Champlain Valley Physicians Hosp Med Ctr S N F

Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #28) of 2 residents reviewed for communication. Specifically, Resident #28, who had impaired vision was not assisted in obtaining optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #28 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a long-term breathing problem), hypertension (high blood pressure), and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The Minimum Data Set (an assessment tool) dated 11/10/2024, documented the resident was understood, able to understand others, and was cognitively intact. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, cleaning chemicals were not stored properly, equipment was not in good repair or installed safely, equipment and floors were not clean, and the proper testing equipment was not available for checking the concentration of sanitizing solution. This is evidenced by: During observations on 01/13/2025 at 12:29 PM, the following was noted: • Glass cleaner was stored above food processor. • The warewashing area spay hose nozzle was hanging below the sink flood rim in water. • The facility did not have correct test papers to check the sanitizing solution; [...]

Inspectors wroteBased on record review and interviews during the recertification and abbreviated survey (Case #s NY00346121, NY00366317, and NY00365618), the facility did not ensure the resident's right to be free from abuse and neglect for 3 (Resident #s 1, 14, and 23) of 4 residents reviewed for abuse and neglect. Specifically, (a.) for Resident #1, a staff member grabbed their forearm and removed their call light on 6/23/2024; (b.) for Resident #14, a bed bolster was not in place when one staff member assisted in the resident's care when the resident required two staff, resulting in a fall on 12/22/2024; (c.) for Resident #23, a staff member grabbed their hand resulting in a skin tear. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #NY00366317), the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #23) of 4 residents reviewed. Specifically, an allegation of physical abuse observed by staff on 12/25/2024 at 2:00 AM was not reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 12/26/2024 at 3:19 PM. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification and abbreviated survey (Case #NY00366317), the facility did not ensure the resident's right to be free from further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for 1 (Resident #23) of 4 residents reviewed for abuse and neglect. Specifically, Certified Nurse Aide #3 was not removed immediately from resident's care when there was an allegation of physical abuse to prevent further abuse from occurring. Certified Nurse Aide #3 was allowed to work until the end of their shift. This is evidenced by: The facility policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #NY00365618), the facility did not ensure adequate supervision and assistive devices were provided to prevent accidents for 1 (Resident #14) of 3 residents reviewed for accident hazards. Specifically, Resident #14, who required 2 caregivers for care was assisted with 1 caregiver and a bed bolster was not in place resulting in the resident rolling out of bed. Resident #14 was admitted to the facility with the diagnoses of dementia, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsion, associated with abnormal electrical activity in the brain), and major depressive disorder. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00343699 and NY00318831), the facility did not ensure that all alleged violations involving abuse was reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the State Survey Agency in accordance with State law through established procedures for 2 (Resident #s 1 and 3) of 4 residents reviewed for abuse reporting. Specifically, allegations of physical and sexual abuse that involved 2 residents was not reported by staff to facility administration within 2 hours. This is evidenced by: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety in the main kitchen. Specifically, a toxic vapor-emitting fly strip was found in the dishwashing machine area; brooms and dust bins were stored in the cafeteria preparation area; and the floor mixer, bake shop table mixer, microwave oven, can opener holders, bake shop sugar bin, refrigerator door gaskets, cooking line floor under equipment, floor at entrance to the walk-in freezer, and fire extinguishers were soiled with food particles, food splatters, or a grease build-up. This is evidenced as follows: During main kitchen observations on 07/13/22 at 10:45 AM, a toxic vapor-emitting fly strip was found in the dishwashing machine area; [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey on 10/11/2022 through 10/14/2022 the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements related to F656; Development and Implementation of Comprehensive Care Plans, and F697; Pain Management. Specifically, the facility did not ensure that the approved Plan of Correction (POC) for F 656, and F 697 cited during the Recertification Survey completed on 12/19/2019 were implemented, resulting in the same deficiencies being issued during the current survey. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification survey dated 10/11/22 through 10/14/2022, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for one (1) of 3 medical records reviewed. Specifically, Resident #84 received Medicare Part A services and did not provide notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC. This is evidenced as follows: [...]

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for three (Residents #,s 6, 7, and #10) of sixteen residents reviewed for comprehensive care plans (CCP). Specifically, for Resident #6, the facility did not ensure a CCP was developed to address the use of oxygen and the use of anticoagulants (blood thinners), for Resident #7, a CCP was not developed to address frequent migraines and for Resident #10, a CCP was not developed to address recent antipsychotic medication. This is evidenced by: Resident #6: [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for 1 (Resident #6) of 1 resident reviewed for respiratory care. Specifically, for Resident #6, the facility did not ensure the resident's medical record included documentation of on-going administration of oxygen and monitoring of the resident's respiratory status. This is evidenced by: The Policy and Procedure (P&P) titled Oxygen Therapy Protocol for Adults last revised 3/28/22, did not address documentation or on-going monitoring of residents receiving oxygen therapy. Resident #6: Resident #6 was admitted with diagnoses of dementia, atrial fibrillation, and chronic pulmonary embolism. [...]

Inspectors wroteBased on record review and interviews during a recertification survey the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #'s 7 and #287) of 3 residents reviewed for pain management. Specifically, for Residents #'s 7 and #287, the facility did not ensure the resident's pain levels were assessed, did not ensure that non-pharmacological interventions for pain relief were provided and did not ensure that the effectiveness of as needed (PRN) pain medications were monitored. This was evidenced by: [...]

Inspectors wroteBased on record review and interview during the recertification survey dated 10/11/2022 through 10/14/2022, the facility did not ensure the policy regarding foods brought to residents is in accordance with adopted regulations. Specifically, the facility does not provide orally and in writing, information for family and other visitors on safe food handling practices or safe reheating of food that is brought to residents. This is evidenced is as follows: The document titled Food Brought By Family/Visitors - SNF and dated 08/2019 documents that safe food handling practices will be explained to family/visitors in a language and format they understand. The facility policy for foods brought in by visitors was reviewed on 12/04/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. [...]

Inspectors wroteThe facility did not ensure person-centered comprehensive care plans were developed and implemented that included measurable objectives and timeframes to meet the residents needs for 5 (Resident #'s 6, 17, 23, 33, and #286) of 12 residents reviewed. [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey the facility did not ensure adequate pain management was provided to a resident who required such services, consistent with professional standards of practice for one (1) (Resident #6) of one (1) residents reviewed. Specifically, the facility did not ensure that circumstances for when pain could be anticipated were identified and communicated, did not ensure the resident's existing pain was routinely evaluated for the management and prevention of pain, and did not ensure the use and administration of an as needed (PRN) medication was adequately monitored for effectiveness with the use of a pain scale per standard of practice. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it established and maintained 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 for one (Resident #23) of one resident observed for dressing changes. Specifically, for Resident #23, the facility did not ensure infection control measures were maintained during a wound vac dressing change. This is evidenced by: Resident #23: The resident was admitted to the facility with the diagnosis of Multiple Sclerosis (MS), quadriplegia and pressure ulcer of the sacral region. [...]