NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Actual harm has occurred
Citation date: April 19, 2022
Corrected date: May 18, 2022
Citation Details Based on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. This was evident in 1 (West Side) of 2 units observed. Specifically, 1. ) A resident's wheelchair has been observed with torn cushion on the left arm rest, 2. ) The Hoyer lift was rusty with dark yellow and blackish stains on the metal frame, 3. ) The wooden door frame on the whirlpool room had chipped paint, and 4. ) The elevator was observed with layers of mismatched black colored paint. The findings are: The facility's policy titled Maintenance Service with a revision date of 01/2024 stated that it is the policy of the facility to provide maintenance services to all areas of the building, grounds, and equipment. The functions of maintenance personnel include maintaining the building in good repair and establish priorities in providing repair service. The following were observed during multiple observations conducted from 09/26/2024 to 10/03/2024 on the West Side unit: 1. ) Resident #54's wheelchair was observed with a torn cushion on the left arm rest. 2. ) The Hoyer lift being used on the West Side unit was observed with rust and had a large area of dark yellow and blackish stain on the metal frame. 3. ) The wooden door frame in the whirlpool room was observed with chipped paint. 4. ) The elevator door was observed with layers of mismatched paint. A review of the West Side unit Maintenance Workbook from 01/2024 through 09/2024 revealed no documentation of the concerns noted during the State Surveyor's observation. During an interview on 10/01/2024 at 10:41 AM, Resident #54 stated that the cushion on their wheelchair arm rest has been torn since they were admitted . They stated that the staff replaced their wheelchair yesterday and gave them another one that has no rip. During an interview on 10/03/2024 at 12:05 AM, the Director of Rehabilitation stated they were responsible for inspecting and repairing the wheelchairs and might have missed the torn arm rest on Resident #54's wheelchair. During an interview on 10/02/2024 at 10:43 AM, the Director of Maintenance stated they were responsible for maintaining the walls and other equipment including the Hoyer lift. The Director stated they make their rounds every morning and missed some areas that need to be repainted. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedMay 9, 2022 1. a. Resident #1 no longer resides in the facility. b. Resident #2 no longer resides in the facility. c. CNA#1 was terminated. 2. a. All residents have the potential to be affected by the finding. b. The facility Director of Social Work (SW)/designee will interview all cognitively intact residents to identify any abuse/neglect or mistreatment. c. All cognitively impaired residents will be audited for S/S of abuse/neglect/mistreatment. Interviews and audits revealed no further complaints/allegations. 3. a. A review of the facility policy titled Abuse??ΓΏ was completed By the DON and Administrator, no changes necessary. b. All staff was re-educated on the facility Abuse Policy. c. All alert residents will be educated to report any S/S abuse/neglect/mistreatment immediately. 4. a. DON/Designee will conduct direct care observation audits for 15 CNAs randomly weekly X4 then monthly X3 to ensure no inappropriate touching behaviors or inappropriate conduct will occur. The results of the audits will be presented at the quarterly QA committee meeting for review and feedback. Responsible party: Director of Nursing |