Seton Health at Schuyler Ridge Residential H C

Inspectors wroteBased on record review and interview during the recertification and abbreviated survey (Case #s, NY00319900 and NY00344983), the facility did not ensure each resident's right to be free from neglect for 2 (Resident #s 53 and 112) of 7 residents reviewed for abuse/neglect. Specifically, (a.) for Resident #53, the resident had a fall out of bed with injuries and staff did not follow the care plan by placing the fall mats next to the resident's bed. Specifically, (b.) Resident #112 had a fall on 5/31/2024 and complained of back pain post fall and X-ray was ordered . Assistant Director of Nursing #2 reviewed the radiology report, which verified the resident had a thoracic (back) #12 vertebrae fracture (bone break), but documented that there was no fracture. This delayed care necessary to avoid the resident's pain. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification and abbreviated survey (case #'s NY00319900, NY00349063, and NY00372837), the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 8 (Residents #s 20, 22, 46, 57, 101, 109, 113, and,114) of 24 residents reviewed for Care Plans. Specifically, (a.) for Resident #20, oxygen administration was not implemented according to the resident's care plan; (b.) for Resident #22, the right blue [NAME] posey splint was not consistently applied as indicated in the Resident's Comprehensive Care Plan; [...]

Inspectors wroteBased on observations, interviews, and record review during the recertification survey, the facility did not ensure dependent residents was provided with appropriate treatment and services to maintain or improve their language and communication for 2 (Resident #s 13 and 74) of 5 residents reviewed. Specifically, (a.) for Resident #13, nursing staff did not ensure there was consistent access to their communication dry/erase board so staff could use it to write down what they wanted to express as Resident #13 had hearing loss, and for (b.) Resident #74, who was nonverbal, communication board was not used to allow resident to express their wants and needs. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were following professional standards of practice, for 3 (Resident #s 20, 60, and 75) of 3 residents reviewed for oxygen administration. Specifically, (a) supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b) supplemental oxygen was not provided as ordered by the physician. This is evidenced by: A review of the facility policy titled Oxygen Administration dated 1/2019 documented the facility was to provide oxygen by oxygen mask/cannula to residents with deficiencies or abnormalities of pulmonary function, to prevent or reverse hypoxia, and improve tissue oxygenation. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 3 ([NAME] Unit Cart A, [NAME] Hills Unit Carts A and B) of 3 medication carts, and 1 ([NAME] Hills Side B) of 3 medication rooms reviewed. Specifically, (a.) 2 open bottles of ear drops had no open dates and or expiration dates (b.) 1 bottle of ear drops had expired; (C.) 3 bottles of open eye drops had expired; (d.) 4 inhalers had no expiration dates; (e.) 2 vials of insulin had no open date and or expiration dates and; (f.) 1 bottle of purified protein derivative (PPD) had no open and or expiration date. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility failed to ensure each resident received drinks, including water and other liquids, consistent with resident needs and preferences and sufficient to maintain resident hydration. Specifically, Residents on Saratoga Hills unit were not offered beverages of their preference during a lunch meal observation. This is evidenced by: The facility policy Hydration effective date 10/15/2021 documented it is the policy to provide residents with sufficient fluids to maintain adequate hydration and health, including fluids served at mealtimes and between meals, offered consistent with care plan, preferences, and choice. [...]

