The Cottages at Garden Grove, a Skilled Nrsg Comm

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for one of five residents (Resident #153) reviewed. Specifically, Resident #153 developed a Stage 2 pressure ulcer (partial thickness tissue loss) to the coccyx (tailbone) and there was no documented evidence that wound care orders were clarified to determine if the treatment was daily or every three days; and there was no documented evidence of regular pressure ulcer assessments between [DATE] and [DATE]. Subsequently, the resident's pressure ulcer deteriorated to an unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) area. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to establish and maintain 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 one (1) of three (3) residents (Resident #35) and one (1) of 12 Cottages (Cottage 31) reviewed. Specifically, staff in Cottage 31 did not change their gloves or perform hand hygiene in between cleaning resident rooms; and Resident #35's urinary drainage tubing was laying directly on the floor.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #129) reviewed. Specifically, Resident #129's urinary catheter drainage bag (collects urine) was uncovered and visible to other residents, visitors, and staff.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (2) of two (2) residents (Residents #18 and #131) reviewed. Specifically, Resident #18 did not receive their prescribed furosemide (diuretic medication) for 4 days, was not weighed daily as ordered, and there was no documented evidence the medical provider was notified; and Resident # 131 had an unwitnessed fall, and neurological checks were not completed as ordered.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure a resident with limited range of motion received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable for one (1) of two (2) residents (Resident #66) reviewed. Specifically, Resident #66 had an order for a thoracolumbar sacral orthosis (a back brace used to keep the spine extended after a fracture) and was observed without the brace and there was no documented evidence the provider was notified of resident refusals.

Inspectors wroteBased on observations, record review, and interviews (iQIES Intake 2628724) the facility failed to ensure adequate supervision to prevent accidents for one (1) of seven (7) residents (Resident #151) reviewed. Specifically, Resident #151 required a mechanical lift for transfers and Certified Nurse Aide #37 transferred the resident using a gait belt resulting in a fall.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents (Residents #134) reviewed. Specifically, Residents #134 had behavioral symptoms related to dementia and did not have a person-centered care plan that included and supported their dementia care needs.

Inspectors wroteBased on observations, record review, and interviews (iQIES #2655817) the facility failed to ensure residents were free of any significant medication errors for two (2) of four (4) residents (Residents #109 and #75) reviewed. Specifically, Resident #109 was administered a crushed medication crushed despite instructions that crushing was contraindicated; and Resident #75 was administered all crushed medications together via their gastrostomy tube (enteral tube, a feeding tube directly into the stomach).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for two (2) of 13 kitchens (Cottages 10 and 11 kitchens). Specifically, Cottage 10 kitchen had undated and expired food items; and Cottage 11 had expired food in the pantry refrigerator and food was out of acceptable temperature range.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a process was in place for residents to have their grievances addressed for 138 of 138 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms was not available to the residents and the facility did not have a process for residents to file an anonymous grievance in 13 of 13 Cottages; and three (3) of three (3) anonymous residents present at the resident group meeting stated they did not know if there were grievance forms or where they were located, their right to file grievances anonymously, who the Grievance Officer was, and there was not always follow up on how their concerns were addressed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the results of the most recent Federal and State surveys were posted in a place readily accessible where individuals who wished to examine the survey results did not have to ask for them for 5 of 13 cottages (Cottages 10, 11, 21, 31, and 77). Specifically, the facility State survey results binders in Cottages 10, 11, 21, 31, and 77 were on a mantle shelf that was not readily accessible to residents in wheelchairs or were partially obscured by other items and not able to be easily seen by residents and families without asking for assistance. Findings Include:The New York State Department of Health Your Rights as a Nursing Home Resident in New York State documented residents had the right to read the results of the most recent State and Federal inspection survey and the facility's plan to correct any violations. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide the resident and their representative with a summary of their baseline care plan that included initial goals, a summary of medications and dietary instructions, and services and treatments to be administered for one (1) of one (1) resident (Resident #14) reviewed. Specifically, there was no documented evidence Resident #14 and their representative were informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.

Inspectors wroteBased on observation, record review, and interviews conducted during the abbreviated survey (iQIES #2643653) the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 did not receive timely treatment or interventions when they did not have bowel movements for more than three (3) days. Additionally, the medical provider was not notified of the resident's bowel status and when a bowel medication was not available to administer.

Inspectors wroteBased on record review and interview during the abbreviated survey (NY00325983), the facility did not promote and facilitate the resident's right to self-determination through support of resident choice, including the resident's right to choose activities and health care services consistent with their interests, assessments, and plan of care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 refused incontinence care and staff continued to provide care following multiple refusals.

