Amsterdam Nursing Home Corp (1992)

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident or their representative was afforded the opportunity to participate in their care planning process. This was evident in 1 (Resident #207) of 1 resident reviewed for care planning out of 38 total sampled residents. Specifically, Resident #207's representative was not consistently invited to participate in their care plan meetings.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. This was evident in 1 (Resident #130) of 2 residents reviewed for Hydration. Specifically, Resident #130 was observed with a soiled dressing on their peripherally inserted intravenous catheter on the left upper extremity.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. This was evident in 1 (Resident #74) of 4 residents observed for Pressure Ulcer Injury out of 35 total sampled residents. Specifically, Registered Nurse #8 failed to follow infection prevention and control practices while performing wound care treatment.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that appropriate services, care, and equipment were provided to assure that residents did not experience a reduction in range of motion or received appropriate treatment and services to prevent further decrease in range of motion. This was evident in 1 (Resident #162) of 5 residents reviewed for Rehabilitation and Restorative Care. Specifically, Resident #162 was observed with a left-hand contracture that has not been thoroughly assessed by the facility.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure drugs and biologicals were stored in accordance with professional standards. This was evident in 1 of 6 units observed for medication storage. Specifically, the 3rd Floor unit medication refrigerator was observed to contain an expired COVID-19 vaccine.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident received dental services in a timely manner. This was evident in 1 (Resident #30) of 1 resident reviewed for Dental out of a sample of 38 residents. Specifically, Resident #30's dentures fell on the floor and broke on 03/12/2025. The dentures were not repaired and returned to the resident for 50 days. There was no documentation of circumstances that led to the delay of replacing the resident's dentures.

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that resident dietary preferences were followed. This was evident in 1 (Resident #137) of 2 residents reviewed for Food out of 37 total sampled residents. Specifically, Resident #137 was provided whole milk instead of their documented preference of lactose-free milk.

Inspectors wroteBased on record review and interview during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that Minimum Data Set assessments accurately reflected each residents' status. This was evident in 2 (Resident # 367 and Resident # 265) of 38 total sampled residents. Specifically, 1.) Resident #367's assessment did not accurately reflect their discharge status and 2.) Resident #265's assessment did not reflect the use of a wander alert device.

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, 1) residents complained of low staffing levels; 2) an incident of resident to resident abuse occurred when the unit was below Par in staffing and care planned supervision was not provided to the residents (F600); [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey, the facility did not ensure that a baseline care plan for each resident that includes the instructions needed to provide effective, person-centered care of the resident was developed and implemented and provide the resident and their representative with a written summary of the baseline care plan. Specifically, Baseline Care Plans were initiated but not completed within 48 hours of admission, and residents and their representatives were not provided with a written summary of the baseline care plan. This was evident for 1 of 7 residents reviewed for Nutrition, and 1 of 5 residents reviewed for Unecessary Medicatiosn out of 38 sampled residents. (Residents #312 and 361).

Inspectors wroteBased on record review, and staff interviews conducted during the recertification survey, the facility did not ensure comprehensive person-centered care plans were developed and implemented for each residents to meet the residents' medical, nursing, and psychosocial needs that were identified in the comprehensive assessment. Specifically, 1.) a comprehensive care plan (CCP) was not developed to address a resident's Foley Catheter; 2.) a CCP was not developed to address a resident's diagnosis of End Stage Renal Disease (ESRD) on Dialysis, and 3.) the facility failed to implement interventions to stabilize or improve nutritional status as identified in the resident comprehensive assessemnt. [...]

Inspectors wroteBased on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that a resident's comprehensive care plan for hospice was reviewed and revised. This was evident for one of 38 sampled residents (Resident #5).

Inspectors wroteBased on record review and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the facility were acted upon. Specifically, the facility failed to document in the resident's medical record that irregularities identified by the consultant pharmacist had been reviewed and what, if any, action has been taken to address the issues. This was evident for 2 out of 5 residents reviewed for Unnecessary Medications out of a sample of 38 residents. (Resident # 215 and Resident #288).

Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey, the facility did not ensure drugs and biological's were labeled in accordance with currently accepted professional principles and stored under proper temperature controls per manufacturer's recommendations. Specifically, four opened insulin pens were not dated with dates they started using them. This was evident for 1 of 8 carts observed out of 12 units reviewed for Medication Storage (Unit 7th).