St. Camillus Residential Health Care Facility

Inspectors wroteBased on observations, record review, and interviews during the recertification survey (complaint #2643650) the facility failed to treat each resident with respect and dignity and in a manner and environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality. Specifically, during a confidential group meeting thirteen (13) of thirteen (13) residents stated they experienced long call bell response times and multiple observations were made of long call bell response times.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for four (4) of seven (7) medication carts (Unit 2 East and West, Unit C, and Unit D) and one (1) of three (3) medication rooms (Unit 2) reviewed. Specifically, the Unit 2 [NAME] cart had insulin pens that were not labeled with the open or expiration dates, and expired medications; the Unit 2 East cart had insulin pens that were not labeled with open or expiration dates; the Unit C cart had insulin pens, nasal sprays, and inhalers not labeled with open or expiration dates and expired medications were left in the cart; the Unit D cart had insulin pens and inhalers that were not labeled with open or expiration dates; and the Unit 2 medication room had supplies directly on the floor under the sink.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey (complaint #652393) the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, in the main kitchen food in the cooler was not labelled, expired food was not discarded, the dish machine was not functioning properly while in use, and food service equipment was unclean.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to 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 diseases and infections for two (2) of ten (10) staff (Certified Nurse Aide #35 and Environmental Services Worker #48) reviewed for influenza vaccinations; and five (5) of eight (8) residents (Residents #66, #87, #195, #244, and #268) reviewed for transmission based precautions. Specifically, Certified Nurse Aide #35 and Environmental Services Worker #48 declined the influenza vaccine and were observed wearing their masks below their nose while in resident areas; [...]

Inspectors wroteBased on observations, interviews, and record review during the recertification survey (complaint #652367) the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own mediations, if clinically appropriate, for two (2) of three (3) residents (Residents #108 and #260) reviewed. Specifically, Resident #108 had a prescribed nasal spray on their bedside table and Resident #260 had unprescribed elderberry supplements on their bedside table. There was no documented evidence of assessments and/or physician orders for the residents to safely self-administer medications.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure that when a restraint was indicated, the least restrictive alternative for the least amount of time was used and included ongoing re-evaluation of the need for the restraint for one (1) of one (1) resident (Resident #13) reviewed. Specifically, a crisscross lap belt (a nylon belt around the waist and hooked to the back of the wheelchair) was implemented for Resident #13 and there was no documented evidence the device was determined to be the least restrictive alternative or the need for the device was periodically reevaluated.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey the facility failed to ensure the development and implementation of a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of three (3) residents (Residents #195 and #6) reviewed. Specifically, Resident #195's person-centered comprehensive care plan did not include the use of an anticoagulant (blood thinner) and Resident #6's person-centered comprehensive care plan did not include the use of insulin (used to treat high blood sugars) or an anticoagulant.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated survey (2643650) the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (1) of four (3) residents (Resident #17) reviewed. Specifically, Resident #17 had brown debris underneath long, untrimmed fingernails; had foul breath; was unshaven; and did not receive their shower as plannedFindings include: The facility policy Activities of Daily Living (ADLs) Supporting, effective 12/22/2023, documented residents were provided with the necessary services to maintain good grooming, nutrition, personal, and oral hygiene when the resident was unable to carry out activities of daily living. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility failed to ensure that residents who required dialysis (used to filter waste products from the blood when the kidneys do not work properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #134) reviewed. Specifically, Resident #134 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site, and consistent ongoing communication and collaboration between the facility and the dialysis center. Additionally, the resident was not always provided a lunch meal on their dialysis days.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey the facility failed to ensure accommodation of resident food preferences for one (1) of two (2) residents (Resident #4) reviewed. Specifically, Resident #4 did not receive double portions at meals as planned.

Inspectors wroteBased on observation, record review, and interview during the abbreviated survey (NY00331278), the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible to prevent accidents for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 obtained and ingested medications from the medication cart and it was unclear whether licensed practical nurse #3 left the medication cart unlocked when it was unattended or whether the lock malfunctioned. After ingesting the medications, the resident required hospitalization and treatment with activated charcoal (emergent treatment for an overdose) and intravenous fluids. This resulted in actual harm to Resident #2 that was not immediate jeopardy.

