Elizabeth Church Manor Nursing Home

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents remained as free of accident hazards as possible, particularly concerning the use of bed rails. Resident #1, who had severely impaired cognition, was found deceased with their head wedged between the bed rail and mattress. The facility did not assess the resident for appropriate alternatives to the bed rail, did not evaluate the risk of entrapment, and did not obtain informed consent from the resident's representative before the installation of the bed rail. Additionally, other residents with bed rails were not properly assessed for risks and benefits, nor was informed consent obtained, placing them at risk for serious harm. The facility also failed to provide adequate supervision to prevent accidents, as evidenced by the elopement of Resident #17, who had severely impaired cognition and known wandering behaviors. The resident exited the building undetected by staff and was found at a nearby gas station after being away from the facility for over 40 minutes. Similarly, Resident #16, who also had severely impaired cognition and a history of wandering, was observed exiting the facility's front lobby door in their wheelchair without staff intervention. These incidents resulted in Immediate Jeopardy for the residents involved and highlighted the facility's failure to ensure the safety of residents with exit-seeking behaviors. The deficiencies were further compounded by inadequate staff training and assessment procedures. The Registered Nurse responsible for bed rail assessments lacked specific training and a clear understanding of the risks associated with bed rail use. The facility's maintenance and security protocols were also insufficient, as evidenced by the failure to properly check and maintain door alarms, which contributed to the elopement incidents. These systemic issues in assessment, supervision, and environmental safety placed residents at significant risk of harm.

Removal Plan

• All residents with bed rails received updated bed rail assessments and physical restraint/safety assessments if their beds were placed against the wall, care plans were updated and orders for bed rails were obtained.
• A revised bed rail assessment tool was created to address interventions attempted prior to bed rail installation taking into consideration medical conditions; an area on the assessment form addressed risks and benefits of bed rail use with an area for documentation; and informed consent, whether verbal or in person, by the resident or resident representative, with their name.
• Education of staff was done for the new bed rail assessment tool, bed rail policy and procedure and safety of the residents' environment.
• Plan to educate any staff that has not received training will be completed before going on the floor to work.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the correct installation, use, and maintenance of bed rails, leading to a significant safety risk for 55 residents. Specifically, the facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. This oversight was evident in the case of a resident with a contour mattress and a right side bed rail, where the facility did not evaluate alternatives to bed rails, review the risks and benefits with the resident or their representative, or obtain informed consent prior to the installation of bed rails. The deficiency was highlighted by a tragic incident involving a resident diagnosed with Alzheimer's disease, who was found with their head wedged between the bed rail and the mattress, resulting in their death. The resident was last observed at approximately 4:30 AM for incontinence care, and at 5:45 AM, they were found in a kneeling position beside the bed, with no pulse or respirations. The cause of death was listed as probable positional asphyxiation. Interviews with facility staff revealed a lack of familiarity with guidelines for the prevention of bed entrapment and an absence of specific measurements regarding entrapment risk zones. Maintenance staff were responsible for installing bed rails and performing bed safety checks, but they did not have a process for measuring entrapment risk zones. The facility's policy did not include entrapment guidelines, and there was no documented evidence that beds were measured for entrapment risk, putting residents at risk for serious injury or death.

