Oneida Health Rehabilitation and Extended Care

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for four (4) out of twelve (12) kitchen staff (Dietary Aides #14, #15, #16, and #17). Specifically, Dietary Aides #14, 15, 16, and 17 had improper hair restraints while preparing food and meal trays in the main kitchen.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to establish mechanisms for documenting and communicating the resident's choices regarding Advance Directives to the staff responsible for the resident's care for one (1) of thirty-three (33) residents (Resident #63) reviewed. Specifically, Resident #63's electronic Medical Orders for Life-Sustaining Treatment form (a medical order for wishes for life-sustaining treatment completed by a medical provider) documented the resident consented to do not resuscitate (allow natural death) and the resident's electronic medical record documented to attempt cardiopulmonary resuscitation (attempt to restart the heart).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey (complaint #466496) the facility failed to ensure a resident's designated representative was notified of changes in condition for one (1) of two (2) residents (Resident #175) reviewed. Specifically, Resident #175 was hospitalized , and their designated representative was not notified of their hospitalization. Findings Include:The facility policy Transfer and Discharges. dated 09/16/2016, documented the proper notification of a transfer or discharge would be made to the resident and/or representative. Notification included the reason for the transfer, and the reason would be documented in the resident's clinical record. The facility would provide the resident and/or representative notice of the bed-hold policies and readmission policies prior to the transfer for hospitalization or therapeutic leave. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #144) reviewed. Specifically, Resident #144's person-centered comprehensive care plan did not include the diagnoses of type 2 diabetes mellitus (the body does not use insulin properly causing high blood sugars), the use of insulin (used to treat high blood sugars), or the use of an anticoagulant (blood thinner).

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (IQIES 466495) surveys, the facility failed to ensure residents' medications were administered in accordance with accepted professional standards and the prescriber's order for two (2) of two (2) residents (Residents #1 and #39) reviewed. Specifically, Resident #1's and #39's physician orders did not include the amount of fluid used with medication instillation; and Resident #1 was administered ginger ale with medications without a physician order.

Inspectors wroteBased on observations, record review and interviews during the recertification survey (Complaint #2699879), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one (1) of two (2) residents (Resident #76) reviewed. Specifically Resident #76 had two Stage 2 pressure ulcers (partial-thickness skin loss) on the buttocks and an unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) pressure ulcer on the right heel that did not have timely treatment orders or interventions; the medical orders for wound treatments were not followed; and the resident was not turned and positioned as planned.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility failed to ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for one (1) of six (6) residents (Resident #123) reviewed. Specifically, Resident #123 was at risk of falls, and their call light was not within reach as care planned.

Inspectors wroteBased on observations, record review, and interviews during the survey conducted 01/27/2026-01/27/2026, the facility failed to ensure an indwelling urinary catheter (removes urine from the bladder) was not used unless there was valid medical justification for one (1) of three (3) residents (Resident #18) reviewed. Specifically, Resident #18 had an indwelling catheter without an order, indication, or care plan for its usage.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of three (3) residents (Resident #101) reviewed. Specifically, Resident #101 had significant weight loss and did not have a timely nutritional assessment.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00377944), the facility failed to ensure that Advance Directives were implemented in a manner that was consistent with residents' wishes for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order for a Full Code (consent to receive life-saving measures in the event of cardiac or respiratory arrest). When the resident was found unresponsive, facility staff failed to timely initiate a Code Blue (signal indicating a medical emergency) and perform cardiopulmonary resuscitation (CPR). Resident #1 was subsequently transferred to the emergency department where they expired. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #12, #38, #40 and #58) reviewed. Specifically, Resident #12 had unclean and untrimmed fingernails; Resident #40 was not assisted out of bed for toileting; Resident #58 was not assisted with toileting every 2 hours as care planned; and Resident #38 had unclean fingernails.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024 the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 12 anonymous residents. Specifically, during a confidential resident group meeting residents stated their call bells were not answered timely and meals were not hot when served due to the lack of staff. Additionally, deficiencies related to staffing levels were identified in the areas Activities of Daily Living (F 677), Food Palatability (F804), and Activities (F 679).