Inspectors wroteBased on interviews during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States for all 241 residents of the facility. Specifically, mail from the United States Postal Service (USPS) was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00321818 and NY00317835 and NY00321978) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 5 of 6 resident units (Units B, C, D, 2, and 3). Specifically, Unit 3 had mattresses and furniture in disrepair; Units B, C, D, 2, and 3 served resident meals directly on trays; and the medication room and the kitchenette were unclean on Unit 3.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00327307, NY00321978, NY00321818 and NY00317835) surveys conducted 11/13/2023-11/20/2023 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 of 10 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) residents stated their call bells could sometimes take an hour to an hour-and-a half to be answered, and that there were not enough certified nurse aides (CNAs) to assist dependent residents with personal hygiene and toileting tasks. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00326461, NY00326492, and NY00317835) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, accurate, and at an appetizing temperature for 3 of 3 meals reviewed (11/14/2023 and 11/15/2023 lunch meals, 11/16/2023 breakfast). Specifically, food was not palatable or served at appetizing temperatures and meal trays were missing items

Inspectors wroteBased on record review and interview during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure they provided the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #353) reviewed. Specifically, Resident #353 was discharged from the facility to home and did not receive a Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00326492) conducted 11/13/2023- 11/20/2023, the facility did not ensure the implementation and development of person-centered comprehensive care plans (CCP) to meet residents' medical, nursing, and mental and psychosocial needs for 4 of 5 residents reviewed (Residents #91, #116, #141, and #216). Specifically, Residents #91's and #216's CCP did not include isolation precautions; Resident #116 did not receive ordered treatments or consume meals in the dining room as care planned; and Resident #141's low air loss mattress (used for pressure reduction) settings were not implemented as planned.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated surveys (NY00312845, NY00317835, NY00321300, NY00321978, NY00326461, NY00326492, NY00326914, and NY00327307) conducted 11/13/2023-11/20/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming, personal hygiene, and oral hygiene for 5 of 7 residents (Residents #36, #100, #120, #141, and #183) reviewed. Specifically, Residents # 36 and #100 were not assisted with oral hygiene; Resident #120 did not receive fingernail hygiene; Resident #141 was not provided with a shower, oral hygiene, and fingernail care; and Resident #183 was not assisted with removal of facial hair.

Inspectors wroteBased on observation, record review, and interviews during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 2 of 2 residents (Residents #53 and #190) reviewed. Specifically, Resident #53 was not provided preferred activity when their television was non-functional; and Resident #190 was not provided meaningful activities that met their interests and preferences.

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated surveys (NY00317835, NY00312624, NY00321818, NY00312845, NY00321300, NY00321978, NY00326461, NY00326492, and NY00326914) conducted 11/13/2023-11/20/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #146) reviewed. Specifically, Resident #146 had an unstageable (full-thickness pressure injuries in which the base is obscured by dead tissue) right heel pressure wound, and an unstageable right buttock wound and there was no documented evidence treatments were completed as ordered.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents received special eating equipment as required for 2 of 2 residents (Residents #135 and #103) reviewed. Specifically, Resident #135 was not provided with a scoop plate as ordered and Resident #103 was not provided with a scoop plate or adaptive silverware.

Inspectors wroteBased on observation and interview during the recertification survey conducted from 11/13/2023-11/20/2023, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, single service items were re-used, the hood filters were not maintained, and the clean ice scoop was not stored properly.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00317835 and NY00321978) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure resident call systems were accessible to call for staff assistance for 1 of 3 residents (Resident #116) reviewed. Specifically, Resident #116 was observed on multiple occasions with their call bell out of reach.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 7/26/21-7/30/21, the facility did not provide each resident an ongoing program to support residents in their choice of activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 2 of 3 (Residents #2 and 31) reviewed. Specifically, Resident #2 was not offered meaningful activities and was not provided with activities of their choosing. Resident #31 was not provided with music of their choosing as care planned. The 10/27/20 updated Assessment and Documentation of Activity Participation policy documents every effort will be made to promote resident participation in preferred, meaningful activities which includes that care plans are individualized and reflect an adequate level of stimulation. [...]