Teresian House Nursing Home Co Inc

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 1 (Resident #77) of 4 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 24%. This is evidenced by: The facility's Policy and Procedure titled Administering Medications, last reviewed 3/16/2023 and Last Revision: 11/5/2024, documented medications were administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation #2: medications may be administered within (1) hour before or after prescribed times. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents were free of any significant medication errors for 2 (Resident #s 88 and 144) of 2 resident reviewed. Specifically, (a.) on 6/27/2024 Resident #88 received medications that were prescribed for another resident; (b.) on 11/02/2024 and 11/03/2024 Resident #144 did not receive a medication as prescribed. Additionally, there was no documented evidence that physician was notified, and that Resident #144 was monitored for side effects. This is evidenced by: The facility's Policy and Procedure titled Administering Medications, last reviewed 3/16/2023 and last Revision: 11/05/2024, documented medications were administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation #15: [...]

Inspectors wroteBased on interviews and record review during the recertification survey and an abbreviated survey (Case #NY00346710), the facility did not ensure that (a.) all alleged violations of resident abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protective services where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures; [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure a Significant Change Minimum Data Set assessment was completed for a 1 (Resident #141) of 42 residents reviewed for significant changes in health status. Specifically, Resident #141 sustained a fractured wrist on 8/18/2024, and a fracture of the other wrist on 9/27/2024 after a fall on 9/04/2024. There was no documented evidence that a significant change assessment was done. This is evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs for 2 (Residents #83 and #261) of 62 residents reviewed. Specifically, for Resident #s 83 and 261, the facility did not ensure an interdisciplinary care plan meeting reviewed the comprehensive care plan to include weight monitoring. This is evidenced by: The Policy and Procedure titled Change in a Resident's Condition or Status dated 04/22/2024, documented it was the facilities policy to promptly identify changes in condition, notify his or her attending physician, and the resident/representative of changes in the resident's medical/mental condition and/or status. [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their language and communication for 1 t (Resident #268) of 1 resident reviewed for Activities of Daily Living. Specifically, Resident #268 was not provided with an adequate, structured approach and tools to communicate effectively in accordance with professional standards of care. This is evidenced by: The facility's Policy on Communication with Residents with Speech Impairments reviewed on 1/24/2024, documented its purpose was to provide staff with a structured approach to communicate effectively and compassionately with residents affected by speech impediments due to stroke, ensuring clear, respectful, and supportive interactions. Procedures include use of communication aids; [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #83) of 9 residents reviewed for Activities of Daily Living. Specifically, Resident #83 was not provided assistance with personal hygiene during care leaving facial hair to grow on the upper lip. This is evidenced by: Resident #83 was admitted to the facility with the diagnoses of anxiety, Alzheimer's, and mood disorder. The Minimum Data Set (an assessment tool) dated 01/19/2024 documented the resident could rarely understand and rarely be understood by others; resident was cognitively impaired. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 1 (Resident #'s 148) of 4 residents reviewed for oxygen administration. Specifically, Resident #148's portable oxygen tank ran out of oxygen. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Administration, last revised on 5/09/2024, documented that oxygen would be administered by licensed nurses with a physician's order. Oxygen could be delivered via an E size oxygen tank for short-term use and when the resident was not on their concentrator. [...]

Inspectors wroteBased on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 2 of 14 resident unit kitchenettes. Specifically, refrigerators and freezers were not operating appropriately. This is evidenced by: A review of facility policy for the environment last revised 3/04/2024 documents that the facility was to maintain a clean and safe environment. The policy documents the facility would maintain the building and all department equipment to comply with all current Federal, State, and Local regulations and guidelines. The facility should maintain a regularly scheduled maintenance on all department equipment and repair as needed. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00279837), the facility did not ensure residents were free from significant medication errors for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specifically, the facility (1) did not ensure Residents #1 and #2 received their own medication as ordered when Resident #2 received Resident #1's antibiotic for 5 days from [DATE] through [DATE] for a total of 5 doses, and (2) did not ensure the electronic medical record was accurate for Resident #s 1 and 2 for those 5 days. This is evidenced by: The Policy and Procedure titled Physician's Order Entry last revised [DATE] documented physician orders would be entered by a licensed nurse in a timely manner. It documented all new orders entered in the electronic medical record order portal by a licensed nurse must be confirmed by a second nurse. [...]

Inspectors wroteBased on observation, medical and facility record review, video footage, and staff interview during a recertification and abbreviated survey (Case # NY00287505) the facility failed to provide adequate supervision for one (Resident #216) of 8 residents reviewed for accidents. Specifically, on 12/3/21 at 11:30 AM the facility failed to provide Resident #216, who was severely cognitively impaired, with supervision. Subsequently, Resident #216 was able to exit the building through a coded/locked door off the unit and 2 sets of alarmed doors exiting the facility for over two hours. Both alarmed doors were disabled by facility staff. Facility video footage revealed resident exited the facility at 11:30AM and facility staff did not discover the resident missing until lunch time at 12:15PM. [...]

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. The sanitizing chemical in the final rinse of low temperature automatic dishwashing machines are to be within a specific range, and food preparation and serving areas are to be kept clean. Specifically, the automatic dishwashing machine chemical sanitizing final rinse was too concentrated, and the unit kitchens required cleaning. This is evidenced as follows. When checked on 12/19/2021 at 9:14 AM, the concentration of sanitizing chemical in the final rinse of the automatic dishwashing machine final rinse was 200 parts per million of available chlorine (ppm). [...]