Removal Plan

• Maintenance was trained on entrapment zones and how to measure per FDA guidelines.
• An audit tool that contained all aspects of bed safety, compatibility of bed, mattress, and bed rails; mattress inspection, and entrapment zones was completed for all beds in the facility.
• The updated bed rail policy and procedure was provided which included Maintenance will check the bed model and install a compatible bed rail. Once installed the bed will be checked prior to use for entrapment zones, and if any are determined to be non-compliant the device will be un-installed immediately and nursing will be informed. Maintenance will close out the work order ticket once completed and update nursing of completion. Staff education was completed.
• A bed rail process and procedure audit tool was developed to monitor alternatives tried, bed rail assessment completed, Interdisciplinary Team review, care plan update, consent after provision of information, order in place, maintenance measured, monitoring resident safety, and physical restraint assessment.
• Continued education provided to all direct care workers, housekeeping, maintenance, social work, therapy, and activities are reminded of bed safety, entrapment zones, bed placement and potential for creating entrapment zones. Mattresses should not move on the bed frame. Mattress stops located on the 4 corners of the bed frame. Staff are responsible for reporting any entrapment zone issues or concerns. All staff who are actively employed by the facility have been trained.
• Education of staff that has not received training (due to illness, vacation, or leave of absence) will be completed before reporting to their workstations on their next schedule day.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's governing body failed to establish and implement necessary policies for managing and operating the facility, leading to significant deficiencies in resident care. Specifically, the facility did not maintain updated policies and equipment to ensure resident safety, resulting in two critical incidents. In one case, a resident with wandering behaviors was not consistently monitored, leading to an elopement incident where the resident exited the building, crossed a busy road, and was later returned to the facility. The facility's outdated door testing procedures contributed to this incident, as exterior doors were not consistently monitored or documented. In another incident, a resident with a contour mattress and bedrails was not properly assessed for bedrail alternatives, nor were the risks and benefits discussed with the resident's representative. This oversight resulted in the resident being found deceased, with their head wedged between the bedrail and mattress. The facility also failed to regularly inspect mattresses and bedrails for potential entrapment risks, as per FDA guidelines. These deficiencies placed residents at risk for serious injury or death, highlighting the facility's failure to maintain accountability and responsibility for resident safety.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at appropriate temperatures during the recertification and abbreviated surveys conducted. Specifically, the lunch meals served on two consecutive days were not at appetizing temperatures and lacked flavor. Residents expressed dissatisfaction with the food, describing it as cold and unappetizing. Observations confirmed that food items such as meatloaf, mashed potatoes, and spinach were served at temperatures below the facility's policy standards, and some items were difficult to consume due to their texture. Interviews with residents and staff revealed consistent concerns about the food quality and temperature. Residents reported that hot food was not served hot enough, and cold beverages were not sufficiently chilled. Staff members acknowledged the importance of serving food at proper temperatures to prevent illness and ensure resident satisfaction. The Dining Service Director admitted to receiving complaints about food service and confirmed that the temperatures of certain food items were not within the acceptable range as per the facility's policy.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly resolve resident grievances, as evidenced by the experiences of three anonymous residents and five specific grievances that lacked documented resolutions. During a Resident Council meeting, residents expressed that their grievances were not always addressed or resolved, and they were not informed of the reasons for inaction. Specific grievances included requests for gluten-free pasta and concerns about an overgrown garden in the courtyard, which remained unaddressed. Additionally, a resident's request to remove garbage cans from under the American flag in the dining room was not fulfilled, as observed during a survey. The facility's grievance policy, last reviewed in 2017, required prompt resolution of grievances and written documentation of the resolution process. However, grievances from August 2023 to August 2024 revealed several unresolved issues. These included a missing wheelchair for a resident, a missing hearing aid, lost dentures and a remote control, a curdled glass of milk, and a broken hearing aid. In each case, there was no documented follow-up or resolution, and the facility's grievance forms lacked the necessary information to confirm whether the issues were addressed. Interviews with the Social Services Director and the Administrator highlighted a lack of clarity and consistency in the grievance resolution process. The Social Services Director was unaware of the exact timeframe for resolving grievances and acknowledged that the forms did not indicate whether grievances were resolved. The Administrator confirmed that the grievance process required documentation of resolutions, but this was not consistently done. The facility's failure to maintain the courtyard garden and address resident concerns contributed to the perception that grievances were not being resolved.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical and nursing needs. Resident #93, who had diagnoses including palliative care and severe pain, did not have a care plan that included pain management or coordination with hospice services. Despite being on hospice care and frequently using morphine for pain, there was no documented evidence of collaboration with hospice providers, and the care plan lacked necessary details for staff to provide appropriate care. Resident #47, diagnosed with severe dementia and receiving antipsychotic medication, did not have a care plan addressing the use of antipsychotics. The absence of a care plan for the medication meant there was no monitoring for potential adverse reactions or considerations for gradual dose reduction. This oversight was acknowledged by the Registered Nurse Unit Manager, who confirmed that antipsychotic medications should be included in the care plan to ensure proper monitoring and management. Resident #74, with diagnoses including diabetes and myasthenia gravis, did not have a care plan for diabetes management or self-medication administration. The resident was self-administering medications and receiving insulin daily, yet the care plan did not reflect these aspects of care. The lack of a comprehensive care plan for diabetes and self-medication administration meant that staff were not adequately informed about the resident's needs and the necessary interventions to ensure safe and effective care.