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: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 02/24/2025 to 02/28/2025, for one (Residents #15) of seven residents reviewed, the facility did not ensure that residents who were dependent on staff for assistance received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #15 did not receive consistent assistance with nail care. This is evidenced by the following: The facility policy Nail Care, dated 04/10/2011, documented routine nail care is to be done following bath and/or shower whenever possible. Resident #15 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 01/04/2025, documented the resident had severely impaired cognition and was dependent with personal hygiene. Review of the Comprehensive Care Plan, last reviewed on 01/05/2025, and current Kardex (plan of care used by Certified Nursing Assistants) revealed Resident #15 required total assistance with bathing/showering and all personal hygiene including nail care on bath/shower day and/or as needed. Scheduled shower day was Monday evening shift. In a nursing progress note, dated 02/08/2025, the Licensed Practical Nurse documented that Resident #15 removes their brief and smears the bowel movement around. During an observation on 02/24/2025 at 11:45 AM, Resident #15 was in bed. Their brief (partially removed by the resident) was soaked through, their bed sheet was wet, and the resident had brown stool on back of their leg and all over their left hand, including fingers and nail beds. Review of the (MONTH) 2024 Treatment Administration Record revealed Resident #15 received a weekly skin monitoring every Monday evening shift for skin integrity and was signed off as being completed on 02/24/ 2025. During an observation on 02/24/2025 at 12:34 PM, 02/25/2025 at 10:03 AM, and on 02/26/2025 at 4:16 PM, Resident #15 had brown debris on multiple fingers, nails, and cuticles. During an observation on 02/27/25 at 8:57 AM, Resident #15 was sitting up in bed eating breakfast with their hands. Their tee shirt, brief, and left hand had brown debris in the cuticles and under the fingernails. During an interview on 02/27/2025 at 5:49 PM, Certified Nursing Assistant #9 stated they were not assigned to Resident #9 (that day) but they have floated to that unit and care for each resident should be on the Kardex which is found in the resident's room. Certified Nursing Assistant #9 stated if a resident refused nail care, they should reapproach and tell the nurse. During an interview on 02/27/2025 at 2:51 PM, Licensed Practical Nurse Manager #2 stated nail care should be completed on the residents' shower days unless refused. Review of Resident #15's electronic medical record with the surveyor at this time revealed no documented evidence that they had refused nail care. Licensed Practical Nurse Manager stated it (the dirty nails) was a problem. During an interview on 02/28/2025 at 11:37 AM, the Director of Nursing stated nail care should be performed on shower days and that if a resident refused nail care, the nurse should be made aware, and the refusal documented in the electronic medical record and on the resident's care plan. 10 NYCRR 415. 12(a)(3) | Plan of Correction: ApprovedMarch 19, 2025 F677 Corrective Action- To assure all residents who were unable to carry out activities of daily living (ADLs) receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. On 3/17/2, Resident #15 had proper nail care performed. Resident#15s Care plan was reviewed for level of assistance required for hygiene and remains appropriate. 2. All residents residing in the facility who require assistance for nail care have the potential to be affected by this practice. A list of all residents who are dependent on staff for nail care will be created. These listed residents will then be audited for appropriate nail care. 3. To ensure this practice does not reoccur, the facility policy on Nail Care will be reviewed and revised if necessary, Education will be provided to all nursing staff (RNs, LPNs, and CNAs). The Director of Nursing/Designee will oversee in-services for all nursing staff. 4. To prevent further deficiency in this practice, the Director of Nursing/Designee will perform 10 resident audits per month for 3 months, and then as needed based on the audit findings. Audits will verify that proper nail care has been completed. The DON will monitor this process and review results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F 677. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for one (Resident #36) of one resident reviewed, the facility did not ensure that [MEDICAL TREATMENT] services provided were consistent with professional standards of practice, the comprehensive care plan and physician orders. Specifically, the facility did not have evidence of consistent monitoring of the resident's ordered 24-hour fluid restriction, did not have physician's orders or a care plan for having a tunneled [MEDICAL TREATMENT] catheter (surgically inserted catheter into the chest wall used to perform [MEDICAL TREATMENT]), did not have documented evidence of monitoring the catheter and dressing for potential complications, and were not following the vascular physician's recommendations. This is evidenced by the following: Resident #36 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 02/11/2025, revealed Resident #36 was cognitively intact and received [MEDICAL TREATMENT] treatments. Review of a hospital Emergency Record, dated 12/31/2023, revealed Resident #36's [MEDICAL TREATMENT] fistula (a surgical connection between a vein and