The Commons on St. Anthony, a S N F & Short T R C

Inspectors wroteBased on record review and interviews, the facility failed to ensure the services arranged or provided by the facility meet professional standards of quality for one of six residents reviewed. Specifically, Resident #2 had increased confusion, urinary frequency and a strong urine odor, a physician order was obtained for a urinalysis, culture and sensitivity and Resident #2's urine sample was not collected to rule out a urinary tract infection.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 1 of 2 residents (Resident #196) and for 3 of 8 resident units (Units 3, 5, and 6) reviewed. Specifically, Resident #196's room had personal care information posted in an area visible to other residents and visitors; and Units 3, 5, and 6 had signs on the elevators documenting they were out of order to keep cognitively impaired residents from using the elevators.

Inspectors wroteBased on record review and interviews during recertification and abbreviated (NY00318491) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure residents had the right to receive visitors of their choosing at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident for 1 of 1 residents (Resident #243) reviewed. Specifically, the facility restricted Resident #243's family member's visitation based on the resident's healthcare proxy's wishes.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the individual financial record was available to the resident through quarterly statements and upon request for 2 of 2 residents (Residents #93 and #198) reviewed. Specifically, Residents #93 and #198 were not provided with personal fund statements within 30 days after the end of the quarter, and upon request.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident to meet medical and nursing needs identified in the comprehensive assessment for 1 of 3 residents (Residents #20) reviewed. Specifically, Resident #20 did not have footrests and lateral supports while in their scoot chair (a specialty chair used to improve positioning and mobility) as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00356778) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure residents received treatment and care in accordance with professional standard of practice for 1 of 2 residents (Residents #1 and #232) reviewed. Specifically, Resident #232 had bilateral (both sides) above the knee amputations and the facility did not follow up on a prosthetics (artificial limb) referral timely and Resident #1 experienced an emotionally distressing event that was not addressed timely.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00347746) surveys conducted 10/28/2024-11/1/2024, the facility failed to ensure a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infections for 1 of 1 resident (Resident #238) reviewed. Specifically, Resident #238's urinary drainage collection bag was not positioned below the level of the bladder to promote free urine flow (allows urine to back flow into urinary tract).

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 2 residents (Resident #152) reviewed. Specifically, Resident #152 received hemodialysis treatments at a community-based dialysis center and: - did not have ongoing assessments of their condition and monitoring for complications before and after dialysis treatments; - there was inconsistent communication and collaboration between the dialysis center and the facility; - the resident did not receive a bagged lunch prior to attending dialysis as planned; [...]

Inspectors wroteBased on observations and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not post on a daily basis the current resident census and the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 5 of 5 days. Specifically, the current daily resident census and nurse staffing schedules were located on the nursing supervisor/staffing office door that was down a hallway off the main lobby and not readily accessible to visitors or residents.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00356778) surveys conducted 10/28/2024-11/1/2024, the facility did not ensure routine and emergency drugs and biologicals were provided to 1 of 1 resident (Resident #1) reviewed. Specifically, Resident #1 was not administered the respiratory syncytial virus vaccine (helps protect against a common respiratory virus, RSV) timely after the vaccine was ordered in 2023 and 2024.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 1 resident (Resident #152) reviewed. Specifically, Resident #152 did not receive 24 of 26 doses of physician ordered levetiracetam (brand name Keppra, used to treat seizures).

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #238 and #52) and for 1 of 1 staff (Cycle Cleaner #1) reviewed. Specifically, Cycle Cleaner #1 did not practice appropriate use of personal protective equipment or hand hygiene during the cleaning of Resident #644's room who was on precautions for COVID-19; Resident #238's urinary drainage collection bag was not stored in a manner to prevent contamination; and Resident #52's urinary collection bag was observed lying directly on the floor.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 10/28/2024 -11/1/2024, the facility did not ensure that a surety bond (an agreement between the facility, the insurance company, and the resident wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds the facility holds, safeguards, manages, and accounts for) was purchased in the amount equal to or greater than the total resident funds to assure the security of all personal funds of residents deposited with the facility for 239 of 296 residents with personal funds accounts. Specifically, the facility's surety bond was for an amount less than the total of all resident personal fund accounts being held by the facility.

