Our Lady of Mercy Life Center

Inspectors wroteBased on observations, interviews, and record review conducted during a recertification survey, the facility did not ensure that residents had the right to, and the facility must make, prompt efforts to resolve grievances the resident may have for all residents reviewed for grievances. Specifically during resident council meeting, 6 Residents reported they did not know there was a grievance process or a process by which grievances could be filed or resolved. This is evidenced by: The Facility's 2024 admission Agreement, Part 17.6, documented Grievance Procedure. Facility has a Grievance Procedure if Resident, Resident's representative, or a family member wishes to file a complaint about the services provided by Our Lady of Mercy Life Center facility or its staff. [...]

Inspectors wroteBased on interviews and record reviews during the recertification survey, the facility did not ensure that the resident had the right to make choices about aspects of their life in the facility that were significant to the resident for 2 (Resident #15 and 60) of 4 residents reviewed for choices. Specifically, Resident #'s 15 and 60 repeatedly requested more than 1 bed bath/shower per week, but the facility continued to provide 1 bed bath/shower per week to them, respectively. This is evidenced by: Resident #15 was admitted with diagnoses that included multiple sclerosis (a chronic disease that damages the central nervous system, including the brain, spinal cord, and optic nerves), dysarthria (a speech impairment) following cerebral infarction (a stroke), and hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction. [...]

Inspectors wroteBased on observation, interviews and record review during the recertification and abbreviated survey (Case #s: NY00329064 and NY00353346), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels were not met every day on multiple shifts and multiple units between 10/08/2024 and 10/15/2024. Additionally, there were multiple residents and family complaints regarding the lack of sufficient staffing resulting in staff's timely response to call lights, and not providing scheduled showers and treatments. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labelled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) medication carts were left unlocked while unattended. (c.) personal items were stored in a medication cart; (d.) a pre-poured medication cup was noted at a resident's bedside; and (e.) a narcotic lock box had a broken lock. This was evident for 4 out of 5 medication carts reviewed ([NAME] Unit Cart #1; Lourdes Unit Cart #1; Lourdes Unit side 2 back half; [NAME] Unit Cart #2), and for 1 out of 5 narcotic lock boxes reviewed ([NAME] Unit). This is evidenced by: [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 3 of 4 resident unit (Units two, three, and four) kitchenettes. Specifically, appliances and surfaces were not clean. This is evidenced by: A review of the policy titled Sanitation and Infection Prevention/Control revised on January, 2024 documented that the supervisor would assign special cleaning tasks on a daily basis which included kitchenette refrigerators. During observations on Unit two on 10/08/2024 at 10:56 AM, the resident kitchenette was dirty, and dust-covered on the top of the refrigerator, and food particles were not cleaned on the freezer and refrigerator seals. The freezer also had ice build-up inside and around the seals. [...]

Inspectors wroteBased on observations 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. Specifically, the staff did not use proper hand hygiene practices while placing clothing protectors on residents and preparing resident meal trays. This is evidenced by: The facility 2024 Infection Prevention and Control and Antibiotic Stewardship Plan-Continuing Care Division 2024 documented that the facility would maintain a continuing educational program for all personnel related to the prevention and control of infections and the use of Standard Precautions. [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure each resident was treated in a dignified manner for 1 (Resident #29) of 31 residents reviewed. Specifically, Resident #29 was left to soil themselves because staff did not attend to the resident in a timely fashion, leaving the resident feeling humiliated on more than one occasion. This is evidenced by: Resident #29 was admitted to the facility with diagnoses of cutaneous abscess of back (a pus-filled pocket that forms under the skin), atrial fibrillation (a fast irregular heartbeat), and difficulty walking. The Minimum Data Set (an assessment tool) dated 8/28/2024 documented the resident was able to be understood, understand others, was minimally cognitively impaired and required significant assistance with activities of daily living. [...]

Inspectors wroteBased on observation, interview, and record review during a certification survey, the facility did not ensure the interdisciplinary team appropriately assessed a resident to self-administer medications for 1 (Resident #29) of 1 resident reviewed for self-administration of medication. Specifically, for Resident #29, there were medications observed at the bedside. Resident's ability to self-administer medication was not periodically assessed by the interdisciplinary team. This is evidenced by: [...]

