Waterview Nursing Care Center

Inspectors wroteBased on interviews and record review, the facility did not ensure all alleged violations involving abuse were reported immediately to the New York State Department of Health no later than 2 hours after the alleged occurrence. This was evident for three (3) (Resident #138, Resident #188 and Resident #108) of four (4) residents reviewed for Abuse out of 37 total sampled residents. Specifically, Resident #138 had an allegation of sexual abuse, Resident #188 had an unwitnessed fall, and Resident #108 had an injury of unknown origin; these allegations were not reported to the Department of Health within a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team periodically and after each comprehensive and quarterly review assessment. This was evident for four (4) residents (Residents #19,11, and 44) out of 38 total sampled residents. Specifically, 1) Resident #19's Vision, Pressure Ulcer Risk, potential for skin breakdown and Behavioral Symptoms care plans were not reviewed and revised after each assessment, 2) Resident #11's Cognition and Falls care plans were not reviewed and revised after each assessment, and 3) Resident #44's Vision's quarterly care plan was not reviewed and revised after each assessment.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure Minimum Data Set (MDS) 3.0 assessments were submitted in a timely manner. This was evident for two (2) (Resident #12 and Resident #61) of two (2) residents triggered for the Resident Assessment Task. Specifically, annual assessments were not submitted withiin 14 days of the Assessment Reference Date (ARD).

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure a resident received adequate supervision to prevent an accident. This was evident in one (1) (Resident #108) of seven (7) residents reviewed for Accidents out of thirty-eight (38) total residents sampled. Specifically, Resident #108, who was identified as having a history of behaviors of wandering and going into other residents' rooms, was not provided adequate monitoring or supervision and on 04/12/2026, Resident #108 was observed with bruise and discoloration under right eye and redness on right hand.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024 , the facility did not ensure sufficient nursing staff were available 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. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on observations and staff interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident room walls with mismatched paint patches, discolored blinds, worn window treatments, torn wall paper, damage furniture and dirty, dusty areas. This was observed during the Environment task and was evident on 4 (1 North, 1 East, 2nd floor and 1 West) of 5 units.

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification and complaint survey (NY00358667, and NY00345814, from 12/02/2024 to 12/09/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made. This was evident for 2 (Resident # 139 and Resident #103) of 6 residents reviewed for Abuse and 1 (Resident #71) of 6 residents reviewed for Accidents out of 37 sampled residents. Specifically, and allegation of sexual Abuse for Resident #139 and an injury of unknown origin for Resident #103 was not reported in a timely manner and an injury of unknown origin for Resident #71 was not reported to the Department of Health.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the Lobby area, hallways, and nursing station. The facility policy and procedure revised 09/01/24 titled Safe, Clean, Comfortable and Home-Like Environment documented, it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible.

Inspectors wroteBased on record review, and interviews conducted during the Recertification survey from 12/2/2024 to 12/9/2024, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 2 (Resident #111 and Resident #13) of 3 residents reviewed for Care Planning out of 37 total sampled residents. Specifically, Resident #111 and Resident #13 were not invited to attend their scheduled Comprehensive Care Plan and quarterly meetings.

Inspectors wroteBased on record review, observations and interviews conducted during a Recertification survey from 12/02/2024 to 12/09/2024 the facility did not ensure that each section of the Minimum Data Set assessment accurately reflected the residents' status. This was evident for 1 (Resident #37 of 5 residents reviewed for Unnecessary Medication and 1 (Resident #130) of 3 residents reviewed for Behavioral-Emotional out of 37 sampled residents. Specifically, the most recent Minimum Data Set Assessment did not accurately document that Resident #37 and Resident #130 displayed wandering behavior.

Inspectors wroteBased on record reviews and interviews conducted during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that a Comprehensive Care Plan was developed and implemented to meet a resident's needs. This was evident for 1 (Resident # 111) of 2 residents reviewed for Skin Conditions out of 37 sampled residents. Specifically, a care plan was not developed for Resident #111 who complained of itchy skin and had ongoing skin issues.

Inspectors wroteBased on record review, and interviews during a Recertification survey and Abbreviated survey (NY00325169, NY00359202) from 12/02/2024 to 12/09/2024, the facility did not ensure that care plans were reviewed and revised by the interdisciplinary team after each assessment. This was evident in 1 (Resident #17) out of 1 resident reviewed for Dental out of 37 sampled residents. Specifically, the care plan related to Oral/Dental Care was not revised quarterly.

Inspectors wroteBased on observation, record review, and interview during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that a resident who used psychotropic drugs received gradual dose reductions unless clinically contraindicated, to discontinue the drug. This was evident for 1 (Resident #153) of 5 residents reviewed for Unnecessary Medications out of 37 sampled residents. Specifically, Resident #153 had a Dementia diagnosis and was receiving antipsychotic medication. There was no evidence that a gradual dose reduction had been attempted and there was no documented evidence that Resident #153 displayed any mood or behavioral symptoms that warranted continued use of the medication. The finding is: Resident #153 was admitted to the facility with diagnoses which include Non-Alzheimer's Dementia, Major Depressive Disorder, and Malnutrition. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00351262), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than two 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 that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in one out of four residents sampled (Residents #1). [...]

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY 00329642) on 08/15/2024-08/16/2024, the facility failed to ensure that the resident is free of significant medication errors. This was evident for one out of five sampled residents (Resident #4). Specifically, on 12/06/2023, Licensed Practical Nurse #1 did not identify the right resident for tube feeding and started to administering tube feeding formula through Resident #4's Gastrostomy tube with no Medical Doctor's orders.

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00323743), the facility failed to ensure that each resident receives adequate supervision to prevent elopement. This was evident in 1 of 3 residents reviewed for elopement risk (Resident #1). Specifically, on 09/12/2023 at 7:15 AM, Resident #1 left the facility undetected by staff. Resident #1 was located by the police at their family member's house on the same day at 3:15 PM.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure safe food storage and handling was practiced to prevent food-borne illness and the facility did not to meet professional food service standards. This was evident during review of the kitchen. Specifically, there were 8 expired packages of 12-ounce chicken breast nuggets observed in the kitchen freezer.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 12/22/22 to 12/30/22, the facility did not ensure the daily staffing was posted in a prominent place readily accessible to residents and visitors. This was evident for 2 (Unit 2 and Unit 3) of 5 units. Specifically, daily staffing was not observed posted in a prominent place for residents and visitors of Unit 2 and Unit 3.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 12/22/22 to 12/30/22, the facility did not ensure alleged violations involving abuse, including injuries of unknown source, were reported to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #109) of 3 residents reviewed for abuse out of 31 total sampled residents. Specifically, the facility did not report to the NYSDOH when Resident #109 sustained a right hip fracture of unknown origin.

Inspectors wroteBased on record review, observation, and interviews conducted during the Recertification survey from 12/22/2022 to 12/30/2022, the facility did not ensure an assessment accurately reflected resident status. This was evident for 1 (Resident #137) of 1 resident(s) reviewed for Accidents and 1 (Resident #395) of 1 resident(s) reviewed for Hospice Care out of 31 total sampled residents. Specifically, 1) the Minimum Data Set 3.0 (MDS) assessment did not document Resident #137's wandering behavior, and 2) the MDS assessments did not document Resident #395 received hospice care.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey from 12/22/2022 to 12/30/2022, the facility did not ensure infection prevention and control standards were maintained. This was evident for 1 (Unit E) of 4 units. Specifically, Licensed Practical Nurse (LPN) #1 was observed improperly wearing a personal protective equipment (PPE) on multiple occasions.