Presbyterian Home for Central New York Inc

Inspectors wroteBased on record review and interview during the abbreviated (NY00348553) survey conducted 3/21/2025, the facility did not ensure an elopement incident was reported to the State Agency as required for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 eloped 6/29/2024 when they removed a window panel from an unoccupied room on their unit, climbed out the window and were discovered standing in the fenced-in courtyard with their walker. The facility did not report the elopement incident to the New York State Department of Health as required.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not ensure a policy and procedure regarding the use and storage of food brought to residents from outside the facility to ensure safe and sanitary storage, handling, and consumption for 2 of 6 resident units (Broadway and Rodeo units) reviewed. Specifically, staff did not know the policy and procedure to properly reheat, and measure temperatures of food brought to residents from outside the facility. Additionally, there was undated resident food in the Broadway and Rodeo Unit kitchenette refrigerators.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/22/2024-4/26/2024, 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 7 of 8 residents (Residents #17, #22, #33, #82, #89, #267, and #278) reviewed. Specifically, -Resident #17 had clostridioides difficile (a contagious germ that causes diarrhea and inflammation of the colon) and transmission-based precautions were not implemented timely. - Resident #22 had extended-spectrum beta-lactamase (enzyme resistant to most antibiotics) in the urine and transmission-based precautions were not properly maintained. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00338896 and NY00310300) surveys conducted 4/22/2024-4/26/2024, the facility did not treat each resident with respect and dignity and did not provide care for each resident in a manner that promoted enhancement of quality of life for 1 of 2 residents (Resident #3) reviewed. Specifically, Resident #3 was asked to use a bed pan rather than being taken to the toilet as requested.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #19) reviewed. Specifically, Resident #19 was observed with glucose tablets (medication to increase low blood sugar) at their bedside and there was no documented evidence the interdisciplinary team had assessed the resident's ability to safely self-administer the medication.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 2 of 2 residents (Resident #4 and #32) reviewed. Specifically, Resident #4 did not have a comprehensive care plan developed with interventions for reoccurring urinary tract infections; and Resident #34 did not have a comprehensive care plan developed for wandering risk.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not review and revise the comprehensive care plan based on changing goals and needs for 1 of 1 resident (Resident #79) reviewed. Specifically, Resident #79's meal tickets and comprehensive care plan included a fluid restriction of 2,000 milliliters daily which was previously discontinued by the medical provider.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00310300, NY00321040) surveys conducted 4/22/2024-4/26/2024, 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 3 of 5 residents (Residents #2, #12 and #35) reviewed. Specifically, Resident #2 was not assisted with removal of unwanted facial hair; Resident #12 had unclean and untrimmed fingernails; and Resident #35 had unclean fingernails.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 2 residents (Resident #12) reviewed. Specifically, Resident #12 did not have their resting palm (hand) guards applied appropriately as recommended by occupational therapy for hand and finger contractures.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 4 residents (Resident #276) reviewed. Specifically, Resident #276 had a significant weight loss, nutritional status and interventions were not reassessed, and there was no documented evidence the medical provider was made aware of the significant weight loss.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not ensure that a resident being fed by enteral means (tube placed in the stomach for feeding) received the appropriate treatment and services to prevent complications of enteral feed including but not limited to aspiration (inhalation of food/fluid into the lungs) for 1 of 1 resident (Resident #82) reviewed. Specifically, Resident #82's head of the bed was not elevated during and after receiving enteral feedings as ordered.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/22/2024-4/26/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 2 of 3 medication carts (Rodeo Drive and Wall Street Unit medication carts) reviewed; and for 2 of 3 medication refrigerators (Rodeo Drive and Wall Street Units) reviewed. Specifically, the Wall Street medication cart had an insulin pen for Resident #3 that was not labeled with an opened or expiration date; and the Rodeo Drive medication cart had an inhaler for Resident #29 that was not labeled with an opened or expiration date, and the medication cart was left unattended and unlocked at the nursing station. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00280158 and NY00283260) conducted 1/10/22-1/14/22, the facility failed to provide adequate supervision to prevent accidents for 3 of 3 residents (Residents #14, 37, and 90) reviewed. Specifically, - Resident #37 eloped when a door on the unit was left ajar and there was no documented follow-up or staff education to ensure doors were secured. Residents #14 and #90 subsequently eloped through a door left ajar on the unit. - A headcount was not completed after Resident #14 eloped, and staff did not identify that Resident #90 had also eloped and was outside unsupervised. - Residents #14's, 37's, and 90's comprehensive care plans (CCP) were not reviewed when elopement risk changed to ensure interventions for elopement prevention were implemented and appropriate.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00285403) surveys conducted 1/10/22-1/14/22, the facility failed to ensure residents had a right to a dignified existence for 1 of 1 resident (Resident #81) reviewed. Specifically, Resident #81 was observed without pillowcases, with a torn pillow, holes in their socks and a room that lacked personalization.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 1/10/22-1/14/22, the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 1 resident (Resident #9) reviewed. Specifically, a grievance by Resident #9 for a missing hearing aid was not addressed timely.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/10/22-1/14/22, the facility failed to ensure that that when a restraint was indicated for a resident, the least restrictive alternative for the least amount of time was used and included documented ongoing re-evaluation of the need for a restraint for 1 of 1 resident (Resident #58) reviewed. Specifically, Resident # 58 had a perimeter mattress (a mattress with defined edges to aid in fall prevention) which was not assessed to determine if it was the least restrictive device and there was no ongoing re-evaluation of the need for the use of the mattress.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 1/10/22-1/14/22, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 21 residents (Residents #23, 69, and 93) reviewed. Specifically, Resident #28's comprehensive care plan (CCP) did not address the use of an anticoagulant (blood thinner); Resident #69's CCP did not include oxygen and insulin use; and Resident #93's CCP did not reflect their morning wake up time preference.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00285403, NY00278786, and NY00274049) surveys conducted 1/10-1/14/22, the facility failed to ensure residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 8 residents (Residents #5, 44, 81 and 93) reviewed. Specifically, Resident #5 was not assisted with nail care, Resident #44 was not dressed and assisted out of bed timely, Resident #81 was not provided nail care or facial grooming, and Resident #93 was not provided oral hygiene.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/10/22-1/14/22, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident (Resident # 96) reviewed. Specifically, Resident #96's pressure ulcer treatments were not completed twice daily as ordered.

Inspectors wroteBased on observation and interview during the recertification survey conducted 1/10/22-1/14/22, the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent place readily accessible to residents and visitors for 5 of 5 days reviewed. Specifically, the facility did not post the most current, daily resident census and nurse staffing information as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey the facility did not ensure all residents had the right to a dignified existence and self-determination that promotes maintenance or enhancement of quality of life for 1 of 1 residents (Resident #511) reviewed for dignity. Specifically, Resident #511 was moved from a table in the dining room, where she had been having coffee and conversing with 3 other residents, to a different table by herself.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #64) reviewed for accidents. Specifically, Resident #64 was planned for a chair alarm and was observed on multiple occasions without the alarm in place; and was transferred in an unsafe manner.

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure each resident's drug regimen must be free from unnecessary drugs for 2 of 5 residents (Residents #13 and 185) reviewed for unnecessary medications. Specifically, Residents #13 and 185 were prescribed as needed antipsychotic medications and the medications were not re-evaluated for continued use after 14 days.

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Residents #16, 25, 28 and 69) reviewed during medication administration observations. Specifically, during a medication administration observation, hand hygiene was not performed between multiple residents. Additionally, the glucometer was not sanitized between resident use.