Penn Yan Manor Nursing Home Inc

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey the facility did not ensure that the completion of a discharge summary that included a recapitulation of the residents stay, a final summary of the resident's status and a post-discharge plan was completed for one (Resident #40) of one resident reviewed. Specifically, the resident was discharged without a complete discharge summary to ensure the facility communicated the necessary information to the resident, the continuing care provided and the resident representative (if applicable) at the time of discharge. The finding is: The undated policy and procedure Discharge Summary and Plan provided by the Administrator, documented when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed. [...]

Inspectors wroteBased on interview and record reviews conducted during the Recertification Survey completed on 8/5/22, it was determined that the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a Nurse Aide Registry (NAR) abuse screening was not completed prior to hire for four out of five employee files reviewed.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey completed on 8/5/22, it was determined that for one of one kitchen the facility failed to dispose of garbage and refuse properly. Specifically, the garbage dumpster outside the facility was not equipped with a tight-fitting lid, door, or cover. This is evidenced by the following: Observations during the follow-up kitchen tour on 8/4/22 at approximately 11:55 a.m., revealed a large rectangular open-top roll-off garbage dumpster outside the facility located outside the nearby hospital kitchen where the facility meals are prepared. There were garbage bags accumulating in the dumpster and with no cover, which could create a potential feeding and harborage area for pests. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed on 8/5/22, it was determined that for one (Resident #13) of five residents reviewed during dining, the facility did not ensure that the resident received care in a respectful and dignified manner during meals. Specifically, Resident #13 did not receive timely assistance with eating. This is evidenced by the following: Resident #13 had diagnoses including dementia with behavioral disturbances, Parkinson's disease, dysphagia (difficulty swallowing), and anxiety. The Minimum Data Set Assessment, dated 5/19/22, documented that Resident #13 had severe impairment of cognitive skills and was totally dependent on staff for eating. Review of current physician orders revealed that Resident #13 was ordered a regular diet, with puree texture and nectar thick fluid consistency. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 8/5/22, it was determined that for 3 (Residents #29, #17 and #19) of 13 residents reviewed, the facility did not ensure that the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive would be honored. Specifically, the color-coded name plates at the entrance of the residents' rooms did not match the wishes documented on the residents' Medical Orders for Life Sustaining Treatment (MOLST). Review of the undated facility policy Advance Directives, indicated; if a resident has executed an advance directive, it will be displayed prominently in the medical record and reflected in the resident's care plan. 1. Resident #27 had diagnoses including schizoaffective disorder, schizophrenia, and major depression. [...]

Inspectors wroteBased on record reviews and interviews conducted during the Recertification survey, completed 8/5/22, it was determined that for 1 (Resident #27) of 13 residents reviewed, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting to meet their needs. Specifically, there was no evidence that a Pre-admission Screening and Resident Review (PASARR) was completed for Resident #27, who had been admitted to the facility with a significant MD diagnosis. This is evidenced by the following: Resident #27 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, schizophrenia, and major depression. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for activities, the facility did not develop a person-centered care plan that included measurable goals and interventions to meet the resident's medical, nursing, and psychosocial needs. Specifically, Resident #13 did not have an activities care plan. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, seizures, and dementia. The Minimum Data Set Assessment, dated 8/22/19, revealed the resident was cognitively intact. The admission Activity Assessment, dated 8/14/19, revealed that books and local newspapers were very important to the resident. The resident liked cards, was Presbyterian, and liked small and large group activities. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY00244354), it was determined that for one of two residents reviewed for accidents, the facility did not ensure that residents received adequate supervision to avoid potential accidents. Specifically, Resident #2 eloped from the facility undetected and fell while outside the building, and the resident's care plan was not revised to include an actual elopement. This is evidenced by the following: Resident #2 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's, osteoarthritis, and diabetes. The Minimum Data Set Assessment, dated 7/29/19, revealed the resident had severely impaired cognition and wandered four to six days but less than daily. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of one resident reviewed for an indwelling urinary catheter (a tubing inserted into the bladder to drain urine into a bag), the facility did not ensure that a resident who entered the facility with an indwelling urinary catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that the indwelling catheter was the only option. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] with diagnoses including benign prostate hypertrophy, urinary retention, and a history of urinary tract infections, including one currently. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #36) of one resident reviewed for Preadmission Screening and Resident Review (PASARR- a screen used to determine developmental disability and/or mental health needs), the facility did not ensure the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The issues included lack of behavioral health services to ensure the resident's behavioral health needs were met as identified in the comprehensive assessment. This is evidenced by the following: Resident #36 was admitted to the facility on [DATE] and has diagnoses including schizophrenia, bipolar disease, depression, and anxiety. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure that it was free of a medication error rate of 5 percent or greater for 2 of 11 residents observed for medication administration resulting in a 6 percent error rate. Specifically, Resident #37's eye drops were administered in both eyes instead of one eye, and Resident #30 had a medication ordered after meals that was given over an hour before meals. This is evidenced by the following: 1. Resident #37 was admitted to the facility on [DATE] and has diagnoses including diabetes and retinal vein occlusion of the right eye with macular edema. Current physician orders included timolol maleate 0.5 percent eye drops with instructions to instill one drop in right eye twice daily for ocular hypertension (increased pressure in the eye). [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of one resident reviewed for hospitalization, the facility did not ensure the resident or the resident's representative received a written Transfer or Discharge Notice when the resident was transferred to the hospital. This is evidenced by the following: Resident #156 was admitted to the facility on [DATE] and had diagnoses that included dementia, depression, and hypertension. The Minimum Data Set Assessment, dated 8/25/19, revealed the resident usually comprehends most conversations. The facility policy, Transfer and Discharge from the Facility, dated 10/19/17, revealed the resident and representative will receive timely notification, adequate preparation and information to make transfers as orderly and safe as possible. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of one resident reviewed for hospitalization, the facility did not ensure a written notification, which specifies the duration of the bedhold policy, was provided to the resident or the resident's representative at the time of transfer to the hospital. This is evidenced by the following: Resident #156 was admitted to the facility on [DATE] and had diagnoses that included dementia, depression, and hypertension. The Minimum Data Set Assessment, dated 8/25/19, revealed the resident usually understands and comprehends most conversations. A nursing progress note, dated 11/2/19 at 6:02 p.m., revealed the resident was transferred to the hospital at 6:30 p.m. The facility was notified at 10:30 p.m. that the resident was admitted to the hospital. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for six (Residents #6, #12, #13, #15, #44, and #95) of eight residents reviewed for Baseline Care Plans, the facility did not consistently develop and implement a Baseline Care Plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and did not consistently review or provide the resident or representative a written summary. This is evidenced by, but not limited to, the following: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses including benign prostatic hypertrophy, urine retention, and an indwelling urinary catheter. The admission Minimum Data Set (MDS) Assessment, dated 4/28/19, revealed that the resident had severely impaired cognition. [...]