Jewish Home of CNY Inspection Report

PRINTED: 04/22/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4101 E GENESEE ST
JEWISH HOME OF CENTRAL NEW YORK
SYRACUSE, NY 13214
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG TAG
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
Recertification and Abbreviated (NY00277399,

NY00281008, NY00257605) Surveys were
conducted at Jewish Home of Central New York
from 3/1/22-3/8/22 to determine compliance with
42 CFR Part 483 requirements for Long Term
Care Facilities. Deficiencies were cited as a
result of this survey:
42 CFR 483.10 Resident Rights

42 CFR 483.12 Freedom from Abuse, Neglect,
and Exploitation
42 CFR 483.21 Comprehensive Resident Center
Care Plan
42 CFR 483.24 Quality of Life
42 CFR 483.25 Quality of Care
42 CFR 483.30 Physician Services
42 CFR 483.60 Food and Nutrition Services
42 CFR 483.80 Infection Control
F 577 Right to Survey Results/Advocate Agency Info F 577 4/22/22
SS=D CFR(s): 483.10(g)(10)(11)
§483.10(g)(10) The resident has the right to-

(i) Examine the results of the most recent survey
of the facility conducted by Federal or State
surveyors and any plan of correction in effect with
respect to the facility; and
(ii) Receive information from agencies acting as
client advocates, and be afforded the opportunity
to contact these agencies.
§483.10(g)(11) The facility must--

(i) Post in a place readily accessible to residents,
and family members and legal representatives of
residents, the results of the most recent survey of
the facility.
(ii) Have reports with respect to any surveys,
certifications, and complaint investigations made
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
04/05/2022
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: E5WY11 Facility ID: 0647 If continuation sheet Page 1 of 60
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)
F 577 Continued From page 1 F 577

respecting the facility during the 3 preceding
years, and any plan of correction in effect with
respect to the facility, available for any individual
to review upon request; and
(iii) Post notice of the availability of such reports
in areas of the facility that are prominent and
accessible to the public.
(iv) The facility shall not make available
identifying information about complainants or
residents.
This REQUIREMENT is not met as evidenced
by:
Based on observation and interview during the
recertification survey conducted 3/1/22-3/8/22,
the facility failed to post in a place readily
accessible to residents, and family members and
legal representatives of residents, the results of
the most recent survey of the facility conducted
by Federal or State surveyors and any plan of
correction with respect to the facility. Specifically,
the facility did not post the survey results and
plan of correction from the most recent Life
Safety Code Federal survey conducted on
9/11/19.
Findings include:
During observations on 3/1/22 at 2:50 PM and

3/2/22 at 9:15 AM, the survey result binder
located next to the front desk included the results
from the 9/11/19 Federal Health Recertification
Survey. The results from the 9/11/19 federal Life
Safety Code Survey and the corresponding plan
of correction was not included inside the binder.
During an interview on 3/2/22 at 5:37 PM, the

Administrator stated that the plan of corrections
for the Health Recertification Survey and the Life
Safety Code Survey from the last federal survey
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

in 2019 were posted in a binder near the front
desk. They stated that these results were
required to be publicly posted. The Administrator
stated any person could have taken these results
out of the binder. The Administrator stated the
Life Safety Code Survey plan of correction from
2019 had been placed in the binder after that
survey.
During an observation on 3/2/22 at 5:40 PM, with

the Administrator present, the survey result
binder located next to the reception desk
included the results from the 9/11/19 Federal
Health Recertification Survey. The results from
the 9/11/19 Federal Life Safety Code Survey and
the corresponding plan of correction was not
included inside the binder.
During an interview on 3/3/22 at 10:54 AM, the

Administrator stated when the binder was last
checked in 12/2021 all required documentation
was there. They stated previous survey results
were required to be posted so families and
residents could have full knowledge of all plans
of correction. The Administrator stated resident
families were told on admission they could
access the facility's plan of correction online for
the last three years. The Administrator stated
they were responsible for ensuring the results
were publicly posted and the survey result binder
located near the front desk was the only location
for the public to view this information.
10NYCRR 415.3 (c)(v)

F 584 Safe/Clean/Comfortable/Homelike Environment F 584 4/22/22
SS=E CFR(s): 483.10(i)(1)-(7)
§483.10(i) Safe Environment.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

The resident has a right to a safe, clean,
comfortable and homelike environment, including
but not limited to receiving treatment and
supports for daily living safely.
The facility must provide-

§483.10(i)(1) A safe, clean, comfortable, and
homelike environment, allowing the resident to
use his or her personal belongings to the extent
possible.
(i) This includes ensuring that the resident can
receive care and services safely and that the
physical layout of the facility maximizes resident
independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for
the protection of the resident's property from loss
or theft.
§483.10(i)(2) Housekeeping and maintenance

services necessary to maintain a sanitary,
orderly, and comfortable interior;
§483.10(i)(3) Clean bed and bath linens that are

in good condition;
§483.10(i)(4) Private closet space in each

resident room, as specified in §483.90 (e)(2)(iv);
§483.10(i)(5) Adequate and comfortable lighting

levels in all areas;
§483.10(i)(6) Comfortable and safe temperature

levels. Facilities initially certified after October 1,
1990 must maintain a temperature range of 71 to
81°F; and
§483.10(i)(7) For the maintenance of comfortable

sound levels.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

by:
Based on observation, record review, and
interview during the recertification survey
conducted 3/1/22-3/8/22, the facility failed to
ensure residents had the right to a safe, clean,
comfortable, and homelike environment for 3 of 3
nursing units (Terrace Unit, Unit 1, and Unit 2)
and for 2 of 2 residents (Residents #10 and 63)
reviewed. Specifically, the Terrace Unit had
unclean rolling window shades in the dining room
and a torn fall mat in resident room 29; Unit 1
had a damaged ceiling in the Ridge shower room
and loose handrails; and Unit 2 had a damaged
section of wall in resident room 222. Additionally,
Resident #10 had an unclean wheelchair and
Resident #63 had an unclean scoot chair.
Findings include:
The facility policy "Resident Services -

Maintenance of Facility" updated 4/1/17,
documents a maintenance logbook will be kept in
the Maintenance shop for documentation of
areas in need of maintenance services and work
orders should be called into [specified extension]
from any phone in the building. Staff will be
responsible to report maintenance needs for
repair, cleaning, equipment failure, etc., to the
supervisor.
Terrace Unit
The following observations were made of

Resident #63's scoot chair on the Terrace Unit:
- on 3/2/22 at 9:45 AM, the foot pedals had a
white dried substance on them.
- on 3/3/22 at 9:33 AM, the chair arms and foot
pedals had a white dried substance on them.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

- on 3/4/22 at 2:12 PM, the scoot chair had a
white dried on substance on it.
- on 3/7/22 at 10:58 AM, the foot pedals had a
white dried on substance on them.
The following observations were made of the

Terrace Unit dining room window rolling shades:
- on 3/2/22 at 10:45 AM, there were three window
rolling shades that had food splatter/stains on
them.
- on 3/3/22 at 4:58 PM, there were three window
rolling shades that had food splatter/stains on
them.

Maintenance Director stated they were not aware
of the Terrace dining room window rolling shades
had food splatter/stains on them. The Director
stated they would check and see if any work
orders had been made for the shades.
During an interview on 3/7/22 at 9:33 AM, the

Maintenance Director stated there were no work
orders for the Terrace dining room rolling shades
having food splatter/stains on them.
During an observation on 3/3/22 at 2:15 PM,

there was a fall mat in resident room 29 with a
36-inch tear in it with exposed foam.
Unit 1
During an observation on 3/1/22 at 3:30 PM, a

9-inch x 12-inch section of a solid ceiling in the
Ridge shower room was peeling from the ceiling.
During an observation on 3/1/22 at 2:00 PM,

there was a loose 3-foot section of a wall handrail
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

near the dietitian office.
Unit 2

Resident #10's wheelchair:
- on 3/2/22 at 10:58 AM, the entire left side and
wheelchair wheels/wheel prongs were
unclean/soiled with splattered material.
- on 3/4/22 at 4:17 PM, the entire left side and
wheelchair wheels/wheel prongs were
unclean/soiled with splattered material.
- on 3/7/22 at 9:54 AM, the wheelchair
wheels/wheel prongs were unclean and soiled.

damaged walls:
- on 3/1/22 at 2:20 PM, there was a wall covering
under a windowsill in the Unit 2 dining room that
was not attached and was taped to the wall.
- on 3/2/22 at 9:55 AM and 3/7/22 at 10:10 AM,
there was a 1-foot x 1-foot section of wall near
the bed in resident room 222 that was poorly
patched/damaged.

