Van Duyn Center For Rehabilitation And Nursing

there were no residents with medication self-administration orders.

The nurses should not leave

the cup, and they would take them when they wanted with breakfast.

The resident knew what routine

was an assessment that could be completed. 10 NYCRR 415.3 (f)(1)(vi)

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Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/17/2025 at 1:27 PM, [NAME] Clerk #39 stated Resident #162 preferred to use the tablet for interpreting or signing.

They did not have a tablet for interpreting before this week; it was not available to them.

The staff would write or Google signs to help understand.

They were taught about the language line but had not used it before this week.

During an interview on 4/17/2025 at 1:32 PM, Licensed Practical Nurse Assistant Unit Manager #40 stated Resident #162 did not own a tablet and was provided a tablet by the facility this week.

The tablet was not readily available to the resident before then.

The resident could see with their glasses on or off, but it was more beneficial when they wore them.

Their right eye was much stronger and if staff used the right side the resident could communicate. 10 NYCRR 415.5(b)(1-3) ******************* The facility was notified of the Immediate Jeopardy on 4/11/2025 at 12:42 PM.

The Immediate Jeopardy was removed on 4/16/2025 at 10:50 AM prior to the completion of the survey.

The facility implemented the following to remove the immediacy: - Initial plan of immediacy was approved on 4/11/2025 at 5:50 PM and included the facility providing Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident.

Education was provided to the staff and residents on their use.

The tablets were to be kept in the resident's rooms. - The second plan for immediacy was approved on 4/12/2025 at 11:14 PM, following determination staff and residents were unable to use the tablet for communication. - The facility provided in-service education to 89.5% of staff as of 4/16/2025 at 10:50 AM, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift. - Multiple interdisciplinary staff were interviewed during onsite visits through 4/16/2025.

All staff demonstrated knowledge of the education provided regarding the communication devices.

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/15/2025 at 1:19 PM, the Director of Maintenance stated all staff were trained on how to enter work orders. If there were walls that needed patching, that would take longer because they had to sand and then paint.

The certified nurse aides cleaned the wheelchairs during the night shift and the Director of Housekeeping rounded to ensure this was completed.

During an interview on 4/15/2025 at 1:24 PM, the Interim Director of Housekeeping stated the wheelchairs were cleaned between nursing and housekeeping and there was a schedule for cleaning them.

Housekeeping was responsible to pick up soiled linen from the utility rooms.

The housekeepers were also required to clean the dining area and kitchenettes.

Nursing staff were responsible to clean soiled floor mats and let housekeeping know if they needed to be sanitized.

Both nursing and housekeeping staff were responsible for emptying trash cans and replacing the bag. 10 NYCRR 415.29(j)(1)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During a telephone interview on 4/18/2025 at 9:30 AM, Housekeeper #112 stated Administration had

Housekeeper #112 stated they were not going to throw them out, so they took them.

They stated they picked up cans every day on the job.

They stated they confirmed with the resident they cashed in the cans. If the resident wanted to cash in the cans or the facility was letting the resident save the cans so they could cash them in, they should not have had staff get rid of them.

During an interview on 4/18/2025 at 12:40 PM, the Administrator stated they were not aware of recycled cans being taken from Resident #102 and cashed in.

They were only looking at the situation from an infection control and pest control standpoint.

The resident collected the cans from the dining room tables after meals, and from other residents who donated the cans to them.

The facility did not have a means for residents to cash in recyclable cans collected to redeem cash. 10 NYCRR 415.4(b)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

resident was interview on 4/8/2025 and they confirmed the staff member's name.

They did not

holding of the resident money financial abuse, just poor judgement.

Activity Aide #5 was not able to

the inability to account for the complete $181 as misplaced funds.

They did not expect Social Worker #121 to report the financial abuse or misappropriation of funds to the Administrator.

They expected them to start the investigation first, which was what was they did. If the situation was communicated to them with the staff member's name, they would have started the investigation right away. 10NYCRR 415.4(b)(3)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/17/2025 at 1:30 PM Speech Language Pathologist #34 stated they worked with the resident when they first received their speaking valve.

