Eddy Memorial Geriatric Center

Inspectors wroteBased on record reviews and interviews during the recertification survey, the facility did not ensure that each resident received an accurate assessment reflective of the resident's status at the time of the assessment including the correct coding for anticoagulants for 7 (Residents #s #12, 25, 52, 53, 57, 62, and 72) of 24 residents reviewed. Specifically, for (a.) Resident #s 12, 25, 52, 53, 57, and 62 antiplatelet medications were coded as anticoagulants in the Minimum Data Set (an assessment tool). (b.) for Resident #72, there was not documented evidence that the resident was on anticoagulant, but it was documented in the Minimum Data Set that Resident #72 was on anticoagulant. This is evidenced by: The Minimum Data Set 3.0 Resident Assessment Instrument Manual (v1.08) Errata (v2) effective 4/1/2012 stated the coding instructions in Section N had been amended to include N0410 E. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure it developed and implemented a comprehensive person-centered care plan that included measurable objectives and timeframe to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident # 57) of 24 residents reviewed for comprehensive person-centered care plans. Specifically, Resident #57 was diagnosed with a urinary tract infection and prescribed an antibiotic. There was no documented evidence that a care plan was written that addressed the change in condition. This is evidenced by: The Policy and Procedure titled, Interdisciplinary Care Conference and Care Planning dated 6/27/2023, documented it was the facility's policy to develop a comprehensive resident centered plan of care within 14 days of admission. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for 2 (Resident #'s 27, and 180) of 24 residents reviewed. Specifically, (a.) for Resident #27, Comprehensive Care Plan for medications was not reviewed and revised for a resident who required Guaifenesin cough medication, daily Aspirin for blood thinning, and Cepacol lozenge as needed for sore throat. (b.) for Resident #180, Comprehensive Care Plan for nutrition was not reviewed and revised to account for discontinuation of the weekly weights that were to be done on Mondays. This is evidenced by: [...]

Inspectors wroteBased on observations, record review and interviews during a Recertification Survey, the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident #11) of 24 residents reviewed. Specifically, the facility did not identify, document, investigate or monitored bruises to Resident #11's bilateral upper extremities. Resident #11 was prescribed an anticoagulant (blood thinning) medication and was at risk for bruising. The is evidenced by: The Policy and Procedure titled, Skin and Wound Care, effective 5/13/2024, documented it was the policy of the facility to assess/inspect the resident's skin, to monitor closely for changes and to document any new skin issues promptly and accurately. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 (Resident # 19) of 3 residents reviewed for accident hazards. Specifically, on 6/10/2024 and 7/26/2024 Resident #19 was injured while nursing staff attempted to cut the resident's fingernails; there was no documented evidence completed incident and accident reports/investigations following the incidents and no interventions implemented to prevent recurrence after the first time the resident was injured. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure that a resident who needs required respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences were provided by a qualified professional for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function for 1 (Resident #58) of 3 residents reviewed for respiratory care. Specifically, Resident #58's oxygen tubing was not labeled with the date and time it was changed in accordance with professional standards and facility policy. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, opened insulin pens had no open and/or expiration dates written on them. This was evident for 1 medication cart on [NAME] Unit out of 2 medication carts reviewed in the facility for medication storage. This is evidenced by: The facility's Medication Administration Policy and Procedure, effective [DATE] documented, the expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date should be recorded on the container. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure food was stored and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchen. Specifically, expired foods were not disposed of in a timely manner, the kitchen was not clean and sanitary, and dented canned foods were not removed from common stock. This is evidenced by: The Policy and Procedure titled Food Supply and Storage, last revised January 2024, documented that food, non-food items and supplies used in food preparation should be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The procedure included that most products had an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. [...]

