WASHINGTON CENTER FOR REHAB AND HEALTHCARE

ROUTE 40, ARGYLE, NY 12809 (518) 638-8274
For profit - Corporation 122 Beds CENTERS HEALTH CARE Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
31/100
#363 of 594 in NY
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Last Inspection: September 2022

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Washington Center for Rehab and Healthcare receives a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #363 out of 594 facilities in New York, they fall in the bottom half, and they are the lowest-ranked option in Washington County. Although the facility is showing improvement in their trend, decreasing issues from 2 in 2023 to 1 in 2025, the staffing rating is below average with a turnover rate of 43%. Additionally, they have concerning fines totaling $14,521, which is higher than 80% of facilities in New York, indicating potential compliance problems. Specific incidents include a failure to provide CPR to a resident in cardiac arrest, which resulted in actual harm, and a resident falling out of bed due to neglect when care protocols were not followed. While the facility has strong quality measures with a 5/5 star rating, the overall care and safety issues raise serious concerns for families considering this nursing home.

Trust Score
F
31/100
In New York
#363/594
Bottom 39%
Safety Record
High Risk
Review needed
Inspections
Getting Better
2 → 1 violations
Staff Stability
○ Average
43% turnover. Near New York's 48% average. Typical for the industry.
Penalties
✓ Good
$14,521 in fines. Lower than most New York facilities. Relatively clean record.
Skilled Nurses
⚠ Watch
Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
19 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 2 issues
2025: 1 issues

The Good

  • 5-Star Quality Measures · Strong clinical quality outcomes
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (43%)

    5 points below New York average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

3-Star Overall Rating

Near New York average (3.1)

Meets federal standards, typical of most facilities

Staff Turnover: 43%

Near New York avg (46%)

Typical for the industry

Federal Fines: $14,521

Below median ($33,413)

Minor penalties assessed

Chain: CENTERS HEALTH CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 19 deficiencies on record

1 life-threatening 1 actual harm
Sept 2025 1 deficiency 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

Based on record review and interviews conducted during the recertification and abbreviated survey (Case # 677094), the facility failed to ensure the residents' right to be free from neglect for one (1...