Inspectors wroteBased on interviews and record reviews during the recertification survey, the facility did not ensure that residents were free from abuse, neglect, and exploitation for 1 (Resident #60) of 7 residents reviewed for abuse. Specifically, Resident #60 stated their roommate (Resident #69) made threatening remarks about them to the point where Resident #60 was terrified, which caused sleeplessness. Resident #60 stated they feared for their life from 3/02/2023 to 03/19/2023 until Resident #60 was finally moved to a new unit. Subsequently, Resident #60 was moved on 6/13/2023 next door to Resident #69 and Resident #69 continued harassing Resident #60 until Resident #69 was moved on 9/30/2023 to a separate unit. This is evidenced by: Cross-referenced to: F609: Reporting of Alleged Violations. [...]

Inspectors wroteBased on interviews and record reviews during the recertification survey, the facility did not ensure that in response to allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #60) of residents reviewed. Specifically, Resident #60 reported allegation of abuse by Resident #69 to facility staff and was not reported to Department of Health. [...]

Inspectors wroteBased on interviews and record reviews during the recertification survey from 10/08/2024 - 10/16/2024, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for 1 (Resident #60) of 7 residents reviewed for abuse. Specifically, Resident #60 reported to facility staff on 3/18/2024 they were verbally abused by Resident #69. There was no documented evidence that a thorough investigation was completed by the facility when the allegation of verbal abuse was made. As evidenced by: Cross-referenced to: F600: Free from Abuse and Neglect. A facility policy titled Abuse Prevention and Investigation Policy dated 6/27/2023, documented that residents have the right Residents have the right to be free from verbal, sexual, physical, and mental abuse; [...]

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 1 (Resident #62) of 31 residents reviewed for Care Plans. Specifically, Resident #62's behavior interventions were not implemented when Resident #62 was having behaviors during meals. This is evidenced by: A facility policy titled Interdisciplinary Care Conference and Care Planning dated 6/27/2023 documented that a comprehensive resident centered plan of care had a follow up evaluation after a significant change in condition. [...]

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, the facility did not ensure the comprehensive care plans were reviewed and revised with measurable objectives, time frame and appropriate interventions for 1 (Resident #23) of 31 residents reviewed. Specifically, for Resident #23, resident's Safety Awareness Deficit Care plan was not updated following a fall on 3/13/2024, 5/9/2024, 7/14/2024, 7/16/2024, and 9/04/2024. This is evidenced by: A facility policy titled Interdisciplinary Care Conference and Care Planning dated 6/27/2023 documented that a comprehensive resident centered plan of care had a follow up evaluation after a significant change in condition. [...]

Inspectors wroteBased on interviews and record reviews during the recertification, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 31 residents reviewed for quality of care. Specifically, for Resident #2 had a blood sugar of 525 on 06/14/2024 at 8:23 AM, 10 units of insulin were administered. There was no monitoring until the next blood sugar was done at 4:29 PM; Resident #2 was transported to the hospital at 6:49 PM and admitted to the hospital for hyperglycemia and severe sepsis. This is evidenced by: Resident #2 was admitted to the facility with the diagnoses of insulin dependent type 2 diabetes mellitus, history of urinary tract infections and neuromuscular dysfunction of bladder. [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 1 (Resident #106) of 4 residents observed during a medication pass for a total of 28 observations. This resulted in a medication error rate of 17.86 percent. This is evidenced by: The Facility's Policy and Procedure titled Medication Administration, effective date: 12/21/2023, documented applicable to nursing responsibility, note times medications were due, doses to be held, and any other pertinent information. Note carefully the name, dose, amount of administration and expiration date. Be sure the frequency and time schedules correspond. [...]

Inspectors wroteBased on record review and interview during an abbreviated survey (Case #NY00321881), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 1 (Resident #4) of 4 residents reviewed. Specifically, Resident #4 blank checks and bank card were obtained by Certified Nurse Aide #1 and cashed the check for the amount of 700.00 dollars and used the bank card to make purchases. This was evidenced by: Resident #4 was admitted with the diagnoses of depression, unspecified asthma, and chronic obstructive pulmonary disease. The Minimum Data Set (an assessment tool) dated 12/08/2023, documented the resident was cognitively intact, could be understood, and understand others. The facility's Abuse Prevention and Investigation Policy dated 6/27/2023 documented residents have the right to be free from exploitation and misappropriation of property. [...]

