Kendal On Hudson

In the surveyor’s words

From the most serious findings on record at Kendal On Hudson, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578May 12, 2022

  Based on observations, interviews and record review conducted during a recertification survey, the facility did not ensure that the advance directives formulated for 3 of 3 residents (#5, #7, and #17) regarding Do Not Resuscitate (DNR) would be honored. Specifically, the facility did not effectively implement a system to carry out Do not Resuscitate (DNR) orders for residents who have been identified to have written consents for DNR (Do Not Resuscitate) that they would not be resuscitated when indicated. […]

• No harm, potential for more than minimal, isolatedF645May 6, 2024

  Based on interviews and record reviews conducted during a Recertification Survey from 04/30/2024 to 5/06/24, it was determined that for 2 of 16 residents (Residents #5 and #14), the facility did not ensure that preadmission screening for individuals identified with an intellectual disability (ID) was fully completed prior to admission, in order to receive care and services in the most integrated setting appropriate to their needs. Specifically, the Pre-Admission Screen Resident Review (PASRR) for Resident #5 and #14, dated 02/29/2024 and 02/23/24 respectively, lacked a screener identification number. Findings include: Resident #5 was admitted on [DATE] with a diagnosis of Alzheimer's/dementia and depression. […]

• No harm, potential for more than minimal, isolatedF677May 6, 2024

  Based on record review, interview and observation during the recertification survey conducted from 4/30/24 through 5/6/24 the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 2 residents (Resident #1) reviewed for activities of daily living. Specifically, Resident #1 who required staff assistance for eating was observed on 2 occasions being fed by a companion (no hands on care). The findings are: The policy and procedure titled Private Companion in the Health Center with a revision date of March 2023 documented the role of the companion included assisting at mealtimes with menu selection, setting up utensils, opening containers. […]

• No harm, potential for more than minimal, isolatedF684May 6, 2024

  Based on observations, record review and interviews conducted during the Recertification Survey from 4/30/24-5/6/24, the facility did not ensure 1 of 2 residents (Resident #19), reviewed for positioning, received treatment and care in accordance with professional standards of practice. Specifically, Resident #19 was observed on multiple occasions sitting in their wheelchair without footrests, legs were dangling, and feet were not touching the floor. The findings are: The facility policy titled Wheelchair Positioning dated 12/2004 and updated in 2023 documented it is the policy of the Rehabilitation Department to provide functional, safe, and comfortable wheelchair positioning to all residents at the time of admission or as identified at any time the need for a new evaluation. […]

• No harm, potential for more than minimal, isolatedF689May 6, 2024

  Based on observations, record review, and interviews conducted during the recertification and abbreviated surveys (NY00321462) from 4/30/24 to 5/06/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 2 of 4 residents (Residents #18 and #74) reviewed for accidents. Specifically, (1) Resident #18 whom has a history of falls with major injuries, was observed on multiple occasions without their floor mats in place to the sides of their bed. (2) Resident #74 who had exit seeking behavior, was not provided adequate supervision and was able to exit the facility undetected by staff. […]