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Based on record review and interviews conducted during the recertification and abbreviated survey (Case # 677094), the facility failed to ensure the residents' right to be free from neglect for one (1) (Resident #128) of six (6) residents reviewed for neglect. Specifically, Resident #128 was care planned for falls with intervention including the resident's bed being in the lower position, bolsters placed on both sides, and high-profile floor mats. On 02/12/2025, Certified Nurse Aide #2 left the resident unattended with the bed in a high position while providing care. The resident fell out of bed and sustained a hematoma (a localized pool of blood) on the head, and bruising in both knees. This resulted in actual harm to Resident #128 that was not Immediate Jeopardy. This is evidenced by:The facility policy titled, Abuse, last revised 07/18/2025, documented that the purpose was to prohibit the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone, including but not limited to staff, family, friends, and residents of the facility. The policy further defines neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or distress.Resident #128 was admitted to the facility with diagnoses of dementia with behavioral disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), traumatic brain injury (a brain dysfunction caused by an outside force, usually a violent blow to the head), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Minimum Data Set (an assessment tool) dated 02/01/2025, documented that Resident #128 sometimes made themselves understood, sometimes understands others, and had severe cognitive impairment.The Comprehensive Care Plan for falls, initiated on 08/21/2021, documented that Resident #128 was at risk for falls and has had an actual fall related to deconditioning, psychotropic drug use, progression of aneurysm, did not seek assistance with transfers, and had declining health related to dialysis stopping. Interventions included the resident's bed being in the lower position, bolsters placed on both sides, and high-profile floor mats. The facility's Investigative Report dated 02/13/2025, documented that Resident #128 was observed on the floor next to their bed on 02/12/2025 at 7:45 PM. The bed was observed in an elevated position, and only one (1) bolster and no floor mats were in place. The resident had been incontinent on linens, so staff stepped into the hallway to obtain fresh linens from the cart that was just outside the resident's room. Upon returning to the room, the resident was observed on the floor next to their bed. A hematoma (a localized pool of blood) was reported on the head, and a bruise was reported on both knees. A review of progress notes dated 02/12/2025 documented that at 7:45 PM, Licensed Practical Nurse #4 on the unit heard a sound followed by Resident #128 yelling, ‘I am on the floor.' Upon entering the resident's room, they noticed the bed in an elevated position, no fall mat or bolster in place on the left side of the bed, the right-side bolster and mat were in place. A review of progress notes dated 02/12/2025 documented that Registered Nurse #2 was called to the resident's room to assess their injuries after the fall. They observed Resident #128 lying on the floor, next to their bed, on their back. Resident with complaint of pain on the left side of their head and a hematoma noted with bruising to their right and left knees.Nurse Practitioner #1's progress notes dated 02/13/2025 at 10:33 AM documented Resident #128 was evaluated for report of fall out of bed on 02/12/2025. Report hematoma left head but nothing visible at this time. No joint tenderness or swelling,Facility staff were educated on 02/13/2025 on care plan violation by Director of Nursing #1 and Assistant Director of Nursing #1. Education was conducted for all staff regarding understanding the importance of reading care cards and the potential consequences of not adhering to them.A review of investigation notes dated 02/13/2025 documented that Certified Nurse Aide #2 stated the resident was in bed getting changed when they had another bowel movement. They stated that they stepped out of the room to get a new pad, and upon returning, the resident was on the floor next to their bed. During an attempted phone interview on 09/11/2025 at 12:35 PM, Certified Nurse Aide #2 was contacted. A phone message was left, and no return phone call was received.During an interview on 09/11/2025 at 2:35 PM, Licensed Practical Nurse #5 stated they were working when they heard a noise from Resident #128's room, and the resident was found on the floor. They stated they observed the resident lying on their back on the floor with their head against the fall mat, and the bed was noted in an elevated position. They stated that they contacted the supervising nurse, who came down to assess the resident.During an interview on 09/12/2025 at 11:35 AM, Director of Nursing #1 stated they assessed the resident the day after the incident. They stated that the staff used a Hoyer lift to place the resident in bed on 02/12/2025 in the evening. They stated Certified Nurse Aide #2 was changing the resident when they became incontinent again and required a clean pad. They stated that the aide stepped out of the room across the hall to obtain a clean pad from the linen cart, and upon re-entering the room, the resident was lying on the floor next to their bed. Director of Nursing #1 stated that during the investigation, it was determined that the resident's bed was not in the lowest position, and only one (1) side floor mat and bolster was observed in place (to the side opposite of which resident fell out). They stated Registered Nurse #2 assessment findings of a hematoma to the forehead and bruising to both knees. They stated there was no skin abnormalities noted on their assessment on 02/13/2025.Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: Completed a full house audit to determine what residents required floor mats to be placed and to determine compliance. Developed and implemented education on 02/13/2025 for entire facility associated with the following of care plans, specifically for residents with safety and fall care plans. Developed and implemented a plan to ensure all residents were safe and free of potential neglect for staff not following care plans. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)
May 2023 2 deficiencies 1 IJ
CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0678 (Tag F0678)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (Case #NY00316364), the facility failed to provide basic lif...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (Case #NY00316364), the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 3 residents reviewed for CPR. Specifically, for Resident #1, whose advance directive status was a full code (full support including CPR, if the resident had no heartbeat and was not breathing), the facility failed to ensure CPR was initiated by Registered Nurse (RN) #1 in a timely manner upon recognition of cardiopulmonary arrest on [DATE] at 9:05 AM. This resulted in actual harm to Resident #1 and the likelihood for serious harm to the health and safety of 16 residents on the Midtown Unit in the facility that is Immediate Jeopardy and Substandard Quality of Care. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of post procedural respiratory failure (the need for ventilation for more than 48 hours after surgery), paralysis of vocal cord and larynx (a condition in which the movement of the vocal cord muscles cannot be controlled), chronic kidney disease (progressive damage and loss of function in the kidneys). The Minimum Data Set (MDS-an assessment tool) dated [DATE] documented the resident was cognitively intact, could understand others, and could make themselves understood. The facility policy and procedure (P&P) titled Code Blue/CPR, dated [DATE], documented the facility was to provide emergency cardiopulmonary resuscitation (CPR) with current standards of practice in accordance with resident end of life determination (MOLST- Medical Orders for Life Sustaining Treatment). The P&P documented in accordance with the resident's CODE status ( full code), CPR would be initiated upon recognition of cardiopulmonary arrest ( no pulse, no respirations, no audible blood pressure) and 911 would be activated. A Licensed Nurse certified in CPR/BLS (basic life support) would assume to the role of Code Leader. The leader would supervise the area of the CPR event, direct the code, summon appropriate personnel and discharge personnel from the area who were not longer needed. The MOLST form dated [DATE] documented the resident was a full code. The Comprehensive Care Plan (CCP) for Advance Directives dated [DATE], documented the resident had a MOLST/CPR ordered and no advanced directives. A Physician Order dated [DATE] documented the resident was a full code. A facility investigation dated [DATE], documented on the morning at approximately 9:05 AM, Resident #1 was observed unresponsive in bed with no pulse and no respirations noted by auscultation (listening to the sounds of the body). Resident #1's MOLST indicated they were a full code. The resident was pronounced dead at 9:40 AM by the physician via emergency medical services (EMS). The conclusion also documented the policy was not followed completely. RN #1 acknowledged they should have called a Code Blue immediately. The CPR Log dated [DATE] documented: - 9:20 AM, Code Blue was announced for Resident #1 - 9:25 AM, Staff arrived at the location - 9:10 AM, CPR was initiated - 9:25 AM, Application of automated external defibrillator (AED) - 9:25 AM, Notification of 911 system - 9:35 AM, Arrival of EMS - 9:40 AM, Physician notified (TOD- time of death) A Nursing Clinical Evaluation note dated [DATE] at 11:00 AM, written by the Director of Nursing (DON) documented the Date/Time of Event OR When Nursing Became Aware of Event: [DATE] 9:05 AM. The event type was documented as an unanticipated death. Vital signs documented at 9:05 AM were 0 Respirations and 0 Pulse. The Clinical Evaluation documented a Certified Nurse Aide (CNA) notified the RN on the unit of the resident who was noted to be unresponsive. During an interview on [DATE] at 9:42 AM, CNA #1 stated on the morning of [DATE], CNA #2 came out of Resident #1's room and told them the resident was not responding. CNA #2 went to get RN #1. CNA #1 stated RN #1 started chest compressions and then asked them to take over doing the chest compressions because they were also CPR certified. CNA #1 stated then all the other nurses in the facility came in the room because a Code Blue was called overhead. The CNA stated they were unsure of the time of the events and did not know when CPR had been started. CNA #1 stated when they did chest compressions no one else was in the room because the RN had left the room. CNA #1 stated they thought RN #1 left to go get the crash cart. During an interview on [DATE] at 9:47 AM, CNA #2 who was not CPR certified, stated they remembered looking at the clock when they went into Resident #1's room to get the resident up for the day, because they were the last resident to get up that morning. The clock said 8:57 AM. CNA #2 stated they called the resident's name and said Good Morning, but the resident did not respond. They removed the resident's CPAP (continuous positive airway pressure) mask and stated they knew something was not right as the resident was not responding. CNA #2 stated they told CNA #1 who was in the hallway that the resident was not responding, as they left the resident's room to get the nurse. CNA #2 stated they immediately notified RN #1 that Resident #1 was not responding. During an interview on [DATE] at 11:22 AM, RN #1 stated CNA #2 made them aware that Resident #1 was not responding at 9:05 AM. RN #1 assessed that the resident did not have a pulse or respirations. RN #1 stated they did not immediately perform CPR on the resident because they were unsure what to do in that situation. They had never been in that situation before. RN #1 stated they left the room, and first went to Licensed Practical Nurse (LPN) #3 on the other side of the unit to tell them about Resident #1. RN #1 stated LPN #3 told them to call the Supervisors. RN #1 stated before they called the Supervisors, they called the on-call physician's line. They were asked a lot of questions and were told they would be called back. RN #1 stated they, then, called the RN Supervisors who were on another unit in the facility. While making the calls to the RN Supervisors, they looked up the resident's code status in the computer and confirmed the resident was a full code. RN #1 was not aware of the resident's code status prior to that point. After they notified the RN Supervisors, they went back to Resident #1's room to start compressions, and CNA #1 came with them. RN #1 initiated compressions and then asked the CNA #1 to take over. RN #1 stated they left the room to see if staff were coming with the crash cart. RN #1 stated they were not sure of the exact time of when compressions started but stated they were notified that the resident was unresponsive at 9:05 AM, and compressions started between 9:15 AM and 9:20 AM after they had notified the Supervisors. RN #1 stated they did not call a Blue Code; one of the other nurses called the Code Blue at 9:20 AM, and staff began to come to the resident's room with the AED and crash cart. RN #1 stated compressions lasted about 20 minutes, and then the EMS called their physician, and the resident was pronounced deceased at 9:40 AM. The RN stated they did not know if they were supposed to call a Code Blue right away when they found the resident unresponsive or check the resident's MOLST form for their code status. During an interview on [DATE] at 12:20 PM, LPN #1 stated they were working in the facility on [DATE] on the Hillview Unit and had not heard a Code Blue called until a CNA came over from the Midtown Unit at 9:20 AM. LPN #1 stated as soon as they heard that there was a Code Blue on the Midtown Unit, another nurse on Hillview Unit overhead paged Code Blue throughout the facility, and staff grabbed the crash cart and the AED and went down to Resident #1's room. During an interview on [DATE] at 2:15 PM, the Assistant Administrator (AA) stated the protocol was that the first staff member who found a resident unresponsive was supposed to call out Code Blue and a nurse would go to the room to see the resident. At the same time, because a Code Blue was called, staff would bring down the medical chart with the MOLST, the AED, and the crash cart to the location, and call 911. The resident's code status should be verified using the MOLST to determine if the resident was a full code prior to initiating CPR. If the resident was a full code, compressions would be immediately initiated. The first nurse on the scene should be the Code Leader and would delegate responsibilities to other staff. Then the physician and the family would also be notified. During an interview on [DATE] at 11:40 AM, RNS #1 stated they were on the Country Meadow Unit passing medications when they received a phone call from RN #1 at 9:21 AM. RN #1 told them they found a resident passed away at 9:05 AM. The RNS stated they were not told the resident was a full code. RNS #1 told RN #1 to call RNS #2 who was also on Country Meadow Unit. RNS #1 stated they did not know why at 9:21 AM, they were just being notified of a resident who had passed away at 9:05 AM. RNS #1 stated after RN #1 told RNS #2 that the resident was a full code, they run over to the Midtown unit where Resident #1 resided. RNS #1 stated compressions had not been initiated prior to RN #1 calling the Supervisors. RNS #1 stated a Code Blue was called overhead at 9:25 AM. When the RNS #1 and RNS #2 arrived to the resident's room at 9:25 AM, RN #1 was performing chest compressions on Resident #1. RNS #1 switched with RN #1 to continue the compressions. During an interview on [DATE] at 2:44 PM, the DON stated the MOLST was the primary identification for code status of a resident and 100% of residents had a MOLST in their chart. The DON stated the investigation showed RN #1 initiated CPR before they called a Code Blue. The DON stated when a resident was found unresponsive, the staff who found the resident should call out Code Blue, get a nurse, and have the code paged in the facility. As soon as the nurse arrived to the location, the nurse was to verify the MOLST to determine whether to start CPR. During an interview on [DATE] at 3:00 PM, LPN #2 stated they worked on Hillview Unit and one of the CNAs from Midtown Unit came down around 9:20 AM, said there was a Code Blue on Midtown Unit. Another LPN on Hilltown Unit called Code Blue overhead. The staff from Hillview Unit grabbed the crash cart and went straight down to the resident's room. The LPN stated when they arrived someone was doing CPR on the resident, then another nurse took over. The staff continued compressions until EMS got there. The LPN stated they were asked to complete the CPR Log. The LPN stated they were not present when CPR was initiated, did not know when the compressions were initiated, and was not in the room at 9:10 AM, the time they documented that CPR was initiated. The LPN stated they tried to be accurate when they documented on the CPR Log and someone had said something about compressions started at 9:10 AM and that was what they wrote down on the log. The LPN stated they were not aware of the Code Blue until 9:20 AM. The LPN stated the nurses in the facility arrived to the resident's room around the same time, at 9:25 AM, and compressions had already been started. During an interview on [DATE] at 3:32 PM, RNS #2 stated they were notified at 9:22 AM by RN #1 that a resident was unresponsive and was a full code. The RNS stated a Code Blue had not been called as of 9:22 AM. The RNS heard the Code Blue being called just as they hung up the phone with RN #1 at 9:22 AM or 9:23 AM. The RNS did not know what time CPR was initiated, but stated they believed RN #1 had started compressions before they were called. The RNS ran to the unit and when they arrived to the unit at 9:25 AM, compressions were being done on the resident by RN #1. During an interview on [DATE] at 4:13 PM, the AA stated, with the Administrator also present, to their knowledge, RN #1 made one phone call to the RN Supervisors before performing CPR. The AA stated the code status was verified when RN #1 spoke with RNS #1 and RNS #2 and CPR was immediately started once the code status was verified. The AA stated during the investigation, they did not notice a gap in the time of events from 9:05 AM, when the resident was noted to be unresponsive to 9:22 AM, when RN #1 spoke to RNS #2. The AA stated through the investigation, they noticed that CPR was initiated prior to the Code Blue being called. During an interview on [DATE] at 9:50 AM, LPN #3 stated they were working on the North hallway of the Midtown Unit when the CPR event happened with Resident #1, who was a resident on the South hallway. The LPN stated RN #1 came over and told them that Resident #1 was unresponsive. LPN #3 told RN #1 to let the Supervisors know if they needed more guidance because RN #1 seemed unsure of what to do and they were busy. LPN #3 stated they told the RN to call the supervisors to come over and assess the resident. LPN #3 stated they were not aware of the resident's code status and Code Blue had not been called yet when they told RN #1 to call the Supervisors. The LPN stated when the Code Blue was called, they responded to the resident's room and saw RN #1 doing compressions on the resident. The LPN stated they could not remember what time RN #1 came over to them, but it was around t 9:00 AM. During an interview on [DATE] at 11:51 AM, the Medical Director (MD) stated a staff from the facility called them soon after the resident was pronounced deceased to notify them of the death. The MD stated they were told a CNA walked into the resident's room and found the resident unresponsive. The CNA notified the nurse, and the nurse confirmed the resident did not have any vital signs. The code status was confirmed, and the staff called on-call, but did not wait for on-call to call back before starting compressions. The timeline of events from 9:05 AM to 9:22 AM was reviewed with the MD. The MD stated they did not think that was accurate, but they were not in the facility at the time of the event. The MD stated they were told that CPR was initiated, 911 was called, but the resident could not be revived. The MD stated the protocol when a resident was found unresponsive, was for a Code to be called, the code status needed to be confirmed and if the resident was a full code, CPR would be initiated and 911 and on-call would be called. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on [DATE]. Based on the following corrective actions, the facility corrected the non-compliance as of [DATE]. (IJ past non-compliance indicates the facility had an IJ but the non-compliance was corrected prior to the survey staff entering the nursing home on [DATE]. A Statement of Deficiency will be issued but a Plan of Correction is not required given the facility had corrected the non-compliance). - The facility immediately investigated the incident on [DATE]. - The Registered Nurse involved was suspended pending the investigation and received individual re-education on [DATE] on Code Blue and the CPR Policy. - The facility reviewed the code status of each resident in the facility with no concerns identified. - Beginning [DATE], the facility began CPR drills to be conducted weekly for 4 weeks then monthly for 3 months. - The facility completed 90% of their facility-wide education on the Code Blue/CPR policy as of [DATE] prior to the state agency entering the facility and the education was on-going until 100% of staff were educated. 10 NYCCR 415.3 (e)(2)(iii)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (Case #NY00316364), the facility did not ensure allegations ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (Case #NY00316364), the facility did not ensure allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for 1 (Resident #1) of 3 residents reviewed for neglect. Specifically, the facility did not ensure a thorough investigation was completed to rule out neglect when the facility investigation did not address the timeline of events for the Code Blue (emergency response) for Resident #1 on [DATE] and therefore, the investigation did not address that CPR (cardiopulmonary resuscitation) was not initiated timely by Registered Nurse (RN) #1 upon recognition of cardiac arrest on [DATE] at 9:05 AM. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses of post procedural respiratory failure, paralysis of vocal cord and larynx, chronic kidney disease. The Minimum Data Set (MDS- an assessment tool) dated [DATE] documented the resident was cognitively intact, could understand others, and could make themselves understood. The facility policy and procedure (P&P) titled Abuse dated 12/2022 documented neglect was the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish or distress. The P&P documented allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. The conclusion must include whether the allegation was substantiated or not and what information supported the decision. A facility investigation dated [DATE], documented on the morning of [DATE] at approximately 9:05 AM, Resident #1 was observed unresponsive in bed with no pulse and no respirations noted by auscultation (listening to the sounds of the body). The investigation conclusion documented Registered Nurse (RN) #1 assessed and noted absence of pulse and respiration and notified the supervisors. CPR was initiated by RN #1, and Code Blue (emergency response) was called. The conclusion also documented due to the policy not being followed completely, a plan of correction was in place to prevent recurrence and RN #1 acknowledged they should have called a Code Blue immediately. During the review of the facility investigation, the conclusion did not rule out abuse, neglect, or mistreatment. The Timeline of Event for the Code Blue dated [DATE], documented the following: - 8:30 AM, Activity Staff was passing out chronicles and the resident was noted to be alive and breathing. - (Time Blank), CNA (Certified Nurse Aide) noted the resident unresponsive and notified the nurse. - (Time Blank), RN notified of resident unresponsive. Auscultated x 1 minute and no pulse noted. - (Time Blank), RN notified the LPN (Licensed Practical Nurse) on the unit - (Time Blank), RN notified Registered Nurse Supervisor (RNS) of resident being deceased - (Time Blank), RN Supervisor notified DON (Director of Nursing) of resident being deceased - (Time Blank), RN initiated CPR - (Time Blank), CNA took over CPR - (Time Blank), CNA from Midtown unit ran to Hillview unit and notified the LPN of the Code Blue on Midtown - 9:20 AM, Code Blue called by LPN - 9:25AM, CPR continued, AED (automated external defibrillator) applied, and 911 called - 9:35 AM, EMS arrived - 9:40 AM, Resident was pronounced deceased by the physician via EMS A Staff Statement by CNA #2 documented, the CNA walked in around 8:57 AM and found Resident #1 in their bed unresponsive. CNA #2 removed the resident's CPAP (continuous positive airway pressure) machine and immediately notified the nurse. A Staff Statement by RNS #2 documented, RN #1 notified them at 9:22 AM of Resident #1 being found unresponsive. The resident was verified to be a full code. CPR initiated. 