Maintenance Director stated there was no work
orders for the findings identified during survey.
They stated that staff could call a specific
maintenance department phone number and/or
send an email to a specific maintenance
department email, and the maintenance staff
would generate a paper trail/work order. The
Maintenance Director stated all staff were aware
of this specific phone number and email, and all
staff were responsible to properly report identified
findings. They stated that they were not aware of
any of the observed findings.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)
During an interview on 3/7/22 10:13 AM, the

Maintenance Director stated he was not aware of
the damaged section of wall in room 222, a work
order should have been completed and they
were unable to locate a work order. They stated
wheelchairs were cleaned by the overnight
nursing staff, and maintenance and
housekeeping departments were not responsible
for completing this task.
During an observation and concurrent interview

on 3/7/22 at 10:58 AM, registered nurse (RN)
Unit Manager #21 stated they were not aware of
the Terrace Unit dining room rolling shades
having food splatter/stains on them. They stated
that resident wheelchairs, scoot chairs, and other
mobility chairs should be cleaned when residents
were having their weekly showers. RN Unit
Manager #21 stated that some resident
wheelchairs needed to be cleaned more
frequently due to resident habits or family
bringing in food. The Wheelchair Cleaning
Schedule for the third shift was the expected
cleaning schedule and depending on the staff
availability the actual cleaning of resident
wheelchairs may not have been documented. RN
Unit Manager #21 stated that outside of visual
checking there was no way to ensure the chairs
were cleaned. RN Unit Manager #21 observed
Resident #63's scoot chair and stated the scoot
chair was not clean and would expect nursing
staff to contact them if they observed unclean
resident chairs. RN Manager #21 stated that
nursing staff was responsible for cleaning
resident wheelchairs, scoot chairs, and other
mobility chairs. They stated that staff should be
completing shower sheets and on shower sheets
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

there was a spot to date and time when a chair
was cleaned.
During an interview on 3/7/22 at 11:15 AM, RN

Unit Manager #2 stated they were not aware of
damaged ceiling in the Unit 1 Ridge shower
room. They stated that nursing staff should either
call a specific maintenance department phone
number and/or send an email to a specific
maintenance department email if there were
concerns. RN Manager #2 stated that resident
wheelchairs, scoot chairs, and other mobility
chairs were cleaned during their shower and as
needed and was documented on the shower
sheets.
During an interview on 3/7/22 at 11:42 AM,

Support RN #3 stated resident wheelchairs were
cleaned on the resident shower days, was
documented on shower sheets, and that the
shower timeframe/frequency was located on the
resident care plan sheet. Upon observation of
Resident #10's wheelchair, the damaged section
of wall within resident room 222 and the
damaged wall covering under a windowsill in the
Unit 2 dining room they stated that there were not
aware of these areas. RN #3 stated the wheels of
a wheelchair were considered part of the chair
and should be cleaned at same time as the chair.
They stated for maintenance issues they should
call the direct maintenance phone number or
email the maintenance department.
10NYCRR 415.29(j)(1)
F 604 Right to be Free from Physical Restraints F 604 4/22/22
SS=D CFR(s): 483.10(e)(1), 483.12(a)(2)
§483.10(e) Respect and Dignity.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

The resident has a right to be treated with
respect and dignity, including:
§483.10(e)(1) The right to be free from any

physical or chemical restraints imposed for
purposes of discipline or convenience, and not
required to treat the resident's medical
symptoms, consistent with §483.12(a)(2).
§483.12
The resident has the right to be free from abuse,
neglect, misappropriation of resident property,
and exploitation as defined in this subpart. This
includes but is not limited to freedom from
corporal punishment, involuntary seclusion and
any physical or chemical restraint not required to
treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(2) Ensure that the resident is free

from physical or chemical restraints imposed for
purposes of discipline or convenience and that
are not required to treat the resident's medical
symptoms. When the use of restraints is
indicated, the facility must use the least restrictive
alternative for the least amount of time and
document ongoing re-evaluation of the need for
restraints.
by:
ensure that when a restraint was indicated, the
least restrictive alternative for the least amount of
time was used and included ongoing
re-evaluation of the need for the restraint for 1 of
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

2 residents (Resident #48) reviewed. Specifically,
Resident #48 had an alarming wheelchair seat
belt that was not assessed to determine if it was
the least restrictive device, and a plan was not
implemented to ensure the device was used for
the least amount of time.
Findings include:
The facility "Restraint Policy" dated 11/2021

documents it was the policy of the facility to
promote restraint reduction to ensure greater
functional independence and a less restrictive
environment, while ensuring resident safety. If a
resident can tell you why the safety measure is in
place and they can release restraint, it is not
considered a restraint. If resident has a noted
change in condition and can no longer recall,
care plan and CNA sheets will be updated, and it
would now be treated as a restraint. The resident
using restraints shall be assessed at least
quarterly. Procedure for reduced use of restraint
includes, "This must be on [care plan] for all
residents with restraint." The restraint may be
removed for meals, and the resident must remain
in direct view of staff when off. Restraint may be
removed while family/visitors are present. The
restraint may be removed at supervised
activities.
Resident #48 had diagnoses including anxiety

disorder and dementia. The 1/13/22 Minimum
Data Set (MDS) assessment documented the
resident had severe cognitive impairment, had no
behavioral symptoms affecting self or others,
required extensive assistance with most activities
of daily living (ADLs), did not have any restraints
and used chair alarms.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

The 2/5/21 comprehensive care plan (CCP)
documented the resident had a potential for falls.
The CCP was updated on 4/7/21 by registered
nurse (RN) #2 and documented a wheelchair
safety belt was added to help remind the resident
to ask for help when standing. The resident was
able to open and close the clasp of the safety
belt.
There was no documented evidence the resident

was assessed to determine if the seat belt was
the least restrictive device and the seat belt was
used for the least amount of time possible.
The care instructions active in 3/2022

documented the resident had a seat belt alarm.
There were no directions on the application and
use of the seat belt.
The resident was observed seated in a manual

wheelchair wearing an alarmed seat belt;
- on 3/2/22 at 10:05 AM seated in the lounge.
- on 3/4/22 at 10:48 AM-11:45 AM seated in the
lounge.
- on 3/4/22 at 12:23 and 1:01 PM seated at a
dining table eating lunch.
- on 3/4/22 at 1:36 PM seated in the lounge area
with their head down on the table.
- on 3/7/22 at 9:10 AM while eating breakfast in
the dining room.
During an interview with certified nurse aide

(CNA) #1 on 3/7/22 at 2:30 PM, they stated the
resident would try to unbuckle the seat belt and
stand from their chair. The seat belt was on the
resident's waist and would pull the resident back
down into their chair. The resident could not
follow directions to unbuckle the belt and did not
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

understand why they had the buckle as they had
a diagnosis of dementia. The resident was
unable to hold a conversation and did not
respond appropriately to questions. The CNA
stated the seat belt had been in place a long
time. The CNA stated the resident was to wear
the seat belt at all times when out of bed.
During an interview with RN #3 on 3/7/22 at 2:38

PM, they stated the resident had a seat belt
alarm on their chair. They stated the resident was
to have this when out of bed and seated in their
chair. It was in place in case the resident tried to
get out of their chair and to prevent falls. They
stated it should have a restraint evaluation if it
was considered a restraint for the resident. A
seat belt would be considered a restraint if the
resident was not able to release the seat belt and
it should be re-evaluated every 90 days. The RN
stated they were unable to find any restraint
evaluations for the seat belt. They stated the
resident may have been able to release and
consent to the seat belt when it was first
implemented. During the interview the RN asked
the resident to release their seat belt and if the
resident knew what it was for. The resident was
unable to respond to either request. The RN
stated the seat belt was not a restraint as it was
used for the resident's safety. They stated if the
resident had a decline in condition, they should
have been referred to occupational therapy (OT)
for re-evaluation of restraint use and this had not
been done.
During a combined interview with Support RN #3

and RN Unit Manager #2 on 3/7/22 at 2:56 PM,
RN Unit Manager #2 stated the resident had
been able to remove and explain use of the seat
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

belt when it was implemented. RN Unit Manager
#2 stated they had added the seat belt to the
care plan in 4/2021. They stated the seat belt
had been in place because the resident would
attempt to self-transfer. A restraint decision tree
form would not have been completed when the
seat belt was implemented as the resident was
able to release it on their own and knew why it
was being used. If the resident was no longer
able to do this, then the resident should be
referred to OT for re-evaluation. If the seat belt
was considered a restraint the decision tree
would be completed and should include a release
plan. The RN Unit Manager stated the resident
had not had any referrals to therapy for the seat
belt.
During an interview with the Director of

Rehabilitation on 3/7/22 at 3:28 PM, they stated
the facility did not often use seat belts. They
stated the resident was able to take the seat belt
on and off when it was first implemented. At that
time the resident was participating in therapy and
frequently was trying to stand and would fall, so
they implemented the seat belt. Once discharged
from therapy it would be nursing's responsibility
to monitor the use of the seat belt. If the resident
had a change, nursing should put in a referral to
therapy to have the seat belt re-evaluated. They
stated they were not aware of any change in the
resident, and they had not received any referrals.
The Director stated given the resident's cognitive
decline and inability to understand, a referral
should have been made.
10NYCRR 415.4(a)(2-3, 5)
F 657 Care Plan Timing and Revision F 657 4/22/22
SS=D CFR(s): 483.21(b)(2)(i)-(iii)
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)
§483.21(b) Comprehensive Care Plans

§483.21(b)(2) A comprehensive care plan must
be-
(i) Developed within 7 days after completion of
the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that
includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the
resident.
(C) A nurse aide with responsibility for the
resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of
the resident and the resident's representative(s).
An explanation must be included in a resident's
medical record if the participation of the resident
and their resident representative is determined
not practicable for the development of the
resident's care plan.
(F) Other appropriate staff or professionals in
disciplines as determined by the resident's needs
or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary
team after each assessment, including both the
comprehensive and quarterly review
assessments.
by:
Based on record review and interview during the
recertification survey conducted 3/1-3/8/22, the
facility failed to ensure, to the extent practicable,
the participation of the resident and the resident's
representative in the development of the
comprehensive care plan for 1 of 2 residents
(Resident #50) reviewed. Specifically, Resident
#50 was not invited and did not attend their
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

comprehensive care plan meetings.
Findings include:
The facility policy "Comprehensive Care Plans"

dated 11/2021 documents it is the policy of the
facility to provide each resident with a
Comprehensive Plan of care to assist the
resident to attain or maintain their optimal,
physical, mental, and psychosocial functioning.
Social Services was to set up care plan meetings
as needed, all care plans are reviewed at that
time (families may join meetings via phone or
face time, families are not required to attend, and
residents are encouraged to attend). Families
may request care plan meetings at any time.
Resident #50 had diagnoses including

depression and anxiety. The 1/6/22 Minimum
Data Set (MDS) assessment documented the
resident was cognitively intact.
The care plan activity report did not document

attendance of the resident or the resident's family
at care plan meetings after 2019.
The comprehensive care plan (CCP) effective

