Mayfair Care Center

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure that each resident received adequate supervision to prevent accidents and the resident environment remained as free of accident hazards as is possible. This was identified for two (Resident #51 and Resident #165) of ten residents reviewed for Accidents. Specifically, 1) Resident #51 had a history of falls and wandering behavior and the Comprehensive Care Plan directed staff to place the resident in a supervised area when awake. Resident #51 was left unsupervised in the hallway on 7/24/2024 at 1:10 AM and was found on the floor with injuries to the right side of their forehead and mouth. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for 1) six (Resident #52, Resident #194, Resident #29, Resident # 32, Resident #1, Resident #50) of six residents reviewed for the Medication Storage and Labeling Task and 2) one (Resident #53) of three residents observed for infection Control Task. Specifically, Licensed Practical Nurse #6 did not use an Environmental Protection Agency approved cleaning agent to sanitize the glucometer (a handheld device used to measure the concentration of sugar in the blood) machine after using the glucometer machine for each resident. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024 the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (Resident #75) of ten residents reviewed for Accidents. Specifically, Resident #75 was applying the Biofreeze Professional Pain-Relieving Gel to their knees and the facility staff was aware. A review of the resident's medical records revealed there was no assessment to determine if the resident could safely self-administer the medication. Additionally, Resident #75 did not have a Physician's Order to apply the Biofreeze Professional Pain-Relieving Gel. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure an assessment was completed to accurately reflect the resident's status. This was identified for one (Resident #167) of one resident reviewed for Hospice and End of Life. Specifically, the Quarterly Minimum Data Set assessment dated [DATE] did not reflect that Resident #167 received Hospice care. The finding is: The facility's policy titled MDS Assessment Coordinator, last reviewed on 1/2024 documented a Registered Nurse should be designated the responsibility of conducting and coordinating each resident's Minimum Date Set assessment. Each individual who completes a portion of the assessment must certify the accuracy of that portion of the assessment by dating and signing the assessment and identifying each section completed. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that a qualified Dietician is licensed or certified as a nutrition professional by the state in which the services are performed. This was identified for one (Registered Dietitian #1) of five employees reviewed for the Criminal History Record Check task. Specifically, part-time Registered Dietitian #1 did not have an active license or certification issued by the New York State as a Dietitian or nutrition professional since [DATE]. Registered Dietician #1 was hired by the facility on [DATE] and continued to work directly with the residents without documented evidence of being supervised by a qualified professional. The finding is: [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024, the facility did not ensure that each resident received food that accommodated resident allergies, intolerances, and preferences. This was identified for one (Resident #39) of eighteen residents reviewed during the dining task. Specifically, Resident #39 had a physician's order for a gluten-free diet (gluten is a protein found in grains like wheat, rye, and barley). During observations on 9/17/2024 and 9/19/2024, the resident was served white bread with their meal for lunch. The finding is: Resident #39 was admitted with diagnoses including Hypertension and Chronic Obstructive Pulmonary Disease. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. [...]

Inspectors wroteBased on interviews and record review during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024 the facility did not ensure that comprehensive assessments of residents were conducted within 14 calendar days after admission and not less than once every 12 months. This was identified for three (Residents #126, Resident#168, and Resident #181) of 11 residents reviewed for the Resident Assessment Task. Specifically, Resident #168's Significant Change Minimum Data Set, Resident #126's Annual Minimum Data Set, and Resident # 181's Discharge Minimum Data Set Assessments were not completed within 14 days of the assessment reference date.

Inspectors wroteBased on interviews and record review during the Recertification Survey initiated on 9/17/2024 and completed on 9/25/2024 the facility did not ensure residents were assessed using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every three months. This was identified for eight (Resident #92, Resident #161, Resident #170, Resident #120, Resident #135, Resident #194, Resident #153, and Resident #155) of 11 residents reviewed for the Resident Assessment Task. Specifically, the Quarterly Minimum Data Set assessments for Resident #92, Resident #161, Resident #170, Resident #120, Resident #135, Resident #194, Resident #153, and Resident #155 were not completed within 14 days of the assessment reference date.

