St. Joseph's Hospital - Skilled Nursing Facility

Inspectors wroteBased on observations, interviews, and record review, the facility did not provide maintenance services necessary to maintain a safe and comfortable environment for one (1) of one (1) automatic door reviewed (Main Entrance). Specifically, the exterior and interior accessibility (handicap) automatic door opening pads at the main entrance were not functional, requiring residents who used wheelchairs to rely on others for entry and exit from the building.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure allegations of neglect were thoroughly investigated and documented for one (1) of two (2) residents reviewed (Resident #9). Specifically, Resident #9 sustained an injury when [NAME] Elevator #5 closed on the resident's arm, and the facility did not complete an incident report, initiate an investigation, or conduct a root cause analysis following the incident.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for two (2) of five (5) residents reviewed (Resident #9 and Resident #12). Specifically, Resident #9's arm was caught in [NAME] Elevator #5 when attempting to stop the elevator door from closing, and Resident #12 was observed using their arm to prevent the elevator door from closing on their wheelchair. The elevator remained operational and accessible to residents, and the facility did not investigate, test, repair, or remove the elevator from service following the incident involving Resident #9.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 7/22/24-7/26/24, for 7 (Residents #27, #35, #36, #38, #58, #66, #76) of 14 residents reviewed, the facility did not ensure the baseline care plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents, that they were able to understand) was completed within 48 hours of a resident's admission and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Resident #36, #38, #58, #76, the facility could not provide documented evidence that a baseline care plan was completed within 48 hours of the resident's admission. [...]

Inspectors wroteBased on observations and interview conducted during the Recertification Survey from 7/22/24-7/26/24, 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 observations, interviews, and record review conducted during a Recertification Survey from 7/22/24-7/26/24, the facility did not ensure the nurse staffing information was posted with the required information and in a prominent place readily accessible to all residents and visitors. Specifically, the nurse staffing information did not consistently include the accurate number and total hours worked by licensed (Registered Nurses and Licensed Practical Nurses) and unlicensed (Certified Nurse Aides) nursing staff who were directly responsible for resident care. Additionally, the staffing information was only posted on one residential unit preventing access of the information to the residents and visitors on the second unit (a secured unit that was locked and required staff to provide elevator access to all residents or visitors). This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey and a complaint investigation (NY00279223), from 3/39/22 to 4/1/22, the facility failed to ensure that one (Resident #7) of five residents reviewed was free of significant medication errors. Specifically, Resident #7 was not provided Keppra (an anti-seizure medication) as ordered and subsequently experienced seizure-like activity requiring hospitalization. This resulted in actual harm to Resident #7 that was not immediate jeopardy.

Inspectors wroteBased on observations, interviews and record reviews, conducted during the Recertification Survey, completed on 4/1/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple undated and unlabeled food items and non-food contact surfaces within the kitchen were not maintained in clean and sanitary condition. This is evidenced by the following: The facility policy, 'Food Storage', reviewed/revised June 2021, included that all products are to be labeled and dated with the receiving date. The policy included that old supplies should be moved to the front of the shelf to ensure rotation of products and new supplies should be placed to the rear of the shelf. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, completed on 4/1/22, it was determined that for two (Resident #64 and #73) of three residents reviewed, the facility did not provide the appropriate appeal notice to the Medicare beneficiary in order to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the Medicare A beneficiaries with a Notice of Medicare Non-Coverage (NOMNC) letter prior to discharge from the facility per the regulations. This is evidenced by: Resident #64 was admitted to the facility 3/2/22 under Medicare part A benefits and was discharged to the community on 3/18/22. There was no documented evidence that the resident or responsible party was provided with and properly completed the required appeal notice prior to discharge. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (one Housekeeping employee and one Certified Nurse Assistant) of eight employees records reviewed, the facility did not properly implement policies and procedures to prevent abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check prior to hiring employees. This is evidenced by the following: A review of the facility records on 1/23/20 from 2:05 p.m. to 2:55 p.m. revealed one Housekeeping employee began work at the facility on 9/16/19 with no proof of Nurse Aide Registry verification prior to their start date. Further record review of the employee's time detail report revealed the employee worked the following dates: 9/16/19, 9/17/19, 9/19/19, 9/20/19, 9/23/19, 9/24/19, 9/25/19, 9/27/19, 9/28/19, and 9/29/19. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that that for one of one main kitchen, the facility did not prepare, distribute, and store food under sanitary conditions. The issues involved grilled ham and cheese sandwiches that were not hot held at the proper temperature for food service, improper freezer and dry storage, and the use of metal scouring pads. This is evidenced by the following: The facility's policy, HACCP and Food Handling Principles, dated February 2010, included that hot foods are to be served at between 140 degrees Fahrenheit (*F) to 155*F. The facility's policy, Cleaning and Sanitizing of Work Surfaces, dated July 2018, revealed that a nylon-scouring pad is used as an abrasive to remove food soil from surfaces. Steel wool and metal scouring pads are not permitted. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for resident right's, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulation. Specifically, Resident #44 did not receive a Skilled Nursing Facility Advanced Beneficiary Notice or a denial letter at the termination of Medicare Part A benefits. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] and was discontinued from Medicare Part A services on 12/6/19 and remained in the facility. There was no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice or denial letter was given to the resident or legal representative informing them of their potential liability for payment. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for non-pressure related skin conditions, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #17 had documented combative behaviors, was at a high risk for skin impairment, and did not have a care plan developed to address behaviors or skin impairment, and Resident #61 had a history of bruising with newly identified bruises on 1/23/20 and there was no care plan in place to address the resident's risk for skin impairment. This is evidenced by the following: 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #55) of one resident reviewed for infections, the facility did not ensure proper infection control procedures were followed. Specifically, a staff member did not remove soiled gloves or wash their hands prior to touching surfaces in the room and handling a stack of clean briefs. This is evidenced by the following: Resident #55 has diagnoses including clostridium difficile (C-diff, a bacterium that causes diarrhea and colitis - an inflammation of the colon), anxiety, and depression. The Minimum Data Set Assessment, dated 12/19/19, revealed the resident was cognitively intact. [...]