Iroquois Nursing Home INC

Based on record review and interviews (iQIES intake 2971099) the facility failed to ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (ensures that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care; a Level II Preadmission Screening and Resident Review identifies the specialized services required by the resident) for one (1) of one (1) residents (Resident #140) reviewed. Specifically, Resident #140 had a known developmental disability not identified on their initial Screen, a new screen was not completed, they were not referred for a Preadmission Screening and Resident Review Level II timely when the resident's discharge plan changed to long term care; and they did not have a care plan reflecting their Level II Preadmission Screening and Resident Review determination following the completion of a Level II assessment. Findings include:The New York…

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 interviews during the abbreviated survey (#2649782) conducted 01/30/2026, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for one (1) of three (3) residents (Resident #2). Specifically, Resident #2 was administered an as needed antipsychotic medication for agitation without a documented medical rationale. There was no documented evidence that the medication was medically necessary, nor that non-pharmacological interventions were attempted prior to administering the medication. Additionally, the resident did not have a care plan to address their behaviors or personalized interventions for their behaviors.Findings include:The undated facility policy, Psychotropic Medication Use, documented a psychotropic drug was any medication that affected brain activities associated with mental processes and behavior which included anti-psychotics. The facility would not use psychotropic medications to address behaviors without first determining if there was a medical, physical, functional, psychological, social or environmental…

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, record review, and interview during the recertification survey conducted 8/14/2024 -8/20/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 4 resident floors (Unit 1) reviewed. Specifically, Unit 1 had multiple unclean and damaged wheelchairs, positioning chairs, and positioning devices. Findings include: The facility policy, Devices and Equipment, dated 3/2028 documented all resident devices and equipment, to include wheelchairs and walkers, would be maintained on a schedule. Defective or worn devices would be repaired or replaced. The undated facility policy, Work Orders, documented all staff were responsible for submitting work orders in the electronic system and then it was to be forwarded to the maintenance director. The Director of Maintenance was responsible to ensure the work was completed in a timely manner. The following observations were made: - on 8/14/2024 at 10:06 AM, Resident #10 was sitting in a positioning chair in their room. The chair's arm rests were unclean, and the material on the right back…

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 conducted 8/14/2024 - 8/20/2024, the facility did not ensure indicated restraints were used for the least amount of time and documented ongoing re-evaluation of the need for restraints for 1 of 2 residents (Resident #7) reviewed. Specifically, Resident #7 had an order for a Merry [NAME] (an enclosed frame wheeled walker) that was evaluated as a restraint and the Comprehensive Care Plan did not address parameters of use for the Merry Walker; and the restraint assessment was incomplete. Findings include: The facility policy, Restraint Policy, revised 2/2021 documented all residents who required the use of a restraint would have a care plan developed. All care plans would be updated quarterly at a minimum. All restraints were to be released at least every 2 hours to allow the resident to exercise and change position. A specific physicians' order was to be entered in the residents' medical record which identified the medical symptom related to the restraint, type of restraint and parameters of use. It…

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, record review, and interview during the recertification and abbreviated (NY00318948 and NY00314795) surveys conducted 8/14/2024-8/20/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 4 residents (Resident #36) reviewed. Specifically, Resident #36 was not assisted with timely toileting. Findings include: The undated facility policy, Certified Nurse Aide Activities of Daily Living, documented the certified nurse aide who completed the resident care was responsible for documenting the level of care the resident received that shift. The undated facility policy, Toileting Schedule, documented an incontinent resident would be placed on a toileting schedule. The resident was to be toileted a minimum of 5 times within a 24-hour period and must be documented. A sign was hung on the resident's bathroom door to serve as a reminder. The resident who required supervision for bowel function was to be taken to the toilet every 2 hours as part 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.

Based on observation, record review, and interview during the recertification survey conducted 8/14/2024 -8/20/2024, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 resident (Resident #22) reviewed. Specifically, Resident #22 was not evaluated by therapy or care planned for the use of a scoot chair (a low-to-the-ground positioning chair that allows self-propulsion by foot and reduces the risk of falls). Findings include: The facility policy, Devices and Equipment, dated 3/2018 documented recommendations for devices, which included wheelchairs, were to be documented in the residents' plans of care. Nursing would request therapy services to evaluate a device that was not properly fitting. The undated facility policy, Comprehensive Care Planning, documented the interdisciplinary team would review the care plan with a significant change and as needed. The care plan would be individualized for each resident. Changes that resulted in a different approach must be documented in…

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, record review, and interview during the recertification survey conducted 8/14/2024 - 8/20/2024, the facility did not ensure that residents who required dialysis services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #301) reviewed. Specifically, Resident #301 received hemodialysis (a process of purifying blood when the kidneys do not work properly) treatments at a community-based dialysis center and did not have a Comprehensive Care Plan that addressed dialysis. Findings include: The undated facility policy, Dialysis, documented the purpose of the policy was to provide proper care for residents receiving dialysis at an external facility. General guidelines included nursing staff observing the resident after returning from each dialysis treatment for their tolerance of the procedure, meals taken, dressing condition, and any other pertinent information as indicated, and to notify the registered nurse of any abnormal findings. Any bleeding from external catheters and fistulas/grafts indicated a medical…

