Minnewaska Community Health Services

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the 13 single resident rooms on the A-wing had at least 100 square feet of useable floor space for 6 of 6 residents (A24, A25, A27, A33, A35, A36) who currently resided in those rooms.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 1 of 1 residents (R5) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) In addition, the facility failed to ensure proper hand hygiene was provided to prevent the spread of infection for 1 of 1 residents (R5) observed while receiving wound care. Findings Include:R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and diagnoses which included: dementia, arthritis and psychotic disorder. [...]

Inspectors wroteBased on interview and document review, the facility failed to implement daily monitoring and assessment of a deep tissue injury ( a type of pressure ulcer, a serious condition that affects the underlying layers of skin, muscle and other soft tissues) for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure dignified and respectful services for 4 of 6 residents (R2, R3, R4, R5) reviewed who reported concerns related to staff treatment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the resident's current wishes which affected 1 of 30 residents (R9) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R9 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R9's electronic health record (EHR) banner and orders identified R9 was to have CPR however, R9's updated physician's order for life sustaining treatment (POLST) signed on [DATE], identified R9's wishes of do not resuscitate (DNR). The administrator, assistant administrator and director of nursing (DON) were notified of the IJ on [DATE], at 5:49 p.m. The IJ was removed on [DATE], at 11:35 a.m. [...]

Inspectors wroteBased on observation, interview and document review, food was not served in a sanitary manner for 30 residents who dined in the dining area observed during dining services and who received an afternoon snack. In addition, the facility failed to maintain the ice machine and the coffee machine in a sanitary manner to prevent potential illness for 30 residents who currently received ice from the ice machine and or coffee from the coffee machine in the dining area. Further, the facility failed to maintain proper holding food temperatures for cole slaw that was to be served during the evening meal for all residents in the dining room. These deficient practices had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to establish an on-going infection control program which included comprehensive surveillance of resident infections. In addition, the facility failed to ensure hand hygiene was completed for 6 of 30 residents (R7,R10, R14, R22, R28, R31) observed during the afternoon water pitchers being delivered. These deficient practices had the potential to affect all 30 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the 13 single resident rooms on the A-wing had at least 100 square feet of useable floor space for 10 of 10 residents (R7, R10, R14, R16, R22, R23, R25, R27, R28, R31) who currently resided in those rooms.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure cleaning chemicals were secured away in a locked cabinet or cart, which had the potential to affect all residents residing on the B-wing (8 rooms - B-39, B-40, B-41, B-42, B-43, B-44, B-45, B-46). Additionally, it had the potential to affect 2 of 30 (R22 and R10) who were observed walking down the hallway.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 1 residents (R9) reviewed for call light accessibility.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 resident (R2) reviewed for medication errors was free of significant medication errors when orders for Warfarin (Coumadin) (a blood thinner used to reduce the risk of blood clots), was not transcribed into the electronic medical record according to physician's orders and resulted in six missed doses of Warfarin 5 milligrams (mg).

Inspectors wroteBased on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 4 July 1st -September 30th, 2023), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 33 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure linen and personal laundry was transported and delivered in a manner that prevented the risk of contamination for one of three hallways observed for linen and laundry transportation. This deficient practice had the potential to affect 9 of the 33 residents residing at the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the 13 single resident rooms on the A-wing had at least 100 square feet of useable floor space for 11 of 11 residents (R21, R20, R9, R11, R25, R26, R18, R14, R29, R134, R135) who currently resided in those rooms.

Inspectors wroteBased on interview and document review, the facility failed to ensure written notification of the reason for transfers were provided to the residents or resident representatives for 2 of 3 residents (R24, R19) reviewed for hospitalization. Findings Include: R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 was cognitively intact with diagnoses which included: heart failure, end stage renal disease, and diabetes mellitus. R24's MDS identified R24 required set up or assistance with eating, oral hygiene and upper body dressing. Review of R24's progress notes from 9/15/23 to 10/15/23, identified the following: -10/2/23 at 6:13 a.m., R24 was clammy, diaphoretic (perspiring), and nauseated. R24's speech was incoherent and R24 was unable to communicate his needs with general weakness. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide notification to the resident and/or resident's representative of the facility's bed hold policy at the time of emergency transfer and hospitalizations for 1 of 4 resident (R19) reviewed for hospitalization.

Inspectors wroteBased on interview, document review, and observation, the facility failed to ensure a door alarm was activated at all times, which resulted in 1 of 3 residents (R1) leaving a secured area, out onto concrete steps in his wheelchair, which placed R1 at risk for serious injury, harm or death. The Immediate Jeopardy (IJ) began on 9/14/23, at 8:00 a.m. when staff had disarmed the WanderGuard system, and R1 went out the door and was found on the cement steps with his wheelchair leaning on top of his head at 11:15 a.m. The IJ was identified on 9/21/23, at 3:30 p.m. and the administrator and nurse consultant were notified of the IJ. The facility had immediately implemented corrective action on 9/14/23, therefore the IJ is being issued at past noncompliance.