artery that helps the body create the flow of blood required to complete [MEDICAL TREATMENT] treatments) was clotted (not functioning) and a right-sided surgically inserted tunneled catheter [MEDICAL TREATMENT] port was placed (via the chest wall) to use for [MEDICAL TREATMENT] treatments (in place of the fistula). In a consultation note, dated 11/21/2024, the Vascular Nurse Practitioner documented that the resident required a new right arm fistula which was planned for after the holidays. Recommendations (capitalized and highlighted) included no blood draws or needle pokes in the right arm. In a consultation note, dated 01/23/2025, the Vascular Nurse Practitioner documented that Resident #36 was recommended to have a new fistula created but had a respiratory illness and they would follow up to reschedule in a few weeks. Current physician orders reviewed on 02/27/2025 documented: a. [MEDICAL TREATMENT] fistula: monitor the site to the left arm for positive thrill and bruit (sounds and vibrations felt and/or heard in a fistula indicating it was functioning) every shift (ordered 01/18/2024). b. Check blood pressure upon return from [MEDICAL TREATMENT], no blood pressures in the shunt (fistula) arm and check for bleeding (ordered 12/26/2023). c. Remove the pressure dressing four hours after the resident returned from [MEDICAL TREATMENT] (ordered 12/26/2023). d. Fluid restriction: document 24-hour totals in the electronic health record at bedtime 1500 milliliters fluid restriction/24 hours with 360 milliliters allowed for nursing and 1140 milliliters allowed for dietary (meals) for the 24-hour total (ordered 05/09/2024). The current physician's orders did not include any monitoring of Resident #36's tunneled [MEDICAL TREATMENT] catheter and included no blood pressures or lab draws in the left arm versus the vascular physician's recommendations referring to the right arm. Resident #36's undated Comprehensive Care Plan, reviewed on 02/26/2025, included the resident received [MEDICAL TREATMENT] three times a week with interventions as followed: a. No blood pressures or labs draws on the left side (arm) b. Monitor the shunt (fistula) for signs of infection or bleeding c. Check the shunt site for positive bruit and thrill d. A 1500 milliliters (per day) fluid restriction, at risk for dehydration and to monitor fluids daily Resident #36's care plan did not include that Resident #36 had a tunneled catheter (in addition to a fistula) or interventions for monitoring the catheter for potential complications or care of the catheter (e.g., during showers). Review of the (MONTH) 2025 and (MONTH) 2025 Medication Administration Records revealed that the 24-hour total fluid look back report had daily totals that ranged from zero to 60 milliliters a day to 2160 milliliters a day with an average daily fluid intake of 345 millimeters per day for the 56 days reviewed (versus 1500 milliliters). The Records also included nursing staff also signed off as completed that they removed a dressing from the residents fistula (not currently in use) after [MEDICAL TREATMENT] and checked it for a positive bruit and thrill. During an observation and interview on 02/25/2025 at 11:09 AM, Resident #36 had a tunneled catheter in the right chest wall covered with a dressing which was clean and dry. There was no dressing to the resident's left arm. During an interview at this time, Resident #36 stated at the time that they were on a fluid restriction when in the dining room. During a telephone interview on 02/27/2025 at 1:58 PM, the [MEDICAL TREATMENT] Clinical Coordinator/ Registered Nurse stated Resident #36 was on a fluid restriction and their tunneled catheter (not their fistula) was used for their [MEDICAL TREATMENT] treatments. The [MEDICAL TREATMENT] Clinical Coordinator stated Resident #36 had a left-sided fistula, but they were told (by medical) not to use it as the resident needed a new fistula and that the fistula (left arm) had not been in use for at least a year. The [MEDICAL TREATMENT] Clinical Coordinator/ Registered Nurse stated that facility staff do not touch (remove or change) the dressing on the tunneled catheter. During an interview on 02/28/2025 at 11:28 AM, Licensed Practical Nurse #2 stated they cared for Resident #36 (approximately a week ago) and usually when caring for [MEDICAL TREATMENT] residents, they check the resident's fistula for a bruit and thrill, and to make sure there was no redness. Licensed Practical Nurse #2 stated [MEDICAL TREATMENT] (catheters or fistulas) were usually listed on the care plan and the fluid restrictions were on the Medication Administration Records. Licensed Practical Nurse #2 stated they were not sure who was responsible for monitoring the resident's 24-hour total fluid intake, and did not believe Resident #36 was on a fluid restriction. Licensed Practical Nurse #2 stated they did not know anything about Resident #36's tunneled [MEDICAL TREATMENT] catheter. During an interview on 02/28/2025 at 12:08 PM, Licensed Practical Nurse #3 stated Resident #36 was on a fluid restriction, but did not know who was responsible for monitoring the 24-hour totals. Licensed Practical Nurse #3 stated they thought Resident #36 had their tunneled [MEDICAL TREATMENT] catheter as far back as a year ago. During an interview on 02/28/2025 at 12:55 PM, Licensed Practical Nurse Manager #2 stated the nurses should document the fluids used during medication administration in the electronic medical record and the Certified Nursing Assistants should document the fluid intake from meals in a separate spot. Licensed Practical