2/12/20 documented the resident required
adjustment to long term care. Interventions
included remind the resident of upcoming events
and keep the resident and the resident's family
informed through team meetings and 1:1
updates.
There was no documented evidence in

interdisciplinary progress notes in 2020 or 2021,
the resident was invited or attended a care plan
meeting.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

During a Resident Council meeting on 3/3/22 at
10:05 AM, the resident stated they had not
participated in a care plan meeting, and they
would like to.
During an interview with the Director of Social

Services on 3/7/22 at 3:10 PM, they stated they
were assigned to the resident's unit. They
reviewed the resident's record and stated care
plan meetings would have been held around the
annual assessment dates of 5/7/20 and 4/29/21.
They stated there was no documentation in the
resident's medical record the resident was invited
or attended care plan meetings. They stated the
resident was alert and oriented and would
participate in meetings if in attendance. They
stated that it was social service's responsibility to
invite the resident to meetings, they had not
worked with the resident during those dates, and
they did not know why the resident had not been
invited.
10NYCRR 415.11(c)(2)(ii)
F 677 ADL Care Provided for Dependent Residents F 677 4/22/22
SS=D CFR(s): 483.24(a)(2)
§483.24(a)(2) A resident who is unable to carry

out activities of daily living receives the
necessary services to maintain good nutrition,
grooming, and personal and oral hygiene;
by:
Based on observation, record review and
ensure residents who were unable to carry out
activities of daily living (ADLs) received the
necessary services to maintain good nutrition,
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

grooming, and personal and oral hygiene for 2 of
4 residents (Residents #100 and 253) reviewed.
Specifically, Resident #100 did not receive
toileting assistance; and Resident #253 was not
assisted with care timely and did not have a care
plan to address behavioral symptoms when
requesting care.
Findings include:
The facility policy "Toileting Residents" dated

12/2018 documents the registered nurse (RN)
will indicate the frequency in which the resident
shall be toileted in [electronic medical record] and
care plan. The time selected reflects the
individual needs of the residents on a two (2) to
four (4) hour basis and as needed basis (PRN)
during the night. Certified nurse aide (CNA)
assignment sheet, residents care plan and
[electronic medical record] will reflect the
resident's toileting needs. Staff will ensure
adaptive equipment based on resident identified
needs are available.
1) Resident #100 had diagnoses including

Alzheimer's disease, constipation, and urinary
tract infection (UTI). The 2/10/22 Minimum Data
Set (MDS) assessment documented the resident
had severe cognitive impairment, required
extensive assistance with toileting, was
incontinent of bowel and bladder and was at risk
for developing pressure ulcers.

6/2/21 documented the resident required
assistance of 2 for toileting. The resident was
incontinent of bowel and bladder and staff were
to maintain a toileting schedule every 2 to 4
hours and as needed.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)
The 2/28/22 care instructions documented the

resident was to be toileted every 2 to 4 hours and
as needed. The resident required assistance of 2
staff for transferring.
The resident was observed on 3/4/22 at 10:03

AM, seated in a lounge area on the unit. There
was a strong odor of feces that was not present
prior to the resident's arrival to the lounge.
Certified nurse aide (CNA) #18 brought the
resident closer to the TV (nearer to the surveyor)
and the odor of feces became stronger. The
resident had a brown substance on their leg
seeping from under their pant leg. At 10:26 AM,
CNA #18 walked through the lounge area, went
to linen closet near the resident, and left the area
without checking the resident. At 10:28 AM, the
same CNA walked through the lounge into
another hallway. At 10:43 AM, CNA #17 came
and assisted the resident to the shower room for
toileting.
On 3/4/22 at 12:03 PM, the activities of daily

living (ADL) did not document that toileting care
had been provided to Resident #100 for the 7:00
AM-11:00 AM shift. On 3/4/22 at 5:00 PM, and
the 7:00 AM-11:00 AM shift, there was no
documentation that toileting care had been
provided on the 7:00 AM - 11:00 AM shift.
During an interview and observation with CNA

#17 on 3/4/22 at 10:43 AM, they stated they
started working on the unit at 9:00 AM that
morning. They were not sure what time the
resident had last been toileted. The resident's
used incontinence brief was observed, and the
brief had a large amount of feces causing the
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

brief to sag. The brief was full of feces, and there
was dried feces on the inside of the resident's
pants and on their ankles. The CNA stated they
needed helped, as there was so much feces on
the resident and in the brief, the resident would
have to be showered.
During a follow up interview with CNA #17 on

3/4/22 at 11:04 AM, they stated the CNA that
worked before them did not report off on the
residents and they did not know who needed to
be toileted. They were not aware the resident
was sitting in feces for 40 minutes and it was not
dignified for the resident. The CNA stated the
resident had a large amount of feces and some
had been dried on. They stated it appeared the
resident had not been toileted or changed in
sometime and the resident was supposed to be
changed every 2 to 4 hours and as needed.
During an interview with CNA #19 on 3/4/22 at

10:49 AM, they stated they were assigned to the
resident that morning and had provided care to
the resident. They stated they last
changed/toileted the resident at 8:30 AM and
assisted them to their chair. The CNA stated they
were just about to change the resident again
when they had an assignment change. They let
the oncoming CNA know the resident required
assistance with changing. The CNA stated that
40 minutes was a long time to be sitting in a
bowel movement with the feces seeping out and
it was not dignified.
During an interview with CNA #18 on 3/4/22 at

11:56 AM, they stated that they brought the
resident to the lounge to sit down and did not
notice any smell or observe any issues with
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

incontinence. They stated CNA #17 came in to
help during the morning shift, and they assisted
CNA #17 with washing the resident in the
shower. The resident had a large amount of
feces, and it was dried and extended down their
leg.
During an interview with registered nurse (RN)

Unit Manager #21 on 3/4/22 at 1:44 PM, they
stated they had changed the CNA assignments
that morning. The CNAs should have
communicated to the person that was taking over
about the residents they were caring for. Sitting
in feces for that long could affect skin, and it was
not dignified. The resident required changing
every 2-4 hours.
2) Resident #253 had diagnoses including

cerebral infarction (stroke), hypertension, and
peripheral vascular disease (poor circulation).
The 2/22/22 Minimum Data Set (MDS)
assessment documented the resident was
cognitively intact, displayed physical behavioral
symptoms towards others, and required
extensive assistance of 2 for toileting.

2/15/22 documented the resident had an
activities of daily living (ADL) deficit and required
assistance of 2 for toileting and dressing. The
resident was incontinent of bowel and bladder
and was to maintain a toileting schedule every 2
to 4 hours and as needed.
The 3/8/22 care instructions documented the

resident required assistance with toileting. Staff
were to transfer the resident with a sit to stand
(mechanical lift) and toilet every 2-4 hours and as
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

needed.
The following continuous observations were

made of Resident #253 on 3/3/22:
- At 9:50 AM with their call light on, sitting in a
recliner in their room and calling out for
assistance.
- At 10:00 AM, an unidentified staff member
entered the room and turned the call light off, did
not provide care, and left the room.
- At 10:15 AM, yelling for help from their room,
the call light was off, and no staff were observed
in the hallway.
- At 10:20 AM, licensed practical nurse (LPN)
#16 entered the room and the resident stated
they needed to use the bathroom. The nurse
exited the room and went and asked the other
LPN on the unit for assistance with the resident.
LPN #16 did not return to the room.
- At 10:56 AM, 2 unidentified certified nurse aides
(CNAs) entered the resident's room with a sit to
stand lift and closed the door. The resident was
observed urinating in a urinal with assistance
from the 2 CNAs.
When interviewed on 3/7/22 at 4:41 PM, CNA #5

stated the resident required the use of a
sit-to-stand lift and 2-3 staff. The resident should
be checked every 2-3 hours, but each time staff
left the room the resident would call out for help
again. They stated the call light should be
answered within 2-5 minutes, and it was not
acceptable to wait 40 minutes.
When interviewed on 3/7/22 at 5:04 PM, CNA

#14 stated Resident #253 required the
assistance of 2 staff with care. The resident often
yelled out from their room, was impatient and
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

would put the call light on shortly after staff exited
the room. The call lights should be answered
immediately and waiting 40 minutes would not be
an acceptable time to wait to be assisted.
When interviewed on 3/7/22 at 5:33 PM, LPN

#15 stated if a resident was frequently calling for
toileting assistance, and it was not the result of a
physical condition, then it should be added to the
care plan as a behavioral condition. The resident
had called often for toileting assistance and
sometimes voided very little. The resident was
not care planned for this toileting behavior, but
they should have been.
When interviewed on 3/7/22 at 5:46 PM

registered nurse (RN) Unit Manager #2 stated if a
resident called frequently for toileting, they
should have ruled out any physical reason why. If
determined it was a behavior, then it should have
been added to the care plan. The resident was
admitted with many behaviors, and they were
unaware that the resident had toileting behaviors.
The nurse stated the resident was not care
planned for this behavior but should have been.
10NYCCR 415.12(a)(3)
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F 686 4/22/22
SS=G CFR(s): 483.25(b)(1)(i)(ii)
§483.25(b) Skin Integrity

§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a
resident, the facility must ensure that-
(i) A resident receives care, consistent with
professional standards of practice, to prevent
pressure ulcers and does not develop pressure
ulcers unless the individual's clinical condition
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives
necessary treatment and services, consistent
with professional standards of practice, to
promote healing, prevent infection and prevent
new ulcers from developing.
by:
Based on observation, interview, and record
review during the recertification and abbreviated
(NY00277399 and NY00257605) surveys
conducted from 3/1/22-3/8/22, the facility failed to
ensure residents with pressure ulcers received
the necessary treatment and services, consistent
with professional standards of practice, to
promote healing, prevent infection and prevent
new ulcers from developing for 1 of 4 residents
reviewed (Resident #79). Specifically, Resident
#79 was admitted and assessed as mild risk for
developing pressure ulcers and had a deep
tissue injury (DTI, deep red, maroon, purple
discoloration) to their coccyx (tailbone) that was
not routinely monitored and developed into a
Stage IV (full thickness tissue loss with exposed
bone, tendon, or muscle) pressure ulcer. This
resulted in harm to Resident #79 that was not
immediate jeopardy.
Findings include:
The facility policy "Wound/Wound Assessment"

dated 12/2021 documents all admissions will
have a skin assessment. Residents admitted with
an injury such as hematomas (pooling of blood
under the skin), rhabdomyolysis (a breakdown of
muscle tissue), and all other injury diagnosis will
be monitored for pain, and once skin opens it will
be considered a wound. Any wounds needing
treatment the [physician] will be notified for
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

orders. Once a week, full body surveillance may
be done during bath time. Any new marks will be
reported to the licensed practical nurse (LPN) for
follow up and a registered nurse (RN)
assessment to be done.
The facility policy "Prevention and Treatment of

