Pontiac Nursing Home

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated survey (reference # 532839 [NY00357482]) conducted 9/8/2024 - 9/12/2024, the facility did not ensure food was prepared, distributed, stored, and served in accordance with professional standards for the facility's food services. Specifically, the facility did not ensure prepared foods were cooled properly, stored properly, the food on the steam tables were served at an appropriate temperature during meal service, and nutrition rooms and storage areas were maintained in a clean sanitary condition.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #52) reviewed and twelve (12) of twelve (12) anonymous residents present during a resident group meeting. Specifically, Resident #52 had intact decision-making ability, and the facility involved the resident's family in financial decisions without asking the resident and informed the resident they could not utilize another cognitively intact resident's cellphone even with permission; and twelve residents present at the resident group meeting voiced concerns they were not allowed to go to the enclosed area outside.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for four (4) of four (4) residents (Residents #6, #21, #41, and #44) reviewed. Specifically, Resident #6 did not have a care plan that included the use of bed rails; Resident #21 did not have a current care plan addressing behaviors and diabetes with insulin use; Resident #41's care plan was not reviewed and/or revised after Minimum Data Set assessments; and Resident #44's care plan did not include the use of a urinary catheter (a tube to drain urine from the bladder).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for two (2) of five (5) residents (Resident #13 and 41) reviewed. Specifically, Residents #13 and #41 were administered long-acting insulin greater than 3 hours past the scheduled administration time and the insulin pens were not primed (removing trapped air) prior to dialing in the ordered dose.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of one (1) resident (Resident #20) reviewed. Specifically, Resident #20 had a change in condition and was not assessed timely by a qualified professional; Licensed Practical Nurse #25 notified Nurse Practitioner #9 via text message and there was no documented evidence of orders received for a chest x-ray and the application of oxygen; Licensed Practical Nurse #25 did not document a change in condition or that a medical professional and family were notified; and there was a delay in notifying the provider of the radiology results.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025 the facility did not ensure the resident environment remained free of accident hazards for one (1) of four (4) residents (Resident #41) reviewed. Specifically, Resident #41 had a physician order for nectar thick consistency liquid and was provided thin liquid consistency hot cocoa. Additionally, Resident #41 was unhappy with their thickened liquids diet, was occasionally non-compliant and was not referred to speech language pathology for their new diet or care planned for their non-compliance.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for two (2) of two (2) residents (Residents #7 and #8) reviewed. Specifically, Resident #7 had a significant weight loss that was not assessed timely, interventions were not reviewed after continued weight loss, and the resident was not provided with the ordered nutritional supplement; and Resident #8's tube feeding orders did not meet the calculated nutritional needs of the resident and did not include free water flushes. Additionally, Resident #8 was self-administering their tube feeding without a physician order or determination of physical and mental competency to self-administer the feeding.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for one (1) of two (2) residents (Resident #48) reviewed. Specifically, Resident #48 received continuous positive airway pressure therapy (a machine used to keep the airway open by delivering continuous air through the nose) without a physician order with a supporting diagnosis, a plan to regularly clean the machine to prevent contamination, and a care plan for use of the device.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents were provided food and drink that was palatable and flavorful, and at an appetizing temperature for one (1) of two (2) meals reviewed (lunch meal on 9/9/2025). Specifically, the 9/9/2025 lunch meal entree was soft and had a soggy texture and the replacement entree was burnt.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for one (1) of one (1) resident (Resident #13) reviewed. Specifically, Resident #13 had a recommendation for an ankle-brachial index test (a test to diagnosis poor blood flow) that was not followed up in in a timely manner.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of two (2) residents (Resident #55) reviewed. Specifically, Resident #55 was on transmission-based precautions (contact precautions) and Housekeeper #22 cleaned Resident #55's room without wearing required personal protective equipment and did not perform appropriate hand hygiene upon leaving the room; and Certified Nurse Aide #23 provided care to Resident #55 without appropriate personal protective equipment or washing their hands upon leaving the resident's room.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every three months for two (2) of four (4) residents (Residents #25 and #52) reviewed. Specifically, Residents #25's and #52's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gather information about a resident's condition when completing the assessment).

