Schervier Pavilion

Inspectors wroteBased on observations, record review, and interviews conducted during the Abbreviated Survey (NY00360889), the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice for 1 (Residents #1) of 3 residents reviewed medication storage. Specifically, during surveyor rounds in Resident #1's room, physicians ordered medications / treatments were observed on the resident's bedside table, nightstand, and the windowsill that included deep sea nasal spray, nystatin topical powder, latanoprost eye drops, refresh tears, and Preparation Hemmorrhoidal cream. There was no documented evidence that the resident can self-administer these medications / treatments.

Inspectors wroteBased on record review and interviews during a recertification survey from 10/22/24 to 10/29/24, the facility did not ensure they had an Infection Preventionist (IP) who was responsible for the facility's Infection Control Program. Specifically, the facility failed to ensure that the Infection Preventionist worked at least part-time in the facility.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification survey from 10/22/2024 through 10/29/2024, the facility did not ensure 2 of 4 residents (Residents #3 and #39) reviewed for pressure ulcers, received care and services to promote healing. Specifically, 1) Resident #3 had a facility acquired Stage 2 pressure ulcer, and 2) Resident #39's pressure ulcer was not consistently and adequately assessed with clear description of size, location, and characteristics.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey between 10/22/2024 and 10/29/24, the facility did not ensure infection control practices and procedures were maintained. This was evident 2 of 2 units during review of enhanced barrier precautions and 2 of 19 residents total sampled residents. Specifically, 1) Resident #44's oxygen tubing was observed soiled and not dated or changed in accordance with professional standards of practice, 2) Resident #58 was observed with their Foley catheter (tube to drain urine from the bladder) tubing and wound vacuum (treatment that uses suction to heal wounds) tubing touching the floor, and 3) 2 of the 5 residents observed for pressure ulcer/injury (Residents #3 and Resident #58) had a Stage 2 pressure ulcers and enhanced barrier precautions were not in place.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 10/22/24 to 10/29/24, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 2 of 5 residents (Residents #14 and #52) reviewed for unnecessary medication and 1 of 1 resident ( resident #44) reviewed for Respiratory therapy. Specifically, 1) Resident #14 did not have a care plan in place for anticoagulant and diuretic use. 2) Resident #52 did not have a plan of care in place for long term antibiotic use. 3) Resident #44 did not have a care plan in place for respiratory care and the use of oxygen.

Inspectors wroteBased on interview and record reviews conducted during the recertification survey from 10/22/2024 to 10/29/2024, the facility did not ensure the attending physician documented in the resident's medical record that the identified drug regimen review irregularity was reviewed, and any action taken to address it. This was evident for 1 (Resident #39) of 5 residents reviewed for unnecessary medication. Specifically, there was no documented evidence the Medical Director reviewed and responded to Resident #39's Drug Regimen Reviews dated 8/13/2024 and 9/3/2024.

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 10/22/24 to 10/29/24, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, 1. the walk-in refrigerator contained expired food products and a product that was to labeled to remain frozen, 2. the walk-in freezer contained unlabeled food products and one item with freezer burn, and 3. the dry storage pantry contained an expired and undated food product. The Facility policy Food and Supply Storage, revised 1/24, stated foods past the use-by,sell-by, best-by, enjoy-by , date should be discarded. Commercially produced foods may be held frozen util the manufacturer's expiration date, or for 3 months if no expiration date on the package. Once the packaging: around the food has been opened, food must be used within 3 months.

Inspectors wroteBased on interview and record reviews conducted during the recertification survey from 10/22/2024 to 10/29/2024, the facility did not ensure medical director was responsible for the coordination of medical care in the facility. This was evident during review of Pressure Ulcer Care and Unnecessary Medication. Specifically, the Medical Director stated they were overwhelmed and not provided with requested assistance to address the responsibilities and requirements of their position in the facility.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification Survey and Abbreviated Survey (#NY00299932) completed 10/25/22 to 10/31/22, the facility did not ensure that residents were treated with respect, dignity, and care in a manner that promotes maintenance or enhancement of their quality of life and recognizes a residents individuality. This was evident for 1 of 1 (#27) residents reviewed for abuse. Specifically, a Certified Nursing Assistant (CNA) did not honor resident #27 preference to wear pants to bed as opposed to a hospital gown. The Findings Are: The facility Policy and Procedure titled Quality of Life-Dignity dated 10/2018 documented residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. [...]

