Minnewaska Community Health Services

In the surveyor’s words

From the most serious findings on record at Minnewaska Community Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Mar 25, 2025

  Based on observation, interview, and document review, the facility failed to ensure resident advance directives were accurately documented in the clinical record to reflect the resident's current wishes which affected 1 of 30 residents (R9) reviewed for advanced directives. This deficient practice resulted in an immediate jeopardy (IJ) for R9 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R9's electronic health record (EHR) banner and orders identified R9 was to have CPR however, R9's updated physician's order for life sustaining treatment (POLST) signed on [DATE], identified R9's wishes of do not resuscitate (DNR). […]

• Immediate jeopardy, isolatedF689Sep 21, 2023

  Based on interview, document review, and observation, the facility failed to ensure a door alarm was activated at all times, which resulted in 1 of 3 residents (R1) leaving a secured area, out onto concrete steps in his wheelchair, which placed R1 at risk for serious injury, harm or death. The Immediate Jeopardy (IJ) began on 9/14/23, at 8:00 a.m. when staff had disarmed the WanderGuard system, and R1 went out the door and was found on the cement steps with his wheelchair leaning on top of his head at 11:15 a.m. The IJ was identified on 9/21/23, at 3:30 p.m. and the administrator and nurse consultant were notified of the IJ. […]

• Immediate jeopardy, isolatedF689Aug 31, 2021

  Based on observation, interview and document review, the facility failed to complete a root cause analysis and develop interventions to prevent reoccurring falls for 1 of 3 residents (R1) which resulted in R1 falling 11 times causing one fracture, and minor injuries that required first aid. This resulted in an immediate jeopardy (IJ) situation for R1 who remained at risk for serious injury from frequent falls. The IJ began on 8/17/21, when R1 had 3 falls requiring emergency services in 48 hours which resulted in a wound over his eyebrow requiring Steri-Strips, a new bruise on right shoulder, right eye was still bruised and swollen and was admitted to the hospital and determined to have a right hand, 5th metacarpal fracture. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2025

  Based on observation, interview and document review, food was not served in a sanitary manner for 30 residents who dined in the dining area observed during dining services and who received an afternoon snack. In addition, the facility failed to maintain the ice machine and the coffee machine in a sanitary manner to prevent potential illness for 30 residents who currently received ice from the ice machine and or coffee from the coffee machine in the dining area. Further, the facility failed to maintain proper holding food temperatures for cole slaw that was to be served during the evening meal for all residents in the dining room. These deficient practices had the potential to affect all 30 residents residing in the facility. […]

• No harm, potential for more than minimal, widespreadF851Mar 25, 2025

  Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 30 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified excessively low weekend staffing. […]