not given Jardiance (medication used to lower blood sugar levels in people with Type 2 Diabetes Mellitus) on 7/27/24 due to being unavailable from the pharmacy.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 7/31/24-8/7/24, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, 1. the walk-in refrigerator contained an open container of Feta Cheese and one 64 oz jug of Cream o Land whole milk which were not dated when opened, 2. the cook's daily/ready to use refrigerator, contained one open/undated 64 oz jug of Cream O Land whole milk, 3. The walk-in freezer, contained unlabeled plastic bags of Tortellini and Croissants which were not dated when opened, and 4. The dry storage room, contained trays of [NAME] Rock diet ginger ale without expiration dates.

Inspectors wroteBased on record review and interview conducted during a recertification survey and abbreviated survey (NY00343508), the facility did not implement the protection component of the abuse prohibition protocol for 1 of 3 residents (Resident #34) reviewed for abuse. Specifically, pending the outcome of investigation Certified Nurse Aide #1 continued to provide care to facility residents, potentially promoting continuation of verbal abuse after Resident #34 accused Certified Nurse Aide #1 of calling them inappropriate names.

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated surveys (NY 00343508), the facility did not ensure that reporting of alleged violations were reported to the New York State Department of Health immediately but not later than 2 hours after the allegation involving abuse is made for 1 of 3 residents (Resident #34) reviewed for abuse. Specifically, Resident #34 accused Certified Nurse Aide #1 of calling them inappropriate names and the facility did not report the incident to the New York State Department of Health

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification and Abbreviated Surveys (NY 00327281) from 7/31/24 to 8/07/24, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident # 257) reviewed for smoking. Specifically, the facility did not develop a care plan to address the 11/1/23 physician ordered Nicotine patch and/or smoking cessation.

Inspectors wroteBased on observations, record review and interview conducted during a recertification survey, the facility did not ensure that food contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with standards for food service safety. Additionally, two bearded dietary employees were not wearing beard guards to minimize hair contact with hands, food and food contact surfaces. Chapter 1 Sub-part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated: non-food contact surfaces are to be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. [...]

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, an overflow of filled garbage bags prevented the lids of the dumpsters from closing and the dumpster area was not maintained in a sanitary condition to prevent harborage and feeding of pests.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey the facility did not ensure that 1 of 34 residents received necessary services to maintain good oral hygiene. Specifically, a resident was observed to have substantial food residue on her upper and lower teeth during numerous observations. (Resident #54).

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. Specifically, during the medication pass 2 medication errors were noted out of 31 opportunities for error which resulted in a 6.45% error rate.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that all drugs and biologicals in 1 of 6 medication carts, and 1 of 3 medication rooms were labeled and stored in accordance with professional standards. Specifically, an open, in use, and undated Admelog Solostar Insulin Pen, and medication contents in an emergency medication box had past due expiration dates.

Inspectors wroteBased on observation and interview conducted during the recertification survey, the facility did not ensure that its staff followed proper hand hygiene during medication pass.