Iroquois Nursing Home Inc

Inspectors wroteBased on record review and interviews (iQIES intake 2971099) the facility failed to ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (ensures that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care; a Level II Preadmission Screening and Resident Review identifies the specialized services required by the resident) for one (1) of one (1) residents (Resident #140) reviewed. Specifically, Resident #140 had a known developmental disability not identified on their initial Screen, a new screen was not completed, they were not referred for a Preadmission Screening and Resident Review Level II timely when the resident's discharge plan changed to long term care; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of five (5) residents (Resident #10) reviewed. Specifically Resident #10's treatment to the pressure ulcer on their back was not administered as ordered.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure adequate supervision to prevent accidents for two (2) of two (2) residents (Residents #105 and #123) reviewed. Specifically, Resident #105 was on a mechanical soft diet with aspiration (inhaling food into airway) precautions with no bread and was served a whole hamburger on a bun; and Resident #123 was on a ground diet and was served a whole hamburger on a bun.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who were fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for one (1) of one (1) resident (Resident #183) reviewed. Specifically, Resident #183 did not receive their water flushes as ordered.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #8) reviewed. Specifically, Resident #8 received hemodialysis treatments at a community-based dialysis center and there was no documented evidence there was consistent ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on observations, record review, and interviews, 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 for one (1) of one (1) resident (Resident #5) reviewed. Specifically, Resident #5 was on enhanced barrier precautions and Licensed Practical Nurse #4 did not wear appropriate personal protective equipment while they performed wound care.

Inspectors wroteBased on record review and interviews during the abbreviated survey (#2649782) conducted 01/30/2026, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for one (1) of three (3) residents (Resident #2). Specifically, Resident #2 was administered an as needed antipsychotic medication for agitation without a documented medical rationale. There was no documented evidence that the medication was medically necessary, nor that non-pharmacological interventions were attempted prior to administering the medication. Additionally, the resident did not have a care plan to address their behaviors or personalized interventions for their behaviors.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/14/2024 -8/20/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 4 resident floors (Unit 1) reviewed. Specifically, Unit 1 had multiple unclean and damaged wheelchairs, positioning chairs, and positioning devices.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/14/2024 - 8/20/2024, the facility did not ensure indicated restraints were used for the least amount of time and documented ongoing re-evaluation of the need for restraints for 1 of 2 residents (Resident #7) reviewed. Specifically, Resident #7 had an order for a Merry [NAME] (an enclosed frame wheeled walker) that was evaluated as a restraint and the Comprehensive Care Plan did not address parameters of use for the Merry Walker; and the restraint assessment was incomplete.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00318948 and NY00314795) surveys conducted 8/14/2024-8/20/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 4 residents (Resident #36) reviewed. Specifically, Resident #36 was not assisted with timely toileting.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/14/2024 -8/20/2024, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 resident (Resident #22) reviewed. Specifically, Resident #22 was not evaluated by therapy or care planned for the use of a scoot chair (a low-to-the-ground positioning chair that allows self-propulsion by foot and reduces the risk of falls).

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/14/2024 - 8/20/2024, the facility did not ensure that residents who required dialysis services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #301) reviewed. Specifically, Resident #301 received hemodialysis (a process of purifying blood when the kidneys do not work properly) treatments at a community-based dialysis center and did not have a Comprehensive Care Plan that addressed dialysis.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 8/14/2024-8/20/2024, the facility did not ensure nurse staffing information was posted daily at the beginning of each shift and included the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides for 4 of 5 days of survey. Specifically, daily nurse staffing was not posted daily at the beginning of the shift as required on 8/14/2024, 8/15/2024, 8/16/2024, and 8/19/2024 as required.

Inspectors wroteBased on interview and record review during the abbreviated survey (NY00306465), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's order for continuous positive airway pressure therapy (a treatment that uses pressure to keep the airway open when sleeping) was not complete and when Resident #2 either refused the treatment or the machine had a missing part, there was no documentation the facility addressed the issues or that the medical provider was notified.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00298995) surveys conducted 7/12/22-7/15/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #31) reviewed. Specifically, Resident #31 was found in a non-resident area of the facility 2 hours after a fire drill when the resident left a secured unit undetected. Additionally, the resident's absence was reported by a family member and unnoticed by staff.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00252303) surveys conducted 7/12/22-7/15/22, the facility failed to provide food and drinks that were palatable, attractive, and at safe and appetizing temperatures for 2 of 2 test trays (lunch trays for Residents #20 and #25). Specifically, food was not served at palatable or safe temperatures. The food service policy Critical Control Daily Temperature Log revised 2009, documented the minimal internal temperatures for cooking raw food were 165 degrees Fahrenheit (F) for poultry, 155 degrees F for ground meats (beef, pork, veal, lamb, and fish), pork (steak & chops), 155 degrees F for pork roasts, and 145 degrees F for beef, veal, and lamb roasts. The policy documented serving temperatures were to be: - under 40 degrees F for cold foods; - soups 160-180 degrees F; [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/12/22-7/15/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the side of the deep fryer was soiled/unclean, the steam kettle had splattered deep fryer oil, the floor of the walk-in cooler had frozen water and melted water on it, the handwash sink near the 3-bay sink area was leaking, there were two soiled/unclean frying pans, and the walls behind the dish machine and the 3-bay sink area were soiled/unclean.