911 called. DON notified. EMS arrived and deemed the resident deceased at 9:40 AM. A Staff Statement by RN #1 documented at 9:05 AM on [DATE], a CNA alerted me to a patient being unresponsive, having no pulse or respirations. The RN listened to the resident's heart for one minute. The RN ran to the other nurse and let them know. The RN called both Supervisors on Country Meadow. The RN documented they looked at the resident's code status and saw that they were a full code. The RN started compressions, someone called a code blue, grabbed the AED, and called 911. Time of death was 9:40 AM. A Nursing Clinical Evaluation note dated [DATE] at 11:00 AM, written by DON documented the Date/Time of Event OR When Nursing Became Aware of Event: [DATE] 9:05 AM. The event type was documented as an unanticipated death. Vital signs documented at 9:05 AM were 0 Respirations and 0 Pulse. The Clinical Evaluation documented a CNA notified the RN on the unit of the resident who was noted to be unresponsive. During an interview on [DATE] at 11:22 AM, RN #1 stated CNA #2 made them aware that Resident #1 was not responding at 9:05 AM. RN #1 assessed that the resident did not have a pulse or respirations. RN #1 stated they did not immediately perform CPR on the resident because they were unsure what to do in that situation. They had never been in that situation before. RN #1 stated they left the room, and first went to Licensed Practical Nurse (LPN) #3 on the other side of the unit to tell them about Resident #1. RN #1 stated LPN #3 told them to call the Supervisors. RN #1 stated before calling the Supervisors, they called the on-call physician's line. RN #1 stated they were asked a lot of questions and were told they would be called back. RN #1 stated they, then, called the RN Supervisors who were on another unit in the facility. While making the calls to the RN Supervisors, they looked up the resident's code status in the computer and confirmed the resident was a full code. RN #1 was not aware of the resident's code status prior to this point. After they notified the Supervisors, they went back to Resident #1's room to start compressions, and CNA #1 came with them. RN #1 initiated compressions and then asked the CNA #1 to take over. RN #1 stated they left the room to see if staff were coming with the crash cart. RN #1 stated they were not sure of the exact time of when compressions started but stated they were notified that the resident was unresponsive at 9:05 AM, and compressions started between 9:15 AM and 9:20 AM after they had notified the Supervisors. RN #1 stated they did not call a Blue Code; one of the other nurses called the Code Blue at 9:20 AM, and staff began to come to the resident's room with the AED and crash cart. RN #1 stated compressions lasted about 20 minutes, and then the EMS called their physician, and the resident was pronounced deceased at 9:40 AM. The RN stated they did not know they were supposed to call a Code Blue right away when they had a resident who was unresponsive or check the resident's MOLST form for their code status. During an interview on [DATE] at 2:10 PM, the Administrator stated through the facility investigation, they found that the Code Blue policy was not followed, but after reviewing everything for the investigation, and discussing it with the Assistant Administrator (AA), they determined it was not a reportable incident based on the New York State (NYS) Reporting Manual (A manual dated 2016 for reporting alleged violations of mistreatment, neglect, and abuse). During an interview on [DATE] at 2:18 PM, the DON stated they initiated the investigation on [DATE] as soon as they were notified of the Code Blue that took place. They came into the facility on [DATE] to initiate the investigation. Upon investigation it was determined the policy was not followed by RN #1. The RN was suspended, and had since been reeducated. During a subsequent interview on [DATE] at 2:44 PM, the DON stated the investigation showed RN #1 initiated CPR before calling the Code Blue. The DON stated when a resident was found unresponsive, the staff who found the resident should be calling out Code Blue, getting the nurse, and having the code paged overhead in the facility. The DON stated for their investigation they did not look at the timing of the events, they looked at the sequence of events and found that the order of events was not per policy. The DON stated they were not aware CPR was not started right away based on the investigation but they were aware the Code Blue was called after CPR was initiated. During an interview on [DATE] at 4:13 PM, the AA stated, with the Administrator also present during the interview, they were also confused when they did the investigation regarding the timeline of events, because they did not know the exact times and neither did the staff because they were not looking at a clock. The investigation focused on the order of the events, rather than the timeliness of events. The AA stated to their knowledge, RN #1 made one phone call to the supervisors before performing CPR. The AA stated the code status was verified when RN #1 spoke with the RN Supervisors and CPR was immediately started once the code status was verified. During the interview, the Timeline of Event for the Code Blue dated [DATE] was reviewed. The AA stated they were able to put together the order of events, but acknowledged the times of events on the timeline were left blank. The AA stated during the investigation, they did not notice a gap in the time of events from 9:05 AM, when the resident was noted to be unresponsive to 9:22 AM, when RN #1 spoke to RNS #2, but they did notice through the investigation, that CPR was initiated prior to the Code Blue being called. 10NYCRR 415.4(b)
Sept 2022 1 deficiency
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an recertification and abbreviated survey (Case #'s NY00258873, NY00269351, NY00269...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an recertification and abbreviated survey (Case #'s NY00258873, NY00269351, NY00269396, NY00279095, NY00285004, NY00289838, and NY00294513) conducted on 9/07 through 9/13/2022, the facility did not ensure that a Level II assessment was conducted as indicated on the DOH-695 (2/2009) Screen form, prior to admission for one (Resident # 117) of 18 residents reviewed for completion of PASRR (Preadmission Screen Resident Review). Specifically, for Resident #117, whose DOH-695 (2/2009) Screen form dated 6/9/2021 indicated the resident was to have a Level II Evaluation completed for determination of needed services due to the diagnosis of Intellectual Disability, the facility did not ensure the Level II Evaluation was done. This is evidenced by: Resident #117 was admitted to the facility with diagnoses included surgical repair of a fractured femur requiring after care, unspecified intellectual disability, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS-an assessment tool) dated 7/2/2022 documented the resident was sometimes understood and could sometimes understand others. Resident #117 had severely impaired cognition for daily decision making. The PASRR Screen form (DOH-695, (2/2009) for Resident #117 dated 6/9/2021, documented the following: 1. Question #26, Does this person present with evidence of cognitive deficits and/or adaptive skill deficits that may indicate the presence of mental retardation or developmental disability? YES Guideline: If any items from question 24-26 are marked Yes, proceed to Categorical Determinations (items 27-30). 2. Question #27, Does this person qualify for convalescent care? NO 3. Question #28, Is this person seriously physically ill? NO 4. Question #29, Is this person terminally ill? NO 5. Question #30, Is this person to be admitted for a very brief and finite stay or a provisional emergency admission? NO Guideline: If any of the items 27-30 are marked YES, proceed to danger and self or other qualifiers (item 31). If all are marked NO, proceed to Level II referral (item 33). 6. Level II evaluation Item 33 not completed. Review of Resident #117's medical record did not include documentation that a Level II referral had been done. A preadmission screen dated 6/09/2022 documented the resident did not have dementia, mental illness, and did not have a diagnosis of intellectual disability (MR) before the age of 22. Questions 27 thru 30 were answered no, indicating a Level II referral was required. The form was accepted by the facility. During an interview 09/09/22 10:36 AM, Registered Nurse Unit Manager (RNUM) #1 stated the resident was admitted on [DATE] for orthopedic aftercare for repair of fracture of a femur. The resident had health care support from the Manager of the Group Home and was to be discharged there after rehabilitation. Resident #117 had an Intellectual disability and COPD. RNUM #1 could not provide a completed PASRR for the resident. RNUM #1 thought the Social Worker may have that information. During an interview on 9/9/2021 at 2:38 PM, the Director of Nursing (DON) stated the facility is responsible to ensure all residents have a PASRR screen completed per regulation before being admitted to the facility. The DON stated Social Services handles the Preadmission paperwork. Resident #117 had no services other than staff monitoring while at the facility. The DON could not find any evidence of a Level II referral for the resident. During an interview on 09/12/22 at 1:34 PM, the Director of Social Work (DSW) stated Resident #117 had been admitted to the facility from the hospital after a surgical repair of a fractured right hip. Aftercare was needed for the resident before returning to the group home setting. The hospital completed the PASRR Screen form but the facility was responsible to ensure it was correct. It had been determined that a Level II referral was not needed because Resident #117 had not been diagnosed with intellectual disability prior to the age of 22. After re-reviewing the PASRR, the DSW stated, based on the answers to the initial screen dated 6/9/2021, question 27 to 30 were answered no and a Level II referral should have been done according to the guidelines and was not done. The DSW has training in completing PASRR's and should have addressed this when it was reviewed at the facility on the day of admission. A Level II referral was not completed for determination of services. 10 NYCRR415.11(e)
Jan 2020 6 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY245216), the ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY245216), the facility did not ensure residents were free from physical abuse for 2 (Resident #'s 19 and 67) of 3 residents reviewed for abuse. Specifically, the facility did not ensure that Resident #'s 19 and 67 were free from physical abuse related to a resident to resident altercation. This was evidenced by: Resident #67: Resident #67 was admitted to the facility with diagnoses of Cerebral Vascular Accident (CVA) with hemiplegia and hemiparesis, Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). The Minimum Data Set (MDS-an assessment tool) dated 9/17/19, documented the resident had severe cognitive impairment, could usually understand others and was usually able to make himself understood. Resident #19 was admitted to the facility with diagnoses of CVA with hemiplegia and hemiparesis, major depressive disorder, recurrent and Traumatic Brain Injury (TBI). The MDS dated [DATE], documented the resident had severe cognitive impairment, sometimes could be understand by others and usually was able to understand others. The facility policy and procedure (P&P) for Abuse, with a revision date of 2/2019, documented physical abuse was defined as any use of willful infliction of injury. Includes hitting, slapping, pinching, scratching, spitting, holding roughly, and kicking. It also includes controlling behavior through corporal punishment. Behavior Care Plan for Resident #67, date initiated 11/20/17, documented the resident exhibited behavior symptoms such as socially inappropriate verbal aggression/abuse, physically aggressive/abuse, hallucinations and delusions. Interventions; document all behaviors in attempt to identify pattern to target interventions, redirect negative behavior as needed and psychology evaluation as needed. Victim/Aggressor Care Plan documented the resident had cognitive impairment and was hard of hearing, had history of becoming physically aggressive if he perceived he was in danger or was being threatened or talked about. Behavior Care Plan for Resident #19, documented he had history of placing wet towels on the outside of his pants and then tell staff he urinated and needed to be changed. He makes animal noises to mimic/mock other residents and can become verbally/physically aggressive towards other residents if he feels provoked. Victim/Aggressor Care Plan, dated 9/18/19, documented resident had the inability to understand his surroundings related to cognitive impairment secondary to TBI, disruptive behavior such as making animal noises and mimicking others, physically abusive when he feels provoked by others such as calling him names and touching his chair in a threatening way. The facility investigation dated 9/18/19, documented a staff member witnessed Resident #67 attempting to pull Resident #19's wheelchair and was swinging a fist at the resident. Resident #19 used his reacher and struck Resident #67 twice in the head. The staff member immediately separated the residents and called for assistance. Resident #67 had slight pink discoloration to the back of his neck with some discomfort. He moved his head without difficulty. Investigation findings documented Resident #19 stated Resident #67 called him a bastard and grabbed his wheelchair so he could hit him. Resident #67 stated Resident #19 started it. The residents were roommates and were great friends until Resident #67 was recently hospitalized . There had been no reports of any trouble between them. They both have behavior careplans as they can become verbally aggressive with others. Resident #19 tends to instigate other residents by mimicking and laughing at them. Both have hemiplegia and cognitive deficits. Resident #67 is very hard of hearing and has long history of thinking people are talking about him or misunderstanding what is said. He has declined any assistive device. He sees psychiatry regularly to help manage his behaviors and outbursts. Plan to prevent a reoccurrence was to move Resident #67 to another room as the residents continued to be angry with each other. The speech therapist statement dated 9/17/19, documented she approached the residents as they were in the middle of a physical and verbal altercation. Resident #67 was attempting to pull Resident #19's wheelchair and was swinging at him while Resident #19 was swinging his reacher twice down onto Resident #67's head. The residents were immediately separated and altercation was reported. Nursing Progress Note dated 9/17/19 at 4:15 PM, documented Resident #19 stated Resident #67 came up to him swearing at him and calling him names then grabbed his arm and kicked him. He denied pain/discomfort. No injury noted. Speech therapist reported that she heard the residents swearing at one another in the hallway. She observed Resident #19 hitting Resident #67 with his reacher. Resident #67 has history of resident to resident physical altercations. On 6/05/19 he grabbed Resident #17 by both arms, causing bruising to both forearms and a scratch to left forearm. Per investigation, Resident #70 had been signing God Bless America in the lunchroom, as he often does. Resident #67 was wheeling by and believed the resident was singing the death song so he grabbed him by both forearms. Resident #67 had history of delusions and receives psych services. Vision and hearing are impaired. After this incident, Resident #67 was seen by Psychiatry on 6/19/19, with consultation documenting resident had history of vascular dementia with depression. Mood and behavior were stable. Stated he was doing fine, denies any problem with anyone. Continue with medications of Risperdone 0.5 milligram (mg) and Zoloft 50 mg every day. Psychiatric note on 9/23/19, documented Resident #67 had a recent resident to resident altercation. Recent diagnosis of pancreatic mass was noted. Resident was preoccupied with not feeling well. Mood/behavior were at baseline, he can be redirected. Continue with current medications, Risperdone 0.5 milligram (mg) and Zoloft 50 mg every day. During an interview on 1/09/20 at 11:36 AM, the Director of Nursing (DON) and Administrator stated Resident #67 misunderstood what he was hearing. He refused a pocket talker and refused audiology. He had delusions and was frustrated when he misunderstood what was being said. The residents were immediately separated by a staff member who witnessed the physical altercation and were physically assessed. The residents were interviewed by the Administrator, DON and Unit Manager. The residents are best friends and recently both came to administration and begged to be in the same room again. They were told they cannot hit each other and are again roommates. Family is in agreement. Resident #67 has gained a trusting relationship with the day time receptionist, the DON and Administrator and reports if something bothers him before it goes too far. He had also been given a guitar which he enjoyed playing. 10 NYCRR 415.4 (b)(1)(i)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable pa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 2 (Resident #'s 80 and 115) of 3 resident reviewed for nutrition. Specifically, for Resident #80, the facility did not ensure a resident with a significant weight loss received adaptive equipment and assistance eating in accordance with the comprehensive care plan; and for Resident #115, the facility did not ensure the resident received a physician ordered supplement in accordance with the comprehensive care plan and the resident's preference. This is evidenced by: The Policy and Procedure (P&P) titled Care Plans dated 10/2019, documented care plan interventions were to be chosen after careful data gathering, proper sequencing of events, careful consideration of the resident's problem areas and their causes, and relevant clinical decision making. Resident #80: The resident was admitted to the facility with diagnoses of frontotemporal dementia, dysphasia, and rheumatoid arthritis. The Minimum Data Set (MDS - an assessment tool) dated 11/15/19, documented the resident had severely impaired cognition, could sometimes understand, and could make self understood. The facility did not have a policy and procedure (P&P) for adaptive equipement. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL's) last updated 1/6/20, documented the resident was to receive extensive assistance, a bent black handled spoon, and alternate liquids/solids at meals. The CCP for Nutrition last updated 1/6/20, documented the resident was to receive a bent spoon and limited assist at meal times. The certified nursing aid (CNA) caregiving instructions dated 1/9/20, documented the resident was to receive extensive assist with eating, a bend black handled spoon, and alternate liquids/solid foods. The weight record documented the following: - On 7/3/19 - the resident weighed 164.2 lbs. - On 12/1/19 - the resident weighed 138 lbs. - On 1/2/20 - the resident weighed 132.3 lbs, indicating a significant 31.9 lb (19%) weight loss over the past 180 days, and continued 5.7 lb (4%) weight loss over the past 30 days. During observations on 1/7/20: - At 11:53 AM, the resident's lunch tray was served with regular (not bent) built up utensils. - At 11:59 AM, staff in the dining room offered to cut the resident's main item (sloppy [NAME] on a bun), moved the resident closer to the table, and then left the table. - At 12:21 PM, the Speech-Language Pathologist removed the resident's tray from the table. - Between 11:53 AM - 12:21 PM, there were no additional observations of staff assistance. During an observation on 1/8/20 at 12:08 PM, the resident was observed at lunch with regular (not bent) built up utensils. During an observation on 1/9/20 at 12:06 PM, the resident's lunch meal was served with regular cups and regular (not bent) built up utensils. The resident was seated at a table without a staff member seated beside her, and did not receive a sandwich with her meal. Finding #1: The facility did not ensure a resident with a significant weight loss received adaptive equipment. During an interview on 1/10/20 at 8:38 AM, the Registered Dietitian (RD) stated the Diet Technician (DT) documents the adaptive equipment the resident needs on his/her meal ticket, and Resident #80's meal ticket should have had bent utensils documented and did not. He/she stated there is no supervisor check for the trayline to ensure the adaptive equipment on the tray is accurate. During an interview on 1/10/20 at 10:14 AM, the Director of Nursing (DON) stated there was a disconnect between disciplines that led to confusion regarding the level of assistance the resident needed. The DON stated the staff in the dining room should be monitoring the residents and notify the interdisciplinary team if a resident requires more or less help than what is documented on the care card, and this did not occur. Finding #2: The facility did not ensure a resident with a significant weight loss received assistance eating in accordance with the comprehensive care plan. During an interview on 1/10/20 at 9:57 AM, Licensed Practical Nurse (LPN #2) stated he/she was familiar with the resident and the resident was to be supervised in the dining room, meaning the resident eats by him/herself after set up. LPN #2 stated the care giving instructions stated the resident was extensive assist and LPN #2 stated she was unsure why. LPN #2 called the Speech Language Pathologist, and LPN #2 stated the Speech Language Pathologist said the resident's level of assistance was changed because the resident needed assistance with the bent spoon, and the resident had difficulty picking the bent spoon up after setting it down. During an interview on 1/10/20 at 8:38 AM, the Registered Dietitian (RD) stated the resident's level of feeding assistance was increased after a significant weight loss in September. The RD stated the resident should receive extensive assist from staff for eating and the care plan interventions should have been consistent. Resident #115 The resident was admitted to the facility with diagnosis of end stage renal (kidney) disease (ESRD), dependence on renal dialysis, and type 2 diabetes. The Minimum Data Set (MDS - an assessment tool) dated 12/13/19, documented the resident was cognitively intact, could understand others and make self understood. The P&P titled Nourishments-Supplements-Snacks dated 10/2019, documented a list of residents receiving specific supplements was kept by the Food and Nutrition Department, reviewed as part of the resident's care plan update, and all supplements were provided by physician order only. The P&P did not include a procedure for procurement of supplements. The CCP for Nutrition last updated 12/28/19, documented the facility was to honor resident food preferences (including Nepro, a nutritional supplement, drinks). A physician order dated 12/11/19 - 12/18/19 documented the resident was to receive Nepro twice daily (berry flavor only) serve with lunch and dinner per patient request. The Medication Administration Record (MAR) documented the following: - On 12/12/19, the patient refused and ate all of her lunch. - On 12/13/19, the resident ate a good lunch. - On 12/14/19, the resident decline and ate all of her lunch. - On 12/16/19, the resident was not given the supplement and the facility did not have any. - On 12/17/19, nursing would discuss with dietary. - On 12/18/19, order discontinued due to resident received at dialysis. During an interview on 1/09/20 at 12:10 PM, the resident stated the dialysis center told her she needed more protein, and she liked the Nepro from the dialysis center. She stated she had asked for Nepro many times at the facility, and it was not provided to her. During an interview on 1/9/20 at 1:35 PM, Registered Nurse (RN #1) stated the Nepro order was discontinued because the resident was receiving Nepro at dialysis, and the intervention to provide the Nepro was still on the care plan and should not have been. He/she stated the facility never received the Nepro to provide to the resident during the time the order was in place. During an interview on 1/10/20 at 9:03 AM, the facility Registered Dietitian (RD) stated the resident was receiving Nepro when she came to the facility, and the facility did not have it in stock. He/she stated that in order to get the Nepro, the nursing department would let central supply know they would need the Nepro once the physician placed the order, and the Food Service Director would complete the purchase order. During an interview on 1/10/20 at 9:37 AM, the Dialysis Center Registered Dietitian (RD) stated the resident is scheduled to receive a protein bar at dialysis per her preference, however all residents are offered a choice at dialysis of a Nepro or a protein bar, so it is possible she has received Nepro on occasion during her treatments. He/she stated the resident's protein labs have been low. During an interview on 1/10/20 at 9:44 AM, Registered Nurse (RN) #1 stated when a supplement is needed for a resident, the physician order would be written, and then the facility would determine who the staff member responsible for placing the order for the product was, and the staff member would place the order for the supplement. He/she stated if there was difficulty obtaining the product, administration should have been notified and the nurse should have notified the physician. He/she stated the notification should be documented by the nurse on the medicine cart. He/she stated a judgement call on whether or not to give the supplement based on intake should not been made without the physician being aware. He/she stated the in-house physician started a protein supplement due to the resident's prealbumin lab value being low (15.7 milligrams per deciliter), and the care plan should be updated with changes to the resident's supplement schedule by someone on the interdisciplinary team. During an interview on 1/10/20 at 10:14 AM, the Director of Nursing stated the physician agreed to provide the Nepro supplement to the resident and wrote the physicians order. He/she stated the facility finally made the determination that they were unable to obtain the supplement, and the order was discontinued. He/she stated the facility also needed to be fiscally responsible. He/she stated the documentation on the medication administration record should have indicated the supplement was not available and that the physician was notified. 10NYCRR415.12(i)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Based on record review and interviews during the recertification survey, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards o...

