Elmhurst Care Center, Inc,

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview during the Recertification survey, the facility did not ensure that housekeeping and maintenance services were maintained. Specifically: 1) Seating furniture in resident room and in the common area were stained, soiled and faded. 2) Holes in the ceiling and walls in the staff bathroom and clean linen closet. 3) Dining room tables were wobbly. 4) Dining room walls and ceiling with dried food particles and stains. 5) Missing window panels. 6) Mechanical lifts, scales layered with accumulation of dust and dirt. 7) Wheelchairs with torn armrest and torn back sides. 8) Window blinds missing vertical panels. This was evident for three (3) of (6) six resident units. (units 4, 5 and 6). The findings are: The following was observed during the initial unit observations and subsequent dates on 06/26/24 at 10:37 AM on the 4th floor and on 06/27/19 at at 7:18 AM on the 5th fl and 06/28/24 at 8:01 AM on the 6th floor. 4th floor unit: Resident scale layered with dirt and stains which was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the re-certification survey, the facility did not ensure that each resident was treated with dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life. Specifically, the physical therapist assistant was observed holding up the residents oversized red sweat pants during floor ambulation. This was evident for one (1) of one (1) resident reviewed for Dignity (Resident #10). The finding is: The facility policy reviewed April 2024, titled, Dignity: Quality of Life, documented, Encouraging and assisting residents to dress in their own clothes (according to season and appropriately fitting). Resident #10 was admitted on [DATE] and re-admitted on [DATE] with diagnoses which included, but not limited to Major Depressive Disorder, Dementia and Schizophrenia. The Quarterly Minimum Data Set 3.0 (MDS), Assessment Reference Date (ARD) 03/21/2024, documented that the resident had clear speech and was usually understood and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident. This was evident for 1 (Resident # 134) of 38 sampled residents. Specifically, ) Resident #134 had no care plan in place for antibiotic therapy. The findings are: The facility policy and procedure titled Comprehensive Care Planning, with the last revised date of March 2024, documented that the registered nurse coordinator is responsible for seeing that the comprehensive care plan correlates with the care area assessment. The care plan must be kept current, and problems well stated. Resident #134 was admitted to the facility with diagnoses that include Respiratory Failure and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #134's cognition as severely impaired with a Brief Interview for Mental Status score of 6. A Physician Order dated 06/24/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY00342009) from 6/26/24 to 7/03/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report, and 2) multiple nursing staff members reported a lack of sufficient staffing. The findings include but are not limited to: The Facility Staffing policy reviewed March 2024 documented it is the policy of this facility to provide sufficient staffing to meet the needs of all residents. The Facility Assessment tool dated 11/28/23 did not provide a staff to resident ratio for comparison and did not provide the number of staff required to work on each of the units. The New York State Department of Health Intake #NY00342009 dated 5/13/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews conducted during the Recertification Survey from 06/26/2024 to 07/03/2024, the facility did not ensure that the nurse staffing information was posted appropriately. Specifically, the posting of daily nurse staffing information was not posted in a prominent area which was readily accessible to residents and visitors. The findings are: The facility policy and procedure titled Staff Posting Policy reviewed March 2024 documented the daily nursing patterns will be posted daily and updated by shifts in front of the nursing supervisor's office to ensure prominent placement to allow accessibility to all residents and visitors of the facility. During observations conducted on 06/26/2024, 06/27/2024, 06/28/2024, 07/01/2024, and 07/02/2024, the State Surveyor was unable to locate the postings of the daily nurse staffing levels for each shift or any signage instructing residents or visitors where it was located. On 07/02/2024 at 2:50 PM, the State Surveyor asked the Staffing Coordinator where the staffing information was located and was shown the posting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview conducted during the Recertification survey from 9/19/22 to 9/27/22, the facility did not ensure that the Minimum Data Set (MDS) 3.0 Assessments were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. Specifically, thirty two (32) Resident MDS Assessments triggered as being over 120 days old. This was evident for, but not limited to, Resident # 51; Resident #34; Resident #13; Resident #10; Resident #12; and Resident # 48. The findings are: The facility's undated Nursing Standards Policies & Procedures protocol Assessment Minimum Data Set 3.0, documented, the Centers for Medicare & Medicare Services has specified a resident assessment for use in nursing facilities called the Minimum Data Set (MDS) 3.0. The MDS 3.0 is used for conducting comprehensive resident assessment at defined timeframes. 1) Resident #51 was admitted on [DATE]. Per CMS Submission Report MDS 3.0 NH Final Validation Report, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews conducted during the Recertification Survey from 9/19/22 to 9/27/22, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were not covered. This was evident for 1 of 2 residents reviewed for Dignity out of a sample of 38 residents. (Resident # 67) The findings are: The Facility's Policy titled 'Foley Catheter- Indwelling' reviewed April 2022, documented that it is the Policy of Elmhurst Care Center to prevent infection to those residents who has indwelling urinary catheters. Catheters will be cared and monitored as often as possible. The Policy also documented that indwelling Foley catheter drainage bag will be placed inside a cover/liner bag to prevent to prevent direct contact of the drainage bag in the floor that can cause infection. Resident # 67 was admitted with diagnoses which included Benign Prostatic Hyperplasia (BPH) and Prostate Cancer. