Schaffer Extended Care Center

Inspectors wroteBased on interview, observation and record review during the Recertification Survey conducted from 4/29/2025 to 5/6/2025, the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and to prevent worsening of pressure ulcers. This was evident for one (1) of five (5) residents (Resident #32). Specifically, Resident #32 was assessed at risk for pressure ulcers, developed a sacral wound and there was no documented evidence that interventions were implemented to address off loading/incontinence schedule/incontinence care to prevent further deterioration of a sacral wound. [...]

Inspectors wroteBased on interview and record review during the recertification survey from 04/29/25 through 05/06/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#13, #14, #15, #16, #17) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 4/25/25 to 5/6/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, unlabeled and undated food items in kitchen and unit pantry, expired food in kitchen storage pantry and unit pantry, and dietary staff did not perform proper hand hygiene before preparing a sandwich.

Inspectors wroteBased on record review and interview during a Recertification Survey on 4/29/2025 - 5/6/2025, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure an infection surveillance plan based on facility assessment was implemented for the identification, containment and prevention of infections.

Inspectors wroteBased on observation, record review and interview during the recertification survey and abbreviated survey (NY00374695) from 4/29/25 to 5/6/25 the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with resident rights that included measurable objectives and time frames to meet a resident's needs for 1 of 5 residents (Resident #32) reviewed for pressure ulcers, 1 of 3 residents (Resident #19 ) reviewed for positioning and mobility and for 1 of 2 residents (Resident #8) reviewed for tube feeding. [...]

Inspectors wroteBased on observation, interview, and record review, during the recertification survey and abbreviated survey (NY00376185) and (NY00342713), the facility did not ensure residents were adequately equipped to call for assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area. Specifically, 1) the 5th floor call bell was not audible and did not have a centralized location to alert staff when residents needed assistance for twenty nine of twenty nine rooms and the light above the door did not light up for five of the twenty nine rooms (Rooms #104A, 105B, 111P, 115A, 115B, bathroom in room [ROOM NUMBER]). Additionally, tap or hand bells were not provided/readily available as per facility plan for ten of the twenty nine rooms (Rooms #104B, 105B, 111P, 115B, 117A, 121A, 121B, 126B, 127A, 127B, 128A, 128B, 129A, and 129B).

Inspectors wroteBased on observation, record review and interview during the recertification survey from 4/29/25 to 5/6/25 the facility did not ensure the right to receive services with reasonable accommodation of needs and preferences for 1 of 3 residents (Resident #19) reviewed for positioning and mobility. Specifically, Resident #19 stated they informed the Director of Social Work their wheelchair needed to be repaired 3 months ago and the wheelchair was observed in disrepair on 4/30/25.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey 4/29/25 to 5/6/25, the facility did not ensure a significant change Minimum Data Set (MDS) Assessment (tool to assess resident care needs) was completed within the 14-day requirement for 1 of 5 residents (Resident #48) reviewed for pressure ulcer/injury. Specifically, a Significant Change Minimum Data Set was not initiated within 14 days for Resident #48 with a decline in swallowing ability who required a 1/28/25 diet downgrade to nothing by mouth.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 04/29/2025 to 05/06/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one of one resident (Resident #67) reviewed for edema. Specifically, for Resident #67 a left foot ace bandage wrap was not consistently applied in the morning to allow 12 hours of use daily and legs were not elevated when out of bed as per physician order.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 4/29/25 to 5/6/25, the facility did not ensure irregularities identified by the pharmacist and forwarded to the facility were acted upon for 1 of 5 residents (Resident #121) reviewed for unnecessary medications. Specifically, for Resident #121 laboratory requests were not ordered and obtained as per consultant pharmacist and physician agreement.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 4/29/2025-5/6/2025, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 2 of 3 residents (Residents #113, #86) reviewed for food. Specifically, 1) Resident #113 had a physician order for mince and moist diet and was served a fruit cup and 2) Resident #86 had a physician order for nectar thick liquids and was provided a pitcher of water by the Certified Nurse Aide.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00336728), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than 2 hours to the state survey agency for 1 of 1 resident reviewed for Abuse (Resident #77). Specifically, Resident #77 was observed with a swollen right arm which was warm to touch and of unknown origin on 3/20/24 at 10:15 AM, and it was not reported to the state agency until 3/21/2024.

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure 4 of 5 residents (Residents #114, 57, 14, and 28) reviewed for pressure ulcers, received care and services to promote healing. Specifically, Resident #114 had a Stage 4 pressure ulcer and was not turned and positioned as planned; additionally, there was not a documented wound assessment, by a qualified professional over a 3-week period. Residents #57, #14 and #28 had Stage 4 pressure ulcers and no documented evidence that wound assessments were completed as planned.

