Charles T Sitrin Health Care Center Inc

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received adequate supervision and failed to identify and reduce hazards and risks for one of one resident (Resident #1) reviewed. Specifically, Resident #1 was admitted to the Neurodegenerative Unit with a history of suicidal ideations and hearing voices they referred to as demons. On [DATE], Resident #1 was found unresponsive in their room with a cord wrapped around their neck; cardiopulmonary resuscitation was initiated; Emergency Medical Services arrived and transported the resident to the hospital where they were pronounced deceased . This resulted in Immediate Jeopardy to Resident #1 and placed all 13 residents on the Neurodegenerative Unit with history of suicidal ideations at risk for the likelihood of serious harm, serious impairment, serious injury, or death.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the services provided or arranged by the facility were provided by qualified persons for three of three licensed nurses reviewed (Licensed Practical Nurses #5, #11 and #12) reviewed. Specifically, Licensed Practical Nurses #5, #11 and #12 performed cardiopulmonary resuscitation on Resident #1 without having valid cardiopulmonary resuscitation certification.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00341115), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the resident's choices for one (1) of three (3) residents reviewed (Resident #1). Specifically, Resident #1 was reported by family to be choking on liquids and there was no documented evidence the resident was assessed by a qualified professional to determine if a modification to their diet was required.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00323986), the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents for one (1) of three (3) Residents (Resident #2) reviewed. Specifically, Resident #2 sustained a fracture of unknown origin to their left arm. The facility investigation identified family members were known to have transferred the resident and there was no evidence the family was educated on safe transfer techniques prior to the identification of the fracture.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00368525) the facility failed to ensure residents were free from abuse for one (1) of seven (7) residents reviewed (Resident #1). Specifically, Resident #1 was physically removed, against the resident's will, from the dining room by Licensed Practical Nurse #4, who then continued to have an altercation in the hallway, which resulted in the resident falling several times. The facility's failure to protect residents from abuse resulted in harm that is Immediate Jeopardy and Substandard Quality of Care for Resident #1 and placed all 173 residents in the facility at risk for the likelihood of serious harm, serious impairment, serious injury, or death.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00368525) the facility failed to ensure an incident of staff abuse toward a resident was reported to the State Agency, law enforcement, and the Administrator for one (1) of seven (7) residents reviewed (Resident #1). Specifically, facility staff witnessed or were present when Licensed Practical Nurse #4 abused Resident #1 and the incident was not reported to facility Administration, law enforcement, and the New York State Department of Health for seven (7) days. Additionally, Licensed Practical Nurse #4 continued to have access to residents following the witnessed abuse. [...]

Inspectors wroteBased on observations and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested (Rehabilitation Unit lunch) and beverages for the [NAME] house breakfast. Specifically, scrambled eggs, home-fried potatoes, toast, applesauce, mixed fruit, corn, milk, orange juice and cranberry juice were not served at palatable temperatures.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/12/2024 - 11/19/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the facility's main kitchen and in 4 of 9 house kitchenettes (Magnolia, Cypress, [NAME], and Sycamore) reviewed. Specifically, the main kitchen had multiple unclean surfaces and undated food; and the Cypress, [NAME], Sycamore and Magnolia house kitchenettes had opened and undated food items.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00353770 and NY00356334) surveys conducted 11/12/2024-11/19/2024, the facility did not make prompt efforts to resolve grievances for 1 of 1 resident (Resident #126) reviewed. Specifically, Resident #126 was missing their right hearing aid, and it was not recovered or replaced. Additionally, placement of both hearing aids was documented in the medical record after the right hearing aid was reported missing. The facility policy, Resident and Family Grievance Policy and Procedure, revised 7/2023, documented all residents/patients and their families would be informed of the steps necessary to communicate a formal grievance without fear of retaliation or barriers to service. Grievances could be through written or verbal communication. [...]

Inspectors wroteBased on record review and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure residents were screened for serious mental disorders, intellectual disabilities, and related conditions prior to admission to the facility for 1 of 35 residents (Resident #104) reviewed. Specifically, there was no documented evidence Resident #104 had a Preadmission Screening and Resident Review Level I completed by a qualified screener prior to admission to the facility to determine if the resident had a mental disorder, intellectual disability, or a related condition.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 11/12/2024- 11/19/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident to meet the medical and nursing needs identified in the comprehensive assessment for 1 of 5 residents (Resident #2) reviewed. Specifically, Resident #2 received an anticoagulant (blood thinner) medication and did not have an individualized care plan for this medication.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00356334) surveys conducted 11/12/2024-11/19/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #73) reviewed. Specifically, clinical nutrition staff did not assess Resident #73 following a significant weight loss.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/12/24-11/19/24 the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #40) reviewed. Specifically, the facility did not follow Resident #40's individualized care plan interventions 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 care.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure residents received psychotropic drugs necessary to treat a specific condition and had behavioral interventions in place, and did not ensure residents as needed (prn) psychotropic drugs were limited to 14 days or had documented physician rationale and indications for extending the drug past 14 days for 2 of 7 residents (Residents #17 and #62) reviewed. Specifically Resident #17 received an antipsychotic medication and did not have an appropriate indication for use and did not have a person centered care plan with non-pharmacological interventions for behaviors; [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure that medications were secure and inaccessible to unauthorized staff and residents, for 1 of 1 resident (Resident #2) reviewed. Specifically, there was a medicine cup full of pills on Resident #2's tray table during breakfast.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/19/2024, 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 diseases and infections for 2 of 4 residents (Resident #17 and #475) reviewed. Specifically, Certified Nurse Aide #31 did not use appropriate personal protective equipment when providing care to Resident #475 who was on transmission based precautions (enhanced barrier precautions); and Resident #17 had an order for transmission based precautions (contact precautions) and did not have those precautions in place.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not ensure there was an effective pest control program for the main kitchen, the neurology unit, Corridors 1 and 2, [NAME] house, and Sequoia house. Specifically, fruit flies, drain flies and an unknown insect were observed in the main kitchen, the neurology unit, Corridors 1 and 2, and [NAME] house. Additionally, resident family members complained of seeing mice in the Sequoia house.