Pressure Ulcers" dated 2/22 policy documents
the purpose was to assess skin conditions and
contributing factors, and to implement protocols
to prevent threatened skin areas. Full body
surveillance will be done on shower days. Any
new marks or changed areas will be reported to
the LPN for follow-up and a RN assessment will
be done. When the completed shower sheet had
noted changes, the LPN will notify the RN and
these changes may be on 24-hour reports.
The National Pressure Injury Advisory Panel

(NPIAP) dated 2016 documents deep tissue
pressure injury as intact or non-intact skin with
localized area of persistent non-blanchable deep
red, maroon, purple discoloration.
Resident #79 had diagnoses including sacral (a

triangular bone at the base of the spine) fracture
and rhabdomyolysis (a breakdown of muscle
tissue that releases a damaging protein into the
blood). The 1/7/22 Minimum Data Set (MDS)
assessment documented the resident had
moderately impaired cognition, required
extensive assistance of 2 for bed mobility,
transfers, and toileting, extensive assistance of 1
for locomotion, dressing, hygiene, and bathing,
was at risk for the development of pressure
ulcers, did not have pressure ulcers, had a
non-surgical dressing, was on a turning and
positioning program and had pressure reducing
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

devices for bed and wheelchair.
The 12/31/21 RN Unit Manager #2 Admission

Nursing Form documented the resident had a red
and bruised area on the coccyx. The Braden
(measures risk of developing pressure ulcers)
scale documented the resident was a mild risk for
skin breakdown.
The 12/31/21 comprehensive care plan

documented the resident was at risk for skin
breakdown and for falls. Interventions included
utilize pressure reducing devices, provide assist
with bed mobility, transfer with staff assist,
complete pressure ulcer risk assessment
(Braden Scale) quarterly and as needed, certified
nurse aide (CNA) report on skin condition daily
during care and report any skin abnormalities to
nurse, provide pressure reducing mattress, use
pressure reducing cushion in wheelchair,
maintain turning and positioning schedule every
2-4 hours and as needed with staff assist,
prevent friction during transfers, use skin
protectant/skin barrier when performing perineal
care, off load heels while in bed, anticipate
needs, use proper footwear, ensure call bell in
reach at all times, and maintain safe
environment.
The 1/18/22 at 2:37 PM RN Unit Manager #2

progress note documented the family wanted the
resident sent to the hospital for dehydration. The
physician was made aware and ordered the
resident be sent to the hospital. The resident was
hospitalized from 1/18/22-1/24/22.
The 1/19/22 updated comprehensive care plan

(CCP) documented the resident as at risk for skin
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

breakdown. Interventions did not include goals,
interventions, or notes for skin breakdown.
The 1/24/22 hospital discharge summary

documented the resident was to be discharged
back to the facility. The resident was admitted to
the hospital for bladder distention. An indwelling
urinary catheter was inserted. The discharge
summary did not document a dressing or
treatment to the coccyx area.
The untimed Nursing Admission Assessment

form created by RN Unit Manager #2 on 1/24/22
and completed 2/8/22 documented the resident's
general skin condition was pale and dry with no
edema (swelling). The resident had a bruise on
the coccyx/sacral area, was chair fast, had very
poor nutrition, and was a moderate risk for skin
breakdown. The resident's skin was clean, dry,
and intact.
The 1/24/22 at 5:32 PM RN Supervisor (RNS) #9

progress note documented the resident had a
new dressing to the coccyx that was undated
upon return from the hospital at 4:06 PM. The
surrounding skin was intact and blanchable. The
resident had bruising to several areas including
the left hip, lower back, left hand, and right wrist
which were apparent IV sites. The resident also
had bruising to the right ankle and right small toe.
There was no further documentation describing if
the coccyx dressing was removed or an
assessment of the underlying area.
The 1/24/22 re-admission Braden scale

completed by RN Unit Manager #2 documented
the resident was at mild risk of developing a
pressure ulcer.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)
The 1/24/22 physician order documented ice to

the sacrum as needed (prn) for pain.
The 1/24/22 updated CCP documented the

resident had a sacral fracture and was at risk for
skin breakdown. Interventions included comfort
measures, provide pain medications as ordered,
utilize pain scale, reposition every 2 hours and as
needed, adaptive devices as directed, assist with
transfers, and utilize pressure relieving devices.
The CCP documented staff were to complete
Braden scale quarterly and as needed, CNA
report of skin condition daily during care and
report any skin abnormalities to a nurse.
Additionally, staff were to provide pressure
reducing mattress, pressure reducing device in
wheelchair, turn and position every 2-4 hours
with staff assistance, use skin protectant/skin
barrier during perineal care, document any pain,
and their fracture was to be followed by the
orthopedic physician.
The treatment administration record (TAR)

documented ice to sacrum prn was not
administered in 1/2022 or 2/2022.
There was no documentation between

1/24/22-2/15/22 the resident's coccyx was
monitored or assessed.
The 2/15/22 at 6:36 AM RNS #8 progress note

documented the resident had a dirty dressing
covering the sacral area. The LPN removed the
dressing and underneath was a large, reddened
area that looked like it was filled with grayish silly
putty in the shape of a hook. The LPN cleaned it
and put a covering on it. The area would be seen
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

by the skin team and the resident was not
complaining of pain.
The 2/16/22 at 11:33 AM Wound RN #7 progress

note documented the resident had an
unstageable (full thickness tissue loss in which
the base of the ulcer was covered by dead
tissue) area on the coccyx measuring 4.5
centimeters (cm) x 3.0 cm, was to have no brief
on in bed, had an alternating air mattress and a
ROHO cushion (both pressure relieving devices).
The treatment was Santyl (used to remove dead
tissue) and back to bed after meals. The note
documented the resident had a noticeable
decline.
The 2/16/22 updated CCP documented the

resident had an unstageable pressure ulcer on
the coccyx. Interventions included treatments as
ordered, assess during treatments and document
weekly. Staff were to put the resident back to bed
after meals, consult with the dietitian as needed,
and turn and reposition every 2 hours as
recommended. The CCP documented to monitor
for infection, perform wound care rounds weekly,
provide ROHO, alternating air mattress, and
weekly wound measurements.
The 2/2022 TAR documented on 2/16/22 at 12:11

PM, a new order to cleanse open area (did not
specify location) with normal saline (NS), pat dry,
apply Santyl to wound bed, cover with border
foam dressing daily and as needed.
The 2/18/22 at 3:38 PM registered dietitian (RD)

#25 progress note documented the resident had
a new unstageable pressure ulcer to the coccyx
and refer to the weekly wound RN note on 2/16
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

for details.
The 2/21/22 Wound RN #7 initial skin

assessment of new area documented the
resident had an unstageable pressure ulcer on
the coccyx measuring 4.3 centimeters (cm) x 3.0
cm.
The TAR documented on 2/18/22 at 11:37 AM,

cleanse open area with NS, pat dry, apply Santyl
to wound bed then crushed Flagyl tab (antibiotic),
cover with border foam dressing daily and prn.
The 2/22/22 at 1:51 PM Support RN #3 progress

note documented family was made aware of the
area on the coccyx when the resident returned
from the hospital and had become a wound. The
facility was treating the wound and the wound
care team was following.
The 2/23/22 at 11:57 AM RN Unit Manager #2

note documented skin rounds were done and the
deep tissue injury (DTI) to the sacrum had now
opened and measured 4.0 cm x 4.0 cm with a 2.0
cm tunnel at 12 o'clock with clear view of the
sacral bone. The family was made aware, and
the resident was to be sent to the wound clinic for
evaluation.
The 2/23/22 physician order documented cleanse

open area with NS, pat dry, NS to roll gauze and
gently pack at 12 o'clock area and roll out to
cover lower portion of wound cover with border
dressing.
The 2/23/22 at 1:01 PM Wound RN #7 progress

note documented the resident now had a Stage
IV pressure ulcer on the coccyx measuring 4.0
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

cm x 4.0 cm with a 2.0 cm tunneling at noon
position. On re-admission a RN noted a deep
tissue injury in the area. Treatment was NS
gentle packing and cover. The facility was to set
up a wound clinic appointment.
The 2/24/22 at 3:28 PM Wound RN #7 progress

note documented the resident had an
unstageable pressure ulcer on the coccyx
measuring 4.5 cm x 3.0 cm. The resident was to
have no brief in bed, and an alternating air
mattress and ROHO cushion. The treatment was
Santyl and back to bed after meals.
The 2/28/22 physician note documented the

resident had a history of sacral fracture, they
were told the resident had rhabdomyolysis that
was corrected, and the resident had a second
hospitalization. When coming to the facility for
the first time, the resident had a sizable bruise
over the sacrum that later opened and basically
exposed a sacral Stage IV decubitus (pressure
ulcer) which could be very difficult to heal since
there was not much viable tissue over the large
area and a very deep space.
During an observation of a treatment with LPN

#6, RN Unit Manager #2, and Wound RN #7 on
3/3/22 at 2:24 PM, RN Unit Manager #2 and
Wound RN #7 rolled the resident to the left side.
Wound RN #7 removed the old coccyx dressing.
LPN #6 cleansed the wound with NS. The wound
was about 4 cm x 4 cm x 2 cm with tunneling at
12 o'clock and the wound was pink with
granulation. The wound was packed as ordered,
covered with a border dressing, and the dressing
was dated.
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