Inspectors wroteBased on observations, record review and interview, during a recertification survey) the facility did not ensure that comprehensive person-centered care plans (CCP) were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for five (5) (Resident #'s 50, 51, 52, 56 & #128) of twenty-five (25) residents reviewed. Specifically, for Resident #50, the facility did not ensure a care plan was developed to address the resident's diagnoses of constipation, diarrhea, and colitis; [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutritional status were maintained for 1 (Resident #52) of 6 residents reviewed for nutrition. Specifically, for Resident #52, the facility did not ensure the resident was weighed in accordance with professional standards. This is evidenced by: Resident #52: Resident #52 was admitted to the facility with the diagnoses of retention of urine, neoplasm of liver and intrahepatic bile duct and chronic pneumothorax. The Minimum Data Set (MDS - an assessment tool) dated 12/29/2021 documented the resident was cognitively intact, could understand others and could make self understood. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 (Resident #47) of 1 resident reviewed for dialysis care. Specifically, for Resident #47, the facility did not ensure to consistently provide the resident with ongoing assessments and monitoring for complications before and after dialysis treatments, did not ensure for the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services and did not develop a dialysis care plan with dialysis staff regarding dialysis care and services. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure laboratory services were obtained or provided timely to meet resident needs for 1 (Resident #50) of 1 resident reviewed for laboratory services. Specifically, for Resident #50, the facility did not ensure a physician order for a stool sample for clostridioides difficilea (c-diff; a germ (bacterium) that causes severe diarrhea and inflammation of the colon), dated 2/5/2022 was obtained in a timely manner and did not notify the physician when the stool was unable to be obtained from 2/5/2022 to 2/10/2022. This is evidenced by: Resident #50: Resident #50 was admitted to the facility with the diagnoses of femur fracture, multiple sclerosis (MS), and noninfective gastroenteritis and colitis. [...]

Inspectors wroteBased on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications, equipment, the floor required cleaning, and cabinetry required repair. This is evidenced as follows: During the inspection of the main kitchen on 02/08/2022 at 9:05 AM, the automatic dishwashing machine registered 161 degrees Fahrenheit (F) at 18 pounds per square inch (psi) water pressure; [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, dumpsters were not clean and maintained to prevent the harborage and feeding of pests. This is evidenced as follows: During an inspection on 02/08/2022 at 10:50 AM, garbage waste was found in the dumpsters, the dumpsters were soiled with black build-up below the side access doors, the left dumpster did not have a drain plug and the side door was open. During an interview on 02/08/2022 at 10:50 AM, the Plant Operations Manager stated that the dumpster vendor will be contacted about cleaning and installing the drain plug. During an interview on 02/08/22 at 12:01 PM, the Administrator stated that staff should keep the dumpster closed, and maintenance will be contacted about having the dumpsters cleaned and installing the drain plug. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and complete for 3 (Resident #'s 56, 128, and #130) of 25 residents reviewed. Specifically, the facility did not ensure Certified Nurse Aides (CNAs) consistently documented the care they provided to Resident #56 and Resident #128 on every shift; for Resident #130, the facility did not ensure that documentation in the resident record accurately reflected the resident's sudden change in condition, course of treatment, care provided and the reason the resident wishes as documented in the MOLST were not followed. This is evidenced by: Resident #56: [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be stored using safe practices to prevent the potential biological contamination of food and to prevent food borne illness, and food and non-food contact surfaces are to be kept clean. Specifically, raw foods were stored above ready-to-eat food, and floors and equipment were not clean. This is evidenced as follows. The main kitchen was inspected on 08/08/2019 at 8:40 AM. In produce/meat walk-in refrigerator raw pork was stored above fully cooked hard-boiled eggs, and raw chicken was stored above pasteurized eggs. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was not clean and the area around it was littered with refuse. This is evidenced as follows. The trash compactor area was inspected on 08/08/19 10:22 AM. The cover of the left dumpster was broken with a 1-foot hole at the top. The lid to the right dumpster was open, and waste was in the dumpster. The Plant Operations Manager stated in an interview on 08/08/19 10:22 AM, that the dumpsters should be kept closed, and he will contact the vendor to replace the broken lid. 10 NYCRR 415.14(h)