Daughters of Sarah Nursing Center

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to immediately notify the resident's legal representative of a significant change in the resident's physical, mental, or psychosocial status, for one (1) out of three (3) residents reviewed for notification of changes. Specifically, when Resident #1 experienced a vasovagal episode (a sudden, temporary drop in heart rate and blood pressure that reduces blood flow to the brain, leading to brief fainting) and episodes of vomiting on 05/14/2026, Family Member #2 was not notified.

Inspectors wroteBased on observation, interviews, and record reviews conducted during a recertification survey, the facility did not ensure treatment with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 3 (Resident #'s 33, 86 and 197) of 35 residents reviewed for dignity. Specifically, (a.) Resident #33 stated Certified Nurse Aide #3's tone of voice was rude, they felt rushed during care and requested Certified Nurse Aide #3 not to be assigned to them as caregiver; (b.) Resident #86 stated they waited a long time for care and then the care was rushed; (c.) Resident #197 stated Certified Nurse Aide #3 was argumentative and used inappropriate language. This is evidenced by: [...]

Inspectors wroteBased on observation, interviews, and record review conducted during a recertification survey, the facility did not promoted and facilitated the residents right to self-determination through support of resident choice. Specifically, the facility did not provide accommodations for heating of food brought to residents from outside the facility. This was evident for Resident #5. This is evidenced by: Facility's policy titled, Resident Personal Food and dated 11/2021, documented resident personal food (food not provided by facility) should be ready to eat, requiring little or no preparation. Food requiring refrigeration may be stored in the unit kitchenette refrigerator or personal refrigerator provided by resident/resident representative. Resident personal food could not require re-heating. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) pre-poured medication cup was noted in medication cart (c.); medication refrigerator temperature was outside of therapeutic range; and (d.) non-medication items were stored in medication cart for 2 (Green and Purple unit medication carts) of 3 medication carts reviewed and 3 (Green, Red, and Purple) of 3 medication storage rooms reviewed. This is evidenced by: The facility's Medication Administration Guidelines, last reviewed 2/2024, Section III. [...]

Inspectors wroteBased on observations and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the staff did not put on and take off personal protective equipment correctly when entering and exiting the room of a COVID-19 positive resident. This was evident for 1 of 5 resident units observed. This is evidenced by: The Centers for Disease Control document titled Sequence for Putting on Personal Protective equipment (PPE) stated the correct sequence for putting on personal protective equipment was gown, mask or respirator, goggles, or face shield, then gloves. The document stated the correct sequence for removing personal protective equipment was gloves, goggles or face shield, gown, and then mask or respirator. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00260768), the facility did not ensure that each resident was treated with respect and dignity for 1 (Resident #4) of 4 residents reviewed. Specifically, the facility did not ensure Resident #4 was treated with respect and dignity on 7/17/2020, when the resident had wandered onto the Blue unit and was escorted inappropriately by the Licensed Practical Nurse (LPN) #3 back to the Gold unit. LPN #3 forcefully grabbed the resident from behind and dragged them towards the Gold unit. This is evidenced by: Refer to F684 Resident #4: Resident #4 was admitted to the facility with diagnoses of dementia with behavioral disturbance, recurrent major depressive disorder, and unsteadiness on feet. The MDS dated [DATE], documented the resident had severe cognitive impairment. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00310437 and NY00260768), the facility did not ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan (CCP) for 2 (Resident #s 2 and 4) of 4 residents reviewed. Specifically, Resident #2 was assessed upon admission with having 3 surgical wounds and a total of 8 staples, following repair of a left hip fracture (a break that occurs in the upper part of the thigh bone). The CCP did not document the location, number of surgical wounds, and the number of staples in the wounds. The facility did not ensure all staples were removed on 12/23/2022, as ordered by the Orthopedic provider. On 1/9/2023, the resident was discharged to another facility. The receiving facility assessed the resident with having 4 staples in their left hip. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure the policy regarding foods brought to residents is in accordance with adopted regulations. Specifically, the policy does not include a procedure to ensure all residents have the necessary assistance in accessing and consuming food brought to them by visitors. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 10/12/2021. This policy did not include a procedure to assist residents that are unable on their own to access and consume food brought to them by visitors. The Director of Nursing stated in an interview on 10/13/2021 at 1:05 PM, that the policy for food brought to residents does not include guidelines on how staff dependent residents will access and consume food brought to them. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean and the area around the compactor was not maintained. This is evidenced as follows. The trash compactor was inspected on 10/12/2021 at 9:30 AM, revealing that the trash compactor, the area under the trash compactor, the walls in the trash compactor access room, and the trash compactor access portal were heavily soiled with a black build-up. The Director of Building Services stated in an interview on 10/01/2020 at 2:45 PM, that the facility will develop a regular cleaning schedule for the trash compactor with the Director of Dining Services. [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey on 10/12/2021, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #'s 45 and 55) of 33 residents reviewed. Specifically: For Resident #45, the facility did not ensure that an assessment was made following the loss of the resident's lower denture, regarding whether the resident was able to eat and maintain adequate nutrition, whether the resident needed a dietary alteration in the consistency of their diet to accommodate the loss of the denture and did not identify or address the decrease in the percentages of meals eaten and the progressive weight loss (31.2 pounds) from the time period the resident's lower denture was missing on 8/6/2021 through 9/15/2021; [...]

Inspectors wroteBased on observation, record review and interview the facility did not promptly, within 3 days, refer residents with lost or damaged dentures for dental services. Specifically, for one (Resident #45) of one resident reviewed for dental services, the facility did not ensure a referral to a dentist was made within 3 days when facilty staff noted Resident #45's lower denture was missing. This is evidenced by: Resident #45: Resident #45 was admitted to the facility with the diagnoses of cellulitis of the left lower extremity, hypertension, and lymphedema. The Minimum Data Set (MDS-an assessment tool) dated 8/5/2021, documented the resident's cognition was intact, was able to make self understood and able to understand others. [...]

Inspectors wroteBased on observations, record review and interview, during a recertification survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for four (4) (Residents #'s 29, 92, 145 and #173) of thirty-five (35) residents reviewed. Specifically; [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not maintain an infection control program to prevent the development and transmission of disease and infection for three (3) (Resident #'s 12, 174 and #299) of 7 residents reviewed. Specifically; for Resident #174, the facility did not ensure standard precautions were maintained during a dressing change to the resident's non-pressure ulcer, for Resident #12, the facility did not ensure standard precautions were maintained during a dressing change to the 3 pressure ulcers on the resident's upper and lower left hip, and for Resident #299, the facility did not ensure the resident's oxygen tubing was kept off the floor. This is evidenced by: Resident #12: This resident was admitted to the facility on [DATE], with diagnoses of vascular dementia, dysphagia, and muscle wasting atrophy. [...]