The Wartburg Home

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 7/22/25 to 7/28/25, the facility did not ensure food was stored, prepared, and distributed in sanitary conditions in accordance with professional standards for food service safety. Specifically, there were unlabeled and undated food items in the kitchen, storeroom, and unit pantry, there was expired foods in the kitchen, storeroom, and unit pantry, there was a cell phone on the food prep area, dietary staff did not wear proper hair and beard restraints, there were boxes stored on the floor, there was personal staff item in kitchen food prep area and there were poor sanitary conditions in unit pantries.

Inspectors wroteBased on observations and interviews during the recertification survey from 7/22/25 to 7/28/25, the facility did not ensure that essential kitchen equipment was maintained in safe operating condition. Specifically, dishwashers in all four-unit pantries were broken, Unit 1 South pantry food warmer, tall standing freezer, and steam table were broken, and the main kitchen dish machine did not reach proper temperature for sanitization in wash (150-165 degrees), rinse, or final rinse (180 degrees) modes.

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 7/22/25-7/28/25, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice for one of one resident (Resident #7) reviewed for respiratory care. Specifically, Resident #7 was receiving oxygen via nasal canula tubing which was observed in the resident's mouth instead of in the resident's nostrils.

Inspectors wroteBased on observation, record review and interviews conducted during the 7/22/25-7/28/25 recertification survey, the facility did not ensure that all medications were secured in a locked storage area. Specifically, Symbicort (budesonide-formoterol) aerosol inhaler was observed on Resident #35's room table, not under direct supervision of authorized staff.

Inspectors wroteBased on record review, and interviews conducted during an abbreviated survey (NY00327590), the facility did not ensure prompt efforts were made to resolve a resident's grievance. Specifically, Resident #1's Family Representative (FR) complained to the facility on [DATE] regarding incontinence care and bathroom ambulation needs not being rendered. There was no evidence that a grievance form was initiated and completed in accordance with the facility policy and there was no documented evidence that the complaints were addressed.

Inspectors wroteBased on record reviews and interviews during the recertification and abbreviated surveys (NY00306039) 6/13/23 to 6/20/23, the facility did not ensure that residents or resident's representatives were notified in writing of the facility Bed Hold Policy for 4 of 5 residents reviewed for hospitalization. Specifically, Residents #257, #103, #74, and #97. were transferred to the hospital and the facility did not provide evidence that a written notice of the facility Bed Hold Policy was given to the residents or representatives.

Inspectors wroteBased on record reviews and interviews conducted during a recertification survey 6/13/2023-6/20/2023, the facility did not ensure that the certified nurse aides (CNA) were provided the required 12 hours of training and annual in-service on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 8 out of 10 CNAs (CNA #1, 2, 3, 4, 5, 6, 7, and 8), reviewed for Nurse Aide training, were provided 12 hours of mandatory training.

Inspectors wroteBased on interview and record review during a recertification survey conducted 6/13/23-6/20/23, the facility did not ensure that baseline care plans were initiated for 2 of 5 residents reviewed for unnecessary medications. Specifically, Residents #46 and 17 were prescribed anticoagulation medications by the physician, and there were no care plans initiated within 48 hours of admission.

Inspectors wroteBased on record review and interview during a recertification survey conducted 6/13/23-6/20/23, the facility did not ensure that 1 of 3 residents (#17), reviewed for pressure ulcer, was provided the appropriate care to prevent the development of a pressure ulcer. Specifically, there were no physician ordered skin checks/monitoring for Resident # 17 with a left knee immobilizer and the resident developed a pressure ulcer.

Inspectors wroteBased upon observation, interview, and record review conducted during a recertification survey the facility did not ensure labeling, dating, and monitoring of refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. This was identified during the initial tour of the kitchen. The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, the facility did not develop a person-centered care plan with measurable objectives, time frames and appropriate interventions based on comprehensive assessments for 1 of 1 resident (Resident #93 ) reviewed for dialysis and 2 of 6 residents (Residents # 97 and #368) reviewed for unnecessary medications. Specifically, there were no care plans to address End Stage Renal Disease on Hemodialysis or Anticoagulation with Coumadin use for Resident # 93, Hypertension or Anticoagulation with Lovenox and Aspirin use for Resident # 97, or Chronic Obstructive Pulmonary Disease (COPD) or Diabetes Mellitus for Resident # 368.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey the facility did not ensure that the care planning team 1. established and implemented the frequency by which a nasal cannula with tubing should have been changed for two of two residents reviewed for respiratory care (Residents #84 and #268) using oxygen, and 2. for 1 of 2 residents (Resident #268) the facility did not ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for Resident #84, there was no evidence to indicate the oxygen tubing/cannula was being changed, labeled with date and initialed. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that current acceptable professional standard of practice regarding storage of multi-dose insulin injection medication were followed. Specifically, (1) Multi-dose Insulin Pens were opened, undated and not discarded after the recommended 28-day period per manufacture specifications; and (2) A multi-dose Insulin Pen was not stored in the refrigerator according to the manufacture specification. This was evident during review of the facility's medication storage for two of six facility units (3 [NAME] and 1 South Units).

Inspectors wroteBased on observation, interview and record review conducted during a Recertification Survey, the facility did not ensure that facility staff followed proper hand hygiene and gloving techniques to prevent cross-contamination and the spread of infection. Specifically, (1) cross-contamination of wounds and wound supplies was observed; and (2) removal of soiled gloves and hand hygiene were not observed during wound care procedures for 2 of 5 residents (Residents #52 and #73) reviewed for pressure ulcer/injury.