Schoellkopf Health Center

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 08/22/2025, the facility did not maintain a pest- free environment and an effective pest control program. Specifically, there was of evidence of rodents (dead rodents, rodent droppings) and complaints of rodent sightings in resident rooms.

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 08/22/2025, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #45) of one (1) resident reviewed. Specifically, Resident #45 was observed with medication in their room. Self-administration was determined through interviews despite the lack of an assessment to determine the resident's ability to safely do so. The finding is: The policy titled Self-Administration of Medications undated, documented residents have the right to self-administer medications if they choose and the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 8/22/2025, the facility did not provide services consistent with professional standards of quality for one (1) (Resident #119) of one (1) resident reviewed for change in condition. Specifically, Resident #119, who had a recent history of seizures, did not receive Levetiracetam (anti-seizure/anti-convulsant medication) as ordered by the physician and the physician was not notified of the omission. The finding is:The policy titled Unavailable Medication last revised 09/27/2016 documented that residents would receive necessary medications as ordered by the physician, if medications were not available the physician would be notified and would adjust medications accordingly. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard Survey completed on 08/22/2025, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (one) (Resident #126) of 2 (two) residents who were reviewed for activities of daily living. Specifically, Resident #126 was not assisted/provided with nail care and was observed with dirty long jagged fingernails. The finding is:The undated policy and procedure titled Nail Care documented that nails are observed daily by staff providing direct care. Nails are to be inspected weekly by a nurse and CNA on bath day and trimmed as indicated. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 08/22/2025, the facility did not ensure that each resident received proper treatment to maintain vision for one (1) (Resident #30) of one (1) resident reviewed. Specifically, Resident #30's optometrist appointment on 06/06/2025 required an outside consult visit that was not scheduled. Additionally, Resident #30 complained that they were unable to see well with their current eyeglass prescription. The finding is:The policy titled Dental, Hearing, and Vision Evaluations, dated 03/2011, documented that the facility will assure residents can function at their highest practical level of oral health, vision, and hearing. The policy states to assess functional status on admission, quarterly, as per the MDS schedule, and when concerns are reported. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Standard survey completed on 08/22/2025, the facility did not ensure correct installation, use, and maintenance of bed rails including assessing the resident for risk of entrapment for one (1) (Resident #12) of one (1) resident reviewed. Specifically, Resident #12's bed cane bedrail was loose, not secured to the bedframe, and there was no documentation of routine inspections. In addition, there was no care plan developed for use of the bed cane. The finding is:The policy titled Mobility Assist Rails or other Assist Devices revised 06/22/2023, documented therapy screens each resident to determine bed mobility and what, if any, mobility assist device is warranted. The Comprehensive Care Plan and Closet Care Plan will indicate what mobility assist devices are to be used. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 08/22/2025, the facility did not establish and maintain an effective Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections one (1) (Resident #30) of four (4) residents reviewed. Specifically, the resident had a draining Stage 3 pressure ulcer (a full-thickness skin loss that extends into the subcutaneous tissue but does not involve muscle, tendon, or bone) and was not placed on enhanced barrier precautions (infection control strategy designed to the reduce transmission of multidrug resistant organisms in nursing homes, involving staff to wear a gown and gloves during high contact care). [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 08/22/2025, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months for three (3) (Certified Nurse Aides #3, #4, and #5) of five (5) Certified Nurse Aide files reviewed. Specifically, there was no evidence Certified Nurse Aides #3, #4, and #5 who had worked at the facility more than 12 months had performance reviews completed at least once every 12 months.

Inspectors wroteBased on observation, interview, and record review during a Complaint Investigation (Complaint #NY00370870), the facility did not maintain an effective pest control program for two (second and third floors) of four resident use floors and the Main Kitchen. Issues included observations of evidence of rodents (dead rodents and rodent droppings) and complaints of rodent sightings in resident rooms. Additionally, on the exterior of the building, used kitchen grease was stored in a manner that had the potential to attract rodents. Residents A, B, C, D, E, F, G, H, I, J, and K were involved.

