Elderwood at North Creek

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not provide effective housekeeping and maintenance services on 2 of 2 resident units (A and B wings) and the building exterior. Specifically, floors, walls, ceilings, sinks, and building exterior were not clean and/or maintained. This is evidenced by: During observations on 9/16/2024 at 1:50 PM, the following areas on the A-Wing unit were soiled or in disrepair: • Door jams casings were chipped. • Walls were cracked at the baseboards. • The wall was cracked in the corridor below the window air-conditioner. • Air vents were dirty and grimy. • Ceiling tiles were not in place, and the suspended ceiling metal grid was or discolored or damaged. • The corridors floors were dirty, grimy, and sticky. [...]

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 had no open and/or expiration dates written on them. This was evident for 2 of 2 medication carts reviewed on Units A and B in the facility for medication storage. This is evidenced by: The facility's Policy and Procedure, titled Medication Label and Container Requirements, last modified [DATE] did not address labeling multi-use medications with expiration dates. During a medication cart review on Unit A with Licensed Practical Nurse #2 on [DATE] 10:53 AM, the following were observed: • Resident #14's Insulin Lispro Solution had a sticker for date opened and date expired with nothing written on it. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice, for 3 (Resident #'s 28, 34, and 59) of 3 residents reviewed for oxygen administration. Specifically, (a.) for Residents #s 28, 34, and 59, their supplemental oxygen tubing were not dated and labeled to reflect when the tubing were changed. (b.) Resident #28's portable oxygen tank was empty. This is evidenced by: A review of the facility's policy and procedure (P&P) titled Oxygen Therapy, Concentrator, last revised on 3/26/2018, documented that oxygen would be administered by licensed nurses with a physician's order. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, equipment and floors were not clean, and equipment and walls were not in good repair. This is evidenced by: During observations in the main kitchen on 9/16/2024 at 11:14 AM, the following areas were soiled with food particles or a black build-up: • The 3 upright freezers were soiled with food particles. • Two drawers in the preparation area were soiled with food particles. • The preparation area floor was soiled with a black build-up. • The kitchen floor in corners, next to walls, and behind cooking equipment was soiled with food particles and a black build-up. • The handwashing sink faucet and 3-bay sink faucet were leaking. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not dispose of garbage and refuse properly for 3 of 3 dumpsters. Specifically, dumpsters were not kept closed, and the dumpster area was not clean. This is evidenced by: During observations on 9/16/2024 at 1:02 PM, the top cover to one garbage dumper was open with refuse inside, the side door to a second dumpster was open with refuse inside, and refuse was on the ground in front of the third dumpster. During an interview on 9/18/2024 at 10:46 AM, Administrator #1 stated the facility staff would be re-educated on keeping the dumpsters closed and to always place the garbage inside. 10 New York Codes, Rules, and Regulations 415.14(h)

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 use appropriate personal protective equipment when entering and exiting the rooms of COVID-19 positive residents and residents on Contact/Droplet Precautions. This was evident for 2 (Unit A and Unit B) of 2 resident units observed. This is evidenced by: [...]

Inspectors wroteBased on observations, interviews, and record review during a recertification survey on 4/4/2022 through 4/8/2022, the facility did not ensure a resident received respiratory care consistent with professional standards of practice for 1 (Resident #47) of 1 resident reviewed for respiratory care. Specifically, the facility did not ensure Resident #47 received 4 liters of continuous oxygen via nasal cannula as documented in the physician order and the respiratory care plan. Additionally, the resident's oxygen saturation (a measure of the amount of oxygen being carried by red blood cells) was not consistently monitored and documented every shift for hypoxemic respiratory failure (low level of oxygen in the blood) as documented in the physician order. This is evidenced by: Resident #47: [...]

Inspectors wroteBased on record review and staff interview during a recertification survey the facility did not ensure the physician was notified in a timely manner when there was a significant change in condition for one (Resident #62) of four residents reviewed. Specifically, for Resident #62, the facility did not ensure the physician was notified of the resident's low blood pressure and oxyygen saturation rate on 9/28/19. This is evidenced by: Resident #62: The resident was admitted to the facility on [DATE], with diagnosis of Myasthenia Gravis (a chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles), anemia, and pneumonia. The resident was discharged to the hospital on 9/30/19 and was re-admitted to the facility on [DATE] with a diagnosis of pneumonia secondary to Methicillin-resistant Staphylococcus aureus (MRSA) (a bacterial infection). [...]

Inspectors wroteBased on observations, interviews and record reviews during a recertification survey the facility did not ensure written notice was provided to the residents and residents representative of the bed hold and return policy at the time of transfer for three (Resident #'s 36, 62 and 175) of three residents reviewed for hospitalization. Specifically, for Residents #'s 36, 62, and #175, the facility did not provide written notice of bed hold and return policy which specifies the duration of the bed hold, how reserve bed payments will be made, and the conditions upon which the resident would return to the facility. This is evidenced by: [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure Preadmission Screening (SCREEN) was complete for 1 (Resident #s 25) of 19 residents reviewed. Specifically, for Resident #25, the facility did not ensure the SCREEN form DOH-695 dated 4/5/19 included an answer to the question regarding serious mental illness when the Patient Review Instument (PRI) dated 4/5/19, documented the resident had a psychotic disorder. This is evidenced by: The Policy and Procedure dated 7/10/18 for admission Screening and Approval Process Long Term Care (New York State), documented for admission to the facility from a hospital of other health facility a PRI must be completed by a qualified Registered Professional Nurse assessor, and the SCREEN must be completed and signed by a qualified assessor. Resident #25: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure an ongoing program to support residents in their choice of activities for 2 (Resident #'s 13 and 71) of 2 residents reviewed for activities. Specifically, the facility did not ensure residents were provided, an ongoing program to support them in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, based on the comprehensive assessment, care plan and preferences of the resident. This is evidenced by: Resident #71: The resident was admitted to the facility on [DATE], with diagnoses of dementia, depression, and anxiety disorder. The Minimum Data Set (MDS - an assessment tool) dated 10/2/19, documented the resident had severe cognitive impairment. The annual MDS dated [DATE]. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process. Specifically, the facility did not ensure a time frame was established when the physician documented an identified irregularity and what action had been taken. This is evidenced by: Medication Regime Review by Pharmacy Consultant Policy revised 08/12/19 documented: The attending physician will document in the medical record (or directly on the written recommendation from the consultant pharmacist) that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the medical record. [...]