Nurse Manager #2 stated a tunneled [MEDICAL TREATMENT] catheter should be on the care plan because it was an access site and would need to be monitored. During a review of the fluid restriction order and Medication Administration Records in Resident #36's electronic medical record with the surveyor at this time, Licensed Practical Nurse Manager #2 stated the Dietician (Diet Technician) was responsible for monitoring the 24-hour total fluid intake and that the intakes did not make sense to them (e.g., resident received 240 milliliters for the whole day) and they did not think the nurses understood how to document this. Licensed Practical Nurse Manager #2 stated they did not see any orders or interventions on the care plan for monitoring Resident #36's tunneled [MEDICAL TREATMENT] catheter and they thought Resident #36's fistula was being used during [MEDICAL TREATMENT]. They stated the Infection Prevention Nurse monitored the tunneled catheter and would look at it during the resident's showers. Review of interdisciplinary progress notes for the prior three months revealed no documented evidence that the Infection Preventionist nurse was monitoring the tunneled [MEDICAL TREATMENT] catheter. During an interview on 02/28/2025 at 2:03 PM, Dietary Technician #1 stated they were not aware of anyone looking at the 24-hour total fluid intake for residents on fluid restrictions and was not sure what the Look Back Report was referring to (in the fluid restriction order) and that their Registered Dietician | Plan of Correction: ApprovedMarch 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F698 Corrective Action- To assure that residents requiring [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. 1. Resident #36 orders were reviewed and updated for: 24-hour fluid restriction, and monitoring of the right chest tunneled catheter dressing. The left AV fistula orders were reviewed and discontinued and the interventions have been resolved. The care plan was reviewed and updated to include the right chest wall tunneled [MEDICAL TREATMENT] catheter, interventions for monitoring, and the 11/26/2024 vascular physician recommendations were reviewed by the provider and added to the care plan. The resident is scheduled to scheduled to have a right arm fistula or graft completed on 4/7/ 2025. 2. All residents who receive [MEDICAL TREATMENT] treatment have potential to be affected by this practice. A list of all Residents on [MEDICAL TREATMENT] will be created and audited to assure fluid restrictions are monitored 24 hours a day, physician orders [REDACTED]. 3. To ensure this does not reoccur, the facility policy on [MEDICAL TREATMENT] will be reviewed and updated as needed. LPN and RN staff will be educated on said policy and written test to be provided to ensure competency. The Director of Nursing will oversee completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform audits of all [MEDICAL TREATMENT] residents each month for 3 months, and then as needed based on findings. Audits will include monitoring of any fluid restrictions, monitoring of physician orders [REDACTED]. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings as needed. If continued improvement is needed the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F 698. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 02/24/2025 to 02/28/2025, for four (Residents #16, #45, #79, #100) of seven residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #45 had respiratory symptoms, tested positive for Covid-19, and was not placed on enhanced droplet/contact precautions (a strategy used by nursing homes to prevent the spread of infectious diseases). Staff were observed within six feet of Resident #45 without wearing personal protective equipment (equipment used to protect against the transmission of communicable diseases/infections such as gloves, gowns, face masks, and face shields), including but not limited to, a face mask and face shield. Resident #79 was admitted with a open area to their leg and subsequently developed a pressure ulcer to their heel, was not placed on enhanced barrier precautions (a strategy used by nursing homes to decrease transmission of infectious disease), and staff were observed changing the dressing to the open heel ulcer without wearing a gown. Resident #100 had respiratory symptoms, tested positive for Covid-19, was placed on contact precautions (versus airborne) and staff were observed within six feet of the resident, touching the resident's environment without wearing appropriate personal protective equipment. Resident #104 was admitted with an unstageable pressure ulcer (a bed sore where depth cannot be seen) to their sacrum (area at bottom of the spine) and was not placed on enhanced barrier precautions. Resident #16 was on enhanced barrier precautions and staff were observed performing high-contact personal care without wearing appropriate personal protective equipment. Additionally, the facility did not ensure the Infection Prevention and Control Program policies and procedures were reviewed at least annually as required. This is evidenced by the following: 1. Resident #45 had [DIAGNOSES REDACTED]. and anxiety. The Minimum Data Set Resident Assessment, dated 02/12/2025, included Resident #45 was cognitively intact. Review of a progress note written by the Registered Nurse Educator on 02/24/2025 at 9:23 AM revealed Resident #45's family was notified Resident #45 had tested positive for Covid-19 and was on isolation precautions. During an observation and interviews on 02/24/2025 at 12:24 PM, Resident #45's room door was