Lewis County General Hospital-Nursing Home Unit

Based on record review and interviews during the abbreviated survey (NY00341596, NY00353814, NY00354138, and NY00354190) the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the administration failed to ensure policies and procedures were properly identified, communicated, and consistently implemented for abuse and dementia care. The administration was not aware of the extent of the deficient practices and Immediate Jeopardy was identified on 9/25/2024 in the area of abuse (refer to F 600). Findings include: The facility policy, Quality Assessment and Performance Improvement Plan, revised 9/2023, documented the program was intended to identify and prioritize problems and opportunities based on performance indicator data and resident and staff input that reflected organizational processes, functions, and services provided to residents. The program would identify corrective actions necessary…

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 abbreviated (NY00348034, NY00353814, NY00354138) surveys, the facility did not ensure a resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 3 of 16 residents (Residents #4, #5, and #16) reviewed. Specifically, Residents #4, #5, and #16 had diagnoses of dementia and resided on the dementia unit in the facility and were not cared for in a dementia-informed manner. Resident #4 was forced to ambulate against their will by several staff members after refusing to go to the dining room; Resident #5 was physically restrained by a registered nurse and a certified nurse aide while a nasal swab was obtained; and Resident #16's care plan was not followed which resulted in a fall with a skin tear. Refer to F 600. Findings include: The facility policy, GEMS Stages of Dementia Classification, created 11/2023,…

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 (NY00308041 and NY00343021) surveys conducted 7/24/2024-7/31/2024 the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 4 resident units (Units 1 and 3) observed and for 1 of 4 residents (Resident #77) reviewed. Specifically: - Unit 1 (dementia unit, also known as the Rainbow Community) had environmental accident hazards readily accessible to residents. - Resident #77, who resided on Unit 1, had a history of wandering throughout the unit and ingesting inedible items, including bar soap. Resident room [ROOM NUMBER] was observed with multiple bars of soap on the sink counter. - the door to the clean utility room on Unit 1 was unsecured and contained oxygen equipment, wound care supplies, and other nursing care items. - Unit 1 common area had metal wheelchair leg rests on a table. - An unsecured, open cart with needle-nose…

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 interview during the recertification survey conducted 7/24/2024-7/30/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meal test tray reviewed (the 7/26/2024 lunch meal on Unit 3 and the 7/29/2024 lunch meal on Unit 2). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 7/26/2024 and 7/29/2024. Additionally, Resident #26 stated the food did not taste good. Findings include: The facility policy Food Temperatures effective date 12/2019 documented: - Temperatures of all food items would be taken and properly recorded prior to service of each meal and ensure quality and safety of food/drinks. - All hot food items must be held and served at a temperature of at least 140 degrees Fahrenheit. - All cold items must be stored and served at a temperature of 41 degrees Fahrenheit or below. During an interview on 7/24/2024 at 12:37 PM, Resident #26 stated they were served cold food, and it did not taste good. During a lunch…

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 7/24/2024 - 7/30/2024, 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, 7 individual serving size portions of moist and minced fish were stored in cardboard containers dated 2/21 with ice buildup inside the containers; 1 cardboard box of cooked chicken was stored on top of 2 packages of flatbreads; the ice cream cooler contained an employee's personal 20-fluid ounce frozen bottle of water; and the tray line preparation cooler contained 10 sheet pans of uncovered coleslaw, and uncovered 4-ounce servings of strawberries with whipped topping. Findings include: The following observations in the main kitchen were made on 7/24/2024 between 10:30 AM and 11:01 AM: - In the walk-in freezer there were 7 individual serving size portions of minced and moist fish dated 2/21 with ice buildup on the inside of the containers, and there was 1 cardboard box of cooked chicken…

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 7/24/2024-7/30/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #85) reviewed. Specifically, Resident #85 had 6 medications left in a medication cup in their room and there was no documented evidence the resident was assessed to determine their ability to safely self-administer medications or had a physician order for self-administration of medications. Findings include: The undated facility policy, Self-Administration of Medications, documented if a resident wished to self-administer medications the interdisciplinary team would assess the resident's cognitive, physical, and visual abilities to administer his/her own medications. Resident #85 had diagnoses including dementia. The 4/30/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required set-up or clean-up assistance for eating and oral hygiene, and was dependent to substantial/maximal assistance…

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 during the recertification survey conducted 7/24/2024-7/30/2024, the facility did not ensure residents were provided appropriate assistive devices and appropriate assistance to maintain or improve their ability to eat and or drink independently for 1 of 1 resident (Resident #29) reviewed. Specifically, Resident #29 was not served food or drinks at meals as planned. Findings include: The facility policy, Meal Delivery, revised 1/2024, documented dietary staff would load meal trays in the kitchen with the appropriate meal service items according to the meal ticket before each meal. This would include adaptive equipment. Meal tickets would be carefully reviewed when passing meal trays to ensure the correct resident was served, all adaptive equipment was present, and tray notes were reviewed. If staff believed something on the meal ticket or the meal itself was incorrect, the meal should not be served, and the Dietary Department contacted for a replacement meal. Resident #29 was admitted to the facility with diagnoses including dementia…

