St. Vincent Depaul Residence

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey 1/02/2025 -1/09/2025, the facility did not ensure that food was stored and prepared in accordance with professional standards for food service safety. Specifically, (1) there were boxes containing food stored past their use by/best by date. There was an open box containing mirepoix vegetable soup mix, an open box Capi vegetable blend, open box with coleslaw stored. There was also an open box containing expired raw frozen shrimp in the freezer. (2) a dietary staff with a beard and mustache was observed in the process of preparing food without a beard net. This was evident in the kitchen observation.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility failed to maintain a clean, orderly, functional, and sanitary (homelike) environment for the residents. The deficient practice was identified for multiple resident rooms/units inspected: 1) room [ROOM NUMBER] had no hot water supply for about 3 weeks, 2) room [ROOM NUMBER] and shared shower room on Unit 3 were observed in disrepair/damaged/discolored/ dirt and dust accumulation, 3) 2nd floor dining room and rooms 201/202/210/211/212 were observed in disrepair/damaged/discolored.

Inspectors wroteBased on interviews and record reviews made during a recertification survey (BYS411), the facility did not ensure that the Arbitration Agreement was explained to residents or their representatives in a form or manner that they understood. This was true in 3 of 21 residents sampled for Arbitration (Residents #22, 57 and 206).

Inspectors wroteBased on record review and interviews during the recertification survey conducted from 01/02/2025 to 01/08/2025, the facility did not ensure that each resident was offered the Pneumococcal immunization. This was observed in 3 of 5 residents (Residents #6, #84, #96) sampled for Immunizations out of a total of 23 sampled residents. Specifically, there was no documented evidence that Residents #6, #84, and #96 were offered or educated on the Pneumococcal immunization. The facility policy titled Resident Immunizations effective 05/2014 documented that all residents will receive immunizations as recommended by the Immunization Practices Advisory Committee (ACIP) of the U.S. Department of Health and Human Resources. The resident's status regarding the Pneumococcal vaccine will be obtained and documented in the electronic medical record. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 2 (Resident #36 and Resident #55) of 3 residents reviewed for Beneficiary Notification out of 23 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made.

Inspectors wroteBased on observations, record reviews, and interviews during a Recertification Survey from 1/02/2025 to 1/08/2025, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for 2 (Resident #36 and Resident #6) out of 23 total sampled residents. Specifically, 1) The Minimum Data Set 3.0 assessment did not document Resident #36's use of a Wanderguard and 2) The Minimum Data Set 3.0 assessment inaccurately documented Resident #6 as having clear speech, with ability to make self-understood.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 1/2/2025 to 1/8/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended 4 quarterly meetings. Specificially, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 2 out of the 4 meetings as required.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 1/02/2025 to 12/08/2025 the facility did not ensure that food was served in accordance with professional standards for food service safety to prevent foodborne illness and ensure that infection control practices were maintained. Specifically, a Certified Nursing Assistant #4 was observed assisting multiple residents with dining room in preparation for dining did not perform hand hygiene between residents. This was evident for 10 residents (of 23 total sampled residents for dining Resident # 7, #18, #19, #38, #39, #49, #52, #70, #72 and #87). (2) the facility did not ensure that disinfecting germicidal wipes, hand sanitizing solution was discarded by the manufacturer discharge date . This was evident for the infection control task.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that the last 3 years of facility survey results were posted in a place readily accessible to residents, family members, public, and legal representatives of the residents, where individuals wishing to examine survey results do not have to ask to see them. This was evident for 5 (#15, #49, #96, #29, #42) out of 11 residents attending the Resident Council meeting. Specifically, survey results were posted at the resident courtesy phone located on the left-hand side of the unit, not in plain view.