When interviewed on 3/4/22 at 4:17 PM, RN Unit
Manager #2 stated the 1/24/22 admission skin
assessment documented the deep tissue injury
as a bruise. The area was unstageable, and staff
could not see below the intact outer skin. RN Unit
Manager #2 stated the resident was initially
admitted with the same area due to a fall prior to
admission. The bruise was later classified as a
deep tissue injury. The RN expected CNAs to
observe the area during care and report any
changes or abnormalities to the nurse.
The 3/7/22 at 3:21 PM Support RN #3 progress

note documented a 2/16/22 follow up report from
the 11-7 nurse who worked 2/15/22 into 2/16/22.
The resident had a pressure ulcer to the coccyx
and was added to wound rounds. Staff were to
continue to monitor.
When interviewed on 3/7/22 at 11:23 AM, CNA

#5 stated the resident could not reposition
themself in bed since returning from the hospital,
so staff were repositioning the resident every
couple of hours. The CNA stated CNAs were not
able to make notes in the electronic record, only
document that care was done or not done, and
were to report any abnormal findings to the nurse
for documentation. The CNA remembered a
sacral dressing prior to mid 2/2022 and that it
had never been observed to be dirty.
When interviewed on 3/7/22 at 11:51, RNS #9

stated they did not remember working the day
their note was written on 1/24/22 and did not
remember assessing the resident upon return
from the hospital.
When interviewed on 3/7/22 at 12:26 PM, LPN
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

#6 stated only the RNs were allowed to complete
assessments. LPN #6 stated they did not
remember the resident having a coccyx dressing
and would have noted it if they did. Upon return
from the hospital, the resident had a reddened
area that staff were putting barrier cream on to
prevent further breakdown. The LPN stated no
CNA asked the LPN to look at the coccyx area
prior to the resident's coccyx area opening to a
Stage IV pressure ulcer.
When interviewed on 3/7/22 at 12:28 PM, RN

Unit Manager #2 stated the resident continued to
have the coccyx bruise upon return from the
hospital. The facility did not track bruises on
pressure areas, was not aware the resident
returned from the hospital with a dressing to that
area, and staff were applying barrier cream to
prevent the bruise from deteriorating.
When interviewed on 3/7/22 at 12:30 PM, Wound

RN #7 stated the facility did weekly wound
rounds and did not observe bruises. Wound RN
#7 stated a DTI looked like a bruise and the
extent of injury was unknown until the area
opened. The resident had the coccyx bruise upon
initial admission and was not identified as a DTI
until the area opened on 2/16/22. A resident with
a bruise was looked at daily by unit staff during
care but would not be formally tracked. Unit staff
should alert the nurse with any changes in the
bruise. The CNAs should have alerted a nurse
for assessment if the resident had a coccyx
dressing. The RN was expected to write a
progress note regarding the area with the
dressing. The wound nurse would be made
aware if the area under the dressing was open.
Wound nurse #7 stated RN Unit Manager #2 was
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

aware of the resident's comorbidities and coccyx
bruise. The resident's comorbidities contributed
to the bruise developing into a Stage IV pressure
ulcer and the facility should have tracked the
bruise closer in hindsight.
When interviewed on 3/7/22 at 12:54 PM,

physician #32 stated they were made aware of
the Stage IV coccyx area after it opened. The
area manifested as a closed bruise, staff were
unable to assess what was under the closed
skin, and the facility did not track bruises. The
physician stated a different treatment would have
been ordered if they knew the area would open
to a Stage IV wound.
When interviewed on 3/8/22 at 10:43 AM, the

agency physician assistant (PA) stated the
resident was not under their care. The PA had
not seen the resident's coccyx wound, but due to
the resident's multiple comorbidities and the area
being on a pressure area, they would have
monitored it more closely.
When interviewed on 3/8/22 at 11:24 AM, the

Director of Nursing (DON) stated bruises on
pressure areas were not tracked by the facility. A
skin assessment was to be done by a RN on the
day of admission/readmission and all dressings
should be removed to assess the area
underneath unless there was a physician order
not to do so. Staff were aware the resident had a
bruise on their coccyx but were unaware of the
dressing on readmission as the RN #9's progress
note did not appear on the 24-hour report as it
should have. The DON stated nurses do not
assess a resident's skin weekly unless asked to
by a CNA. The DON expected the CNA to notify
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

the RN if there was a new or dirty dressing on a
resident. It was expected that the RN remove the
dressing, assess the area, and document it in a
progress note. The DON stated RN Unit Manager
#2 informed her there was no dressing and a
bruise on the resident's coccyx on admission.
The resident did not have a physician's order for
the dressing at any time prior to 2/15/22. The
DON expected CNAs to perform daily skin
checks during care and report abnormal findings
to the nurse. The DON stated staff were unsure if
the dressing from re-admission on 1/24/22 was
the same as the dirty dressing found on 2/15/22
as there was no documentation of a coccyx
dressing between those dates. There was no
investigation done on the dirty dressing found on
2/15/22 as staff were not aware of the reported
1/24/22 coccyx dressing. The DON stated there
should have been follow up to the 1/24/22
dressing and why it was in place on readmission.
When interviewed on 3/8/22 at 1:09 PM, Wound

RN #7 stated they were unsure how long the
dressing found on 2/15/22 was on the resident.
The resident should have had an order for a
coccyx dressing.
When interviewed on 3/8/22 at 02:34 PM,

physician #32 stated the resident was assessed
by them on 1/25/22 and the bruise was not
looked at. The bruise was not checked by the
physician with subsequent visits as they did not
assess bruises unless asked by staff. The
resident was placed on wound rounds once the
bruise opened.
10NYCRR 415.12(c)(2)
F 692 Nutrition/Hydration Status Maintenance F 692 4/22/22
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

SS=D CFR(s): 483.25(g)(1)-(3)
§483.25(g) Assisted nutrition and hydration.

(Includes naso-gastric and gastrostomy tubes,
both percutaneous endoscopic gastrostomy and
percutaneous endoscopic jejunostomy, and
enteral fluids). Based on a resident's
comprehensive assessment, the facility must
ensure that a resident-
§483.25(g)(1) Maintains acceptable parameters

of nutritional status, such as usual body weight or
desirable body weight range and electrolyte
balance, unless the resident's clinical condition
demonstrates that this is not possible or resident
preferences indicate otherwise;
§483.25(g)(2) Is offered sufficient fluid intake to

maintain proper hydration and health;
§483.25(g)(3) Is offered a therapeutic diet when

there is a nutritional problem and the health care
provider orders a therapeutic diet.
by:
interview during the recertification and
abbreviated (NY00257605) surveys conducted
3/1/22-3/8/22, the facility failed to ensure
residents maintained acceptable parameters of
nutritional status for 1 of 5 residents (Resident
#97) reviewed. Specifically, Resident #97 had a
significant weight loss without timely nutritional
assessments and interventions, and weekly
weights were not consistently obtained as
ordered.
Findings include:
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

The facility policy "Nutritional Assessment and
Care Plan" dated 12/21 documents all residents
will receive a comprehensive nutritional
assessment by a qualified professional
(registered dietitian [RD] or dietetic technician).
Assessment and documentation of nutritional
concerns is documented and recorded in a timely
manner in the medical record to ensure the
provision and documentation of optimal
nutritional care for all residents. Each
assessment and care plan may include, but is not
limited to, consideration of the resident's diet
history, height and weight, functional status,
medical and physical impairments, nutritionally
significant medications, laboratory test results,
food and fluid intake, counseling needs and
discharge planning. All residents are assessed
and documented at a minimum of 90 days and as
needed; the frequency depends ultimately on the
condition of the resident.
The facility policy "Resident Weight Monitoring"

dated 2/22 documents all residents with
patterned or a significant weight change, which
may indicate those residents are at a nutritional
risk, will be assessed by the interdisciplinary
team as indicated. Weights are to be obtained in
the following manner: within 72 hours of
admission to the facility, Nursing will weigh
resident to establish a baseline weight which will
be documented into the weight book; Nursing is
responsible for weighing each new resident.
Residents may be weighted more frequently, i.e.,
daily, every other day, weekly, etc. as determined
by the physician/nurse practitioner, nursing
and/or registered dietitian recommendation.
Criteria for a re-weight may be used by Nursing if
the resident has had a 3 pound (lb) weight loss or
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

gain and weighs 100 lbs or less; or a 5 lb weight
loss or gain and the resident weighs 100 lbs or
more, unless otherwise directed by the MD
(medical doctor, physician)/NP (nurse
practitioner); all weights will be recorded in the
EMR (Electronic Medical Record) on the shift
they were retained. A re-weigh will be done at the
dietitian's discretion and all residents plans for
weights and re-weights are done resident
specific.
Resident #97 had diagnoses including dementia

and depression. The 2/10/22 Minimum Data Set
(MDS) assessment documented the resident had
severe cognitive impairment, required
supervision/set up with eating, weighed 124
pounds (lbs) and had a significant non-physician
prescribed weight loss.
The 8/13/21 physician orders documented the

resident was on a regular consistency diet with a
plan for weekly weights.
The 8/14/21 comprehensive care plan (CCP)

documented the resident was at risk for weight
loss. Interventions included monitor intakes and
weights per physician order, offer alternates for
dislikes or when 25% or less was eaten at meals,
provide a regular liberalized diet, and update
food preferences. The resident required set up
with cues and hands on feeding assistance at
meals.
The 8/20/21 initial nutrition assessment by

registered dietitian (RD) #26 documented the
resident was admitted for palliative care with
diagnoses of atrial fibrillation (abnormal
heartbeat) and heart failure. The resident had
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

