St. Mary's D'youville Pavilion

Inspectors wroteBased on facility policy, record reviews, and interviews, the facility failed to thoroughly investigate a resident-to-resident altercation, ensure that the facility's investigation was completed, and failed to send the investigation to the State Agency within 5 business days of the incident for 2 of 3 facility reported incidents investigated on 1 of 5 units (Resident #35, Resident #39, Resident #59, and Resident #186).

Inspectors wroteBased on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to ensure a resident was free from an avoidable accident and environmental hazards. Specifically, Resident #1 [R1] exited their assigned unit onto an exterior courtyard/patio area without staff knowledge. The resident remained outdoors, inadequately dressed for the weather, for approximately 30 minutes before being discovered face down on the snow-covered ground. This failure created an immediate jeopardy situation.

Inspectors wroteBased on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to notify the State agency of a resident's elopement within 24 hours of the incident; and failed to provide the State agency with a 5 day follow up report for 1 of 1 investigated incident of neglect. (#1)

Inspectors wroteBased on review of the facility's incident report, record reviews, interviews, and internal investigation, the facility failed to ensure staff spoke to residents in a dignified manner for 2 of 3 residents reviewed for abuse (R1, R2).

Inspectors wroteBased on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units (3rd floor unit and 4th floor unit) and the laundry rooms for 1 of 1 environmental tour (3/28/25).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care on 3 of 4 days of survey (3/25/25, 3/26/25 and 3/27/25) for 9 of 13 residents reviewed for respiratory care. (#40, #52, #153, #370, #366, #42, #24, #468 and #472)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who requires Hemodialysis receives such services, consistent with the professional standards of practice and failed to ensure the care plan contained the needed information, including emergency interventions necessary to properly care for 2 of 2 residents reviewed for Hemodialysis. (#105 and #32)

Inspectors wroteBased on record reviews and interviews, the facility failed to assess resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 2 of 3 sampled residents reviewed with a current diagnosis of PTSD (Resident #39 and #110).

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 8 sampled residents reviewed for new admissions (Resident #36).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a physician's order and care plan was followed for 1 of 11 residents reviewed for oxygen therapy (#42).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 1 of 1 resident reviewed for smoking (105).

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 4 survey days. (3/25/25)

Inspectors wroteBased on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI), the facility failed to present evidence that the required members attended 2 of 4 quarters provided (April 2024 and July 2024).

Inspectors wroteBased on observations and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection for 1 of 7 residents on contact precautions (Resident #6).

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 1 of 3 floors (3rd) and the laundry rooms for 1 of 1 environmental tour. (1/26/24)

Inspectors wroteBased on record review, observations and interview, the facility failed to develop or implement the care plan interventions for the residents' current needs for 6 of 33 sampled residents/care plans reviewed (Resident #2, #20, #52, #101, #166 and #173)

Inspectors wroteBased on record review and interview, the facility failed to revise a care plan to reflect the current needs for 3 of 33 sampled residents/care plans reviewed (#104, #135 and #144)

Inspectors wroteBased on record review and interviews, the facility failed to follow a physician order for obtaining daily weights for 1 of 8 sampled residents for rehospitalization (#114) and failed to follow physician orders for making a referral to a specialist for 1 of 5 residents reviewed for unnecessary medications. (#144)

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean manner on 1 of 1 days of survey (1/22/24) for ceiling vents, ceiling tiles, and an auto bag machine; failed to ensure the male kitchen staff were wearing facial hair protection, failed to ensure wet sacking of glasses, and failed to ensure foods were dated and/or labeled in freezers and refrigerators. Further, the facility failed to monitor temperatures of the dish washing machine and the refrigerators and freezers. In addition, the facility failed to ensure that proper hand sanitizing and proper food handling, during lunch service, was followed for 1 of 2 lunch observations (1/22/24) on the 3rd floor [NAME] Unit.

Inspectors wroteBased on observations, interviews, record review and facility policy, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Methicillin Resistant Staphylococcus Aureus (MRSA- a Multidrug-Resistant Organism) colonized in sputum and urine for a 2 of 2 sampled residents (Resident #20 and #148) diagnosed MRSA for 1 of 5 days of survey (1/22/24). This has the potential to affect all 39 residents on the 4 East unit.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's right to formulate an advance directive regarding cardiopulmonary resuscitation (CPR) or Code Status was accurate in the clinical record for 1 out of 7 sampled residents reviewed for advanced directives (Resident #108).

Inspectors wroteBased on record review and interview, the facility failed to conduct a comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days after a resident experienced a significant change of condition and hospice services were initiated for 1 of 4 sampled residents receiving hospice services (R173).

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 new admissions requiring Transmission Based Precautions (TBP). (Resident #160).

Inspectors wroteBased on record review and interview, the facility failed to ensure the pharmacist provided services to identify that a physician's order for the psychiatric evaluation was completed for 1 of 5 residents reviewed for unnecessary medications (Resident #144).

Inspectors wroteBased on record review and interview, the facility failed to show evidence of an attempt of a gradual dose reduction (GDR) and lacked documentation to justify the continued use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (#52).

Inspectors wroteBased on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 1/26/24, was effective. The Federal citation F584 and F812 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 3/21/24.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 of 4 residents with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASARR) evaluation and determination (#152).

Inspectors wroteBased on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, ceiling lights, ceiling tiles, ceiling grids and food mixers. In addition, the facility failed to ensure that foods were labeled and dated in the walk-in freezers and the walk-in refrigerators. Further, the facility failed to monitor the chemical sanitizer levels for the sanitizing sink and the sanitizing buckets for 1 of 1 kitchen tours on 1 of 4 days of survey (3/6/22).