Inspectors wroteBased on interviews and record review conducted during the Recertification/Complaint Survey (NY00343189) from 01/02/2025 to 01/08/2025, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #96) reviewed for Accidents out of 23 total sampled residents. Specifically, the facility did not report that Resident # 96 was found with injuries of an unknown source to the New York State Department of Health within 2 hours.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated Survey (NY00358734), the facility did not ensure the resident was immediately informed, consult with the resident's physician, and notify, consistent with their authority, the resident representative when there was need to alter treatment significantly. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 08/07/2024, the Medical Doctor #1 ordered a urine test to rule out Urinary Tract Infection. On 08/11/2024, the positive urine test results were reported to the facility and the Medical Doctor was not informed. On 09/04/2024 at 1:55 PM, the Medical Doctor #2 reviewed the laboratory results and ordered antibiotic treatment for Urinary Tract Infection on 09/05/2024. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00358734), the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 08/07/2024, the Medical Doctor #1 ordered a urine test to rule out Urinary Tract Infection. On 08/11/2024, a positive urine test results were reported to the facility for Escherichia coli (greater than 100.000 Colony-Forming Unit/Milliliter Escherichia coli). On 09/04/2024 at 1:55 PM, Medical Doctor #2 reviewed the urine test results, and ordered antibiotic treatment for Urinary Tract Infection which started on 09/05/2024, this resulted in 26 days delayed in treatment for Urinary Tract Infection.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 8/1/2023 to 8/7/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during observation of the kitchen. Specifically, cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 08/01/2023 to 08/07/2023, the facility did not ensure that person-centered comprehensive care plans (CCP) were developed to address the residents' medical, physical, mental, and psychosocial needs. This was evident for 3 (Resident # 40, # 98, and # 91) out of 5 residents reviewed for Unnecessary Medications out of 27 total sampled residents. Specifically, 1) a CCP related to anticoagulant (AC) therapy was not developed for Resident #40, 2) a CCP related to AC therapy was not developed for Resident #98, and 3) a CCP related to AC therapy was not developed for Resident #91.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 08/01/2023 to 08/07/2023, the facility did not ensure infection control practices and procedures were maintained. This was evident for 3 (Resident #100, #103, and #42) of 27 total sampled residents. Specifically, Registered Nurse (RN) #1 was observed using the same Blood Pressure (BP) cuff with Resident #100, #103, and #42 without cleaning and disinfecting the BP cuff in between each resident.

Inspectors wroteBased on observations, record reviews, and interviews during a Recertification survey, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for 2 (Resident #39 and #64) 38 total sampled residents. Specifically, The Minimum Data Set 3.0 (MDS) assessment did not document Resident #39 and Resident #64's use of Wander Alert Device (WAD).

Inspectors wroteBased on record review and interviews conducted during a Recertification survey from 8/1/2023 to 8/7/2023, the facility did not ensure that the resident and/or their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident # 219) 27 total sampled residents. Specifically, there is no documented evidence Resident #219, and their representative were provided with a copy of the resident's BCP within 48 hours of the admission to the facility.

Inspectors wroteBased on staff interview and record review conducted during a recertification survey, the facility did not ensure that a person-centered care plan with measurable goals, time frames and interventions were developed to address resident concerns. Specifically, 1). a care plan was not developed and implemented for a resident with diagnoses of Bipolar Disorder, and Fracture of Right Patella and 2). a care plan was not developed and implemented to provide the appropriate care and services for a resident with chronic constipation. This was evident for 1 of 1 resident reviewed for Advanced Directives and 1 of 1 resident reviewed for Constipation/Diarrhea out of a sample of 25 Residents. (Resident #156, and Resident #83)

Inspectors wroteBased on observations, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that necessary housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, a corroded radiator cover, unpainted areas, and mis-matched paint on the walls were observed in residents' areas and rooms. This was evident in multiple rooms on the 2nd floor. (Day room, Rooms 201, 203, 215, 216, 221).

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that residents were free of physical restraints. Specifically, hand mittens were not released every two hours as ordered by the physician. This was evident for 1 of 1 resident reviewed for Physical Restraints out of total sample of 25 residents (Resident #67).

Inspectors wroteBased on observation, record review and staff interview conducted during the Recertification and complaints survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, there was no documented evidence of medical follow-up for a resident admitted with a diagnosis of Diabetes Mellitus who had elevated blood glucose levels daily and an elevated Hemoglobin A1C. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 25 residents (Resident #40). The finding is: The facility policy titled Diabetes Management Protocol revised in 07/2011 documented to consistently and in an organized fashion manage residents with diabetes and to document such care, the facility has established a diabetic protocol. [...]