Archcare at Providence Rest

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure a resident received adequate supervision to prevent an accident. This was evident in one (1) (Resident #79) of six (6) residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #79, who was identified as high risk for falls and had a history of multiple falls, was not provided adequate monitoring or supervision. Subsequently, on 01/15/2025 at approximately 9:10 AM, Resident #79 had an unwitnessed fall in their room and sustained a fracture of the left femur (commonly known as the thigh bone). This resulted in actual harm to Resident #79 that was not Immediate Jeopardy.

Inspectors wroteBased on the interviews, observations and record reviews conducted during the Recertification Survey from 3/02/2025 to 3/07/2025, the facility did not ensure that it had sufficient staff to provide nursing care and services to maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the CASPER Payroll Based Journal Staffing Data report for 4th quarter 2024 triggered for low weekend staffing and review of staffing indicated that actual staffing levels were not maintained at par levels indicated in the Facility Assessment.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 03/02/2025 to 03/07/2025, the facility did not ensure that that the notice of the availability of the most recent New York State Department of Health survey report and plan of correction, was posted in areas that are prominent and readily accessible to the public. Specifically, there were no prominent postings of notices of availability throughout the facility and no posting in the facility lobby which is readily accessible to the public. In addition, members of the Resident Council who were interviewed, were unable to identify locations where signs or postings documented the availability and location of the survey results.

Inspectors wroteBased on interview and record review conducted during the Recertification Survey from 3/02/2025 to 3/07/2025, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 1 (Resident #79) out of 6 residents reviewed for Accidents out of 38 total sampled residents. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification Survey from 03/02/2025 to 03/07/2025, the facility did not ensure that residents' and their representatives were provided with a written summary of the Baseline Care Plan. This was evident in 1 (Resident #10) of 2 residents reviewed for Tube Feeding out of 38 total sampled residents. Specifically, residents or their representatives did not receive a copy of their baseline care plan.

Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey conducted from 3/2/2025 to 3/7/2025, the facility did not ensure that a person-centered comprehensive care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, comprehensive care plan was not developed and implemented for a resident prescribed an antibiotic for urinary tract infection. This was evident in 1(Resident #179) of 4 residents reviewed for Urinary Tract Infections out of total 37 sampled residents.

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY00310625) the facility failed to ensure the resident was free of significant medication errors. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 02/10/2023, Medical Doctor #1 stated that they mistakenly scheduled medication four times a day instead of one time at bedtime for Resident #1. The Medical Doctor #1 ordered Warfarin Sodium (Coumadin, a blood thinner) three (3) milligram one tablet by mouth at bedtime for rapid heartbeats caused by poor blood flow. The Medical Doctor #1 entered the times that the medication must be given at 07:30 AM, 12:00 PM, 5:30 PM and 9:00 PM. On 02/10/2023, Resident #1 was given two (2) doses, one (1) at 12:00 PM by Registered Nurse #1 and another dose at 9:00 PM by Registered Nursing #2. [...]

Inspectors wroteBased on record review, and staff interviews conducted during the Recertification survey conducted from 1/19/2023 to 1/26/2023, the facility did not ensure that Resident or Resident's representative were offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 3 of 3 residents reviewed for Care Planning out of 38 residents sampled (Residents #159, #160 and #140).

Inspectors wroteBased on observation, record reviews, and staff interviews conducted during the Recertification/Complaint Survey (NY00307787), the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs and residents who use psychotropic drugs receive behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, 1). A gradual dose reduction was not done for a resident as recommended by the Psychiatrist for a resident without behavioral symptoms, and 2). Antipsychotic medication was used without an appropriate diagnosis and there was no documentation of behaviors or non-phamacological interventions utilized. This was evident for 2 of 5 residents reviewed for Unnecessary Medications out of 38 sampled residents. (Residents #88, and #107)

