Iroquois Resident Home, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and safe ambient temperature for six (R1, R2,R3 R4, R7 and R8) of eight residents reviewed for physical environment.

Inspectors wroteBased on observation, interview and record review the facility failed to employ an Infection Preventionist. This failure has the potential to affect all 27 residents residing in facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess, treat, and notify the physician of newly acquired pressure ulcers and apply a physician ordered treatment for one of one (R23) resident reviewed for pressure ulcers on the sample list of 18.

Inspectors wroteBased on interview and record review the facility failed to implement fall prevention interventions, complete thorough fall investigations to determine root causes and failed to complete Neurological Assessments post falls for two (R2, R25) residents out of two residents reviewed for accidents in a sample list of 18 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to position urinary drainage bags in a manner that prevented potential cross contamination for two of two residents (R23, R230) reviewed for catheters on the sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to assess one (R2) resident for the use of side rails out of one resident reviewed for side rails in a sample list of 18 residents.

Inspectors wroteBased on interview and record review the facility failed to obtain psychotropic medication consents, assess the need for psychotropic medications, determine symptoms or behaviors warranting use, utilize nonpharmacological interventions, monitor for adverse reactions, establish a psychotropic care plan, and establish parameters for the use of an as needed antianxiety medication for three (R230, 231, 232) of three residents reviewed for psychotropic medications on the sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for three residents (R23, R25, R230) out of four residents reviewed for Infection Control in a sample list of 18 residents.

Inspectors wroteBased on interview and record review the facility failed to follow their Antibiotic Stewardship Protocol by administering a prophylactic antibiotic for one of four residents (R10) reviewed for Infection Control in a sample list of 18 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure bed rails were safely attached to a bed for one of one resident (R2) reviewed for side rails in a sample list of 18 residents.

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of sexual abuse to the Administrator for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of sexual abuse for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. The Investigation only contained witness statements from R1, R2, V4 CNA (Certified Nursing Assistant), V3 Secretary, and V10 RN (Registered Nurse). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R1) was not subjected to verbal abuse by an employee. R1 is one of three residents reviewed for abuse on the sample list of five.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility was sufficiently staffed to meet the needs of the residents. This failure affects five residents (R5, R14, R20, R23, R28) on the sample list of 21. This failure has the potential to affect all 28 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the dishwashing machine was operating in a manner to sanitize residents food service dishes, wares, and utensils. This failure has the potential to affect all 28 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a comprehensive resident assessment for one (R20) resident reviewed for resident assessments on the sample list of 21.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain kitchen equipment to prevent the potential for cross contamination of food. This failure has the potential to affect all 32 residents residing in the facility, all of whom consume food prepared in the facility kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain written authorization to manage resident's personal funds, and failed to deposit resident's, whose care is funded by Medicaid, personal funds over $50.00 in an interest bearing account. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds management on the sample list of 23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quarterly statements to residents or their representatives to account for resident's personal funds entrusted to the facility on the resident's behalf. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds on the sample list of 23.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a surety bond, or other financial security, in an amount sufficient to protect all resident funds deposited with the facility. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds on the sample list of 23.

Inspectors wroteBased on record review and interview the facility failed to obtain and document Physician Orders for resident advance directives. This failure has the potential to affect one of three residents (R83) reviewed for advanced directives in the sample of 23.

Inspectors wroteBased on record review and interview, the facility failed to provide required Advanced Beneficiary Notices to residents having their Medicare Part A services terminated, precluding residents from selecting the options to continue these services by billing Medicare for an appeal, or at their own expense. This failure affects two residents (R6 and R29) out of three reviewed for Beneficiary Protection Notification on the sample list of 23.

Inspectors wroteBased on record review and interview the facility failed to provide resident (R14) a facility Bed Hold Policy when being discharged to the hospital. R14 is one of one resident reviewed for Bed Hold Notices in the sample of 23.

Inspectors wroteBased on record review and interview, the facility failed to encode, format, and transmit a resident's Minimum Data Set for discharge from the facility. This failure affects one resident (R1) out of 12 reviewed for Minimum Data Sets on the sample list of 23.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a resident's comprehensive care plan, documenting resident needs and services required to meet those needs. This failure affects one resident (R29) out of 12 reviewed for care plans on the sample list of 23.

Inspectors wroteBased on record review, interview and observation, the facility failed to monitor a resident's (R20) pressure ulcer and failed to complete a proper dressing change of R20's pressure ulcer. R20 is one of one resident reviewed for pressure ulcers in the sample of 23.

Inspectors wroteBased on observation, record review, and interview, the facility failed to post the required nurse staffing data on a daily basis and failed to maintain the required nurse staffing data for 18 months. This failure has the potential to affect all 32 residents residing in the facility.