They stated the resident did great with it and learned quickly.

There was no indication the resident's cognition was impaired, and the resident was quite sharp since their admission.

During a telephone interview on 4/18/2025 at 12:40 PM Registered Nurse #118 stated the Minimum Data Set indicated the resident had no speech.

This was their status since their admission. If there was not a significant change, they would look at the previous Minimum Data Set but, in this case, they stated they most likely looked at the care plan and if the care plan was inaccurate the Minimum Data Set information would be entered inaccurately as well.

They explained they work remotely therefore relied on correct documentation to complete the care plans.

They stated a Minimum Data Set assessments should reflect the resident within the time frame on the tool itself and this was a problem that cascaded from prior inaccurate assessments. 10NYCRR415.11(B)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/17/2025 at 10:11 AM, the Director of Rehabilitation Services stated all residents should have leg rests unless care planned not to. If a resident's feet did not touch the floor while sitting in their wheelchair, they should have leg rests as it could cause leg edema and discomfort. If therapy recommended leg rests, then they should be used. Resident #372 should have bilateral leg rests per the 3/11/2025 Physical Therapy Assistant #31's progress note and if the resident had edema, required leg wraps, and had chronic leg pain they should have leg rests. 10NYCRR 415.11(c)(1)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/18/2025 at 1:44 PM, the Director of Nursing stated they combatted earbuds.

Staff were not supposed to have them or cell phones because of Health Insurance Portability and Accountability Act concerns (resident privacy). It could make residents feel not heard.

Staff were not allowed to eat when the residents were eating, and they did not expect staff to be in break rooms as they should be caring for the residents. 415.11(c)(3)(i)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/18/2025 at 12:21 PM, Certified Nurse Aide #173 stated Resident #336 asked

hair was so matted they were not able to comb through it.

They stated the barber came into the resident's room about two months ago and said they would be back and did not return. If a resident wanted to be groomed and was not it could be a dignity issue.

During an interview on 4/18/2025 at 1:44 PM, the Director of Nursing stated activities of daily living care should be provided according to the care plan and resident preference.

Hair should be brushed, and oral care should be done every day unless a resident refused. If hair and teeth were not brushed or showers not provided it could make the resident feel down.

During an interview on 4/15/2025 at 12:29 PM, Certified Nurse Aide #169 stated they were responsible for providing care to residents including bathing, showering, feeding, dressing, hair care, and oral care. A lot of staff did not provide oral care because they lost track of it over the years.

They completed all care for their assigned residents for the day and included brushing hair and teeth.

They were assigned to Resident #160 and brushed their hair and teeth.

The resident had intact cognition and did not refuse care.

They threw away the toothbrush they used and was unable to locate the hairbrush.

They stated the tangled mat of hair on Resident #160 was worse before when they had to cut out the chunk of hair because it could not be combed through. Resident #160 stated they did not have their teeth brushed and showed the certified nurse aide their electric toothbrush.

Certified Nurse Aide #169 stated they were not sure why they did not wash the resident's hair or comb it. 10 NYCRR 415.12(a)(3)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an observation and interview on 4/9/2025 at 8:56 AM, Wound Care Registered Nurse #128 completed wound care and applied Resident #274's wound vacuum.

The wound was dry without drainage or redness.

Wound Care Registered Nurse #128 stated if the wound vacuum was to come off, a dressing would be put in place until the wound vacuum was able to be replaced.

Wound Care Registered Nurse #128 stated in the event of their absence, the nursing supervisor, or the unit nurse would be responsible for applying the device.

They stated they were off for 10 days between 2/6/2025 and 2/21/2025 and they expected Wound Care Registered Nurse #136 to monitor or consult for residents with specialized treatments such as Resident #274.

Anyone who provided care for the resident was expected to document in the Medication Administration Record to indicate the treatment was done.

They stated there was a lack of continuity of care during their absence.

