Ozanam Hall of Queens Nursing Home Inc

Inspectors wroteBased on record review, and interviews conducted during survey the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for one out of six residents (Resident #8). Specifically, Resident #8 reported to Assistant Director of Nursing #8 on 02/10/2025 that they were handled roughly on 02/07/2025 at approximately 10:15 AM by a Certified Nursing Assistant. The facility summary of investigation documented Resident #8 was assessed by Registered Nurse Supervisor #8 with no visible injuries and that Physician #8 was notified. The assessment was not documented in Resident #8's medical record.

Inspectors wroteBased on observations, and interviews conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not ensure that residents are treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. This was evident for 6 (Residents #239, 106, 164, 160, 245 & 166) residents observed during the Dining Observation Task on Unit 6 and Unit 4. Specifically, 1). staff members were observed feeding residents (Residents #239, 106, 164, 160 & 245 ) while standing, and 2.) a resident (Resident #166) was observed in the dining room sitting at a table where another resident was served their lunch, and they were not served for an additional 30 minutes while the other resident ate at the table.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not ensure that residents were afforded the opportunity to participate in their care planning process This was evident for 1 (Resident #103) of 2 residents reviewed for Care Planning out of 38 total sampled residents. Specifically, Resident #103 or their representative were not invited to attend care planning meetings.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 09/26/24 to 10/03/24 the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain grooming, and personal hygiene. This was evident for 1 (Resident #43) of 6 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #43 was observed unkempt with brown, dirty looking clothing and also noted with a strong urine odor. The finding is: The facility policy and procedure titled Completing the Activity of Daily Living Support created 5/6/2022 stated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. [...]

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment and care plan and the preferences of each resident, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 2 (Resident #347 and Resident #408) reviewed for Activities out of a sample of 38 residents. Specifically, Resident #347 and Resident #408 were observed on multiple occasions not engaged in any activity programs.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification Survey-09/26/2024 to 10/03/2024 facility did not ensure that residents received proper treatment and assistive devices to maintain hearing abilities. This was evident for 1 (Resident #287) of 1 resident reviewed for Communication/Sensory out of a sample of 38 residents. Specifically, Resident #287 with a hearing impairment did not receive an audiology consultation or assistive devices to improve hearing ability. The finding is: Upon request, the Director of Nursing stated that the facility does not have a policy and procedure related to consultation, and that resident care is based on an individual plan of care. Resident #287 was admitted to the facility with diagnoses that included End Stage Renal Disease, Hypertension, benign prostatic hyperplasia. [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility did not ensure that residents who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for 2 of 4 Residents (Resident #58 and Resident #127) reviewed for Respiratory Care out of a sample of 36 total sampled residents. Specifically, Resident #58 and Resident #127 who received continuous oxygen did not have pulse oxygen saturations appropriately monitored and there was no date on their nasal cannula/ tubing date indicating when the tubing was last changed.

Inspectors wroteBased on staff interview, observation and record review during the Recertification and Complaint Survey (NY00349107) conducted from 09/26/2024 to 10/03/2024, the facility did not ensure that injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the New York State Department of Health. This was evident for 1 (Resident #148) of 5 residents reviewed for Falls out of a sample 38 residents. Specifically, Resident #148 was observed with discoloration of the chin and mouth of unknown origin which was not reported to New York State Department of Health. The finding is: Resident #148 was admitted to the facility with diagnoses which included Non-Alzheimer's' Dementia, Traumatic Brain Dysfunction, and Fracture of Nasal Bones. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification and Complaint (#NY00298552) survey, the facility did not ensure that there was sufficient staff available to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. This was evident for 2 (Resident #42 and Resident #238) of 5 residents reviewed for Activities of Daily Living (ADLs) out of a total sample of 38 residents, the Resident Council facility task, and the Sufficient and Competent Nurse Staffing facility task. Specifically, (1) Residents #42 and #238 did not receive showers for a 3-week period from 6/27/22 to 7/14/22. (2) The facility nurse staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment.

Inspectors wroteBased on record review and staff interview, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment(s) were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. This was evident for 1 (Resident #4) out of 1 residents reviewed for Resident Assessment. Specifically, the MDS for Resident # 4 was scheduled for submission on [DATE] and was not submitted.

Inspectors wroteBased on record review, and interview during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #314) of 38 sampled residents (Resident #314). Specifically, the MDS assessment for Resident #314 did not accurately reflect the resident's discharge to the community.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, the facility did not ensure residents were provided with care and interventions to carry out Activities of Daily Living (ADL) in accordance with their needs and preferences. This was evident for 2 (Resident #283 and #42) of 5 residents reviewed for ADLs out of a sample of 38 total residents. Specifically, 1) Resident #283 and 2) Resident #42 were not provided with the ADL assistance to receive showers or bed baths in accordance with their needs and preferences.

Inspectors wroteBased on observation, record review, interviews conducted during the recertification survey, the facility did not ensure infection control practices were maintained during meals. This was evident for 1 (Unit 4) of 7 Units observed during dining. Specifically, Certified Nursing Assistants (CNA) did not perform hand hygiene in between sanitizing residents' hands prior to meal service.

Inspectors wroteBased on record review and staff interviews conducted during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a quarterly assessment was not transmitted within 14 days after the completion date. This was evident for 1 of 5 residents reviewed for the Resident Assessment task out of a sample size of 38 residents. (Resident # 6) The finding is: The facility policy and procedure titled MDS/RAI Process and Coding Integrity revised in October 2019 documented it is the policy of this facility to provide an interdisciplinary approach in conducting and completing the Resident Assessment Instrument (RAI), including both OBRA and Prospective Payment System Assessments. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that person-centered comprehensive care plan were revised and updated to reflect the current resident condition. Specifically, care plan was not revised to reflect that resident had a left heel pressure ulcer on admission that worsened. This was evident for 1 of 2 resident reviewed for Pressure Ulcer out of a sample size of 38 residents.

Inspectors wroteBased on observation, record review and staff interviews conducted during the recertification survey, the facility did not ensure that medications and biological were stored under proper temperature controls, were not dated when first accessed and were not discarded within 28 days of opening. This was evident during the Medication Storage Task on 2 of 10 units.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that the survey results were posted in a place readily accessible to residents, resident representatives or legal representatives without having to ask for them. In addition, the facility did not post notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public. Specifically, the survey results were located in a closed wooden credenza drawer in the corridor that housed administrative offices. The finding is: The facility policy and procedure titled Resident Right- Right to Survey Results/Advocate Agency Information effective Sep 2010 and revised August 2017 documented the facility will: 1. [...]