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (NY00305185) initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure each resident was free from abuse, neglect, misappropriation of resident property, and exploitation. This was identified for one (Resident #140) of two residents reviewed for Resident-to-Resident Abuse. Specifically, on 11/8/2022, Resident #326, with intact cognition, verbalized that they are going to hit Resident #140 if the resident went to their room again. Soon after the verbal threat, Resident #326 went to Resident #140's room and was observed hitting Resident #140 in the head. Subsequently, Resident #140 was transferred to the hospital and was diagnosed with a left orbital (eye) skull fracture and bruising to the head. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (NY 00311955) initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that each resident representative was notified timely when there was a change in the resident's condition and a need to commence a new form of treatment was identified. This was identified for one (Resident #276) of two residents reviewed for notification of change. Specifically, Resident #276 was identified with significant weight loss of twenty-nine pounds in last six months and received intravenous fluids due to poor oral intake. The facility staff did not notify the resident's family in a timely manner of the resident's poor oral intake, significant weight loss, and administration of the Intravenous (IV) fluids in response to the poor oral intake. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and the Abbreviated Survey (NY00311955) initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that a Baseline Care Plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care was developed within 48 hours of admission. This was identified for one (Resident #276) of four residents reviewed for Pressure Ulcer (PU). Specifically, Resident #276 was admitted with a Sacral PU on 12/16/2022. A Baseline care plan for the Sacral Pressure Ulcer was not completed within 48 hours as required. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that high protein supplements were provided as ordered by a Physician. This was identified for one (Resident #128) of four residents reviewed for Nutrition. Specifically, Resident #128 was assessed by the Registered Dietician (RD) on 10/13/2022 with recommendations to provide LPS (liquid protein supplement) and then again on 12/17/2022 with recommendation to provide LPS and Juven (a powdered protein supplement) to aid in wound healing. A Physician's order first documented on 12/17/2022 indicated to administer both LPS and Juven as per the RD's recommendations. There was no documented evidence in the Medication Administration Record (MAR) that the resident received the LPS until 1/22/2023 and the Juven until 2/2/2023. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #128) of four residents reviewed for Nutrition. Specifically, Resident #128 was not provided the adequate amount of protein via tube feeding that was needed for wound healing, as assessed and recommended by the Registered Dietician (RD). The finding is: The facility's policy titled, Enteral (tube) Nutrition last reviewed on 1/2022 documented that the Dietitian will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. [...]

