Northern Metropolitan Res Health Care Facility Inc

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Surveys (2663420 and 2700684), the facility did not ensure residents had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #3) of 3 residents reviewed for resident rights. Specifically, Resident #3, who was assessed by therapy for wheelchair use and whose most recent Minimum Data Set documented wheelchair as the resident's primary mode of locomotion, was observed seated in a wheelchair in the dining room labeled with the name of another resident who no longer resided in the facility. Resident #3 was visibly upset and pointed at the armrest of the wheelchair. The wheelchair was too wide for Resident #3. The right armrest pad was missing, and the left armrest pad was observed frayed. [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Abbreviated Surveys (2663420 and 2700684), the facility did not ensure that the facility-wide assessment determined the required resources to provide the care and services to its residents during day-to-day operations, did not address what is considered sufficient, particularly on weekends, and did not include behavioral health services necessary to meet resident needs for three (3) of three (3) units reviewed. Specifically, the Facility Assessment provided during the onsite survey did not include minimum staffing requirements for weekends for certified nurse aides and licensed practical nurses, did not identify the number of staff needed to provide behavioral health care and services, and listed zero registered nurses on the day, evening, and night shifts for all three resident units.

Inspectors wroteBased on observation and interview conducted during Recertification and Abbreviated Survey (NY00330514) conducted from 7/23/24-7/30/24 the facility did not ensure a clean, comfortable, and homelike environment was provided on 1 of 4 units (2 West). Specifically, walls in multiple resident rooms had stains, scuffs, chipped paint, missing moldings, and the floor had visible dirt, dust, food particles and dried food stains.

Inspectors wroteBased on observation, interview, and record review during the Recertification Survey conducted from 7/23/24 through 7/30/24, the facility did not ensure menus were followed for 5 of 32 residents, (Residents #2, #18, #20, #46, and #96) reviewed for food. Specifically, 1. on 2 occasions Resident # 2 did not receive a hardboiled egg and 4 ounces of split pea soup as per meal ticket, 2. Resident #96 did not receive 4 ounces of strawberry yogurt as per meal ticket. 3. Resident # 20 did not receive 6 ounces of split pea soup, ice cream and a frosted cupcake as per meal ticket,. 4. Resident # 18 did not receive 4 ounces of split pea soup as per meal ticket, and. 5. Resident # 46 did not receive 6 ounces of split pea soup and tossed salad as per meal ticket.

Inspectors wroteBased on observation and interview during the Recertification Survey conducted from 7/23/2024 to 7/30/2024, the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, 1) kitchen equipment (mixer) was noted with dry and crusted food 2) undated unlabeled and expired foods were in the refrigerator/s. 3) there was peeling paint above the pot storage shelves 4) logs to document testing of chemicals in the 3 bay pot sink were incomplete and 5) refrigerator temperature/s were above acceptable range.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 7/23/24-7/30/24, the facility did not ensure that a resident's dignity was maintained for 2 of 2 residents (Resident #109 and #84) reviewed for Dignity. Specifically, during multiple observations, the catheters for Residents (# 109, #84) did not have privacy bag/s and were visible to roommate/s and/or visitors.

Inspectors wroteBased on record review and interview conducted during a Recertification Survey from 7/23/2024 through 7/30/2024, the facility did not ensure that the Office of the Long-Term Care Ombudsman was given written notice of the transfer or discharge of residents. This was evident for 2 of 4 residents (Residents #2 and #96) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey from 7/23/24-7/30/24, the facility did not ensure that a comprehensive person-centered care plan was developed for 1 of 1 resident (#364) reviewed for indwelling urinary catheter. Specifically, there were no care plans in place to address care of indwelling urinary catheter for Resident #364.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey and Abbreviated Survey (NY00321083), it was determined that for one of five residents (Resident #263) reviewed for unnecessary medication, the facility did not ensure that pain management was provided for each resident who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals. Specifically, for Resident # 263 there was a lack of consistent pain assessment and monitoring of effectiveness of pain medication. The findings is:: The current facility policy, titled Pain Assessment, last revised 3/2023 documented each resident would be assessed for pain and if present would have an effective pain management plan in place that would allow for optimal independence and an improved quality of life. [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards, including expiration dates when applicable for 1 of 2 medication storage rooms, and 1 of 3 treatment carts reviewed. Specifically, the treatment cart on 1 [NAME] had two boxes of DynaGinate AG, Silver Calcium Alginate rope dressings containing the name of a discharged resident (one box had a [DATE] expiration date and the second box had a [DATE] expiration date) and the Medication Storage Room on 2 East, had a box containing Ear Wax Removal Drops with an expiration date of 12/23.

Inspectors wroteBased on observation, record review, and interview during a Recertification Survey (7/23/24-7/30/24), the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey from 7/23/24-7/30/24, the facility did not ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one of one resident (Resident #5) reviewed for antibiotic use. Specifically, Resident #5 who had a urinary tract infection and was receiving Levaquin (an antibiotic) since 7/22/24 was not monitored and tracked by the Infection Control Practitioner. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Program with a 7/1/23 revision date documented the facility will adhere to the principles of Antibiotic Stewardship as defined and described in the Centers for Disease Control and Prevention for Long-Term Care. Develops, promotes, and implements a facility-wide system to monitor the use of antibiotics. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a recertification survey, the facility did not ensure accurate staffing information was posted in a prominent place readily accessible to residents, staff, and visitors. Specifically, 1) the facility did not post the total and actual hours of licensed and unlicensed staff directly responsible for resident care daily and 2) did not provide complete staffing records for the six months reviewed.

Inspectors wroteBased on observation, interview and record review conducted during a recent recertification survey, the facility did not ensure that the comprehensive assessment for 1 of 5 residents (#12) reviewed for unnecessary medications addressed the resident's psychosocial needs as they relate to dementia care and the use of psychoactive medications. This was necessary to ensure that an appropriate person-centered care plan was developed to address dementia care, behavior management and the ongoing use of psychoactive medications.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not develop a person-centered care plan to ensure that a resident did not consume fluids in excess of the ordered daily 2-liter fluid restriction and conduct ongoing assessment of the resident's medical condition that may potentially affect the resident's hydration status for 1 of 1 resident (#95) reviewed for urinary catheter or Urinary Tract Infection (UTI).