Trustees of Eastern Star Hall & Home of the N Y S

In the surveyor’s words

From the most serious findings on record at Trustees of Eastern Star Hall & Home of the N Y S, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Nov 8, 2024

  Based on observations, record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 2 of 2 medication carts ([NAME] and [NAME] Unit's medication carts); 1 of 2 medication rooms ([NAME] Unit); and 1 of 2 treatment carts ([NAME] unit). Specifically, the [NAME] and [NAME] Units medication carts had expired stock medications and insulin; the [NAME] medication room had expired stock medications and biologicals; and the [NAME] treatment cart was unlocked and unattended. […]

• No harm, potential for more than minimal, patternF689Feb 23, 2023

  Based on observation, interview, and record review during the recertification survey conducted 2/21/23-2/23/23, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 14 windows on the [NAME] unit (1 window at the nursing station, 2 windows in the dining room, 1 window in the soiled utility room, 1 window in the kitchenette, 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], and 1 window in the shower room). Specifically, windows on the [NAME] unit were able to fully open without restriction. Findings included: There was no documented facility policy addressing window restrictors or routine window inspections. […]

• No harm, potential for more than minimal, isolatedF577Nov 8, 2024

  Based on observations and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 Federal Health Recertification survey. Specifically, the results of the most recent Federal health recertification survey conducted 2/23/20223 were located behind the reception desk on a high shelf and was not accessible to all without having to ask for assistance. […]

• No harm, potential for more than minimal, isolatedF582Nov 8, 2024

  Based on record review and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #276) reviewed. Specifically, Resident #276 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required. […]

• No harm, potential for more than minimal, isolatedF684Nov 8, 2024

  Based on record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 1 resident (Resident #218) reviewed. Specifically, Resident #218 did not have their ordered blood sugars documented in the medical record and were not available for the medical provider's review. Findings include: The undated facility policy, Protocols for Diabetic Residents, documented if a resident on insulin had a blood sugar over 240 (milligrams/deciliter) the provider was notified the following day. […]