Rome Memorial Hospital, INC - R H C F

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice. Specifically, Resident #1's advanced directives were Do Not Resuscitate (allow natural death) and when they became unresponsive, the staff did not verify the Resident #1's advance directives per facility policy, and initiated cardiopulmonary resuscitation for approximately three minutes. Findings include:The 12/2025 revised facility policy, [Cardiopulmonary Resuscitation] Identification, documented All residents would have a [Medical Order for Life Sustaining Treatment] form completed upon admission. The [Medical Order for Life Sustaining Treatment] was the only identifier for code status ([Do Not Resuscitate] or Full Code). The [Medical Order for Life Sustaining Treatment] form should be located in the front of the resident's hard chart. Resident #1 had diagnoses including Parkinson's Disease and metabolic encephalopathy. 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 record review and interviews during the recertification and abbreviated (NY00362429) surveys conducted 1/2/2025-1/8/2025 the facility did not ensure the resident's physician was consulted and the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #61) reviewed. Specifically, Resident #61 did not receive 5 doses of their Parkinson's disease (a progressive neurological disorder) medication (pramipexole dihydrochloride) and there was no documented evidence the physician or resident's representative were notified of the omission. Findings include: The facility policy, Notification of Medical Condition Changes, reviewed 6/2022, documented the nurse immediately reported specific changes in a resident's condition or treatment to their attending physician and shared with the resident and/or the resident's representative. The notification was documented in the resident's medical record. The pharmacy policy Provider Pharmacy Requirements, effective 9/2018, documented the provider pharmacy agreed to provide…

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 recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every 3 months for 3 of 3 residents (Residents #28, #46, and #53) reviewed. Specifically, Residents #28's, #46's, and #53's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gathering information about a resident's condition when completing the assessment). Findings include: The facility policy, Interdisciplinary Minimum Data Set 3.0 Completion, revised 1/2023, documented to complete an accurate Minimum Data Set on all residents based on New York State Department of Health and Centers for Medicare and Medicaid Services guidelines. Assessments would be completed based on the Minimum Data Set 3.0 Manual. The Minimum Data Set Coordinator was responsible for setting up timely assessments within…

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 survey conducted 4/11/23-4/14/23, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 10 of 10 residents (Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38) reviewed. Specifically, for Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38 there was no documented evidence bed rail assessments were completed, and consents were obtained prior to bed rail installation; there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives prior to bed rail use; and there were no care plans that included the use and monitoring of bed rails. Findings include: The facility policy Bedrail Safety last reviewed 8/2021, documented it was the facility's policy to prevent entrapment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification and abbreviated (NY00307214) surveys conducted 4/11/23-4/14/23, the facility failed to ensure residents were free from abuse for 1 of 1 resident (Resident #38) reviewed. Specifically Resident #15 was witnessed by facility staff making inappropriate sexual contact with Resident #38 on 10/10/22, 11/18/22, and 12/16/22 and the facility did not have a plan in place to protect Resident #38 from Resident #15's advances. Additionally, the incidents on 10/7/22 and 11/18/22 were not reported to the New York State Department of Health (NYS DOH) as required. Findings include: The facility policy Abuse and Adverse Incident Prevention and Reporting reviewed 3/2023 documented the facility did not permit verbal, mental, sexual, or physical abuse. The facility provided initial and ongoing education for all employees which addressed abuse identification and prevention. Prevention included analysis completed on a continued basis of assessment, care…

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 survey conducted 4/11/23-4/14/23, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #16) reviewed. Specifically, Resident #16 developed a Stage 2 pressure ulcer (partial-thickness skin loss), and the ulcer was not monitored, treatments were not completed as ordered, and the resident's plan of care was not followed. Additionally, the resident had a significant weight loss, and their nutritional needs were not reassessed after the development of the pressure ulcer and significant weight loss. Findings include: The facility policy Prevention and Care for Skin Impairment - Pressure Ulcers revised 1/2023 documented: -A resident who had pressure ulcers would receive necessary treatment and services to promote healing,…

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 4/11/23-4/14/23, the facility failed to ensure that 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 #14) reviewed. Specifically, Resident #14 was observed receiving oxygen (O2) via a nasal cannula (NC, a tube delivering oxygen through the nose) and did not have a physician order or indications for use, and did not have ongoing assessments of respiratory status, and response to O2 therapy. Findings included: The facility policy Oxygen Therapy last reviewed on 6/2021 documented routine oxygen therapy required a physician order to include device and percentage of liter flow. Resident #14 had diagnoses including chronic obstructive pulmonary disease (COPD, airflow obstruction), iron deficiency anemia, and congestive heart failure. The 1/31/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive 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, record review, and interview during the recertification survey conducted 4/11/23-4/14/23 the facility failed to ensure that licensed nurses had specific competencies and skill sets to provide nursing services to assure resident safety for 1 of 3 licensed nurses (licensed practical nurse [LPN]) #12 observed during medication administration. Specifically, LPN #12 was observed pre-pouring resident medications before the ordered times and placing them in plastic cups in the medication cart. Findings include: The facility policy titled Medication Administration Overview revised 4/2023 documented prior to medication administration, scan all required medications, and visually confirm that the correct dose, correct medication, and correct resident ID were displayed on the eMAR (electronic medication administration record) screen. The facility policy Pharmacy Services revised 1/2021 documented when administering medication to review the following: Is it the correct resident? Correct medication? Correct dose? Correct time? Correct route? Identify the resident with 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 during the recertification survey conducted [DATE]-[DATE], the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Unit 3 East) reviewed. Specifically, the Unit 3 East medication cart contained an insulin pen for Resident # 9 that did not have an opened date. Findings include: The facility policy Insulin Injection Administration reviewed 9/2022 documented insulin pens could be housed outside the refrigerator safely for 28 days. Check for labeled date/time/initialed when opened. Discard vial if opened more than 30 days. During a medication cart observation with licensed practical nurse (LPN) #12 on [DATE] at 3:16 PM, the Unit 3 East medication cart contained an insulin glargine (long acting insulin) pen for Resident #9. The insulin pen was not labeled with an opened date. LPN #12 stated insulin pens should…

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 surveys (NY00247612 and NY00249167) the facility did not ensure it maintained 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 2 of 2 nursing units (North/South and East) and 1 of 1 laundry room (first floor laundry room) reviewed. Specifically, dirty lunch trays were observed placed on top of multiple clean PPE (personal protective equipment) carts on 2 of 2 nursing units (North/South and East); and two drying tumblers and two front loading washer-extractors were not maintained per manufacturer instructions. Findings include: NURSING UNITS/MEAL TRAYS The facility's infection control policy, under RHCF Policy Updates for COVID-19 Pandemic effective 9/23/2020 documented meal trays from isolation rooms will be handled with gloves and will be placed directly onto 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 observation and interview during the recertification survey, the facility did not 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 2 of 3 medication carts (north hall medication carts #1 and #2) reviewed for medication storage and labeling. Specifically, multiple expired medications were observed stored in two north hall medication carts. Findings include: The facility policy Pharmacy Services for Rural Health Care Facility (RHCF) reviewed 01/2021, documented the facility stores stocked medications locked in medication carts and medication rooms. All outdated, discontinued, changed, or otherwise unusable drugs will be pulled from the medication cart by the medication nurse and placed in the medication room. The 6:00 AM through 2:00 PM medication nurse is responsible for delivering these medications to the pharmacy by the end of their shift, daily. During an observation on 04/13/21 at 10:41 AM, the 2 north hall medication…

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.