Tolstoy Foundation Rehabilitation And Nrsg Center

In the surveyor’s words

From the most serious findings on record at Tolstoy Foundation Rehabilitation And Nrsg Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF578Sep 2, 2025

  Based on interview, observation and record review during the recertification and extended survey from 08/21/2025 - 09/02/2025, the facility failed to establish consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for the resident's care, resulting in staff not being able to appropriately identify Do Not Resuscitate orders for (6) six of 26 residents with Advance Directives. Specifically, Residents #64 and #67 were admitted to the facility with Do Not Resuscitate directives signed at the hospital that were not transcribed to the physician orders in the electronic medical record at the time of admission. […]

• Immediate jeopardy, widespreadF678Sep 2, 2025

  Based on interview and record review conducted during the recertification survey, the facility failed to ensure that properly trained personnel (and certified in CPR for Healthcare Providers) were available immediately (24 hours per day) to provide basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring emergency care prior to the arrival of emergency medical personnel, and subject to accepted professional guidelines, the resident's advance directives, and physician orders between [DATE] and [DATE]. Specifically, eight (8) out of 14 licensed nurses reviewed did not have current or acceptable completed standardized training and certification. […]

• No harm, potential for more than minimal, widespreadF725Sep 2, 2025

  Based on observations, interviews and record reviews conducted during the recertification and extended survey from 08/21/2025 to 09/02/2025, the facility did not ensure sufficient staff was consistently provided to meet the needs of residents on all shifts. Specifically, residents and family members reported during confidential interviews and group meetings that there were frequent delays in responses to call bells. An analysis of the facility assessment and the daily staffing levels documented on multiple occasions between 07/21/2025 and 08/21/2025 the facility did not meet their staffing requirements set forth in their Facility assessment dated [DATE].Findings include: The Facility assessment dated [DATE], documents that each day the facility will have, in total, nine licensed nurses, 20… […]

• No harm, potential for more than minimal, widespreadF835Sep 2, 2025

  Based on interview and record review during the recertification and extended survey on [DATE] - [DATE] the facility administration did not use its resources effectively and efficiently to attain, or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) the facility administration failed to ensure policies and procedures for residents' advance directives were properly identified, communicated, and consistently implemented (See F578). 2) The facility failed to ensure a the policy for cardiopulmonary resuscitation (CPR) was implemented and there were certified staff on every shift (See F678). […]

• No harm, potential for more than minimal, widespreadF837Sep 2, 2025

  Based on interview conducted during the recertification and extended survey on 08/21/2025 - 09/02/2025 the facility did not have a process and frequency by which the administrator reported to the governing body, the method of communication was not recorded, and the governing body did not establish and implement procedures for a clear line of communication regarding the management and operation of the facility. Specifically, the governing body did not receive minutes of the facility Quality Assurance Performance Improvement. The facility did not provide documented evidence that minutes of Quality Assurance Performance Improvement were provided to the governing body. […]