Inspectors wroteBased on interviews and record review during a recertification and abbreviated survey (Complaints # NY00300634 and NY00300356) from 10/25/2022-10/31/2022, the facility did not implement a comprehensive person-centered care plan for 2 of 3 residents (Residents #23 and #41) reviewed for Neglect. Specifically, Resident #23 required 2 staff present for all cares however the Certified Nursing Assistant (C.N.A.) provided care without another staff member present, and Resident #41 required two-person assistance for transfers, however the resident was transferred with one person assistance.

Inspectors wroteBased on record review and staff interview during a Recertification Survey and Abbreviated Survey (# 00298673 and #00300356) onducted from 10/25/2022- 10/31/2022, the facility did not ensure that all residents received the necessary care and services to attain and maintain the resident's highest practicable well-being in accordance with professional standards of practice and the comprehensive person-centered care plan for two of three residents (R#24 and #41 ) reviewed for Neglect. Specifically, 1. Resident #24 did not receive Risperdal 0.5mg at bedtime (medication to treat psychosis) as per physician order on (6/23/22, 6/24/22, 6/25/22, 6/26/22, 6/27/22 and 6/28/22). 2. [...]

Inspectors wroteBased on observation, interview and record review conducted during the Recertification and Abbreviated Survey (#NY00299932) completed 10/25/22 to 10/31/22, the facility did not ensure a resident diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 of 1 (resident #27) reviewed for Abuse. Specifically, the facility did not ensure that resident care reflected the resident's goals and maximized the resident's dignity and autonomy. The facility did not thoroughly develop care plan interventions to ensure resident #27 dementia care needs were met.

Inspectors wrote2. Resident #99 was admitted to the facility with diagnoses including Renal Insufficiency, Diabetes and Seizure Disorder. The 4/19/19 MDS assessment revealed that the resident was cognitively intact, required extensive assistance of two persons for toileting and hygiene, and had an indwelling catheter. The resident had no pressure ulcers/injuries and no other wounds or skin problems. The 5/2/19 MDS included a diagnosis of Retention of Urine. Review of the current physician's orders revealed the following: - 4/25/19 urology consult; - 4/26/19 ultrasound of kidney and bladder, provide catheter care every shift, change Foley catheter every month size 16 french, change Foley bag/tubing every week on Thursday; - 4/27/19 post void bladder scan every shift due to voiding trial- contact MD if results are above 200 cc and Foley catheter care every shift. [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure that the plan of care for 1 of 2 residents (Resident #4) reviewed for bladder incontinence was revised to address the change in the level of continence. Specifically, after the resident's assessments showed that the resident had developed urinary incontinence, the resident's plan of care was not revised to address this problem.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 1 of 4 residents (Resident #10) reviewed for hospitalization and 1 of 3 residents (Resident #99) reviewed for urinary catheter or urinary tract infection was provided the necessary care to maintain the highest practicable physical well-being. Specifically, 1. Resident #10, who was on palliative care, experienced significant ongoing decline in food and fluid intake that was not promptly recognized and addressed to prevent dehydration/hypernatremia and possible fecal impaction. This necessitated the need for the resident to be hospitalized on [DATE], and 2. Resident #99 who had an indwelling catheter did not receive a timely urology consult as per physician orders.

Inspectors wroteBased on interview and record review conducted during the most recent recertification survey, the facility did not ensure that 2 of 2 residents (Residents #4 and #70) reviewed for bladder incontinence was provided the necessary care to restore continence to the extent possible. Specifically, Residents #4 and #70 experienced a decline in their level of urinary continence after admission to the facility and the nursing staff did not ensure that attempts were made to decrease the frequency of the episodes of incontinence and if possible restore normal bladder function.

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that written notification of hospital transfers was provided to the families/resident representatives and the ombudsman when residents were transferred to the hospital. This was evident for four of four residents reviewed for hospitalization (Residents #10, #27, #78 and #106).