Katherine Luther Residential Hlth Care & Rehab

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from abuse and neglect for one of one resident (Resident #167) reviewed. Specifically, Resident #167 required assistance of two for transfers using a mechanical lift and on 05/19/2025, Certified Nurse Aide #21 used a stand pivot transfer without assistance resulting in a fractured right arm. This resulted in actual harm to Resident #167 that was not Immediate Jeopardy.

Inspectors wroteBased on observations and interviews (iQIES #2730965), the facility failed to ensure a safe, clean, comfortable, and homelike environment for one of five units (Maple unit) reviewed. Specifically, the Maple Unit dining room ceiling leaked.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00379334), the facility failed to ensure residents received treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 developed abdominal distention with pain, had one bowel movement in 6 days, was provided bowel medications without a physician order, and was not assessed by a qualified professional in a timely manner. Subsequently, Resident #1 was hospitalized for a bowel obstruction requiring emergency surgery. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/1/2024-8/7/2024, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 10 of 10 residents (Residents #2, #18, #53, #58, #59, #66, #67, #101, and #312) reviewed. Specifically, Residents #2, #18, #53, #58, #59, #66, #67, #101, and #312 were previously assessed for appropriate siderail use to improve functional independence and bed mobility, and their siderails were subsequently removed without explanation or replacement of an alternative positioning device.

Inspectors wroteBased on record review, observation, and interview during the recertification and abbreviated (NY00345143) surveys conducted 8/1/2024-8/7/2024, the facility did not ensure residents had a safe, clean, comfortable, and homelike environment for 3 of 3 resident units ([NAME], [NAME], and [NAME]) reviewed. Specifically, water temperatures were greater than 120 degrees Fahrenheit in shower rooms and resident bathrooms on [NAME] and [NAME] Units; The bathroom floor in room [ROOM NUMBER] on the [NAME] Unit was in disrepair and stained with a brown substance at the base of the toilet; resident wheelchairs on [NAME] and [NAME] Units were unclean; and the mechanical lifts on [NAME] and [NAME] Units were unclean with debris on the footplates.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 8/1/2024 - 8/7/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen and in 3 of 3 nursing unit kitchenettes ([NAME], [NAME], and [NAME] Units) reviewed. Specifically, the main kitchen walk-in cooler and walk-in freezer floor were unclean and soiled with food debris; the dishwasher in the main kitchen was not working properly; the refrigerator in the [NAME] Unit kitchenette had a broken temperature gauge and was not at an appropriate temperature; the refrigerator/freezer in the [NAME] Unit pantry was unclean with food spills; and the [NAME] Unit microwave was unclean with food debris, and the sink was leaking into the cabinet below.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/1/2024-8/7/2024, the facility did not 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 2 of 2 residents (Residents #14 and #312) reviewed and for 2 of 2 staff (Licensed Practical Nurses #1 and #2) observed. Specifically, Resident #312's and #14's urinary catheter drainage tubing was laying directly on the floor; Licensed Practical Nurse #2 provided wound care without performing appropriate hand hygiene or taking precautions to prevent contamination of the wound and clean supplies; and Licensed Practical Nurse #1 did not practice appropriate glove usage or hand hygiene during multiple resident care tasks.

Inspectors wroteBased on record review and interview during the recertification and abbreviated (NY00348869) surveys conducted 8/1/2024-8/7/2024, the facility did not permit a resident to return to the facility after they were hospitalized for 1 of 1 resident (Resident # 360) reviewed. Specifically, Resident #360 was sent to the hospital for evaluation for behaviors, was medically cleared by the hospital to return to the facility, was transported back to the facility, and was refused return to the facility.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 8/1/2024-8/7/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 5 residents (Residents #48, #57, and #88) reviewed. Specifically, Resident #48 did not receive a lid for their hot beverage cups as care planned and did not have their palm guard (contracture management device) applied as care planned; Resident #57 did not have their palm guards applied as care planned; and Resident #88 did not have their elastic tubular compression bandage (Tubigrip) applied as ordered.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/1/2024-8/7/2024 the facility did not ensure residents with pressure ulcers or at risk for 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 2 of 4 residents (Residents #14 and #312) reviewed. Specifically, Residents #27 and #312 had specialty air mattresses (mattresses that provides air flow to relieve pressure) that did not have individualized settings and were not monitored to ensure appropriate settings were used.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/1/2024-8/7/2024 the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 5 residents (Residents #44 and #106) reviewed. Specifically, Resident #44's bed was not maintained in the low position as care planned; and Resident #106's meal was reheated in a microwave by nursing staff and the temperature was not checked prior to serving the meal to the resident.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/1/2024-8/7/2024, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #88) reviewed. Specifically, Resident #88 received oxygen at a higher flow rate than the physician ordered.

