Elderwood at Lancaster

Inspectors wroteBased on observation, interview, and record review conducted during the Abbreviated Survey (2615979), the facility did not ensure the resident's right to be free from verbal abuse for one (1) (Resident #1) of three (3) residents reviewed. Specifically, based on audio recording and facility surveillance footage, a maintenance staff member was verbally abusive to Resident #1. The finding is:The policy titled Abuse Prevention, Identification, Investigation, Protection and Reporting dated 4/30/24 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. [...]

Inspectors wroteBased on interview, and record review conducted during an Abbreviated survey (2615979) the facility did not ensure that all alleged violations involving abuse are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (1) (Residents #1) of three (3) residents reviewed for abuse. Specifically, an allegation of staff to resident verbal and physical abuse was not reported to the New York State Department of Health within the required (2) two-hour timeframe. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00360394, NY00317661) during the Standard survey completed on 11/22/24, the facility did not ensure that there was sufficient nursing staff on a 24-hour basis to provide care to all residents. Specifically, one of one facility reviewed for sufficient staffing the facility did not meet their assessed minimum staffing levels for Certified Nurse Aides to meet the needs of each resident.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 11/22/24, the facility did not ensure the Director of Nursing served as a charge nurse/Supervisor, only when the facility has an average daily occupancy of 60 or fewer residents. Specifically, the Director of Nursing worked as a charge nurse when the facility had a daily average census of greater than 60. The finding is: Review of a facility provided document titled Director of Nursing, last revised 2/2024, revealed the Director of Nursing ensures the health and well-being of our residents by being responsible for oversight and operations of the nursing department and its staff including staffing, training, and development, and management of personnel. [...]

Inspectors wroteBased on interview and record review during the Standard survey completed on 11/22/24, the facility did not employ a qualified professional to furnish a specific service to be provided by the facility and the facility did not have that service furnished to residents by a person or agency outside the facility under an arrangement. Specifically, the facility did not have a dentist on their staff and did not have dental services provided by an outside person or agency under an arrangement. This involved Resident #23 and has the potential to affect 83 of 83 residents. The finding is: The facility document titled Dental Care Requirements, dated 9/18, documented the dentist (or designee) must complete an oral exam within fourteen days of admission and document dental status in the medical record. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 11/22/24, the facility did not ensure the resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States. Specifically, two (Residents #19 and #49) of two reviewed for voting was not afforded the right to vote in the November 2024 Presidential Election.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 11/22/24, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (Resident #11) of one resident reviewed. Specifically, Resident #11 was observed with medications in their room and has stated they self-administered those medications without being evaluated as to whether they could safely do so. The finding is: The policy and procedure titled Self Administration of Medications, last revised 04/10/18, documented residents who desire to self-administer medication are permitted to do so upon review and approval by the inter-disciplinary care planning team members and with an order from the attending physician. [...]

Inspectors wroteBased on interview and record review conducted during the Recertification survey completed on 11/22/24, the facility did not ensure the resident's representative was notified immediately when the residents mental and psychological condition changed requiring a change in treatment. Specifically, for one (Resident #71) of one resident reviewed the facility did not notify Resident #71's responsible when there was need to alter their treatment and a new psychotropic medication was initiated. The finding is: The policy and procedure titled Notification of Resident Changes dated 5/31/18 documented the facility will immediately notify the resident's legal representative when there is: a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 11/22/24, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. The issues included an active roof leak, foul odors in a shower room, and a shower chair with sharp edges from a broken footrest. Additionally, oxygen concentrator filters were dust-laden and were not cleaned according to manufacturer's recommendations. This affected one (Unit 2) of two resident units.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 11/22/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Resident #16 and #79) of four residents reviewed. Specifically, Resident #16 was not provided with timely incontinence care and Resident #79 had long dirty fingernails.

Inspectors wroteBased on observation, interview, and record review conducted the Standard survey completed on 11/22/24, the facility did not ensure that drugs and biologicals were securely stored in accordance with State and Federal laws for one (Unit 2) of two units reviewed for medication storage. Specifically, medications were signed as administered and left unattended at Resident #66's bedside. The finding is: The policy and procedure titled Medications Administration Methods dated 1/25/24 documented a Licensed Nurse will be responsible for passing medications according to techniques and procedures that meet current practice standards in compliance with State Codes, Rules, and Regulations and other applicable state and federal laws. A medication must never be left at bedside or be out of sight of the nurse administering the medication. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed 11/22/24, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for two (Residents #2, #11) of two residents reviewed. Specifically, staff did not maintain proper infection control measures after completing foley catheter (tube inserted into bladder to drain urine) care prior to touching high contact areas, and the resident's catheter tubing was observed directly on the floor (#2); staff did not wear appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions while providing care (#2); [...]

Inspectors wroteBased on observation, interview, and record review during an Abbreviated survey (Complaint # NY00323906) completed on 10/18/24, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for one (Resident #1) of three residents reviewed for care plan implementation. Specifically, the resident was not provided with posey boots (therapeutic footwear that help prevent and treat heel ulcers) at all times as ordered and care planned. The finding is: The policy and procedure titled Pressure Ulcer, Pressure Injury and Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management last modified 2/27/2023, documented residents with pressure ulcers, injuries or skin conditions will receive evaluation, treatment, and services to promote healing and prevent new conditions from developing. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed 11/20/22 through 12/6/22, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services for one (Resident #50) of three residents reviewed. Specifically, there was a three-day delay in the initiation of a treatment for a newly identified unstageable (not stageable due the coverage of wound bed by slough (soft, moist, dead tissue that may be white, tan, yellow or green), and/or eschar (black or brown dead tissue)) pressure ulcer. The finding is: The facility policy and procedure (P&P) titled Skin Conditions, Wounds and Pressure Ulcers (Assessment and Monitoring Program) dated 3/12/20 documented identified skin conditions and/or wounds will be assessed and documented by a registered nurse (RN) in the medical record. [...]

Inspectors wroteBased on interview and record review conducted during the Standard Survey completed on 12/20/19, the facility did not ensure the Pharmacist reported irregularities to the attending physician and the facilities Medical Director and Director of Nursing (DON) for one (Resident #8) of five resident's residents reviewed for drug regimen reviews. Specifically, the lack of Consultant Pharmacist's identification and recommendation regarding the continued use of Wellbutrin (antidepressant medication) without attempt of a gradual dose reduction (GDR). The finding is: The policy and procedure titled Medication Regimen Review by Pharmacy Consultant dated 8/2019 documented the pharmacy consultant will assess the medication regimen for appropriateness and rationality to determine if the medication therapy is optimally effective and to identify any irregularities or unnecessary drugs. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 12/20/19 the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. One (Resident #8) of five residents reviewed for unnecessary medication had issues. Specifically, the lack of documented specific behaviors that led to a failed GDR attempt of Fluphenazine HCL (antipsychotic medication) and lack of care plan revisions during that GDR attempt. In addition, the lack of a GDR attempt of an anti-depressant (Bupropion).