During an interview on 4/15/2025 at 11:11 AM, Registered Nurse Unit Manager #9 stated there was a gap in treatment documentation between 2/6/2025 and 2/21/2025 which indicated they forgot to document the wound care.

They were confident the care was done; however, it was not documented.

Registered Nurse Unit Manager #9 stated in the absence of the primary wound nurse, the other wound nurse should be responsible for changing the wound vacuum-assisted closure.

During an interview on 4/16/2025 at 12:38 PM, the Director of Nursing stated all licensed practical nurses completed wound vacuum-assisted closure care competencies annually and were able to provide that care.

When the wound team registered nurses were off, it was communicated to the licensed practical nurses they would be responsible for the treatments.

They were not aware Resident #274's wound vacuum-assisted closure dressing had not been changed.

The Medication Administration Record documented the dressing was on, but not that it was changed.

During an interview on 4/18/2025 at 9:30 AM, Licensed Practical Nurse #7 stated nursing staff failed to document the resident's wound care between the dates of 2/6/2025 and 2/21/2025.

They stated adhering to a wound care plan was important because the resident was a diabetic and had already lost the top half of their foot and failure to follow physician orders for wound care could result in the wound not healing.

During an interview on 4/18/2025 at 10:51 AM, Wound Care Registered Nurse #136 stated they had not provided wound care to Resident #274.

They stated they were not responsible for covering the entire caseload of the other wound care nurse during their absence. 10NYCRR 415.12

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/16/2025 at 11:14 AM, the Director of Central Supply #150 stated the wound nurses put in a work order if they needed an air mattress set up.

The air mattresses were set up based on the resident's weight which was obtained by asking a certified nurse aide or the Nurse Manager.

From there, the wound nurses made sure it was set appropriately, and the weight setting was accurate.

During an interview on 4/17/2025 at 11:06 AM, the Assistant Director of Nursing #47 stated air mattress checks were documented on the Treatment Administration Record.

Checks consisted of checking to make sure the mattress was on and functioning and did not include checking the settings.

Before yesterday, they had not realized the air mattresses had a weight setting. Resident #114 was followed by the wound team and did not weigh 420 pounds. Resident #71 did not have a pressure wound but was at risk to develop one.

Resident #71was tiny and not [PHONE NUMBER] pounds.

They thought the weight setting should be checked to ensure the mattress was effective. It if was not set at the appropriate weight it was not at the right pressure and defeated the purpose of the mattress.

During an interview on 4/18/2025 at 9:39 AM, Wound Registered Nurse #136 stated there was an order to check air mattress inflation and function every shift once central supply installed the mattress.

The air mattresses were regulated by body weight.

They double checked the settings after central supply installed the mattress. If the setting was too low, it would not work and if it was too high it could cause harm. Resident #114 had a sacral wound which was staying about the same. Resident #71 had limited mobility in bed and was at risk for a pressure wound. If their air mattresses were inappropriately set it could increase the chances of Resident #71 getting a wound and increase Resident #114's chance of their wound worsening.

The nurses were signing off on the Treatment Administration Record for inflation and function.

The appropriate weight setting was part of checking function and if it was signed off, it should have been checked. 10NYCRR 415.12(c)(1)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/10/2025 at 11:47 AM, Registered Nurse Unit Manager #9 stated that residents could not reheat food independently and it had to be done by staff in the core microwave to prevent a burn or incident.

There were staff who used the breakroom microwave to heat resident food because it was closer, but they should not.

Staff were to heat resident food in 20-30 second intervals to ensure it was not too hot. Resident #419 had an incident where they were burned by food being removed from the microwave.

During a follow up interview on 4/17/2025 at 1:47 PM, they stated they were unaware Resident #419 was using the breakroom microwave prior to the incident but the resident liked to do things their way.

They would have care planned the resident attempting to use the breakroom microwave themselves if they had known.

During a phone interview on 4/10/2025 at 1:39 PM, Certified Nurse Aide #162 stated microwaves were in the core and in the breakroom on the unit.