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Based on record review and interviews during the recertification survey, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 (Resident #115) of 1 residents reviewed for dialysis care. Specifically, the facility did not ensure there was ongoing communication with the dialysis treatment center. This is evidenced by: The Policy and Procedure (P&P) titled Dialysis Management, dated 5/2019, documented the facility was to establish communication with the dialysis center using the dialysis communication form. The P&P documented the nurse would establish pre-dialysis vital signs, advanced directives, and any pertinent resident information and the nurse would review the communication when the resident returned from the dialysis center. Resident #115 was admitted to the facility with diagnosis of end stage renal (kidney) disease (ESRD), dependence on renal dialysis, and type 2 diabetes. The Minimum Data Set (MDS - an assessment tool) dated 12/13/19 documented the resident was cognitively intact, could understand others and make self understood. The Comprehensive Care Plan (CCP) for Dialysis dated 12/28/19, documented the facility was to communicate with the Dialysis Center as needed. A physician order dated 12/7/19 documented the resident was to receive dialysis Monday, Wednesday, and Friday. During a record review on 1/09/20 at 9:56 AM, the resident's Dialysis Communication Form sheets dated 12/11/19, 12/20/19, 12/23/19, 12/26/19, 1/6/20, and 1/8/20 did not include documentation of the resident's name or any other information from the nursing facility to the dialysis center. During an interview on 1/10/20 at 10:14 AM, the Director of Nursing stated the Licensed Practical Nurse or any of the nurses on the unit should have completed the facility portion (the resident's vital signs, medications, meal time, diet, fluid restriction, significant alerts, and signature) of the dialysis communication sheets prior to the resident leaving for dialysis, the unit manager was responsible for oversight of the completion. 10NYCRR 415.12
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected 1 resident

