Schervier Nursing Care Center

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/24/2025 to 03/31/2024, the facility did not ensure it promoted and facilitated resident self-determination through support of resident choice. This was evident in 2 (Resident #9 and #212) of 4 residents reviewed for Choices out of 38 total sampled residents. Specifically, Residents #9 and 212's bathing preferences were not honored.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure timely completion of each resident's quarterly review assessments. This was evident in 2 (Residents #311 and #322) of 5 residents reviewed during the Resident Assessment Task. Specifically, Residents #311 and #322's Quarterly Minimum Data Set assessments were not completed within 14 days of the assessment reference date.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey conducted from 03/24/2025 to 03//2025, the facility did not provide food and drink that were palatable and at a safe and appetizing temperature. This was evident in 1 (Unit 1) of 1 unit observed during Dining Task. Specifically, food served during lunch in Unit 1 had suboptimal temperatures.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure all mechanical, electrical, and patient care equipment are in safe operating condition. This was evident in 1 (Resident #231) of 2 residents reviewed for Hospitalization, out of 39 total sampled residents. Specifically, the facility failed to maintain Resident #231's bed in proper working condition.

Inspectors wroteBased on observation, record review, and interviews during the Recertification and Complaint (NY00362960) Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure a resident's room had adequate outside ventilation by means of windows or mechanical ventilation, or a combination of the two. This was evident in 1 (Resident #67) of 3 residents reviewed for Environment out of 39 total sampled residents. Specifically, Resident #67's room had no operable window that can provide good air circulation.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 3 (Residents #21, #120, and #193 ) of 38 total sampled residents. Specifically, Residents #21, #120, and #193's Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed.

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00341219), the facility did not ensure a resident was adequately supervised to prevent accidents. This was evident in one (1) out of three (3) residents sampled (Resident #1). Specifically, on 05/02/2024 at 1:00 PM, Resident #1 who was cognitively declining left the facility unescorted for a self-arranged clinic appointment without the knowledge of the facility's nursing staff. Resident #1 's wheelchair was bumped by a truck while crossing the street. Resident #1 had right elbow pain but there were no fractures.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey conducted on 10/02/23 - 10/11/23, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. This was evident for 1 (Resident #199) of 6 residents reviewed for Dignity and random observations of 4 residents (Resident #s141, 184, 144, 199, and 47) on 1 of 8 units observed for Dining. Specifically, (#1) On 2 occasions a Licensed Practical Nurse (LPN) #8 was observed administering medication (insulin) to the resident in the hallway next to the nursing station (Resident #199) and on another occasion LPN #8 was observed assessing the resident's fingerstick in the hallway next to the nursing station (Resident #31). [...]

Inspectors wroteBased on record review and staff interview conducted during the re-certification survey, the facility did not ensure quarterly Minimum Data Set (MDS) 3.0 assessments were completed timely. This was evident for 6 of 12 residents reviewed for Resident Assessment (Resident #s 54, 255, 38, 162, 114, and 156). Specifically, quarterly MDS assessments were not completed within 14 days of the Assessment Reference Date (ARD).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident for 4 (Residents #210, #82, #503, # 284, and #123) of 8 residents reviewed for Activities. Specifically, (1) Resident #210 was not provided with a program of activities appropriate for their mental and physical abilities. (2) Resident #123, a resident with severely impaired cognition, was observed for extended periods of time without meaningful activities, and there was no activity plan to provide activities to the resident while in their room. (3) Resident #503 was not provided with adequate assistance to attend preferred activities. [...]

Inspectors wroteBased on staff interviews and record review conducted during the Recertification and Complaint (NY00318133)Survey from 10/02/23 to 10/11/23, the facility did not ensure that residents received adequate supervision and assistance to prevent accidents. This was evident for 3 (Resident #10, #453, #242) of 10 residents reviewed for accidents out of 40 sampled residents. Specifically, 1) Resident #453 had an unwitnessed 2nd fall in their room after being left alone and unsupervised by staff directly following the 1st fall, 2) Resident #242 was observed being wheeled backwards with their legs dragging, by a Certified Nursing Assistant (CNA) in a scoot chair, and 3) Resident #10 was observed coughing uncontrollably after being fed by the unit helper.

Inspectors wroteBased on observation, record review and staff interviews during the re-certification and Complaint Investigation survey, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 1 resident reviewed for Personal Funds (Resident #19), out of total sample of 38 residents.

