St. Ann's Community

Based on observations, interviews, and record review conducted during a Recertification Survey, for one (Resident #330) of one resident reviewed, the facility did not provide services to meet professional standards of quality.Specifically, multiple doses of a medication were left unattended at the resident's bedside with no assessment completed to ensure the safety of. This is evidenced by the following: The facility policy, Patients on Self-Medication, dated 6/6/20, documented that medical and nursing staff determine if an elder is safe to self-administer medications using nursing admission assessment to identify if patient self-medicated at home. Medical staff orders self-medications based on this information. Elders on self-medication will have a secure area provided. Resident #330 had diagnosis including narrowing of the esophagus, mild cognitive impairment, and gastroesophageal reflux disease (stomach acid repeatedly flowing back into the esophagus). The Minimum Data Set Resident Assessment, dated 3/6/24, revealed Resident #330 was moderately impaired cognitively. 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.

Based on observations, interviews, and record review conducted during a Recertification Survey, for one (Resident #78) of two residents reviewed, the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infections for a resident with an indwelling urinary catheter (tube inserted into the bladder to drain urine). Specifically, Resident #78 was observed on several occasions with their uncovered urinary drainage bag (bag used to collect urine through the indwelling urinary catheter) lying directly on the floor including an observation of their urinary drainage bag resting on a dining room table above the level of their bladder with several staff within view. Additionally Resident #78's Comprehensive Care Plan did not include goals and/or interventions related to any resident behaviors related to their urinary catheter and/or urinary drainage bag. This is evidenced by the following: The current facility policy, Urinary Catheter Use and External Catheter Use Guidelines dated 7/12/22, included maintenance procedure of indwelling urinary…

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 review conducted during a Recertification Survey, for two (Residents #62 and #238) of four residents reviewed, 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 development and transmission of communicable disease and infections. Specifically, there was a lack of appropriate hand hygiene (washing hands or using alcohol-based hand sanitizer) and lack of appropriate glove use observed during wound care for both residents. This is evidenced by the following. The facility policy, Precautions-Standard and Transmission Based of Infectious Organisms, revised 3/22/24, documented that gloves are to be worn at all times when delivering resident personal care, and when there is contact with blood, body fluids or mucous membranes. Wearing gloves does not replace the need for hand hygiene. Hand hygiene must be performed whenever gloves are removed.…

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 conducted during the Recertification Survey completed on 9/22/22, it was determined that for three (Employees #1, #4 and #5) of five employee files reviewed, 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 new employees beginning work. The findings are: On 9/19/22 from 2:00 p.m. to 3:27 p.m., documentation related to five recently hired employees was reviewed. The records included: 1. Employee #1 was hired as an Environmental Services Assistant on 8/8/22. The documentation provided included a NAR abuse screening for employee #1 dated 8/24/22. Further record review included a fingerprinting consent form signed by employee #1 marked as having a final finding of patient or resident abuse. When interviewed via email regarding this statement by Employee #1, the Director of Human Resources stated that Employee #1 said this was a…

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 Recertification Survey completed on 9/22/22, it was determined that for 7 (Residents #178, #187, #245, #247, #281, #298 or #357) of 35 residents reviewed, the facility did not ensure that a Baseline Care Plan (BCP) was developed and implemented within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and that a written summary of the care plan, that they were able to understand, was provided and reviewed with the resident and/or their representative in a timely manner per the regulations. This was evidenced by, but not limited to, the following: The facility policy Care Planning - Interdisciplinary, dated as last revised on 7/12/22, documented that the policy of the facility was to initiate and complete a BCP within 48 hours of admission and address, at a minimum, initial goals based on admission orders, dietary orders, therapy services, social services…

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 reviews and interviews conducted during a Recertification Survey and complaint investigation (#NY00287538 and #NY00285375) completed 9/22/22, it was determined that for two (Residents #121 and #608) of seven residents reviewed for abuse, neglect and mistreatment, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, both resident's care plans were updated indicating a need for increased assist during transfers, but the change was not made on the Certified Nursing Assistant (CNA) Resident Care Summary (care cards used by the CNAs for daily care) that were posted in the residents' rooms resulting in falls with injuries. The findings are: Facility policy # NSG-03, titled, 'care cards' (also known as Resident Care Summary), included: review care cards with CNAs that are floats, new to assignment, unit, or St. Ann's Community and when café plans have been changed. Interdisciplinary team will update care cards as needed. When plan of care is changed the care card is updated and distributed to designated…