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 8/1/2024-8/7/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch meal on [NAME] and [NAME] Units on 8/5/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures for the lunch meals on [NAME] and [NAME] Units on 8/5/2024.

Inspectors wroteBased on record review and interview during the abbreviated and extended survey (NY00323717), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 6 residents reviewed (Resident #2 and #7. Specifically, Resident #2 had a fall with a hematoma (pooling of blood under the skin) to the back of their head and neurological checks were not completed. When the resident had a change in condition (lethargy, sluggish eye movement, slow to speak, and vomiting), a medical provider was not notified in a timely manner (approximately 2 hours after symptoms began). Additionally, a delay in transport to the hospital occurred when the facility was not able to reach Emergency Medical Services. [...]

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00323717), the facility did not ensure licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure residents attained or maintained the highest practicable physical well-being for 2 of 6 residents reviewed (Resident #2 and 7). Specifically, Resident #7 had a fall with a hematoma (pooling of blood under the skin) to the back of their head and was sent to the emergency room for evaluation. When the resident returned approximately 4 hours later, neurological checks did not resume per facility protocol. Resident #2 had a fall with a hematoma to the back of their head and neurological checks were not completed per the facility process. [...]

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 4/13/22-4/18/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 4 nursing units ([NAME], [NAME], and [NAME]) reviewed. Specifically, ceilings and floors were not maintained for the [NAME] unit, and walls and floors were not maintained for the [NAME] and [NAME] units.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 4/13/22-4/19/22, 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, including COVID-19, for 1 of 12 residents (Resident #67) and for 3 staff (maintenance worker #25, licensed practical nurse [LPN] #10, and LPN #12). Specifically; - Resident #67 was exposed to influenza and was not placed on transmission-based precautions; - Maintenance worker #25 did not wear appropriate personal protective equipment (PPE) on a unit with COVID-19 positive residents; - LPN #10 did not wear PPE appropriately on a unit with contact precautions; [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/13/22-4/19/22, the facility failed to ensure each resident had the right to a dignified existence for 3 of 3 residents (Residents #25, 41, and 87) reviewed. Specifically, Residents #41 and 87 were observed in the dining room during meals waiting to be assisted while other residents were eating their meals. Residents #25's tube feeding pump was unclean.

Inspectors wroteBased on record review and interview during the recertification survey conducted 4/13/22-4/19/22, the facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health (NYS DOH) for 1 of 1 resident (Resident #30) reviewed. Specifically, Resident #30 was inappropriately touched by Resident #9 and the incident was not reported to the NYS DOH as required.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00272132) surveys conducted 4/13/22-4/19/22, the facility failed to ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Residents #19, 41, and 87) reviewed. Specifically, Residents #19, 41 and 87 were not assisted with dressing for 2 days of survey.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/13/22- 4/19/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #114) reviewed. Specifically, Resident #114 had a significant weight loss with advance directive wishes for a trial period of a feeding tube and there was no documented evidence those wishes were honored or addressed following the significant weight loss. Additionally, the resident had multiple tooth extractions impacting their nutritional intake and they did not have denture molds done timely as recommended.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/13/22- 4/19/22, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #25) reviewed. Specifically, Resident #25 received nutrition and hydration via a gastrostomy tube (G-tube, a feeding tube) with continuous feedings. The resident's tube feeding was observed; - disconnected and pooling on the floor; - not running and empty; causing the resident to not receive the calculated amount of tube feeding to meet their nutritional needs. Additionally, there was no documented evidence the medical provider was informed timely of the lapses in tube feeding administration.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident # 158) reviewed for pressure ulcers. Specifically, Resident #158 developed a pressure ulcer that was not treated timely and there was no evidence pressure relief interventions were implemented to promote healing. Subsequently the pressure ulcer worsened, and the resident required surgical intervention to promote healing. This resulted in actual harm to Resident #158 that was not immediate jeopardy.

Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00232603) the facility did not ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 of 5 residents (Residents #227) reviewed for accidents hazards. Specifically, Resident #227 sustained second degree burns (partial-thickness) from an electric fireplace (portable space heater) located in the main lobby. (See Life Safety Code recertification survey K781 Portable Space heaters.) This resulted in actual harm to Resident #227 that was not immediate jeopardy.

Inspectors wroteBased on observation and interview during the recertification survey the facility did not ensure a clean and comfortable environment was maintained for 5 of 7 resident units (Applewood, [NAME], Mapleview, Valleycrest, and Willowway Units). Specifically, stained and unclean furniture, unclean floors, doors, and heating units, and resident equipment were observed on Applewood, [NAME], Mapleview, Valleycrest, and Willowway Units.

Inspectors wroteBased on record review and interview during the recertification survey the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized for 4 of 4 residents (Residents #46, 101, 129, and 131) reviewed for medication regimens. Specifically, Residents #46, 101, 129 and 131 did not have pharmacy drug regimen reviews included in the medical record or maintained in the facility, readily available for review.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not protect and promote the rights of 9 of 13 residents (Residents #21, 55, 70, 100, 104, 142, 156, 191 and 384) reviewed for resident rights and dignity. Specifically, Residents #21, 70, 100, 104, 142, 156 and 191 were not invited or in attendance at the Resident Council Meeting on 10/23/19. Resident #55 was not provided advance notice of the Resident Council Meeting and arrived late. Resident #384 did not have protection of her personal space maintained when another resident continuously entered her room.

Inspectors wroteBased on record review and interview during the recertification survey the facility did not ensure 1 of 1 resident (Resident #125) reviewed for care plans had the right to participate in the development and implementation of her person-centered plan of care. Specifically, Resident #125 was not invited to or in attendance at her comprehensive care plan meeting.

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 3 residents (Resident #384) reviewed for anticoagulant (blood thinner) therapy. Specifically, Resident #384's comprehensive care plan (CCP) did not include a plan and approaches for use of an anticoagulant.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure 3 of 5 residents (Residents #9, 167 and 186) who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal and oral hygiene. Specifically, Residents #9, 167, and 186 were observed with poor oral hygiene, positioning, nail care, and/or unclean attire.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure 3 of 6 residents (Residents #121, 167, and 186) reviewed for activities received an ongoing program of activities to meet the interest of and support the physical, mental and psychosocial well-being of each resident. Specifically, Residents #121, 167 and 186 did not have consistent documentation that they received activities that met their interests and needs.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure correct installation, use and maintenance of bed rails for 2 of 3 residents (Residents #66 and 201) reviewed for accident hazards. Specifically, Residents #66 and 201 were assessed to not require bed rails and were observed on multiple days of survey with bed rails in use.

Inspectors wroteBased on record review, observation, and interview during the recertification survey the facility did not ensure that a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #175) reviewed for dementia care. Specifically, Resident #175 resided on the short-term rehabilitation unit and did not have an individualized person-centered plan in place to address wandering into other resident rooms. In addition, staff did not possess the appropriate competencies and skill sets to support the resident's diagnosis of dementia.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 5 residents (Resident #122) reviewed for psychotropic drug use. Specifically, Resident #122's antipsychotic medication dosage was increased without documented evidence of behavioral symptoms or non-pharmacological interventions.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not 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 disease and infection for 1 of 5 residents (Resident #93) reviewed for pressure ulcers. Specifically, staff did not follow proper infection control technique during a wound treatment observation for Resident #93.