Elcor Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a sanitary, orderly, and comfortable environment for residents for three (3) of eight (8) resident units reviewed (Colonial Ridge South, Colonial Ridge North, and Maple Creek Meadows). Specifically, resident rooms and Resident #247's shared bathroom were observed in unsanitary condition, and Resident #48 who resided in a shared room did not have a privacy curtain in place to support a homelike and dignified environment. Issue One (1):The facility policy Daily Patient Room Cleaning and Common Areas revised 11/20/2018 documented bathroom toilets are cleaned inside and out with toilet cleaner, sanitizer is used on all horizontal surfaces, vertical surfaces are to be spot cleaned, and damp mop solution is used to mop the bathroom. Resident #247 resided in a shared room with access to a shared bathroom. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (2) of eight (8) residents reviewed (Resident #5 and Resident #247). Specifically, Resident #5 was observed on multiple occasions with long chin hair and unclean fingernails and had not received assistance with nail care, or facial hair removal. Resident #247 did not receive scheduled hygiene care including shaving, and the facility did not ensure care was completed, documented, or reattempted when missed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision to prevent accidents for two (2) of eleven (11) residents reviewed (Residents #11 and Resident #49). Specifically, Resident #49 had multiple prepared medications left unattended at the bedside without an assessment or physician order for self-administration, and Resident #11 had unsafe smoking practices with access to smoking materials and an incomplete safety assessment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure suitable, nourishing snacks were available and provided consistent with resident needs, preferences, and plan of care for two (2) of six (6) residents reviewed (Resident #45 and Resident #189). Specifically, Resident #45 and Resident #189 were offered only limited snack items and staff were unable to provide alternative snack options when those items were not desired or appropriate, and the facility did not sustain interventions to address ongoing concerns regarding snack availability.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) kitchen observed. Specifically, the facility did not ensure implementation of its established kitchen cleaning schedule, resulting in unsanitary kitchen conditions including grease accumulation on cooking equipment, damaged and dirty ventilation hood filters, and broken flooring with standing water and debris, which created the potential for food contamination. Additionally, there was a shortage of non-disposable plates and utensils for meal service.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an effective pest control program for one (1) of eight (8) resident units reviewed (Colonial Ridge South). Specifically, the facility did not ensure resident rooms were included in routine pest control inspections and treatments, resulting in the presence of small black flies within and around resident rooms.

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (NY00333741) for six (Residents #16, #17, #18, #19, #20, and #21) of six residents reviewed, the facility did not ensure the environment remained free from accident hazards. Specifically, the facility did not ensure that all six residents who were identified as cigarette smokers had been assessed and care planned for safe smoking. This is evidenced by, but not limited to, the following: 1. Resident #16 had diagnoses including peripheral vascular disease and congestive heart failure. The Minimum Data Resident Assessment, dated 09/26/2024, documented that Resident #16 was cognitively intact. During an observation on 11/12/2024 at 8:05 AM, Resident #16 was seated in a wheelchair behind a stop sign on facility property, approximately 200-300 feet away from the facility, smoking a cigarette. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (NY00339596, NY00342850, NY00343008), for six of six residents (Resident #6, #11, #12, #15, #16, and #23) reviewed, the facility did not ensure that the residents on multiple units were treated in a respectful and dignified manner. Specifically, Resident #6 stated staff do not like them and staff are not mean, but not nice either. Resident #11 was repeatedly ignored by a staff member during care when asking questions about their care, Resident #12's family member stated they overheard a staff member using foul language in the resident's presence, Resident #15 stated the Registered Nurse speaks nasty to them, Resident #16 stated that staff were not always respectful, and Resident #23 stated the nurse was nasty to them. This was evidenced by, but not limited to, the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (NY00359178), for two (Residents #22 and #23) of three residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. Specifically, the facility did not report allegations of abuse, neglect, or mistreatment involving Residents #22 and #23.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed on 11/27/23 to 12/1/23, it was determined that for six (Colonial Ridge North, Colonial Ridge North, Maple Creek Meadows, Maple Creek Valley, Hickory [NAME] Upper Level, Hickory [NAME] Lower Level) of eight resident units the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically: furniture and equipment were damaged, exhaust ventilation was not functional, there was wall damage and missing ceiling tiles, fabric lining corridor walls was pilling and had stains, floors and walls were dirty, there were damaged heater covers, and a dirty oxygen concentrator.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey 11/27/23 to 12/1/23, it was determined that for one of one main kitchen and two (Maple Creek Valley, Hickory [NAME] Upper Level) of eight resident units the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically: potentially hazardous foods were not cold held at or below 45 degrees (°) Fahrenheit (F), cooking equipment was not maintained in good working order, non-food contact surfaces were dirty, food items and utensils were stored beneath unprotected sewer pipes, there was moldy bread, and food was not protected from contamination.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 11/27/23 to 12/1/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide (CO) detection in a building that has fuel-burning appliances.

Inspectors wroteBased on observations, interviews, and records review conducted during the Recertification Survey completed 11/27/23 to 12/1/23 it was determined that for one (Hickory [NAME] Upper Level) of eight resident units, the facility did not maintain an effective pest control program. Specifically, small brown flies and fruit flies were present and untreated.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00316076) from 11/27/23 to 12/1/23, for one (Resident #41) of two residents reviewed for personal funds, the facility did not act as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility. Specifically, Resident #41 did not receive their entitled monthly Medicaid funds for an extended period of time or notify the resident if funds were no longer available to the resident. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 11/27/23 to 12/1/23, it was determined that for one (Hickory Knolls) of four medication carts reviewed for medication storage, the facility did not ensure that all drugs and biological were properly stored in accordance with State and Federal Laws. Specifically, multiple loose unlabeled pills were observed stored in a drawer of one medication cart. This is evidenced by the following: The facility Nursing Home Policy and Procedure, Drug Procurement, Storage, and Inspection, dated 2/20/12 documented that the responsibility for control of medications within this facility rests with Professional Nursing Staff (Registered Nurses-RNs and Licensed Practical Nurses-LPNs). [...]