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 interview, and record review during the recertification survey conducted 6/28/22-7/5/22, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, Specifically, there was no documented evidence of a carbon monoxide (CO) policy and procedure including staff education on responding to a CO activation. Findings include: The International Fire Code, 2015 Edition Section 915 Carbon Monoxide Detection (adopted by New York State), documented the requirement of facilities to have a policy for carbon monoxide detection and activation and for all staff to be trained on how to respond. The facility Emergency Preparedness and Disaster Plan with a revised date of 9/2021, did not include a policy and procedure for a CO activation incident in the facility. The annual staff training records for Emergency Preparedness had no documented evidence of training specific to CO and the response to the activation of a CO detector. When interviewed on 6/29/22 at 4:00 PM, the Director of Emergency Preparedness stated…

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 6/28/22-7/6/22, the facility failed to ensure that all alleged violations involving abuse and neglect were reported to The New York State Department of Health (NYS DOH) as required for 1 of 4 residents (Resident #37) reviewed. Specifically, Resident #37 required limited assistance of one for ambulation, sustained a fall with a fracture while ambulating independently and the incident was not reported to the NYS DOH as required. Findings include: The facility policy Incident Report Completion reviewed 1/2019 documented incident reports would be competed prior to the end of the shift. Upon completion of the report, it was reviewed by registered nurse (RN) Nurse Manager/Supervisor and then immediately forwarded to the Director of Nursing (DON). After review by the DON it was then forwarded to the Administrator and Risk Manager. If the report is determined to be resident abuse, neglect, misappropriation of property, sexual abuse, seclusion, significant injury resulting from staff negligence,…

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 and abbreviated (NY00282162) surveys conducted 6/28/22 to 7/6/22, the facility failed to ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated for 1 of 9 residents reviewed (Resident #4). Specifically, Resident #4 sustained a burn from coffee, a timely assessment was not completed by the registered nurse (RN) which lead to confusion as to which arm sustained the burn. Findings include: The facility policy Incident Report Completion reviewed 1/2019 documented incident reports would be completed prior to the end of the shift when a resident had an injury of unknown origin or accident. If determined to be abuse, neglect, or failure to follow the plan of care, the Director of Nursing (DON) or Administrator must be notified immediately. Resident #4 had diagnoses including traumatic brain injury (TBI) and left-sided weakness. The 6/28/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive to total assistance with most activities…

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 6/28/22-7/6/22, the facility failed to ensure a resident with an indwelling catheter received the necessary care and services to prevent urinary tract infections for 1 of 3 residents (Resident #104) reviewed. Specifically, Resident #104's catheter bag was observed multiple times in contact with the floor without a barrier or protective cover. Findings include: The facility policy Foley Catheter: Insertion/Removal/Care Of last reviewed 12/2019, documented the drainage bag should hang with tubing on the bed and bag lower than bladder level. The policy did not document the tubing and bag should be off the floor or a non-permeable barrier placed between the bag and floor. Resident #104 had diagnoses including a history of urinary tract infections (UTIs), a history of extended spectrum beta-lactamase (ESBL- antibiotic resistant infection), and dementia. The 6/4/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was dependent for most activities of daily…

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 6/28/22 - 7/6/22, the facility failed to store drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication rooms (Unit 3) reviewed. Specifically, in the Unit 3 medication refrigerator, multiple tetanus booster vaccines were expired and one purified protein derivative (ppd, for tuberculosis skin test) multidose vial was dated as opened 5/12/22 and was not discarded after 28 days. The facility policy Nursing Home Medication Management-Consultant Pharmacy Services created 4/2020 and reviewed 11/2021 documented: - The pharmacy consultant ensured a process was in place for checking the medication storage areas and the medication carts for proper storage and labeling of medications, cleanliness and removal of expired medications. - All multi-dose vials of medications, such as insulin and Tubersol (PPD solution) would be dated with the expiration…

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 interview during the recertification survey the facility did not ensure 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 4 of 4 anonymous residents in attendance at the Resident Council Meeting. Specifically, survey results were not in an area that was readily accessible to residents or visitors and where individuals wishing to examine survey results did not have to ask to see them. Findings include: During the Resident Council meeting on 12/2/19 at 2:45 PM, 4 anonymous residents stated they were not aware of the location of the most recent Department of Health (DOH) Federal/State survey results and would like to know where they were located. On 12/2/19 at 3:42 PM, a framed sign in the lobby was observed hung high on the wall to the left of the elevators. The sign stated the survey results were located in the Family Room. From 12/2/19 to 12/4/19, the facility provided the New York State (NYS) DOH survey team the Family Room, located on the first…

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 ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 4 of 4 medication carts reviewed for medication storage and labeling. Specifically, multiple insulin pens and vials were opened and undated. The facility policy, Nursing Home - Pharmacy Services, dated 11/2019, documented the following: - Labeling of Medication- medication labels are to be clean and legible, and may not be defaced, altered or revised. When the label becomes soiled and/or illegible, the medication will be destroyed in accordance with State and Federal laws, all multi-dose vials of medications, such as insulin and Tubersol, will be dated with the expiration date on the date opened- affixing a piece of tape or label to the bottle, medications must be check regularly for expiration dates and deterioration. - Storage of 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.