Resort Nursing Home

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Incident # 2581915), the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress. This was evident for one (1) out of three (3) residents (Resident #1) sampled for abuse. Specifically, on 08/05/2025 at 1:59 PM Certified Nursing Assistant #1 reported to Registered Nurse #1 that Resident #1 slapped Clinical Transportation Aide #1, who was providing 1:1 supervision to Resident #1, and Clinical Transportation Aide #1 in return slapped Resident #1 while they were assisting them with repositioning the resident in their wheelchair. Registered Nurse #1 did not protect Resident #1 from further potential abuse; [...]

Inspectors wroteBased on record reviews and interviews, during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 to 05/29/2024, the facility did not ensure that all alleged violations involving abuse and neglect, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency. Additionally, the facility did not ensure the results of all investigations were reported to the State Survey Agency within 5 working days of the incident. This was evident for 3 (Resident #126, #136, and #195) of 7 residents reviewed for Abuse out of 36 sampled residents. Specifically, 1.) On 01/13/2024 at approximately 2:30 PM, the facility was made aware that Registered Nurse #3 administered the wrong medication to Resident #126. An initial report was made to the New York State Department of Health on 01/14/2024 at 9:01 AM. [...]

Inspectors wroteBased on interview and record review during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 through 05/29/2024, the facility failed to ensure that residents were free of significant medication errors. This was evident for 1 (Resident #126) of 1 resident reviewed for medication administration. Specifically, Resident #126 had a physician's order for 12 tablets of Methadone 10 milligram by oral route once daily. On 01/13/2024, the Resident was administered 12 tablets of Percocet 10-325 milligrams instead of Methadone. Cross Reference: F658 - Services Meet Professional Standards

Inspectors wroteBased on observation and interview conducted during the Recertification Survey from 05/21/2024 to 05/29/2024 , the facility did not ensure that the nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Specifically, there was no available posting of daily nurse staffing information.

Inspectors wroteBased on interviews and record review conducted during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 to 05/29/2024 the facility did not ensure that services provided by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for 1 (Resident #126) of 1 resident reviewed for medication administration. Specifically, Resident #126 had a physician's order for 12 tablets of Methadone 10 milligram by oral route once daily. On 01/13/2024, Registered Nurse #3 administered 12 tablets of Percocet 10-325 milligrams instead of Methadone.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure the garbage and refuse were disposed of properly. This was evident during observation of the Kitchen. Specifically, the garbage compactor (GC) was observed open on more than one occasion.

Inspectors wroteBased on observations and interviews during the Recertification/Complaint Survey, the facility did not ensure a resident was cared for in a manner that maintained. This was evident for 1 of 1 resident out of a sample of (Resident # 46). Specifically, Resident #46's stomach and gastrostomy tube were left uncovered and exposed to public view.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey, the facility did not ensure that a resident was invited to participate in comprehensive care planning (CCP). This was evident for 1 of 32 sampled residents (Resident #69). Specifically, Resident #69 was not invited to CCP meetings with the interdisciplinary team (IDT).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure infection prevention control practices were maintained. This was evident for 2 of 2 residents reviewed out of a sample of 32 residents (Resident #62 and #69). Specifically, respiratory equipment for Resident #62 and Resident #69 was observed on multiple occasions unprotected, unlabeled, and undated.

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not ensure the dishwasher was functioning properly to sanitize dinnerware and that food was stored under the proper temperatures. Specifically, 1) The facility dishwashing machine was not operating at the proper temperature to ensure proper sanitization of serving plates and utensils; and 2) The walk-in Freezer was not operating at the proper temperature to ensure that frozen foods remain frozen.

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure that each resident who displays or is diagnosed with Dementia receives the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well being. This was identified for 7 (Resident #38, #72, #64, #154, #177, #111 and #454) of 7 residents reviewed for Dementia care. Specifically, the facility did not develop person-centered care plans to reflect individualized approaches to care with measurable goals, timetables, and specific interventions, nor identify effective non-pharmacologic interventions to maintain the highest psychosocial wellbeing for these residents. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure that each resident receive reasonable accommodation of needs by ensuring each resident's call bell was within reach. This was identified for 9 (Residents #160, #20, #68, #108, #175, #40, #195, #155, and #165) of 38 sampled residents. Specifically, 1) The call bell for Residents #160, #20, #68, and #108 was observed with the wire of the call bell wound, tied, and hung on the wall near the head of bed (HOB). 2) Resident #175 was observed with his call bell placed on top of the overhead lighting fixture above the HOB. 3) The call bell for Residents #155, #195, #40, and #165 was observed on the floor.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not implement a comprehensive person-centered care plan for each resident. This was identified for 1 (Resident # 64) of 1 resident reviewed for Range of Motion (ROM). Specifically, Resident # 64's Comprehensive Care Plan (CCP) developed for the Development of the Functional Limitation in ROM included an intervention to use an Abductor pillow. The Physician ordered Abductor pillow was not observed in place on two separate occasions. The finding is: The Facility's Comprehensive Care Plan (CCP) policy dated 2/2018 documented that the Care Plan guides the care and treatment provided to each resident. The CCP addresses the resident's medical, functional, and severity of the resident's condition. [...]

Inspectors wroteBased on record reviews and staff interviews during the recertification survey, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was identified for 1 (Resident #40) of 3 residents reviewed for anticoagulant medication and 1 (Resident #155) of 3 residents reviewed for advance directives a total of 38 sampled residents. Specifically, 1) Resident #40 has a Physician's Order to administer Heparin injection. The Physician's Order of Heparin did not specify the route of administration. 2) Resident #155 had a) Physician's Order for Physical Therapy and Occupational Therapy (PT/OT) treatments rather than for a rehabilitation screen. Additionally, Comprehensive Care Plans were developed for both Occupational and Physical Therapy. [...]