Haym Solomon Home for the Aged

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00323375 & NY00316928), the facility failed to ensure that a resident received adequate supervision to prevent accidents. This was evident for two (2) out of two (2) residents (Resident #1 & Resident #2). Specifically, On [DATE] at 5:30 AM, Certified Nurse Assistant #1 transferred Resident #1 from their bed to the wheelchair and Resident #1 fell. Resident #1 required two-person assist with mechanical lift. Resident #1 was assessed by Nursing Supervisor #1 and was observed with an opened purpura (purple-colored spots and patches on the skin) on their left lower extremity. A nursing note dated [DATE] documented Resident #1 was transferred to the emergency room at 8:38 AM on [DATE] after being observed with decreased oxygenation and breathing with their abdominal muscles. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 10/31/2024 and 11/07/2024, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. This was evident for 2 (Residents #60 and #174) of 2 residents reviewed for Personal Funds out of a total sample of 38 residents. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey between 10/31/24 and 11/07/24, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds was obtained to assure the security of all personal funds of residents deposited with the facility. This was evident for 81 residents who maintained personal funds accounts with the facility. Specifically, the surety bond obtained by the facility was not sufficient to cover the total held in all resident's accounts.

Inspectors wroteBased on observations, record reviews and interviews during the Recertification and Abbreviated Survey (NY00341031, NY00353026) conducted from 10/31/2024 to 11/07/2024 the facility did not ensure that injuries of unknown origin were reported immediately but not later than 2 hours after the allegation was made, if the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the New York Department of Health. This was evident for 2 (Resident #144 and #130) of 2 residents reviewed for Abuse out of 38 total sampled residents. Specifically, 1). [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and Abbreviated (NY00330333) survey from 10/31/2024 to 11/07/2024, the facility did not ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident for 1 (Resident #3) of 6 residents reviewed for Pain out of 38 sampled residents. Specifically, Resident #3 had a Morphine pump installed in 7/2020, and there was no documented evidence that the cartridge of the pump was changed and or refilled as required every 6 months, or that Resident #3 had been referred to pain management in over 12 months. [...]

Inspectors wroteBased on observation, record review and staff interviews during the recertification survey, the facility did not ensure that person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This was evident for 5 of 5 residents reviewed for Accidents out of a sample of 40 residents (Resident #s 156, 184, 218, 519, 522). Specifically, no CCP was developed and implemented for residents' use of side rails.

Inspectors wroteBased on observations, record reviews, and staff interviews conducted during the recertification survey, the facility did not ensure that residents observed using bed side rails were appropriately assessed for risk of entrapment or that the risks and benefits of side rail use was explained to the resident and/or representative. This was evident for 4 of 7 residents reviewed for accidents out of a sample of 40 residents (residents #184, #218, #519, #522)

Inspectors wroteBased on record review and staff interviews conducted during a Recertification/Complaint Survey from 9/19/2022 to 9/26/2022, the facility did not ensure that a resident's designated representative was provided with a written summary of the baseline care plan. This was evident for 1 of 2 residents reviewed for Care Plan out of 40 sampled residents. (Residents # 431).

Inspectors wroteBased on observations, record reviews and interviews during the recertification survey the facility failed to ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. Specifically, the physician did not review the Rehab assessment and place order for the resident's use of bed side rails. This was evident for 1 of 5 residents reviewed for Accidents out of a sample of 40 residents. (Resident #156).

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint survey, the facility did not ensure safe food handling and storage was practiced to prevent food-borne illness. Specifically, two expired boxes of enteral feeding was found in the central supply storage room on the 2nd floor in the enteral feeding and liquid nutritional supplement storage area on the main floor of the facility. This was evident during the Kitchen Observation task.

Inspectors wroteBased on observation and staff interviews during recertification survey, the facility did not ensure that raw food was handled appropriately during food preparation in accordance with professional standards for food service safety. Specifically, potentially hazardous raw chicken and raw fish were handled with bare hands during food preparation. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. Specifically, 1). care plans were not developed to address Diabetes Mellitus and the use of anticoagulant, anti-hypertensive medication, and diuretic medication, and 2). Care plans were not developed to address the use of anticoagulant and diuretic medication. This was evident for 2 of 5 residents reviewed for Unnecessary Medications out of a sample of 39 residents. (Resident #110 and #610)

Inspectors wroteBased on record review and interview conducted during recertification survey, the facility did not ensure cognitively intact residents were afforded the opportunity to participate in care planning meetings. This was evident for 2 of 3 residents reviewed for Care Plan out of a sample size of 39 residents. (Resident #176 & #107)

Inspectors wroteBased on observation and staff interview, the facility did not ensure that residents who have limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with contractures was not observed wearing a hand splint device as ordered by the physician. This was evident for 1 of 3 resident reviewed for Position/Mobility out of a sample of 39 residents. (Resident #135)

Inspectors wroteBased on observation, and staff interviews during the re-certification survey, the facility did not ensure medical supplies containing biologicals were stored with appropriate pharmacy labels, following cautionary and expiration instructions. Specifically, 2 insulin pens were observed in a plastic bag with the name and room number of a resident. There were no pharmacy issued labels affixed and pens did not contain an opened or discard date. This was evident for 1 medication cart on the 6th Floor during the Medication Storage Task. The undated facility policy and procedure titled Medication Storage documented prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, a housekeeper was observed removing waste from the rooms of residents who were maintained on Contact Precautions and did not perform hand hygiene. This was observed during the Infection Control task.