Inspectors wroteBased on interviews during the recertification survey conducted 10/28/2024-11/1/2024, the facility did not ensure the rights of citizenship, including the right to receive mail, were maintained for 296 of 296 residents residing in the facility. Specifically, mail was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Additionally, 3 of 6 anonymous residents present at the resident group meeting stated their mail was opened prior to it being delivered to them.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00333847), the facility failed to ensure residents were free from neglect for 1 of 5 residents reviewed (Resident #1). Specifically, Resident #1 was care planned for transfers with a mechanical lift and certified nurse aides #1 and #2 did not utilize a mechanical lift when transferring the resident out of bed; certified nurse aides #14 and 15 did not use a mechanical lift when transferring the resident back into bed, and the resident was not assessed timely after complaints of extreme pain. Subsequently, Resident #1 was found with a fractured arm. This result in actual harm to Resident #1 that was not immediate jeopardy.

Inspectors wroteBased on observation, record review, and interview during the abbreviated (NY00330077) survey, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #4) reviewed. Specifically, Resident #4 exhibited exit seeking behaviors and had a wanderguard (device to detect wandering) and eloped from the facility (left the facility undetected) during a fire drill when staff did not monitor the exit doors per facility policy.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00334306), the facility did not comply with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 1 of 5 residents reviewed (Resident #5). Specifically, Resident #5 was found deceased on the floor in another resident's room. The resident had a laceration to their head with bleeding. The facility called the County Coroner (referred to as the Medical Examiner by the facility), who instructed them to notify the police. The facility did not comply with the directives to immediately notify the police, moved the resident's body, and performed post-mortem care prior to the coroner's and police department's arrival.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 7 residents (Residents #44, 82, and 209) reviewed. Specifically, Residents #44, 82, and 209 were observed with unclean wheelchairs.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 9 (Resident #204) reviewed. Specifically, Resident #204 was observed unshaven and with soiled clothing. The facility policy Activities of Daily Living - ADLs dated 1/21/2020 documented the resident who was unable to carry out activities of daily living would receive all the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident #204 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease), tremor, and need for assistance with personal care. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 12/12/22-12/20/22, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive person centered care plan for 1 of 4 residents (Resident #214) reviewed. Specifically, Resident #214 did not have a physician order for oxygen (O2) and was observed on multiple days receiving O2 via a nasal cannula (NC, a tube delivering oxygen through the nose).

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated (NY00303532) surveys conducted 12/12/22-12/20/22, the facility failed to ensure residents were free of significant medication errors for 1 of 8 residents (Resident #1) reviewed. Specifically, Resident #1 did not receive their phenobarbital (anti-seizure medications) and diazepam (antianxiety/sedative) as ordered.

Inspectors wroteBased on record review and interview during the recertification survey the facility did not ensure assessment of residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 6 of 7 residents (Residents #1, 2, 3, 5, 6 and 7) reviewed for resident assessments. Specifically, Residents #1, 2, 3, 5, 6 and 7's Minimum Data Set (MDS) assessments were completed later than 14 days following the Assessment Reference Date (ARD).

Inspectors wroteBased on record review and interview during the recertification survey the facility did not ensure residents received the necessary care and services to ensure that a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 1 resident (Resident #55) reviewed for rehabilitation and restorative services. Specifically, there was no documentation Resident #55 was ambulated by staff as care planned; in addition staff reported the resident had a decline in ambulation and it was not re-assessed timely.

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure residents with limited range of motion received the appropriate treatment and services to increase or prevent decrease in range of motion (ROM) for 2 of 6 residents (Residents #96 and 282) reviewed for range of motion. Specifically, Resident #96 was provided a palm guard (a device used for hand contractures) with no parameters for use. Resident #282 did not have interventions in place to prevent further decline in a neck contracture.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #155) reviewed for respiratory care. Specifically, Resident #155 had orders for a Continuous Positive Airway Pressure machine (CPAP, a machine used to deliver constant and steady air pressure to people with sleep apnea) and scheduled care and cleaning of the equipment was not provided.