Samaritan Senior Village, Inc

Inspectors wroteBased on observations and interviews, the facility failed to serve food in accordance with professional standards for food service safety in one of four unit pantries (Unit 4 pantry). Specifically, Food Service Worker Team Lead #12 and Food Service Worker #13 did not change their gloves or perform hand hygiene between tasks and proceeded to touch food with contaminated gloves.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for one of one resident (Resident #21) reviewed. Specifically, Resident #21 had a physician order for oxygen at 2 liters per minute as needed to keep oxygen saturations (amount of oxygen in the blood stream) above 90% (the order did not include the oxygen delivery method) and the resident received continuous oxygen via nasal cannula, the Medication Administration Record did not include oxygen administration, oxygen saturations were not ordered or obtained to determine if the oxygen was needed, and the care plan did not include oxygen therapy.

Inspectors wroteBased on record review and interviews the facility failed to ensure each resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for one of one resident (Resident #9) reviewed. Specifically, Resident #9 was not seen by a medical provider (physician, physician assistant, or nurse practitioner) every 30 days for the first 90 days after admission and did not have an admission assessment completed by a registered nurse.

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 of seven residents (Resident #117) reviewed. Specifically, Resident #117 had conflicting isolation precautions signage and orders, and staff were observed not wearing appropriate personal protective equipment while in the resident's room.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024 the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, potentially hazardous foods were not cooled properly in the main kitchen, and there was insufficient lighting in the walk-in cooler and walk-in freezer.

Inspectors wroteBased on observations, record review, and interview during the recertification and abbreviated (NY00344344, NY00344487, and NY00347064) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 3 residents (Residents #59, #67 and #86) reviewed. Specifically, Resident #59 did not have their palm protectors (contracture management device) applied as care planned; Resident #67 did not have their elastic tubular compression bandage (Tubigrip) applied as ordered; and Resident #86 had a skin tear (a wound resulting from separation of the top layer of skin from the second layer) and initial treatment orders were not obtained, and the wound dressing was unclean.

Inspectors wroteBased on observation and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 3 of 5 medication carts (Second floor B side and Fourth floor A and B sides), and 1 of 4 medication rooms (First floor B side). Specifically, the First floor B side medication room was missing medication refrigerator temperatures; the Fourth floor B side medication cart was unlocked and unattended; the Second floor B side and the Fourth floor A side medication carts had eye drops that were not labeled after they were opened.

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for 1 of 2 meal test trays (the 8/13/2024 First floor A side lunch meal); for 2 of 2 residents (Residents #22 and #31) reviewed; and for 7 of 7 anonymous residents present at the Resident Council meeting. Specifically, food was not served at palatable and appetizing temperatures for the First floor A side lunch meal on 8/13/2024; and Residents #22, #31, and the attendees of the Resident Council meeting stated the food did not taste good and was not hot.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00347064) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 1 of 1 resident (Resident #92) reviewed. Specifically, Residents #92's electric wheelchair was unclean.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated (NY00344487) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure that prompt efforts were made to resolve grievances for 1 of 1 resident (Resident # 26) reviewed. Specifically, Resident #26's family member sent an electronic message to the facility's Administrator regarding their concerns and their concerns were not addressed timely.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 2 residents (Resident #125) reviewed. Specifically, Resident #125's comprehensive care plan did not include a diagnosis of Type 2 diabetes (the body is unable to use insulin properly causing high blood sugar).

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00344344, NY00344487, and NY00347064) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 8 residents (Resident #26) reviewed. Specifically, Resident #26 was not assisted out of bed as requested.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 2 residents (Resident #137) reviewed. Specifically, Resident #137 was not assisted to attend an activity that was meaningful to them and met their interests and preferences.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure that residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #37) reviewed. Specifically, Resident #37 received hemodialysis treatments at a community-based dialysis center and did not have ongoing assessments of their condition and monitoring for complications before and after dialysis treatments. Additionally, there was not consistent ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024, 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 1 of 4 residents (Resident #54) reviewed. Specifically, Licensed Practical Nurse #23 did not maintain infection control precautions when administering medications to Resident #54 who was on transmission based precautions (contact precautions) and staff were not aware why the precautions were in place.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/21/22-6/24/22, the facility failed to store food in accordance with professional standards for food service safety for 3 of 5 kitchenettes (1B, 3B, and 4B kitchenettes) reviewed. Specifically, there were undated and outdated foods stored in the 1B, 3B, and 4B kitchenettes.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/21/22-6/24/22, the facility failed to ensure a resident's right to personal privacy of accommodations and personal care for 1 of 1 resident reviewed (Resident #13). Specifically, Resident #13 had a video monitor in their room which transmitted live video of the resident to the nursing station and the facility did not obtain the resident's or the resident representative's consent for video monitoring.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00297453, NY00295650, NY00286645, NY00294873, NY00280209, NY00281251) conducted 6/21/22-6/24/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 6 residents (Resident # 120) reviewed. Specifically, Resident #120 was not provided incontinence care in a timely manner as care planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/21/22-6/24/22, the facility failed to ensure the resident environment remained free of accident hazards as is possible for 1 of 7 residents (Resident # 120) reviewed. Specifically, Resident #120 was assessed as unable to use bedrails appropriately or safely and was observed with bedrails in the up position.