They stated residents were not supposed to use the microwave in the breakroom and if they saw a resident in there, they tell the resident they can't be there.

They stated on 3/15/2025 they walked into the breakroom and saw Resident #419 in there.

The resident told them they had burnt themselves by taking their food out of the microwave.

They stated the nurse was right there when the interaction occurred.

They stated they weren't sure if the resident always used the microwave in the breakroom but did know the resident liked to do what they wanted.

During an interview on 4/10/2025 at 2:14 PM, the Director of Nursing stated the staff were aware of the protocol for reheating food for the residents.

They were unaware of any residents in the facility who could access microwaves independently.

Residents should not be utilizing the breakroom microwaves but if staff did heat up a resident's food in the breakroom, they would have heat to it in increments and take the temperature prior to giving it to the resident. 10NYCRR 415.12 (h)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/10/2025 at 11:58 PM Dietetic Technician #73 stated Resident #740 had

with the resident. Resident #740 preferred yogurts and peanut butter and jelly pocket sandwiches so they added them up to the resident's meal trays.

They stated if tomato soup, crackers and yogurt were on the resident's meal ticket they should receive them. If the resident did not receive preferred foods, it was not acceptable and could lead to further weight loss.

During an interview on 4/15/2025 at 9:58 AM Certified Nurse Aide #74 stated they had never seen Magic Cups or supplements on Resident #740's meal trays.

They were unsure if the resident had lost weight.

During an interview on 4/15/2025 at 12:47 PM Registered Dietitian #75 stated residents had a full annual nutritional assessment and if they exhibited changes, such as significant weight loss, the registered dietitian should re-assess.

Food preferences and supplements were initiated first, then the resident would be re-assessed and medical notified if the interventions did not work. Resident #306 had significant weight loss, received supplements such as fortified juice and if the juice was not available, it should be replaced by Ensure clear.

The Director of Dietary notified the registered dietitians if a supplement was not available.

There was a substitution list in the kitchen if a supplement was not available. Resident #306 should have received their supplements on their meal tray to prevent further weight loss.

Registered Dietitian #75 stated Resident #740 had significant weight loss and multiple food preferences were honored. It was unacceptable for the resident not to receive their soup and yogurts; those were the resident's choices and assisted in maintaining their weight.

Dietary staff and certified nurse aides should check meal trays for accuracy and notify them if an item was not available.

During an interview on 4/15/2025 at 11:15 AM the Director of Dietary Services stated dietary staff gathered the cold food items, and a cart was brought to the unit.

The cold food cart included milks, juices, fortified juices and Health Shake supplements to be distributed to the residents per their meal ticket.

Dietary aides and certified nurse aides were responsible for meal ticket accuracy. If a resident required a supplement and it was not available, a substitution list would tell them what to put on the tray.

The facility did not have fortified cran-apple juice due to a national recall.

Staff should substitute fortified cran-apple with fortified orange juice or Ensure Plus. If a resident had supplements ordered they should receive them to maintain their nutritional needs.

During an interview on 4/15/2025 at 1:30 PM Nurse Practitioner #23 stated Resident #740 had significant weight loss.

They stated the resident should receive Ensure and fortified foods on their meal trays. If preferred food items were missing from their tray, it was not acceptable. Resident #740 had preferred food items such as soup and yogurt to assist them in maintaining their weight and nutritional needs. It was important for the resident to receive them to prevent further weight loss. 10NYCRR 415.12(i)1

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on [DATE] at 1:44 PM, the Director of Nursing stated pain medication should be

medication was not administered as ordered the resident could be in pain. 10NYCRR 415.12

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an observation and interview on 4/10/2025 at 11:31 AM, Resident #41 was sitting up in bed, and had bilateral bed rails on their bed.

They stated they only got out of bed for appointments and used the bed rails to hold onto during wound care.

They had the bedrails for as long as they had been in the facility and wanted the bed rails.