Inspectors wroteBased on observation and interview during the recertification survey, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for 3 of 5 resident unit kitchenettes and the main kitchen. Specifically, walls were not in good repair and microwave ovens, refrigerators, and tables were not clean. This is evidenced by: During observations on 2/25/2025 at 10:21 AM: • 10 wall coving tiles were broken in the dishwashing machine area. • Seven wall coving tiles were broken in the main kitchen. • The microwave ovens, the refrigerators including door gasket, and the underside of dining tables were soiled with food particles on the [NAME] kitchenette, [NAME] A kitchenette, and [NAME] B kitchenette. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey, the facility did not ensure an infection control prevention and control program was implemented to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #s 57 and #77) of 5 residents. Specifically, (a.) for Resident #57, staff did not perform proper doffing and donning of personal protective equipment between care of residents; and (b.) for Resident #77, the staff did not perform proper infection control procedures while conducting wound care. This is evidenced by: A review of the 2025 Infection Prevention and Control Plan documented that the plan's purpose is to provide an effective system-wide program for the surveillance, prevention, and control of infection and infectious diseases. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure each resident was treated in a dignified manner for 4 (Resident #'s 46, 57, 59, and 74) of 24 residents reviewed. Specifically, (a.) for Resident #'s 46, 57, and 59, stated staff did not knock on their doors prior to entering their rooms. Specifically, (b.) for Resident #59, staff distributed meals to all residents at each table before serving residents eating in their rooms; and (c.) Certified Nurse Aide #13 delayed assisting the resident with their meal while using their personal phone in the dining room for over 20 minutes; and (d.) for Resident #74's personal items were disturbed by Resident #44. This is evidenced by: Finding #1: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure assessments were coordinated with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid for 1(Resident #78) of 24 residents reviewed. Specifically, Resident #78 with a new diagnosis of a serious mental disorder was not referred for a PASARR Level II Evaluation. This is evidenced by: The facility's Policy and Procedure titled, Pre-admission Screening and Resident Review (PASSAR), effective 9/10/2022, documented All individuals seeking admission will undergo a PASRR Level I screening prior to admission to determine if they have a mental illness or intellectual disability. Screening would be conducted in accordance with New York State Department of Health guidelines and Centers for Medicare and Medicaid Services regulations. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised by interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for 1 (Resident #20) of 3 residents reviewed. Specifically, for Resident #20, the Comprehensive Care Plan for Respiratory Therapy was not reviewed and revised to include changes in the resident's oxygen liter flow to reflect the medical order. This is evidenced by: A review of the facility policy titled Oxygen Administration dated 01/2019 documented the facility was to provide oxygen by oxygen mask/cannula to residents with deficiencies or abnormalities of pulmonary function, to prevent or reverse hypoxia, and improve tissue oxygenation. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, personal and oral hygiene for 1 (Resident #74) of 24 residents reviewed. Specifically, Resident #74 was observed in bed, without morning care provided on two separate dates, 2/28/2025 and 3/03/2025 at 11:10 AM and 10:20 AM respectively, while other residents on the unit were attending meals and activities. This is evidenced by: The facility's Policy and Procedure titled Resident's Rights, effective 5/28/2024, documented that the resident had the right to be dressed in clothing, accessories, or cosmetics that were permitted for other residents. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey, the facility did not ensure each resident had an environment that was as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 (Resident #11) of 10 residents reviewed for accident hazards. Specifically, Resident #11 was left alone while in the bathroom despite signs posted in their room saying not to leave resident alone in the bathroom, care plan, and [NAME] (Certified Nurse Aide resident care card) documented resident was not to be left alone in the bathroom. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure that a resident received routine and 24 -hour emergency dental care for 1 (Resident #76) of 1 resident reviewed for dental services. Specifically, Resident #76 reported having pain on their lower gum making it difficult for them to chew their food on 2/25/2025. Resident #76 was not assisted in obtaining emergency dental care and had not been seen by the dentist since 3/15/2023. This is evidenced by: Resident #76 was admitted to the facility with diagnoses of cerebral infarction (a medical condition where blood flow to the brain is interrupted, causing brain tissue to die), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and epilepsy (a brain disease where nerve cells do not signal properly that causes seizures). [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case #s NY00367938 and NY00372837), the facility did not ensure they immediately consulted with the resident's physician and notify the residents representative when there was a significant change in condition for 2 (Residents #s #101 and #114) of 2 residents reviewed for significant changes. Specifically, (a.) for Resident #101 there was no notification to the physician, that the resident acquired a new moisture associated skin damage condition that required treatment. (b.) for Resident #114's representative was not notified on 6/25/2024 when the resident developed an open wound on their abdomen. This is evidenced by: A document titled Change in Condition (Notification of Resident, Physician, and Designated Representative) dated 02/2020 documented the following: [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case # NY00367938), the facility did not ensure allegations of abuse and neglect were immediately reported but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Agency, for 1 (Resident #101) of 9 residents reviewed for abuse, neglect, and mistreatment. Specifically, Resident #101 reported an allegation of verbal abuse and rough treatment by Certified Nurse Aide #5 to four facility staff on 1/03/2025. It was not reported to the New York State Department of Health until 1/06/2025. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during a recertification and abbreviated survey (Case #NY00367938), the facility did not ensure that all allegations of abuse were thoroughly investigated for 1 (Resident #101) of 9 residents reviewed for abuse and neglect. Specifically, Resident #101 reported an allegation of verbal abuse and rough treatment during care given on a night shift between 1/02/2025 and 1/03/2025 by Certified Nurse Aide #5 to four facility staff on 1/03/2025. The facility initiated an investigation on 1/06/2025, and did not interview Registered Nurse #5 who was in the facility at the time of the incident. This is evidenced by: The facility's policy and procedure titled Abuse and Neglect, dated 6/27/2023, documented the following: [...]

Inspectors wroteBased on record review and interview during the recertification survey and an abbreviated survey (Case #NY00344983), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #s 76 and 112) of 2 residents reviewed. Specifically, for (a.)Resident #76, Certified Nurse Aide provided a saltwater rinse for residents. sore gums without medical order. (b.) for Resident #112, Assistant Director of Nursing #2 did not notify the facility health care practitioner after reviewing the radiology report verifying that the resident had a thoracic #12 vertebrae fracture. This is evidenced by: A review of the policy titled Change in Condition dated 2/2020 documented that the attending physician would be notified immediately as indicated by the significance of the change and need for medical intervention. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated survey (Case # NY00344983), the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 2 (Resident #s 20 and 112) of 2 residents reviewed. Specifically, for Resident #20, staff observed and verified that the resident's oxygen flow rate was 2 liters per minute when the concentrator was set at 4 liters per minute. Specifically, for Resident #112, the medical records documented by the nursing staff that the resident did not have a fracture from a fall and the radiology report documented that the resident did have a fracture from a fall on 5/31/2024 at 5:38 PM. This is evidenced by: [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure two (2) (Resident #'s 72 and 117) of three (3) residents reviewed for hospitalization, received written notice of discharge. Specifically, the residents and their representatives did not receive written notice of discharge to a hospital. This evidenced by: Resident #72: The resident was admitted to the facility with diagnosis of left hip fracture, Alzheimer's disease and dementia. The Minimum Data Asset (MDS- an assessment tool) dated 12/18/19, documented the resident had severe cognitive impairment. A progress note dated 12/8/19 at 12:03 PM, documented the resident was sent to the emergency room for evaluation related to change in mental status and to rule out sepsis. [...]

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure written notice was provided to the resident's representative of the bed hold and return policy for two (2) (Resident #'s 72 and 117) of three (3) residents reviewed for hospitalization. Specifically, there was no documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Resident #72: The resident was admitted to the facility with diagnoses of left hip fracture, Alzheimer's disease and dementia. The Minimum Data Asset (MDS- an assessment tool) dated 12/18/19, documented the resident had severe cognitive impairment. [...]