Aaron Manor Rehabilitation and Nursing Center

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 10/17/2024 to 10/24/2024, the facility did not ensure residents were assessed for safe use of bed (side) rails prior to installation, did not review the risks and benefits of bed rails with the resident or resident representative, and did not obtain informed consent prior to the installation of bed rails for 6 of 12 residents (Resident #13, #42, #49, #107, #112 and #128) reviewed for accidents. Specifically, the residents were observed, in bed with bed rails of different types in use and no evidence that assessments had been completed or updated to ensure the safety of the bed rails, that the risks and benefits of the bed rails had been provided to the resident or their representative, or that consent had been obtained physician orders obtained prior to installation. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 10/17/2024 to 10/24/2024, for one of one kitchen, the facility did not provide housekeeping and maintenance services necessary to maintain a clean, comfortable, and homelike environment. Specifically, there was wall damage that was previously identified but not repaired.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 10/17/2024 to 10/24/2024, for two (Resident #73 and #96) of five residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were two medication errors for 27 opportunities resulting in a medication error rate of 7.4 percent. Specifically, a narcotic pain medication was signed for but not administered until eight hours after its scheduled time. A second medication was pre-poured that was not labeled as to what it was or who it was for and the medication nurse was not aware of what the medication for for or where to apply it. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 10/17/2024 to 10/24/2024, for one (3-400 Unit) of two medication storage rooms reviewed, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws. Specifically, the 3-400 Unit controlled medication (medications whose possession and use of are regulated by the government due to their potential for serious side effects) cabinet, contained several blister packs of controlled medications that were secured with one locked door (versus two). The exterior door of the cabinet was unlocked. This is evidenced by the following: The undated facility policy Center Medication Storage Policy included that schedule II-controlled medications are maintained within a separately locked permanently affixed compartment. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 10/17/2024 to 10/24/2024, for four (Residents #11, #13, #51 and #61) of 11 residents reviewed, the facility did not 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. Specifically, two Certified Nursing Assistants did not wear the appropriate personal protective equipment (equipment used to prevent or minimize exposure and transmission of diseases/infections) when transferring a resident on enhanced barrier precautions (an infection control practice that involves wearing gloves and gowns during high-contact patient care activities). [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (#s NY00323049, NY00316578 & NY00311666), it was determined that for one (Resident #1) of three residents reviewed, the facility did not ensure resident records were accurately documented in accordance with professional standards of practice. Specifically, both agency Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) were not appropriately identifying themselves in the resident's electronic medical record (EMR) following administration of medications, documenting progress notes and providing personal care. All were signing care provided using a common generic title. The finding is: The facility policy Medication Administration, dated February 2012, documented that each dose of medication administered shall be properly recorded in the resident's medical record. [...]

Inspectors wroteBased on observations, and interviews, conducted during the Recertification Survey, completed on 1/27/23, it was determined that the facility did not ensure residents' rights to privacy and confidentiality were maintained for ten residents. Specifically, a copy of a facility email, which included ten residents' names, room numbers and health information was posted on a bulletin board in a common area that all staff, residents, and visitors had access to. This is evidenced by the following: During an observation on 1/25/23 at 12:58p.m., a copy of an intra-facility email, dated 1/8/23 at 3:01 p.m., was seen hanging from a green bulletin board located in a common area alcove on the first floor. [...]

Inspectors wroteBased on observation, interviews, and record review during the Recertification Survey, completed on 1/27/23, the facility did not ensure all residents had a safe, clean, comfortable home-like environment for one (Resident #40) of 25 resident investigations. Specifically, the floors, walls, and equipment used for resident care were not maintained in a safe, clean, comfortable, and homelike environment. The finding is: Resident is a [AGE] year-old with diagnoses that include cerebral infarction (stroke), vascular dementia, major depressive disorder, anxiety disorder and unspecified visual loss in both eyes. The Minimum Data Set assessment dated [DATE] documented that the resident had severe cognitive impairment and that their vision was severely impaired-no vision or sees only light, colors or shapes and eyes do not appear to follow objects. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 1/27/23, it was determined that for one (Resident #27) of two residents observed during medication pass, the facility did not ensure that it was free of medication error rate of 5 percent (%) or greater. There were 3 medication errors for 25 opportunities resulting in a 12% medication error rate. The issues involved not administering the correct dose of eye drops, not mixing a medication in the correct amount of liquid, and not administering a medication on an empty stomach and without other medications.

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey completed on 1/27/23, it was determined that for 10 (Residents #65, #270, #110, #30, #59, #54, #379, #67, #370, and #113) of 16 residents reviewed, the facility did not ensure that a Baseline Care Plan (BCP) was developed and implemented within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and that a written summary of the care plan, that they were able to understand, was provided and reviewed with the resident and/or their representative in a timely manner per the regulations. This was evidenced by, but not limited to, the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey completed on 5/11/21, for one (Resident #37) of three residents reviewed, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Specifically, the facility did not consistently monitor the resident's oxygen liter flow or oxygen saturation levels (amount of oxygen in the blood stream) according to physician orders. This is evidenced by the following: Resident #37 had diagnoses including chronic obstructive pulmonary disease (COPD) dependent on oxygen, respiratory failure, and congestive heart failure (CHF). [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 5/11/21, it was determined that for one of one resident (Resident #95) the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, medical orders to monitor the bruit and thrill (the flow of blood) of the resident's left arm fistula (a surgical graft used for dialysis) was not consistently documented as completed as ordered and there was no documentation that a fluid restriction was being monitored as ordered. This is evidenced by the following: Resident #95 had diagnoses including end stage renal disease requiring dialysis three times per week, a new arterial venous fistula in the left arm and Parkinson's disease. [...]

Inspectors wroteBased on observation, interview and record review during the Recertification Survey, completed on 5/11/21, it was determined that for one (unit one) of three medication carts and one (unit one) of two medication rooms reviewed, the facility did not ensure that all medications and biologicals were properly labeled and stored according to state and federal laws. Specifically, opened, unlabeled or undated medications were observed in a medication cart and a medication room was observed unlocked and unattended. Additionally, narcotic counts were not documented as being done consistently in one (unit 3) of two medications rooms. This is evidenced by the following: 1. During observation of medication storage on 5/7/21 at 8:55 a.m., the Unit One medication room door was unlocked and unattended allowing the surveyor easy entry into the medication room and easy access to the medications. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, completed on 5/11/21, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute and serve food under sanitary conditions. The issue included potentially hazardous food that was not cooled properly. This is evidenced by the following: Review of a facility policy (undated), Cooling Potentially Hazardous Foods, directs to chill food rapidly using an appropriate cooling method, separate food into smaller or thinner portions, place food in shallow containers no more than four inches deep and uncovered on the top shelf in the back of the walk-in or reach-in cooler. Cooked hot food should be chilled from 140 degrees Fahrenheit (°F) to 70°F within two hours. Take corrective action immediately if food is not chilled from 140°F to 70°F within two hours. [...]