Glendale Home-Schdy Cnty Dept Social Services

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident # 3) of three residents reviewed. Specifically, Resident #3 who was at high risk for falls and at risk for bleeding, fell out of bed with no injury on 05/25/2023, while care was provided by one Certified Nurse Aide per care planned interventions. The facility failed to (a.) reassess the resident's risk for falls, (b.) assess the resident for safe bed mobility with one staff, and (c.) implement new interventions to mitigate the risk of an accident. [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for three (3) (Resident #s 3, 2, and 7) of 4 residents reviewed. [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to provide pain management consistent with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #3) of three (3) residents review. Specifically, for Resident #3, the facility did not have evidence of an assessment of the resident's pain, when there was a new physician order dated 9/23/2023 for Tramadol (narcotic pain medication) and the resident was already receiving Acetaminophen (helps treat mild to moderate pain) Extra Strength 1000 milligrams, every eight (8) hours.

Inspectors wroteBased on record reviews and interviews conducted during the survey, the facility failed to maintain and account for all controlled substances in accordance with professional standards of practice. Specifically, the narcotic count record signature sheet for three (3) of five (5) units were incomplete.

Inspectors wroteBased on observation and interview during the survey, the facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in the main kitchen and in 2 (two) of 5 (five) kitchenettes/nourishment stations. Specifically, proper dating of open items was not followed, and expired food items were found stored ready for use in the refrigerators and freezers.

Inspectors wroteBased on observation, record review, and interview conducted during the survey, the facility failed to maintain an infection 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 (2) (Resident #'s 28 and 137) of four (4) residents reviewed for infection control practices. Specifically, 1.) Certified Nurse Aide # 1 failed to utilize Enhanced Barrier Precautions during resident care, increasing the risk of cross- contamination. 2.) Licensed Practical Nurse #3, while administering medications via gastrostomy tube (a tube placed into the stomach to provide nutrition) failed to maintain aseptic technique by placing the medication cup and supplies for the gastrostomy tube directly on the Resident's bedside table. [...]

Inspectors wroteBased on record review and interview during a survey, the facility failed to ensure a resident received a written notice, including the reason for the change, before a room change. In addition, the resident was not provided with the opportunity to disagree and or decline the decision to change rooms. This was evident for one (1) of one (1) residents (#43) reviewed. Specifically, Resident #43 was verbally informed of a room change because it was alleged that a roommate was assisting Resident #43 with activities of daily living.

Inspectors wroteBased on record review and interviews conducted during a survey, the facility did not ensure it consulted with the resident's physician and notified the resident's representative when there was a significant change in the resident's physical status for two (2) (Resident #s 16 and 207) of four (4) residents reviewed. Specifically, (a.) Resident #16 family representative were not made aware of resident's change in condition and that resident received intravenous fluids. (b.) Resident #207 was assessed at pain level 10/10, the physician ordered medication adjustments and was not notified that the pain medication was ineffective.

Inspectors wroteBased on observations and interviews conducted during survey the facility did not ensure residents' personal property were free from loss or theft for one (1) of one (1) residents reviewed. Specifically, Resident #43 reported they did not receive their laundry back in a timely manner and also five (5) nightgowns were not returned.

Inspectors wroteBased on record reviews and interviews during a survey, the facility failed to ensure residents were free from unnecessary medications for,(4) four (Residents #55, 97, 13, and #155) of six (6) residents reviewed, Specifically, a) Residents #55 and #97 had as needed psychotropic medications with end dates outside the regulatory limit of 14 days. b) resident #13, did not have documented attempts of gradual dose reduction or documentation that a gradual dose reduction is clinically contraindicated c) Resident #155 did not have an appropriate diagnosis for an antipsychotic medication.

Inspectors wroteBased on record reviews and interviews conducted during a survey, the facility failed to timely report an injury of unknown origin to the State Survey Agency immediately, but not later than two (2) hours after the findings of serious bodily injury in accordance with State law through establish procedure for one (1) (Resident #8) of one (1) resident reviewed. Specifically, for Resident #8 a fracture of unknown origin was not reported

Inspectors wroteBased on record reviews and interviews during the survey, the facility failed to provide care to dependent residents in accordance with professional standards of practice for two (2) (Resident #s 2 and #201) of five (5) residents reviewed. Specifically, (a.) for Resident #2, staff failed to provide the resident with a shower/bath for the first two weeks after admission and (b.) for Resident #201, staff failed to provide assistance to the bathroom and toilet resident as scheduled.

Inspectors wroteBased on observation, record review and interviews during a survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for ONE (1) (resident #207) of thirty-five (35) residents reviewed. Specifically, on 7/14/2024 at 11:42 AM, Resident #207's daughter called expressing concern and stated resident complained of trouble breathing and pain 10/10. At 4:47 PM the provider was notified of pain 10/10 and adjusted the resident's pain medication. At 9:46 PM, resident #207 was lethargic with no appetite; the provider was not made aware of the change in condition and or persistent pain. On 7/15/2024 at 4:09 PM, Resident #207 was unresponsive, hypotensive and sent to the Emergency Room.