open and there were no visible precaution signs posted or personal protective equipment near the room. Resident #45 stated they were tested for Covid-19 due to having laryngitis (inflammation of the vocal cords) and nobody let them know their results. During an immediate interview, the Director of Social Work stated Resident #45 was tested for Covid-19 and their results were not in yet. During an observation on 02/24/2025 at 1:00 PM, Resident #45's room door was closed, there was a sign for enhanced droplet/contact precautions posted and a cart with personal protective equipment outside the room. During an observation on 02/27/2025 at 9:44 AM, Resident #45 was in their wheelchair at the threshold of their opened room door. Certified Nursing Assistant #4 was standing within six feet of Resident #45, talking with them, and was not wearing a face mask or shield. 2. Resident #100 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/20/2024, included Resident #100 had mildly impaired cognition. Review of a progress note written by Licensed Practical Nurse #1 on 02/22/2025 at 6:08 PM revealed Resident #100 presented with shortness of breath, was coughing, and complained of a sore throat. Review of physician's orders [REDACTED]. 2025. During an observation and interview on 02/24/2025 at 12:53 PM, Resident #100 was in their room and had a wet, harsh cough. There was a contact precaution sign posted on the door and had an x marked next to handwashing, gloves, and gowns. There was no x marked for mask or eye protection. Certified Nursing Assistant #3 put a surgical mask on, entered the room, was within six feet of the Resident #100 talking with them, picked up items, and exited the room carrying their lunch tray. During an interview at this time, Certified Nursing Assistant #3 stated they did not know why there was a contact precaution sign on the resident's door as they were not told that information. The precaution sign was reviewed with Certified Nursing Assistant #3 at that time, and they stated they only needed to wear the equipment that did not have an x marked next to them and had worn a mask (surgical) and glasses when entering Resident #100's room. During an observation on 02/25/2025 at 9:21 AM, there was a sign on Resident #100's door for enhanced droplet/contact precautions and had an x marked for handwashing, gloves, gown, eye protection, and N-95 mask. 3. Resident #79 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 01/21/2025, included Resident #79 had mildly impaired cognition, was dependent on staff for care, had surgical wound(s), and required surgical wound care. Review of physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of a progress note written by Nurse Practitioner #1 on 01/27/2025 revealed Resident #79 was admitted to the facility after hospitalization for treatment of [REDACTED]. During an observation on 02/25/2025 at 9:52 AM, Resident #79 lying in bed while the Registered Nurse Educator was holding the resident's right leg and Nurse Practitioner #2 was standing at the end of the bed. Resident #79's right heel had an open wound that was bright red in color. The Registered Nurse Educator and Nurse Practitioner #2 were not wearing gowns. There were no visible precaution signs posted or personal protective equipment near the room. During an interview on 02/28/2025 at 11:15 AM, the Registered Nurse Educator/Infection Preventionist stated they were responsible for the Infection Control Program. Staff on the units were responsible for putting up precaution signs and personal protective equipment carts outside of the resident's rooms and the Registered Nurse Educator would verify placement. The Registered Nurse Educator stated they did not realize there was no precaution sign for Resident #45 and was not aware Resident #100 had the wrong precaution sign posted on their door. The Registered Nurse Educator stated residents were supposed to be placed on enhanced droplet/contact precautions when they showed any signs and symptoms or were being tested for Covid- 19. They stated staff should wear N-95 masks and a face shields in those resident rooms as Covid-19 could spread and nine staff were currently out of work due to Covid-19 illness. The Registered Nurse Educator stated the facility used enhanced barrier precautions for any resident that had significant multi-drug-resistant organisms, a device like a Foley (a medical device that helps drain urine from the bladder), a wound greater than a stage three (a deep pressure sore), or for an unhealed wound. St | Plan of Correction: ApprovedMarch 19, 2025 F880 Corrective Action-To assure the facility establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. On 2/27/25 Resident #45 was placed on enhanced droplet/contact precautions for Covid-19 and the proper precaution sign was posted. CNA #4 was educated on proper PPE for enhanced droplet/contact precautions including a wearing mask/face shield. On 2/27/25 Resident #79 was placed on enhanced barrier precautions and the proper precaution sign was posted. The RN Educator and the Nurse practitioner were educated on proper PPE/gown use. On 2/27/25 Resident #100 was placed on enhanced droplet/contact precautions and CNA #3 was educated on proper PPE for precautions. Resident #104 was placed on enhanced barrier precautions. Additionally, the facility will ensure that Infection Prevention and Control Program policies are reviewed annually. Resident #16s care plan was reviewed to assure the residents enhanced barrier precautions remained appropriate and the proper precaution sign was posted. CNA # 1and 2, were educated on proper PPE precautions. 