San Simeon by the Sound Center for Nursing & Rehab

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility failed to ensure the residents' environment remained free of accident hazards. This was evident at the resident sinks and common shower rooms on all 4 of 4 resident units. Specifically, the facility failed to protect all 114 residents from the likelihood of burns related to excessive hot water temperatures from the facility's domestic hot water system. This resulted in no actual harm with likelihood of serious harm that is Immediate Jeopardy and Substandard Quality of Care to all residents' health and safety.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all residents were provided a safe, clean comfortable, and homelike environment. This was identified for two (B Unit and [NAME] Unit) of four units reviewed during the environmental task; and for two residents (Resident #48 and Resident #100) of three residents reviewed for the environment task. Specifically, 1) the suction machine on the [NAME] Unit dining room was observed with used suction tubing and a dirty suction canister that contained cloudy fluid with food particles, and 2) the privacy curtains for Resident #47 and Resident #100 were observed to be soiled. 3) The hallway bathroom on B Unit and the bathroom in room [ROOM NUMBER] were observed to have a dried brown feces-like substance on the toilet bowl seat.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles. This was identified for three (Unit B, Unit C, and East Unit) of four units observed during the Medication Storage Task. Specifically, loose unidentifiable medications were observed in a medication cart for Unit B, East Unit, and Unit C. Additionally, the medication carts were utilized for storing items other than the medications.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey, initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, 1) an opened, undated package of cod fish and pancakes was observed in a single-door refrigerator. In the dry storage area, four packages of opened and undated dry cereals were observed 2) Dietary Aide #1 was observed licking their fingers and then setting up napkins and utensils on resident trays without performing hand hygiene. 3) A chicken salad sandwich temperature was not maintained within the acceptable temperature range for food safety.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident. This was identified for one (Resident #85) of four residents reviewed for Advanced Directives and for one (Resident #99) of one resident reviewed for skin conditions. Specifically, 1) Resident #85 had physician's orders for advance directives to include Do Not Resuscitate, Do Not Intubate, and No Feeding Tube. There was no comprehensive care plan developed to reflect the resident's Advanced Directives status. 2) Resident #99 had a physician's order to treat the left shin (front of the leg below the knee) wound twice a day. There was no documented evidence that the staff consistently provided the wound care as ordered by the Physician.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #256) of one resident reviewed for Pain Management. Specifically, Resident #256 reported left-hand pain on 8/4/2024. The medical provider was contacted and ordered an x-ray of the left hand. Registered Nurse #6 wrote the telephone order in the medical record and erroneously indicated an x-ray order for the right hand. The x-ray of the right hand was completed; however, neither the Medical Doctor nor the Nurse Practitioner reviewed the x-ray results. The facility staff were not aware of the transcription error until it was brought to the facility's attention by the surveyor. [...]

Inspectors wroteBased on record review and interviews the facility did not ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. This was evident for one (Resident #79) of four residents reviewed for Nutrition. Specifically, Resident #79 was admitted to the facility on [DATE] and was receiving tube feeding via enteral means. The facility did not obtain and monitor the resident's weight since the resident was admitted to the facility. The finding is: A facility policy titled Weight and Weight Changes last updated in March 2024, documented to obtain weights on all residents as per the medical doctors' orders. All residents will be weighed within 72 hours of admission and/or readmission to the facility. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was identified for one (West Unit) of four Units during the infection control task. Specifically, the facility did not ensure staff appropriately discarded dirty linens in a sanitary manner and did not timely change suction canister and tubing after use.

Inspectors wroteBased on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY00329617), the facility failed to ensure that two allegations of sexual abuse were reported to the Department of Health and Local Law Enforcement within two hours. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. This resulted in Immediate Jeopardy for Resident #1 and Resident #2 and a potential to affect 104 other facility residents.

Inspectors wroteBased on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY00329617), the facility failed to ensure that two allegations of sexual abuse were investigated. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. This resulted in Immediate Jeopardy for Resident #1 and Resident #2 and a potential to affect 104 other facility residents.

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #31) of eight residents reviewed for accidents. Specifically, Resident #31, required supervision at all times and was not to be left alone in their room as per their Comprehensive Care Plan (CCP). Resident #31 had an unwitnessed fall in their room on 10/11/2022 when a Certified Nursing Assistant (CNA) #4 left the resident unsupervised in their room and exited the room. Resident #31 fell out of the wheelchair and sustained a C 1 Cervical fracture. This resulted in actual harm to Resident #31 that is not Immediate Jeopardy. The finding is: The facility Policy on Accident and Safety: [...]

Inspectors wroteBased on observations, record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00286139) initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified on two of four nursing units. Specifically, 1) The facility's nursing staffing assignments did not reflect the staffing needs as indicated in the facility assessment for the Certified Nursing Assistants (CNA); 2) Resident #61 did not receive assistance to meet their toileting needs in a timely manner 3) Resident #5 was not ambulated as per their Physician's orders.

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This was identified for one (Resident #31) of eight residents reviewed for Accidents. Specifically, Resident # 31's Comprehensive Care Plan (CCP) for falls included an intervention dated 10/03/2022 that the resident is not to left alone in their room when out of bed in their wheelchair. On 10/11/2022 Certified Nursing Assistant (CNA) # 3 left Resident # 31 alone in their room. [...]

Inspectors wroteBased on record review, and staff interview during the Recertification Survey and Abbreviated survey (NY 00281584) initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. This was identified for two (Resident #153 and Resident #31) of eight residents reviewed for accidents. Specifically, 1) Resident #153 who required assistance with transfer, had an unwitnessed fall on 8/12/2021 and was found sitting on the floor at 8:25 PM in the common/television area. The Accident and Incident (A/I) report did not investigate whether the staff applied the wheelchair breaks prior to the accident. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00286139) initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure that based on the comprehensive assessment of a resident and consistent with resident's needs and choices the facility must provide the necessary care and services to ensure that a resident's ability in Activities of Daily Living (ADL) do not diminish. This includes that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living including elimination, transfer, and ambulation. This was identified for one (Resident #61) of two residents reviewed for bowel and bladder incontinence and one (Resident #5) of two residents reviewed for ADLs. [...]

Inspectors wroteBased on observation, record review, and interview during the Recertification and Abbreviated Survey (Complaint # NY 00286139) initiated on 11/17/2022 and completed on 11/23/2022, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible. This was identified for one (Resident #61) of two residents reviewed for bowel and bladder incontinence. Specifically, Resident #61, who required total assistance with toileting and was frequently incontinent of bowel and bladder, was heard sobbing in their room from the hallway. The resident was observed crying with eyes reddened and tears running down their cheeks. Resident #61 was lying in bed wearing a urine and stool-soaked brief and had a soiled wet cloth pad underneath the resident on the bed. [...]