Inspectors wroteBased on observation, record review and interviews during a recertification survey, the facility did not maintain the residents' right to personal privacy and confidentiality on 2 (1st floor and 6th Floor) of 6 units (the 4th floor was closed). Specifically, for the 1st Floor and 6th Floor, the facility did not ensure the residents' right to privacy and confidentiality were maintained when finger sticks (blood sugar monitoring for diabetes) and blood pressures were obtained, and the results were read out loud, with other residents were present in the dining rooms and common areas. This was evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment were immediately reported to the Administrator of the facility for 1 (Resident #167) of 4 residents reviewed for abuse. Specifically, the facility did not ensure an allegation of abuse involving Resident #167 was immediately reported to the Administrator. This is evidenced by: Resident #167: Resident #167 was admitted with diagnoses of non-ST elevation myocardial infarction, muscle weakness generalized and acute respiratory failure. The Minimum Data Set (MDS - an assessment tool) dated 12/2/2021 documented the resident was cognitively intact, was understood and could understand others. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #195) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #195, the facility did not ensure a PRN Trazodone (antidepressant medication) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #195: [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five (Residents #'s 24, 120, 134, 152, and #221) of thirty-two residents reviewed for comprehensive care plans (CCP). Specifically; for Resident #152, the facility did not ensure a CCP for the diagnosis of urinary retention requiring the need for monitoring and treatment was developed and implemented with specific person-centered interventions; for Resident #221, the facility did not ensure a CCP was developed for the resident's diagnosis of pulmonary embolism, and deep vein thrombosis with anticoagulant therapy; [...]

Inspectors wroteBased on observation 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. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and food and non-food contact surfaces are to be kept clean. Specifically, automatic dish washing machines were not rinsing at the specified water pressure, and floors and equipment were not clean. Also, safe food handling was not practiced to prevent the outbreak of foodborne illnesses. This is evidenced as follows: Finding #1: The main kitchen and unit kitchenettes were inspected on 10/03/2019 at 9:00 AM. The slicer and the floor under cooking equipment and next to walls in the main kitchen were soiled with food particles. [...]

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 potential financial liability for rehabilitative services during a non-covered stay. Specifically, residents who remained in the facility and after receiving covered rehabilitative services were not provided with the SNF ABN, Form CMS-10055. This was evident for two (2) (Resident #'s 214 and 234 out of three (3) sampled residents reviewed for Beneficiary Protection Notification. This is evidenced by:

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident was free from physical restraints, for one (Resident #126, of three reviewed for physical restraints. Specifically, the facility did not ensure that the least restrictive restraint for the least amount of time was used for the resident and that the Merry [NAME] (an enclosed walker, that the resident could not exit alone), was care planned as a restraint. This is evidenced by: Resident #126: The resident was admitted to the nursing home on 9/8/16, with diagnoses of Alzheimer's disease, hypertension, and glaucoma. The Minimum Data Set (MDS-an assessment tool) dated 5/24/19, assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. [...]

Inspectors wroteBased on record review and interview, the facility did not refer residents with newly evident mental illness for a level II resident review for two (Resident #'s 31 and 280) of two residents reviewed for PASRR (Pre-admission Screening and Resident Review). Specifically, the facility did not ensure Resident #'s 31 and 280, both newly diagnosed with a mental illness, received a level 1 screen to determine if a level II screen needed to be done. This is evidenced by: Resident #31: The resident was admitted on [DATE] with diagnoses of schizoaffective disorder-bipolar type, major depressive disorder and obsessive-compulsive disorder. The Minimum Data Set (MDS) of 7/05/19, documented the resident had moderate impairment for cognition, was able to understand others, and was able to be understood by others. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure it had an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for one (Resident #109) of one resident reviewed for activities. Specifically, the facility did not ensure that the resident was provided activities based on the resident's mental and physical abilities, and for 3 of 6 units the facility did not ensure that television (TV's) stations in the common areas were set on stations appropriate for residents' who were in the those areas. This is evidenced by: Resident #89: [...]

Inspectors wroteBased on record review and interview during a recertification survey and an abbreviated survey (Case #NY00241822), the facility did not ensure the resident environment remained as free of accident hazards as possible, and did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #383) of 4 residents reviewed for accidents and supervision. Specifically, for Resident #383, the facility did not ensure the resident, with a roam alert, was adequately supervised after the resident was escorted to the chapel by a staff member. Additionally, the front door did not alarm when the resident exited the building and returned a short time later through the same front door. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process. Specifically, the facility did not ensure there were time frames established for the steps in the MRR process concerning actions the pharmacist and facility needed to take when an irregularity was identified. This is evidenced by: Pharmacy Consultation Reports with a review date of 2/12/18 documented: - The pharmacy will compile any recommendations and send them to the facility to the attention of the Director of Nursing. A detailed summary is emailed to the Medical Director and copy to the DON/designee. - The Director of Nursing/designee will send the original to the specific units for the MD to address and sign. [...]

Inspectors wroteBased on record review and staff interview during the recertification survey, the facility did not ensure the policy regarding foods brought in to residents is in accordance with adopted regulations. Specifically, the facility policy does not include the provision to provide information to families and other visitors on the safe and sanitary storage, handling and consumption of food and does not include a procedure to ensure facility staff assist dependent residents in accessing and consuming the food. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 10/03/2019. [...]

Inspectors wroteBased on record review and interview during the recertification surveys the facility did not conduct an ongoing review that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for Resident #238, the facility did not ensure that their antibiotic stewardship program was implemented to improve antibiotic use when an antibiotic was prescribed without appropriate indications and monitoring. This was evidenced by: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it treated each resident with respect and dignity and cared for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for one of fourteen dining rooms observed. Specifically, the facility did not ensure staff were talking with the residents rather than each other while assisting with meals, and that three (Resident #'s 119, 122 and #175) of three residents in Broda chairs (chair that the seat can be moved closer to the ground to prevent falls) were not eating their meals while sitting at nose level to the table. This is evidenced by: Finding #1: [...]