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety. During the recertification survey, it was observed that potentially hazardous foods, such as brown gravy, were not cooled properly in the main kitchen. The gravy was found at temperatures between 124 and 128 degrees Fahrenheit, which did not meet the required cooling standards of reducing the temperature to 70 degrees Fahrenheit within 2 hours and then to 40 degrees Fahrenheit within the next 2 hours. The Dining Service Director acknowledged that the cooling logs were incomplete and did not provide sufficient information to confirm proper cooling procedures. Additionally, the facility's kitchen and food storage areas were found to be unclean and contained unprotected food products. Observations revealed food debris, grease, and grime under and behind cookline equipment, as well as mold and condensation in the walk-in cooler. Uncovered desserts were left in the cooler, and flies were seen landing on uncovered cakes. The old kitchen walk-in cooler and freezer, used as backup storage, were also found to be unclean, with moldy shelving and excessive ice buildup. The Dining Service Director admitted that the old kitchen coolers were not cleaned regularly, and the cleaning documentation was incomplete. The facility's cleaning list indicated that certain cleaning tasks were not completed, such as sweeping under cook equipment and cleaning the walk-in cooler. The lack of cleanliness in food preparation and storage areas posed a risk to the health and safety of the residents.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary assistance with activities of daily living, specifically toileting, for two residents, leading to deficiencies in maintaining grooming and personal hygiene. Resident #6, who had severe cognitive impairment and was dependent on staff for toileting, was not checked or provided incontinence care for approximately 4.5 hours, despite the care plan requiring checks every 2 hours. Observations revealed that the resident was left in a wet brief, which was uncomfortable and posed a risk for skin issues. Resident #71, with diagnoses of Alzheimer's disease and Crohn's disease, was also not provided timely toileting care. The resident was observed in bed with a noticeable urine odor and no call bell within reach, indicating a lack of interaction and care from staff. The care plan required checks every 2 hours, but the resident was not toileted for over 4 hours. Staff interviews revealed that the resident was resistive to care, but refusals were not reported to the nurse, and no alternative approaches were attempted. Interviews with staff, including CNAs and nursing management, highlighted a lack of adherence to the care plans and communication failures regarding care refusals. Staff acknowledged the importance of regular checks to prevent skin breakdown and infections but did not follow through with the required care protocols. The failure to provide timely and adequate care compromised the residents' dignity and increased their risk for health complications.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's ability to self-administer medications was clinically appropriate. Resident #74, who had diagnoses of acute pancreatitis, myasthenia gravis, and diabetes, was observed with medications stored in an unlocked drawer of their dresser. There was no documented evidence that the interdisciplinary team had assessed the resident's ability to safely self-administer medication, as required by the facility's policy. The resident's comprehensive care plan did not include self-administration of medications and interventions, and there was no documented assessment for medication self-administration. Observations revealed that the resident self-administered Creon and pyridostigmine bromide without supervision, and the medications were not stored in a locked drawer as required. Interviews with nursing staff indicated uncertainty about whether an assessment had been completed and confirmed that the medications were not counted by nursing staff. The Assistant Director of Nursing acknowledged that residents should have an assessment for safe self-medication administration and a care plan documenting a resident-specific plan, with medications kept locked to ensure compliance.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #71's call bell was within reach, as care planned, during the recertification survey conducted from August 19 to August 22, 2024. The resident, who had diagnoses including Alzheimer's disease and dysphagia, was usually able to make themselves understood and understood others, despite having severely impaired cognition. The resident was independent with bed mobility, transfers, and ambulation but required moderate to maximal assistance with personal hygiene and dressing. The Comprehensive Care Plan initiated on August 1, 2023, documented that the resident was at high risk for falls and required the call light to be within reach to request assistance as needed. Observations made during the survey revealed that on multiple occasions, the resident's call bell was not within reach. On August 19, 2024, the call bell was hooked to itself at the wall, out of the resident's reach. On August 20, 2024, the call bell was found under a chair and on the floor, both times out of reach. Interviews with staff, including a CNA, RN Unit Manager, LPN, and the Assistant Director of Nursing, confirmed that call bells should be within reach to allow residents to communicate their needs. However, there was uncertainty among staff about whether Resident #71 could use the call bell, and it was noted that if a resident could not use a call bell, an alternative should be provided and documented in the care plan.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's care plan. Specifically, the resident, who had diagnoses of lymphedema and localized edema, did not have their elastic compression bandage (ACE wrap) applied as ordered. The physician's order required the ACE wraps to be applied every day in the morning and removed at bedtime, but observations on multiple occasions revealed that the resident was not wearing the ACE wraps, despite documentation indicating they had been applied. The resident was observed with swollen ankles and bilateral lower extremity edema without the ACE wraps on several occasions. The resident stated that staff did not always apply the wraps. Interviews with nursing staff revealed inconsistencies in the application of the ACE wraps, with one LPN unable to confirm if they had applied the wraps on specific dates, despite having signed the Treatment Administration Record. The care plan did not include the use of ACE wraps, and the failure to apply them as ordered was not documented as a resident refusal.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident #31, who had a Stage 4 pressure ulcer on the left elbow, did not receive the required pressure relief as outlined in their care plan. Observations revealed that the resident's left arm was not supported by a pillow or towel as mandated, which was crucial to prevent further deterioration of the ulcer. Interviews with staff indicated a lack of awareness and adherence to the care plan, resulting in improper positioning of the resident's arm. Similarly, Resident #58, who had a Stage 2 pressure ulcer on the right heel and deep tissue damage on the left heel, did not receive the prescribed pressure relief measures. The resident was observed without heel elevator cushions or pressure relieving boots while in a recliner chair, contrary to the care plan and physician's orders. Staff interviews revealed that the necessary pressure relieving devices were not implemented, and there was a lack of communication and understanding regarding the resident's care plan. The facility's policies on pressure ulcer prevention and resident-centered care planning were not effectively executed, as evidenced by the failure to apply pressure relieving devices for both residents. The interdisciplinary team did not ensure that the care plans were followed, leading to inadequate pressure ulcer management and potential risk of worsening conditions for the residents involved.