Based on record review and interviews during the recertification survey, the facility did not ensure qualified staff were employed to carry out food and nutrition services. Specifically, the facility ...

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Based on record review and interviews during the recertification survey, the facility did not ensure qualified staff were employed to carry out food and nutrition services. Specifically, the facility did not ensure that when a qualified dietitian was not employed full-time, the person designated to serve as the Director of Food and Nutrition met the requirements. This is evidenced by: The Facility Survey Report (FSR) dated 1/6/20, did not include documentation of the Food Service Director (FSD) qualifications. The FSR documented the qualified dietitian was part time. The facility assessment, reviewed by the Food Service Director (FSD) on 9/19/19, documented the Registered Dietitian position would be staffed as follows: 0.4 FTE's, 5 days a week, 2 shifts per week, 19 hours total. The facility assessment also documented the nutrition needs of the facility included individualized diet requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, and the facility was in process for Total parenteral nutrition (TPN) implementation. During an interview on 01/09/20 at 1:38 PM, the FSD stated he did not have a certification or degree in food service management per regulatory requirements. He/she stated he was designated as the FSD for the facility after November 28, 2016. During an interview on 1/10/20 at 8:38 AM, the Registered Dietitian (RD) stated she was employed by the facility 19 hours per week and her credential is a RD. During an interview on 1/10/20 10:51 AM, the Administrator stated the regulatory non-compliance was an oversight due to the FSD transfer from another facility. 10 NYCRR 415.14(a)(1)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition ...

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Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 01/06/2020 at 1:00 PM, revealed fuel burning appliance in the basement boiler room, laundry room, and the kitchen without carbon monoxide detection. The Director of Maintenance stated in an interview on 01/06/2020 at 1:15 PM, that he will add carbon monoxide protection in all areas with gas fuel fired equipment. 483.70 (b); 2015 International Fire Code, Section 915
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the ...

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Based on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. Specifically, face masks were not properly worn by three employees while on resident units. This is evidenced by: Policy Statement on Influenza Vaccination of Health Care Personnel dated 8/09/19, documented it is recommended that health care personnel who do not receive an influenza vaccination must wear personal-protective masks when in direct resident contact during the influenza season (October through April). It is also recommended to target education to any health care personnel who do not receive an influenza vaccination. On 01/07/20 at 12:08 PM, an aide was observed feeding Resident #120 in the dining room with her face mask below her nose. On 01/07/20 at approximately 2:00 PM, Activity Personnel #5 was observed walking through Midtown Nursing Unit and then proceeded to Hillview Nursing Unit with her face mask below her nose. On 01/08/20 at 11:46 AM, Licensed Practical Nurse (LPN) #1 was observed walking onto the Hillview Nursing Unit with her face mask below her nose. During an interview on 01/08/20 at 11:46 AM, LPN #1 stated she was wearing it in that manner because she was just coming back from break. During an interview on 01/10/20 at 11:56 AM, the Assistant Director of Nursing (ADON) stated LPN #1 and activities personnel #5 are common culprits with wearing their face mask below their nose. LPN #1 has just received the flu shot. The ADON stated every department head gets a list of employees who are supposed to be wearing a mask. Nursing home policy is to inform the employee by verbal communication three times if they are wearing the mask incorrectly. After that, the employee is issued a written warning. Staff are inserviced how to correctly wear face masks. Employees who do not receive the flu shot sign a declination and are educated on the importance of wearing a mask 10NYCRR415.19(a)(1-3)
Sept 2018 9 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that...

