Mountainside Residential Care Center

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00347949 and NY00347739), the facility did not ensure the resident had the right to be free from abuse for 2 (Resident #s 1 and 2) of 4 residents reviewed for abuse. Specifically, on 7/08/2024, Resident #2 was observed in Resident #1's room with their hand down the front of Resident #1's gown holding their left breast and attempting to kiss the resident. Both residents had severe cognitive impairment and could not consent. This is evidenced by: The Policy and Procedure titled, Nursing Services: Resident Abuse, Neglect, Mistreatment, Exploitation, Misappropriation, Reporting and Elder Justice Act dated August 2001, documented the resident would be free from all sexual abuse. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00347949 NY00347739), the facility did not ensure in response to allegations of abuse that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse for 3 (Resident #s 1, 2, and 3) of 4 residents reviewed for abuse. Specifically, the facility did not report witnessed resident-to-resident sexual abuse between Resident #s 1 and 2, neither of whom were cognitively intact within 2 hours. Additionally, the facility did not report suspected sexual abuse within 2 hours for an alleged resident-to-resident incident that involved Resident #s 2 and 3. Resident #2 was not cognitively intact. This is evidence by: The Policy and Procedure titled, 483.35 Nursing Services: [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (Case #s NY00347949 and NY00347739), the facility did not ensure a resident who displayed or was diagnosed with a mental disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 2 (Resident #s 1 and 2) of 4 residents reviewed. Specifically, Resident #1's care plan documented to notify a mental health provider if they had signs of post- traumatic stress disorder following a witnessed incident of sexual abuse by Resident #2. Additionally, it was documented Resident #2 had a diagnosis of depression, had become predatory and staff were concerned about their escalating sexual activity accompanied by opportunistic behavior/lack of judgement, insight, and impulsivity. [...]

Inspectors wroteBased on observations, record review, and interview during a post-survey revisit completed on 9/30/2024, the facility was determined not to be in compliance with this citation. Specifically, the facility's plan of correction and documented evidence of implementation of this citation did not satisfy what corrective actions would be accomplished for those residents found to have been affected by the deficient practice; how the provider would identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; what measures would be put in place or what systemic changes you will make to ensure that the deficient practice does not recur; and how the corrective actions would be monitored to ensure the deficient practice would not recur, i.e., what quality assurance program will be put into practice. This is evidenced by: [...]

Inspectors wroteBased on observations, record review and interviews during a recertification survey, the facility did not ensure a safe, clean, comfortable, home-like environment for on the second and third floor care units two of two resident care units reviewed. Specifically, the resident rooms and common spaces were not cleaned, sanitized, and areas of disrepair were repaired. This is evidenced by: The Policy and Procedure titled Residential Room Cleaning Procedure, last revised 10/01/2022, documented that the intent of the procedure was to ensure complete and systematic cleaning and disinfection of each residential unit. The bathroom cleaning procedure included the following: dampen clean cloth in solution and clean bathroom beginning with the light over the sink, moving downward and clean the ledge of the mirror. Using the window cleaning cloth and window cleaner, clean the mirror. [...]

Inspectors wroteBased on record review and staff interviews during the recertification survey and abbreviated survey (Case #NY003318803), the facility did not have documented evidence that all alleged violations were thoroughly investigated for 2 (Residents # 34 and 56) of 7 residents reviewed for accidents. Specifically, Resident #34 had a fall with a left hip fracture (a break in thigh bone) on 3/21/2024, and Resident # 56 was found with facial bruising and swelling. The facility did not thoroughly investigate the root cause to rule out abuse or neglect. This is evidenced by: [...]

Inspectors wroteBased on records reviewed and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 1 (Residents #39) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #39, as-needed psychotropic medication orders did not include a stop date., Additionally, for twenty administrations of Ativan (an antianxiety/sedative/hypnotic medication) there were two notes documenting indications for use, one of the two documented non-pharmacological interventions attempted, and one documented monitoring of medications for efficacy. This is evidenced by: Resident #39 was admitted with the diagnoses of nontraumatic subarachnoid hemorrhage (bleeding in the brain), diabetes, and anxiety disorder. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections for 1 (Resident #26) of 1 resident reviewed for respiratory care. Specifically, for Resident #26, the nebulizer mask was observed in the resident's room not properly protected from infection. This is evidenced by: Resident #26 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus, and gastro-esophageal reflux disease (Acid Reflux). The Minimum Data Set (an assessment tool) dated 5/30/2024 documented the resident was cognitively intact, could be understood, could understand others. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed, maintained, and implemented for the monthly medication regimen review (MRR) that included time frames for the different steps in the process when an irregularity that requires action to protect the resident is identified. This is evidenced by: The facility policy titled Drug Regimen Review last revised 10/3/2019, did not document time frames for the different steps of the process. During an interview on 11/18/2021 at 3:09 PM, the Registered Nurse Educator stated the current MRR policy dated 10/3/2019 did not include time frames for the different steps in the process. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure each resident received adequate supervision for 1 (Resident #67) of 4 residents reviewed for prevention of accidents. Specifically, for Resident #67, who fell on 11 occasions from March 2019 to August 2019, the facility did not ensure the resident received adequate supervision to prevent a fall from the toilet when left alone in the bathroom on two occasions. This was evidenced by: Resident #67: This resident was admitted on [DATE], and readmitted on [DATE], with diagnoses of history of falling, dementia with sundowning, and delusional disorder. The Minimum Data Set (an assessment tool) dated 6/04/19, documented the resident was moderately impaired for cognition. The resident sometimes understands others and is sometimes understood. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The facility policy titled Drug Regimen Review - Mountainside, initiated 9/00, and last reviewed 5/2019, documented the pharmacist must report irregularities to the attending medical staff and Director of Nursing (DON) and these reports must be acted upon. The policy further documented the DON sends copies of the review to each nurse manager for review with medical staff/FNP. There was no time frame documented for these steps. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food contact and non-food contact equipment and floors in the main kitchen and satellite kitchenettes were not clean. This is evidenced as follows. The main kitchen and the kitchenettes were inspected on 09/17/2019 at 10:18 AM. In the main kitchen, the floor mixer, table mixers, can opener holders, kitchen fire suppression system canister, K-rated fire extinguisher, and kitchen door threshold to the dining area were soiled with food particles or grime. In the kitchenettes, the microwave ovens, counters, cupboards, cabinet doors, floors under refrigerators and next to walls, thermometer cups, and/or the underside of dining room tables were soiled with food particles or dirt. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility does not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. Record review of the facility policy for foods brought in by visitors was reviewed on 09/17/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. The Administrator stated in an interview on 09/16/2019 at PM, that the facility has not yet, but will develop an information sheet on food safety for visitors that bring food in to residents. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, essential equipment was not maintained in safe operating condition. Specifically, plumbing fixtures in the main kitchen were not functioning properly. This is evidenced as follows. The main kitchen was inspected on 09/16/2019 at 10:18 AM. A strong obnoxious odor was detected upon entering the kitchen from the employee dining area. The Administrator, Director of Food Services, and Maintenance Technician #1 stated in an interview on 09/16/2019 at 10:18 AM, that the odor is coming from the bakers area floor drain; the kitchen underground floor plumbing was replaced this past spring; the odor from the floor drain did not exist before the recent plumbing work; and the floor drain might not have been plumbed with a water trap thereby allowing odors into the preparation area. [...]