The Brook at High Falls Nursing Home and Rehabilit

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure it established and maintained 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 seven (7) of nine (9) residents (Residents #1, #2, #12, #18, #21, #25, and #33) and one (1) of one (1) residential unit reviewed. Specifically, staff were observed performing wound care for Resident #1 and touching environmental surfaces without appropriate glove changes and hand hygiene. For Residents #2, #18, #21, #25, and #33 medications were prepared and handled by a licensed nurse with their bare hands. For Residents #2, #12, #18, #21, #25, and #33 a reusable blood pressure monitoring device was not cleaned and disinfected between residents; [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents exercised their rights without interference, coercion, discrimination, or reprisal from the facility for one (1) of five (5) residents reviewed (Resident #4). Specifically, the facility did not ensure changes in Resident #4's Medicare health coverage were initiated by the resident or the resident's authorized representative, and did not ensure the resident and/or responsible party received required oral and written explanations regarding the impact of changing Medicare coverage.

Inspectors wroteBased on observation and interview, the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior for one (1) of one (1) resident use floor and one (1) of one (1) kitchen. Specifically, the facility did not ensure interior spaces were maintained free from unsanitary conditions and environmental hazards, as evidenced by damaged, jagged, or missing radiator covers; a dirty bathtub with a non-functioning lift chair; wall damage; a non-functional fan used for air drying dishes; cracked light lenses and missing end caps above the kitchen tray line; a damaged ice machine lid with exposed ice; and dirty floors and surfaces in resident rooms.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the resident environment remained free of accident hazards for one (1) of one (1) resident use floor. Specifically, hot water exceeding 120 degrees Fahrenheit ( F) was accessible to residents at point of use, creating a risk for scalding.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure medications were stored securely and accessible only to authorized personnel, in accordance with professional standards of practice and State and Federal regulations, for one (1) of one (1) residential unit reviewed. Specifically, the facility stored medications in an unsecured and frequently opened soiled linen room being used as a temporary medication room during renovations. Medications stored in this area were accessible to residents, visitors, and non-authorized staff. Additionally, there were unidentified, loose pills found in a medication cart and missing signatures identified on narcotic count sheets for various shifts with no additional evidence of accurate narcotic counts and/or accountability for controlled substances.

Inspectors wroteBased on observations and interviews conducted during a Recertification Survey completed 11/07/2024 to 11/14/2024, the facility did not provide maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike environment. Specifically, kitchen lighting was not protected or operable, a residential kitchen freezer and a staff bathroom were inoperable, bathrooms exhaust ventilation was not installed or was inoperable, there was no soap in resident bathrooms, a call bell was not installed in a resident bathroom, and a corridor exit sign was not affixed to the ceiling.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 11/07/2024 to 11/14/2024, 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 infection. Specifically, for one of one dining room reviewed during a meal, a staff member was observed making direct contact with a resident's food without applying gloves and did not perform hand hygiene after touching used meal trays and utensils prior to touching unused meal trays and meal set-up for multiple residents. For one of one laundry room, a laundry staff was observed handling soiled potentially contaminated linen without wearing appropriate personal protective equipment that included gowns. [...]

Inspectors wroteBased on interviews and record review conducted during a Recertification Survey from 11/07/2024 to 11/14/2024, for one (Resident #3) of twelve residents reviewed for care planning, the facility did not ensure a comprehensive person-centered care plan meeting was held at least quarterly and that the resident and/or their representative had been invited to attend. Specifically, Resident #3 had been in the facility for approximately 22 months, and there was no evidence that the resident and/or their representative had been invited to any care plan meetings. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (Resident #9) of one resident reviewed for activities of daily living. Specifically, Resident #9 was observed over several days with debris underneath their fingernails, including while eating with their hands. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #178) of three residents reviewed for nutrition/hydration and one (Resident #178) of one resident for pressure injury. Specifically, the facility did not ensure the resident received the highest practical, physical, mental and psychosocial wellbeing, including maintaining adequate hydration status and ensuring interventions to promote pressure ulcer injury healing. This is evidenced by the following: Resident #178 was recently admitted with diagnoses that included a stroke and hemiparesis (weakness or the inability to move on one side of the body), a history of falls, and a compression fracture of the lower back. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, for one (Resident #13) of four residents reviewed, the facility did not ensure that the resident's menus items containing dietary recommendations were followed. Specifically, Resident #13 did not receive multiple food items as listed on their tray ticket during mealtime and refused 100% of their meal without staff intervention to assist and encourage them. This is evidenced by the following: Resident #13 had diagnoses that included vascular dementia, depression, and anxiety. The Minimum Data Set Resident Assessment, dated 08/03/2024, documented the resident was severely impaired cognitively, did not exhibit behaviors or rejection of care at the time, and required supervision or touching assistance with eating. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility did not ensure all resident rooms were equipped with privacy curtains which extended around the bed to provide total visual privacy in combination with adjacent walls and curtains for two (Residents #9 and #15) of two residents reviewed. Specifically, privacy curtains were not present in two semi-private rooms both occupied with two residents. This is evidenced by the following: 1. Resident #15 had diagnoses including congestive heart failure, depression, and diabetes. The Minimum Data Set Resident Assessment, dated 09/20/2024, documented the resident was moderately impaired of cognitive function. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/14/2024, the facility did ensure the nurse staffing information was posted on a daily basis. Specifically, the nurse staffing information was not posted at the beginning of each shift and was not posted on weekends per the regulations. This is evidenced by the following: During observations on 11/08/2024 at 9:02 AM, 9:58 AM, 11:38 AM, and 1:12 PM, the nurse staffing information sheet was dated 11/07/2024. During an interview on 11/08/2024 at 1:26 PM and on 11/14/2024 at 9:52 AM, Receptionist #1 stated they were responsible for completing and posting the nurse staffing sheets including the resident census and had been since 2022. [...]

