Sachem Center for Health and Rehabilitation

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#9), out of a total sample of 19 residents with an alteration in skin integrity, specifically a Left Transmetatarsal Amputation (TMA-surgical procedure that removes the front part of the foot) received necessary treatment and services to promote healing. Specifically, the facility failed to monitor, assess, and identify wound deterioration and signs/symptoms of an infection until he/she was seen by the Wound Care Physician, and the clinical signs of infection were identified and a treatment implemented.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for supervised residents who smoke, out of a total sample of 19 residents. Specifically, the facility failed:1. To ensure safe smoking practices were implemented for supervised residents who smoke; and2. For Resident (#58), to ensure the appropriate protective equipment was applied while smoking.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to ensure staff served palatable, attractive, and flavorful food at appetizing temperatures for two out of two test trays conducted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Residents #22 and #6, who were on enhanced barrier precautions due to wounds, to ensure staff wore appropriate personal protective equipment (PPE) while providing care;2. For Residents #11 and #9, to ensure proper infection control practices were maintained during a dressing change;3. For Resident #37, who was on contact precaution for Vancomycin Resistant Enterococcus Faecalis (VRE, a species of enterococcus bacteria that have developed resistance to the antibiotic vancomycin) to ensure staff wore appropriate PPE while providing care; and4. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide care and services consistent with professional standards for one Resident (#5), out of a total sample of 19 residents. Specifically, the facility failed to implement a physician's order for a left-hand roll.

Inspectors wroteBased on observation and interviews, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:-Ensure food items were properly dated and stored in the main kitchen; and-Ensure the main kitchen and food storage areas were maintained in a sanitary and safe condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident at high risk for developing pressure ulcers received the necessary care, treatment, and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for one Resident (#10) out of 18 sampled residents. Specifically, the facility failed to complete wound care as ordered, complete skin check/assessment as ordered, complete Norton Assessments as ordered, and to offload his/her heels, resulting in the worsening of a Stage 3 Pressure Ulcer (full thickness skin loss, exposing subcutaneous tissue, not bone, muscle, or tendon) to the coccyx (tailbone) and the development of a new Unstageable Deep Tissue Injury (DTI: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication Metformin (diabetic medication) was discontinued per the Resident's request which had been documented in the Nurse Practitioner Progress Notes multiple times for one Resident (#65), out of a sample size of 18 residents, resulting in Resident #65 receiving 100 extra doses of Metformin.

Inspectors wroteBased on observation, interview, and test tray results, the facility failed to provide food to residents that was palatable and served at appetizing temperatures for both food and drinks for one of three test trays.

Inspectors wroteBased on observation, meal ticket review, and interview, the facility failed to ensure residents were receiving the correct therapeutic diets. Specifically, the facility failed to: 1. Ensure during tray service in main kitchen that the dietary aides calling out the diets off the meal tickets were including the resident specific therapeutic diets, including heart healthy, no salt added, and low concentrated sugar diets for three meals observed; and 2. Ensure the residents were being offered and choosing the correct therapeutic diet off the menu and the alternative menu.

Inspectors wroteBased on record review and interviews, the facility failed to ensure staff maintained accurate documentation for two Residents (#1 and #65), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #1, to ensure Medication Administration Records (MAR) and Treatment Administration Records (TAR) were accurate and reflected the administration of medications and treatments per physician's orders; and 2. For Resident #65, to accurately record the resident's weight in the medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper size mattress was on the bed for one Resident (#323), out of a sample of 18 residents. Specifically, the facility failed to ensure the Mattress Bolster/Extender (an object used to fill gaps between the mattress and footboard of a bed) was put on the bariatric (obesity) bed, leaving a gap of approximately 10 inches between the end of the mattress and the footboard with the metal bed frame exposed, leaving the Resident at risk for entrapment and/or injury.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure a functional, safe, and clean environment. Specifically, the facility failed to ensure residents and/or staff properly dispose of cigarette butts in designated smoking receptacles.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one Resident's (#33) right to be free from neglect. Specifically, for Resident #33, the facility failed to respond to requests for pain medications for at least 75 minutes for a Resident with a Stage 4 pressure injury (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone) of the sacral region.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to manage and effectively treat two Residents (#33 and #69), out of a total sample of 21 residents for pain. Specifically, the facility failed: 1. For Resident #33, to ensure staff provided requested as needed pain medication timely when the Resident had a 9 out of 10 pain level (based on a pain scale of 1-10 with 10 being the worst pain); and 2. For Resident #69, to implement Benzocaine spray (a topical anesthetic) when recommended to assist with pain during wound dressing changes of a Stage 4 pressure injury (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) to the coccyx and a Deep Tissue Injury (DTI- pressure related injury to subcutaneous tissue under intact skin) to the left buttock.

Inspectors wroteBased on document review and interview, the facility failed to provide their staff training on facility ethic standards, policies, and procedures.

Inspectors wroteBased on review of Resident Council Minutes, resident and staff interviews, and policy review, the facility failed to ensure staff documented, addressed, and promptly resolved concerns brought forward during Resident Council Meetings held from 8/7/23 through 1/12/24.

Inspectors wroteBased on document review, policy review, and interviews, the facility failed to maintain a grievance process that supported the resident's right to formulate grievances anonymously and consistently document a resolution with acknowledgement. The total sample was 21 residents. Specifically, the facility failed to: 1. Have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns; and 2. Document evidence of a concern of missing items being resolved with an acknowledged by the complainant for Resident #14.