made improvements in therapy and end of life
medications were discontinued by medical. The
resident continued on a regular diet, meal intakes
averaged 61%, the resident weighed 152.7
pounds, family selected menus, the resident
continued on weekly weights, and weight
maintenance of 150-155 pounds was a goal.
The weight record documented the resident

weighed:
- 152.7 lbs on 8/17/21
- 145.3 lbs on 8/24/21 (-4.85%/7.4 lbs loss in 1
week)
- 146.7 lbs on 8/31/21
- 145.0 lbs on 9/13/21
- 144.8 lbs on 9/14/21
- 145.6 lbs on 9/21/21
- There were no documented weights between
9/21/21 and 10/13/21.
- 138.6 on 10/13/21 (-9.23 %/14.1 lbs loss in 2
months)
- 138.8 on 10/19/21 and 10/29/21 (-4.5%/ 6.8
pounds loss from 9/21/21).
There was no documented evidence the resident
was weighed weekly as ordered.
There were no documented nutrition progress

notes between 8/20/21 and 10/29/21 and no
documented evidence the medical provider was
notified of the resident's weight loss.
A 10/29/21 RD #25 progress note documented

the resident had an unplanned weight loss on
9/21/21, weighing 145.6 pounds and was
weighed at 138.8 pounds on 10/19/21. This was
6.7 pounds/4.6% loss at one month. The weight
was not significant. The resident's appetite had
shown an increase and they were consistently
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

consuming 75% of meals. The resident's family
member continued assisting with menu selection
to ensure food preferences were provided.
Current intakes appeared to be adequate to meet
estimated nutritional needs. The plan was to
continue to monitor need for additional
interventions.
The 11/5/21 RD #25 progress note documented

the resident weighed 138.8 pounds and
appeared to have overall stabilized. The resident
had variable intakes, and family member assisted
with menu completion. Staff were to offer 240
milliliters of fluids with medication pass to
promote optimal fluid intake. The plan was to
continue to monitor.
A 11/17/21 RD #25 progress note documented

the resident weighed 138.7 pounds on 11/16/21
and the resident had stabilized.
An 11/18/21 RD #25 assessment documented

the resident had a 9.2 % loss at 3 months. The
family member assisted with menu selection. The
resident was independent with set up at meals.
Weight showed stabilization over on month,
following an unplanned weight loss.
The resident weight record documented:

- between 11/23/21 and 12/15/21 had
documented weights between 138.5-138.9 lbs.
12/16/21-1/10/22.
- On 1/11/22, the resident weighed 138.5 lbs.
- On 1/18/22, the resident weighed 140.0 lbs.
1/19-2/7/22.
- On 2/8/22, the resident weighed 124.3 lbs
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

(-10.25%/14.2 lbs loss at 1 month; -10.45%/14.5
lbs loss at 3 months; 18.60%/28.4 pounds since
8/17/21).
There were no documented nutrition progress

notes or nutrition assessments between 11/19/21
and 2/9/22.
The 2/10/22 RD #25 assessment documented

the meal intake had insufficient documentation.
The resident weighed 124.1 lbs at time of
assessment, 140.0 lbs on 1/18/22, and 138.0 lbs
on 11/16/21. The resident had a 18.7% weight
loss at 6 months. The resident had a significant
unplanned weight loss over the past month. The
resident's Levothyroxine was adjusted related to
an elevated TSH (blood test measuring thyroid
stimulating hormone) of 18.4 on 2/7/22. The RD
recommended weekly weights and weight
stabilization was desired. If there were further
weight loss, they would consider a nutritional
supplement.
The weight record documented the resident

weighed:
- 124.1 lbs on 2/15/21; and
- 119.0 lbs on 2/22/22 (-15%/21 lbs loss at 1
month; -4.12%/5.1 lbs at 1 week).
There were no documented nutrition

assessments following the 2/22/22 weight loss
through 3/1/22.
The 3/1/22 RD #25 progress note documented to

see the 2/18/22 RD note for significant weight
loss. The resident weighed 119.0 pounds on
2/22/22, indicating further unplanned weight loss
of 5.1 pounds in a week. Re-weight was
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

requested and pending. The registered nurse
(RN) was made aware. Meal consumption
average was 61%. Recommended addition of
120 milliliters (ml) 2 cal HN (nutritional
supplement) daily to add 237 Kcals (Kilocalories)
and 10 grams (g) of protein. Continue weekly
weights to monitor weight trends.
The 3/2/22 RD #25 progress note documented

the resident weight 128.2 which was a desired
gain of 4.1 pounds. The plan was to continue
weekly weights and adjust plan of care as
needed.
A physician's order on 3/2/22 included 120 ml of

2 Cal HN (nutritional supplement) once daily.
The resident was observed on 3/2/22 at 2:03 PM,

seated in the dining room. The resident was
sitting at the table not eating. The resident had
eaten 25% of their Ruben sandwich, 25% of
French fries, 50% of fruit cup, 100% water, 100%
of coffee, and 50% apple juice.
During an interview with certified nurse aide

(CNA) #34 on 3/7/22 at 12:04 PM, they stated a
CNA would know what residents needed to be
weighed or re-weighed by reviewing the CNA
assignment sheet. If a resident declined to be
weighed, they would notify the licensed practical
nurse (LPN) and try again. They stated if a
resident was as on weekly weights, they should
be done weekly.
During an interview with LPN #35 on 3/7/22 at

12:34 PM, they stated the registered nurse (RN)
Unit Manager, or the LPN would complete the
assignment sheet that would note if a resident
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

required to be weighed by a CNA. CNAs would
then obtain the weights and write them in the
book. If a resident declined, staff would
re-approach. The LPNs then entered weights
from the sheet into the computer. Weekly weights
were to be done weekly to keep track of weight
gain/loss and nutritional status, especially on a
floor that had more residents with diagnoses of
dementia. They stated they did not know if the
resident declined to be weighed but did not think
they had. They stated the resident's weights
fluctuated recently and the resident had been
started on 2 Cal HN because of weight loss.
During an interview with RN Unit Manager #21

on 3/7/22 at 12:42 PM, they stated weights,
including weekly weights, would be noted on a
CNA assignment sheet by them or the LPN. If a
re-weight was needed RD #25 would let them
know via telephone, verbally or in e-mail. The
LPN was responsible for checking that weights
were completed and entered into the electronic
record. The RN Manager stated they were aware
weekly weights had started for the resident in
8/2021. The resident had weight loss and in
11/2021, they had a hard time getting the
resident to eat. They stated it was important to
monitor weights related to the resident's variable
intakes.
During an interview with RD #25 on 3/7/22 at

2:31 PM, they stated the resident had "crazy"
weights. The resident's weight had stabilized in
10/2021, and they were not concerned at that
time. In 11/2021, the resident had a significant
weight loss at 3 months, and it was desired the
resident's weight would stabilize. The RD stated
it seemed the resident's weight declined in
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

2/2022. The Levothyroxine could affect weight,
and they planned for weekly weight to continue
and made the physician assistant (PA) and social
services aware. The RD felt the resident had a
weight loss in 2/2022 related to a change in
medication and a high TSH level. When there
was a weight loss, they tried to figure out the root
cause of the weight. They would keep the
resident on weekly charting related to concern
with the resident's weights. The resident
continued on weekly weights. They had talked to
the NP about keeping weekly weights in place as
well. The RD requested 2 Kcal when the
resident's weight reached 119 pounds. They did
not put a supplement into place prior to this.
10NYCRR 415.12(i)(1)
F 812 Food Procurement,Store/Prepare/Serve-Sanitary F 812 4/22/22
SS=E CFR(s): 483.60(i)(1)(2)
§483.60(i) Food safety requirements.

The facility must -
§483.60(i)(1) - Procure food from sources

approved or considered satisfactory by federal,
state or local authorities.
(i) This may include food items obtained directly
from local producers, subject to applicable State
and local laws or regulations.
(ii) This provision does not prohibit or prevent
facilities from using produce grown in facility
gardens, subject to compliance with applicable
safe growing and food-handling practices.
(iii) This provision does not preclude residents
from consuming foods not procured by the
facility.
§483.60(i)(2) - Store, prepare, distribute and
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

serve food in accordance with professional
standards for food service safety.
by:
store, prepare, distribute, and serve food in
accordance with professional standards for food
service safety for 1 of 1 main kitchen reviewed.
Specifically, there were damaged sinks,
unclean/soiled floors, unclean soiled deep fryers,
unused lids, and containers stored on an unclean
shelf, improperly stored food scoops, missing
ceiling tiles, and uneven floor surfaces.
Findings include:
The undated facility weekly 7-3 & 3PM Shifts task

sheet and the undated Daily Cleaning Lists did
not include:
- cleaning the floors within and around the
cooking areas;
- cleaning cooking equipment and food surfaces;
and
- to report deficient issues identified as per the
facility maintenance policy.
The following kitchen observations were made on

3/1/22 between 12:30 PM-1:30 PM:
- the kitchen hand wash sink near the meat
cooking area was loose and not attached to the
wall;
- the corner of the floor near the meat cooking
area stove had loose grains of rice;
- a water pipe connected to the baking/production
two bay sink faucet had a leak and sprayed water
when turned on;
- the scoop for the dairy side flour was inside the
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

flour bag;
- both dairy cook area deep fryers were soiled;
- the floor around the dairy cook area deep fryers
had French fries and miscellaneous debris on it,
and directly under the fryers the floor had an
unclean black substance;
- the dairy area steam table had over 50 multiple
sized plastic lids and paper containers lying
loosely on the unclean bottom shelf. There was
miscellaneous microfiber and plastic lids kept in
an unclean detergent container.
- the dairy preparation line area of the kitchen
had open 2-foot (ft) x 3 ft ceiling tile.
- the dish machine room had a missing 8-inch x 3
ft ceiling tile, and a 4-inch x 2 ft missing ceiling
tile.
The following kitchen observations were made on

3/3/22 at 12:21 PM:
- the floor in the produce cooler had an uneven
one-inch lip which was a tripping hazard.
- the corner of the floor near the meat cooking
area stove had loose grains of rice; and
- the scoops for the meat cooking area chicken
based powder, the vegetable based powder and
beef based powder were stored inside of the
containers. A scoop for brown rice was inside the
brown rice bag.

