D'youville Senior Care

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required daily administration of a diuretic and had been newly admitted from an acute care setting, the Facility failed to ensure he/she was free from a significant medication error, when his/her medication orders were not transcribed correctly by nursing, his/her Furosemide (diuretic) 80 milligrams was omitted and as a result, he/she was not administered his/her diuretic three days in a row.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for four Residents (#175, #139, #93 and #143) out of a total sample of 40 Residents. Specifically,For Resident #175 the facility failed to a). ensure that they obtained physician's orders for the use of CPAP (continuous positive airway pressure, used to treat obstructive sleep apnea) and b). store the CPAP mask and tubing in a bag. For Resident #139, Resident #93, and Resident #143, the facility failed to ensure the respiratory equipment was maintained in a sanitary condition. Specifically, the oxygen concentrators used to administer continuous oxygen had filters covered with a thick layer of dust.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically,1. For Resident #69 the facility failed to ensure medications were not stored at the bedside. 2. For Resident #175 the facility failed to ensure medications were not stored at the bedside.3a. The facility failed to ensure the treatment cart on the Sweet Land Unit was locked.3b. The facility failed to ensure the medication carts on the Sweet Land Unit, Short Term Rehab Unit and Wannalancit Unit were secured.

Inspectors wroteBased on observation, record review and interview, the facility failed to 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. Specifically,The facility failed to implement Enhanced Barrier Precautions (EBP) for five residents (#2, #48, #143, #33, and #183) out of a total of 69 residents who required the use of EBP.The facility failed to follow proper infection control practices for shared medical equipment, a). Nursing Staff failed to disinfect the blood pressure cuff between uses on the Sweet Land Unit and [NAME] Unit, and b). Nursing staff failed to disinfect a blood glucometer machine after use on the Wannalancit Lane Unit and c). failed to ensure staff performed hand hygiene while performing blood sugar checks. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure staff treated residents in a dignified manner for two Resident (#73 and #4) out of a total sample of 40 Residents. Specifically,1. For Resident #73 the facility failed to ensure the Physician did not dictate a history and physical at the nursing station in the presence of 14 residents, a laundry aide, a housekeeper, and a nurse. 2. For Resident #4 the facility failed to ensure the Hospice Nurse did not assess the Resident in a common area.

Inspectors wroteBased on observation record review and interview, the facility failed to develop and implement individualized care plans related to pacemakers for two Residents (#130 and #172) out of a total of 40 sampled Residents and 13 total residents with cardiac pacemakers.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care in accordance with professional standards of practice for two Residents (#96, #78) out of a total of 40 sampled residents. Specifically:1. For Resident #96 the facility failed to a. implement physician's orders for booties to bilateral lower extremities while in bed and b. implement orders for bilateral fall mats on the floor while the Resident was in bed.2. For Resident #78 the facility failed to administer medications in accordance with professional standards.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure standards of quality of care for the treatment of a pressure ulcer for one Resident (#124), who has a pressure ulcer, out of a total sample of 40 residents. Specifically, the nursing staff failed to ensure the intervention of the air mattress on Resident #124's bed was implemented in accordance with Resident #124's weight to assist with prevention and healing of the pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for one Resident (#189) out of a total sample of 40 residents. Specifically, the facility failed to ensure Resident #189 was scheduled to be seen by the podiatrist since admission to the facility resulting in thickened, yellow, long-curling toenails.

Inspectors wroteBased on observation, record review and interview, the facility failed for one Resident (#9), out of a total sample of 40 residents, to ensure acceptable perimeters of nutritional standards of practice were implemented when Resident #9 experienced a significant weight loss. Specifically, the facility failed to ensure Resident #9, who is assessed as being at risk of malnutrition and experienced a significant weight loss of 5.1% in less than a month, had the weight verified to determine/verify the significant weight loss, and when the reweigh occurred Resident #9 had continued weight loss of a total body weight loss of 6.44 % in less than 30 days, resulting in a delay to intervene to abate further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and maintenance of a Midline Catheter (A midline catheter is an IV longer than 3 inches and it is inserted into the upper arm through the basilic, brachial or cephalic vein, with the catheter tip located at the or near the level of the axilla), consistent with professional standards of practice for one Resident (#124), out of three reviewed Resident's with an IV catheter. Specifically, for Resident #124, the facility failed to ensure that the midline insertion site was able to be visualized.

