Soldiers and Sailors Memorial Hospital Extended Ca

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 10/28/2024 to 11/04/2024, the facility failed to ensure correct installation, use, and maintenance of bed rails (side rails) to ensure there were no entrapment zones (an event in which a resident was caught, trapped, or entangled in the spaces in or about the side rail, mattress, or hospital bed frame), or safety hazards for six (6) (Resident # 17, 29, 52, 71, 106, and 110) of 31 residents reviewed for bed rails. Specifically, Residents #29 and #52 were identified by the facility with bed rails that were loose, and that the residents' head, body, or extremities were small enough to pass between the bed rail bars or through gaps between the mattress and bed rails. Resident #110's bilateral bed rails were not in position as care planned for which created two entrapment zones. [...]

Inspectors wroteBased on observations, interviews and record review conducted during an extended Recertification Survey from 10/28/2024 to 11/04/2024, for six (Residents #17, #29, #52, #71, #106, and #110) of 31 residents reviewed, the facility did not conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment (when a person is trapped in a hospital bed's rails, mattress or frame, preventing them from moving). Specifically, Residents #29, #52, and #110 were observed to have loose bed rails and entrapments zones that exceeded the United States Food and Drug Administration's recommended dimensional limits. For Residents #17, #71, and #106, bed rails were observed to be loose and not properly secured to the bedframes. This is evidenced by, but not limited to, the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an extended Recertification Survey and complaint investigation (NY00354636), for one (Unit One) of three units reviewed, the facility did not ensure that the residents were treated in a dignified manner. Specifically, there were multiple observations of approximately half the residents in the dining room waiting longer than one hour to receive their meals, while the other residents consumed their meals in their presence. Resident #65 was observed yelling out angrily because they had not received their meal. This was evidenced by the following: Review of the facility's meal delivery schedule documented the first lunch meal cart (Unit One) was scheduled to arrive on the unit at 11:46 AM and the second lunch meal cart was scheduled to arrive at 12:25 PM. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an extended Recertification Survey and complaint investigation (NY00354636), for three (Residents #13, #81, and #106) of seven residents, the facility did not ensure that residents who were dependent on staff for assistance received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #81 did not receive assistance with shaving or obtaining a haircut, Resident #106 did not receive assistance with nail care, and Resident #13 did not receive assistance with daily hair grooming. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during an extended Recertification Survey from 10/28/2024 to 11/04/2024, for one (Resident #22) of three residents reviewed, the facility did not ensure that residents with limited mobility received the appropriate services, equipment, and assistance to maintain mobility and prevent complications. Specifically, Resident #22 did not consistently receive a hand device (rolled cloth) for a hand contracture (a shortening of muscles, tendons, and skin) to prevent complications per Occupational Therapy's recommendations and as ordered by the physician. This is evidenced by the following: [...]

Inspectors wroteBased on observations and interviews conducted during an extended Recertification Survey from 10/28/2024 to 11/04/2024, for two (Unit 2 and Unit 3) of four resident units, the facility did not ensure the resident environment remained free of accident hazards. Specifically, there was an electric stove with hot surfaces that was fully operational and accessible to residents.

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed 9/30/22, it was determined that for one (Resident #95) of seven residents reviewed for accidents, the facility did not ensure that the resident's environment was free from accident hazards and each resident received adequate supervision to prevent accidents. Specifically, the facility did not thoroughly investigate an incident involving a serious injury to Resident #95 from falling out of a hoyer (a full body mechanical lift) during a transfer in order to prevent further potential accident. This was evidenced by the following Resident #95 had diagnoses including Huntington's disease, contractures (hardening and shortening of muscles casuing deformities and rigidity) of both upper and lower extremities and major depression. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed 9/30/22, it was determined that the facility did not post, in a manner accessible and understandable to residents and resident representatives, the pertinent contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline number, including a statement that the resident may file a complaint.

