Elmhurst Care Center, Inc,

Inspectors wroteBased on observation and interview during the Recertification survey, the facility did not ensure that housekeeping and maintenance services were maintained. Specifically: 1) Seating furniture in resident room and in the common area were stained, soiled and faded. 2) Holes in the ceiling and walls in the staff bathroom and clean linen closet. 3) Dining room tables were wobbly. 4) Dining room walls and ceiling with dried food particles and stains. 5) Missing window panels. 6) Mechanical lifts, scales layered with accumulation of dust and dirt. 7) Wheelchairs with torn armrest and torn back sides. 8) Window blinds missing vertical panels. This was evident for three (3) of (6) six resident units. (units 4, 5 and 6).

Inspectors wroteBased on observation, record review, and interview during the re-certification survey, the facility did not ensure that each resident was treated with dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, the physical therapist assistant was observed holding up the residents oversized red sweat pants during floor ambulation. This was evident for one (1) of one (1) resident reviewed for Dignity (Resident #10). The finding is: The facility policy reviewed April 2024, titled, Dignity: Quality of Life, documented, Encouraging and assisting residents to dress in their own clothes (according to season and appropriately fitting). Resident #10 was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included, but not limited to Major Depressive Disorder, Dementia and Schizophrenia. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was evident for 1 (Resident # 134) of 38 sampled residents. Specifically, ) Resident #134 had no care plan in place for antibiotic therapy.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility did not ensure that the survey results were posted in a place readily accessible to residents, and family members or legal representatives of residents. Specifically, the survey results were located on top of high shelf in the lobby with no signage in the area and was not readily accessible to residents. The finding is: The facility policy and procedure titled Residents' Rights with a last revision date of 03/2024 documented that residents has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated survey (NY00342009) from 6/26/24 to 7/03/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report, and 2) multiple nursing staff members reported a lack of sufficient staffing.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility did not ensure that the nurse staffing information was posted appropriately. Specifically, the posting of daily nurse staffing information was not posted in a prominent area which was readily accessible to residents and visitors.

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 9/19/22 to 9/27/22, the facility did not ensure that the Minimum Data Set (MDS) 3.0 Assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. Specifically, thirty two (32) Resident MDS Assessments triggered as being over 120 days old. This was evident for, but not limited to, Resident # 51; Resident #34; Resident #13; Resident #10; Resident #12; and Resident # 48.

Inspectors wroteBased on observation and staff interviews conducted during the Recertification Survey from 9/19/22 to 9/27/22, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were not covered. This was evident for 1 of 2 residents reviewed for Dignity out of a sample of 38 residents. (Resident # 67)

Inspectors wroteBased on record review and staff interview conducted during a Recertification survey from 9/19/22 to 9/27/22, the facility did not ensure that each portion of the MDS assessment accurately reflect the resident's status. Specifically, the most recent MDS did not accurately document that the resident had a diagnosis of Psychosis as documented in the psychiatric consultant notes and physician's orders. This was evident for 1 of 6 residents investigated for Unnecessary Medication out of 38 sampled residents. (Resident # 198).

Inspectors wroteBased on interviews and record review conducted during the Recertification survey from 9/19/22 to 9/27/22, the facility did not ensure that a Comprehensive Care Plan (CCP) that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was developed. Specifically, a care plan was not developed to address a resident's pacemaker. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of sample of 38 residents (Resident #162). The finding is: The policy and procedure titled Comprehensive Care Planning reviewed April 2022 documented all long-term care residents will be reviewed, as necessary, and at intervals not to exceed 90 residents day. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification survey from 9/19/2022 to 9/27/2022, the facility did not ensure a resident with limited range of motion (ROM) and mobility received appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. Specifically, a left ankle foot orthosis (AFO) and a left wrist hand and finger orthotic device were not provided to the resident as per physician order. This was evident in 1 of 4 residents reviewed for Position, Mobility and 1 of 6 residents reviewed for Activities of Daily Living out of 34 sampled residents. (Resident #3 and #74). The finding is: The facility policy titled Assistive/Adaptive Devices revised 4/2022 documented the following: [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure that services provided, as outlined by the comprehensive care plan, met professional standards of quality. Specifically: (1) A resident with a Gastrostomy Tube (GT) and Nothing by Mouth (NPO) order was given water by mouth. (2) Insulin was not administered as ordered (Resident #200). This was evident for 2 of 38 sampled residents (Resident #221 and #200).

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically: (1) A resident with a Gastrostomy Tube (GT) and Nothing by Mouth (NPO) order was given water by mouth. (2) Insulin was not administered as ordered (Resident #200). This was evident for 2 of 38 sampled residents (Resident #221 and #200).

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, the floor tiles at the foot of the bed in a resident's room were lifting up and uneven with a hole measuring approximately 3 inches by 3 inches with a circumference of approximately 10 inches. This was evident for 1 of 1 residents reviewed for Accident (Resident #93). The finding is: Resident # 93 was admitted with diagnoses which include: Hemiparesis, Cerebral Vascular Accident (CVA) and Seizure Disorder. The Quarterly Minimum Data Set 3.0 (MDS) Assessment Reference Date (ARD) of 09/05/19 documented the resident had moderately impaired cognition. The MDS further documented the resident required extensive assist for activities of daily living needs (ADL). A walker and/or wheelchair were used for mobility. [...]