Penalty

Inspection fine: $151,624

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper wound care practices for a resident with a Stage 4 pressure ulcer. During a wound care observation, a Licensed Practical Nurse (LPN) did not perform appropriate hand hygiene between glove changes and used unclean scissors to cut iodoform packing strips, which were then placed into the resident's wound. The LPN also placed unpackaged gauze squares on an unclean nightstand before moving them to a barrier sheet, further compromising the sterility of the wound care process. The resident involved had a severely impaired decision-making ability and was dependent on staff for all activities of daily living. The resident's care plan included specific interventions for managing the Stage 4 pressure ulcer, such as using a pressure-reducing device and providing wound care per treatment orders. However, the LPN did not adhere to these protocols, as they failed to perform hand hygiene at critical points during the wound care procedure, increasing the risk of infection. Additionally, the facility's infection control policies were not reviewed annually as required. The policies, including those for antibiotic stewardship and skin and wound infection prevention, lacked documented review dates, indicating a lapse in maintaining up-to-date infection control standards. The Assistant Director of Nursing/Infection Control Nurse acknowledged that the policies were supposed to be reviewed annually but were not documented as such, highlighting a systemic issue in the facility's infection control program.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure adequate supervision to prevent accidents for Resident #5, who exhibited increased anxiety and aggressive behaviors towards other residents. Resident #5, diagnosed with frontal temporal neurocognitive disorder, pseudobulbar disorder, and dementia, had a history of wandering and aggressive behaviors. Despite these known risks, the facility failed to provide consistent and adequate supervision, resulting in multiple incidents where Resident #5 physically assaulted other residents and staff members. The comprehensive care plan for Resident #5 was not consistently updated to address these behaviors, and interventions such as 15-minute checks were not effectively implemented or documented. On several occasions, Resident #5 was involved in altercations with other residents, including hitting, slapping, and taking belongings from them. For instance, on 12/1/2023, Resident #5 hit Resident #6, and on 12/29/2023, Resident #7 hit Resident #5 in retaliation for entering their room. Despite these incidents, the care plan was not revised to include adequate supervision or additional non-pharmacological interventions. The facility's failure to provide meaningful activities and consistent monitoring allowed Resident #5 to continue wandering and exhibiting aggressive behaviors. Interviews with staff revealed a lack of specific direction on how to handle Resident #5's behaviors and inadequate training on non-pharmacological interventions. The Director of Nursing and other responsible staff members acknowledged that the care plan was not consistently reviewed or updated following incidents. The facility's approach to managing Resident #5's behaviors was insufficient, leading to repeated incidents of aggression and inadequate supervision to prevent harm to other residents and staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated or reported to the New York State Department of Health timely when required for three residents. Specifically, incidents involving physical altercations between residents were not thoroughly investigated, and some were not reported to the state health department as required. For instance, an incident on 12/1/2023 where one resident hit another was not fully investigated to determine if a stop sign was in place as per the care plan. Another incident on 12/25/2023 involving aggressive behavior and physical altercations was not investigated or reported to the state health department. The facility's policies on abuse and incident/accident investigation were not followed. The policies required thorough investigation, documentation, and reporting of incidents involving resident mistreatment or abuse. However, the facility failed to document whether care plan interventions, such as the placement of a stop sign on a resident's door, were in place at the time of the incidents. Additionally, there was no evidence that the incidents were reported to the New York State Department of Health as required. Interviews with staff revealed inconsistencies in the reporting and investigation process. Some staff members were unaware of the proper procedures, and there was a lack of documentation and follow-up on reported incidents. The Director of Nursing acknowledged that some incidents were not reported to the state health department and that the investigations were incomplete. This lack of thorough investigation and timely reporting led to deficiencies in ensuring resident safety and compliance with state regulations.