Elderwood at Waverly

Inspectors wroteBased on record reviews and interviews during the facility failed to protect residents from sexual abuse for six (6) of six (6) residents (Residents #3, #4, #5, #6, #7, and #8). Specifically, Resident #2 was found in separate sexually inappropriate situations with six (6) residents, all of whom had impaired cognitive function with the exception of Resident #5. The facility's failure to protect residents from sexual abuse placed all 176 residents in the facility at risk of abuse. This resulted in actual harm for Residents #3, #4, #5, #6, #7, and #8 that was Immediate Jeopardy and Substantial Quality of Care for residents' health and safety.

Inspectors wroteBased on record review and interviews during the abbreviated survey (iQIES reference #2740895), the facility failed to ensure residents were free from physical abuse for one (1) of seven (7) residents (Resident #1) reviewed. Specifically, Resident #1 was combative during care, struck Support Aide #2, and Support Aide #2 struck the resident back in the left shoulder. The 04/30/2024 facility policy, Abuse Prevention, Identification, Investigation, Protection and Reporting documented all staff would be trained on prevention of all forms of abuse. Training would include recognizing forms of abuse. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 7 of 7 resident beds (beds for Resident #15, #29, #31, #38, #91, #99, and #106) reviewed. Specifically, Resident #15's mattress was not securely placed within the bedframe brackets; Resident #29's mattress did not fit within the bedframe mattress brackets resulting in a gap between the mattress and the assist rail; Resident #99's mattress was not securely placed in the bedframe brackets resulting in an entrapment zone that exceeded the United States Food and Drug Administration's recommended dimensional limits; [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/24/2025 to 3/28/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 7 residents (Resident #142) reviewed. Specifically, Resident #142 was not provided with supervision and maximum cueing with eating and was not provided meals in the dining room as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 13 residents (Residents #164, and #171) reviewed. Specifically, -Resident #171 had dysphagia (difficulty swallowing), was on aspiration (inhaling food/fluid into the lungs) precautions and the resident was provided ice chips without a physician order or supervision. -Resident #164 was at high risk for elopement (leaving premises/safe area without facility knowledge), the resident frequently wandered in non-residential areas, and there was no documented evidence of a plan to limit the resident's wandering to potentially unsafe areas. Additionally, the resident's wander alert device was not checked for function as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00343302 and NY00370767) surveys conducted 3/24/2025-3/28/2025 the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Residents #143) reviewed. Specifically, Resident #143's telepsychiatry recommendations for non-pharmacological interventions for behavioral symptoms were not implemented.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 5 medication rooms (Unit 1 North and Unit 3) reviewed. Specifically, lorazepam (a controlled substance) was stored in unlocked refrigerators (not double locked) that were not permantly affixed in Unit 1 North's and Unit 3's medication rooms. The facility policy Medication Rooms on Nursing Units, revised 7/30/2024, documented a double locked box in the refrigerator would be used for the storage of controlled substances that required refrigeration. The facility policy Medications Administration Methods, revised 1/25/2024, documented controlled substances should be stored in a double-locked cabinet until immediately before administration. [...]

Inspectors wroteBased on observations and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure the provision of food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals tested (3/24/2025 and 3/28/2025 lunch meals). Specifically, the 3/24/2025 lunch meal entree was difficult to cut; and the 3/28/2025 lunch meal was not served at palatable and safe temperatures.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. Specifically, the main kitchen had food items past their expiration dates, undated food items, the walk-in freezer had ice buildup on an open box of food, and food was stored on the floor.

Inspectors wroteBased on interview and record review during the recertification survey conducted 3/24/2025 through 3/28/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the facility matrix for all residents and access to all resident electronic health records requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00369096), the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding Advance Directives to the staff responsible for the resident's care for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 updated their Medical Orders for Life-Sustaining Treatment to reflect a change in their wishes from cardiopulmonary resuscitation (attempt to restart the heart) to do not resuscitate (allow natural death). The paper medical record (Medical Order for Life Sustaining Treatment form) and electronic medical record code status orders did not match to reflect the resident's Advance Directives wishes to allow natural death (do not resuscitate). [...]

