Isabella Geriatric Center Inc

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, interviews with residents, resident representatives, the Resident Council, and staff members indicated that there were staffing concerns in the facility. Additionally, a review of staffing from 12/15/2025-03/25/2026 indicated multiple dates where the facility did not ensure sufficient nursing staffing based on their facility assessment's staffing levels.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that each resident's Comprehensive Care Plans were reviewed and revised. This was evident for one (1) resident out of five (5) residents reviewed for Unnecessary Medications out of 38 sampled residents. Specifically, there was no documented evidence that the Seizure Disorder Comprehensive Care Plan was reviewed and revised for Resident #148 after their last quarterly Minimum Data Set assessment was completed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident for 14 ( # 38, #100, #286, #358, #373, #440, #493, #573, #587, #614, #621, #626, #663, #670) of 14 residents reviewed for resident assessment.

Inspectors wroteBased on record review, and interview during the Abbreviated Survey (ID# 2685553) the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs. This was evident in one (1) of six (6) residents (Resident #1) sampled for comprehensive care plan. Specifically, Resident #1 who was receiving medications to prevent constipation did not have a person-centered care plan with interventions in place.

Inspectors wroteThe findings are: The facility policy titled 'Consultations' dated 10/2021 documented after consultation is completed, the nurse reviews recommendations and contacts attending physician to report recommendations or changes in treatment plan. Resident #1 was admitted to facility with diagnoses including chronic pulmonary embolism ( a blood clot that blocks and stops blood flow to an artery in the lung), coronary heart disease, moderate pericardial effusion (refers to collection of excess fluid in the pericardial sac surrounding the heart) and small cell carcinoma of the Lung complicated by superior vena cava syndrome (occurs when blood flow through the heart blood vessel is obstructed, often due to tumors or blood clots, leading to symptoms like swelling and difficulty breathing). The Minimum Data Set, dated [DATE], documented Resident #1 had moderately impaired cognition. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated Survey (Complaint 2588679), the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for one (1) (Resident #2) of six (6) residents reviewed for accidents. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint (NY00315735 & NY00330475) survey from 03/26/24 to 04/02/24, the facility did not ensure there was sufficient numbers of nursing assistants available to provide nursing care to all residents in accordance with the resident's plan of care. This was evident during review of the Sufficient and Competent Nurse Staffing task. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 3/26/2024 to 4/2/2024, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during kitchen observation and in 1 (9th floor) of 18 pantries. Specifically, 1) the kitchen walk-in refrigerator contained expired, opened, and undated food and drink items, 2) the 9th floor pantry refrigerator was 44 degrees Fahrenheit and contained undated, unlabeled food, and 3) Dietary staff were observed not wearing head coverings in the food preparation area of the kitchen

Inspectors wroteBased on observation, record review, and staff interviews conducted during the recertification survey from 3/26/2024 to 4/2/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 (Unit 10W) of 18 resident units during medication pass and during infection control review. Specifically, 1) infection control policies were not reviewed annually, and 2) License Practical Nurse #4 did not sanitize a blood pressure cuff in between resident use or perform hand hygiene during medication administration.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 3/26/2024 to 4/2/2024, the facility did not ensure that notice of the availability of the survey results was posted in prominent areas accessible to the public. This was evident for 10 (Resident #s 60, 410, 571, 74, 113, 611, 287, 371, 470, and 250) of 10 resident attendees during Resident Council Meeting. Specifically, notification of survey result availability was not posted in prominent areas of the facility accessible to the public.

Inspectors wroteBased on record review and interview conducted during the Recertification survey from 3/26/2024 to 4/02/2024, the facility did not ensure that appropriate notices were provided to Medicare beneficiaries when they were discharged from skilled services. This was evident for 2 (Residents #311 and #554) of 3 residents reviewed for Beneficiary Notification out of 39 total sampled residents. Specifically, a copy of the Notice of Medicare Non-Coverage was not mailed to the resident's representative on the same date that the telephone notification was made.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification and Complaint (NY00315735 & NY00330475) Survey from 3/26/2024 to 4/2/2024, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for 2 (Resident #175 and Resident #210) of 9 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, 1) Resident #175 did not receive staff assistance and was unable to shower in 12/2023 and 1/2024, and 2) Resident #210 was not provided with physical assistance necessary to transfer out of bed.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 3/26/2024 to 4/2/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #210) of 3 residents reviewed for limited range of motion out of 38 total sampled residents. Specifically, Resident #210 had a right-hand contracture and was observed without a carrot splint per Physician Order.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification and Complaint (NY00327086) Survey from 3/26/2024 to 4/2/2024, the facility did not ensure a resident remained free of accident hazards. This was evident for Resident #494 reviewed for accidents out of 38 total sampled residents.