2. All residents who have respiratory symptoms and are being tested for COVID-19 have the potential to be affected by this deficient practice. A list of residents who have respiratory symptoms and are being tested for COVID-19 will be audited to ensure they are on enhanced droplet/contact precautions per policy, their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. All residents who have a wound with an expected healing time of greater than 4 weeks as per policy, have the potential to be affected by this deficient practice. A list of residents with wounds will be generated and audited to determine if enhanced barrier precautions are necessary and their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. 3. The facility policies for its Infection Control Program including: Infection Prevention and Control- General Statement, Policy on Use of Criteria for Infection Identification, Antibiotic Stewardship Program, Policy on Influenza Immunization (Seasonal/H1N1), Pneumococcal Vaccination Program-Residents, Policy on Surveillance, PPE Donning and Doffing, Enhanced Barrier Precautions and Coronavirus Policies will be reviewed and updated (if necessary), as well as annually. All facility staff will be educated on PPE Donning and Doffing. And all licensed nursing staff (RN/LPNs) will be educated on all our Infection Control Program policies listed above. The Director of Nursing/Designee will oversee the completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform 10 audits per month for 3 months, and then as needed based on findings. Audits will verify that residents on precautions (EBP, contact/ droplet/ airborne) have appropriate precaution signs on doors and that appropriate PPE is worn by staff during direct care. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F 880. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #51) of one resident reviewed for [MEDICAL CONDITION]. Specifically, the facility did not ensure the resident received the highest practical, physical, mental, and psychosocial wellbeing, including ace wraps to both lower extremities. This is evidenced by the following: Resident #51 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 02/07/2025, documented the resident had moderately impaired cognition. Review of Resident #51's current physician's orders [REDACTED]. Review of Resident #51's Care Plan, dated 08/05/2024, documented under skin integrity issues for staff to encourage ace wraps and document refusals. Observations on 02/24/2025 at 11:34 AM, 02/26/2025 at 4:15 PM, and 02/27/2025 at 09:00 AM revealed Resident #51 in a recliner chair, both legs were elevated and bright red with extreme [MEDICAL CONDITION] swelling and had multiple blisters on each leg. At no time was the resident observed wearing ace wraps. Review of Resident #51's Treatment Administration Record revealed no documentation of the ace wraps provided for the month of (MONTH) from 02/01/2025 to 02/27/ 2025. During an interview on 02/27/2025 at 01:58 PM, Certified Nursing Assistant #9 stated they work the evening shift and do not apply the ace wraps but have removed them at times. Certified Nursing Assistant #9 stated that Resident #51 will refuse care from male caregivers, but does not refuse care from them as the resident knows them. During an interview on 02/27/2025 at 1:58 PM, Licensed Practical Nurse Manager #2 stated Resident #51 does refuse care at times. During a review of the resident's electronic medical record at this time with the surveyor, Licensed Practical Nurse Manager #2 stated there was no documented evidence of the resident's refusing the ace wraps for the past month. During an interview on 02/28/2025 at 11:37 AM, the Director of Nursing stated if a resident refused treatments or care, the Certified Nursing Assistants should let the nurses know and reapproach the resident to provide the care or have another staff member try to provide care. If a resident still refused, then the refusal should be documented by nursing. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMarch 19, 2025 F684 Corrective Action- To assure that Residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices. 1. On 2/27/25, the provider reviewed and revised residents #51s order for ace wraps, requiring progress notes for all refusals. On 3/17/25, resident #51s care plan was reviewed and remains appropriate in regards to ace wraps. 2. All residents who have orders for ace wraps have the potential to be affected by this practice. A list of all residents requiring ace wraps will be created and audited to ensure that ace wraps are applied as directed and documented appropriately. 3. To ensure this practice does not reoccur, the facility policy on ?ôMedication/Treatment administration: Documentation?Ø will be reviewed and revised if necessary. All licensed nursing staff (RN, LPN) will be re-educated on this policy. The Director of Nursing/designee will oversee in-services for all licensed nursing staff. 4. To prevent further deficiency in this practice, the Director of Nursing /designee will perform 10 audits per month for 3 months, and then as needed based on the audit findings. Audits will verify ace wraps are applied as ordered, and that all refusals are documented. The Director of Nursing will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of nursing will assume overall responsibility for correction of F 684. