St. Margarets Center

Inspectors wroteBased on records review and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 10 (Resident #s 1, 6, 10, 45, 46,48, 54, 62, 68, and 79) of 19 residents reviewed for unnecessary medications. Specifically, for Resident #s 1, 6, 10, 45, 46, 48, 54, 62, 68, and 79, as-needed psychotropic medication orders did not include end dates. This is evidenced by: A facility policy titled, Medication Management dated 12/10/2024, documented that as needed orders for psychotropic drugs were limited to 14 days. The use of psychotropic medication to treat an emergency situation must be consistent with the requirements regarding as needed orders for psychotropic medications. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility water management and sampling plan did not include a simple schematic that visually described the building water system and the identification of areas where Legionella could grow and spread. This is evidenced by: There was no documented evidence that the facility water management and sampling plan included a simple schematic that visually described the building water system and the identification of areas where Legionella could grow and spread. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification and abbreviated survey (Case #s NY00311240, NY00320508, NY00321961, and NY00329555), the facility did not ensure residents were free from neglect for 4 (Resident #s 1, 5, 6, and #45) of 19 residents reviewed for abuse and neglect. Specifically, (a.) Resident #1, was provided personal care by Certified Nurse Aide #2 instead of two staff members as their care plan indicated, and Resident #1's bed was not set up as the care plan required, subsequently, the resident hit their head and sustained a small injury to their forehead; (b.) Resident #5 sustained a fall from a mechanical lift due to improper technique; (c.) Resident #6 sustained a fractured left great toe with evidence of improper transfer found; [...]

Inspectors wroteBased on record review and interviews conducted during recertification and abbreviated survey (case #NY00329555), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs for 3 (Resident #s 4, 59, and 62) of 19 residents reviewed for comprehensive care plans. Specifically, (a.) for Resident #s 4 and 59 , the Comprehensive Care Plan did not include the use of medications with specific indication for use; (b.) for Resident #62, intervention of floor mat on the floor was not implemented to ensure safety while at play. This is evidenced by: A facility policy titled, Care Plans, dated 4/01/2019, documented under Policy Interpretation and Implementation: 1. Each resident's care plan was designed to: a. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were stored properly and labeled in accordance with professional standards of practice. Specifically, opened medications had no open and/or expiration dates for 2 out of 5 medication carts reviewed for medication storage. This is evidenced by: The Facility's Medication Storage Policy, revised on 1/10/2024, documented under Medication Storage section that the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; medications were stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems; medications were stored separately from food and were labeled accordingly. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00323346), the facility did not ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 resident (Resident #1) of 22 residents reviewed for abuse. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00323346), the facility did not ensure in response to allegations of abuse the facility must have evidence that all alleged violations were thoroughly investigated for 1 resident (Resident #1) of 22 residents reviewed for abuse. Specifically, the facility did not ensure it investigated the allegation of sexual abuse for Resident #1 when the hospital Discharge summary dated [DATE] that documented it was reviewed, or following the resident's representative call to the facility who voiced concerns regarding the alleged abuse. This was evidenced by: The Policy and Procedure titled, Incident Reporting Policy reviewed 4/6/2022, documented the licensed nurse or supervisor shall promptly initiate a thorough investigation regarding the alleged incident to determine whether it is reportable in accordance with this policy. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00288015), the facility did not ensure resident records were maintained in accordance with professional standards of practice for 5 (Resident #'s 32, 38, 76, 77, and #280) of 21 residents reviewed. Specifically, for Resident #32, the facility did not ensure staff documented whether the resident was provided with toileting per their assigned toilet training program between 12/1/2021 - 12/15/2021; for Resident #38, the facility did not ensure that the resident's care plan was updated with a new focus, goals, and interventions following a condition change on 6/16/22 when the resident was diagnosed with COVID-19; [...]

Inspectors wroteBased on record reviews and interviews during the recertification survey dated 6/23/2022 through 6/29/2022, the facility did not ensure the resident, residents' representatives and the Office of the State Long-Term Care Ombudsman were notified in writing of the reason for the transfer/discharge to the hospital in a language and manner they understood for 1 (Resident #46) of 3 residents reviewed for hospitalizations. Specifically, for Resident #46, the facility did not provide a written transfer/discharge notice to the resident, residents representative or the Ombudsman when the resident was transferred to the hospital on 5/31/2022 and again on 6/3/2022. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the residents and the resident representatives for 1 (Resident #46) of 3 residents reviewed for hospitalization. Specifically, for Resident #46, the facility did not ensure the resident and the resident representative received written notice of the facility's bed hold policy when the resident was transferred to the hospital. This was evidenced by: The facility Policy and Procedure titled Bed Reservations dated 4/2/2019, documented at the time of admission and again at the time of transfer for any reason, the facility shall inform and provide written information to the resident and the designated representative regarding bed reservation. Resident #46: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #'s 32 and #76) of 4 residents reviewed for respiratory care. Specifically, for Resident #76, the facility did not ensure that the resident's respiratory status including their response to therapy, and changes in their respiratory condition were consistently assessed, monitored and documented and for Resident #32 the facility did not ensure physician orders for the oxygen (O2) tubing changes were followed. Resident #76: [...]

Inspectors wroteBased on medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, for one (1) (Resident #55) out of one (1) sampled residents reviewed for Beneficiary Protection Notification the facility did not ensure residents received written notification upon termination of rehabilitative services. Residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123. This is evidenced by:

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure each resident received adequate supervision for 1 (Resident #23) of 1 resident reviewed for prevention of accidents. Specifically, for Resident #23, the facility did not ensure the resident's siderails on the crib were properly positioned and latched to prevent a fall from the crib. This was evidenced by: Resident #23: This resident was admitted with diagnoses of disorders of the brain, accidental drowning and submersion while in natural water and spastic quadriplegia cerebral palsy. The Minimum Data Set (an assessment tool) dated 11/12/19, documented the resident was severely impaired for cognition. The resident rarely/never understood others and rarely/never was understood by others. [...]

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications, sink faucets leaked, and equipment and floors required cleaning. This is evidenced as follows. The kitchen and unit nourishment rooms were inspected on 02/05/2020 at 8:16 AM. When checked, the automatic dishwashing machine final rinse was 125 F at 58 pounds per square inch (psi) water pressure. The automatic dishwashing machine information date plate states that the minimal final rinse water temperature is to be 180 F at 25 psi. The faucets leaked in the 3-bay sink, preparation sink, and warewashing area handwashing dish. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, dumpsters were not maintained to prevent the harborage and feeding of pests. This is evidenced as follows. The garbage dumpsters were inspected on 02/05/2020 at 9:20 AM. Garbage waste was found in the dumpsters and drain holes in each of the dumpsters did not have plugs to prevent pest entry. The Maintenance Supervisor stated in an interview on 05/05/2020 at 9:20 AM, that he will contact the dumpster vendor to get the required plugs. 10 NYCRR 415.14(h)