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #37, #105, and #280) reviewed. Specifically, Resident #280 was admitted to the facility with a diagnosis of COVID-19 and transmission based precautions were not maintained; and Residents #37 and #105 had indwelling medical devices and were not placed on enhanced barrier precautions as required. Additionally, during a medication administration observation licensed practical nurse #8 did not perform hand hygiene between residents.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not maintain an effective pest control program so that the facility was free of pests in four isolated areas (the main kitchen, and the 2nd, 3rd, and 4th floor tub rooms) reviewed. Specifically, there were fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents' right to privacy and confidentiality of medical records was maintained for 3 of 3 residents (Residents #44, #118, and # 381) reviewed. Specifically, the electronic medication administration records that displayed health information for Residents #44, #118, and # 381 were left open on the medication cart and were visible to passersby in the hallway.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 5 of 6 residents (Resident #43, #58, #92, #97 and #102) reviewed. Specifically, Resident #58's care plan did not include the use of a video monitoring device in their room; Resident #43's care plan did not include the use of anticoagulants (blood thinner) or insulin (a medication to control high blood sugar); Resident #102's care plan did not include the use of anticoagulants; Resident #97's care plan did not include the use of antipsychotics (medication used to treat psychosis); and Resident #92's care plan did not include the use of antidepressants or anticoagulants.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #40 and #79) reviewed. Specifically, Residents #40 and #79 were not provided meaningful activities that met their interests and preferences.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #278) reviewed. Specifically, Resident #278 was admitted to the facility with congestive heart failure (the heart does not pump efficiently often causing fluid buildup) with hospital discharge orders for torsemide (diuretic, water pill) and instructions for monitoring weights; the torsemide was not ordered until 5 days after admission; and weights were not monitored as recommended.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00336433) surveys conducted 4/9/2024-4/12/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 3 residents (Resident #119) reviewed. Specifically, Resident #119 developed facility acquired pressure ulcers and had a physician order for a specialty mattress (a powered pressure reducing air mattress). There was no documented evidence the mattress was checked for function for 14 days after it was ordered, and the mattress was observed not connected to the pump and the pump was not operational.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #278) reviewed. Specifically, Resident #278 received continuous positive airway pressure therapy (a machine used to keep the airway open by delivering continuous air through the nose and mouth) without a plan to regularly clean the machine to prevent contaminations.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure that residents were free of any significant medication errors for 2 of 5 residents (Residents #44 and #118) reviewed. Specifically, Resident #118 did not receive sacubitril-valsartan (used to treat heart failure) as ordered; and Resident #44 did not receive brimonidine tartrate (used to treat glaucoma) eye drops, ammonium lactate (used to treat dry skin) lotion, docusate sodium (stool softener), and Juven (a protein supplement) as ordered.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not assist residents in obtaining routine and emergency dental care for 1 of 1 (Resident #102) resident reviewed. Specifically, the facility did not obtain dental services for Resident #102 when they complained of tooth pain and concerns about tooth decay.

Inspectors wroteBased on observation and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at an appetizing temperature for 1 of 2 meals reviewed (4/12/2024 lunch meal). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meal on 4/12/2024.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/9/2024-4/12/2024, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety for 1 of 1 kitchen (the main kitchen) reviewed. Specifically, the main kitchen floors had food debris and were stained; and the clean drying rack had pans that were improperly stacked.

Inspectors wroteBased on record review and interview during the recertification survey conducted 4/9/2024 - 4/14/2024 the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #229) reviewed. Specifically, Resident #229 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident or resident representative with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (Centers for Medicare and Medicaid Services) for Medicare Part A as required.

Inspectors wroteBased on record review and interview during the recertification survey conducted 1/20/22 through 1/25/22 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 3 of 3 residents (Residents #347, 348 and 349) reviewed. Specifically, Residents #347, 348 and 349 were discharged to home and the facility did not provide the residents with Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required.