Inspectors wroteBased on observation, record review and interviews conducted during a recertification survey from 12/12/23 through 12/20/23, the facility did not review and revise the comprehensive care plan with appropriate interventions for 2 out of 2 residents (Residents #89 and #98) reviewed for Activities. Specifically, Residents # 89 and #98's recreation care plans were not updated quarterly and did not reflect the residents' preferred activities.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that they evaluated, updated, and implemented an effective discharge plan for one of four residents reviewed for discharge (Resident #127). Specifically, Resident #127 who expressed a desire to be discharged to the community was not re-evaluated and a new discharge plan developed based on the resident's choice when the initial community discharge plan could not be implemented, and planned community support were no longer available.

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure that residents with a Foley (indwelling) catheter (a tube inserted into the bladder via the urethra to drain urine into a drainage bag) received the treatment and services needed to prevent urinary tract infections to the extent possible for one (Resident #87) of 3 residents reviewed for indwelling catheters. Specifically, Resident #87's Foley catheter drainage bag was not changed as per physician orders, and there was a lack of Foley care provided per professional standards to prevent complications.

Inspectors wroteBased on record review and interview conducted during a recertification survey 12/12/2023-12/20/2023, the facility did not ensure an infection prevention and control program designed to provide a safe and sanitary environment was maintained. Specifically, (1) The facility could not provide evidence that a facility risk assessment was conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system and 2)Foley catheter tubing was observed on the floor without a barrier for 1 of 3 residents reviewed for foley catheters (Resident #87).

Inspectors wroteBased on record review and interview conducted during the recertification survey from 12/12/2023 through 12/20/2023, the facility did not ensure the required quarterly Minimum Data Set ( a resident assessment and screening tool) was conducted within the regulatory time frame as per the Centers for Medicare and Medicaid Services resident assessment instrument process. Specifically, the Minimum Data Set records for Residents #27 and #38 revealed that the quarterly Minimum Data Sets were not completed within the assessment reference date plus 14 days.

Inspectors wroteBased on observations, interviews and record review during a recertification and abbreviated survey (Complaint #NY00244321), the facility failed to develop plans of care with measurable goals, time frames and interventions to address the residents assessed needs for one of two residents reviewed for respiratory therapy (Resident #102) and one of two residents reviewed with a urinary drainage bag (catheter, Resident #243). Specifically, Resident #102's plan of care failed to address strict aspiration precautions for a resident with a tracheostomy tube in place. Resident #243's Comprehensive Care Plan did not provide measurable goals and interventions to address her diagnosis of overactive bladder leading to the need for a urinary catheter.

Inspectors wroteBased on interviews and record review during recertification and abbreviated surveys (Complaint #N00244321), it cannot be ensured that the facility completed a discharge summary that included a course of treatment, resident status and post-discharge plans for 1 of 4 residents reviewed for Admission, Transfer and Discharge (Resident #243). Specifically, Resident #243's discharge summary furnished to the receiving Assisted Living Facility (ALF) did not summarize the course of treatment for urinary continence, did not provide a final summary of urinary status and did not provide a post-discharge plan for urinary continence.

Inspectors wroteBased on interview and record review conducted during a recerfication survey, it could not be ensured that facility residents (Residents #51 and # 85) who are unable to carry out activities of daily living (ADL's) receive the necessary services to maintain personal hygiene and bathing.

Inspectors wroteBased on observations, interviews and record review on a recent recertification survey, the facility did not ensure proper care and treatment of a resident receiving oxygen therapy. Specifically, a resident with a tracheostomy received 4 liters of humified oxygen via tracheostomy collar without a physician order for twelve weeks. Additionally, there was no documentation of pulse oximetry measurements and a self-inflating bag resuscitator was not provided in the resident room.

Inspectors wroteBased on observation, interview and record review conducted during the most recent re-certification survey, it could not be ensured that the facility provided services consistent with standards of practice and in accordance with the written plan of care for 1 of 2 residents (Resident #193) reviewed for dialysis. Specifically, the resident's pre and post dialysis weights were not consistently obtained from the dialysis center in accordance with the resident's plan of care.

Inspectors wroteBased on interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 4 residents (Resident #125) reviewed for dementia care was provided appropriate care to maintain the highest psychosocial well-being and to avoid the use of antipsychotic medication for behavior management. Specifically, there was no documented evidence that 1) underlying causes for behavioral symptoms were determined during the onset of these behaviors; and 2) person-centered behavioral interventions were attempted prior to initiating the use of Haldol, an antipsychotic medication.