St. Ann's Community

Inspectors wroteBased on interviews and record review conducted during the Abbreviated Survey (NY00345886) for one (1) (Resident #3) of (3) three residents reviewed for pressure ulcers (injury), the facility failed to ensure the resident received the necessary care, treatment and services consistent with professional standards of practice to promote the healing of a pressure ulcer, prevent infection, and prevent new ulcers from developing (unless the individual's clinical condition demonstrates they were unavoidable). Specifically, Resident #3, who was assessed to be at risk for pressure ulcer development, was identified as having an open area on their left buttocks on 06/07/2024. A wound consult was ordered, but the medical team was not notified of the open area for five (5) days and there were no medical treatments ordered. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, for one (Resident #330) of one resident reviewed, the facility did not provide services to meet professional standards of quality. Specifically, multiple doses of a medication were left unattended at the resident's bedside with no assessment completed to ensure the safety of. This is evidenced by the following: The facility policy, Patients on Self-Medication, dated 6/6/20, documented that medical and nursing staff determine if an elder is safe to self-administer medications using nursing admission assessment to identify if patient self-medicated at home. Medical staff orders self-medications based on this information. Elders on self-medication will have a secure area provided. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, for one (Resident #78) of two residents reviewed, the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infections for a resident with an indwelling urinary catheter (tube inserted into the bladder to drain urine). Specifically, Resident #78 was observed on several occasions with their uncovered urinary drainage bag (bag used to collect urine through the indwelling urinary catheter) lying directly on the floor including an observation of their urinary drainage bag resting on a dining room table above the level of their bladder with several staff within view. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, for two (Residents #62 and #238) of four residents reviewed, the facility did not establish and 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 disease and infections. Specifically, there was a lack of appropriate hand hygiene (washing hands or using alcohol-based hand sanitizer) and lack of appropriate glove use observed during wound care for both residents. This is evidenced by the following. [...]

Inspectors wroteBased on record review and interview conducted during the Recertification Survey completed on 9/22/22, it was determined that for three (Employees #1, #4 and #5) of five employee files reviewed, the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry (NAR) abuse screening was not completed prior to new employees beginning work.

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey completed on 9/22/22, it was determined that for 7 (Residents #178, #187, #245, #247, #281, #298 or #357) of 35 residents reviewed, the facility did not ensure that a Baseline Care Plan (BCP) was developed and implemented within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and that a written summary of the care plan, that they were able to understand, was provided and reviewed with the resident and/or their representative in a timely manner per the regulations. This was evidenced by, but not limited to, the following: [...]

Inspectors wroteBased on record reviews and interviews conducted during a Recertification Survey and complaint investigation (#NY00287538 and #NY00285375) completed 9/22/22, it was determined that for two (Residents #121 and #608) of seven residents reviewed for abuse, neglect and mistreatment, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, both resident's care plans were updated indicating a need for increased assist during transfers, but the change was not made on the Certified Nursing Assistant (CNA) Resident Care Summary (care cards used by the CNAs for daily care) that were posted in the residents' rooms resulting in falls with injuries.

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey completed on 9/22/22, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one resident (Resident #187) of three residents reviewed for abuse, the facility did not investigate a concern of rough handling during care that was reported to the nurse. This is evidenced by the following: Resident #187 has diagnoses including a stroke with hemiplegia (paralysis), hemiparesis (weakness), and osteoarthritis. The Minimum Data Set Assessment, dated 11/18/19, revealed that the resident's cognitive skills for daily decision making were severely impaired, and the resident required the extensive assistance of two staff members for personal hygiene, bed mobility, bathing, and transfers. When interviewed on 1/2/20 at 8:52 a.m., Licensed Practical Nurse (LPN) #1 said she works the day shift. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for mobility, and one of six residents reviewed for activities of daily living, the facility did not ensure that each resident received appropriate treatment or services to improve or maintain ambulation. Specifically, Resident #187 was not walked consistently on a daily basis with the appropriate equipment, and Resident #254 was not walking independently on a daily basis and staff did not monitor or evaluate for a decline. This is evidenced by the following: 1. Resident #187 has diagnoses including a stroke with hemiplegia (paralysis), hemiparesis (weakness), and repeated falls. The Minimum Data Set Assessment, dated 11/18/19, revealed that the resident's cognitive skills for daily decision making were severely impaired. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #143) of two residents reviewed for respiratory care and oxygen, the facility did not provide proper care and treatment. Specifically, the resident's oxygen equipment was signed off as cleaned and changed weekly but was observed dirty and dated as last changed approximately a month earlier. This is evidenced by the following: Resident #143 had diagnoses including chronic obstructive pulmonary disease, pulmonary edema, and respiratory failure. The Minimum Data Set Assessment, dated 11/6/19, revealed that the resident had moderately impaired cognition and received oxygen therapy. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for four of eight medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. The issues involved a controlled substance that was not double locked, multiple unlabeled pre-poured medications, and multiple loose pills in the bottom of drawers in the medication carts. This is evidenced by the following: Home for the Aged: In an observation on 1/2/20 at 10:10 a.m., a medication cart on the third floor contained multiple loose pills in the bottom of the drawer. On 1/3/20 at 9:07 a.m., a medication cart on the sixth-floor contained several loose pills in the bottom of the drawer. Wegman's Continuing Center: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure food was prepared in a form designed to meet each resident's needs. Specifically, the pureed lasagna was prepared without a recipe and the serving size was not equivalent to the regular portion size. This is evidenced by the following: When interviewed on 1/6/20 at 10:13 a.m., the Assistant [NAME] said that he pureed the lasagna entrée for lunch that day. He said that he needed 34 servings of 4 ounces each. He said that he did not follow a recipe but put the lasagna into the blender and added water to make it liquidy. He said he did not know how much water he added to the lasagna. He said the lasagna was a heat and serve purchased product and he used two half pans. The lasagna was Molly's Kitchen: 15 orders per half pan. [...]