Inspectors wroteBased on observations and interviews during a recertification survey, the facility did not ensure to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the possible development and transmission of communicable diseases/illnesses. Specifically, the facility did not ensure staff completed hand hygiene when indicated during meal service. This is evidenced by: The Policy and Procedure titled Hand Hygiene/Artificial Fingernails, last revised 6/18/2024, documented the purpose of the policy was to prevent the direct or indirect spread of microorganisms via the hands of colleagues and healthcare workers who provided direct patient care. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 7 (Resident #'s 5, 6, 7, 17, 18, 30, and #49) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #5, the facility did not ensure the resident's CCP was implemented, resulting in a resident fall on 1/21/2022; for Resident #6, the facility did not ensure geri-sleeves were implemented and were added to the resident's CCP and [NAME] after documenting these as completed post-incident interventions on an incident report on 5/8/2022; [...]

Inspectors wroteBased on record review and interviews during a recertification survey and an abbreviated survey (Case #NY00287716) from 5/11/2022 through 5/17/2022, the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency for 2 (Resident #'s 5 and #274) of 2 residents reviewed for abuse. [...]

Inspectors wroteBased on record review and interviews during a recertification survey and an abbreviated survey (Case #NY00287716) from 5/11/2022 through 5/17/2022, the facility did not ensure alleged violations of abuse, mistreatment, and neglect, including an injury of unknown source were thoroughly investigated for 2 (Resident #5 and #274) of 3 residents reviewed for investigations. Specifically, for Resident #5, the facility did not ensure the investigation for the incident dated 1/22/2022 was thorough when the facility's plan for corrective action to prevent reoccurrence was not performed. The facility's corrective action to provide education to agency staff regarding the need to follow resident care cards and the transfer policy by 1/31/2022 had not been provided as of the date of survey (5/17/2022); [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey on 04/11/2022 through 04/17/2022 and an abbreviated survey (Case # NY00273659), the facility did not ensure each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 (Resident #275) of 2 residents reviewed for nutrition. Specifically, the facility did not ensure that the resident's actual intake of food and fluid at meals was monitored and documented and did not identify the resident had refused multiple meals. This was evidenced by: Resident #275: Resident #275 was admitted with the diagnoses of dementia, fracture of left femur, and hypertension. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants, and food preparation and serving areas and equipment are to be kept clean. Specifically, cans of food were dented, and non-food contact equipment in the main kitchen was not clean. This is evidenced as follows. The main kitchen was inspected on 12/03/2019 at 10:55 AM. In the storage area two dented cans of food were found with the common stock. [...]

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 determined for 1 of 2 dressing changes for one (1) (Resident #38) of two (2) residents reviewed. Also, the nursing home did not ensure infection control standards were maintained during the medication pass. Specifically; for Resident #38, the facility did not ensure standard precautions were maintained during a dressing change to the resident's unstageable decubitus ulcer on the left great toe and for Resident #70, the resident was not provided LPN with one tissue for each eye after eye drops were instilled. This is evidenced by: Finding #1: Resident #38: [...]

Inspectors wroteBased on interviews and record review during the recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 4 (Resident #'s 10, 16, 35, and 38) of 7 residents reviewed for baseline care plans. Specifically, for Resident #'s 10, 16, 35, and 38, the facility did not ensure a baseline care plan was developed within 48 hours of admission. This is evidenced by: Resident #10: The resident was admitted to the facility on [DATE], with diagnoses of dementia, dysphagia, and vertigo. The Minimum Data Set (MDS- an assessment tool) dated 11/23/19, documented the resident had severely impaired cognition, could sometimes understand others, and could make self understood. [...]

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey and abbreviated survey (Case #NY00240461), the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP), that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs, for 3 (Residents #'s 1, 31, and #35) of 21 residents reviewed. Specifically: For Resident #1 the facility did not ensure that a CCP was developed to address edema, for Resident #'s 31 and 35, the facility did not ensure the CCP for Communication included person-centered interventions to meet the residents' needs, and for Resident #35, did not ensure the CCP for Altered Mood and Anxiety included person-centered interventions to meet the resident's needs.