Nathan Littauer Hospital Nursing Home

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents were observed to be fed by staff wearing gloves in the west dining room and by the east nurses station. This is evidenced by: Policy titled Quality of Life- Dignity effective 05/2020 last reviewed 05/2024 documented each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Interpretation and implementation of this policy included residents should be treated with dignity and respect at all times. [...]

Inspectors wroteBased on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment and effective housekeeping and maintenance services were maintained for 2 (East and West) of 2 resident units. Specifically, (a.) the floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and [NAME] Units; (b.) door frames and doors were in disrepair for multiple resident rooms; walls in the East and [NAME] units were in disrepair with scrapes, smudge, chips, and marks; (c.) resident room NH. 44 wall was in disrepair and unfinished; (d.) ceiling tiles in the television rooms had water stains; [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 (Residents #s 3, 9, and 19) of 25 residents reviewed for Care Plans. Specifically, (a.) Resident #3 did not have a care plan for falls that documented interventions that were in place including the use of multiple mattresses in their room; (b.) Resident #9's intervention for treatment of edema (swelling caused by fluid buildup in the body's tissues) was not care planned, and Resident #19 did not have a care plan that addressed their vision problems. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 2 (Resident #s 4 and 38) of 16 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 8%. This is evidenced by: The facility's policy and procedure titled Medication Administration last revised 11/2024 documented, all Registered Nurses and Licensed Practical Nurses must have successfully passed the written medication exam and the medication administration competency to administer medications as outlined below. Registered Nurses and Licensed Practical Nurses have the responsibility to administer medications in accordance with this policy and any other relevant education and/or certification. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 1 (West Unit Team 1) of 2 medication carts reviewed. Specifically, (a.) opened medications had no open and or expiration dates (b.) open bottles of eye drops had no label identifying patient and had no open and or expiration dates. This is evidenced by: The facility's policy and procedure last revised 11/2024 documented, Multiple-Dose Vials a. Multiple-dose vials would not be used beyond the manufacturer's expiration date. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in 2 of 2 resident unit nutrition areas and the main kitchen. Specifically, the area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During the initial inspection in the main kitchen on 2/10/2025 at 11:05 AM, the following observations were made: • The manual can open had a build-up of debris in the cutting area of the device • The mixer had dirt and debris on and under the device. • Dust and dirt were on top of two fire extinguishers in the main kitchen. During an inspection of the East nutrition area on 2/12/2025 at 12:48 PM, the following observations were made: [...]

Inspectors wroteBased on record reviews, and interviews conducted during a recertification survey, the facility did not ensure that Quality Assessment and Assurance Committee consisted at a minimum of the Director of Nursing, Medical Director or designee, Administrator, and Infection Preventionist. The failure to meet to coordinate and evaluate the need for performance improvement projects had the potential to affect all residents of the facility. Specially, Director of Nursing was also the Infection Preventionist. This is evidenced by: A review of the facility's undated Quality Assurance and Performance Improvement Plan, revealed that the Quality Assurance and Performance Improvement Plan provides leadership through its committee. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not designate one or more individual(s) as Infection Preventionist (s) responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have a specified designated individual as their Infection Control Preventionist, and the Director of Nursing had performed a dual role since May 10, 2023. This is evidenced by: A Review of the Policy and Procedure titled Infection Prevention and Control created in November 1977 and revised in August 2024 documented under Mission/Goal of the Infection Control Program: [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification survey, the facility did not ensure that the resident and resident representative had the right to participate in the development and implementation of their person-centered plan of care by facilitating the inclusion of the resident and resident representative in the planning process for 1 1(Resident #6) of 1 resident reviewed for care planning. Specifically, for Resident #6, their family member was not afforded the opportunity to participate in quarterly care plan meetings. This is evidenced by: Facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 stated a comprehensive care plan was developed within seven days after the completion of a comprehensive assessment by the interdisciplinary team with participation of the resident and revised with significant changes. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #sNY00368587 and NY00370779), the facility did not ensure that residents were free from neglect for 2 (Resident #s 10 and 19) of 25 residents reviewed. Specifically, (a.) Resident #10 was not monitored, turned and positioned or received personal care for at least one full shift on 11:00 PM-7:00 AM, 1/29/2025 - 1/30/2025; (b.) Resident #19 rolled out of bed and hit their head on furniture when receiving care by a Certified Nurse Aide on 1/21/2024 at 10:35 AM. This is evidenced by: The Facility's Policy and Procedure titled, Resident Abuse revised 8/2024, documented the facility would investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment or injuries of unknown origin. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #NY00370103) , the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency for 1 (Resident #7) of 1 resident reviewed for reportable incident. Specifically, an injury of unknown origin was discovered for Resident #7 on 01/23/2025. This injury of unknown origin was not reported until 01/25/2025 at 10:51 AM. This was evidenced by: The Policy titled Resident Abuse effective 10/24/2022 last reviewed 09/2023 documented resident abuse and/or misappropriation of resident property should not be tolerated by the facility. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital for 1 (Residents #12) of 1 resident reviewed for notice of bed hold policy before/upon transfer. Specifically, for Resident #12 a written notice of the facility's bed hold policy was not provided to the resident and/or their representative upon transfer to the hospital on [DATE]. This is evidenced by: The policy titled Admission, Discharge and Transfer effective 10/24/2022, last revised 03/2024 documented facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 (Resident #10) of 25 residents reviewed. Specifically, Residents #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure Titled, Recreational Therapy, revised 9/2024, documented the Department of Recreational Therapy was responsible for providing meaningful leisure time programs for all residents on a seven-day-per-week basis. [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #sNY00368587 and NY00370779), the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident # 62) of 25 residents reviewed. Specifically, Resident #62 sustained a fall; 3 Certified Nurse Aides assisted resident from the floor and did not notify a nurse or report the incident, and no assessment or interventions were put into place after the fall and prior to discharge. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not ensure that residents received proper treatment and assistive device to maintain vision abilities for 1 (Resident #19) of 1 resident reviewed. Specifically, Resident #19 did not receive an eye exam, glasses, and or a follow up ophthalmology appointment. This is evidenced by: [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on two (2) of 2 resident units wheelchairs and floors were clean, and resident room walls were in good repair. This is evidenced as follows: During observations on 05/05/2022 at 10:55 AM, the floors were soiled in resident rooms numbered 2, 9, 10, 12, 17, 19, 31, 32, 39, and 40, and the corridor floors were soiled next to walls and by all door thresholds on the East Unit and [NAME] Unit. Walls and/or doors were scraped in resident rooms numbered 2, 4, 9, 10, 12, 17, 19, 31, 32, 39, and 40. The wheelchairs assigned to the residents in resident rooms numbered 4, 9, and 25 were soiled with dust, dirt, and/or drip marks. [...]