Inspectors wroteBased on observations and interviews, conducted during the Recertification Survey from 11/27/23 to 12/1/23, it was determined that the facility did not implement the appropriate standard for use of Personal Protective Equipment (PPE) and transmission-based precautions (TBP) by all staff on one of six resident care units reviewed for TBP. Specifically, a medical professional was observed on multiple occasions with inappropriate wearing of a face mask while on a TBP unit with several positive COVID-19 residents. This is evidenced by the following: The facility policy, COVID- 19 Vaccine Policy and Procedure documented; [...]

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey from 11/27/23 to 12/1/23, it was determined that for three (Residents #75, #241 and #242) of three residents reviewed for transfer and/or discharge, the facility did not notify the resident, the resident's representative, and/or the Ombudsman of the transfer and/or discharge and the reasons for the transfer and/or discharge in writing in a language and manner that they understood. Specifically, the facility could not provide evidence that the notification of a transfer and admittance to the hospital (Resident #75) was provided in writing to the resident, the resident's representative, or the Ombudsman and could not provide evidence that the Ombudsman was notified of facility initiated discharges home (Residents #241 and #242).

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey from 11/27/23 to 12/1/23, it was determined that for one (Resident #75) of three residents reviewed for transfer and/or discharge, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy. Specifically, Resident #75 was transferred to the hospital and the facility was unable to provide evidence that the facility Bed Hold Policy was given to the resident or their representative.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute and serve food under sanitary conditions. Specifically, food was contaminated by condensate in the walk-in freezer and a drain pipe from an ice machine was below the top of the funnel going into the sewer system. This is evidenced by the following: 1. Observation conducted on 11/26/18 at 10:23 a.m., during the initial walk through of the Main Kitchen with the Director of Food Service and Assistant Director of Food Service, there was condensation dripping from the insulated line below the evaporator in the walk-in freezer. There was frozen condensate found on boxes of frozen potato wedges and frozen egg patties. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #134) of five residents reviewed for pain, the facility did not develop a person centered Comprehensive Care Plan (CCP) that included measurable goals and interventions to meet the resident's medical, physical, and nursing needs. Specifically, there was no care plan, developed that addressed the presence of or management of the resident's pain. This is evidenced by the following: The facility policy, Pain Assessment/Management, revised January 2018, included for staff to document the resident's pain management plan on their CCP. Resident #134 was admitted to the facility on [DATE] with diagnoses including a stroke with right-sided hemiplegia (paralysis), aphasia (difficulty speaking), and depression. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #211) of two residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care and services to maintain personal hygiene. The issue involved lack of timely nail care. This is evidenced by the following: Resident #211 was admitted to the facility on [DATE] and readmitted after a hospital stay on 11/15/18 with diagnoses including end stage renal disease on dialysis, a stroke with right hemiplegia (paralysis of one side of body) and diabetes. The Minimum Data Set Assessment, dated 10/7/18, revealed that the resident was cognitively intact and required extensive assist for personal hygiene. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined for the one (Maple Creek Valley) of seven resident units reviewed for accident hazards, and one (Resident #345) of five residents reviewed for accidents, the facility did not ensure that the resident's environment was free from accident hazards and did not ensure that supervision and assistive devices were provided to each resident to prevent avoidable accidents. The issues involved broken window stops in seven resident rooms and the lack of an assessment for the safety of a resident being transported via a wheelchair. This is evidenced by the following: 1. Resident #345 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (stroke), endocarditis (infection in the heart) and status post coronary angioplasty implant and graft. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one residents reviewed for hydration, and one of two residents reviewed for dialysis, the facility did not have a system in place to ensure that daily fluid intake was consistent with or followed physician orders. The issues involved inconsistent monitoring and documentation for residents on fluid restrictions (Residents #89 and #41). This is evidenced by the following: 1. Resident #89 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease with dialysis three times a week. The Minimum Data Set (MDS) Assessment, dated 9/1/18, revealed the resident had moderately impaired cognition, received a therapeutic diet and was on dialysis. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #40 and #270) 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 physician orders. This is evidenced by the following: Review of the facility policy, Administration and Maintenance of Oxygen Therapy, dated as revised November 2017, revealed that an order is required for continuous and 'as needed' use of oxygen and saturation levels will be checked per orders. Maintenance of the oxygen concentrator is the responsibility of the Registered Nurse (RN) or the Licensed Practical Nurse (LPN). 1. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for 3 (Resident #41, #134, and #243) of 16 residents reviewed for Baseline Care Plans, the facility did not develop a baseline care plan within 48 hours of admission that included instructions needed to provide care, and the resident and/or representative were not provided with a written summary of the baseline care plan. This is evidenced by the following: The facility policy, dated 2/28/18, CMS Guidelines to Notify Resident and or Responsible Party of Baseline Care Plans revealed that a baseline care plan will include a Discharge Planning Review, a [NAME] (Certified Nursing Assistant Care Plan), and Physician orders. [...]