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for one (Resident #66) of four resident reviewed, the facility did not ensure that all alleged violations involving potential abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, the facility did not report a resident falling out of bed during care that was being provided by one Certified Nursing Assistant opposed to two Certified Nursing Assistants per the resident's person-centered Comprehensive Care Plan. This is evidenced by the following: The facility policy Accident/Incident Investigation and Prevention, dated (MONTH) 2023, included in the event a resident is involved in an accident or incident in which it is reasonable to assume, based on the facts, that negligence is involved, the occurrence shall be reported to the New York State Health Department according to the Patient Abuse and Reporting regulations. Resident #66 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 01/23/2025, documented Resident #66 had severely impaired cognition. Review of the resident's Comprehensive Care Plan (initiated 06/02/2024) and the current Kardex (care plan used by the Certified Nursing Assistants for daily care) included Resident #66 had a self-deficit in bed mobility and required two staff for bed mobility and rolling side to side. Review of the document titled #4434 witnessed fall, dated 02/19/2025 (identified by the facility as an Incident and Accident form) and signed by Licensed Practical Nurse #3, revealed that Resident #66 had a fall out of bed during incontinence care that was provided by Certified Nursing Assistant # 7. Resident #66 was care planned for two-person assist for incontinence care while in bed. Resident #66's mental status was oriented to person and situation, both Licensed Practical Nurse #3 and the night shift Supervisor Licensed Practical Nurse #5 were notified. The resident sustained [REDACTED]. Both Provider (medical team) and family were notified. Intervention initiated was a fall mat to left side of bed. Review of statements, all dated 02/19/2025 obtained by the facility included the following: 1. In a statement Certified Nursing Assistant #7 stated they were changing Resident #66, told Resident to roll back to them, but the resident rolled the wrong way and fell off the bed. 2. In a statement Licensed Practical Nurse #3 stated they were passing medications to another resident when Certified Nursing Assistant #7 told them Resident #66 was on floor. Licensed Practical Nurse #3 documented in their statement that the aide (Certified Nursing Assistant #7) rolled the resident out of bed. Additionally, Licensed Practical Nurse #3 documented that Certified Nursing Assistant #8 approached them to inform them another resident had complained to them that Certified Nursing Assistant #7 had been rough with them during care. Licensed Practical Nurse #3 documented that they felt Certified Nursing Assistant #7 was a detriment to the residents. 3. Resident #66's statement included that the aide rolled them onto the floor. During an interview on 02/27/2025 at 2:51 PM, Licensed Practical Nurse Manager #2 stated if an accident or incident occurred it was the nurse's responsibility to start the Accident and Incident form which included witness statements, neuro checks, vital sign sheets, and to write up findings in the resident's electronic medical record. Licensed Practical Nurse Manager #2 stated as a Nurse Manager they review Accident and Incident reports in the electronic medical records, review care plans and bring the incidents to morning meeting to discuss the situation (with the interdisciplinary team). During an interview on 02/28/25 at 10:07 AM, the Director of Nursing stated any signs of abuse or neglect with an injury should be reported to the Department of Health. The Director of Nursing stated they did not report this incident because they felt the bruise was related to a fall, so they did not need to report it. During an interview on 02/28/25 at 12:28 PM, the Administrator stated that neglect and/or mistreatment included not following the care plan. The Administrator stated they did not feel that the incident on 02/19/2025 with Resident #66 rose to the level of reporting to the Department of Health because it was not a serious injury. 10 NYCRR 415. 4 | Plan of Correction: ApprovedMarch 19, 2025 F609 Corrective Action- To assure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator and to other officials in accordance with State law through established procedures 1. As noted, the investigation regarding resident #66, dated 2/19/25, was made aware to the state DOH during survey 2/24/25 through 2/28/ 25. C.N.A. # 7, was educated/counseled on properly following the residents care plan. 2. All residents with alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source and misappropriation of resident property have the potential to be affected by this deficient practice. A retrospective review of all residents who have had such incidents in the past 30 days will be created and reviewed to assure that proper notification took place (if necessary). 3. The facilitys ?ôAccident/Incident Investigation and Prevention?Ø and ?ôFacility Incident/abuse investigation and reporting?Ø policies will be reviewed and revised if necessary to assure compliance. All staff will be in-serviced on these policies and the NYSDOH reporting guidelines. The Director of Nursing/Designee will oversee all education for staff. 