Cayuga Nursing and Rehabilitation Center

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00341003) surveys conducted 1/16/2025-1/24/2025, the facility failed to ensure the residents' environment remained free of accident hazards for one (1) of three (3) residents (Resident #171) reviewed. Specifically, Resident #171 had a physician order for a regular dysphagia (difficulty swallowing) pureed texture diet and was served and fed ground vegetables, began to cough, and was sent to the hospital. Additionally, staff education was not initiated timely after the incident. This resulted in Immediate Jeopardy past non-compliance to Resident #171 and placed all residents on modified consistency diets at risk for serious injury, serious harm, serious impairment, or death.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice 1 of 1 resident (Resident #49) reviewed. Specifically, Resident #49 was administered 14 doses of expired levetiracetam (seizure medication) from 1/10/2025 to 1/17/2025.

Inspectors wroteBased on interviews and record review during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that views, grievances, or recommendations voiced by residents during Resident Council group meetings were considered or acted upon and responded to with a rationale for 10 of 10 anonymous residents present at the resident group meeting. Specifically, 10 of 10 anonymous residents present at the resident group meeting stated they did not receive responses to topics or concerns addressed in prior meetings. Additionally, there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided to the residents.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00354013) surveys conducted 1/20/2025-1/24/2025, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 1 of 1 resident (Resident #371) reviewed. Specifically, Resident #371 was care planned for 2-person assistance with a mechanical lift for transfers and Certified Nurse Aide #29 transferred the resident alone resulting in the resident nearly falling. The resident was not assessed by a qualified professional following notification of the care plan violation and was subsequently found with skin tears to both legs.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure at the time of admission residents had physician orders for immediate care consistent with the resident's physical status for 1 of 1 resident (Resident #473) reviewed. Specifically, Resident #473's hospital discharge orders and hospital discharge summary had conflicting diet consistency information that was not clarified on admission to the facility.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care; a Level II Preadmission Screening and Resident Review identifies the specialized services required by the resident) for 1 of 2 residents (Resident #66) reviewed. Specifically, Resident #66 had a significant mental illness and a change in behavior that required medication intervention and there was no documentation a new Screen Level I was completed, or a Level II referral was initiated.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure a discharge planning process was in place addressing each resident's discharge goals and needs and involved the resident and the resident representative for 1 of 2 residents (Resident #105) reviewed. Specifically, Resident #105 expressed the goal to be discharged back to their prior living situation and was not assisted with discharge planning or updates on the status of their discharge goal.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #65) reviewed. Specifically, Resident #65 received hemodialysis treatments at a community-based dialysis center and there was inconsistent communication and collaboration between the dialysis center and the facility. The facility policy, Care of Hemodialysis Resident, revised 3/30/2024, documented all residents receiving dialysis-hemodialysis would have interventions in place for appropriate care and treatment. The facility would complete the hemodialysis report prior to each dialysis treatment and send it to the dialysis center with the resident. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure medication rates were not greater than 5 percent for 2 of 5 residents (Resident #27 and 110) reviewed. Specifically, Resident #27 was administered 5 medications over one hour late; their sliding scale insulin dose was given after breakfast and not before as ordered; and the insulin pen was not primed (removal of air bubbles); and Resident #110 was administered four medications via mouth and not via a gastrostomy tube as ordered and the medications were administered over one hour late. The facility's medication error rate was 37.04%.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, there were unclean areas in the kitchen; and potentially hazardous foods in the main kitchen were prepared and left out of temperature too long.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00289457 and NY00288549), the facility did not ensure residents were provided a therapeutic diet prescribed by a physician for 1 of 3 (Resident #1) residents reviewed. Specifically, Resident # 1 was admitted to the facility with a recommendation for an altered consistency diet due to a history of food obstruction. The resident did not have a physician ordered diet until after an episode of coughing and vomiting during a meal. The resident subsequently required hospitalization for removal of an esophageal food obstruction.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 3 resident units (Unit 2 including resident rooms 203, 214, 217, the second floor lounge area near the elevator, dining room, nursing station, tub room near room [ROOM NUMBER], soiled utility room across from the nursing station, the central shower room, the hallway to the ramp lounge; Unit 3 including resident room [ROOM NUMBER], and the hallway near emergency exit stairwell #2). Specifically, there were unclean and damaged floors, damaged walls, and unclean ceilings.

Inspectors wroteBased on record review and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure each resident was offered influenza and/or pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 3 of 5 residents (Residents #79, 102, and 416) and 6 of 11 staff (licensed practical nurse [LPN]#10, recreation aide #20, nurse practitioner [NP] #25, resident helper #26, certified nurse aide [CNA] #28, and dietary aide #30) reviewed. Specifically, there was no documented evidence Residents #79 and #146 were offered, declined, or educated on the pneumococcal immunization; no documented evidence Resident #102 was offered, declined, or educated on the influenza and pneumococcal immunization; [...]