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 01/19/2023 to 01/26/2023, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. Specifically, the facility did not ensure the resident was appropriately dressed to maintain privacy and was not exposed to passersby in the hallway when wearing a hospital gown. This was evident for 1 of 2 residents reviewed for Dignity out of a sample of 38 residents. (Resident # 351)

Inspectors wroteBased on observation, interview and record review conducted during a Recertification survey from 01/19/2023 to 01/26/2023, the facility did not ensure that residents received appropriate care and treatment to prevent potential urinary tract infections. Specifically, 1). There was no physician order for care and treatment of the Nephrostomy tube (a Nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects), and 2). Proper infection control measures were not maintained to prevent the potential development and transmission of infections for a resident with a urinary catheter connected to a drainage bag which was not properly monitored. This was evident for 2 of 4 residents reviewed for Urinary Catheter or UTI out of a sample of 38 residents. (Resident # 5 and #351) The finding is: 1. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 1/19/23 to 1/26/23, 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 had been taken to address the irregularities. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 38 residents. (Resident # 88) The finding is: The Long Term Solutions Pharmaceutical Consultant Policy and procedure for Drug Regimen Review provided by the facility on 01/26/2023 documented: .Drug regimen reviews (DRR) that require physician intervention will be responded to by the physician/designee within 7 days. [...]

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 1/19/23 to 1/26/23, the facility did not ensure that the residents drug regimens were free from unnecessary drugs. Specifically, the facility did not document the diagnosed condition for which a medication is prescribed. This was evident for 1 of 5 residents reviewed for Unnecessary Medication out of a sample of 38 residents (Resident #20).

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey conducted from [DATE] to [DATE], the facility did not ensure that within 7 days after a facility completes a resident's assessment, they encoded and transmitted a subset of data upon a resident's transfer, reentry, discharge, and death. This was evident for 3 of 5 residents reviewed for Resident Assessment out of a sample of 39 residents. Specifically, there was no evidence that a Discharge Minimum Data Set (MDS) was submitted for Residents #80 and #179, and that a Death in Facility MDS was submitted for Resident #68.

Inspectors wroteBased on record reviews and staff interviews during the re-certification survey, the facility did not ensure comprehensive care plans were developed, reviewed, and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments. Specifically (1) a comprehensive care plan for psychotropic drug use was not reviewed and revised for approximately eight months from May 10, 2019 to January 8, 2020 to reflect the resident's current status and medication dosage (Resident #43), (2) care plan updates did not reflect a resident's psychotropic medication increase, indicating the resident was on the same dosage (Resident #60); (3) a care plan was not developed to reflect the care needs of a resident's nephrostomy (Resident #45). This was evident for 3 of 38 residents reviewed in the final sample (Resident #s 43, 60, and 45).

Inspectors wroteBased on record review and staff interview during the re-certification survey, the facility did not ensure that the attending physician documented in the medical record that an identified irregularity in the drug regimen review was reviewed and what, if any, action has been taken to address it. This was evident for 1 of 5 residents reviewed for unnecessary medications out of a final sample of 38 residents (Resident #43). The finding is: Resident #43 was admitted with diagnoses which include Depression other than bipolar. The Minimum Data Set 3.0 (MDS) Annual and Quarterly assessments dated 02/07/2019 and 10/17/2019 respectively were reviewed. Resident has intact cognition and has a mood score of 1 and then a 0 and no behaviors indicated. Resident also received seven days of anti-depressant medication. The Comprehensive Care Plan (CCP) titled, Psychotropic Drug Use: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure that a resident receiving psychotropic drugs received adequate monitoring and gradual dose reductions (GDR) in an effort to discontinue these drugs. Specifically, a resident with depression has been on an anti-depressant medication, Remeron 22.5 milligram (mg) daily, from 08/08/2018 to 01/13/2020 without a gradual dose reduction or monitoring for the effectiveness and continued need for the medication. This was evident for 1 of 5 residents reviewed for unnecessary medications out of a final sample of 38 residents (Resident #43). The finding is: The facility policy and procedure titled, Psychotropic Medication Usage (Dated 09/07) documented the following: [...]