Food Service Director stated that a work order for
the
leaking baking/production two bay sink faucet
was submitted on 3/3/22.
During an interview on 3/3/22 12:44 PM, the

Food Service Director stated the black substance
on the floor under the dairy cook area deep fryers
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

was grease, and the person that was tasked to
clean the kitchen floors was a no call/no show on
Sunday 2/27/22. They stated that there was no
current cleaning checklist, staff were just
reminded of their tasks as needed, and this has
been the process since September 2021. The
Food Service Director stated that they had to
cover the 11 AM to 6 PM shift on 2/27/22
because the kitchen was short staffed. The
Director stated they were responsible for
cleaning the floors that day. They stated that
there was no signoff sheet that would indicate
that the daily cleaning of the floors and walls was
completed. They stated maintenance staff would
clean ceiling tiles as needed. The Food Service
Director stated that the rice on the meat cooking
area floor did not look like it had just occurred.
They stated it was not acceptable to have food
on the floor from the night before, and that there
should never be any items kept on the lower
shelf of the steam tables. The Food Service
Director stated that the shelf under the dairy cook
area steam table was supposed to be cleaned
after each meal, it was not being done, and a
kitchen manager should check this daily to
ensure this shelf stayed empty. They stated that
the dairy cook area was used by staff every day
and the items on the shelf were overlooked. They
stated they were not sure how long the cup lids
and containers were on the shelf, and that this
shelf should be wiped clean daily. They stated
when a ceiling tile was missing, dust and other
particles could fall from the space above the
ceiling into the food production area. There were
no specific work orders regarding missing ceiling
tiles. The Food Service Director stated the
missing ceiling tile by the preparation line area
was from a leak on 1/22/22. The Food Service
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

Director shared a video of the water leak and an
email from maintenance worker #22 documenting
the ceiling tile was going to be replaced 1/24/22.
The Food Service Director stated that
maintenance worker #22 was made aware of the
loose handwash sink last week on 2/23/22 or
2/24/22 and thought that it would have been
corrected. They stated that scoops should not be
kept inside containers when not in use.

Maintenance Director stated that staff could call a
specific maintenance department phone number
and/or send an email to a specific maintenance
department email, and the maintenance staff
would generate a paper trail/work order. They
stated that all staff had been made aware of this
phone number and email and were responsible
to properly report identified issues.

Maintenance Director stated there were no work
orders for the issues identified during the tour of
the kitchen.
During an interview on 3/4/22 at 12:38 PM,

maintenance worker #22 stated on 1/22/22 the
heat unit located on the kitchen roof had burst
and water had run down the pipe onto a kitchen
ceiling tile. They stated they had forgotten to
replace the ceiling tile.
10NYCRR 415.14(h)
F 880 Infection Prevention & Control F 880 4/22/22
SS=D CFR(s): 483.80(a)(1)(2)(4)(e)(f)
§483.80 Infection Control

The facility must establish and maintain an
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

infection prevention and control program
designed to provide a safe, sanitary and
comfortable environment and to help prevent the
development and transmission of communicable
diseases and infections.
§483.80(a) Infection prevention and control

program.
The facility must establish an infection prevention
and control program (IPCP) that must include, at
a minimum, the following elements:
§483.80(a)(1) A system for preventing,

identifying, reporting, investigating, and
controlling infections and communicable
diseases for all residents, staff, volunteers,
visitors, and other individuals providing services
under a contractual arrangement based upon the
facility assessment conducted according to
§483.70(e) and following accepted national
standards;
§483.80(a)(2) Written standards, policies, and

procedures for the program, which must include,
but are not limited to:
(i) A system of surveillance designed to identify
possible communicable diseases or
infections before they can spread to other
persons in the facility;
(ii) When and to whom possible incidents of
communicable disease or infections should be
reported;
(iii) Standard and transmission-based
precautions to be followed to prevent spread of
infections;
(iv)When and how isolation should be used for a
resident; including but not limited to:
(A) The type and duration of the isolation,
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

depending upon the infectious agent or organism
involved, and
(B) A requirement that the isolation should be the
least restrictive possible for the resident under
the circumstances.
(v) The circumstances under which the facility
must prohibit employees with a communicable
disease or infected skin lesions from direct
contact with residents or their food, if direct
contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed
by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents

identified under the facility's IPCP and the
corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and
transport linens so as to prevent the spread of
infection.
§483.80(f) Annual review.

The facility will conduct an annual review of its
IPCP and update their program, as necessary.
by:
3/1/22-3/8/22, the facility failed to establish and
maintain an infection prevention and control
program designed to provide a safe, sanitary,
and comfortable environment and to help prevent
the development and transmission of
communicable disease and infections for 4 staff
(registered nurse [RN] Unit Manager #21,
receptionist #31, security guard #27, and activity
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

aide #30) observed. Specifically, RN Unit
Manager #21, receptionist #31, and security
guard #27 were observed wearing masks
inappropriately and security guard #27 and
activity aide #30 wore masks of unsuitable
materials.
Findings include:
The facility policy "Coronavirus (COVID-19)"

dated 2/22 documents the facility recognizes the
need to minimize exposure to respiratory
pathogens and promptly identify residents with
clinical features and an epidemiologic risk for the
COVID-19 and to adhere to Federal and
State/Local recommendations. All healthcare
personnel will be correctly trained and capable of
implementing infection control procedures and
adhere to requirements. Health Care personnel
must be counseled to continue strict adherence
to all recommended non-pharmaceutical
interventions, including hand hygiene, and the
use of face masks as well as the importance of
being vaccinated.
The New York State Department of Health (DOH)

Health Advisory: Nursing Home Staff and
Visitation Requirements dated 1/12/22
documents all staff must be masked at all times,
regardless of vaccination or booster status.
The Centers for Disease Control and Prevention

(CDC) "Interim Infection Prevention and Control
Recommendations for Healthcare Personnel
during the Coronavirus Disease 2019
(COVID-19) Pandemic" updated 2/22/22
documents source control refers to use of
respirators or well-fitting facemasks or cloth
masks to cover a person's mouth and nose to
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

prevent spread of respiratory secretions when
they are breathing, talking, sneezing, or
coughing. Source control options for health care
personnel (HCP) include a NIOSH-approved N95
or equivalent or higher level respirator or a
well-fitting facemask.
During an interview with the Ombudsman

Coordinator on 3/1/22 at 1:47 PM, they stated
staff did not wear masks, especially the nursing
staff on the Terrace Unit.
The following observations of staff were made:

- on 3/1/22 at 12:15 PM, receptionist #31 was
sitting at the reception desk with their mask
below their nose.
- on 3/1/22 registered nurse (RN) Unit Manager
#21 had their mask below their nose at 12:48
PM, within 6 feet of the surveyor. They shifted the
mask at 12:51 PM and it remained with their
nose exposed; and at 3:37 PM, walking with a
resident and standing next to another resident.
- on 3/2/22 at 8:39 AM security guard #27 was
wearing a black cloth neck/facial guard with the
facial guard under their chin with their mouth and
nose exposed. Security guard #27 stated
everyone in the facility was to wear a mask. The
security guard was observed wearing a black
cloth neck/facial guard on 3/4/22 at 9:30 AM and
3/7/22 at 8:35 AM, and on 3/8/22 at 8:45 AM and
8:50 AM, with their nostrils exposed.
- on 3/4/22 at 9:10 AM, receptionist #31 was
behind the reception desk and was not wearing a
mask, while 2 unidentified individuals were
screening to enter the facility. The receptionist
stated everyone was to wear a mask when they
entered the facility and they had been educated
on mask use. They stated they were responsible
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

for making sure everyone had a mask on.
- on 3/4/22 at 12:23 PM, activity aide #30 was
observed wearing a leopard patterned cloth
mask. The aide was walking through the dining
room and assisted one resident with cutting their
meal items and then talked with several other
residents.
During an interview with security guard #27 on

3/8/22 at 8:50 AM, they stated they were
responsible for making sure visitors were
screened and that everyone entering the building
was wearing a mask. The security guard pulled
their cloth neck/facial cover below their chin and
proceeded to talk with their mouth and nose
exposed. During the interview 2 staff came to
self-screen and were within 3 feet of the security
guard. The security guard stated they were
allowed to wear any type of mask if covered their
mouth and nose. They stated if someone came in
without a mask, they would give them an ear loop
mask. Security guard #27 stated they were not
vaccinated against COVID-19 or influenza.
During an interview with Infection Control RN #7

on 3/8/22 at 1:19 PM, they stated the security
guards were required to wear an ear loop mask
or an N95. Staff were not to wear cloth masks or
respirator masks. If they did, an ear loop mask
was required underneath. They stated when
wearing a mask, it should be up over the mouth
and nose. The Infection Control RN stated they
had spoken to the security guard in the past and
they should not have been wearing a cloth
neck/facial covering.
10NYCRR 415.19
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)
F 888 COVID-19 Vaccination of Facility Staff F 888 4/22/22