Inspectors wroteBased on observations, record review, and interviews during the abbreviated survey (NY00369577), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive assistance at meals as care planned.

Inspectors wroteBased on record review and interview conducted during the abbreviated survey (NY00327113 and NY00327592), the facility did not ensure adequate supervision was provided to prevent accidents for 8 of 14 residents (Residents #3, #5, #6, #7, #8, #9, #10, and #11) reviewed. Specifically, Residents #7, #8, and #9 had histories of behaviors towards other residents and adequate supervision was not implemented to prevent further resident to resident incidents towards Residents #3, #5, #6, #8, #10, and #11.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 occupied resident floors (First, Third, and Fourth floors) reviewed. Specifically, - the fourth floor had stained ceiling tiles and the elevator alcove had a loose handrail. - the third floor had a damaged bathroom sink, the soiled utility room did not have a paper towel dispenser, and the dining room window was cracked. - the first floor had damaged walls and ceilings, unsealed penetrations, an open junction box in the education classroom closet, and the library had two sliding windows that opened more than 6 inches.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the main kitchen's tray service line cooler was propped open and not maintaining proper temperature, floors were in disrepair, the ceiling was damaged, and cooking and storage equipment was unclean.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/19/23 -4/27/23 the facility failed to determine if medication self-administration was clinically appropriate for 1 of 1 resident (Resident #98) reviewed. Specifically, Resident #98 was observed on 5 days with Odomzo (generic name sonidegib, a chemotherapeutic medication) in a cup at their bedside and there was no assessment to determine the resident's ability to safely self-administer medications or a physician order for self-administration of medications. The facility policy Self Administration of Medication dated 5/2018 documented residents who desired to self-administer medications required review and approval of the interdisciplinary care planning team members and an order from the attending physician. [...]

Inspectors wroteBased on record review and interview during the recertification survey conducted 4/19/23-4/27/23 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #438) reviewed. Specifically, Residents #438 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (Centers for Medicare and Medicaid Services) for Medicare Part A as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 10 residents (Residents #108 and 109) reviewed. Specifically, Resident #108 was not assisted with shaving, nail care, or eating; and Resident #109 was not assisted with eating.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 2 of 4 residents (Residents #66 and #93) reviewed. Specifically, Resident #93 was not wearing their bilateral palm devices (helps prevent hand contractures) as care planned during multiple observations; and Resident #66 did not have their neck brace applied appropriately and was not wearing positioning and palm devices as care planned for multiple observations. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 4 of 10 medication carts (medication carts 1 and 2 on Unit 100 South and medication carts 1 and 2 on Unit 3) inspected. Specifically, there were 4 insulin pens and 1 eye drop bottle observed without pharmaceutical labels including resident information, medication name, medication dosage, and administration instructions.

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for 2 of 3 meals (4/20/23 and 4/21/23 lunch meals) reviewed, and food items in 1 of 1 steam table observed. Specifically, lunch meals trays on 4/20/23 and 4/21/23 were not served at palatable and appetizing temperatures; and the main kitchen steam table was not holding the temperature for hot food items.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 residents (Residents # 38 and #52) reviewed. Specifically, Residents #38 and 52 were provided food items that were not consistent with the physician ordered diet.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to special eating equipment and utensils for residents who needed them for 2 of 2 residents (Residents #30 and 38) reviewed. Specifically, Resident #38 was not provided with adaptive curved utensils or a Kennedy cup (spill-proof drinking cup); and Resident #30 was not provided with weighted utensils and an inner lip plate as care planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to dispose of garbage and refuse properly for 1 isolated area (the waste fryer oil drums outside the main kitchen). Specifically, the waste fryer oil had been spilled on the ground surrounding the waste drums outside of the main kitchen.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00275715 and NY00300682) surveys conducted 4/19/23-4/27/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #178) reviewed. Specifically, during Resident #178's wound treatment licensed practical nurse (LPN) #5 did not perform appropriate hand hygiene.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the results of the most recent Federal health recertification survey conducted 10/16/20 were not posted in a location that would allow individuals to examine the survey results without having to ask to see them; and the results of the most recent Life Safety Code Federal survey conducted on 10/15/20 were not posted.