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Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that facility floors, walls, ceilings and windows were clean and in good repair on 3 of 3 resident units and did not ensure that on 1 of 3 units wheelchairs were kept clean. This is evidenced as follows. Finding 1 The floors, walls, ceilings and windows were spot checked in resident rooms 102, 105, 108, 120, 127, 129 and 132 on the Country Meadows unit; 1, 2, 6, 8, 9, 10, 18, and 22 on the Midtown unit; and 25, 32, 36, and 37 on the Hillview unit on 09/13/2018 at 1:15 PM. Floors were soiled with a brown build-up, ceiling tiles were stained, bird droppings were found on outside window sills, and/or holes were found in walls. The Director of Maintenance in an interview conducted on 09/13/2018 at 2:15 PM, stated that the soiled floors, ceilings, and windows, and tables should have been kept clean and holes in walls repaired. Finding 2 During observation on the Country Meadows Unit on 9/10/18 at 12:05 AM, Resident #2's wheelchair armrest had dried white matter on it. The inside of the left side of the wheelchair also had a large area of dried white matter. This was observed again at 3:18 PM. During observation on 9/10/18 at 3:22 PM, Resident #82's scoot chair left armrest was soiled with white stains. During observation on 9/12/18 at 10:16 AM, Resident #2's wheelchair arm rest and inside left side was still soiled with white stains. This was again observed at 12:15 PM. During observation on 9/12/18 at 12:15 PM, Resident #93's wheelchair was soiled with food spills During observation on 9/13/18 at 12:02 PM, Resident #2 still had the same soiled wheelchair. During observation on 9/13/18 at 12:06 PM, Resident #102's wheelchair was soiled with food spills and debris. During observation on 9/17/18 at 11:51 AM Res #2, 82, 93,102 still had the same soiled wheelchairs as last week. During interview on 9/17/18 at 12:05 PM, the Registered Nurse Manager said housekeeping cleans the resident's wheelchairs on a monthly basis. The Certified Nurse Aides should clean them if they see they are dirty. During interview on 9/17/18 at 12:19 PM, the Director of Housekeeping stated they do wheelchair cleaning two times a month on Wednesdays and really messy wheelchairs get cleaned weekly. 483.10(i)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not refer residents with newly evident or possible serious mental illness ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not refer residents with newly evident or possible serious mental illness for level I to determine if level II review was needed for one (Resident #97) of two residents reviewed for PASRR (Preadmission Screening and Resident Review). Specifically, the facility did not ensure that Resident #97 was referred for the completion of a new SCREEN to determine whether a level 11 SCREEN was needed when the resident experienced a new diagnosis of mental illness. This is evidenced by: Resident #97 The resident was admitted to the facility on [DATE], with diagnoses of status post cerebral vascular accident (CVA), Benign Prostatic Hyperplasia (BPH), and Obstructive Uropathy. The Minimum Data Set (MDS) dated [DATE], documented the resident was understood and could understand with a Brief Interview of Mental Status (BIMS) of 3/15. Review of the Pre-admission Screening and Resident Review (PASRR) form for the Level 1 Review dated 10/19/2017, documented that the resident did not have a dementia diagnosis or a serious mental illness. A MDS dated [DATE] documented no diagnosis of Vascular dementia or Psychosis with behaviors, delusions, and hallucination. A psychiatric diagnostic evaluation dated 10/30/17, documented the resident had mild cognitive impairment secondary to CVA. The resident was being evaluated to rule out (R/O) mild vascular dementia. There was a negative psychiatric history. A psychiatric follow up consultation dated 11/27/17, documented the resident was oriented to place, had an increase in agitation, positive for hallucinations and delusions. The resident was being evaluated to R/O vascular dementia and depression. Judgement is impaired. The resident was started on Risperdal 0.5 milligram (mg) every night to help with psychotic symptoms. A psychiatric follow up consultation dated 12/11/17, the psychiatrist documented Resident #97 was oriented to place, had an increase in agitation, and was positive for delusions. Now on Risperdal. Staff reports ongoing paranoia. Throws chair, throws self out of his wheelchair. Resident has diagnosis of vascular dementia with delusions. Judgement is impaired. Risperdal increased to 1 mg 2 times a day. Zoloft 25 mg at night. The MDS dated [DATE] section I under active diagnoses, documented new diagnoses for the resident of Vascular dementia and Psychotic Disorder. These were not previously documented on the MDS of 10/27/18. During interview on 9/17/18 at 12:01 PM, the MDS Coordinator said some new diagnoses came after the resident was seen by the psychiatrist. The resident had behavioral changes and they were trying to get a review for competency to prevent him from leaving in November 2017. She stated the diagnoses may not be an actual change in the resident, but they just weren't documented at the time of admission. He had a CVA with encephalopathy and maybe it just wasn't apparent at the time of the admission. After admission the resident was seen by psychiatry due to behaviors. The resident had diagnoses of vascular dementia with behaviors and Psychotic Disorder added to the MDS of 12/21/17. Also, the MDS of 12/21/17 documented the resident was on antipsychotics. She did not do a PASRR and was not sure if he should have been referred for a repeat level 1 screen. During interview on 9/17/18 at 1:45 PM, the Director of Social Work (DSW) stated resident was frequently discussed in Interdisciplinary Team meetings (IDT). He had a change in behaviors after admission. He had become verbally and physically aggressive with hallucinations and delusions. He was seen by psychiatry and new diagnoses of Vascular Dementia and Psychotic Disorder were added and documented on his 12/21/17 MDS. He had BIMS change as well from a score of 8/15 on admission, to a score of 4/15 on the 12/21/17 MDS. He had not been on any antipsychotics when admitted . The MDS of 12/21/17 documented the use of antipsychotics and antidepressants 7 days a week. The DSW stated the resident had not had a repeat level 1 PASRR done to determine if a Level II Screen was needed. He was not familiar with the regulation requiring a new Level 1 Screen to be done with a new diagnosis of serious mental disorder. He was working on becoming familiar with the regulations put in place in 11/2017 by the Centers for Medicaid and Medicare (CMS). The DSW stated he was the one responsible to address any PASRR concerns when the resident is admitted . Both nursing and SW should revisit the residents need with any changes of condition. No documentation of another Screen was provided other than the initial admission Screen dated 10/19/18. 10NYCRR415.11(e)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure a Level 1 SCREEN was completed prior to admission to the nursin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure a Level 1 SCREEN was completed prior to admission to the nursing home for 1 (Resident #88) of 23 residents reviewed for pre-admission screening during the recertification survey. Specifically, Resident # 88 did not have a level 1 SCREEN prior to the resident's admission to the facility. This is evidenced by: Resident #88: The resident was admitted on [DATE], with diagnoses of Alzheimers Disease, anxiety disorder, and depression. The Minimum Data Set of 7/28/18, assessed the resident sometimes understands, was usually understood and had severely impaired cognitive ability. The SCREEN form found in the resident's medical record was dated 12/1/16, three days after admission. During interview on 9/17/18 at 12:00 PM, the Director of Social Work (DSW) stated residents come with the Screen or get it the day of admission, he was not sure what happened with Resident 88's Screen, he would look into it. At 1:30 PM, the DSW said he could not find any other screen for Resident # 88. He did not know why the SCREEN was done after the resident arrived, he was not here then. He stated there was no policy in place at this time about SCREENs. 10NYCRR415.11(e)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not maintained in a sani...