Inspectors wroteBased on observation, record review and interviews, the facility failed to implement standards of care related to dialysis for the 1 Resident (#78), out of 2 residents reviewed for dialysis, out of a total sample of 40 residents. Specifically, for Resident #78 the staff failed to ensure the dialysis order was signed off in accordance with the dialysis treatment schedule. (Hemodialysis is a machine that removes blood from the body, filters it through a dialyzer (artificial kidney) and returns the clean blood to the body).

Inspectors wroteBased on interviews and record review, the facility failed to ensure one Resident (#28) out of a total sample of 40 residents, was seen by the Physician at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with alternate visits by a Nurse Practitioner (NP) as indicated.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure dental service recommendations were provided for one Resident (#130) out of a total of 40 sampled Residents. Specifically, the facility failed to obtain a consent form to begin denture fabrication for Resident #130.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure for one Resident (#75), out of a total sample of 40 residents, that he/she was provided with food items that were on his/her diet slip. Specifically, staff failed to follow the diet slip, resulting in food items not being provided to Resident #75 for three observed meals.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately document in the medical record for one Resident (#86) out of a total sample of 40 residents. Specifically, for Resident #86 the facility documented that oxygen therapy was administered when it was not.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest) the Facility failed to ensure nursing staff honored his/her right to self-determination, when after being found unresponsive and without a pulse, nursing staff initiated life saving measures.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives indicated he/she was a Do Not Resuscitate (DNR, medical order written by a physician, it instructs healthcare providers not to do cardiopulmonary resuscitation in the event of cardiac or respiratory arrest), the Facility failed to ensure services provided by nursing met professional standards of quality, when nursing initiated life saving measures including performing Cardiopulmonary Resuscitation on a resident who was a DNR.

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #3), who was moderately cognitively impaired and dependent on staff to meet his/her care needs, the facility failed to ensure he/she was treated in a dignified and respectful manner when Hospice Aide #1 was witnessed by staff on more than one occasion respond to Resident #1's adverse behavior by insulting and calling him/her names, and did so in a demeaning manner.

Inspectors wroteBased on records reviewed and interviews, for two of four sampled residents (Resident #1, Resident #3), the facility failed to ensure staff consistently implemented and followed their abuse policy related to protecting residents and reporting abuse allegations, when 1) on 12/19/25 Resident #1 reported to Nurse #1 that he/she had been slapped in the face, and 2) despite multiple staff member witness Hospice Aide #1 allegedly verbally abuse Resident #3, neither of these incidents were immediately reported to a Supervisor or Administrative staff, as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Residents (Resident #3) the facility failed to ensure that staff immediately reported incidents of alleged verbal abuse to administration staff as required, so they could report timely to the necessary state agencies.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and Resident #2), who were at risk for developing Diabetes-related foot complications, the Facility failed to ensure they received proper care and treatment to maintain good foot health.

Inspectors wroteBased on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, and that medication carts were kept clean and tidy in four out of six medication carts reviewed. Specifically, 1. The facility failed to store medications as indicated in the refrigerator. 2. The facility failed to store treatment supplies separate from oral and other medications. 3. The facility failed to maintain clean medication carts without spills. 4. The facility failed to ensure that medication stored in the medication carts were labeled with resident identifiers.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that food was dated in the main kitchen and on three of five unit kitchenettes, that produce showing significant signs of decomposition was discarded, that food was not stored on or below potential sources of environmental contamination, that food was not stored directly on the floor and that the facility process for dented cans was followed.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure one Resident (#259) out of a total sample of 35 residents did not self-administer medication without an assessment or physician's order.

