Fort Hudson Nursing Center INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the recertification, the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels of Certified Nursing Aides and Licensed Practical Nurses were not met every day on multiple shifts and multiple units, from 12/01/2024 - 12/05/2024. In addition, record review indicated resident grievances related to staffing shortages, there were observations of delayed call light responses times, and resident complaints of low staffing. This is evidenced by: Based on the facility assessment, dated 8/28/2024, the following was the current staffing plan, presented as the number of Full Time Employees by position by shift. 6 AM-2 PM (days) 2 PM-10 PM(evenings) 10 PM-6 AM (nights) Registered Nurse 11 2 1 Licensed Practical Nurse 10 10 5 Certified Nursing…

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 interviews during a recertification survey, the facility did not ensure residents could safely self-administer medication when clinically appropriate for 2 (Residents #35 and #168) of 2 residents reviewed for medication administration. Specifically, (a) Resident #35 was observed with their prescribed Albuterol inhaler on their overbed table on 12/02/2024 and 12/04/2024, and (b) Resident #168 was observed changing their empty oxygen tank to a full oxygen tank on 12/03/2024 and setting the flow rate. There was no documented evidence that Resident #'s 35 and 168 were assessed to determine their ability to safely self-administer medications, or for physician orders for self-administration of medications. This is evidenced by: The facility Medication Self-Administration Policy, dated 9/2017, documented that staff and practitioners would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for 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.

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Residents #334) of 35 residents reviewed. Specifically, Resident #334 received oxygen that was not noted in the care plan. This is evidenced by: The Policy titled Care Planning dated 09/21/2017, documented the purpose of the policy was to have a written plan for staff to follow to provide care to a resident of the facility. Upon admission the 48-hour care plan would be developed and reviewed with the resident and/or the health care proxy within 48 hours. The care plan would be completed by the first care plan meeting within 14 days of admission. The care plan will be added to as new issues arise and when recognized plans have been resolved. Resident #334 was admitted to the facility with the diagnoses of hypertension, paroxysmal atrial…

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 records review and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 2 (Residents #59 and #86) of 6 residents reviewed for unnecessary medications. Specifically, for Residents #59 and #86, as-needed psychotropic medication orders did not include stop dates. This is evidenced by: The policy and procedure titled Psychotropic Medication Use, dated 6/2024, stated as needed orders for psychotropic medications would be time limited. Resident #59 Resident #59 was admitted to the facility with diagnoses of dementia, anxiety disorder and depression. The Minimum Data Set, dated [DATE] documented the resident was usually able to be understood and could usually understand others; the resident was severely cognitively impaired. Resident #59 had an order for lorazepam (a sedative), 0.5 milligrams by mouth every 6 hours as…

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, record review, and interviews during the recertification survey, the facility did not ensure that each resident received accommodated resident choices, intolerances, and preferences. This was identified for one (Resident #82) of 35 residents reviewed. Specifically, Resident #82 had a dietician recommendation, signed by the physician, to discontinue a collagen supplement. For 35 days after the recommendation, the collagen was still ordered. This is evidenced by: The Policy titled Pressure Injury (PI)/ and Wound Care dated 11/15/2024 documented the facility was to ensure that the residents would receive wound care consistent with resident needs, goals, and recognized standards of practice. The procedure was that the nurse manager or designated registered nurse, dietician, physical therapist, and other interdisciplinary team members as needed would evaluate resident's clinical condition and pressure ulcer risk factors. The interdisciplinary team would define and implement interventions as appropriate. The facility would maintain a system to assure that 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, record review, and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 3 (Residents #21, 144. and #171) of 35 residents reviewed. Specifically, (a.) for Resident #21, the facility incontinence care provided was not documented; (b.) for Residents #144 and #171 the care provided by Certified Nurse Aides were not consistently documented, including the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. This is evidenced by: A review of policy titled Documentation for Certified Nursing Assistants dated 11/22/2010 documented all documentation of care delivered to a resident by a Certified Nursing Assistant would be done using the Point Click Care (PCC) kiosks. The policy stated care should be entered as close as possible after the care had been rendered and staff was to enter information at the kiosk at…

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, manufacturer directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer, shelving and sections of the floor were not in good repair, and equipment and floors required cleaning. This is evidenced as follows. The kitchen was inspected on 12/08/2021 at 9:39 AM. The concentration of QAC used to sanitize food contact equipment at the 3-compartment sink was found to be less than 150 parts per million (ppm) when measured at 70 degrees Fahrenheit (F), and the concentration of QAC used to sanitize food contact equipment at the preparation sink was found to be less than 150 ppm when measured at 71 F. The manufacturer's label directions stated the concentration is to be between 150 ppm and 400 ppm when the solution is measured between 65 F and 75 F. The tabletop mixer, can opener 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 record review and interviews during the recertification survey, the facility did not ensure to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #57) of 1 resident reviewed for dental services. Specifically, for Resident #57, the facility did not ensure the physician was notified when a physician ordered medication, Kenalog in Orabase (triamcinolone- a corticosteroid used to reduce swelling and ulcers in the mouth) was not available to be administered. This is evidenced by: Resident #57: Resident #57 was admitted to the facility with the diagnoses of rheumatoid arthritis, chronic kidney disease, and diabetes. The Minimum Data Set (MDS - an assessment tool) dated 10/1/2021, documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure (P&P) titled Medication Administration and Treatment Documentation last revised 3/29/2012, documented when a medication was not…