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Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not maintained in a sanitary condition to prevent the harborage and feeding of pests. This is evidenced as follows. The facility's trash compactor was observed on 09/17/2018 at 11:00 AM, revealing insect activity (flies), and the compactor door had not been activated exposing facility waste. On 09/10/2018 at 9:20 AM, fly activity was observed on 3 of 3 resident units (Hillview, Country Meadows, and Midtown). Observations on 09/10/2018 at 10 AM revealed that weather-stripping on the loading dock doors was missing. The Maintenance Director stated in an interview conducted on 09/17/2018 at 11:15 AM, that the trash compactor lids must be activated after each use and he will discuss this with staff. Additionally, he will repair the weather-stripping on the loading dock doors. The Director of Housekeeping stated in an interview conducted on 09/17/2018 at 12:15 PM, that she was aware of the insect activity around the trash compacter and the pest control vendor recommended compacting the garbage after each use to keep insects from accessing the garbage. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.160 14-1.170.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure that written notification was ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman of the resident's transfer or discharge and the reasons for the move for 5 (Residents #'s 6, 29, 31, 61, and 80) of 5 residents reviewed for hospitalization. Specifically, the facility did not ensure that there was documented evidence that the resident, the resident's representative, or the Ombudsman were notified in writing by the facility when the residents were admitted to a hospital. This is evidenced by: Resident #80 The resident was admitted on [DATE], with diagnosis including end stage renal disease, presence of prosthetic heart valve, and diabetes. The Minimum Data Set, dated [DATE], assessed the resident to understand, be understood and to be cognitively intact. A Progress Note dated 6/26/18 documented the resident was transferred to the hospital from dialysis earlier today. A Progress Note dated 7/4/18 documented that a call was received from the hospital reporting the resident would be return to the facility via ambulance at noon. The facility was unable to provide documentation showing the Resident, Resident's Representative, or the Ombudsman were notified in writing of the Resident's discharge to the hospital. During an interview on 9/12/18 at 12:29 PM, the Director of Nursing (DON) and the Administrator reported, residents, resident representatives, and the Ombudsman were not notified in writing when a resident was discharged to the hospital. Resident #6: The resident was admitted on [DATE] and readmitted on [DATE], with diagnoses of pneumonitis due to inhalation, and history of left lower extremity forefoot gangrene. He underwent an above knee amputation related to sepsis, history of right extremity below the knee amputation. The Minimum Data Set of 5/11/18, documented the resident had moderate cognitive impairment and understood others and was able to understand. A Nursing Progress Note dated 4/22/18 at 10:00 PM, documented the resident had been vomiting on and off since after dinner with projectile vomiting initially. Resident continues to vomit bile. A Nursing Progress Note dated 4/24/18 at 3:58 PM, documented the resident continued to vomit. Initially he vomited bile and the last episode the resident vomited coffee ground emesis. The resident was transported to the hospital. Hospital Discharge summary dated [DATE], documented the resident had diagnoses of sepsis secondary to aspiration pneumonia, upper gastrointestinal bleed and acute kidney injury. During an interview on 9/12/18 at 11:36 AM, Social Worker #1 stated he had not notified the family and the ombudsman in writing of the resident's transfer to the hospital in 5/2018 and stated he was recently educated on this. Resident #31 The resident was admitted on [DATE] with a readmission on [DATE] after a hospitalization on 5/24/18 with diagnoses of Peripheral Artery Disease (PVD), non- Alzheimer's dementia, and Chronic Ischemic Heart Disease. The MDS dated [DATE] documented the resident was able to understand and was understood with a Brief Interview for Mental Status (BIMS) of 9/15, moderately impaired for decisions of daily living. A Progress Note dated 5/24/18, documented the resident was transferred to the hospital directly from wound care for complaints of abdominal pain. A Progress Note dated 5/31/18, documented the resident was returned to the facility via ambulance in the afternoon and was re-admitted to his room. The facility was unable to provide documentation showing the Resident, Resident's Representative, or the Ombudsman were notified in writing of the Resident's discharge to the hospital. During an interview on 9/11/18 at 12:00 PM, the Registered Nurse Unit Manager #3 (RNUM) stated the resident went out to the hospital from wound care on 5/24/18 and was readmitted to the same room he had been in when he returned the afternoon of 5/31/18. During an interview on 9/12/18 at 12:29 PM, the Director of Nursing (DON) and the Administrator reported, residents, resident representatives, and the Ombudsman were not notified in writing when a resident was discharged to the hospital. They had not developed a policy to address this but were working on it. They just had become aware recently that they needed to notify the resident or representative in writing. The social worker for the facility was the one responsible to notify the ombudsman of resident discharge and transfer. He had not done this. 10NYCRR 415.39(H)(1)(III)(a-c)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization. This was evident for 5 (Residents #'s 6, 29, 31, 61, and #80) of 5 residents reviewed for hospitalization. Specifically, there was no documented evidence the resident and the resident's representative were notified in writing of the bed hold policy when the resident was admitted to the hospital. This is evidenced by the following: Resident #80: The resident was admitted on [DATE], with diagnosis including end stage renal disease, presence of prosthetic heart valve, and diabetes. The Minimum Data Set, dated [DATE] assessed the resident to understand, be understood and to be cognitively intact. A Progress Note dated 6/26/18, documented the resident was transferred to Saratoga hospital from dialysis earlier today. A Progress Note dated 7/4/18, documented the hospital called to report the resident was returning to this facility via ambulance at noon. The facility was unable to provide documentation showing the resident or Resident's Representative, were provided with a bed-hold notice at the time of hospitalization. During an interview on 9/12/18 at 11:36 AM, the Director of Social Services reported that bed-hold letters had not been sent because he was not aware until recently that this should be done. Resident #6: The resident was admitted on [DATE] and readmitted on [DATE], with diagnoses of pneumonitis due to inhalation, history of left lower extremity forefoot gangrene. He underwent an above knee amputation related to sepsis, history of right extremity below the knee amputation. The Minimum Data Set of 5/11/18, documented the resident had moderate cognitive impairment and understood others and was able to understand. A Nursing Progress Note dated 4/24/18 at 3:58 PM, documented the resident continued to vomit. Intially he vomited bile and last episode the resident vomited coffee ground emesis. The resident was transported to the hospital. Hospital Discharge summary dated [DATE], documented the resident had diagnoses of sepsis secondary to aspiration pneumonia, upper gastrointestinal bleed and acute kidney injury. During an interview on 9/12/18 at 11:36 AM, Social Worker #1 stated he had not notified the family in writing of the facility's bed hold policy when he was transferred to the hospital in 5/2018 and stated he was recently educated on this. Resident #31: The resident was admitted on [DATE], and readmitted on [DATE] after a hospitalization on 5/24/18, with diagnoses of Peripheral Artery Disease (PVD), non- Alzheimer's dementia, and Chronic Ischemic Heart Disease. The MDS dated [DATE], documented the resident was able to understand and was understood with a Brief Interview for Mental Status (BIMS) of 9/15, moderately impaired for decisions of daily living. A Progress Note dated 5/24/18 documented the resident was transferred to the hospital directly from wound care for complaints of abdominal pain. A Progress Note dated 5/31/18, documented the resident returned to the facility via ambulance in the afternoon and re-admitted to his room. The facility was unable to provide documentation showing the resident or Resident's Representative, were provided with a bed-hold notice at the time of hospitalization. During an interview on 9/12/18 at 12:29 PM, the Director of Nursing (DON) and the Administrator reported neither residents or resident representatives, were given a bedhold notification in writing when discharged to the hospital. They just had become aware recently they needed to notify the resident or representative in writing of the bed hold policy. The social worker for the facility was the one responsible to do this but had not done it. During an interview on 9/17/18 at 1:36 PM the Director of Social Services stated I did not notify in writing the resident or family of any bedhold policy whe he was transfered to the hospital. He further stated he was not aware of the regulation at the time. 10NYCRR 415.3(h)(4)(i)(a)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure comprehensive per...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 9 (Resident #'s 6, 29, 109, 30, 64, 4, 48, 59, and #97) of twenty three (23) residents reviewed. Specifically: For Resident #6 the facility did not ensure; that a comprehensive care plan (CCP) was developed for the diagnosis of aspiration pneumonia; that the resident's [NAME] included interventions to prevent aspiration; that the Nutrition Careplan documented interventions for the resident's weight gain; and that a CCP for Advanced Directives was developed. For Resident #4, the facility did not ensure the resident's Dementia Care Plan included non-pharmacological interventions. For Resident #29, the facility did not ensure the Care Plan for Falls included interventions. For Resident #64, the facility did not ensure there was a care plan in place to address the resident's needs associated with use of anticoagulant medications. For Resident #48, the facility did not ensure a CCP for the Potential for Pressure Sores was developed. For Resident #109, the facility did not ensure a CCP for Advanced Directives was developed; For Resident #59 and #97, the facility did not ensure the development a CCP for discharge from the facility. This is evidenced by: A Policy and Procedure for Person-Centered Comprehensive Care Plans with a revision date of 12/2016, documented comprehensive person-center care plans that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. The person centered care plan will incorporate identified problem areas and their causes and develop interventions that are targeted and meaningful to the resident. The care plan will reflect treatment goals, timetables and objectives in measurable outcomes. Resident #6: The resident was admitted on [DATE] and readmitted on [DATE], with diagnoses of pneumonitis due to inhalation, diabetes and history of left lower extremity forefoot gangrene. The resident underwent above the knee amputation related to sepsis, and has a history of right extremity below the knee amputation. The Minimum Data Set (MDS) of 5/11/18, documented the resident had moderate cognitive impairment and was understood by others and was able to understand. Finding #1 The facility did not ensure that a comprehensive care plan (CCP) was developed for the diagnosis of aspiration pneumonia. A Nursing Progress Note dated 4/22/18 at 10:00 PM, documented the resident had been vomiting on and off since after dinner with projectile vomiting. Resident continues to vomit bile. A Nursing Progress Note dated 4/23/18 at 3:09 PM, documented the resident was assessed and noted to be diaphoretic (sweating) with respirations at 28 per minute (normal rate is 12 to 20). Oxygen saturation was at 93% on room air (RA). Resident denies shortness of breath and denies he is in pain. The physician ordered labs, chest x-ray and KUB (an abdominal x-ray of kidney, ureters and bladder). Swallow evaluation ordered by the physician by a speech therapist to rule out possible aspiration. Clysis (introduction of fluid into the body by parenteral injection) was started in right lower abdomen for hydration. A Medical Sick Visit Note dated 4/23/18, documented the resident's respiratory condition escalated. Respiratory rate was at 28 and oxygen saturation levels dropped to 93 and 92% (normal level is 95 to 100%). The resident was started on oxygen and an antibiotic with suspicion of vomiting and related aspiration. Solu-Medrol (a steroid) 6 milligrams (mg) ordered for audible wheezing and tightness. Chest x-ray was negative for pneumonia. Lab values indicated the resident was dehydrated and he was started on clysis. He had a temperature of 100.3. A Nursing Progress Note dated 4/24/18 at 3:58 PM, documented the resident continued to vomit. Initially he vomited bile and last episode the resident vomited coffee ground emesis. The resident was transported to the hospital. Hospital Discharge summary dated [DATE], documented the resident had diagnoses of sepsis secondary to aspiration pneumonia, upper gastrointestinal bleed and acute kidney injury. A Speech Therapy Evaluation dated 5/02/18, documented an assessment summary of mild-moderate orophyarygneal dysphagia. The resident was educated on continued recommendations to alternate solids and liquids, take small bites and slow rate of intake. Upright posture during meals and upright posture for 30 minutes after meals as the resident is at risk for aspiration. During an interview on 09/12/18 at 10:55 AM, Registered Nurse Manager #1 (RNM), reviewed the resident's careplans and stated the resident did not have an aspiration pneumonia careplan which included goals and interventions to prevent a reoccurrence. She stated the Activities Care Plan documented interventions to keep the resident out of bed during and after meals. She agreed there was not an aspiration pneumonia careplan but that one should have been written. Finding #2 The facility did not ensure the resident's Nutrition Careplan included interventions for the resident's weight gain. The Weights and Vitals Summary documented Resident #6 was gaining weight. The weights were as follows: 2/01/18 - 189.6 lbs; 3/05/18 - 190.0 lbs; 4/05/18 - 202.0 lbs; 5/01/18 - 202.8 lbs; 6/01/18 - 210.0 lbs; 7/01/18 - 216.4 lbs; 8/09/18 - 220.0 lbs; 9/03/18 - 229.6 lbs. Hemoglobin A1C (blood test that measures the amount of hemoglobin in the blood that has glucose attached to it) results dated 7/23/18, revealed an elevated value of 7.2% (normal level is 5.7%). On 8/20/18, Hemoglobin A1C results increased to 7.6%. Physician Order dated 5/11/18, documented the resident was to receive Humalog insulin 2 units one time a day. Physician Orders dated 6/05/18, documented the resident was to receive Lantus insulin 21 units at bedtime. Physician orders dated 7/20/18, documented the resident was to receive Humalog insulin 3 units three times a day with meals. Sliding scale was discontinued. Physician's Orders dated 7/26/18, documented the resident was to receive Humalog insulin 5 units before meals. During an interview on 9/11/18 at 10:37 AM, the resident's wife stated the resident is being served too many carbohydrates. He is a diabetic and is being served white bread instead of a healthier alternative such as wheat bread. He has gained weight. His blood sugars are elevated slightly at the 140's to 160's (normal levels are 70 to 130). He is now taking insulin. During an interview on 9/13/18 at 11:51 AM, Dietitian #2 stated interventions for the resident's weight gain should probably be in his care plan. She stated she could add interventions that the resident is a diabetic and to encourage healthier choices. She stated she does not have experience with a resident with weight gain. She stated the resident's wife brings in a lot of food from outside, She has talked to and educated his wife. He has been given half portions for desserts and will not be given a roll or bread with meals unless he asks for it. The diet technician plans to speak to his wife about a diet change to cut portions, but the resident must be in agreement with this. Finding #3: The facility did not ensure that a care plan for the resident's Advance Directives was developed. Review of Resident #6's record did not include documented evidence of an Advance Directives Care Plan. During an interview on 9/12/18 at 11:38 AM, Social Worker #1 questioned the need for an Advance Directives Care Plan for the resident. He stated he was not seeing one and will set it up. The resident's Medical Orders for Life-Sustaining Treatment (MOLST) documented the resident had a Do Not Resuscitate Order (DNR). (This means do not begin CPR to make the heart or breathing start again). A Physician Order dated 5/01/18 documented the resident had an order for a DNR. Resident #4: The facility did not ensure the resident's Dementia Care Plan included non-pharmacological interventions. The resident was admitted on [DATE], with diagnoses of Alzheimers Disease, anemia, and anxiety. The MDS dated [DATE], assessed the resident as usually understood, sometimes understands, and had severely impaired cognitive ability. It documented the resident had behaviors not directed towards others 1-3 days and received anti-anxiety medication. The resident's CCP initiated on 1/31/17, documented the resident exhibits behaviors of socially inappropriate use of vulgar language, wandering, non stop chatter, and masturbation. The interventions included: Distract from wandering by offering pleasant distractions; distract resident with activities of interest, i.e. music, resident loves to dance; document all behaviors; attempt to identify pattern to target behaviors; identify triggers for wandering. The [NAME] (used by caregivers to provide needed care to the resident), with a print date of 9/17/18, documented under Behavior: 1:1 visits with residents from all departments as needed; distract resident from wandering by offering pleasant distractions; distract resident with activities of interest, i.e. music, resident loves to dance; document all behaviors; attempt to identify pattern to target behaviors; identify triggers for wandering. On 9/10/18 12:02 PM, the resident was in the hallway near the dining room. He was talking to everyone, animatedly and loudly. Staff were able to convince him to sit down at the overbed table in the hallway to wait for lunch. During interview on 9/13/18 at 2:51 PM, CNA #6 said the resident gives staff problems, but not other residents. He is usually good on days, not aggressive physically, but can be verbally aggressive. He hates to be ignored. You have to talk to him. He knows us well so we don't have problems with him. During interview on 9/13/18 at 4:01 PM, CNA #5 said the resident yells sometimes, he can get louder than the TV. Walking him helps. You have to keep him away from other residents. She discovered at night he likes to socialize, just sit and talk, he does not like to be ignored. During interview on 9/17/18 at 9:27 AM, RNM #2 stated the behavior CCP did not include that if he is talking to you, you have to respond to him. She stated not all interventions are individualized for this resident. Resident #64 The facility did not ensure there was a care plan in place to address the resident's needs associated with use of anticoagulant medications. The resident was admitted on [DATE] with diagnoses of Non- Alzheimer's Dementia, Atrial fibrillation (A-Fib) (an irregular, often rapid heart rate), Heart Failure, and Chronic Obstructive Pulmonary Disease (COPD). The admission MDS dated [DATE], assessed that the resident was understood and able to understand, had mild cognitive impairments and received anticoagulant medication. Physician's orders dated 8/7/18, documented the resident was to receive Rivaroxaban 20 milligrams (mg) by mouth in the evening for anticoagulation, give with meal or light snack. The Medication Administration Record (MAR) dated September 2018, documented the resident received the medication every day at 6:00 PM. There was no care plan in place to address the resident's needs associated with use of anticoagulant medications. During an interview on 09/17/18 01:32 PM, Registered Nurse Unit Manager (RNUM) #2 stated Currently there is no anticoagulant care plan in place, I will create one now. RNUM #2 reported a care plan to address the resident's needs associated with the use of anticoagulant medications should be included in the Comprehensive Care Plan (CCP) since the resident was receiving Xarelto (rivaroxaban). Resident #59 The facility did not ensure the development a CCP for discharge from the facility. The resident was admitted on [DATE], with diagnoses of Muscular Dystrophy (MD), malnutrition, and dysphagia requiring a tube feeding. The MDS of 7/9/18, documented the resident was understood and could understand with a Brief Interview of Mental Status (BIMS) score of 15/15 demonstrating the resident was cognitively intact. A physician's note dated 6/14/18, documented the resident is tolerating tube feeding, is walking around but also stays in bed and uses the wheelchair. It further documented the resident is quite determined to go home. During interview on 9/13/18 at 1:00 PM, Licensed Practical Nurse #3 (LPN) stated the resident is self-suctioning without difficulty and learning to manage her care. She is planning on discharge to home. During interview on 9/13/18 at 2:00 PM, Resident #59 stated the social worker is helping her to find outside housing. She is learning how to self-care, has learned to self-suction, and will be managing her tube feeding to discharge to home when a place to live is found. During interview on 9/17/18 at 8:23 AM, the facility physician stated the resident has inability to swallow from progression of her MD. A peg tube was surgically placed, and she is receiving tube feeding for nourishment in place of food. She is learning to self-care and is expected to discharge to independent living. During interview on 9/17/18 at 1:37 PM, the Director of Social Work stated he was working with the resident on a safe discharge plan. Originally, the resident was going to be supervised by a family member, but that was not realistic. He had not developed a new discharge care plan for the resident or updated the baseline care plan to reflect the residents needs with interventions. 10NYCRR415.11(c)(1)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Based on staff interview and record review during a recertification survey, it was determined that the environment was not free from accident hazards over which the facility has control. The resident ...