Inspectors wroteBased on record review and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure residents and/or resident representatives the right to participate in the development and implementation of the person-centered plan of care for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 and/or the resident's representative were not invited to attend the resident's interdisciplinary care plan meeting and were not included in the care planning process.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure that prompt efforts were made to resolve grievances that residents may have for 1 of 1 resident (Resident #42) reviewed. Specifically, Resident # 42 had a pair of gray pants misplaced in the laundry that were not replaced. The facility policy, Resident Complaint and Grievance Process dated 2/2012 documented as part of the facility's commitment to safe, respectful, and high-quality care, all concerns brought to the organization's attention by residents/legal representatives shall be reviewed in a timely manner. This organization shall respond to such concerns in a timely, reasonable, and consistent manner. Resident #42 was admitted with diagnoses including Parkinson's disease (a progressive neurological disorder), depression, and anxiety. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 6/1/23-6/8/23 the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident that included services to attain or maintain the highest practicable well-being for 2 of 3 residents (Residents #101 and 102) reviewed. Specifically, Resident #102 received Lovenox (blood thinner) injections and did not have a care plan that included precautionary and monitoring measures for possible adverse effects; and Resident #101 did not have an individualized care plan that included the resident's customary routines, interests, preferences, and choices to enhance their well-being and to guide staff in managing the resident's dementia care.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00316633) surveys conducted 6/1/23-6/8/23, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Residents #6 and 50) reviewed. Specifically, Resident #6 was not assisted with toileting as planned; and Resident #50 was not assisted with getting out of bed and was not dressed.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure they provided residents with an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 4 residents (Residents #83 and 86) reviewed. Specifically, Residents #83 and 86 were not offered meaningful activities of their choosing as care planned.

Inspectors wroteconducted 6/1/23-6/8/23, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #99) reviewed. Specifically, Resident #99 had a history of multiple falls and did not have their locked wheelchair placed next to them while in bed as planned.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00316633) surveys conducted 6/1/23-6/8/23, the facility failed to ensure that residents maintained acceptable parameters of nutritional status for 1 of 8 residents (Resident #101) reviewed. Specifically, Resident #101 had a significant weight loss that was not reviewed with the medical provider or reassessed by clinical nutrition staff.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23 the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #75) reviewed. Specifically, Resident #75 was not administered oxygen (O2) as ordered.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety for the main kitchen, for 2 of 3 kitchenettes (1st and 3rd floor kitchenettes), and for 2 of 2 food service employees (dietary aides #43 and 47) reviewed. Specifically, the handwashing facilities in the main kitchen and kitchenettes were inaccessible; the main kitchen and the 3rd floor kitchenette hand sinks were not equipped with paper towels; dietary aide #47 was observed performing improper hand hygiene and using gloves inappropriately; and dietary aide #43 did not perform hand hygiene before preparing and serving lunch meals.

Inspectors wroteBased on record review and interview during the recertification survey conducted 6/1/23-6/7/23, the facility did not ensure maintenance of 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 diseases and infections including Legionella (a type of bacteria usually found in water causing Legionnaires' disease). Specifically, the facility Legionella Risk Assessment was not reviewed annually as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized work area for 1 of 1 resident (Resident #15) reviewed. Specifically, Resident #15 had disabilities that prevented them from utilizing their provided call bell and the resident was not assessed for an alternate type of communication system.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted from 7/27/21-7/30/21 the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 3 residents (Resident #72) reviewed. Specifically, Resident #72 was observed on multiple occasions with their call bell out of reach.

Inspectors wroteBased on observations, record review and interview during the recertification survey conducted 7/27/21-7/30/21 the facility did not ensure residents right to a safe, clean, comfortable, and homelike environment, allowing the resident to use their personal belongings to the extent possible for 1 of 1 (Resident #62) reviewed. Specifically, Resident #62's room was stark and devoid of any personal belongings.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated surveys (NY00275631) conducted 7/27/21-7/30/21 the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse and were reported to the New York State Department of Health (NYS DOH) for 2 of 3 (Residents #50 and 65) reviewed. Specifically, Residents #50 and 65 were observed by staff engaging in a sexual interaction, the incident was not investigated, reported timely and a plan was not implemented to prevent further incidents. Residents #50 and 65 were observed the following day engaged in a sexual interaction.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted from 7/27/21-7/30/21 the facility did not ensure each resident receives and facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meals (third floor unit dinner and first floor unit lunch) reviewed. Specifically, meal temperatures were not maintained at acceptable parameters during the 2 meals.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 7/27/21 to 7/30/21, the facility did not ensure food was prepared and stored in accordance with professional standards for food service safety for three isolated food items (slices of pork, crab salad, and pureed peaches). Specifically, the pork slices, crab salad and pureed peaches were not discarded three days after being prepared.

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (NY00271957) conducted from [DATE]-[DATE], the facility did not notify hospice of a resident's passing as required for 1 of 3 (Resident #99) residents reviewed. Specifically, Resident #99 expired and the facility did not notify hospice of the resident's death.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated survey (NY00271957) conducted 7/27-7/30/21, the facility did not establish and maintain an infection prevention and control program to ensure the health and safety of residents and to prevent the transmission of COVID-19 for 1 of 1 resident (Resident #302) and 1 licensed practical nurse (LPN) #1 reviewed. Specifically, LPN #1 was observed at a distance closer than 6 feet with their surgical mask not covering their nose and mouth during a treatment administration with Resident #302. Additionally, LPN #1 was observed on multiple occasions in the hall and at the nursing desk with incorrect mask use.