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 and staff interview during the recertification survey, the facility did not maintain floors and floor coverings in a clean and sanitary manner in accordance with professional standards for food service safety. Floors are to be maintained in good repair and are to be smooth, durable, and not absorbent. Specifically, the floor of the dish machine room and walk in cooler #2 were not maintained in a sanitary manner. This is evidenced as follows. The main kitchen was inspected on 07/09/2019 at 9:39 AM. The floor tiles in the dish room of the main kitchen were not properly grouted, and the floor of the walk-in freezer #2 was covered in a layer of brown debris under the storage racks. The Director of Food Service stated in an interview on 07/09/2019 at 10:15 AM, that the facility just power washed the floors in the dish room and noticed that the floor needed to be re-grouted. Additionally, he stated that the floor in the walk-in cooler will be cleaned. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.150 (c) 14-1.170.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview during the recent recertification survey, the facility did not ensure that resident and/or their designated representative were fully informed of potential financial liability for rehabilitative services during a non-covered stay. Specifically, the facility did not ensure that residents who remained in the facility and received covered rehabilitative services were provided with the Skilled Nursing Advanced Beneficiary Notice (SNF ABN), Form CMS-10055 or residents who were discharged from the facility were not provided with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123. This was evident for three (3) out of three (3) sampled residents reviewed for Beneficiary Protection Notification (Residents #'s 93, 162, and #439). This is evidenced by: A policy titled Medicare Notice of Non-Coverage dated April 2018 documented: Form CMS-10055 (2018) - To be used when Medicare Part A services are determined to no longer be required or if Medicare coverage…

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 interviews, and record reviews during a recertification survey, the facility did not ensure the assessment accurately reflected the resident's status for two (Resident #'s 36 and #125) of thirty-five residents reviewed for accurate resident assessments. Specifically; for Resident #125, the facility did not ensure the accuracy of the Minimum Data Set (MDS) when the reason for the resident's weight loss was documented as intentional rather than unintentional, and for Resident #36, whose medical record did not include a diagnosis of schizophrenia, the facility did not ensure the Minimum Data Set (MDS) did not include documentation that the resident had a diagnosis of schizophrenia. This is evidenced: Resident #36: The resident was admitted to the facility on [DATE], with the diagnoses of mood disorder, delusional disorder, and major depressive disorder. The MDS dated [DATE] documented the resident had moderately impaired cognition and was able to make herself understood and understand others. A review of…

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 conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) resident (Residents #37) of one (1) resident reviewed. Specifically, for Resident #37, the facility did not ensure an oxygen tank was replaced when empty. This is evidenced by: The Policy and Procedure for Oxygen Use and Storage, last updated 8/31/17, documented, nurses are to check each shift, or more frequently as appropriate, the oxygen tank to ensure appropriate flow and sufficient oxygen is present in the tank Resident #37: This resident was admitted [DATE], with diagnoses of obstructive sleep apnea, respiratory failure, type II diabetes, peripheral vascular disease, atrial fibrillation and morbid obesity. The Minimum Data Set (MDS) dated [DATE], documented the resident was without impaired cognition, was able to understand others and was able to be understood. The physician's…

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 interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: A facility Policy titled Timeliness of Medication Regimen Review (MRR) Reports approved 1/2/19, documented that when the consultant pharmacist identified an irregularity that required immediate or urgent action, the pharmacist would notify the Director of Nursing (DON) and the assigned nurse at the time the irregularity was identified. The policy did not include the timeframe for contacting the physician. During an interview on 7/12/19 at 1:10 PM, the Administrator stated that she thought the policy did addressed the timeframe's. 10NYCRR 415.18(c)(2)

Based on record review and interview, the facility did not ensure a policy regarding use and storage of foods brought to residents by family and other visitors was developed to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure facility staff would assist dependent residents in accessing and consuming food brought in by family or visitors. This is evidenced by: A Policy and Procedure titled Food From Outside Sources dated 3/19, did not include documentation of how the facility would assist dependent residents in accessing and consuming food brought in by family or visitors. During an interview on 7/12/19 at 10:18 AM, the Food Service Director (FSD) stated the policy did not include a process or procedure to ensure dependent residents could access and consume foods brought in by family or visitors. 10NYCRR415.14 (h)