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, interview, and record review conducted during the Recertification Survey completed on 9/22/22, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: During the initial tour of the ground floor kitchen on 9/15/22 between 8:53 a.m. and 9:40 a.m. it was observed that a natural gas range was present and in use, and there were no carbon monoxide detectors within the kitchen. Additionally, on 9/16/22 from 8:30 a.m. to 10:00 a.m. it was observed that there were no carbon monoxide detectors present in the basement, ground floor, and lobby level of the 9-story St. Ann's Home. The basement was observed to include a potential carbon monoxide source in the boiler room. A summary of carbon monoxide detectors throughout the facility was sent to the surveyor via email by 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 interviews and record reviews conducted during the Recertification Survey, it was determined that for one resident (Resident #187) of three residents reviewed for abuse, the facility did not investigate a concern of rough handling during care that was reported to the nurse. This is evidenced by the following: Resident #187 has diagnoses including a stroke with hemiplegia (paralysis), hemiparesis (weakness), and osteoarthritis. The Minimum Data Set Assessment, dated 11/18/19, revealed that the resident's cognitive skills for daily decision making were severely impaired, and the resident required the extensive assistance of two staff members for personal hygiene, bed mobility, bathing, and transfers. When interviewed on 1/2/20 at 8:52 a.m., Licensed Practical Nurse (LPN) #1 said she works the day shift. She said the resident's family member had reported to her that there are some evening Certified Nursing Assistants (CNAs) that are rough with the resident during cares. LPN #1 said she did not report the concerns to a supervisor because she had not observed rough cares on her…

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 three residents reviewed for mobility, and one of six residents reviewed for activities of daily living, the facility did not ensure that each resident received appropriate treatment or services to improve or maintain ambulation. Specifically, Resident #187 was not walked consistently on a daily basis with the appropriate equipment, and Resident #254 was not walking independently on a daily basis and staff did not monitor or evaluate for a decline. This is evidenced by the following: 1. Resident #187 has diagnoses including a stroke with hemiplegia (paralysis), hemiparesis (weakness), and repeated falls. The Minimum Data Set Assessment, dated 11/18/19, revealed that the resident's cognitive skills for daily decision making were severely impaired. The resident required the extensive assist of one staff member to walk on and off the unit and had a functional limitation in range 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 reviews conducted during the Recertification Survey, it was determined that for one (Resident #143) of two residents reviewed for respiratory care and oxygen, the facility did not provide proper care and treatment. Specifically, the resident's oxygen equipment was signed off as cleaned and changed weekly but was observed dirty and dated as last changed approximately a month earlier. This is evidenced by the following: Resident #143 had diagnoses including chronic obstructive pulmonary disease, pulmonary edema, and respiratory failure. The Minimum Data Set Assessment, dated 11/6/19, revealed that the resident had moderately impaired cognition and received oxygen therapy. The current medical orders included oxygen at 3 liters via nasal cannula and directed to change, label, and date the oxygen tubing and humidifier bottle every week on the evening shift, check and refill the humidifier bottle every shift, check the concentrator filter and clean with sterile water if needed once a day on the evening shift. Observations conducted on 12/31/19…

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, it was determined that for four of eight medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. The issues involved a controlled substance that was not double locked, multiple unlabeled pre-poured medications, and multiple loose pills in the bottom of drawers in the medication carts. This is evidenced by the following: Home for the Aged: In an observation on 1/2/20 at 10:10 a.m., a medication cart on the third floor contained multiple loose pills in the bottom of the drawer. On 1/3/20 at 9:07 a.m., a medication cart on the sixth-floor contained several loose pills in the bottom of the drawer. Wegman's Continuing Center: In an observation on 1/3/20 at 10:24 a.m., the medication cart on the third floor contained two medication cups filled with multiple pills and one medication cup was filled with multiple crushed pills. The resident's name or the name 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.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure food was prepared in a form designed to meet each resident's needs. Specifically, the pureed lasagna was prepared without a recipe and the serving size was not equivalent to the regular portion size. This is evidenced by the following: When interviewed on 1/6/20 at 10:13 a.m., the Assistant [NAME] said that he pureed the lasagna entrée for lunch that day. He said that he needed 34 servings of 4 ounces each. He said that he did not follow a recipe but put the lasagna into the blender and added water to make it liquidy. He said he did not know how much water he added to the lasagna. He said the lasagna was a heat and serve purchased product and he used two half pans. The lasagna was Molly's Kitchen: 15 orders per half pan. The label read serving size one cup; 227 grams, servings per container about 12. When interviewed at that time on 1/6/20 at 10:18 a.m., the Chef said one pan equals 96 ounces divided by 12, so one serving should be 8…

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.