Sayville Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record review during an abbreviated survey (Complaint Number: NY00371931), the facility did not ensure resident rights to be free from neglect. Specifically, one (Resident #2) of three residents reviewed for neglect, required two-person assistance for mechanical lift (Hoyer) for transfers as documented in the Comprehensive Care Plan (CCP). A Certified Nursing Assistant (CNA #2) neglected to implement the Comprehensive Care Plan. Certified Nursing Assistant #2 placed a Hoyer sling under Resident #2 by themselves and proceeded to transfer Resident #2 alone. This negligence resulted in Resident #2 's being lowered to the floor. Resident #2 was transferred to the hospital and diagnosed with a contusion.

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, 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 well-being of each resident. This was identified for two of the two units reviewed for the Sufficient Nursing Staffing Task. Specifically, 1) a review of the Payroll-Based Journal (PBJ) Staffing Data Report Quarter 2, 2024 (January 1 - March 31) indicated excessively low weekend staffing; 2) a review of the daily staffing sheets revealed the facility did not provide sufficient numbers of Certified Nursing Assistants as indicated in the facility assessment; [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit (first floor and second floor) in the facility. Specifically, the Facility Assessment, last updated June 2024, did not include a breakdown of staffing needs for each of the facility's two units. The finding is: The facility's policy, titled Facility Assessment, dated 9/26/2024, documented a facility assessment is conducted at least annually and as needed to determine and update the facility's capacity to meet the needs of and competently care for residents during both day-to-day operations (including nights and weekends) and emergencies. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not ensure that each resident was offered sufficient fluid intake to maintain proper hydration and health. This was identified for one (Resident #127) of two residents reviewed for Hydration. Specifically, Resident #127 received intravenous hydration for 72 hours due to an elevated blood urea nitrogen level (an abnormal blood test result that could indicate dehydration). The resident's nutritional assessment indicated the resident needed 1620 milliliters of fluid per day. The meal tray observation indicated the resident was not offered an adequate amount of fluids as indicated in the nutritional assessment. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 10/3/2024 and completed on 10/10/2024, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. This was identified for one (Resident #38) of three residents reviewed for Respiratory Care. Specifically, Resident #38 was utilizing oxygen therapy for Chronic Obstructive Pulmonary Disease (COPD) and did not have a physician's order for the oxygen therapy. The finding is: The policy and procedure for Oxygen Administration dated January 2020 documented the administration of supplemental oxygen is an essential element of appropriate management for a wide range of clinical conditions. Oxygen should be regarded as a drug and therefore, requires prescribing in all but emergency situations. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 10/03/2024 and completed on 10/10/2024, the facility did not ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #64) of four residents observed for Pressure Ulcers. Specifically, Resident #64, who resided in a two-bedded room with a roommate, had a sign outside the doorway for Enhanced Barrier Precautions. During Resident #64's wound care observation, Licensed Practical Nurse #2 and Charge Nurse Licensed Practical Nurse #3 did not know which resident in the room was on Enhanced Barrier Precautions and started the wound care without utilizing an isolation gown as indicated on the Enhanced Barrier Precaution Signage. The finding is: [...]

Inspectors wroteBased on observations, record review and interviews during the Recertification Survey initiated on 3/6/2023 and completed on 3/13/2023, the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of their quality of life. This was identified for two (Resident #132 and Resident #85) of four residents reviewed for dignity. Specifically, during a lunch meal observation on date 3/6/2023 two staff members were observed standing over Resident #132 and Resident #85 while feeding the residents their entire lunch meal.

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 3/6/2023 and completed on 3/13/2023 the facility did not ensure that each resident's comprehensive person-centered Care Plan (CCP) was reviewed and revised by the Interdisciplinary Team after each assessment. This was identified for one (Resident #97) of one resident reviewed for Ventilator and Tracheostomy care. Specifically, Resident #97 had a Physician's order to remove the Laryngectomy tube (a clear flexible tube that is placed in the stoma to keep the stoma open and aides in breathing) and cleanse the site with normal saline (NS) once daily and as needed (PRN). A review of the Respiratory CCP lacked documented evidence that the CCP was updated to include the care of the Laryngectomy tube. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00274885) initiated on 3/6/2023 and completed on 3/13/2023, the facility did not develop a discharge plan that addressed all of the needs for a resident that was being discharged home. This was identified for one (Resident #249) of one resident reviewed for Discharge Planning. Specifically, Resident #249 had bilateral lower extremity wounds that required wound care. The resident was discharged home on 4/13/2021 and the facility did not confirm that Home Care Services were in place to provide wound care treatments prior to the resident's discharge. Additionally, there was no documented evidence that the resident or their representative were trained to provide wound care prior to the resident's discharge to home The finding is: [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 3/6/2023 and completed on 3/13/2023, the facility did not ensure that each resident's environment remains as free of accident hazard as is possible and was provided assistive devices to prevent accidents. This was identified for one (Resident #134) of three residents reviewed for Accidents. Specifically, Resident #134, who was at risk for falls, was to be out of bed after breakfast as per the resident's plan of care. The resident was observed climbing out of their bed on 3/7/2023 at 12:12 PM. There were no floor mats observed on the floor by the resident's bed. The finding is: The facility's Policy and Procedure for Falls dated 11/2022 documented staff will implement interventions based on the resident's individual needs and communicate interventions to the care givers and resident/family. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey, the facility did not ensure that the comprehensive person-centered care plan for each resident was implemented to meet the residents' medical needs. This was identified for 1 (Resident #58) of 5 residents reviewed for unnecessary medications. Specifically, Resident #58 had a Physician's order to administer Metoprolol and Taztia Xt for high Blood Pressure (BP). The Physician's order indicated to hold both medications when the heart rate was less than 60 beats per minute (bpm) or the systolic BP was less than 110 millimeters of mercury (mmHg). The facility staff did not obtain Resident #58's heart rate or BP before administering the medication on multiple occasions in July 2020. The finding is: [...]

Inspectors wroteBased on observation and staff interviews during the Recertification Survey, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional standards. Specifically, an inspection of one (Unit 1) of two medication rooms revealed an opened multidose vial of Tubersol (Diagnostic Antigen used for detecting Tuberculosis infection), that was undated and not discarded 30 days after opening. The finding is: On 09/10/20 at 3:57 PM, during the Unit 1 medication storage room observation, a multi-dose tuberculosis vaccine vial was opened and undated. The Medication Licensed Practical Nurse (LPN # 1) was interviewed on 9/10/20 at 4:00 PM and stated that she did not know when the multi-dose vial of the Tubersol was opened. LPN #1 further stated that the vial should be dated when opened and discarded 30 days after opening. [...]