Inspectors wroteBased on record review and staff interviews during the recertification survey, the facility did not ensure that an appropriate surety bond was purchased, or otherwise assurance satisfactory to the Secretary was provided, to assure the security of all personal funds of residents deposited with the facility. Specifically, there is no surety bond in place to assure the residents fund against lost. This was evident for 434 residents who maintained personal funds accounts, current total balance of $356,043.48, (Three hundred fifty-six thousand, forty-three dollars, and forty-eight cents)

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure that Advance Directives (AD) were implemented in a manner that was consistent with resident's wishes. This was evident for 1 (Resident #183) of 41 total sampled residents. Specifically, facility did not ensure Resident #183's AD that included specific instructions not to provide antibiotics or IV were followed.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure the resident's representative was notified of a significant change in resident's condition and a need to alter treatment. This was evident for 1 (Resident #183) of 41 total sampled residents. Specifically, Resident #183's designated representative was not notified of initiation of IV antibiotic therapy and fluids administered for resident who developed an infection.

Inspectors wroteBased on observation, record review, and interview, during the recertification survey, the facility did not ensure that a resident was free from physical restraints. Specifically, a resident had half upper side rail on the left side and half lower side rail on the right side up. This was evident for 1 of 1 resident reviewed for Physical Restraints (Resident #254).

Inspectors wroteBased on record review and interviews conducted during the Recertification and Complaint (NY00319294) survey from 10/02/2023 to 10/11/2023, the facility did not ensure all allegations of abuse, including injuries of unknown origin were reported to the New York State Department of Health (NYSDOH) within two hours. This was evident for 2 (Resident #11 and #20) of 41 total sampled residents.

Inspectors wroteResident #11 Based on record review and interviews conducted during the Recertification and Complaint (NY00319294) survey from 10/02/2023 to 10/11/2023, the facility did not ensure that all allegations of abuse, including injuries of unknown origin, were thoroughly investigated. This was evident for 2 (Resident #11 and #20) of 41 total sampled residents. Specifically, 1) there was no documented evidence an investigation was conducted when Resident #11 reported a fall to their designated representative and complained of headaches and tenderness to their forehead, and 2) there was no documented evidence an investigation was conducted for Resident #20 who had ecchymosis to their forehead.

Inspectors wroteBased on record review and interviews conducted during the recertification survey from 10/2/23 to 10/11/23, the facility did not ensure Minimum Data Set (MDS) 3.0 assessment was completed in a timely manner. This was evident for 1 (Resident #504) of 12 residents reviewed for Resident Assessment. Specifically, the admission MDS assessment was not completed within 14 calendar days from the Assessment Reference (ARD) Date (Resident #504).

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification/ Complaint survey (NY00307350 & NY003188668), the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, No CCP developed and implemented for resident's use of IV Antibiotic for chronic Urinary Tract infection (UTI). This was evident for 1 of the 5 complaint investigations (Resident #71).

Inspectors wroteBased on record review and staff interview conducted during the Recertification survey from 10/2/23 through 10/11/23, the facility did not ensure that a resident Comprehensive Care Plan (CCP) was reviewed and/or revised after each assessment and as needed to reflect the resident's needs. This was evident for 2 out of 41 residents reviewed (Resident # 82 and #289). Specifically:1) CCP related to Activities for Resident #82 were not reviewed and revised quarterly, and 2) the Nutrition CCP for Resident #289 was not reviewed quarterly and after a significant weight loss.

Inspectors wroteBased on record review, observations, and staff interviews during the Recertification survey on 10/2/2023 to 10/11/2023, the facility did not ensure that a resident with limited range of motion (LROM) received appropriate treatment and needed services, and equipment to increase range of motion and/or to prevent further decrease in range of motion and contracture. This was evident for 1(Resident # 321) of 2 residents reviewed for Position, Mobility. Specifically, Resident #321 had changes in the right wrist with negative x-ray findings. The wrist issues continued and were not assessed by an Occupational Therapist (OT)/Physical Therapist (PT). The orthopedist recommended Occupational Therapy (OT)/Physical Therapy (PT), a right wrist brace, and Range of Motion (ROM) as tolerated. Resident #321 never received the OT/PT or right wrist brace as ordered.

