Penfield Place

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 01/27/2025 to 01/31/2025, for one (Resident #13) of five residents reviewed, the facility did not ensure a resident was clinically appropriate to self-administer medications. Specifically, Resident #13 was observed to have multiple medications left on their bedside table and there was no documented evidence their ability to self-administer medications had been assessed or care planned for. This is evidenced by the following: Review of the facility policy Comprehensive Care Plan, dated November 2016, revealed the Comprehensive Care Plan for each resident would include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that were identified on the comprehensive assessment. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 01/27/2025 to 01/31/2025, for one (Resident #13) of one resident reviewed for oxygen use, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs including resident goals, desired outcomes and preferences. Specifically, there was no comprehensive care plan including goals and interventions for the resident's respiratory disease and oxygen therapy requirements. This is evidenced by the following: Review of the Comprehensive Care Plan Policy, revised November 2016, documented in part, it is the policy of this facility that each resident has an interdisciplinary, comprehensive care plan. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed 5/4/23 to 5/10/23, it was determined that for two (north and east halls) of four resident units, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees Fahrenheit (°F) were accessible to residents at point of use.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey 5/4/23 to 5/10/23, it was determined for one (Resident #10) of three residents reviewed for activities of daily living (ADLs) the facility did not ensure that residents who are unable to carry out ADLs received the necessary services to maintain personal hygiene. Specifically, there were issues with incorrect use of a bathing cleanser.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey 5/4/23 to 5/10/23, it was determined that for one (Resident #26) of one resident reviewed for pressure ulcers, the facility did not ensure that the resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the nurse did not change gloves or perform hand hygiene while doing dressing changes on multiple wounds including a pressure ulcer. This was evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey 5/4/23-5/10/23 it was determined that for one (Resident #32) of four residents observed during medication pass, the facility did not ensure that it was free of medication error rate of 5 percent (%) or greater. There were 2 medication errors for 26 opportunities resulting in a 7.69 % medication error rate. The issue involved not mixing a medication in the correct amount of liquid, and not using a spacer nor rinsing the mouth after administering an inhaled medication as ordered by the phusicain. This is evidenced by the following: The facility Medication Administration Policy, revision dated March 2012, documented that medication is administered as ordered by the physician. Resident #32 had diagnoses including constipation, chronic obstructive pulmonary disease (COPD), and asthma. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (#NY00272983), completed on 2/10/22, it was determined that for one (Resident #245) of three residents reviewed for accidents, the facility did not thoroughly investigate multiple falls to rule out abuse, neglect, or mistreatment. This is evidenced by: Resident #245 had diagnoses including dementia without behavioral disturbance, anxiety, and ataxia (impaired balance). The Minimum Data Set assessment dated [DATE], documented that the resident had moderately impaired cognitive function, limited mobility and required extensive assist from staff for transfers. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 2/10/22, it was determined for that for 1 of 16 residents reviewed for care planning, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs and includes the resident's goals, desired outcomes, and preferences. Specifically, Resident #34 had a physician's order for the use of Tubigrips (a compression covering that provides support to extremities and helps reduce swelling) and was observed not wearing them. In addition, the Tubigrips were not included in the residents Comprehensive Care Plan (CCP) nor the Certified Nursing Assistant (CNA) [NAME] (care plan used by the CNAs to drive daily care). The evidence is: 1. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, completed on 2/10/22, it was determined for one (Resident #39) of five residents reviewed, the facility did not ensure each resident's drug regimen was free of unnecessary medications. Specifically, the resident's medications were not held despite demonstration of potential adverse side effects and the medical team was not notified of the potential side effects. This is evidenced by the following: Resident #39 is [AGE] years old with diagnoses including dementia, dysphagia (difficulty swallowing), and weight loss. The Minimum Data Set assessment dated [DATE], documented that the resident had severe impairment of cognitive function, was incontinent of bowel function and was totally dependent on staff for toileting and bathing. [...]