Inspectors wroteBased on observations and interview conducted during a Recertification Survey completed from 11/07/2024 to 11/14/2024, the facility did not safeguard resident medical record information against loss, destruction, or unauthorized use. Specifically, resident medical records were stored in damaged boxes and in a room that was unlocked.

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (NY00316809, NY00322695, NY00327824, NY00328450, NY00326411, and NY00330622) for one of one resident-use floor the facility did not provide an environment designed, constructed, equipped, and maintained to provide a safe, healthy, functional, sanitary, and comfortable home like environment. Specifically a railing on an exit ramp was deteriorated and unsafe, a door threshold transition strip was missing, walls were damaged, there were broken floor tiles in a resident room, resident room windows could not be opened due to missing handles, and there was a hole in the carpet in a resident room.

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (complaint #s NY00333143, NY00316809, and NY00330622) for one of one resident floor and two of two basements, the facility did not maintain an effective pest control program. Specifically, there was evidence of rodent activity and pest harborage areas within the facility.

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey and complaint investigations (#NY00311675, #NY00302654) from 5/4/23 to 5/10/23, it was determined that the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days per week per the regulations. Specifically, the facility was unable to provide documented evidence that a RN had worked any hours on 26 days during the four months reviewed. This is evidenced by the following: Review of the nurse staffing reports (report posted to inform residents and visitors of the number and hours of nursing staff working) that are posted adjacent to the front entrance, revealed the facility had no RN coverage for all three shifts for the following: a. On 4 of 30 days in the month of April 2023. b. On 8 of 31 days in the month of March 2023. c. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Standard Recertification Survey completed from 5/4/23 to 5/10/23, it was determined that for one of one kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food was not thawed properly, foods were held at improper temperatures in a refrigerator, a three-bay sink and milk cooler were inoperable, and a hand-wash sink was not properly maintained.

Inspectors wroteBased on interviews and record review conducted during a Recertification Survey 5/04/23 to 5/10/23, the facility did not maintain a quality assessment and assurance committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role, and the infection preventionist. Specifically, the facility could not provide documented evidence that the Medical Director or their designee attended the quality assurance meetings for the past 10 months (available documentation). This is evidenced by: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey 5/04/23 to 5/10/23, for two (Resident #5, Resident #329) of 14 residents reviewed the facility did not provide services, as outlined by the resident's person-centered comprehensive care plan (CCP), that meet professional standards of quality. Specifically, for Resident #5 the facility did not provide the resident with adult briefs that had been prescribed by the physician. For Resident #329, there was no documented evidence that medications were consistently administered per the current physician orders. This is evidenced by: 1. Resident #5 had diagnoses including multiple sclerosis, quadriplegia, and pemphigoid (a rare auto-immune disorder that results in skin rashes and blistering on the legs, arms, and abdomen). [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 5/04/23 to 5/10/23, for one of one resident care unit and one of one hot water tank the facility did not ensure the resident environment remained as free of accident hazards as was possible. Specifically, there were observations of unsafe water temperatures as high as 140 degrees (°) Fahrenheit (F) in multiple resident bathrooms accessible to residents including the facility's hot water tank creating a potential risk to resident safety. Additionally, the facility was not consistently monitoring the water temperature in resident rooms to avoid high risk temperatures. This is evidenced by: Review of the facility policy Domestic Water Temperature dated 2/1/16, documented that water temperature readings will be obtained daily before the end of each day. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 5/4/23 to 5/10/23, it was determined for one of one resident reviewed for dialysis, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive care plan (CCP) and physician orders. Specifically, the Resident #329's 24-hour fluid restriction as requested by dialysis and ordered by the physician was not being consistently monitored to ensure the resident was receiving the appropriate amount of fluids on a daily basis. The finding is: Resident #329 was admitted to the facility on [DATE] with diagnosis including end stage renal disease requiring hemodialysis three days a week. The Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey 5/4/23 to 5/10/23, for one (Resident #6) of five residents reviewed for unnecessary medications, the facility did not ensure that residents who use psychotropic drugs (drugs that affect brain activities associated with mental process and behaviors and include, but not limited to anti-depressant drugs), received a gradual dose reduction (GDR), unless clinically contraindicated, in an effort to discontinue/decrease these drugs. Specifically, a psychiatry evaluation to assess the residents continued need for an antidepressant drug after a year at the same dose following a pharmacy recommendation and the physician's agreement was never implemented. This is evidenced by the following: Resident #6 was admitted to the facility 4/1/22 with diagnoses including dementia and depression. [...]

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey 5/04/23 to 5/10/23, for one (Resident #4) of two residents reviewed the facility did not provide written notice to the resident or resident representative at the time of transfer of the resident for hospitalization or therapeutic leave which specifies the duration of the bed-hold policy and the reserve bed payment policy. Specifically, for Resident #4 who was transferred and admitted to the hospital on [DATE], the facility could not provide documented evidence that written notice of the bed-hold policy was provided to the resident and/or resident representative. This is evidenced by: Resident #4 had diagnoses including acute kidney failure, diabetes mellitus, and urinary tract infection. The Minimum Data Set (MDS) Assessment, dated 3/10/23, documented the resident had severely impaired cognition. [...]