Degraff Memorial Hospital-Skilled Nursing Facility

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #2678647), the facility did not ensure that all alleged abuse violations were reported immediately but not later than two (2) hours after the allegation was made to the Administrator of the facility and to the State Survey Agency for one (1) (Resident #1) of three (3) residents reviewed. Specifically, staff did not report an allegation of physical abuse to the Administrator immediately which resulted in delayed reporting to the New York State Department of Health within the required time frames. The finding is:The policy titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d last revised on 10/22/24 documented any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation shall immediately report their concerns to the Nursing Home Administrator or designee. The Long-Term Care Administrator will report abuse to 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 observations, interviews, and record reviews conducted during a complaint investigation (NY00346092) conducted during an extended standard survey from 9/26/2024 to 10/3/2024, the facility did not to ensure that each resident receives adequate supervision to prevent accidents for three (Residents #12, 14, and 29) of three reviewed. Specifically, the facility did not monitor the wander guard signaling device's (tag/bracelet) battery life/functionality of those that were assigned (#12, 14, 29) and Resident #14 exited the building unsupervised without staff's knowledge. In addition, the facility staff lacked education and training regarding the wander alert system and policy. The findings are: The policy and procedure titled WanderGuard dated 12/2022 documented all batteries of activated bracelet signaling devices are continuously monitored by the wander guard computer system and, if a battery is low, an alarm on the computer will be activated and identify the low battery; and nursing will be responsible to…

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 conducted during an extended survey completed on 10/3/24, the facility's quality assurance and performance improvement program did not perform improvement activities that tracked adverse resident events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the facility. Specifically, the facility did not ensure their WanderGuard policy was updated; that staff were educated about the wander guard system, and did not ensure preventive actions were implemented to ensure resident safety. The finding is: Refer to: F 689 - Free from Accident Hazards/Supervision and Devices to Prevent Accidents The 2024 Facility Assessment Review dated 2/6/2024 documented the facility assessment was used to determine gaps in service or expected outcomes, when identified, are reviewed and correction plans are discussed for implementation. The corrective activities are then review during subsequent meetings to assure changes are sustained and there is no recurrence of the issue. The policy and procedure…

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 interviews conducted during the Extended survey completed on 10/3/24, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft for one (Resident #51) of three residents reviewed for personal property. Specifically, Resident #51 had no pants available to wear in their closet and their inventory sheets documented the resident had 17 pairs of pants. The finding is: Resident #51 had diagnoses including dementia, age related physical debility, and high blood pressure. The Minimum Data Set (a resident assessment tool) dated 8/11/24 documented the resident had moderately impaired cognition. The comprehensive care plan dated 8/21/24 documented the resident required extensive assistance with dressing, was non ambulatory, and was not able to make their needs known. During a telephone interview on 9/27/24 at 9:54 AM, the resident's family member stated when they came to visit, the resident would be wearing clothes that were too small for them, like they weren't the clothes they had brought in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during an Extended Recertification survey completed on 10/3/24, 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 one (Resident #2) of four residents reviewed for infection control processes during care. Specifically, staff did not wear proper personal protective equipment during hands on care and transfer of the resident, who required enhanced barrier precautions. The finding is: The policy and procedure titled Enhanced Barrier Precautions dated 6/18/24 documented personal protective equipment is used to prevent the spread of multi-drug resistant organism transmission. The recommendations include the use of enhanced barrier precautions during high-contact activities for residents with chronic wounds (open wounds that typically require a dressing change such 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during a Standard Survey completed on 5/14/21, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown origin are thoroughly investigated for one (Resident #24) of three residents reviewed for abuse. Specifically, the facility did not complete an investigation of bruising to the resident's left forehead and left periorbital (area around the eye) area. The finding is: The facility Policy and Procedure (P&P) titled Identification and Reporting of Abuse, Neglect or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d with revised date of 12/19 revealed that the facility is to begin an investigation immediately upon discovery of an incident. Specifically, an investigation of injuries of unknown origin must be immediately investigated to rule out abuse. Injuries included in injuries of unknown origin are, but not limited to, bruising of the inner thigh,…

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 conducted during an Abbreviated survey (Complaint #NY00253905) completed during the Standard Survey on 5/14/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, one (Resident #216) of two residents reviewed for quality of care lacked follow up to have staples removed, from left hip, that were in place greater than three weeks. The finding is: Review of the facility policy and procedure entitled Staple Removal dated 3/19/19 revealed this document outlines the responsibilities of the Registered Nurse (RN) to safely remove incision closures (staples) used to approximate edges of an incision after healing has occurred. Instructions included check the Medical Doctor (MD)/Nurse Practitioner (NP) order to determine the details for the procedure. Document in a progress note the procedure, condition of incision, pertinent…

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 completed during the Standard survey completed on 5/14/21, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #6) of two residents observed for pressure ulcers. Specifically, infection control practices were not maintained during a pressure ulcer treatment application and the treatment was not completed as ordered by the physician. The finding is: Review of facility policy titled Physician Orders- Long Term Care (LTC) dated 7/21/14 documented telephone or other verbal orders shall be accepted only by a license nurse, pharmacist or such other licensed practitioner as permitted by law. Telephone and verbal orders that follow this policy are considered to be valid orders and will be executed as if the authorized prescriber wrote them. Review of the facility policy titled Pressure Ulcers-LTC revised 11/17 documented the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview completed during the Standard survey completed 5/14/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion for one (Resident #7) of two residents observed for range of motion (ROM-normal range of motion of a joint) services. Specifically, Resident #7 did not have rolled washcloths to the right and left hands as recommended by OT (Occupational Therapy), and lacked comprehensive assessments, including measurements of joint mobility. Additionally, there was no documented evidence to support range of motion services were provided as recommended. The finding is: The facility policy and procedure (P&P) entitled Physical / Occupational Therapy- SNF-Range of Motion (Preventative routine) dated 7/23/19 documented ROM programs are implemented by the rehabilitation department to prevent and manage contractures, maintain joint mobility, and for stretching 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.