Casa Promesa

In the surveyor’s words

From the most serious findings on record at Casa Promesa, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 28, 2025

  Based on observation, record review, and interviews during an Abbreviated Survey (NY00380952), the facility failed to ensure that a resident, identified as an elopement risk based on a history of previous elopement attempts, received adequate supervision to prevent elopement from the facility. This was evident for one (1) of eight (8) residents sampled (Resident #1). Specifically, on 05/16/2025 at 10:12 AM, Resident #1, who was assessed as cognitively impaired and at risk for elopement, who had a Wander Alert Device on their left ankle, exited the building undetected. Interview revealed Security Guard #1 heard a beeping sound and was not aware that it was the Wander Alert Alarm. […]

• No harm, potential for more than minimal, patternF657Dec 9, 2024

  Based on record review and interviews conducted during the Recertification and Complaint (NY00355130, NY00355122) Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that each resident's comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect a change in resident's status. This was evident in 4 (Residents #42, #51, #50, #61) of 20 total sampled residents. Specifically, the comprehensive care plans for Residents #42, #51, #50, and #61 were not reviewed and revised following their involvement in a resident to resident altercation. […]

• No harm, potential for more than minimal, patternF761Dec 9, 2024

  Based on observation, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident in 2 (3rd and 4th Floor) of 3 units. Specifically, 1.) Expired Heparin lock flush syringes were stored in the medication room. 2.) Food items were stored together with the intravenous bags in the medication room. The findings are: The facility policy on Medication Storage and Handling with a last revision date of ,d+[DATE] documented that medications, biologicals, and intravenous sections having an expiration date are removed from storage and usage and properly disposed of after such date. […]

• No harm, potential for more than minimal, patternF812Dec 9, 2024

  Based on observations, record review, and interview conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the Kitchen Task. Specifically, there were multiple cans of expired beef stew in the emergency food storage and expired frozen omelets stored past the expiration date in the kitchen freezer. The findings are: The undated facility policy titled Food Storage documented sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. […]

• No harm, potential for more than minimal, patternF577Sep 15, 2023

  Based on observations, record review and interview conducted during the recertification survey from 9/10/23 to 9/15/23, the facility did not ensure that the results of the most recent survey report and any plan of correction in effect were posted in a place readily accessible to residents, and family members and legal representatives of residents. This was evident for all residents, including 10 of 10 attendees of the Resident Council Meeting. Specifically, the results of the most recent state survey were not posted. […]