Inspectors wroteBased on record reviews and interviews during the survey process, the facility failed to obtain necessary treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, for Resident #13, there was no psychiatric service follow-up as ordered by the psychiatrist.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #'s 32 and #57) of eight (8) residents observed during a medication pass for a total of 35 observations. This resulted in a medication error rate of 31.43 percent. Findings Include: The facility's policy and procedure titled Administering Medications revised 03/2023, documented the expiration/beyond use date was to be checked prior to administering a medication. Resident #32 Resident #32 was admitted to the facility with diagnoses of essential primary hypertension (most common type of high blood pressure), herpes viral ocular disease unspecified (group of eye disorders caused by infection with the herpes simplex virus), hyperlipidemia unspecified (excess amount of fats in your blood). [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and time frames to meet the resident's medical, nursing, mental and psychosocial needs for 3 (Resident #s 77, 135 and #78) of 34 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #77, the facility did not ensure the CCP included a care plan to address the resident's hearing deficit and use of hearing aids; for Resident #135, the facility did not ensure the CCP included interventions related to the use of a splint. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure care plans were reviewed and revised in a timely manner for 2 (Resident #'s 45, and 78) of 34 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #45, the facility did not ensure the Comprehensive Care Plan (CCP) for Sensory Deficit (At Risk for Visual Deficit), Musculoskeletal Disorder (Vitamin D Deficiency), and Sleep Pattern Disturbance were reviewed at least quarterly. Specifically, for Resident #78, the facility did not ensure the CCP for Resident #78 for Neuromuscular disease related to Multiple Sclerosis and Altered Urinary Elimination were updated quarterly with goals and interventions as treatment was changed. This is evidenced by: [...]

Inspectors wroteBased on observation, record reviews and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan (CCPs) for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Resident #'s 20, 24, 34, 43, 118, and # 141) of 29 residents reviewed for comprehensive care plans (CCPs). [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey the facility did not ensure it provided services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 3 (Resident #'s 94, 7, and #15) on 3 (Dutch Hallow, Pine Plains and [NAME] Crossing) of 5 units. Specifically, for Resident #94, the facility did not ensure the resident was transferred out of bed and/or transferred to the toilet due to inadequate staffing on the weekends, for Resident #7, the facility did not ensure the resident was transferred out of bed on the weekends and for Resident #15, did not ensure incontinence care was provided every 4 hours, in accordance with the Comprehensive Care Plan (CCP) due to inadequate staffing on the weekends. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure it conducted and documented a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. Specifically, the facility did not ensure their facility assessment included an evaluation of the overall number of facility staff needed to ensure that a sufficient number of qualified staff were available to meet each resident's needs. This was evidenced by: The Facility Assessment last reviewed on 1/14/2021, did not include an evaluation of the minimum staff required to ensure a sufficient number of qualified staff were available to meet each resident's needs. [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey, the facility did not ensure residents received care to prevent avoidable pressure ulcers, and that residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #49) of 3 residents reviewed for pressure ulcers. Specifically, for Resident #49, the facility did not ensure a mechanical wound treatment (wound vac) was applied correctly. Additionally, the facility did not ensure the care plan developed for a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) contained interventions for an infected wound or for suspected deep tissue injuries (DTI: [...]

Inspectors wroteBased on observation, interview, and record review during a recertification survey, the facility did not ensure adequate pain management was provided to residents who required such services, consistent with professional standards of practice for 2 (Resident #'s 24 and #131) of 2 residents reviewed. [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during the recertification survey, it was determined that the facility did not ensure that it was free of medication error rates of 5 percent or greater for two (Residents #88 and #165) out of six residents reviewed for medication administration with 26 total observations resulting in a 34.62 percent error rate. Specifically, the facility did not ensure medication was administered as ordered by the medical doctor for Residents #88 and #165. This is evidenced by the following: The facility Policy and Procedure (P&P) titled Glendale Nursing Home Medication Administration Schedule Protocol dated 2/6/2012 stated drugs must be administered no more than sixty minutes before or after the scheduled time. Resident #88: Resident #88 was admitted to facility with hypertension, major depressive disorder and Alzheimer's disease. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, non-food contact equipment were not clean in the main kitchen and in 5 of 5 unit kitchenettes. This is evidenced by: The main kitchen and the kitchenettes were inspected on 05/13/2021 at 9:45 AM. In the main kitchen, the sides of both convection ovens, the stovetop, and the electric outlets under the food preparation tables were covered in food debris. In 5 of 5 unit kitchenettes, the gaskets and the exhaust fans in the refrigerators were covered in food particles and dust, and the underside of the juice machines were covered in a black syrup like substance. The Director of Food Services stated in an interview on 05/17/2021 at 11:30 AM. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure the policy regarding foods brought in to residents by visitors is in accordance with adopted regulations. Specifically, the facility policy does not have provisions to ensure facility staff assist dependent residents in accessing and consuming food brought to them by visitors. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 05/13/2021. This policy did not include a method by which staff assist residents in accessing and consuming food if the resident is not able to do so on their own. [...]

Inspectors wroteBased on observation and interview during a recertification survey conducted on 5/26/2021, 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. Specifically, the facility did not ensure facility staff members changed gloves and performed hand hygiene during the process of collecting specimens via nasal swabbing for COVID-19 testing for 4 (Certified Nurse Assistant (CNA) #5, Resident Support Worker (RSW) #5, Human Resource (HR) #6, and [NAME] #7) of 5 staff members swabbed. This is evidenced by: [...]