Our Lady of Peace Nursing Care Residence

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 10/15/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Resident #66 and #100) of four residents reviewed. Specifically, Resident #66 was not assisted with removing unwanted facial hair. Resident #100 did not receive incontinent care in a timely manner, received incomplete incontinent care, and staff did not complete proper glove changes and hand hygiene during care. Additionally, moisture barrier cream was not applied to Resident #100 per their care plan.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 10/15/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected three (First, Second, and Third Floors) of three resident use floors and one of one Basement.

Inspectors wroteBased on interview and record review during the Standard survey completed on 10/15/24, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, two (Employee #5, Agency Licensed Practical Nurse and Employee #7, Nutritional Services Aide) of 13 employees that worked in the facility and were subject to the New York State Nurse Aide Registry verification, were reviewed through the New York State Nurse Aide Registry prior to their employment as required.

Inspectors wroteBased on observation, interviews, and record review conducted during a Complaint Investigation (Complaint #NY00280511) completed during a Standard survey started on 11/16/22 and completed 11/23/22, the facility failed to protect the residents' right to be free from mental abuse and neglect for one (Resident #27) of 3 residents reviewed for abuse. Specifically, Unit Attendant (UA) #1, who was restricted from interacting with Resident #27, entered Resident #27's room on 7/31/21 on 8 different occasions, sat on the resident's bed and spoke to the resident about harming others and themselves. This resulted in actual psychosocial harm that was not immediate jeopardy to Resident #27 who became fearful, anxious, and was unable to sleep. The finding is: [...]

Inspectors wroteBased on interviews and record review conducted during a Complaint Investigation (Complaint #NY00280511) completed during a Standard survey started on 11/16/22 and completed 11/23/22, the facility did not have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated for one (Resident #27) of three residents reviewed. Specifically, there was a lack of statements/interviews with other residents that had the potential for victimization. The finding is: The facility policy and procedure (P&P) titled Abuse Investigation and Reporting, last revised 8/2020, documented all reports of resident abuse shall be thoroughly investigated by community management. The individual conducting the investigation will, at a minimum interview other residents to whom the accused employee provides care or services. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey started on 11/16/22 and completed on 11/23/22, the facility did not ensure the resident environment remains as free from accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #104) of four residents reviewed. Specifically, Resident #104 was transferred and ambulated without the use of a gait belt (assistance safety device) as planned. The finding is: Review of the facility policy and procedure titled Safe Lifting and Moving of Patients revised date 12/2019 included the following: In order to protect the safety and well-being of associates (employees) and residents, and promote quality care, this community uses appropriate techniques and devices to lift and move residents. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 1/10/20, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #209) of nine residents reviewed for accidents. Specifically, a resident on aspiration precautions and care planned for small bites and sips, alternate solids with liquids, encourage to eat slow, supervision assistance with eating, and one person staff support was not adequately supervised during meals and was observed to cough several times during the breakfast meal on 1/9/20.

Inspectors wroteBased on interview and record review conducted during the Standard Survey completed on 1/10/2020 the facility did not ensure the pharmacist reported any irregularities to the attending physician and the facilities Medical Director and Director of Nursing (DON). Specifically, one (Resident #132) of seven resident's residents reviewed for drug regimen reviews had issues involving the lack of Consultant Pharmacist's identification of duplicate therapy of antipsychotic medication, specifically Seroquel and Risperdal for two months. The finding is: The policy and procedure titled Pharmacy Services- Role of the Pharmacy Consultant dated 4/2018 documented the pharmacy consultant determines that drug records are in order and reconciled through a Medication Regime Review (MMR). [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 1/10/20 the facility did not ensure that a resident's drug regimen was free from unnecessary psychotropic medications for two (Resident #132, 149) of seven residents reviewed for unnecessary medications. Specifically, the lack of a documented diagnosis to support the addition of duplicative antipsychotic drug therapy and the lack of non-pharmacological interventions prior to the start of Seroquel (antipsychotic medication) (#132). Additionally, the lack of adequate indications to justify the initiation and continued use of Seroquel antipsychotic medication (#149). The facility policy titled Psychotropic Medication dated 9/2018 documented medications shall generally be used only for the following diagnoses: [...]