Laconia Nursing Home

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure e facility did not ensure a list of names, addresses, and telephone numbers of the State Survey Agency and the Long-term Care Ombudsman was posted. This was evident during observation of the Main Floor and 3rd, 4th, 5th, 6th, and 7th Floor resident units. Specifically, there was no evidence the New York State Department of Health and Ombudsman's Office information was posted in an accessible manner for residents throughout the facility.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure the results of the most recent survey of the facility were posted in a place readily accessible to residents and family members. This was evident during observation of the Main Floor and 2nd, 3rd, 4th, 5th, 6th, and 7th Floor resident units. Specifically, the facility's most recent survey results were not posted anywhere in the facility.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure nurse staffing data was posted. This was evident for the Main Lobby and 2nd, 3rd, 4th, 5th, 6th, and 7th Floors. Specifically, the nursing staffing data was posted above a staff time clock in an area not accessible to residents and visitors.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure residents remained free from physical restraints. This was evident for 4 (Resident #97, #64, #195, and #99) of 5 residents reviewed for physical restraints out of 35 total sampled residents. Specifically, 1) Resident #97 had a lap tray in place without assessment and medical justification, 2) Resident #64 had bilateral upper half siderails raised while in bed without assessment, 3) Resident #195 had bilateral upper half siderails raised while in bed without assessment, and 4) Resident #99 had bilateral upper half siderails raised while in bed without assessment.

Inspectors wroteBased on interviews and record review conducted during the Recertification and Complaint survey (NY00329940) from 1/16/2024 to 1/23/2024, the facility did not ensure a resident's right to privacy and confidentiality. The was evident for 1 (Resident #222) of 35 total sampled residents. Specifically, the Director of Social Services had a conversation with Resident #222 while the door to the Social Work Office was open for public and staff to overhear.

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and abbreviated (NY00310176) survey from 1/16/2024 to 1/23/2024, the facility did not ensure an alleged violation of abuse was reported immediately, but not later than 2 hours, to the New York State Department of Health. This was evident for 2 (Resident #106 and #167) of 4 residents reviewed for abuse out of 35 total sampled residents. Specifically, Residents #106 and #167 were involved in a physical altercation that was not reported to the New York State Department of Health within 2 hours of occurrence.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 01/16/2024 to 01/23/2024, the facility did not ensure that a copy of the notice of transfer or discharge was sent to the Office of the State Long-Term Care Ombudsman. This was evident for 1 (Resident #78) of 2 residents out of 35 total sampled residents. Specifically, the facility did not notify the Ombudsman's Office of Resident #78's discharge to the hospital on [DATE].

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 (2nd Floor) of 6 resident units. Specifically, Licensed Practical Nurse #5 did not reconcile the count of Fentanyl narcotics patches for Resident #148.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure drugs and biologicals were labeled in accordance with professional standards of practice. This was evident for the 2 (4th and 6th Floor) out of 6 resident units. Specifically, 1) an opened and undated vial of insulin was in the 4th Floor medication cart, and 2) Certified Nursing Assistant #5 transported medications from the 6th Floor to the Nursing Office on the Main Floor without supervision from a licensed nurse.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure food was stored according to professional standards for food safety. This was evident for 1 (3rd Floor) of 6 resident units observed during review of the kitchen. Specifically, the 3rd Floor pantry refrigerator had an internal temperature of more than 41 degrees Fahrenheit and contained unlabeled, undated food.

Inspectors wroteBased on record review and interview during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a discharge assessment was not submitted and transmitted within 14 calendar days from the MDS Completion Date. This is evident for 1 of 1 resident reviewed for the Resident Assessment facility task (Resident #1). The finding is: The facility Policy and Procedure titled, MDS 3.0 with a review date of 01/2021 documented: [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. Specifically, the facility did not provide residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS-10055) at the termination of their Medicare Part A benefits. The residents remained in the facility. This was evident for 2 of 3 residents reviewed for Beneficiary Protection Notification Rights (Resident #15 and #371).

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure the assessment accurately reflected the resident's status. Specifically, a resident's Minimum Data Set (MDS) assessment did not include the active diagnosis of Paranoid Schizophrenia. This was evident for 1 of 5 resident reviewed for Unnecessary Medication and Dementia Care (Resident #209).

Inspectors wroteBased on observations, record review, and staff interviews during the re-certification survey, the facility did not ensure a resident with limited Range of Motion (ROM) and mobility received appropriate treatment and services to improve or prevent further decrease in range of motion. Specifically, gauze hand rolls were not provided to a resident as per physician order. This was evident for 1 resident reviewed for Range of Motion out of a total investigation sample of 35 residents (Resident #100). The finding is: The facility policy and procedure titled Prevention of Complication of Immobility/Contractures dated 5/6/2012 documented the following: If any device is indicated the Rehab Director will take an MD T/O (telephone order), the therapist will issue the device and rehab nursing will get a wearing schedule, which will be communicated, to the nurses. [...]