Chemung County Health Center - Nursing Facility

Inspectors wroteBased on observations, interviews and record review conducted during an Abbreviated Survey (NY00346373, NY00361053, NY00369686, and NY00369760) for three (Residents #1, #2, and #5) of five residents reviewed, the facility did not ensure the residents' environment remained free of accident hazards. Specifically, Resident #1's bed was left in an unsafe position creating a fall hazard. Resident #2's bed was left in an unsafe position and fall mats were not placed per their care plan to prevent injuries in the event of a fall. Resident #5 was on aspiration precautions (steps taken to prevent inhalation of food/drink into the lungs) and was not supervised while eating. This is evidenced by the following: 1. Resident #2 had diagnoses including dysphagia (difficulty swallowing) and hemiplegia (paralysis) affecting the right dominant side. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (ACTS Reference Number: NY00343164), the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Regulations for two of two medication carts reviewed. Specifically, the medication carts on the North and South halls of residential Unit 4 were observed on multiple occasions unsupervised and/or unlocked by multiple nursing staff. Additionally, residents identified by facility documentation as cognitively impaired and wanderers were observed self-propelling their wheelchairs on both halls by the medication carts during the observations. This is evidenced by, but not limited to, the following: [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY00319989) 9/18/23 to 9/22/23, it was determined that for 1 (Resident #315) of 26 residents reviewed for person centered Comprehensive Care Plans (CCP) the facility did not review and revise the resident's care plans as necessary to meet the resident's current needs. Specifically, the care plan was not revised to reflect the current level of assist the resident required for safe toileting. This is evidenced by the following: Resident #315 had diagnoses including difficulty with walking, muscle weakness, and heart failure requiring a pacemaker. The Minimum Data Set assessment dated [DATE] included that the resident was cognitively intact, required extensive assistance involving two persons for transferring and toileting, and had no behavioral symptoms or rejection of care. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 9/18/23 to 9/22/23, it was determined that for one (Resident #34) of three residents reviewed, the facility did not ensure that Activities of Daily Living (ADLs) care was provided for dependent residents. Specifically, the resident was observed on multiple occasions in soiled clothing and was not provided care (for urinary incontinence) in a timely manner. This is evidence by the following: Resident #34 was admitted to the facility with diagnoses that included hemiplegia (unable to move one side of the body), dementia and a right-hand contracture (a shortening of muscles or tendons leading to deformity and rigidity of joints). [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 5/28/21, it was determined for one (Resident #103) of one resident reviewed, the facility did not provide appropriate treatment and services to prevent complications for a resident who receives nutrition via a feeding tube (a tube inserted directly into the stomach via the abdomen). Specifically, the facility did not provide staff with thorough education and training on correct use of the feeding tube pump and did not provide timely preventive maintenance of a feeding pump to ensure the resident was receiving accurate amounts in order to prevent complications. This is evidenced by the following: Resident #103 had diagnoses including Parkinson's disease, dementia, and dysphagia (difficulty swallowing) requiring a feeding tube. [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey, it was determined that for five of five residential units that the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. Specifically, rigid plastic door coverings were damaged and jagged. This is evidenced by the following: 1. Observations during the initial tour of the facility on 10/29/18 from approximately 1:00 p.m. to 1:20 p.m. revealed the lower edges of the doors and frames to the third-floor day room and Resident room [ROOM NUMBER] were covered with a pink rigid plastic material that was broken and jagged. 2. Observations on 10/30/18 at 8:30 a.m. revealed the rigid plastic covering the lower edges of doors and doorframes in Resident Rooms #200, #202, #206, #210, #214, and #225 were broken, jagged and damaged. 3. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for 5 of 35 residents reviewed for care planning, the facility did not develop and/or implement a plan of care for each resident that included measureable objectives and interventions to address the residents' medical, physical, mental and psychosocial needs. The issues involved the lack of a care plan with person centered approaches for behaviors (Residents #98 and #42), the lack of a care plan for impaired vision (Resident #183), the lack of a plan of care for Tubi-grips (Resident #117), and the lack of following the plan of care for feeding strategies (Resident #56). This evidenced by, but not limited to, the following. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #9) of one resident reviewed for rehabilitation and restorative care, the facility did not provide the treatment and services in the resident's plan of care to maintain functional ability. Specifically, the resident was not consistently ambulated by staff per the resident's individualized plan of care. This is evidenced by the following: Resident #9 was admitted to the facility on [DATE] and had diagnoses including dementia, spinal stenosis and generalized muscle weakness. The Minimum Data Set Assessment, dated 10/12/18, revealed the resident had severely impaired cognition and required the limited assist of one staff member to walk in her room but did not walk in the corridor at all during the period assessed from 10/6/18 through 10/12/18. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #131) of two residents reviewed for indwelling urinary catheters, the facility did not ensure that the residents with a urinary catheter received the treatment and services needed to prevent infections to the extent possible. Specifically, the resident's indwelling catheter was not secured to prevent tension on the insertion site, and the tubing and drainage bag were observed on several occasions in a manner that could potentially predispose the resident to an infection. This is evidenced by the following: Resident #131 was admitted to the facility on [DATE] and had diagnoses including dementia, a pressure ulcer and recurrent urinany tract infections, including a hospital stay for an antibiotic resistant urine infection. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey, it was determined that for two (Residents #51 and #159) of four residents reviewed for respiratory care, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. Specifically, oxygen therapy was not provided per the physician order and/or the resident's respiratory status was not consistently monitored. This is evidenced by the following: Review of the facility policy, Oxygen Therapy, dated October 2014, revealed oxygen was a drug and must be administered as prescribed. The policy included to monitor and document the effectiveness of oxygen therapy, check oxygen saturations levels every shift, and document on the vital signs sheet. The policy instructed to change the tubing every other Wednesday on the 3-11 shift. 1. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #48) of one resident reviewed for a death in the facility, the facility did not provide medically related social services to attain or maintain the highest practical, mental and psychosocial well-being of each resident. Specifically, there was a lack of social services for a resident and family during end of life care and related family interactions prior to the resident's death in the facility. This is evidenced by the following. Resident #48 was admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease and a stroke. [...]