Inspectors wroteBased on record review and interviews during the Recertification initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #7) of four residents reviewed for Nutrition. Specifically, Resident #7 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. The resident's Physician did not monitor the resident's blood work timely to evaluate the progression of the disease and need for treatment. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure it provided pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This was identified for two (Resident #47 and #98) of four residents observed during medication pass. Specifically, on [DATE], 1) Resident #47 did not receive the scheduled Furosemide (a medication for Hypertension) dose; and 2) Resident #98 did not receive the scheduled Divalproex (Depakote-prescribed for Schizophrenia) dose during the medication pass observation. The medications were not available for administration because the medications were not re-ordered in a timely manner from the pharmacy. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that Physician Responses (actions) documented on Monthly Medication Regimen Reviews (MRR) were carried out to address irregularities identified by the Pharmacist. This was identified for two (Resident #7 and Resident #109) of five residents reviewed for Unnecessary Medications. Specifically, 1) a Psychiatric Consult was requested for Resident #7 by the Physician in February 2023, in response to the MRR dated 2/11/2023; however, no Physician's Order was documented in the resident's Electronic Medical Record (EMR). A Psychiatric Consult was not completed until 3/27/2023 after a subsequent MRR was completed on 3/7/2023 and the physician again recommended a Psychiatry Consult. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that all residents were free of any significant medication errors. This was identified for two (Resident #8, and Resident #114) of two residents reviewed for choices. Specifically, both residents did not receive their medications as ordered by the Physician. On 3/22/2023 Resident #8 complained that they received all their 9:00 AM medications at 11:00 AM, and Resident #114 did not receive the 9:00 AM Buprenorphine HCl-Naloxone (treatment of Opioid Dependency) medication until 12:00 PM. The finding is: 1). Resident #8 was admitted with diagnoses that included Pain, Deep Vein Thrombosis, Bipolar Disorder, Panic Disorder and Muscle Spasticity. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023 the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #24) of one resident reviewed for Hydration. Specifically, Resident #24 was observed with Intravenous (IV) hydration fluid infusing via an IV port. The IV bag was not labeled with the resident's name nor the date and time the IV fluid was hung. The finding is: The facility Intravenous Administration of Fluid and Electrolytes policy and procedure reviewed 1/2023 documented for continuous therapy, mark solution container with label that states when the bag was started and approximate time of completion. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00308569) initiated on 3/22/2023 and completed on 3/30/2023, the facility did not obtain laboratory services to meet the needs of its residents. This was evident for one (Resident #226) of four residents reviewed for Nutrition. Specifically, Resident #226 had Physician's Orders dated 12/14/2022 for the resident to have a Urinalysis with Culture and Sensitivity test which was never completed. The finding is: The facility's policy titled, Lab and Diagnostic Test Results - Clinical Protocol last revised in January 2023 documented that the Physician will identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. Resident #226 has diagnoses which include Hypertension and Diabetes Mellitus. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that each resident received food that accommodates resident preferences and receive appealing options of similar nutritive values to residents who chose not to eat food that is initially served or who request a defend meal choice. This was identified for two (Resident #46 and Resident #76) during the Dining Observation task for one of three dining rooms. Specifically, during the Dining Observation Task on the second floor, Resident #46 and Resident #76 verbalized they were not made aware or offered the alternate meal for lunch on 3/24/2023. The finding is: [...]

Inspectors wroteBased on observation and staff interview during a Recertification Survey, the facility did not follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Specifically, during a Kitchen tour on 9/28/20, the Ice Maker's ice receptacle lid was visibly soiled with dark brown stains and the inside walls of the ice receptacle were covered with black soil like material. The finding is: During a tour of the Kitchen on 9/28/20 at 10:30 AM, Ice Maker was inspected. The ice receptacle lid was visibly soiled. The inside walls of the ice receptacle holding the ice were soiled and black soil like material came off onto the paper towel when wiped off. The Food Service Director (FSD) was interviewed on 9/28/20 at 10:45 AM, he stated that the Ice Maker is cleaned monthly by an outside vendor service company. [...]

Inspectors wroteBased on observation, record review, and staff interview during the Recertification Survey, the facility did not ensure that services provided or arranged by the facility, as outlined by the Comprehensive Care Plan (CCP) were provided in accordance with each resident's written plan of care. This was evident for one (Resident # 55) of one resident reviewed for pressure ulcers. Specifically, Resident #55 who was assessed at high risk for develping Pressure Ulcers. The CCP documented Heel Booties to both feet as an intervention to prevent the development of Pressure Ulcers. On 9/28/20, on two seperate occasions, Resident #55 was observed out of bed, seated in a lounge chair wearing non-skid socks . The resident's heels were resting on the lounge chair and the heel booties were observed on the overbed table on both occasions. The finding is: [...]

Inspectors wroteBased on observation and interview during the Recertification Survey completed on [DATE], the facility did not ensure expired and undated biologicals were removed and discarded according to the manufacturer's recommendations for 2 of 3 medication carts. Specifically, during observation of two medication carts on two separate units the glucose test Control Solutions used for calibration of the glucometer were opened and undated with an expiration date beyond the date listed on the container labels.