Inspectors wroteBased on staff interviews and record review conducted during the Recertification Survey from 10/2/23 to 10/11/23, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for a resident's needs as described in the plan of care. This was evident for 1 (Resident #242) of 10 residents reviewed for accidents out of 40 sampled residents. Specifically, Certified Nursing Aide (CNA) #6 was not competent in the usage of a scoot chair that was assigned to Resident #242.

Inspectors wroteBased on observation, record review and interview during the Recertification/Complaint survey (NY00307350 & NY003188668), the facility did not ensure that resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the resident. Specifically, resident's medication was not crushed prior to administration as per physician's order and the plan of care. This was evident for 1 of the 5 complaint investigations (Resident #71).

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 10/2/2023 to 10/11/2023, the facility did not ensure that foods were served at an appetizing temperature during meal service. This was evident for 1 of 1 resident (Resident #37) reviewed for Food out of total 41 sampled residents. Specifically, hot food items served during lunch meal service were not maintained at palatable and appetizing temperatures.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey 10/02/23 - 10/11/23, the facility did not ensure that food was stored according to professional standards for food safety. This was evident for 1 of 8 unit pantries observed for the Kitchen task (Unit 3 North). Specifically, food items were stored in the pantry refrigerator without being labelled and dated.

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. This was evident for 12 of 12 residents reviewed out of 117 Residents triggered for Resident Assessments. (Resident #s 308, 82, 105, 140, 181, 257, 205, 52, ). Specifically, admission, annual, and quarterly MDS assessments were not submitted and transmitted within 14 calendar days after the assessments were completed.

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (Case # NY 00309085), the facility did not ensure that a resident receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was evident in 1 out of 5 residents sampled (Resident #1). Specifically, on 01/15/2023, at approximately 9:00 AM, Certified Nurse Assistant (CNA) #1 reported to Licensed Practical Nurse (LPN) #1, that Resident #1 had redness to the chest and the clothes in the chest area was wet. LPN #1 observed the redness on Resident #1's chest but did not notify the Registered Nurse Supervisor (RNS) or the Medical Doctor (MD). On 01/15/2023 at 7:00 PM, CNA #2 observed redness with a blister on Resident #1 's chest and reported to LPN #1. [...]

Inspectors wroteBased on observation, interviews and record review conducted during an Abbreviated Survey (NY00320576), the facility failed to protect the resident's right to be free from physical abuse by nursing home staff. This was evident for one out of three residents (Resident #1) sampled for abuse. Specifically, on 07/21/23, an undated video clip provided by the Administrator, showed Licensed Practical Nurse (LPN) #1 roughly grabbed Resident #1's upper right arm. Resident #1 did not sustain any visible injuries.

Inspectors wroteBased on observation and staff interview during an abbreviated survey (NY00321535), the facility did not ensure that infection control practices were maintained. Specifically, on 08/25/2023 at 9:50AM, Certified Nursing Assistant (CNA) #3 entered a positive COVID-19 resident's (Resident #3) room without donning gloves and an isolation gown. CNA #3 exited the positive COVID-19 resident room, then entered a non-COVID-19 room afterward. Additionally, CNA #3 did not perform hand hygiene.

Inspectors wroteBased on observations and interviews during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 3 resident reviewed for Dignity out of a sample of 39 residents. (Resident #300) The finding is: The facility's policy titled Urinary Catheter Change/Care created in 2011, revised on 01/15/19, documented that nursing staff is to ensure that the urinary bag is not touching the floor, and the bag is covered for privacy. Resident #300 was admitted with diagnoses that included Heart Failure, Neurogenic Bladder, and Hypertension. [...]

Inspectors wroteBased on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that residents with limited Range of Motion (ROM) were provided services and treatment to increase ROM and to prevent further decrease in ROM, including the provision of equipment. Specifically, a resident observed with limited range of motion on the right hand was not being provided with interventions to help maintain the joint integrity and prevent a worsening contracture. This was evident for 1 of 4 residents reviewed for Position/Mobility out of a sample of 39 residents. (Resident #151)

Inspectors wroteBased on observation, record reviews, and staff interviews, the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, the facility did not effectively monitor a resident who was at risk for weight loss and weight fluctuations and who sustained a significant weight loss. This was evident for 1 of 4 residents reviewed for Nutrition out of a sample of 39 residents. (Resident # 44) The finding is: The facility policy titled Weight Monitoring Program created on 11/2011, revised on 01/16/20 documented the following: The facility will identify significant, undesirable weight gain\loss and initiate a plan of care to address undesirable weight changes. [...]