Vestal Park Rehabilitation and Nursing Center

Inspectors wroteBased on record review and interviews (iQIES intake 3053282), the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and effectively transitioned the resident to post-discharge care for one of one resident (Resident #64) reviewed. Specifically Resident #64 was not provided with a home health agency referral or a rolling walker as recommended by physical therapy upon discharge.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two of two meals (lunch meals on 07/07/2026 and 07/08/2026) and for nine of nine anonymous residents present at the resident group meeting. Specifically, the 07/07/2026 and 07/08/2026 lunch meal trays had hot foods served below 130 degrees Fahrenheit, cold foods served above 49 degrees Fahrenheit, and foods were not palatable; and nine anonymous residents at the resident group meeting stated the hot food was served cold and meals were served late.

Inspectors wroteBased on record review and interview during the abbreviated (NY00329596) survey the facility did not consult with the resident's physician and notify the resident representative when there was a need to alter treatment significantly for 1 of 1 resident (Resident #1) reviewed. Specially, Resident #1 was not administered twenty doses of their physician ordered antipsychotic medication and there was no documented evidence the physician or the resident representative was notified.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00329596) the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed. Specially, Resident #1 was not administered twenty doses of their physician ordered anti-psychotic medication.

Inspectors wroteBased on record review and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure licensed nurses had specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 4 licensed nurses (Licensed Practical Nurses #22, #26, #35 and Registered Nurse #27); and did not ensure certified nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 2 certified nurse aides (Certified Nurse Aides #12 and #36). Specifically: - Licensed Practical Nurse #22 left medications at a resident's bedside who did not have a physician order for medication self-administration. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, food was not maintained at proper temperatures and the dishwasher was not maintaining the proper temperature.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure the resident environment remained as free of accident hazards as is possible for 3 of 3 residents (Resident #127, #148, and #146) reviewed. Specifically, Residents #127, #148 and #146 had medications left unattended in their rooms. Additionally, there was no documented evidence Residents #127, #148 and #146 were assessed to determine their ability to safely administer medications or had physician orders to self-administer their medications.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00323929 and NY00339707) surveys conducted 7/22/2024-7/26/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for 1 of 1 resident (Resident #71) reviewed. Specifically Resident #71's urinary catheter drainage bag was uncovered and visible to other residents, visitors, and staff. The facility policy, Quality of Life-Dignity, revised 3/2024 documented residents should be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents were treated with dignity and respect at all times. Staff was expected to promote dignity and assist residents in keeping urinary catheter bags covered. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 4 of 6 residents (Resident #20, #69, #71, and #83) reviewed. Specifically, Resident #71's and #83's care plan did not include the use of an anticoagulant (blood thinner) or insulin (used to treat diabetes); Resident #20's care plan did not include the use of insulin; and Resident #69's care plan did not include specific resident centered care interventions for behavioral symptoms.

Inspectors wroteBased on observations, record review, and interview during the recertification and abbreviated (NY00289910, NY00305753, NY00316721, NY00323929, and NY00339707) surveys conducted 7/22/2024-7/26/2024, 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 2 of 7 Residents (Residents #88 and #127) reviewed. Specifically, Resident #88 was not assisted with shaving and Resident #127 was not assisted with showering and oral care.

Inspectors wroteBased on observation and interview during the recertification survey conducted 7/22/2024-7/26/2024, the facility did not post daily at the beginning of each shift, the current resident census and the total number and the hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, and accessible to residents and visitors for 4 of 5 days reviewed. Specifically, the nurse staffing was not consistently posted.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted [DATE] through [DATE], the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 1 of 4 medication carts (Brookside Garden medication cart), 1 of 1 treatment cart (Brookside Terrace cart), and 1 of 2 medication rooms (Brookside Terrace medication room) reviewed. Specifically, the Brookside Garden medication cart contained 3 insulin pens without opened dates; and the Brookside Terrace medication refrigerator did not have a complete record of refrigerator temperatures, and the treatment cart was unlocked.

Inspectors wroteBased on observation, interview, and record review during recertification survey conducted 7/22/2024-7/26/2024, the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional needs, taking into consideration the preferences of each resident for 2 of 4 residents (Resident #107 and #148) reviewed. Specifically, Residents #107 and #148 were missing food items on their meal trays.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00339707) surveys conducted 7/22/2024-7/26/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 7/23/2024 lunch meal and the 7/24/2024 lunch meal). Specifically, food was not palatable or served at palatable and appetizing temperatures during the lunch meals on 7/23/2024 and 7/24/2024. Additionally, Residents #36, #88, #107 and #136 stated the food was not palatable.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 7/22/2024-7/26/2024, 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 communicable diseases and infections for 1 certified nurse aide and 1 registered nurse (Certified Nurse Aide #12 and Registered Nurse #15) observed. Specifically, Certified Nurse Aide #12 did not wear a gown and gloves as required in a room requiring transmission based precautions and did not perform appropriate hand hygiene before exiting the room; Registered Nurse #15 did not perform hand hygiene or change their gloves during wound care.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 07/22/2024-7/26/2024, the facility did not ensure call bells were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet, and bathing facilities for 1 of 1 resident (Resident #28) reviewed. Specifically, Resident #28's call bell was not within reach.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00307423), the facility did not immediately inform the resident's representative when there was a need to alter treatment for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 was prescribed a medication for dementia and the resident's representative was not notified.

