Schofield Residence

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/9/25, 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 #66) of one (1) resident reviewed. Specifically, Resident #66 was observed with medications in their room, and they self-administered the medications without being evaluated as to whether they could safely do so. The finding is: The policy and procedure titled Resident Self-Medication/Self-Treatment Instructions dated 8/2012 documented at the request of the resident to self-medicate, complete an assessment to determine if the resident has the ability to self-administer. [...]

Inspectors wroteBased on interview and record review conducted during a Compliant investigation (#NY00354229) during the Standard survey completed on 4/9/25, the facility did not ensure that all residents comprehensive person-centered care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (1) (Resident #8) of four (4) residents reviewed. Specifically, the resident was not provided with a maximal assist by two staff members for bed mobility as care planned. The finding is: The facility provided document titled Certified Nurse Aide Job Description dated 1/2021 the Certified Nurse Aide was responsible for knowing and following resident's plan of care via verbal report, door cards and review of care plans. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 4/9/25, the facility did not ensure that each resident who was unable to carry out activities of daily living received services to maintain grooming and personal hygiene for one (1) (Resident #26) of five (5) residents reviewed for activities of daily living. Specifically, Resident #26 was observed on multiple days with dark brown debris under their fingernails on both hands and the resident was observed eating with their hands. The finding is: The policy titled Resident hygiene dated 2/2022, documented the purpose of the facility was to maintain cleanliness and comfort. Residents received sponge baths with morning care and evening care in bed, bathroom, or at resident's bedside. [...]

Inspectors wroteBased on observation, interview. record review, conducted during the Standard survey completed on 4/9/25, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive centered care plan for one (1) (Resident #52) of one (1) resident reviewed. Specifically, a wound treatment was initiated without a physicians order, and lack there was a delay in assessment of the wound. The finding is: The policy titled Skin Care dated 10/2017 documented the purpose was to identify altered skin integrity, facilitate adequate assessment of skin integrity, determine need for preventative/therapeutic intervention, and ensure proper treatment was provided to residents with altered skin. Staff would remain alert to skin changes on a daily basis and report areas of concern immediately to ensure prompt intervention. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 4/9/2025, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for one (1) (Resident #60) of five (5) residents reviewed for psychotropic medication use. Specifically, there was no gradual dose reduction attempted for a resident started on an antidepressant medication and there was no documented evidence that a gradual dose reduction was contraindicated. The finding is: The policy and procedure titled Tapering of a Medication Dose/Gradual Dose Reduction-GDR, dated 11/2017 documented the purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. [...]

Inspectors wroteBased on interview and record review completed during a complaint investigation (Complaint #NY00317688), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two (Residents #1 and #4) of three residents reviewed for accidents. Specifically, Resident #1 and Resident #4 both had dementia with wandering behavior, were not accurately assessed and care planned for wandering/elopement, and subsequently eloped through the front door of the facility.

Inspectors wroteBased on interview and record review during a complaint investigation (#NY00285020) on a Standard survey completed on 7/12/23, the facility did not immediately inform the resident's representative of a change in their physical/ mental status and a decision to transfer the resident from the facility to the hospital for one (Resident #1) of three residents reviewed for notification of change. Specifically, Resident #1 was noted to have a change in condition on the morning of 10/16/21 and was transferred to the hospital and the health care representative was not notified.

Inspectors wroteBased on observation, interview and record review conducted during a Standard survey completed on 7/12/23, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing for one (Resident #41) of two residents reviewed. Specifically, Resident #41 did not receive a pressure ulcer treatment as ordered by physician. The finding is: The policy and procedure (P&P) titled Clean Dressing Techniques dated January 2004 documented to check the physician's order for specific wound care and medication order. 1. Resident #41 was admitted to the facility with diagnosis of osteomyelitis (infection of the bone) of sacral region, pressure-induced deep tissue damage of sacral region, and type 2 diabetes. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 7/12/2023, the facility did not ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice for one (Resident #76) of one resident reviewed for respiratory care. Specifically, Resident #76 did not receive oxygen (O2) at a flow rate of 2 liters via nasal canula (NC) as ordered by the physician. The finding is: The policy and procedure (P&P) titled Oxygen Administration Of, revised 11/2015, documented oxygen may be administered to a resident, with the permission of the physician, using either of the following items of equipment: Oxygen concentrator, or liquid cylinder. 1. Resident #76 had diagnoses that included pneumonia, chronic respiratory failure, and hypertension (HTN). [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 7/12/23, the facility did not maintain 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 two (Residents #67 and 132) of two residents reviewed for infection control practices during personal care. Specifically, there was a lack of proper hand hygiene after providing incontinence care (Resident #67) and staff emptied the water basin twice during incontinent care (Resident #132) into a shared bathroom sink, which is used by the roommate.

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 7/12/23, the facility did not post, on a daily basis the staff total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facilities posted Daily Nursing Staff form did not include the total Actual Worked number of licensed and unlicensed nursing staff directly responsible for resident care facility and Actual Hours for each category for each shift. The finding is: During observations on 7/6/23 at 3:45 PM, 7/7/23 at 9:04 AM, 7/10/23 at 12:24 PM and 7/11/23 at 10:30 AM the Daily Nursing Staff Form documented the number of scheduled nursing staff by titles for each shift: [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 9/21/21, the facility did not ensure that residents had a right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. Specifically, the facility was not allowing visitations to all residents on the weekend days (Saturday and Sunday). This involved Residents #11, 26, 47 and 68. The finding is: [...]

Inspectors wroteBased on interview and record review during a Standard survey completed on 9/22/21, 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 three (Employee #2, Employee #3, and Employee #4) of five employees reviewed for background checks who worked in the facility and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to employment. The finding is: Per Part 415 - Nursing Homes - Minimum Standards: Nursing home shall develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of residents and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 9/22/21, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #43) of three residents reviewed for ADL's. Specifically, a resident who was dependent on staff for toileting was not provided with timely incontinence care. Additionally, a care plan was not developed to address the resident's incontinence. The finding is: 1. Resident #43 had diagnoses including sacral pressure ulcer, hypothyroidism, and weakness. Review of the Minimum Data Set (MDS-resident assessment tool) dated 8/3/21 documented Resident #43 needed extensive assistance for toileting, was occasionally incontinent of urine, and was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 9/22/21, the facility did not ensure each resident's drug regimen is free from unnecessary drugs, and residents do not receive psychotropic drugs pursuant to a PRN (as needed) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days, 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. An unnecessary drug includes drugs used without adequate indications and without adequate monitoring for one (Resident #69) of three residents reviewed for psychotropic medications. [...]