Penn Yan Manor Nursing Home Inc

Based on interviews and record review conducted during the Recertification Survey the facility did not ensure that the completion of a discharge summary that included a recapitulation of the residents stay, a final summary of the resident's status and a post-discharge plan was completed for one (Resident #40) of one resident reviewed. Specifically, the resident was discharged without a complete discharge summary to ensure the facility communicated the necessary information to the resident, the continuing care provided and the resident representative (if applicable) at the time of discharge. The finding is: The undated policy and procedure Discharge Summary and Plan provided by the Administrator, documented when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed. The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge. A post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of 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 interview and record reviews conducted during the Recertification Survey completed on 8/5/22, it was determined that the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a Nurse Aide Registry (NAR) abuse screening was not completed prior to hire for four out of five employee files reviewed. The findings are: 1. On 8/4/22 from 10:34 a.m. to 11:45 a.m. the surveyor was provided documentation related to five newly hired employees. The files included Employees #1, #4 and #5 were hired as: Certified Nurse Assistants (CNAs) and Employee #2, was hired as a Housekeeper. The files also included hire dates of 6/17/22, 6/23/22, 4/4/22, and 4/17/22 for Employees #1, #2, #4 and #5, respectively. The documentation provided did not include a NAR abuse screen for employee #4, and the NAR abuse screen for employees #1, #2, and #5 were run on 8/4/22 (after hire). 2. 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 observations, interviews, and record reviews conducted during the Recertification Survey completed on 8/5/22, it was determined that for one of one kitchen the facility failed to dispose of garbage and refuse properly. Specifically, the garbage dumpster outside the facility was not equipped with a tight-fitting lid, door, or cover. This is evidenced by the following: Observations during the follow-up kitchen tour on 8/4/22 at approximately 11:55 a.m., revealed a large rectangular open-top roll-off garbage dumpster outside the facility located outside the nearby hospital kitchen where the facility meals are prepared. There were garbage bags accumulating in the dumpster and with no cover, which could create a potential feeding and harborage area for pests. During an interview on 8/4/22 at 11:55 a.m., the Kitchen Supervisor stated that the garbage dumpster had been in place for one year and was emptied twice a week. The Kitchen Supervisor stated there was never a tight-fitting lid, cover, or door on the dumpster. During an interview on 8/4/22 at 12:17 p.m., the Director 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 observations, interviews, and record review conducted during the Recertification Survey completed on 8/5/22, it was determined that for one (Resident #13) of five residents reviewed during dining, the facility did not ensure that the resident received care in a respectful and dignified manner during meals. Specifically, Resident #13 did not receive timely assistance with eating. This is evidenced by the following: Resident #13 had diagnoses including dementia with behavioral disturbances, Parkinson's disease, dysphagia (difficulty swallowing), and anxiety. The Minimum Data Set Assessment, dated 5/19/22, documented that Resident #13 had severe impairment of cognitive skills and was totally dependent on staff for eating. Review of current physician orders revealed that Resident #13 was ordered a regular diet, with puree texture and nectar thick fluid consistency. The current comprehensive care plan (CCP) and current Certified Nursing Assistant (CNA) care card (used by CNAs for daily care) included that Resident #13 was at risk for aspiration and was not allowed to be fed by…

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, interviews, and record reviews conducted during the Recertification Survey, completed on 8/5/22, it was determined that for 3 (Residents #29, #17 and #19) of 13 residents reviewed, the facility did not ensure that the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive would be honored. Specifically, the color-coded name plates at the entrance of the residents' rooms did not match the wishes documented on the residents' Medical Orders for Life Sustaining Treatment (MOLST). Review of the undated facility policy Advance Directives, indicated; if a resident has executed an advance directive, it will be displayed prominently in the medical record and reflected in the resident's care plan. 1. Resident #27 had diagnoses including schizoaffective disorder, schizophrenia, and major depression. The Minimum Data Set (MDS) Assessment, dated 6/27/22, included that the resident had severe cognitive impairment. Review of the MOLST form, dated 3/19/21, documented Resident #27's wishes as Do Not Resuscitate (DNR) and Do 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during the Recertification survey, completed 8/5/22, it was determined that for 1 (Resident #27) of 13 residents reviewed, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting to meet their needs. Specifically, there was no evidence that a Pre-admission Screening and Resident Review (PASARR) was completed for Resident #27, who had been admitted to the facility with a significant MD diagnosis. This is evidenced by the following: Resident #27 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, schizophrenia, and major depression. The Minimum Data Set (MDS) Assessment, dated 6/27/22, indicated the resident had severe cognitive impairment. Review of the Electronic Medical Record (EMR) and the paper record for…