During an interview on 4/15/2025 at 10:41 AM, Certified Nurse Aide #166 stated Resident #41 had enabler bars they used to hold themself during wound dressing changes or during bed linen changes.

The residents were not supposed to have them, and the facility had tried to take them off, but the resident refused.

During an interview on 4/15/2025 at 10:54 AM, Licensed Practical Nurse Assistant Unit Manger #149 stated Resident #41 was allowed the bed rails because they were grandfathered in.

Therapy often asked if the resident still used them.

One of the bars needed to be removed every time the resident went on an appointment and maintenance had to put it back on after they came back, but they were not sure if maintenance checked the other rail.

They were not sure if there were any routine assessments that needed to be completed.

During an interview on 4/16/2025 at 11:58 AM, the Director of Rehabilitation stated bed rails needed to be appropriate for the resident and used to improve independence.

There was a quarterly therapy screen and nursing also had to complete a quarterly assessment. Resident #41's bed rails were taken off yesterday as they were not appropriate for bed rails.

They had required total assistance for a long time and did not have any strength in their hands.

There was risk of the resident getting their hands stuck in the bed rails, bruising, or entrapment.

They stated they attempted to remove the resident's bed rails in the past, but the resident repeatedly refused.

The quarterly therapy screens were not completed as required and the ones completed did not mention the use of bed rails.

During an interview on 4/16/2025 at 12:44 PM, the Director of Maintenance stated maintenance checks were completed on bed rails once a year and entrapment zones were tested. If nursing reported the bedrails were loose, they were tightened. It was important for routine assessments to ensure safety and prevention of bed entrapment.

The bed rail inspections were due this month.

During an interview on 4/17/2025 at 10:59 AM, the Assistant Director of Nursing #47 stated the facility policy was there were no side rails. Resident #41 adamantly wanted to keep their bilateral quarter bed rails. It required a physician order, and they were not sure why Resident #41 did not have an order for them.

The resident had an order discontinued by the system on 8/12/2024 for a hospitalization and it was never reordered upon their return.

They stated they were responsible to ensure quarterly assessments were completed and they just did not get done.

There was one done in March but otherwise the last one was a year ago. It was important the assessments were completed for safety risk.

They were not sure if reeducation of risks/ benefits or consents needed to be obtained routinely or just once prior to installation. 10NYCRR 415.12(h)(1)(2)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/16/2025 at 12:05 PM, Registered Nurse #145 stated they reviewed the medications for newly admitted residents.

They received a discharge summary and discharge medication summary and reviewed the orders with the admitting nurse practitioner or the provider. Resident #322 was a longevity resident, and they would have reviewed the order with longevity Nurse Practitioner#78.

The resident had a new tube feeding order with standard sliding scale insulin coverage per their discharge orders.

They stated they discontinued the insulin because the resident had a lot of nausea and vomiting, and the nurse practitioner decided to just do fingerstick and see how the resident did with the long action insulin.

The discharge orders had an injection algorithm, and two scales, one for a tube feeding and one without.

Those were discontinued, and the nurse practitioner ordered to monitor the fingerstick.

When the resident was admitted the blood sugar checks were at the same time as the bolus tube feeding.

The fingerstick were not getting checked during the tube feeding time.

Blood sugars should be checked prior to the bolus feeding to verify accurate sugar levels.

During an interview on 4/18/2025 at 1:37 PM, the Director of Nursing stated they oversaw the admission nurses, and all orders should be reviewed for a new admission.

When the nurse called the provider, they should go over all orders to finalize.

All medications were reviewed by the providers, and it was the providers decision what to order for the resident. 10 NYCRR 415.15(b)(2)(iii)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/15/2025 at 10:40 AM, Certified Nurse Aide #27 stated if a resident left for an

back.

They saw residents leave for appointments without any food and did not think there were any

During an interview on 4/15/2025 at 12:32 PM, Licensed Practical Nurse #26 stated if a resident had to leave early for an appointment, they could get a sandwich or snacks from the kitchenette.