Inspectors wroteBased on record review and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not electronically submit encoded, accurate and complete Minimum Data Set assessment data to the Centers for Medicare and Medicaid Services System within 14 days after the assessment completion date for 11 of 11 residents (Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50) reviewed for resident assessments. Specifically, the Minimum Data Set assessments for Residents #2, 6, 8, 17, 19, 21, 23, 28, 35, 43, and 50 were not transmitted to the Centers for Medicare and Medicaid Services system within 14 days of completion.

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch on 2/13/2024 and breakfast on 2/14/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 2/13/2024 and the breakfast meal on 2/14/2024.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00326851 and NY00327641) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated and did not prevent further potential abuse for 1 of 4 residents (Resident #17) reviewed. Specifically, Resident #17 reported an allegation of abuse that was not investigated timely and did not remove the alleged perpetrator from access to residents pending the results of the investigation.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00306949) surveys conducted 2/12/2024-2/15/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Residents #6) reviewed. Specifically, Resident #6 was observed with dirty and untrimmed fingernails and was not provided a shower as planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 2 medication carts (Unit 2) reviewed. Specifically, prescribed controlled drugs on the second-floor unit were stored in an untethered (free-moving) medication cart and not returned to the double-locked medication room narcotic storage cabinet after the medication passes were completed.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 food preparation areas (the main kitchen and the first-floor kitchenette). Specifically, in the main kitchen there was expired and undated food, a dented can of fruit cocktail in the dry food storage, and the clean drying rack had two unclean cooking pans with food debris; the first-floor kitchenette had expired and undated food.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/15/2024 the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #11, and #32). Specifically, Residents #2, #11, and #32 were on droplet and contact precautions and staff were observed not applying appropriate personal protective equipment when entering the resident rooms, not removing personal protective equipment in a safe, or sanitary manor to prevent the spread of infectious organisms, and not performing appropriate hand hygiene.

Inspectors wroteBased on record review and interview during the recertification survey conducted 2/12/2024 through 2/15/2024, the facility did not ensure each resident was offered influenza immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 6 residents (Residents #11 and #43) reviewed. Specifically, there was no documented evidence Residents #11 or #43 were offered, educated, received, or declined the influenza immunization for the 2023-2024 influenza season.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 3 residents (Resident #21) reviewed. Specifically, Resident #21 was not provided timely nail care.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 3 residents (Residents #4 and 26) reviewed. Specifically, Resident #4 had an excoriated (abraded or chaffed) area on their skin that was not addressed timely by qualified nursing staff and Resident #26 was not provided with physician ordered TED (thrombo-embolus deterrent, compression) stockings.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 10/12-10/14/21, the facility failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 1 resident (Resident #19) reviewed. Specifically, the facility did not make arrangements for Resident #19's physician ordered optometry consult.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 10/12/21 -10/14/21, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 2 of 4 residents (Residents #26 and 236) reviewed. Specifically, Resident #26 had a significant weight gain and was not re-assessed timely, and Resident #236 had a preference to gain weight and the facility did not monitor the resident's weight to ensure they met the resident's nutritional goals.

Inspectors wroteBased on observation and interview during the recertification survey conducted 10/12/21-10/14/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 nursing unit medication rooms (Unit 1) reviewed. Specifically, the facility had expired stock medications (Tylenol suppositories) and biologicals (influenza vaccine) in the Unit 1 medication room refrigerator.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 10/12/21 - 10/13/21, the facility failed to provide carbon monoxide (CO) detection in compliance with Federal, State, and Local Laws and Professional Standards on 1 of 3 Units (basement) reviewed. The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection (adopted by New York State), requires carbon monoxide detection in all areas with fuel burning/gas operated equipment. Specifically, carbon monoxide detection was not installed in the basement level where there was fuel burning equipment.