Schoellkopf Health Center
February 12, 2025 Complaint Survey

Standard Health Citations

FF15 483.25(e)(1)-(3):BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

REGULATION: § 483. 25(e) Incontinence. § 483. 25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. § 483. 25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. § 483. 25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: April 1, 2025

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during a Complaint (# NY 959) investigation, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment during care while emptying a urine drainage bag. The finding is: Review of the policy titled Infection Prevention dated 12/2024 revealed procedures for isolation and universal precautions will be placed for residents suspected or confirmed to have a contagious or infectious disease. Masks, gowns and gloves should be used as protective barriers when needed to reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infectious material. Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of personal protective equipment to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug-resistant organisms to staff hands and clothing including dressing, bathing/showering, transferring, changing linens, changing briefs, wound care, and contact with a urinary catheter. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool), dated 11/23/24, documented Resident #2 had moderate cognitive impairment, was usually understood, usually understands. Resident #2 required maximal assistance for personal hygiene, was totally dependent on staff for toilet hygiene and dressing, and moderate assistance for bed mobility. Review of the Comprehensive Care Plan initiated on 12/2/24 revealed Resident #2 required assistance with transfers and activities of daily living due to decreased balance and strength and required Foley catheter care. Review of the current Closet Care Plan (used by staff to guide care) dated 11/14/24 revealed the resident had a Foley catheter for continence and required extensive to maximal assistance for bathing and extensive assistance for bed mobility. Review of Physician order [REDACTED]. Review of the Physician's Progress note dated 2/6/25 revealed the resident has a history of [MEDICAL CONDITION] with frequent urinary tract infections and had a cystoscopy, with plans to continue the use of a Foley and for the resident to complete a course of [MEDICATION NAME] (antibiotic medication to treat infections). During an observation on 2/10/25 at 11:52 AM, a sign for enhanced barrier precautions was posted on Resident #2's door and directed staff to use a mask, gowns, and gloves for hands on care. Certified Nurse Aide #1 was observed at the resident's bedside wearing gloves, but no mask or gowns. Certified Nurse Aide #1 performed a bed bath that included assisting the resident with bed mobility, emptied the urinary collection, changed the resident's clothing, and handled soiled linens while wearing the same pair of gloves; the resident care activities performed were completed at 12:09 PM. During an interview on 2/10/25 at 12:27 PM, Certified Nurse Aide #1 stated yes, they should have had a gown and mask on in Resident #2's room to prevent infection, they forgot. During an interview on 2/10/25 at 12:26 PM, Registered Nurse #3 Infection Control Preventionist stated Resident #2 is on enhanced barrier precautions because of the use of the Foley catheter in accordance with the facility's nursing standard of practice. Staff are required to wear a gown, mask, and gloves for residents on enhanced barrier precautions to prevent the spread of infections. During an interview on 12/10/25 at 1:27 PM, the Director of Nursing stated that the resident is on enhanced barrier precautions for the use of the Foley catheter and staff are required to wear a mask, gown and gloves during hands on care to prevent infections. 10 NYCRR 415. 19(a)(2)

Plan of Correction: ApprovedMarch 6, 2025

Schoellkopf Health Center submits that its policies, systems and procedures related to the resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey Schoellkopf Health Center did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. However, in an effort to enhance the care furnished to our residents, we have improved some of our existing policies, procedures and systems. I.) The following corrective action was accomplished for the deficiency stated: A.) The CNA that provided inadequate Foley care to Resident #2 was termed from her agency employment contract on (MONTH) 11, 2025 prior to notification of this deficiency. Due to concerns that the administrator and director of nursing were made aware, the facility had already placed her and her agency contract on a watch status??ÿ for performance improvement, which was not accomplished. This appears to be an isolated incident with this particular CNA as she is quoted by state surveyor during interview saying she was aware the bag was supposed to remain below the resident's bladder to prevent infection.??ÿ B.) Resident #2 had a cystoscopy procedure on 2/4/2025, returned same day to facility with a leg bag attached to her thigh below the bladder. RN unit manager contacted the surgeon on 2/10/2025 and obtained orders to remove leg bag and replace with full urinary collection bag. C.) Resident #2 was on 24-hour report for nursing to monitor for any ill effects s/p cystoscopy or s/s of UTI. D.) The CNA did not care for any other residents with a foley. II.) The following corrective actions have been implemented to ensure all CNA staff are aware of proper Foley care as all residents have the potential to be affected by the same practice. A.) All CNA staff will be in-serviced by IP/In-service Coordinator on proper Foley catheter care to help prevent infections. B.) All residents with an indwelling urinary foley identified and they will be monitor for s/s of UTI. III.) The following systemic changes have been implemented to assure continued compliance with regulations. A.) All nursing staff: RN, LPN, and CNA will be required to complete a Relias training titled Care of a Urinary Catheter??ÿ on a yearly basis. B.) IP/In-service Coordinator or designee will audit 1 resident with a foley per week times 4 weeks, then 1 per month times 2 months to ensure competency in emptying procedure. C.) Administrator and Director of Nursing reviewed policy titled Catheter Care,??ÿ remains appropriate and no changes were made to the policy. IV.) The facilities compliance will be monitored utilizing the following QAPI system: A.) IP/In-service Coordinator will track all staff's compliance with assigned Relias trainings and report results to QAPI committee, which meets quarterly. B.) IP/In-service Coordinator will report audits to the QAPI committee, which meets quarterly. C.) The IP/In-service Coordinator Nurse will be responsible for overall monitoring and evaluation of implemented plans.

