Elderwood at Wheatfield

Inspectors wroteBased on observation, interview, and record review conducted during complaint investigations (NY00344374, NY00348550, and NY00347789) conducted during the Standard survey completed on 8/14/24, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facility. Specifically, the facility did not meet their established minimum number of staff for each shift. Additionally, there was a lack of sufficient nursing staff to get residents out of bed and provide appropriate care according to residents' care plans and preferences. Resident #'s 1, 13, 15, 32, 55, 56, 76, 82, 86, 89 and 91 were involved.

Inspectors wroteBased on observation, interview, and record review during the Standard survey completed on 8/14/24, the facility did not maintain an effective pest control program so that the facility was free from insects for one (Unit 1) of three resident units. Specifically, flies were observed in resident rooms, dining rooms and common (lounge) area on Unit 1.

Inspectors wroteBased on observation, interview, and record conducted during the Standard survey completed on 8/14/24, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #59) of two residents reviewed for dignity. Specifically, Resident #59 was observed to have a hospice (specialized care for people nearing the end of life) nursing assessment completed in the dining room while they were being assisted with their lunch. The finding is: The policy and procedure titled Resident's Rights Policy (General) revised 6/6/22 documented each staff member will be personally responsible for ensuring that the rights of each resident are respected and not violated. [...]

Inspectors wroteBased on observation, record review and interview conducted during a Complaint investigation (#NY00339558) during the Standard survey completed on 8/14/24, the facility did not ensure residents had the right to choose schedules, and health care consistent with their interests, assessments, and plan of care for three (Resident #1, #55, and #56) of six residents reviewed for choices. Specifically, Residents #1, #55, and #56 were not given showers twice a week as care planned and preferred. Additionally, Resident #56 was not gotten out of bed as care planned and preferred.

Inspectors wroteBased on observation and interview during the Standard survey completed on 8/14/24, the facility did not ensure housekeeping services necessary to maintain a sanitary, comfortable interior. Specifically, one (Unit 1) of 3 resident units had a strong urine odor present throughout the survey period.

Inspectors wroteBased on interview, and record review conducted during a Complaint investigation (#NY00343934) during the Standard survey completed on 8/14/24 the facility did not ensure that all alleged violations including abuse, or mistreatment were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency for one (Resident #69) of six residents reviewed. Specifically, an allegation of resident abuse/mistreatment was not reported to the New York State Department of Health as required. The finding is: The policy and procedure titled Abuse Prevention, Identification, Investigation, Protection and Reporting last modified 4/30/2024 documented the facility will provide protection for the health, welfare and rights of each resident residing in the facility. [...]

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed 8/14/24, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing for one (Resident #38) of three residents reviewed. Specifically, there was a delay in an assessment from a qualified individual of the resident's newly identified right buttock pressure ulcer to include a description, stage, location, and measurements. The finding is: The policy and procedure titled Pressure Ulcer, Pressure Injury, and other Skin Conditions: [...]

Inspectors wroteBased on interview and record review conducted during a Complaint investigation (#NY00321764) during the Standard survey completed on 8/14/24, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #84) of one resident reviewed for elopement. Specifically, Resident #84 was found in the parking lot by a visitor on 8/9/23. The finding is: The policy and procedure titled Elopement-Wandering-Missing Resident last modified 10/11/2018, documented all residents are assessed as needed to determine risk level for unsafe wandering/elopement. In the event a resident successfully leaves the facility undetected and unsupervised, the Missing Resident procedure will be put into place immediately. 1. Resident #84 had diagnosis including dementia, cognitive communication deficit, and anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/14/24, the facility did not ensure that each resident was provided special eating equipment and utensils for residents who need them while consuming meals for one (Resident #85) of one resident reviewed. Specifically, Resident #85 was not provided bowls for solid foods or mugs for liquid beverages as care planned. The finding is: The policy and procedure titled Meal Serving-Resident dated 9/24/2018, documented that designated dietary staff will be responsible for ensuring that the necessary items are present at mealtime, or are obtained immediately upon request, for the consumption of food. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 8/14/24, the facility did not 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 two (Resident #15 and Resident #82) of eight residents reviewed for infection control processes during care. Specifically, Certified Nurse Aide #4 and Certified Nurse Aide #18 did not wear proper personal protective equipment for a resident requiring enhanced barrier precautions with a multidrug resistant organism infection while they emptied a catheter bag (urine collection bag), changed the catheter bag to a leg bag, and transferred the resident to a shower chair (#15). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/14/24, the facility did not post, on a daily basis, the staff total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility's posted staffing was not updated at the beginning of each shift and/or reflected changes in the schedule. Additionally, the facility did not have a policy for completing the DOH Staffing Report. The finding is: During observations from 8/8/24 through 8/14/24 from 7:45 AM through 5:00 PM, the DOH Staffing Report was posted at the front desk of the facility, however it did not include an updated total number of actual licensed and unlicensed nursing staff for each shift. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 8/14/24, it was determined that the facility did not ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized. Specifically, three of five residents (Residents #1, #12, #59) reviewed for complete immunization records had issues with no documented evidence of signed consents or declinations for the 2023 influenza vaccine.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard Survey completed on 12/6/19, the facility did not ensure provision of a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. One (Resident #20) of one resident reviewed for transmission-based precautions had issues. Specifically, the lack of maintaining proper infection control practices during incontinence care, the lack of maintaining appropriate infection control practices and hand hygiene after staff provided fecal incontinence care.