Inspectors wroteBased on record review and interview, the facility failed to ensure it developed a baseline care plan for skin breakdown within 48 hours of admission for one Resident(#181) out of a total sample of 35 residents.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure a resident-centered personalized care plan was developed and/or implemented for three Residents (#95, #89 and #8) out of a total sample of 35 residents. Specifically: 1. For Resident #95, the facility failed to develop a Hemodialysis (a medical treatment used for patients with advanced kidney failure It involves a machine that filters wastes and fluids form the body when the kidneys can no longer perform this function adequately) care plan. 2. For Resident #89, who has hearing and vision deficits, the facility failed to develop hearing and vision care plans. 3. For Resident #8, the facility failed to implement his/her right Prevalon boot (pressure relieving boot) per his/her physician's order. Finding Include: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure care and services were provided according to accepted standards of clinical practice for one Resident (#118) out of a total sample of 35 residents. Specifically, the facility failed to ensure Resident #118's diet was changed as recommended, following a choking incident, that resulted in a hospitalization to have food extricated from his/her esophagus.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure nursing staff provided assistance with Activities of Daily Living (ADLs) for one dependent Residents (#43) out of a total sample of 35 residents. Specifically, for Resident #43 the facility failed to provide assistance with the removal of unwanted facial hair. Findings Include: Review of the facility policy titled Activities of Daily Living (ADL's), undated, indicated the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care. [...]

Inspectors wroteBased on interviews, record review and observation, the facility failed to provide the prescribed therapeutic diet to one Resident (#16), out of a total sample of 35 residents. Specifically, the facility failed to provide Resident #16 with a ground textured diet as prescribed by the physician. Findings Include: Review of the facility policy titled Therapeutic diets, revised July 2023, indicated, but was not limited to, the following: - The attending physician will prescribe a therapeutic diet. - A tray identification system is established to ensure that each patient/resident receives his or her diet as ordered. - The dietitian records in the patients/residents medical record significant information relating to the patients/residents response to his or her therapeutic diet. - Mechanically altered diets will be considered therapeutic diets. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an accurate medical record for three Residents (#8, #40 and #95), out of a total sample of 35 residents. Specifically: 1. For Resident #8, the nurses documented in the Treatment Administration Record (TAR) the Resident was wearing his/her right lower extremity Prevalon boot (pressure relieving boot) when he/she was not. 2. For Residents #40 and #95 the facility failed to accurately document the location of blood pressure (BP) readings. Findings Include: Review of the facility policy titled Documentation in the Medical Record, dated 11/29/23 indicated the following: Policy: [...]

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents, (Resident #1 and Resident #2) the Facility failed to ensure they maintained complete and accurate medical records, when 1) a signed informed written consent was not obtained for Resident #1 related to the administration of psychotropic medications, as required and 2) nursing documentation for Resident #2 related to the conduction of weekly skin assessments was incomplete, and assessments missing.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure staff stored medications and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) Ensure medications with shortened expiration dates were dated once opened in 5 of 6 medication carts observed, and 2.) Ensure medication carts were locked when unattended.

Inspectors wroteBased on observations and interview, the facility failed to implement practices for the prevention of potential infection on 1 out of 5 resident units. Specifically: 1.) Nursing staff failed to properly disinfect equipment used for multiple residents during the medication pass. 2.) Nursing staff failed to appropriately perform hand hygiene after doffing contaminated gloves.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of the unavailability of a treatment supply for daily wound care for one Resident (#9), in a total sample of 36 residents. Specifically, for Resident #9, nursing failed to notify the physician when his/her physician's ordered flagyl (medication used for wound odor) was unavailable for two days and the santyl (medicated ointment for wounds) was unavailable for four days.

Inspectors wroteBased on record review and interview, the facility failed to investigate an allegation of potential sexual abuse for one Resident (#121) out of a total sample of 36 residents.

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to follow professional standards of practice for three Residents (#109, #117, and #43), out of a total sample of 36 residents. Specifically: 1.) For Resident #109, the facility failed to ensure nursing changed an indwelling urinary catheter drainage bag as ordered by the physician. 2.) For Resident #117, the facility failed to ensure nursing implemented a physician's ordered wander guard. 3.) For Resident #43, the facility failed to provided nursing services or care that adhere to accepted standards of quality regarding administration of injectable medications.

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed provide necessary services to ensure one Resident (#36) out of a total sample of 36 Residents, was able to effectively communicate his/her needs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) consistent with professional standards of practice for one Resident (#95), out of a total sample of 36 residents. Specifically, for Resident #95, the facility failed to ensure nursing completed a PICC line dressing change as ordered by the physician.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a therapeutic diet as ordered for two Resident's (#179 and #142) out of a total sample of 36 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the correct adaptive equipment for one Resident (#179) out of a total sample of 36 residents.