Diabetics should get something to eat because their sugar could drop. If a resident received insulin before they left that would be even worse. Resident #1098 was a diabetic and received insulin based on a sliding scale.

They did not recall the resident going out on an appointment last week and did not send them with any food, but food should have been sent with the resident just in case.

During an interview on 4/16/2025 at 12:21 PM, Registered Nurse Manager #30 stated outside appointments were listed on the daily assignment sheet and they notified the dietetic technician if a resident was going to need a breakfast due to an early appointment.

They were not always aware of every appointment and if not, [NAME] Clerk #110 might catch that a resident needed a meal and order one.

There was no concrete process in place to ensure meals were provided. Resident #1098 was a diabetic and on sliding scale insulin before meals.

The resident had an appointment on 4/7/2025 with a pickup time of 8:15 AM.

They did not call the dietetic technician to get the resident food because they were unaware of the appointment.

After reviewing the medication administration record, they stated at 7:00AM on 4/7/2025 the resident's glucose level was 196 and they were given 3 units of insulin. If a resident was on a sliding scale the facility needed to make sure they had food to take with them and the certified nurse aide should know the resident needed to eat.

Without food the resident could become hypoglycemic and confused.

Someone should have touched base to make sure the resident had food.

During an interview on 4/16/2025 at 12:59 PM, [NAME] Clerk #110 stated if a resident had an early appointment, they or the certified nurse aide tried to get the resident an early breakfast or something to bring with them from the unit refrigerator. It was important to make sure that a resident did not go hungry. Resident #1098 had an appointment on 4/7/2025 and was picked up around 8:15 AM. An aide went with them and their family met them at the office.

They did not call for any food for the resident to take with them.

During an interview on 4/16/2025 at 1:06 PM, Certified Nurse Aide #109 stated only residents that went to dialysis received food to take with them not residents who went on regular appointments. On 4/7/2025 at 8:15 AM they went on an appointment with Resident #1098 and did not bring a meal for the resident.

While at the appointment the resident told them they were hungry and had not yet eaten.

The resident's daughter, who met them at the appointment, had to get the resident something to eat. 10NYCRR 415.12(m)(2)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

schedule to destroy narcotics. It was a big facility, and they could not destroy/dispose of medications

change between having only one medication card or multiple.

Medication diversion could be a risk

multiple bags and boxes of expired/discontinued medications remaining in the medication rooms.

They should be picked up every day. 10NYCRR 415.18(d)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/06/25 at 2:45 PM, Resident #102 stated they had not received any dental care, and they stated they have a cracked and rotting tooth.

During an interview on 4/09/2025 at 11:33 AM, Licensed Practical Nurse #11 stated the facility dentist does not do extractions. If there was a referral, they would put the order in and then whoever was the ward clerk would set up the appointment with whatever clinic they follow with. Resident #102 was recently seen for their annual exam.

The resident needed to be seen by dental hygienist.

Tooth #18 had not been extracted, it was a fractured tooth that required extraction, the tooth had broken off.

They confirmed there was an order placed on 3/7/2024 for a dental consult.

They stated once they put the order in, they do not follow up.

During an interview on 4/15/25 at 9:09 AM, [NAME] Clerk #111 stated if a resident had referrals from a dentist, they would get the referral from the Nurse Supervisor or nurse practitioner and send the referral to the dental office.

They stated Resident #102 had a referral for a tooth extraction but there was something wrong with their insurance and they were trying to get the resident into a dentist in Rochester.

During an interview on 4/16/2025 at 11:41 AM, Resident #102 stated administration was supposed to be assisting them with getting the insurance set up and they would try to send them to Rochester dental.

They stated they were in agony with this tooth. 10NYCRR 415.17(b)

During a meal observation on 4/8/2025 at 1:03 PM, Resident #480's meal tray was tested in the presence of certified nurse aide #56, and a replacement tray was requested.

The sliced meat sandwich was 68.4 degrees Fahrenheit, mixed fruit was 71.1 degrees Fahrenheit, apple juice was 66.4 degrees Fahrenheit, ginger ale was 59.5 degrees Fahrenheit, and milk was 63 degrees Fahrenheit.