Inspectors wroteBased on interviews during the recertification survey conducted 11/12/2024-11/19/2024, the facility did not protect and promote the rights of the residents were maintained for 182 of 182 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens and residents of the United States.

Inspectors wroteBased on observation, record review, and interview during the abbreviated survey (NY00339657), the facility did not maintain an effective pest control program so that the facility was free of pests for 4 of 10 nursing units (Sequoia, Sycamore, Chestnut, and Aspen) reviewed. Specifically, evidence of mouse droppings and mouse infestation was observed on the Sequoia, Sycamore, Chestnut, and Aspen units.

Inspectors wroteBased on record review and interview during the Abbreviated survey (NY00331215) the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents reviewed (Resident #5). Specifically, Resident #5 was found with a skin impairment and was not assessed timely by a qualified professional and the medical provider was not notified timely of the areas for consideration of a treatment order. Additionally, the licensed practical nurse applied ointment and a dressing without an assessment or order provided by a qualified professional.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00289926) the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents reviewed (Resident #103). Specifically, on/around July 2, 2022, a cognitively impaired resident (Resident #103) with exit-seeking behaviors was able to leave their facility house undetected. Staff were not immediately aware the resident was missing. The resident was located by resident service aide (RSA) #3 who was entering an adjacent house and they notified staff in the Aspen house a resident was found outside. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/23/23-1/31/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 8 of 9 resident houses (Aspen, Chestnut, [NAME], Hickory, Magnolia, [NAME], Sequoia, and Sycamore) and 1 additional building (Community Center). Specifically, - the Aspen house resident room [ROOM NUMBER] had an unclean carpet and smelled of urine. The Aspen house dining room carpeted walls were unclean and peeling. - the Chestnut house dining room had unclean and peeling carpeted walls. - the [NAME] house resident room [ROOM NUMBER]'s bathroom shower area had a floor rubber water stop strip that was partially peeling/not attached to the floor. - the Hickory house had a section of carpeted wall that was unclean and peeling near resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 1/23/23-1/31/23, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for the main kitchen, the neurology unit kitchenette, and 8 of 9 house kitchenettes (Chestnut, Aspen, Cypress, [NAME], Hickory, Magnolia, [NAME], and Sycamore). Specifically, the main kitchen had dented cans of food, an unclean frying pan, a missing ceiling tile, and an unclean wall by the dish machine; the neurology unit kitchenette had an unclean wall and stove; the Chestnut and Cypress house kitchenettes had unclean shelves; the Aspen house, [NAME] house, and Hickory house kitchenettes had expired loaves of bread; the Hickory house, the [NAME] house, and the Sycamore house kitchenettes had damaged countertops; [...]

Inspectors wroteBased on interview and record review during the recertification survey conducted 1/23/23-1/31/23, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident (Residents #26) reviewed. Specifically, Resident #26 was not assessed timely when they had decreased food and fluid intakes, had increased lethargy, and a change in mentation. The resident required hospitalization for sepsis (an extreme reaction to an infection) secondary to a urinary tract infection (UTI).

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00299315) surveys conducted 1/23/23-1/31/23, the facility failed to ensure each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals reviewed. Specifically, food was not served at palatable and appetizing temperatures.

Inspectors wroteBased on record review, observation and interview during the recertification survey, the facility did not ensure the resident had the right to a safe, clean, comfortable homelike environment for 1 of 5 residents (Resident #88) reviewed for environment. Specifically, Resident #88 was unable to enjoy a calm, quiet homelike environment because the unit door alarm system was on the wall outside of the resident's door causing uncomfortable sound levels.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure all residents were provided an ongoing program to support residents in their choice of activities designed to meet their interests for 1 of 3 residents (Resident #145) reviewed for activities. Specifically, Resident #145 was not provided meaningful activities as care planned.

Inspectors wroteBased on interview, observation and record review during the recertification survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice 1 of 1 resident (Resident #77) reviewed for constipation. Specifically, Resident #77 was not provided medications as ordered to relieve constipation.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 of 11 residents (Resident #18) reviewed for accidents. Specifically, Resident #18 had a bottle of alcohol on their dresser which was visible from the hallway and accessible to other residents.

Inspectors wroteBased on observation, interview, and record review during the recertification survey the facility did not maintain drugs and biologicals stored and labeled in accordance with currently accepted professional standards for 1 of 6 medication storage rooms ([NAME]) reviewed for medication labeling and storage. Specifically, the medication room and cupboards containing multiple medications were not kept locked or under direct supervision of staff in an area where residents had access. Additionally, an opened undated bottle of lidocaine (used for numbing) was on the shelf.