Inspectors wrote3. Resident #9 was admitted to the facility in July 2019 with diagnoses including: multiple sclerosis (MS), dementia, and cognitive communication deficit. On 1/30/24 at 9:02 A.M., the surveyor observed Resident #9 sitting in a Broda chair (positioning chair) in his/her room with a closed left hand. The surveyor did not observe a brace or assistive device in the room or on the Resident. During an interview on 1/31/24 at 8:09 A.M., Nurse #9 said the Resident's left hand is contracted closed and is not usable. Review of the medical record for Resident #9 indicated but was not limited to the following: [...]

Inspectors wrote3. Resident #73 was admitted to the facility in December 2023 with diagnoses including Stage 3 pressure injury of the left buttock, weakness, and rhabdomyolysis (breakdown of skeletal muscle due to direct or indirect muscle injury). Review of the MDS assessment, dated 12/23/23, indicated Resident #73 had a BIMS score of 14 of 15, indicating he/she was cognitively intact. Review of Section M: Skin Conditions of the MDS assessment indicated the Resident had two stage 3 pressure ulcers/injuries on admission. The assessment also indicated Resident #73 was receiving pressure ulcer/injury care including the application of non-surgical dressings and ointments. Review of Resident #73's December 2023 Physician's Orders indicated the following: - Start Date 12/18/23: Left Buttock - Normal Saline Wash (NSW) + Calcium Alginate + Cover with Border Gauze Dressing every day shift and as needed (PRN). [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications with a shortened expiration date upon opening were properly labeled once opened to prevent potential use of an expired medication in one medication cart out of five medication carts in use by the facility.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to: 1. Implement COVID-19 testing every 48 hours for all staff during a COVID-19 outbreak for 1 out of 5 sampled staff members; 2. Follow infection control standards during a medication pass, for Resident #66 and Resident #75; 3. Follow infection control practices during a wound dressing change for Resident #73; and 4. Appropriately utilize personal protective equipment (PPE) for residents on enhanced barrier precautions and transmission-based precautions for Resident #33.

Inspectors wroteBased on document review and interview, the facility failed to maintain an effective training program, as indicated in their facility assessment.

Inspectors wroteBased on documentation review and interview, the facility failed to provide their staff training in effective communication, as indicated by the Facility Assessment.

Inspectors wroteBased on document review and interview, the facility failed to ensure staff attended and received education on the facility Quality Assurance and Performance Improvement (QAPI) program, as indicated in the Facility Assessment.

Inspectors wroteBased on documentation review and interview, the facility failed to ensure their staff were educated on infection control and prevention which included, training on standards, policies, and procedures for the facility's infection prevention and control program.

Inspectors wroteBased on document review and interview the facility failed to provide behavioral health trainings as required in accordance with their facility assessment.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to notify the physician and the Resident's responsible party about a change in condition, specifically a significant weight loss of 10.95% in one month, and to re-evaluate the potential need to alter the treatment plan for one Resident (#71), out of a total sample of 21 residents.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to implement their policy for reporting and investigating an allegation of neglect for Resident #33 who was in pain and not administered pain medications for over an hour.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure an allegation of neglect was reported for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to report an allegation of neglect to the State Survey Agency (Department of Public Health) for Resident #33, who was experiencing pain of a 9 (on a scale of 1-10 with 10 being the worst pain), and who was not administered pain medications for over an hour.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#33), out of a total sample of 21 residents. Specifically, the facility failed to follow their policy for investigating an allegation of neglect for Resident #33 who was experiencing pain of a 9 (on a pain scale of 1-10 with 10 being the worst pain), and who waited over an hour for pain medication.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide the resident and their representative with a summary of the baseline care plan for two Residents (#65 and #74), out of a total sample of 21 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#60), out of a total sample of 21 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed, for Resident #60, to administer scheduled pain medication as ordered.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to provide an activities program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for two Residents (#56 and #65), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #56, to provide an activities program that would meet his/her individual interests to enhance his/her quality of life; and 2. For Resident #65, to plan for or provide an activities program that would meet his/her individual interests to enhance his/her quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to manage a contracture and prevent further potential complications in one Resident (#9) with muscular sclerosis, out of a total resident sample of 21 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to identify a significant weight loss of over 10% in one month and provide treatment and interventions to prevent further unprescribed, unplanned weight loss for one Resident (#71), out of a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition and fluids provided via a percutaneous endoscopic gastrostomy tube (PEG, an opening into the stomach for delivery of nutrition and hydration) or gastrostomy tube (G-tube, a tube inserted into the stomach through which nutrition is provided) were provided in accordance with professional standards of practice and facility policy for two Residents (#74 and #48), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #74, to ensure enteral feedings were provided via PEG tube in accordance with physician orders; and 2. For Resident #48, to ensure enteral formula containers and water flush bags were labeled with the Resident's name, date and time hung, and initialed by staff members.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure staff provided respiratory care in accordance with professional standards for one Resident (#16), out of a total sample of 21 residents. Specifically, the facility failed to ensure nebulizer equipment was changed weekly and stored in a sanitary manner.

Inspectors wroteBased on record review and interview, the facility failed to maintain in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid program.

Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS-State agency reporting system), the facility failed to provide written notice to the State agency when a change in the facility's Director of Nursing (DON) occurred.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the functional limitation status for one Resident (#9), in a total sample of 21 residents.