Latta Road Nursing Home East

Inspectors wroteBased on interview and record review conducted during the Recertification Survey 04/14/2025 to 04/18/25, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for two (2) (Resident #186 and Resident #187) of the three (3) residents reviewed. Specifically, both residents were discharged and there was no documented evidence that the facility provided the residents and/or their representatives with a Notice of Medicare Noncoverage letter (NOMNC) explaining their termination of Medicare A benefits and appeal rights as required by the regulations.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 04/14/2025 to 04/18/2025, for one (1) (Resident #12) of one (1) resident reviewed, the facility did not ensure residents who were unable to carry out activities of daily living (basic self-care tasks people perform regularly to maintain their well-being, such as bathing) received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #12 was observed on several days with unwashed/greasy hair and long facial hair. The facility was unable to provide documented evidence that Resident #12 had received a shower, had their hair washed or their facial hair trimmed for several weeks. The finding is: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 04/14/2025 to 04/18/2025, for one (1) (Resident #185) of one (1) resident reviewed, the facility did not provide specialized services for the provision of respiratory care in accordance with professional standard of practice. Specifically, Resident #185 was observed receiving oxygen therapy on several occasions without physician orders for oxygen, without a care plan for the goals and interventions related to oxygen use and without any documentation related to the daily monitoring of oxygen use. This is evidenced by the following: The facility policy Oxygen Administration, dated October 2010, included to verify there was a physician's order and to review the resident's care plan to assess for any special needs of the resident. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey 04/14/2025 to 04/18/2025, the facility did not follow the manufacturers' recommendations and specifications for installing and maintaining bedrails for one (1) (Resident #16) of four (4) residents reviewed for accidents. Specifically, Resident #16 was observed in bed with the assist rail (a type of bed rail) not secured in the locked position. The finding is: The User-Service Manual, dated 2015, for the assist rails documented do not use this assist device until you have verified that it is locked in place. Injury to resident or caregiver may result if this procedure is not followed. Lock the assist handle by engaging the latch pin into the latch. Verify that the assist handle is locked prior to leaving any resident unattended. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 04/14/2025 to 04/18/2025, the facility did not maintain the kitchen in accordance with professional standards for food service safety. Specifically, food items were not labeled and dated, there was bare hand contact with ready to eat food, and a dishwashing machine was dirty.