Inspectors wroteBased on observation, record review, 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. Automatic dishwashing machines are to operate according to the manufacture specifications, and equipment and floors are to be kept clean. Specifically, the dishwashing machine final rinse water pressure was too high, and the cooking line table fan, cooking line shelf, floor below the cooking line, and the 4 fire extinguishers in the main kitchen and microwave ovens, refrigerators, and floors on three (3) of 3 resident unit kitchenettes were soiled with food particles, grime, or dirt. This is evidenced as follows: [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey dated 05/02/2022 through 05/06/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #'s 9, 19, and #46) of 15 residents reviewed. Specifically, for Resident #9, the facility did not ensure personalized interventions were included in the dementia care plan, for Resident #19, the facility did not ensure personalized interventions were included in the depression/anxiety care plan, and for Resident #46, the facility did not ensure a care plan was developed for discharge. This was evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification survey from 5/2/2022 through 5/6/2022, the facility did not ensure that a resident who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #51) of 1 resident reviewed for dialysis. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and abbreviated survey (Case #NY00294316) from 5/2/2022 through 5/6/2022, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 2 (Resident #'s 36 and #368) of 2 residents reviewed for catheter use. Specifically, for Resident #36, who had an indwelling catheter and history of urinary tract infections (UTIs), the facility did not ensure the Comprehensive Care Plan for an indwelling catheter's interventions for catheter care every shift, and that urinary catheter assessments were consistently documented in the medical record. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not adhere to adopted food safety regulations. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours. Specifically, the automatic dishwashing machine and the automatic pot washing machine were not operating within the manufacturer's specifications required to sanitize food surfaces, and TCS foods were not cooled safely. This is evidenced as follows. The main kitchen was inspected on 12/04/2019 at 09:48 AM. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in an area with gas fuel fired equipment. This is evidenced as follows. Observations on 12/09/2019 at 10:20 AM, revealed a fuel burning appliance, gas clothing dryer, in the laundry room without carbon monoxide detection. The Environmental Services Supervisor/Safety Officer stated in an interview on 12/09/2019 at 10:25 AM, that the laundry room has gas dryers and does not have carbon monoxide detection in this area or anywhere in the nursing home. 483.70 (b); 2015 International Fire Code, Section 915

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, and 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. The facility policy for foods brought in by visitors was reviewed on 12/04/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean on 2 of 2 resident units. This is evidenced as follows. The floors were spot checked on 12/09/2019 at 1:30 PM. The floors next to walls, in corners, and at the base of door frames were soiled with dirt and a brown build-up in resident rooms 1, 3, 15, 16, 22, 29, 32, 34, 38, 40, 48, 49, 50, and 51 and the corridors. The Environmental Services Supervisor stated in an interview on 12/10/2019 at 1:10 PM, that due to some staff being on family leave the floor cleaning has gotten a little behind, but he will make cleaning in corners a priority. 483.10(i)(2)

Inspectors wroteBased on observation, record review and interview during a recertification survey, the facility did not ensure it developed and implemented an ongoing infection prevention and control program (IPCP) which was reviewed and updated annually and as necessary. This would include revision of the IPCP as national standards change. This is evidenced by: Infection Control Policies and Procedures (P&P) were dated as followed: Infection Control Committee - dated September 2016. Antibiotic Stewardship Program - dated November 2017. During an interview on 12/10/19 at 11:32, Registered Nurse/Acting Unit Manager/Infection Control Nurse/Minimum Data Set Coordinator/Wound Nurse #1 reviewed the above P&P and noted they had not been updated, and/or reviewed to include a date within the past year. The facility could not provide documentation that the policies had been reviewed within the past year. [...]