Trustees of Eastern Star Hall & Home of the N Y S

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 2 of 2 medication carts ([NAME] and [NAME] Unit's medication carts); 1 of 2 medication rooms ([NAME] Unit); and 1 of 2 treatment carts ([NAME] unit). Specifically, the [NAME] and [NAME] Units medication carts had expired stock medications and insulin; the [NAME] medication room had expired stock medications and biologicals; and the [NAME] treatment cart was unlocked and unattended.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 Federal Health Recertification survey. Specifically, the results of the most recent Federal health recertification survey conducted 2/23/20223 were located behind the reception desk on a high shelf and was not accessible to all without having to ask for assistance.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #276) reviewed. Specifically, Resident #276 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required.

Inspectors wroteBased on record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 1 resident (Resident #218) reviewed. Specifically, Resident #218 did not have their ordered blood sugars documented in the medical record and were not available for the medical provider's review.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, 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 1 of 1 resident (Resident #37) reviewed. Specifically, Resident #37 did not have their pressure ulcer wound vacuum dressing (a vacuum assisted wound closure device that uses suction to help heal wounds) changed every three days as ordered.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00353222) surveys conducted 11/5/2024-11/8/2024 the facility did not ensure the resident environment remained as free of accident hazards as is possible for 1 of 3 residents (Resident #26) reviewed. Specifically, the facility did not ensure egress doors were secure and Resident #26 was able to exit through the doors and was found in the stairwell, scooting down the steps on their bottom.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen had unclean, scratched, and dented ceiling tiles, unclean ovens, pans with baked on debris, and expired cannisters of 3 bay sink sanitizer test strips.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure there was an effective pest control program for the main kitchen and the [NAME] Unit. Specifically, fruit flies and drain flies were observed in the main kitchen and on the [NAME] Unit.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure they assessed 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 3 of 70 residents (Residents #14, #16, and #50) reviewed. Specifically, Residents #14's, #16's, and #50's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gather information about a resident's condition when completing the assessment).

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 2/21/23-2/23/23, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 14 windows on the [NAME] unit (1 window at the nursing station, 2 windows in the dining room, 1 window in the soiled utility room, 1 window in the kitchenette, 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], and 1 window in the shower room). Specifically, windows on the [NAME] unit were able to fully open without restriction.

Inspectors wroteBased on observation, interview and record review during the recertification survey conducted 2/21/23-2/23/23, the facility failed to ensure that residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident #23) reviewed. Specifically, Resident #23 had a significant weight loss, weights were not obtained as ordered, and the medical provider was not notified of the significant weight loss.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not 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 resident (Resident #35) reviewed for respiratory care. Specifically, a staff member was observed entering Resident #35's room without donning the appropriate personal protective equipment (PPE) when droplet precautions were in place. Additionally, the facility infection prevention control program policies were not reviewed annually as required.

Inspectors wroteBased on observation, interview, and record review during the recertification survey, the facility did not ensure residents who used psychotropic drugs were not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. Specifically, Resident #22 was receiving an antipsychotic and there was no documented evidence of specific clinical indications to support its continued use.