SS=D CFR(s): 483.80(i)(1)-(3)(i)-(x)
§483.80(i)
COVID-19 Vaccination of facility staff. The facility
must develop and implement policies and
procedures to ensure that all staff are fully
vaccinated for COVID-19. For purposes of this
section, staff are considered fully vaccinated if it
has been 2 weeks or more since they completed
a primary vaccination series for COVID-19. The
completion of a primary vaccination series for
COVID-19 is defined here as the administration
of a single-dose vaccine, or the administration of
all required doses of a multi-dose vaccine.
§483.80(i)(1) Regardless of clinical responsibility

or resident contact, the policies and procedures
must apply to the following facility staff, who
provide any care, treatment, or other services for
the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or
other services for the facility and/or its residents,
under contract or by other arrangement.
§483.80(i)(2) The policies and procedures of this

section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or
telemedicine services outside of the facility
setting and who do not have any direct contact
with residents and other staff specified in
paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the
facility that are performed exclusively outside of
the facility setting and who do not have any direct
contact with residents and other staff specified in
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

paragraph (i)(1) of this section.
§483.80(i)(3) The policies and procedures must

include, at a minimum, the following components:
(i) A process for ensuring all staff specified in
paragraph (i)(1) of this section (except for those
staff who have pending requests for, or who have
been granted, exemptions to the vaccination
requirements of this section, or those staff for
whom COVID-19 vaccination must be temporarily
delayed, as recommended by the CDC, due to
clinical precautions and considerations) have
received, at a minimum, a single-dose COVID-19
vaccine, or the first dose of the primary
vaccination series for a multi-dose COVID-19
vaccine prior to staff providing any care,
treatment, or other services for the facility and/or
its residents;
(iii) A process for ensuring the implementation of
additional precautions, intended to mitigate the
transmission and spread of COVID-19, for all
staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely
documenting the COVID-19 vaccination status of
all staff specified in paragraph (i)(1) of this
section;
(v) A process for tracking and securely
any staff who have obtained any booster doses
as recommended by the CDC;
(vi) A process by which staff may request an
exemption from the staff COVID-19 vaccination
requirements based on an applicable Federal
law;
(vii) A process for tracking and securely
documenting information provided by those staff
who have requested, and for whom the facility
has granted, an exemption from the staff
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

COVID-19 vaccination requirements;
(viii) A process for ensuring that all
documentation, which confirms recognized
clinical contraindications to COVID-19 vaccines
and which supports staff requests for medical
exemptions from vaccination, has been signed
and dated by a licensed practitioner, who is not
the individual requesting the exemption, and who
is acting within their respective scope of practice
as defined by, and in accordance with, all
applicable State and local laws, and for further
ensuring that such documentation contains:
(A) All information specifying which of the
authorized COVID-19 vaccines are clinically
contraindicated for the staff member to receive
and the recognized clinical reasons for the
contraindications; and
(B) A statement by the authenticating practitioner
recommending that the staff member be
exempted from the facility's COVID-19
vaccination requirements for staff based on the
recognized clinical contraindications;
(ix) A process for ensuring the tracking and
secure documentation of the vaccination status of
staff for whom COVID-19 vaccination must be
temporarily delayed, as recommended by the
CDC, due to clinical precautions and
considerations, including, but not limited to,
individuals with acute illness secondary to
COVID-19, and individuals who received
monoclonal antibodies or convalescent plasma
for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully
vaccinated for COVID-19.
Effective 60 Days After Publication:

§483.80(i)(3)(ii) A process for ensuring that all
staff specified in paragraph (i)(1) of this section
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

are fully vaccinated for COVID-19, except for
those staff who have been granted exemptions to
the vaccination requirements of this section, or
those staff for whom COVID-19 vaccination must
be temporarily delayed, as recommended by the
CDC, due to clinical precautions and
considerations;
by:
3/1/22-3/8/22, the facility failed to develop and
implement policies and procedures to ensure that
all staff are fully vaccinated for COVID-19 and
include a process for ensuring the
implementation of additional precautions,
intended to mitigate the transmission, and spread
of COVID-19 for 3 of 11 staff (security guards
#27, 28, and 29) reviewed. Specifically, the
facility did not maintain documentation of
COVID-19 vaccination status for 3 contract staff,
security guards #27, 28, and 29, and did not
implement a contingency plan to address
non-vaccinated employees.
Findings include:
The facility policy "Coronavirus (COVID-19)"

dated 2/22 documents health care personnel
must be counseled to continue strict adherence
to all recommended non-pharmaceutical
interventions, including hand hygiene, and the
use of face masks as well as the importance of
being vaccinated. (All employees are offered and
encouraged to get COVID-19 vaccination
boosters). No Unvaccinated employees can work
here. Resident and staff testing will be done as
directed by DOH (Department of Health) and/or if
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

any symptoms are present. The policy did not
include a process for tracking and securely
all staff or contingency plans for staff who were
not fully vaccinated for COVID-19.
Security guard #27 was observed wearing a

black cloth neck/facial guard:
- On 3/2/22 at 8:39 AM, with the facial guard
under their chin with mouth and nose exposed.
- On 3/4/22 at 9:30 AM, and
- On 3/7/22 at 8:35 AM.
There was no documented evidence security

guard #27 was tested for COVID-19 when test
results were requested from the Administrator on
3/7/22.
During an interview with security guard #27 on

3/8/22 at 8:50 AM, they stated they had worked
at the facility full time for some time. They stated
they were not vaccinated against COVID-19 and
got tested about once a month for COVID-19.
They stated there were 15-minute rapid tests
available to take, but they had not taken any as
they had not had any symptoms. They stated
they were around residents who were waiting for
family or appointments in the lobby. They stated
they could wear any material mask if their mouth
and nose was covered, and they had not been
fit-tested for an N95 mask.
On 3/8/22 at 11:13 AM, the Director of Human

Resources stated they did not keep COVID-19
vaccination status for their contract staff and the
contract company was responsible for ensuring
the employees were vaccinated. They stated
they did not conduct COVID-19 testing on
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

contract employees and did not have any copies
of testing or vaccination status for security guard
#27 for 2022.
On 3/8/22 at 11:29 AM, the Administrator

documented in an e-mail that the security guards
were required to have the COVID-19 vaccination
to work in health care. The guards' employer was
responsible for documentation/compliance. The
facility would test the guards if they showed signs
of infection.
During an interview with Infection Control

registered nurse (RN) #7 on 3/8/22 at 1:19 PM,
they stated the contract company was
responsible for tracking the security guard's
vaccinations. They knew at some point the
security guard did not want the vaccination. The
Infection Control RN stated after discussion with
the security guard, they thought the security
guard received the COVID-19 vaccination. The
Infection Control RN stated the facility did not
keep track of the contract company's security
guard COVID-19 vaccinations and thought
security guards #27, 28 and 29 were vaccinated.
They stated they had not asked the company for
record of their vaccinations. Infection Control RN
#7 stated the facility required all their employees
to be vaccinated. Infection Control RN #7 stated
if an employee was not vaccinated, they would
need to be tested twice weekly. Since they did
not know the security guard was not vaccinated,
they did not test them. They stated if an
employee was not vaccinated or partially
vaccinated, they would have been removed from
work.
During a follow up interview with Infection Control
PRINTED: 04/22/2022
A. BUILDING ______________________
335190 B. WING _____________________________

03/08/2022
4101 E GENESEE ST
SYRACUSE, NY 13214
TAG TAG
DEFICIENCY)

RN #7 on 3/8/22 at 2:40 PM, they stated they did
not count the facility's contract employees,
including the security guards, in their National
Healthcare Safety Network reporting on
percentage of vaccinated staff. They stated the
remaining contract employees in other areas of
the building were all fully vaccinated.

Infection Control RN stated the Director of
Facilities was responsible for the security guards
and was attempting to contact the contract
company to obtain vaccination information as
they did not have or retrieve it prior to this date.
When they spoke with the company on the
phone, they stated security guards #28 and 29
were vaccinated against COVID-19, but they had
not yet been supplied documentation.
10NYCRR 415.19(a)(1)

Jewish Home of CNY Inspection Report

Uploaded by

Copyright:

Available Formats

Jewish Home of CNY Inspection Report

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Jewish Home of CNY Inspection Report

Uploaded by

Copyright:

Available Formats

What deficiencies were cited in the survey?

What deficiencies were cited in the survey?

What is the facility required to do regarding posting and providing survey results?

What is the facility required to do regarding posting and providing survey results?

PRINTED: 04/22/2022

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

335190 B. WING _____________________________

F 000 INITIAL COMMENTS F 000

Recertification and Abbreviated (NY00277399,

42 CFR 483.10 Resident Rights

§483.10(g)(10) The resident has the right to-

§483.10(g)(11) The facility must--

335190 B. WING _____________________________

F 577 Continued From page 1 F 577

During observations on 3/1/22 at 2:50 PM and

During an interview on 3/2/22 at 5:37 PM, the

335190 B. WING _____________________________

F 577 Continued From page 2 F 577

During an observation on 3/2/22 at 5:40 PM, with

During an interview on 3/3/22 at 10:54 AM, the

10NYCRR 415.3 (c)(v)

§483.10(i) Safe Environment.

335190 B. WING _____________________________

F 584 Continued From page 3 F 584

The facility must provide-

§483.10(i)(2) Housekeeping and maintenance

§483.10(i)(3) Clean bed and bath linens that are

§483.10(i)(4) Private closet space in each

§483.10(i)(5) Adequate and comfortable lighting

§483.10(i)(6) Comfortable and safe temperature

§483.10(i)(7) For the maintenance of comfortable

335190 B. WING _____________________________

F 584 Continued From page 4 F 584

The facility policy "Resident Services -

The following observations were made of

335190 B. WING _____________________________

F 584 Continued From page 5 F 584

The following observations were made of the

During an interview on 3/3/22 at 4:58 PM, the

During an interview on 3/7/22 at 9:33 AM, the

During an observation on 3/3/22 at 2:15 PM,

During an observation on 3/1/22 at 3:30 PM, a

During an observation on 3/1/22 at 2:00 PM,

335190 B. WING _____________________________

F 584 Continued From page 6 F 584

The following observations were made of

The following observations were made of

During an interview on 3/3/22 at 4:40 PM, the

335190 B. WING _____________________________

F 584 Continued From page 7 F 584

During an interview on 3/7/22 10:13 AM, the

During an observation and concurrent interview

335190 B. WING _____________________________

F 584 Continued From page 8 F 584

During an interview on 3/7/22 at 11:15 AM, RN

During an interview on 3/7/22 at 11:42 AM,

§483.10(e) Respect and Dignity.

335190 B. WING _____________________________