Inspectors wroteBased on observation, interview, and record review completed during a Complaint (#NY00339959) investigation, the facility did not ensure that each resident received adequate treatment and services for a Foley catheter (tube that drains urine) for one (Resident #2) of two residents reviewed for catheter care. Specifically, staff did not keep the urine collection bag below the level of Resident #2's bladder during care and the resident had a history of frequent urinary tract infections. The finding is: Review of the policy titled Catheter Care, Urinary obtained from the Med-Pass Nursing Services Policy and Procedure Manual for Long-Term Care dated 2001, provided by the Director of Nursing, revealed staff are required to always position the drainage bag lower than the bladder to prevent urine flowing back into the urinary bladder. [...]

Inspectors wroteBased on observation, interview, and record review completed during a Complaint (# NY00339959) investigation, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment during care while emptying a urine drainage bag. The finding is: [...]

Inspectors wroteBased on observation, interview, and record review during a Complaint Investigation (Complaint #NY00351197), the facility did not maintain an effective pest control program for three (First, Second, and Third Floors) of four resident use floors and the Main Kitchen. Issues included observations of evidence of rodents (droppings) and complaints of rodent sightings in resident rooms. Additionally, on the exterior of the building, garbage and used kitchen grease were stored in a manner that had the potential to attract rodents. Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P were involved.

Inspectors wroteBased on interview and record review during the Standard survey completed on 8/22/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified seven (three Housekeeping Attendants, one Diet Technician, one Registered Nurse, one Social Worker, and one Activities Leader) of eleven employees that worked in the facility and were subject to the New York State (NYS) Nurse Aide Registry, had been screened through the NYS Nurse Aide Registry prior to their employment. The finding is: Per Part 415 - Nursing Homes - Minimum Standards: [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure maintenance of an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for one (Resident #15) of two residents reviewed for infection control practices during personal care and one of one facility water management system. Specifically, staff did not perform adequate hand hygiene and change gloves after touching Resident #15's colostomy (an artificial connection of the bowel to the skin surface) bag and urine collection bag, then proceeded to wash the resident's face and touch items in the environment. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for one (Resident #29) of one resident reviewed. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #29's wishes. The finding is: The policy and procedure titled Resident Choice and Preference revised 12/2016 documented each resident's personal preferences would be honored to maintain quality of life, dignity and maintain a comfortable living environment. Staff will inquire with residents and/or their representative as to residents' personal preferences regarding daily routine such as frequency of showers/baths. [...]

Inspectors wroteBased on interview and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON), and that these reports were acted upon for one (Resident #85) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not identify the continued use of a PRN (as needed) Ativan (a psychotropic antianxiety medication) for two months and report the irregularity. The finding is: The policy and procedure (P&P) titled Use of Psychoactive Medications dated 12/2021 documented each resident's drug regimen must be free from unnecessary drugs. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure that PRN (as needed) orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for one (Resident #85) of five residents reviewed for unnecessary medications. Specifically, PRN Ativan (a psychotropic antianxiety medication) was ordered longer than 14 days and there was no documented provider rationale to extend the order or the duration of the order. The finding is: [...]

Inspectors wroteBased on interviews and record review conducted during a Complaint investigation (Complaint NY#00278522) during the Standard survey completed on 11/23/21, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #1) of two residents reviewed for abuse. Specifically, there was an incomplete investigation completed by the facility to rule out abuse, neglect or mistreatment for a reported allegation that Resident #25 was handled roughly by staff. The finding is: The facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, misappropriation revised 10/19, documented reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) were promptly and thoroughly investigated. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 11/23/21 the facility did not ensure that residents who use psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #35) of five residents reviewed for unnecessary medications. Specifically, the resident received Seroquel (antipsychotic medication) 50 milligrams (mg) every 12 hours since 1/13/2020 without GDR attempts or a documented reason why a GDR was clinically contraindicated. Also, there was lack of documented behaviors for the ongoing use of the antipsychotic medication. The finding is: [...]