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 interview and record review during the abbreviated survey (NY00306465), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2's order for continuous positive airway pressure therapy (a treatment that uses pressure to keep the airway open when sleeping) was not complete and when Resident #2 either refused the treatment or the machine had a missing part, there was no documentation the facility addressed the issues or that the medical provider was notified. Findings include: The 2019 Oxygen Therapy policy documented continuous positive airway pressure therapy was used for residents with sleep apnea (condition where the person stops breathing when sleeping) and a physician order was required for use of the machine. The procedures included: - residents may have personal machines or the facility rents 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 interview during the recertification and abbreviated (NY00298995) surveys conducted 7/12/22-7/15/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #31) reviewed. Specifically, Resident #31 was found in a non-resident area of the facility 2 hours after a fire drill when the resident left a secured unit undetected. Additionally, the resident's absence was reported by a family member and unnoticed by staff. Findings include: The facility policy Fire Procedures revised 6/2018, documented for alarms including Secured Unit, keep/move residents to the Resident Dining/Activity Room. Following the evacuation, the charge nurse would verify that all residents/staff were accounted for, and report results to Control Station. The Nursing Director/Supervisor was responsible to verify that each unit/department had accounted for all residents/staff and report results to Command Station.…

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, interview, and record review during the recertification and abbreviated (NY00252303) surveys conducted 7/12/22-7/15/22, the facility failed to provide food and drinks that were palatable, attractive, and at safe and appetizing temperatures for 2 of 2 test trays (lunch trays for Residents #20 and #25). Specifically, food was not served at palatable or safe temperatures. The food service policy Critical Control Daily Temperature Log revised 2009, documented the minimal internal temperatures for cooking raw food were 165 degrees Fahrenheit (F) for poultry, 155 degrees F for ground meats (beef, pork, veal, lamb, and fish), pork (steak & chops), 155 degrees F for pork roasts, and 145 degrees F for beef, veal, and lamb roasts. The policy documented serving temperatures were to be: - under 40 degrees F for cold foods; - soups 160-180 degrees F; - meats, poultry, seafood, and eggs 145-165 degrees F; and - sauces, gravies, and vegetables 160-180 degrees F. Resident #20 had diagnoses including acute…

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, record review, and interview during the recertification survey conducted 7/12/22-7/15/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the side of the deep fryer was soiled/unclean, the steam kettle had splattered deep fryer oil, the floor of the walk-in cooler had frozen water and melted water on it, the handwash sink near the 3-bay sink area was leaking, there were two soiled/unclean frying pans, and the walls behind the dish machine and the 3-bay sink area were soiled/unclean. Findings include: There was no documented policy or procedure for kitchen cleaning and maintenance. The following observations were made in the kitchen: - on 7/13/22 at 11:25 AM, the side of the deep fryer was soiled/unclean with food particles/debris. The back section of the steam kettle next to the deep fryer had deep fryer oil residue on it. - on 7/13/22 at 11:45 AM, the walk-in cooler had frozen water/ice along the bottom of the wall…

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, interview, and record review during the recertification survey the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meal trays (Unit 1 breakfast tray and a dinner tray for Resident #33) tested. Specifically, food was not served at palatable and safe temperatures. Findings include: The 1/2019 Meal Temperature Record facility policy documented all food and drink should be palatable, attractive and served at a safe and appetizing temperature as determined by the type of food to ensure resident's satisfaction. Hot food should be held for service at 140 degrees Fahrenheit (F) or higher. The policy did not document at what temperature cold food was to be held for service. Resident #33 had a diagnosis of depression. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The 11/2019 physician order documented the resident was on a regular diet. During the 2/3/20 Resident Council…

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, record review, and interview during the recertification survey 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 spread of communicable diseases and infections for 1 of 2 residents (Resident #26) reviewed for pressure injury. Specifically, a nurse did not perform hand hygiene between donning and doffing of gloves during a wound care dressing treatment. Findings include: The undated Aseptic Dressing Change policy documented the steps to a clean/aseptic dressing change technique should include the following: - Perform hand hygiene. - [NAME] gloves. - Remove old dressing/discard - Remove gloves/discard. - Perform hand hygiene. - Put on gloves. - Cleanse the wound. - Remove gloves, perform hand hygiene. - Apply clean gloves. Resident #26 was admitted with diagnoses of a Stage 2 (partial thickness skin loss) pressure ulcer of coccyx (tailbone) and cellulitis (skin infection) of left lower limb. The 5/21/19 Minimum Data Set (MDS) assessment…

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.