Samaritan Keep Nursing Home Inc

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents had the right to a dignified existence for two (2) of two (2) residents (Residents #184 and #257) reviewed. Specifically, Residents #184 and #257 had their side rails removed and there was no documented evidence they were provided with education, a therapy evaluation, side rail alternatives, or an opportunity to discuss their concerns prior to the side rails being removed. This resulted in a decline in bed mobility for Residents #184 and #257.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own medications, if clinically appropriate, for one (1) of one (1) resident (Resident #133) reviewed. Specifically, Resident #133 had a medication cup at their bedside containing one white round pill and one half of a round white pill. There was no documented evidence of assessments and/or physician orders for the residents to safely self-administer medications.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for one (1) of three (3) residents (Resident #281) reviewed. Specifically, Resident #281 was admitted with a Stage 2 (partial thickness skin loss) pressure ulcer and did not have admission orders for wound care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure adequate supervision to prevent accidents for one (1) of one (1) resident (Resident #215) reviewed. Specifically, Resident #215's elopement safety interventions of 30 and 60-minute safety checks and wander guard tag checks were not completed as planned/ordered.

Inspectors wroteBased on observations, record review, and interviews the facility failed to provide the necessary services and treatment for indwelling urinary catheter use for two (2) of six (6) residents (Residents #1 and #13) reviewed. Specifically, Resident #1 did not have a provider recommended voiding trial completed; and Resident #13 had an indwelling urinary catheter with a history of bladder infections and did not receive assistance with changing between their urinary collection leg bag (a small, wearable, and discreet receptacle used to collect urine) and a large capacity urinary collection bag.

Inspectors wroteBased on observations and interviews during the survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) Residents (Resident #197) reviewed. Specifically, Resident #197 had significant weight loss, was not assisted with meals as care planned, and there was no documented evidence a medical provider addressed the resident's weight loss.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (1) of one (1) resident (Resident #257) reviewed. Specifically, Resident #257 had a bilevel positive airway pressure machine (non-invasive mechanical ventilator that keeps airway open when sleeping) that was not cleaned per professional standards; was not maintained with water in the reservoir; did not have an order for supplemental oxygen use when used; was not documented as administered on the medication administration record; and there was no documented evidence of ongoing assessment of the resident's respiratory status, response to the therapy, documentation of the equipment settings or when to use the equipment.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident who required dialysis (a process that filters blood during kidney failure) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #13) reviewed. Specifically, Resident #13 received dialysis at a community-based dialysis center, and the facility did not perform ongoing assessments of their condition or monitor for complications before and after dialysis treatments and there was inconsistent communication between the dialysis center and the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of seven (7) medication carts (8th floor and 4th floor medication carts); one (1) of four (4) medication rooms (4th floor medication room); and one (1) of seven (7) treatment carts (3rd floor treatment cart) reviewed. Specifically, one medication cart on the 8th floor was unlocked and unsupervised; one medication cart on the 4th floor contained pre-poured, unlabeled medications; the 4th medication room refrigerator contained an open, undated multi-dose tuberculin purified protein derivative vial; and the 3rd floor treatment cart was unlocked and unattended.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received and the facility provided a diet in a form designed to meet individual needs for one (1) of one (1) resident (Resident #241) reviewed. Specifically, Resident #241 received a whole regular brownie instead of a pureed brownie as ordered; and the resident's person-centered Comprehensive Care Plan did not include the ordered altered food consistency.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to 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 one (1) resident (Resident #1) reviewed. Specifically, Resident #1 was on transmission-based precautions (enhanced barrier precautions) and Certified Nurse Aide #37 did not perform hand hygiene prior to entering the resident's room, emptied the resident's urinary catheter without wearing required personal protective equipment, and did not perform hand hygiene with glove changes.

Inspectors wroteBased on record review and interviews during the survey (Complaint #756448), the facility failed to ensure residents were free from abuse and neglect for one (1) of three (3) residents (Residents #3) reviewed. Specifically, on 03/24/2024 at approximately 12:00 AM, Resident #3 was zip tied (a fastener with a locking, self-snagging nylon strap used to secure items) to the able riser (enabler bar) on their bed by Licensed Practical Nurse #7, for approximately 45 minutes to one (1) hour. This resulted in Immediate Jeopardy Past Non-Compliance for Resident #3 and placed all residents at risk for abuse.

