Fifth Avenue Health Care

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled Accidents and Incidents - Investigating and Reporting, Elopement, and Dementia Care, the facility failed to maintain an accident-free environment and provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). This had the potential to affect at least 10 additional residents identified as being at risk for wandering/elopement. Specifically, the facility failed to implement effective interventions to prevent the elopement of R1, creating an ongoing risk for resident elopement and injury. This deficient practice placed residents at risk for serious harm, injury, and death. [...]

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Policy and Procedure Abuse, Neglect, and Exploitation, the facility failed to keep one of three sampled residents (R) (R10) free of sexual abuse by another resident, R11. This failure had the potential to cause physical and psychosocial harm to R10.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled Medication Administration-General Guidelines, the facility failed to ensure accurate administration of medications for three of 32 medication opportunities observed, resulting in a medication error rate of 9.37%. This deficient practice had the potential to negatively impact residents (R), leading to complications of their current health status.

Inspectors wroteBased on observations and staff interviews, and review of the facility policy titled, Preparing Pureed Foods, the facility failed to prepare pureed food in a manner that preserved the nutrient value of resident meals. The deficient practice had the potential to affect 15 of 15 residents receiving an oral pureed diet.

Inspectors wroteBased on observations, interviews, and a review of the facility policy titled Food Storage Guidelines, the facility failed to discard food items past the best-by date. This deficient practice had the potential to affect 66 of 66 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Legionella Water Management Program and Handwashing/ Hand Hygiene, the facility failed to develop an effective water management program and failed to perform hand hygiene or wash hands when entering and exiting resident rooms when serving lunch trays. The deficient practice of not developing an effective water management program had the potential to affect the health and safety of all residents that reside in the facility and failing to perform hand hygiene or hand washing to affect 64 residents who received a food tray from the kitchen. The facility census was 66 residents.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of facility policy titled, Medication Administration, the facility failed to assess one of 41 sampled residents (R) (R12) for self-administration of medication. The deficient practice had the potential to result in negative outcomes such as medication errors, incorrect dosages, or access by other residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Maintenance Service, the facility failed to maintain a safe, clean, comfortable, homelike environment in two of 25 rooms on East Hall (room [ROOM NUMBER] and room [ROOM NUMBER]) and free of black substance in one of 34 rooms on [NAME] Hall (room [ROOM NUMBER]). Specifically, ceiling tiles were stained with brown and black marks. The deficient practice had the potential to compromise the hygiene and safety of the room environments, negatively impacting the health and well-being of residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plan, the facility failed to develop and implement a comprehensive care plan for eye glasses and tobacco use for one of four residents (R) (R50) care plans reviewed. The deficient practice had the potential for unmet care needs for R50.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to protect one of 41 sampled residents (R) (R28) from an accident with a fall. Specifically, R28 fell from a wheelchair to the floor.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide an environment free from accident hazards for one of six residents (R)(R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that resident care equipment was maintained in safe operating condition for one of six residents (R) (R1) reviewed for accidents. Harm was identified to have occurred on 2/24/2024, when R1 fell from a faulty shower bed and sustained a closed right peritrochanteric femur fracture requiring admission to an acute care hospital.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to provide the necessary care and services to maintain good oral hygiene for one of 31 sampled residents (R) (R55) reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to provide the resident with oral hygiene supplies, staff assistance, and/or reminders to complete oral hygiene care.

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled Emergency Pharmacy Service and Emergency Kits, the facility failed to ensure that an emergency medication kit (E-Kit) was readily available for use in a resident emergency for one of two medication rooms (Medication Room West) observed.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure adequate blood glucose monitoring for residents receiving insulin. This deficient practice affected one of five residents (R) (R55) reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure expired medications were properly discarded in two of two medication rooms (Medication Room East and Medication Room West).

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to label, and date stored and opened food items; failed to ensure the three-compartment sink had proper sanitizing solution concentration; and failed to ensure dietary staff properly washed dishware in three-compartment sink to prevent food borne illness. 49 of 51 residents were receiving an oral diet.

Inspectors wroteBased on observations and interviews the facility failed the maintain the walk-in freezer in proper working condition as evidenced by ice build-up on a food storage rack. Facility census was 51.