Inspectors wroteBased on observation, record review, and staff interviews conducted during the Recertification survey from 03/26/2024 to 04/2/2024, the facility did not ensure psychotropic drugs were not given to residents unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. This was evident for 2 (Resident #190 and #141) of 5 residents reviewed for Unnecessary Medications out of 38 total sampled residents. Specifically, 1) Resident #190 was prescribed Risperdal without documented evidence of behavior or staff attempts to use nonpharmacological interventions, and 2) there was no documented evidence Resident #141 displayed behavior, nonpharmacological interventions were used, or a medical assessments was done prior to placing Resident #141 on psychotropic medication.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00322374 & NY00327956), the facility did not ensure that an alleged violation involving abuse was reported immediately but not later than two hours after the allegation was made if the events that caused the allegation involve abuse or result in serious bodily injury to New York State Department of Health (NYSDOH). This was evident for two out of eight residents (Resident #2 & Resident #3) sampled for abuse. Specifically, 1) Resident #2 reported to Licensed Practical Nurse (LPN) #1 on 10/16/23 at approximately 11:30 am (as per the facility's investigation), that two females (identified as Certified Nursing Assistant #1 and #2) gabbed Resident #1 by their left wrist and ripped off their disposable brief. Resident #1 also complained of pain to their left wrist. [...]

Inspectors wroteBased on record review and interviews during the Recertification survey conducted from 12/11/2022 to 12/16/2022, the facility did not ensure a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility. This was evident for 367 residents with personal funds accounts (PFA) out of 632 residents. Specifically, the facility's PFA for 367 residents exceeded the facility's surety bond amount. There are 367 residents with personal fund balances amounting to a total of $935,493.32 held by the Facility and the amount of bond to assure residents against loss was only $100,000.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/11/2022 to 12/16/2022, the facility did not ensure a safe, clean, comfortable, and homelike environment was maintained for residents. This was evident for 6 of 18 resident units. Specifically, 1) resident bathrooms on Unit H-7 had a strong smell of urine and were stained and 2) medication carts, linen carts, wheelchairs, and a Hoyer lift from Units SNF-4, SNF-5, SNF-6, SNF-7, and SNF-8 were dirty and stained.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 12/11/22 to 12/16/22, the facility did not ensure person-centered comprehensive care plans (CCP) was developed and implemented to address resident medical, physical, mental, and psychosocial needs. This was evident for 6 (Resident #116, #219, #95, #115, #600, and #207) of 38 total sampled residents. Specifically, 1) a CCP related to contractures was not developed for Resident #116, 2) a CCP related to contractures was not developed for Resident #219, 3) a CCP related to antipsychotic medication was not developed for Resident #95, 4) a CCP related to vision impairment was not developed for Resident #115, 5) a CCP related to wandering/elopement was not developed for Resident #600, and 6) a CCP related to anticoagulant therapy was not developed for Resident #207.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 12/11/22 to 12/16/22, the facility did not ensure residents with limited mobility receive appropriate equipment to maintain or improve mobility. This was evident for 2 of 2 residents (#116 and #219) reviewed for Limited Range of Motion (ROM) out of 38 total sampled residents. Specifically, 1) there were multiple observations of Resident #116 without right handroll in place and 2) there were multiple observations of Resident #219 without left hand gauze roll in place.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification and Complaint (NY00300469) survey from 12/11/22 to 12/16/22, the facility did not ensure there was sufficient staff available to meet the residents' needs considering the number, acuity and diagnoses of the facility's resident population as determined by the Facility Assessment. This was evident during review of the Sufficient and Competent Nurse Staffing task. [...]

Inspectors wroteBased on record review and interview conducted during the recertification survey from 12/11/22/ to 12/16/22, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments accurately reflected a resident's status. This was evident for 1 (Resident #600) of 38 total sampled residents. Specifically, the MDS for Resident #600 did not reflect the resident's wanderguard (WG) use.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 12/11/22 to 12/16/22, the facility did not ensure resident Comprehensive Care Plans (CCP) were reviewed and revised after each assessment and as needed to reflect changing needs. This was evident in 2 (Resident # 316 and #128) of 38 total sampled residents. Specifically, 1) Resident #316's CCP related to seizure disorder was not reviewed and revised upon each assessment or episode of seizure and 2)Resident #128's CCP related to COVID-19 was not reviewed and revised upon each assessment.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 12/11/22 to 12/16/22, the facility did not ensure a resident diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practical, physical, mental, and psychosocial wellbeing. This was evident for 1 (Resident #298) out of 4 residents reviewed for dementia care. Specifically, the facility did not develop and implement a person-centered comprehensive care plan (CCP) that included and supported the dementia care needs of Resident #298.

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 12/11/22 to 12/16/22, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days of completion. This was evident for 22 (Resident #s 45, 321, 435, 407, 265, 301, 518, 280, 227, 221, 500, 91, 562, 339, 348, 356, 139, 110, 43, 392, 495, and 117) of 26 residents reviewed for Resident Assessment. Specifically, MDS assessments for Resident #s 45, 321, 435, 407, 265, 301, 518, 280, 227, 221, 500, 91, 562, 339, 348, 356, 139, 110, 43, 392, 495, and 117 were not transmitted and submitted to QIES within 14 days of their completion date.