Inspectors wroteBased on observations, record review, and interviews during the abbreviation survey (NY00373359), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 was care planned for two staff for care, a staff member provided care alone, and the resident sustained skin tears. The resident also sustained a fracture and it was not able to be determined if the fracture occurred during the care, or following the incident.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/8/2024-7/16/2024, the facility failed to ensure all allegations of abuse, neglect, and mistreatment were thoroughly investigated or reported to the New York State Department of Health as required for 1 of 1 resident (Resident #77) reviewed. Specifically, Certified Nurse Aide #1 had a physical altercation with Resident #77 causing a skin tear (a wound caused when layers of skin separate or peel back) to the resident's arm and Certified Nurse Aide #1 was not immediately removed from direct resident care pending investigation. Additionally, the facility did not conduct a thorough investigation to rule out abuse and neglect and did not report the incident to the New York State Department of Health as required.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00340968, NY00316430, and NY00302422) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living for 1 of 4 residents (Resident #61) reviewed. Specifically, Resident #61 leaned far to the right in their wheelchair and was not assisted with repositioning.

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated (NY00302422, NY00316430, NY00340968) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 7 residents (Resident #100) reviewed. Specifically, Resident #100 was not assisted with removing unwanted facial hair and had unclean and untrimmed fingernails.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00316340 and NY00336542) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #120) reviewed. Specifically, Resident #120 was not offered meaningful activities that included their interests and preferences.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00316430) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Residents #125 and #7) reviewed. Specifically, Resident #125 did not have an alternating pressure overlay (a specialty mattress overlay that provides air flow to relieve pressure) in place as ordered, and Resident #7's wound treatments were not completed as ordered.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00316430 and NY00336542) surveys conducted 7/8/2024-7/16/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 7/10/2024 lunch meal in Cottage 60 and the 7/15/2024 lunch meal in Cottage 31). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 7/10/2024 and 7/15/2024 and Residents #40 and #105 stated the food did not taste good.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00336542) surveys conducted 7/8/2024-7/16/2024, the facility did not establish and maintain 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 2 staff (Licensed Practical Nurse #7 and Certified Nurse Aide #8) reviewed. Specifically, Licensed Practical Nurse #7 did not perform hand hygiene or change their gloves during wound care, and Licensed Practical Nurse #7 and Certified Nurse Aide #8 did not perform hand hygiene or wear gowns when providing incontinence and wound care to Resident #106 who was on enhanced barrier precautions.

Inspectors wroteBased on record review and interview conducted during the abbreviated survey (NY00329594 and NY00331170), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 3 residents (Resident #1 and 2) reviewed. Specifically, - Resident #1 was found with a bruise of unknown origin and an assessment was not completed timely, and an investigation to rule out abuse/neglect was not initiated at the time of the report. - Resident #1 fell and sustained an injury and the investigation did not identify if the resident's care plan was followed for toileting (every 2 to 4 hours) or if the resident's fall mat was in place at the time of the fall. -Resident #2 had a fall and it was documented they were clearly incontinent. [...]

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/7/22-6/10/22, the facility failed to ensure each resident had the right to a dignified existence for 12 of 19 residents (Residents # 6, 13, 28, 34, 43, 47, 60, 66, 69, 77, 84, and 96) reviewed. Specifically, Resident #43 was observed with an unclean wheelchair; Residents #66 and 69 waited for their meals for extended periods of time after their tablemates were served and eating: and Residents #6, 13, 28, 34, 43, 47, 60, 66, 69, 77, 84, and 96 were served their breakfast meals over an hour after the scheduled meal service time.

Inspectors wroteBased on observation and interview during the recertification and abbreviated (NY00276492) surveys conducted 6/7/22-6/10/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 8 of 9 cottages (Cottages #11, #21, #31, #50, #51, #60, #77, and #87) reviewed. Specifically, Cottages #11, 21, 31, 50, 51, 60, 77 and 87 were observed with stained chairs and multiple areas in need of repair, and Cottage #77 had leaking water from the kitchen to the dining room from the dishwasher and 3 bay sink.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 6/7/22-6/10/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 of 2 meal trays tested. Specifically, 1 breakfast meal test tray and 1 lunch meal test tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted from 6/7/22 -6/10/22, the facility failed to maintain 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 1 of 1 licensed practical nurse (LPN #7) observed during medication administration, and for 3 of 7 meal observations. Specifically, LPN #7 did not perform appropriate hand hygiene during medication administration, and proper hand hygiene was not performed during resident meal service

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated surveys (NY00276492) conducted 6/7/22-6/10/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 of 4 residents (Resident #51) reviewed. Specifically, Resident #51 did not receive assistance with shaving as planned.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/7/22-6/10/22, the facility failed to ensure residents who had a prosthesis (artificial limb) were provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences, to wear and be able to use the prosthetic device for 1 of 6 residents (Residents #18) reviewed. Specifically, Resident #18 did not receive assistance applying a prosthetic limb to ambulate independently, resulting in decreased functional mobility.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 6/7/22-6/10/22, the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 3 residents (Resident #66) reviewed. Specifically, Resident #66 did not receive an approved substitution at one meal and did not receive gluten (a protein found in some grain products) free bread as ordered.