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview conducted during a Recertification survey from 9/19/22 to 9/27/22, the facility did not ensure that each portion of the MDS assessment accurately reflect the resident's status. Specifically, the most recent MDS did not accurately document that the resident had a diagnosis of Psychosis as documented in the psychiatric consultant notes and physician's orders. This was evident for 1 of 6 residents investigated for Unnecessary Medication out of 38 sampled residents. (Resident # 198). The findings are: The Center for Medicare and Medicaid Services Long-Term Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 documented check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. 1.Resident #198 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review conducted during the Recertification survey from 9/19/22 to 9/27/22, the facility did not ensure that a Comprehensive Care Plan (CCP) that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment was developed. Specifically, a care plan was not developed to address a resident's pacemaker. This was evident for 1 of 6 residents reviewed for Unnecessary Medications out of sample of 38 residents (Resident #162). The finding is: The policy and procedure titled Comprehensive Care Planning reviewed April 2022 documented all long-term care residents will be reviewed, as necessary, and at intervals not to exceed 90 residents day. At these quarterly meetings (or subsequent review) the responses to the current plan of care and the establishment of new goals and treatment plans are executed. Resident # 162 was admitted to the facility with diagnoses that included Rheumatoid Arthritis, Coronary Artery Disease - Status Post (S/P) Pacemaker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews during the Recertification survey from 9/19/2022 to 9/27/2022, the facility did not ensure a resident with limited range of motion (ROM) and mobility received appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion. Specifically, a left ankle foot orthosis (AFO) and a left wrist hand and finger orthotic device were not provided to the resident as per physician order. This was evident in 1 of 4 residents reviewed for Position, Mobility and 1 of 6 residents reviewed for Activities of Daily Living out of 34 sampled residents. (Resident #3 and #74). The finding is: The facility policy titled Assistive/Adaptive Devices revised 4/2022 documented the following: It is the policy of Elmhurst Care Center to provide assistive/adaptive devices for residents who presents with decreased motor functioning that impairs the ability to use their extremities. Staff will make sure that applications of devices are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey, the facility did not ensure that services provided, as outlined by the comprehensive care plan, met professional standards of quality. Specifically: (1) A resident with a Gastrostomy Tube (GT) and Nothing by Mouth (NPO) order was given water by mouth. (2) Insulin was not administered as ordered (Resident #200). This was evident for 2 of 38 sampled residents (Resident #221 and #200). The findings are: 1.) Resident # 221 was admitted with diagnoses that included: Dysphagia, Vascular Dementia, and Malignant Neoplasm of the Colon. The Quarterly Minimum Data Set (MDS) Assessment Reference Date 10/27/2019, documented the resident had severely impaired cognition. The MDS further documented the resident received tube feeding for nutrition and hydration. The Comprehensive Care Plan (CCP) for Tube feeding documented that, the resident requires tube feeding due to inability to intake nutrition orally due to dysphagia. On 12/01/19 at 11:43…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically: (1) A resident with a Gastrostomy Tube (GT) and Nothing by Mouth (NPO) order was given water by mouth. (2) Insulin was not administered as ordered (Resident #200). This was evident for 2 of 38 sampled residents (Resident #221 and #200). The findings are: 1.) Resident # 221 was admitted with diagnoses that included: Dysphagia, Vascular Dementia, and Malignant Neoplasm of the Colon. The Quarterly Minimum Data Set (MDS) Assessment Reference Date 10/27/2019, documented the resident had severely impaired cognition. The MDS further documented the resident received tube feeding for nutrition and hydration. The Comprehensive Care Plan (CCP) for Tube feeding documented that, the resident requires tube feeding due to inability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, the floor tiles at the foot of the bed in a resident's room were lifting up and uneven with a hole measuring approximately 3 inches by 3 inches with a circumference of approximately 10 inches. This was evident for 1 of 1 residents reviewed for Accident (Resident #93). The finding is: Resident # 93 was admitted with diagnoses which include: Hemiparesis, Cerebral Vascular Accident (CVA) and Seizure Disorder. The Quarterly Minimum Data Set 3.0 (MDS) Assessment Reference Date (ARD) of 09/05/19 documented the resident had moderately impaired cognition. The MDS further documented the resident required extensive assist for activities of daily living needs (ADL). A walker and/or wheelchair were used for mobility. On 12/01/19 at 11:01 AM, the the floor tiles by the foot of the resident's bed were loose and uneven with a hole measuring approximately 3 inches by 3 inches with a circumference of approximately 10 inches. Staff were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.