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 04/14/2025 to 04/18/2025, the facility did not ensure they established and maintained an Infection 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 10 staff members reviewed. Specifically, Licensed Practical Nurse #3 and Scheduler #1 did not receive the influenza vaccine and were observed not wearing face masks while in resident care areas during the current influenza season (as determined by the State Health Department). The finding is: The facility policy Influenza and Pneumococcal Vaccine updated November 2023 included that residents/resident representatives and employees of the facility would be offered to receive influenza vaccine annually. [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00357033), the facility did not ensure that one (Certified Nursing Assistant [Aide] #4) of three Certified Nursing Assistants' certifications were current during the employees' employment at the facility. Specifically, the New York State Nurse Aide Registry Verification Report for Certified Nursing Assistant #4 documented their certification had lapsed (expired) effective [DATE] and not been renewed. Certified Nursing Assistant #4 continued to work in the facility with direct resident care for a period of time without a valid certification from the New York State Nurse Aide Registry (Prometric). This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00348559) for one (1) (Resident #4) of three (3) residents reviewed, the facility did not ensure food was prepared in a form designed to meet the residents needs as recommended by the speech-language pathologist and physician's orders. Specifically, Resident #4 had a diagnosis of dysphagia (difficulty swallowing) with a history of choking, was on a ground/soft diet (food that is ground or minced into pieces no larger than a quarter inch and are moist) and had a choking episode related to incorrect food consistency, which resulted in hospitalization. This resulted in actual harm to Resident #4 that was not Immediate Jeopardy as evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00348559) for one (Resident #4) of three residents reviewed, the facility did not ensure that an incident was thoroughly investigated to rule out potential abuse, neglect, mistreatment, or a care plan violation. Specifically, Resident #4 had a choking episode that resulted in hospitalization. The facility was unable to provide documented evidence (including, but not limited to, statements from involved staff members or potential witnesses) that the incident was thoroughly investigated to rule out potential abuse, neglect, mistreatment, or a care plan violation. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY00301222) 8/2/23 to 8/8/23, it was determined that for one (Resident #9) of two residents reviewed for abuse, neglect, and mistreatment the facility did not ensure that an investigation to rule out abuse, neglect or mistreatment was initiated in a timely manner. Specifically, Resident #9 reported to a staff member an incident where they were held down against their will and making them afraid was not investigated in a timely manner. This is evidenced by the following: [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey 8/2/23 to 8/8/23, it was determined that for one (Resident #9) of 15 residents reviewed for care planning, the facility did not ensure that the resident's care plan was revised and updated to reflect their current medical condition. Specifically, Resident #9's care plan did not reflect their positioning preferences during care to prevent breathing difficulties. This is evidenced by the following: The facility policy, Comprehensive Resident Centered Care Planning, dated effective 11/28/16 included that each resident will have a Comprehensive Resident Centered Care plan that is consistent with the resident's rights and person-centered care. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey 8/2/23 to 8/8/23, it was determined that for 3 (Resident #'s 10, 11, and 30) of 5 residents reviewed for unnecessary medications, the pharmacy recommendations made following the monthly medication reviews were not addressed by the medical team or acted upon by the facility in a timely manner. Specifically, for Resident #10 the pharmacy recommendations were not addressed at all or timely for several medications, Resident #11's recommendation was not addressed timely, and Resident #30's recommendation was not addressed at all. Evidence includes, but is not limited to the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 8/2/23 to 8/8/23, it was determined that the facility did not ensure a resident was free from significant medication errors during one of 29 opportunities of medication administration and involved one (Resident #29) resident. Specifically, an antibiotic medication was not prepared and was not administered per physician orders. The finding is: Medication Error means the observed or identified preparation or administration of medication or biologicals which is not in accordance with the physician orders or acceptable professional standards of practice (principles, which apply to professionals providing services. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 8/2/23 to 8/8/23, it was determined that for two of two medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal laws. Specifically, multiple loose unlabeled pills were observed scattered in the bottom of both medication carts. This is evidenced by the following: During an observation on 8/7/23 at 8:46 AM, at least 20 plus loose unlabeled pills (medications) of varying colors, shapes, and sizes, were observed at bottom of a medication cart drawer. Licensed Practical Nurse (LPN) #3 stated at this time that they were unable to identify the pills and that there was no telling how long the pills had been at the bottom of the drawer. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey completed on 3/25/22, it was determined that two (Resident #8 and Resident #20) of three residents reviewed, did not receive the necessary services to maintain good grooming and personal hygiene. Specifically, residents were not provided assistance with shaving facial hair. This is evidenced by the following: The facility policy, titled Activities of Daily Living (ADLs), with a revised date of March 2018, revealed that residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene. 1. Resident # 8 had diagnoses including dementia, weakness, and glaucoma. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 3/25/22, it was determined that for one of one Activities Room and one of one Medication Room, the facility did not ensure that drugs and biologicals were securely stored. Specifically, medications were observed stored in an unlocked, unsupervised Activities Room and observed in an unlocked and unsupervised Medication Room. Both rooms were accessible to residents. This is evidenced by the following: During an observation on 3/24/22 at approximately 3:00 p.m.- 3:10 p.m., Resident # 19 (identified by the facility as being moderately impaired cognitively and not interviewable) was ambulating unattended in front of the Activities Room. [...]

Inspectors wroteBased on interviews and record reviews conducted during a Recertification Survey, completed on 3/25/22, it was determined that for one (Resident #283) of three residents reviewed, the facility did not provide the appropriate appeal notice to the Medicare beneficiary in order to notify them of their appeal rights as per the regulations. Specifically, the facility did not provide the Medicare A beneficiary with a Notice of Medicare Non-Coverage (NOMNC) letter prior to discharge from the facility. This is evidenced by: Resident #283 was admitted to the facility 1/13/22 under Medicare part A benefits and was discharged to the community on 2/2/22. There was no documented evidence that the resident or responsible party was provided with the required appeal notice prior to discharge. [...]