During an interview with Resident Dining Experience Manager #99 on 4/8/2025 at 1:05 PM, they stated residents sometimes would complain the food was cold or did not look good.

During an interview with Certified Nurse Aide #51 on 4/9/2025 at 11:19 AM, they stated the residents complained the food didn't taste good.

During an interview Licensed Practical Nurse #52 on 4/9/2025 at 11:48 AM, they stated the residents complained the food was cold.

During an interview with the Food Service Director on 4/17/25 on 9:45 AM, they stated hot food temperatures should be 140 degrees Fahrenheit and cold food and beverages temperatures 40 degrees Fahrenheit or below.

They stated meal trays were plated by the food service department, but the nursing staff were responsible for passing the trays. If the trays were not passed in a timely manner, it could affect the temperature and taste of the food. 10NYCRR 415.14(d)(1)(2)

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Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

past 6 weeks.

The residents were to receive a different oral nutritional supplement such as ensure or

should call the kitchen for a replacement item. It was important for the residents to receive all their

10NYCRR 415.14(d)(3)(4)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/8/2025 at 4:47 PM, the [NAME] President of Operations #181 stated the facility had a staff person who stocked and cleaned the kitchenettes daily and they should have been checking that the handwash sinks were properly equipped with soap and paper towels.

During an interview on 4/8/2025 at 5:15 PM, Director of Dietary Services #76 stated staff were supposed to use any of the 9 hand wash sinks in the main kitchen and kitchenettes to wash their hands.

Staff should have had hot water available, soap, and paper towels to properly wash their hands.

They stated if any of the facilities lacked any of those items, staff should have reported that to a supervisor and they would send an email to housekeeping.

They stated they were not aware that 8 of the 9 sinks available were not properly equipped, but that had been reported to maintenance and housekeeping. 10NYCRR 415.14(h)

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

During an interview on 4/11/2025 at 11:46 AM, the Director of Nursing stated if a resident had a cough, they should be assessed by nursing, who then reported to medical.

The resident would also be placed on precautions in case anything infectious came back from testing.

The order for the precautions was put in by either the Infection Preventionist or the Registered Nurse Unit Manager.

The signs for the precautions were put up by the ward clerk. If there was no ward clerk on shift, the precaution signs could be placed by the nurse.

The door caddy of personal protective equipment was put up by central supply and there were extra personal protective equipment items in the clean utility room. If the resident had a positive result of an infectious disease, there should be the appropriate signage hung.

All staff should review the isolation precaution signs prior to entering the room and follow the directions on the sign. If the appropriate sign was not hung or the staff did not wear the correct personal protective equipment, infection could spread.

The rooms of residents on precautions for clostridium difficile colitis should be cleaned with bleach.

They were unsure how the laundry was separated for a resident on precautions for clostridium difficile colitis, but laundry staff was required to wear personal protective equipment when handling all laundry. 10 NYCRR 415.19(a)(b) **************** The facility was notified of the Immediate Jeopardy on 04/11/2025 at 2:03 PM.

The Immediate Jeopardy was removed on 4/15/2025 at 2:40 PM prior to the completion of the survey.

The facility implemented the following to remove the immediacy: - Initial plan of immediacy was approved on 4/11/2025 at 4:47 PM and included the facility ensuring all residents on precautions were reviewed and had the appropriate isolation precaution signage in place, all in-house staff were educated on infection control with competency-based training, and all oncoming staff would be educated prior to the start of their shift. - The facility provided in-service education to 85% of staff as of 04/15/25 at 1:25 PM, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift. - Multiple interdisciplinary staff were interviewed during onsite visits through 4/15/2025.

All staff demonstrated knowledge of the education provided on appropriate infection control precautions.

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215

335184 04/18/2025

Van Duyn Center for Rehabilitation and Nursing 5075 West Seneca Turnpike Syracuse, NY 13215