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, it was determined that for one of one resident reviewed for activities, the facility did not develop a person-centered care plan that included measurable goals and interventions to meet the resident's medical, nursing, and psychosocial needs. Specifically, Resident #13 did not have an activities care plan. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, seizures, and dementia. The Minimum Data Set Assessment, dated 8/22/19, revealed the resident was cognitively intact. The admission Activity Assessment, dated 8/14/19, revealed that books and local newspapers were very important to the resident. The resident liked cards, was Presbyterian, and liked small and large group activities. Review of the Comprehensive Care Plan and Closet Care Plan (care plan used by Certified Nursing Assistants - CNA) revealed that neither care plan…

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 conducted during the Recertification Survey and complaint investigation (#NY00244354), it was determined that for one of two residents reviewed for accidents, the facility did not ensure that residents received adequate supervision to avoid potential accidents. Specifically, Resident #2 eloped from the facility undetected and fell while outside the building, and the resident's care plan was not revised to include an actual elopement. This is evidenced by the following: Resident #2 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's, osteoarthritis, and diabetes. The Minimum Data Set Assessment, dated 7/29/19, revealed the resident had severely impaired cognition and wandered four to six days but less than daily. The current Comprehensive Care Plan revealed the resident's behavior symptoms included wandering as evidenced by exit seeking behaviors since admission, and wandering in and out of other's rooms. Exit seeking attempts occurred on…

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, it was determined that for one (Resident #44) of one resident reviewed for an indwelling urinary catheter (a tubing inserted into the bladder to drain urine into a bag), the facility did not ensure that a resident who entered the facility with an indwelling urinary catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that the indwelling catheter was the only option. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] with diagnoses including benign prostate hypertrophy, urinary retention, and a history of urinary tract infections, including one currently. The Minimum Data Set Assessment, dated 10/28/19, included that the resident had moderately impaired cognition, had a urinary catheter, and required extensive assistance from staff for personal hygiene. The Current Comprehensive Care Plan included 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 observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #36) of one resident reviewed for Preadmission Screening and Resident Review (PASARR- a screen used to determine developmental disability and/or mental health needs), the facility did not ensure the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The issues included lack of behavioral health services to ensure the resident's behavioral health needs were met as identified in the comprehensive assessment. This is evidenced by the following: Resident #36 was admitted to the facility on [DATE] and has diagnoses including schizophrenia, bipolar disease, depression, and anxiety. The Minimum Data Set (MDS) Assessment, dated 10/12/19, revealed the resident was cognitively intact, had occasional feelings 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 observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure that it was free of a medication error rate of 5 percent or greater for 2 of 11 residents observed for medication administration resulting in a 6 percent error rate. Specifically, Resident #37's eye drops were administered in both eyes instead of one eye, and Resident #30 had a medication ordered after meals that was given over an hour before meals. This is evidenced by the following: 1. Resident #37 was admitted to the facility on [DATE] and has diagnoses including diabetes and retinal vein occlusion of the right eye with macular edema. Current physician orders included timolol maleate 0.5 percent eye drops with instructions to instill one drop in right eye twice daily for ocular hypertension (increased pressure in the eye). During observation of medication administration on 11/7/19 at 9:39 a.m., Licensed Practical Nurse (LPN) #1 instilled one drop of timolol eye…

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.