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Based on staff interview and record review during a recertification survey, it was determined that the environment was not free from accident hazards over which the facility has control. The resident environment is to remain as free from accident hazards as is possible. Specifically, resident area walls and doors had sharp edges, and chemical spray bottles were not labeled. This is evidenced as follows. On the Country Meadows resident unit, the right-side smoke barrier door hardware was loose and had exposed hard edges, and the cover to a wall-mounted device in the left dining room was missing exposing hard edges. Two unlabeled spray bottles with unidentified solutions were found in the basement. The Director of Maintenance stated in an interview conducted on 09/17/2018 at 11:30 AM, that he was not aware of the sharp edges on the doors, the missing device cover, and the unlabeled chemical spray bottles in the basement. 10 NYCRR 415.12(h)(1)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation and staff interview during the recertification survey, the facility did not maintain equipment in accordance with professional standards for food service safety. Specificity, food...

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Based on observation and staff interview during the recertification survey, the facility did not maintain equipment in accordance with professional standards for food service safety. Specificity, food preparation and serving areas were not in good repair, equipment was not kept clean, and free of insects. This is evidenced as follows: The main kitchen and kitchenettes were inspected on 09/10/2018 at 10:39 AM. The meat slicer, can opener, and walls in walk in cooler #2 were soiled with dust, grease or food particles. The floors in the main kitchen area were soiled with grease and food particles. Additionally, the wet wiping cloths used for wiping countertops were not stored in sanitizer solution. The window screen by the 3-bay sink was in disrepair and the weather stripping was missing from the door on the loading dock, permitting the house fly activity found in the main kitchen area. The automatic dish washing machine wash cycle temperature was observed at 140 Fahrenheit (F). The automatic dish washing machine information data plate requires a wash cycle temperature of not less than 160 F. The cabinetry in the Hillview unit and the two Country Meadows kitchenettes was soiled with food particles and drip marks, and the gasket on the refrigerator in the left-side Country Meadows kitchenette was ripped. The Dietary Director stated in an interview conducted on 09/12/2018 at 2:45 PM, that he will reeducate staff about cleaning and will submit work orders to the maintenance department to repair/replace broken and faulty equipment. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.160 14-1.170. .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "What safeguards are in place to prevent abuse and neglect?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • 43% turnover. Below New York's 48% average. Good staff retention means consistent care.
Concerns
  • • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
  • • 19 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $14,521 in fines. Above average for New York. Some compliance problems on record.
  • • Grade F (31/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

About This Facility

What is Washington Center For Rehab And Healthcare's CMS Rating?

CMS assigns WASHINGTON CENTER FOR REHAB AND HEALTHCARE an overall rating of 3 out of 5 stars, which is considered average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Washington Center For Rehab And Healthcare Staffed?

CMS rates WASHINGTON CENTER FOR REHAB AND HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 43%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Washington Center For Rehab And Healthcare?

State health inspectors documented 19 deficiencies at WASHINGTON CENTER FOR REHAB AND HEALTHCARE during 2018 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 17 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Washington Center For Rehab And Healthcare?

WASHINGTON CENTER FOR REHAB AND HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CENTERS HEALTH CARE, a chain that manages multiple nursing homes. With 122 certified beds and approximately 116 residents (about 95% occupancy), it is a mid-sized facility located in ARGYLE, New York.

How Does Washington Center For Rehab And Healthcare Compare to Other New York Nursing Homes?

Compared to the 100 nursing homes in New York, WASHINGTON CENTER FOR REHAB AND HEALTHCARE's overall rating (3 stars) is below the state average of 3.1, staff turnover (43%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Washington Center For Rehab And Healthcare?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.

Is Washington Center For Rehab And Healthcare Safe?

Based on CMS inspection data, WASHINGTON CENTER FOR REHAB AND HEALTHCARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Washington Center For Rehab And Healthcare Stick Around?

WASHINGTON CENTER FOR REHAB AND HEALTHCARE has a staff turnover rate of 43%, which is about average for New York nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Washington Center For Rehab And Healthcare Ever Fined?

WASHINGTON CENTER FOR REHAB AND HEALTHCARE has been fined $14,521 across 1 penalty action. This is below the New York average of $33,224. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Washington Center For Rehab And Healthcare on Any Federal Watch List?

WASHINGTON CENTER FOR REHAB AND HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

WASHINGTON CENTER FOR REHAB AND HEALTHCARE

ROUTE 40, ARGYLE, NY 12809 | (518) 638-8274

F
Trust Grade (31/100)
3.0
CMS Rating
19
Deficiencies

Strengths

  • 5-star quality

Concerns

  • 1 Immediate Jeopardy citation
  • Abuse finding

Ask about: Inspection Response, Abuse Safeguards, Rn Coverage

nursinghomedata.org | Data: CMS November 2025