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey completed on 9/30/22, it was determined that the facility did not ensure that the daily posting of licensed and unlicensed nursing staff was posted in a prominent place readily accessible to residents and visitors per the regulation. This was evidenced by the following: During observations on 9/26/22 at 10:30 a.m., and again on 9/27/22 at 10:30 a.m., the nurse staffing sheet was posted on a cork board, on the ground floor, outside the staffing coordinators office off the main hall near the Administration offices (not an area where residents and visitors would normally access). In an interview on 9/26/22 at 2:16 p.m., the Staffing Coordinator stated that the staffing sheets used to be posted by the social work office near the entrance to the nursing home. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, completed on 9/30/22, it was determined that for two (Unit 3 and Unit 4) of three units reviewed for medication storage, the facility did not ensure that an accurate reconciliation of all controlled substances was maintained. Specifically, multiple Narcotic Count sheets which included reconciliation of narcotic medications and the signatures of staff members for each shift-to-shift count were not completed to validate the correct controlled substance count was done and was correct. This is evidenced by the following: [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #74) of one resident reviewed for grievances, the facility did not respond promptly to the resident's request to increase their weekly allowance. This is evidenced by the following: Resident #74 has diagnoses including schizophrenia, depression, and chronic obstructive pulmonary disease. The Minimum Data Set Assessment, dated 9/13/19, revealed the resident was cognitively intact. During an interview on 11/19/19 at 11:36 a.m., the resident said the Social Worker (SW) and the Administrator will not let them have more than three dollars a week for allowance. Interviews conducted on 11/22/19 included the following: a. At 9:00 a.m., the SW said the resident has a personal funds account that is managed by the facility. [...]

Inspectors wroteBased on observation, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #24) of one resident reviewed for tube feedings, the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, daily tube feedings and water flushes where not monitored to ensure physician orders were followed. This is evidenced by the following: Resident #24 had diagnoses including cerebral palsy, severe protein calorie malnutrition, dysphagia (difficulty swallowing), and disorders of electrolyte and fluid balance. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for nutrition, the facility did not ensure the medical care of each resident was supervised by a physician. Specifically, the physician did not evaluate Resident 85's significant weight loss. This is evidenced by the following: Resident #85 has diagnoses including a recent amputation of the left great toe due to osteomyelitis (infection in the bone), Parkinson's disease, morbid obesity, and a history of dependent edema and diarrhea. The Minimum Data Set Assessment, dated 10/11/19, revealed the resident had severely impaired cognition, significant weight loss, and was not on a physician prescribed weight-loss regime. Physician orders, dated 11/15/19, included a lactose free diet with mechanical soft texture and to obtain weights monthly. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #79 and #113) of eight residents reviewed for unnecessary medications, the physician did not act upon or respond to pharmacy recommendations in a timely manner. Specifically, recommendations related to gradual dose reduction of psychotropic medications were not addressed. This is evidenced by the following: The facility policy, Drug/Medication Regimen Review Policy and Pharmacy Consultant, effective January 2018, revealed that the drug regime review findings will reflect information to assist the medical provider in ordering the most effective medication regime for the resident. The pharmacist will notify the attending physician/licensed practitioner, Director of Nursing (DON), and Medical Director of any irregularity within 24 to 72 hours of review. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #72) of seven residents reviewed for unnecessary medications, the facility did not ensure orders for an as needed psychotropic medications were limited to 14 days. This is evidenced by the following: Resident #72 was admitted to the facility on [DATE] and had diagnoses including Huntington's Disease and dementia with behavioral disturbance. The Minimum Data Set Assessment, dated 10/4/19, revealed that the resident was cognitively intact. Physician orders, dated 10/28/19, included Haldol inject 2 milligrams intramuscularly every 24 hours as needed for severe agitation and physical aggression. The medication was given as a one-time dose on 9/5/19 and then ordered indefinitely on 9/11/19. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two of five residents observed for medication administration, the facility did not ensure that drugs and biologicals used were labeled in accordance with currently accepted professional principles. Specifically, Resident #90 and Resident #2 were prescribed an over-the-counter calcium supplement that was prepared and administered from a container that was not the original manufacturer's bulk container. This is evidenced by the following: The facility policy and procedure, Medication Administration Protocols, dated December 2009, included that medications are to be prepared and administered in accordance with accepted standards and a medication with questionable contents should be returned to Pharmacy. 1. [...]