Inspectors wroteBased on observations, record review, and interview during the recertification and abbreviated surveys (NY00289678, NY00280940, NY00268244, NY00270091, NY00277226, and NY00277318) conducted 3/28/22-4/4/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #54, 90, 115, and 140) reviewed. Specifically, Residents #54, 90 and 140 were observed with unclean and unkept fingernails and Resident #115 did not receive timely assistance with toileting as requested.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent for 8 of 11 residents (Residents #34, 41, 47, 54, 115, 128, 140 and 174) reviewed. Specifically, - Resident #54 became entrapped in a bed rail and sustained a fracture as a result. Resident #54's bed rails were not reassessed timely after the incident to determine their continued use and safety. The bed rails were not removed timely after it was determined they were no longer needed. - Resident #34 was physically compromised and was not appropriately assessed for use of bed rails. [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure residents were assessed to determine ability to safely self-administer medication when clinically appropriate for 1 of 1 resident (Residents #116) reviewed. Specifically, Resident #116 had an inhaler (hand-held, portable devices that deliver medication to the lungs) at their bedside and there were no physician order for self-medication administration and/or resident assessments to determine ability to safely self-administer medications.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00268244) surveys conducted 3/28/22-4/4/22, the facility failed to promote and facilitate resident self-determination through support of resident choice for 6 of 6 residents (Residents #11, 41, 47, 54, 67 and 77) reviewed for choices. Specifically, Residents #11 and 47 were administered a medication during their normal sleeping hours without consideration of their preferences; Residents #41 and 67 were not offered their preferred food or drink; and Residents #54 and 77 were not provided haircuts per their preference.

Inspectors wroteBased on interview and record review during the recertification and abbreviated surveys (NY00284523) conducted [DATE]-[DATE], the facility failed to ensure conveyance, within 30 days of death, the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate, in accordance with State law for 1 of 1 resident (Resident #182) reviewed. Specifically, Resident #182 expired in the facility and disbursement or final accounting of the resident's funds was not sent to the resident's representative within 30 days of their death. Findings Include: Resident #182 was admitted to the facility with diagnoses including neoplasm stromal tumor (formation of abnormal cells) and major depression. The [DATE] Minimum Data Set (MDS) discharge assessment documented the resident had expired in the facility on [DATE]. [...]

Inspectors wroteBased on record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were reported immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury, to the New York State Department of Health (NYSDOH) for 1 of 1 resident (Resident #54) reviewed. Specifically, Resident #54 was entrapped in a bed rail and sustained a fractured anatomic neck of the left humerus (upper arm bone where it meets the shoulder) and the incident was not reported to the NYSDOH as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure allegations of abuse, exploitation, or mistreatment were thoroughly investigated for 1 of 5 residents (Resident #140) reviewed. Specifically, Resident #140 had a fall and the resident's care plan was not reviewed to determine if the care plan was followed.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 1 of 3 residents (Resident #54) reviewed. Specifically, use of a palm guard (used for hand contractures) was not addressed in Resident #54's comprehensive care plan (CCP) and care instructions to ensure staff applied the palm guard. Additionally, when the palm guard was not available, therapy was not notified to provide a replacement.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00277226. NY00293036, NY00263802) conducted 3/28/22-4/4/22, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed. Specifically, Resident #4's care plan for falls was not followed and the resident had a fall with injury.

Inspectors wroteBased on record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to develop and implement appropriate plans of action to identify quality deficiencies after an incident involving bed rail entrapment for Resident #54 (see F 700 Bed Rails). Specifically, Resident #54 became entrapped in a bed rail resulting in a fracture and a plan of action was not implemented to include review of residents with bed rails in place to ensure accurate and current assessments were completed.

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 resident (Resident #31) reviewed for restraints. Specifically, Resident #31 had a wheelchair brake applied at meal times to prevent the resident from leaving the table and the resident was not able to release it independently. Findings Include: The 8/2004 Physical Restraints facility policy defined a restraint as any physical or mechanical device attached or adjacent to the resident's body that the resident cannot easily remove which restricts freedom of movement. A locked wheelchair was listed in the examples of a restraint. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure the assessment accurately reflected the resident's status for 1 of 1 resident (Resident #49) reviewed for hospice and end of life care. Specifically, Resident #49's quarterly Minimum Data Set (MDS) assessment incorrectly identified the resident as receiving hospice services (medical services to help with terminal illness) when she was not.

Inspectors wroteBased on observations, interview, and record review during the recertification survey, the facility did not ensure residents were provided care and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) including dining/eating for 1 of 5 residents (Resident #87) reviewed for ADLs. Specifically, Resident #87 was care planned for assistance at meals and was not assisted timely.

Inspectors wroteBased on observation, record review and observation during the recertification survey the facility did not provide proper treatment and assistive devices to maintain vision for 1 of 1 resident (Resident #148) reviewed for vision/hearing. Specifically, Resident #148 did not receive new eyeglasses as recommended by her optometrist.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meal trays tested during dining observations. Specifically, food was not served at palatable and safe temperatures.

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not store food in accordance with professional standards for food service safety in 1 of 1 main kitchen reach-in coolers. Specifically, the cooler had non-potable condensation dripping from the top of the cooler and there was a container of egg salad with a cracked lid exposing the egg salad to open air.