Inspectors wroteBased on record review and interviews during the abbreviated surveys (NY00308228 and NY00322916) the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported to the New York State Department of Health as required. Specifically, Resident #2 sustained a fracture from a transfer with a mechanical lift and Resident #3 eloped (exited, undetected by staff) to a non-resident area and the incidents were not reported as required.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 2/26/2024-3/1/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 7 of 7 residents (Resident #33, #103, #212, #124, #75, #68, and #92) reviewed. Specifically, Resident #33 did not have pressure relief for their heels as planned and Residents #33, #103, #212, #124, #75, #68, and #92 had air mattresses (a specialty mattress that provides air flow to relieve pressure) in use that were not monitored for functioning.

Inspectors wroteBased on record review and interview during the recertification survey conducted 2/26/2024 -3/1/2024, the facility did not ensure a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 had a wedge positioning pillow (a wedge-shaped pillow used to aid with positioning) tucked under their fitted bedsheet that was not included on their comprehensive person-centered care plan.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00302726, NY00316052, NY00322441) surveys conducted 2/26/2024- 3/1/2024, 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 2 of 8 residents (Residents #638 and #109) reviewed. Specifically, Resident #638 was not assisted with meals and Resident #109 was observed with unwanted facial hair.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 2/26/2024-3/1/2024, the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion and proper positioning for 2 of 4 residents (Residents #166 and #124) reviewed. Specifically, Resident #166 did not have bilateral hand splints in place as ordered and planned and Resident #124 did not have hand splints in place as planned.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00322441) surveys conducted 2/26/2024-3/1/2024, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 9 residents (Residents #4 and #162) reviewed. Specifically, Resident #4 was care planned to be out of bed for meals with use of specific swallowing strategies and was left in bed unsupervised during a meal; Resident #162 had a diagnosis of dysphagia (difficulty swallowing) with aspiration precautions and was observed eating meals alone in their room.

Inspectors wroteBased on record review and interview during the recertification and abbreviated surveys (NY00316052) conducted 2/26/2024-3/1/2024 the facility did not ensure residents were free of significant medication errors for 1 of 3 residents (Resident #21) reviewed. Specifically, Resident #21's medications were crushed, combined, and administered all at once through their gastrostomy tube (feeding tube). Additionally, prednisone (corticosteroid) was ordered to be given orally and was given via the gastrostomy tube.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/26/2024-3/1/2024, 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 infection for 1 of 3 residents (Residents #92) reviewed. Specifically, Resident #92's wound care was completed by licensed practical nurse #1 without performing appropriate hand hygiene and precautions to prevent contamination of the wound and clean supplies.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00278827 and NY00279852) surveys conducted from 8/30/21-9/3/21, the facility failed to ensure allegations of abuse, exploitation, or mistreatment were thoroughly investigated for 5 of 7 residents (Residents #1, 153, 165, 189, and 239) reviewed and did not take appropriate corrective action to prevent abuse for 2 of 7 residents (Residents #46 and 199) reviewed. Specifically, Resident #165 exhibited signs of at-risk behavior and was not provided adequate supervision to prevent abuse towards Residents #46 and 199; Resident #239 made an allegation of abuse that was not investigated; and Residents #1, 153, and 189 were involved in physical altercations with another resident that were not investigated by the facility to rule out abuse, neglect, or mistreatment.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 8/30/21 - 9/3/21 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 transmission of communicable diseases and infections for all 246 residents of the facility. Specifically, there was cross-contamination of dirty and clean laundry.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/30-9/3/21, the facility failed to ensure reports with respect to any surveys, certifications and complaint investigations and any plan of corrections, were made available for any individual to review upon request. Specifically, the facility did not post all survey results or notice of availability of such reports including standard, extended and complaint investigation surveys from the 3 preceding years.

Inspectors wroteBased on observation and interviews during the recertification survey conducted from 8/30/21- 9/3/21, the facility failed to maintain a safe, clean, comfortable, and home-like environment for 2 of 7 resident units (Units 6 and 8). Specifically, there were stained, non-waxed and sticky floors, plastic raceways (protective plastic covers over wires running from the plug to the computers on the walls) hanging from the walls, a stained chair and water condensation observed on the resident units.

Inspectors wroteBased on observation, interview and record review during the recertification and abbreviated surveys (NY00281073) conducted from 8/30/21- 9/3/21, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 of 6 residents (Residents #67 and #153) reviewed. Specifically, Resident #67 was not assessed, or care planned to use side rails, and Resident #153 was not care planned for protection from potential accident hazards.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 8/30/21-9/3/21, the facility failed to ensure each resident received food and drink prepared in a form to meet individual needs for 1 of 3 residents (Resident #150) reviewed. Specifically, Resident #150 had a physician order to receive a mechanically altered level 2 diet (consisting of foods that are moist, soft-textured, and easily formed into a bolus) and received a regular consistency entrée.