FF15 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: § 483. 80 Infection Control The facility must establish and maintain 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. § 483. 80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: § 483. 80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to § 483. 71 and following accepted national standards; § 483. 80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. § 483. 80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. § 483. 80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. § 483. 80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: April 1, 2025

Citation Details

None

Plan of Correction: ApprovedMarch 6, 2025

Schoellkopf Health Center submits that its policies, systems and procedures related to the resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey Schoellkopf Health Center did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. However, in an effort to enhance the care furnished to our residents, we have improved some of our existing policies, procedures and systems. I.) The following corrective action was accomplished for the deficiency stated: A.) The CNA that provided care to Resident #2 without donning proper PPE was termed from her agency employment contract on (MONTH) 11, 2025 prior to notification of this deficiency. Due to concerns that the administrator and director of nursing were made aware, the facility had already placed her and her agency contract on a watch status??ÿ for performance improvement, which was not accomplished. This appears to be an isolated incident with this particular CNA as she is quoted by state surveyor during interview saying she forgot??ÿ. This CNA was hired through agency on (MONTH) 10, 2024. During her orientation period she passed bathing and incontinence care, including infection control competency. B.) The facility's policy and procedure to alert staff of transmission-based precautions, including Enhanced Barrier Precautions were followed as evidence by the proper identification and needed PPE was present outside resident's room. II.) The following corrective actions have been implemented to ensure all CNA staff are aware of proper PPE/hand hygiene/infection prevention control technique during resident bathing and incontinence care, as all residents have the potential to be affected by the same practice. A.) All CNA staff in serviced by the IP/In-service Coordinator on the proper PPE/ hand hygiene/infection prevention technique for residents on EBP. Inservice will address the proper PPE to wear for residents on EBP to promote a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. B.) All CNA staff will have a competency evaluation performed by the IP/In-service Coordinator on proper PPE/hand hygiene/infection prevention technique while performing resident bathing and incontinence care. C.) IP/In-service Coordinator or designee will provide individualized instruction / training with any CNAs who do not pass competency. D.) All resident on Enhanced Barrier Precautions identified. RN Unit Manger or designee will interview appropriate residents on EBP to confirm staffs' compliance with infection control measures as all residents on EBP have potential to be affected by same practice. III.) The following systemic changes have been implemented to assure continued compliance with regulations. A.) In addition to current competency evaluations that the IP/In-service Coordinator or designee performs, all staff will be required to complete a Relias training titled Infection Control: Enhanced Barrier Precautions,??ÿ and Basics of Personal Protective Equipment??ÿ by (MONTH) 1, 2025 and then on a yearly basis. B.) Administrator and Director of Nursing reviewed policy titled Infection Prevention??ÿ remains appropriate and no changes were made to the policy. C.) IP/In-service Coordinator or designee will audit resident's care performed by a CNA for a resident on EBP. Will complete I audit per week times 4 weeks, then 1 per month times 2 months to ensure compliance with infection control measures/PPE. D.) IP/In-service Coordinator or designee will provide individualized instruction / training with any CNAs who do not pass competency. IV.) The facilities compliance will be monitored utilizing the following QAPI system. A.) IP/In-service Coordinator will track all staff's compliance with assigned Relias trainings and report results to QAPI committee, which meets quarterly. B.) IP/In-service Coordinator will report audits to the QAPI committee, which meets quarterly. C.) The IP/In-service Coordinator Nurse will be responsible for overall monitoring and evaluation of implemented plans.