4. To prevent further deficiency in this practice, the Director of Nursing / Administrator will perform audits of 10 resident accident and incident investigations each month for the next 3 months and then as needed based on the audit findings. Audits will verify that the facility is appropriately reporting all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are being reported immediately to the administrator of the facility and to other officials in accordance with State Law through established procedure. The administrator will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F609 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Life Safety Code Survey from 02/24/2025 to 02/28/2025, for one (patient electric beds) of four resident care items the facility did not ensure patient care related electrical equipment was properly maintained. Specifically, electric beds were not being inspected at intervals specified by the manufacturer and there was no documentation of formal inspections or maintenance of the beds. The findings are: The facility policy titled Medical equipment management plan, dated 7/2017, listed: Establishing criteria for identifying, evaluating and taking inventory of medical equipment to be included in the equipment management program. All medical and electrical patient care equipment will be evaluated prior to use, based on function including diagnosis, care, treatment and monitoring; physical risks associated with use, maintenance requirements and history of equipment incidents. Observations on 02/24/2025 from 10:25 AM to 1:24 PM included electrically operated beds plugged into wall outlets in resident sleeping rooms throughout the facility, including an M.C. Rexx brand bed in resident room 201. Record review on 02/26/2025 at 11:15 AM revealed an electrical equipment power and extension cords audit, dated 05/28/2024, listing to ensure proper power strips are used for medical equipment and non-medical equipment, and also to ensure extension cords are not being used to substitute fixed wiring from the facility. Resident rooms and offices were listed on the form and no specific items were listed or identified as checked, nor was there an inventory of electrically operated beds within the facility or unique identification. Record review on 02/26/2025 at 11:15 AM revealed an M.C. Rexx brand bed manual, listing a preventative maintenance section including: There are a number of maintenance items that should be reviewed every six months to ensure proper functioning of the bed. Page 19 of the manual listed that each bed must be inspected at least once a year by qualified technicians. A corresponding inspection form and chart was included to document these inspections and listed the following items to be checked: power cord, bushings, [MEDICATION NAME], motor operation, normal operation over full range, grinding popping and other noises, bent parts, clevis pins and fasteners, retaining rings, cabling, caster locking, side rail and latches, head and foot board panels, cleanliness, and paint finish. The chart also included a section for date, initials, and comments. Further review of facility records revealed there were no documented preventative maintenance forms for the resident electrically powered beds to indicate electrical safety was checked on a routine basis per manufacturer's requirements. During an interview on 02/26/2025 at 11:30 AM, the Environmental Services Director stated there were no unique identifiers used for beds and they were checked annually using the room audit form. The Environmental Services Director also stated all equipment was checked in rooms to include beds during those audits and specific beds could be identified moving forward. The 2012 edition of NFPA 99, Health Care Facilities Code, requires the facility to establish policies and protocols for the type of test and intervals of testing patient care-related electrical equipment. Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. A record shall be maintained of the tests required by this chapter and associated repairs or modifications. At a minimum, the record shall contain all of the following: (1) Date, (2) Unique identification of the equipment tested , (3) Indication of which items have met or have failed to meet the performance requirements. Equipment shall be serviced by qualified personnel only. 10 NYCRR: 415. 29(a)(1), 711. 2(a)(1); 2012 NFPA 99: 10. 5. 2. 1. 1, 10. 5. 3. 1. 2, 10. 5. 6. 2. 1, 10. 5. 6. 2. 2, 10. 5. 8. 3 DAL NH 18-04 (dated (MONTH) 21, (YEAR)) | Plan of Correction: ApprovedMarch 19, 2025 K921 Corrective Action- To ensure the facility meets all the requirements for NFPA 101 Electrical Equipment Testing and Maintenance in regards to the testing of portable patient care related electrical equipment (PCREE), specifically patient electric beds. 1. The Maintenance Director has obtained manufacturers recommendations for each type of in-house electrical bed, and created an auditing system to monitor testing of each type of bed per manufacturer recommendations. 2. The Maintenance Director will complete a full house audit of resident beds to ensure all bed types are inspected per manufacturer recommendations, and documented as required by the NFPA 101. 3. The Administrator will oversee in-services to all maintenance department staff in regard to the NFPA 101 guidelines for patient care related electrical equipment testing and maintenance requirements. 4. To prevent future deficit in this practice, the Maintenance director will perform 1 audit per month for 3 months to ensure bed inspections have been performed and documented according to the manufacturers recommendations. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K 921. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details Based on observations, interview, and record review conducted during the Life Safety Code Survey from 02/24/2025 to 02/28/2025, for one of one fire alarm system, the facility did not properly maintain and inspect initiating devices. Specifically, semi-annual visual inspection was not completed and documented for all fire alarm system initiating devices. The findings are: Observations during the initial tour of the facility on 02/24/2025 included multiple fire alarm system initiating devices throughout the building including, but not limited to smoke detectors, heat detectors, and pull stations. Record review on 02/25/2025 at 10:00 AM, revealed annual fire alarm inspection reports dated 01/30/2024 and 01/14/2025 listing functional testing of all initiating devices including heat detectors, smoke detectors, and pull stations. There were no additional semiannual visual inspections of fire alarm system initiating devices for calendar year of 2024. During an interview at this time, the Environmental Services Director stated they were not aware of the semi-annual visual inspection requirements for the fire alarm system, and only the vendor does inspection or testing on the system. The 2010 edition of National Fire Protection Association 72, National Fire Alarm and Signaling Code, defines Semiannual Frequency as twice per year with a minimum of 4 months, maximum of 8 months. NFPA 72 also requires visual inspections shall be made to ensure that there are no changes that affect equipment performance. Visual inspection frequencies for initiating devices including duct detectors, manual fire alarm boxes, heat detectors, and smoke detectors shall be completed semi-annually. A record of all inspections, testing, and maintenance shall be provided. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1); 2012 NFPA 101: 19. 3. 4. 1, 9. 6. 1. 5, 2010 NFPA 72: 3. 3. 106, 3. 3. 106. 4, 14. 1. 1, 14. 3. 1, 14. 3. 4, 14. 6. 2. 4 | Plan of Correction: ApprovedMarch 19, 2025 K345 Corrective Action- The facility will ensure that it meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Alarm System Testing and Maintenance. 1. The facilitys contracted Fire Alarm Inspection company has been contacted to perform the semi-annual visual inspection for all fire alarm system initiating devices. 2. The semi- annual visual inspection for fire alarm system initiating devices will be added to the facilitys electronic work order system. 3. The Administrator will oversee in-services to all maintenance department staff in regards to the NFPA 101 Fire Alarm System Testing and Maintenance requirements including the importance of the visual inspection for initiating devices. 4. To prevent future deficit in this practice, the Maintenance director will perform 1 audit per month for 3 months to ensure the visual inspection requirements have been met and documentation is in place. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K 345. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during a Life Safety Code Survey from 02/24/2025 to 02/28/2025, for one (second shift) of three staff work shifts, the facility did not ensure fire drills were properly performed. Specifically, fire drills were not conducted quarterly on each shift or were not properly documented. The findings are: Record review on 02/25/2025 at 9:10 AM revealed fire drill reports for calendar year 2024 did not include a second shift (2:00 PM to 10:00 PM) fire drill during the fourth quarter (October, November, December). The drill reports for the fourth quarter of 2024 listed drills were performed on: 10/31/2024 at 8:43AM, 11/01/2024 at 9:30AM, and 12/27/2024 at 4:00AM. Additionally, the fire drill report, dated 11/01/2024, did not list staff signatures or other documentation that staff participated in the drill, and the section of the drill form Attendance to be signed by all staff was blank. During an interview at this time, the Environmental Services Director stated they did not use a schedule for fire drills and had not realized the second shift fire drill was not conducted during the fourth quarter. The Director of Environmental Services also stated they must have forgotten to get staff signatures during the 11/1/2024 fire drill and staff should be signing all fire drill reports. 10 NYCRR: 415. 29(a)(1), 711. 2(a)(1); 2012 NFPA 101: 19. 7. 1. 4, 19. 7. 1. 6 | Plan of Correction: ApprovedMarch 19, 2025 K712 Corrective Action- To ensure that the facility meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Drills. 1. On 3/6/25 a 2nd shift fire drill was performed to compensate for the missed second shift fire drill from the fourth quarter of Calendar Year 2024. 2. The Maintenance Director will complete an audit of fire drills for Calendar Year 2025, to ensure fire drills are properly documented (including sign in sheets) and performed on each shift as required by The Life Safey Code of the NFPA. 3. The Administrator will oversee in-services to all maintenance department staff in regards the importance maintaining compliance with the NFPA Fire Drill requirements. 4. To prevent future deficit in this practice, the Maintenance director / designee will perform 1 audit per month for 3 months to ensure fire drills have been performed and documented quarterly on each of 3 shifts. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K 712. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2025
Corrected date: N/A
Citation Details Based on observations and interview conducted during the Life Safety Code Survey from 02/24/2025 to 02/28/2025, for four (A1, C2, D1, and D2) of seven exits, the facility did not ensure means of egress were properly illuminated. Specifically, outdoor exit discharge pathways did not have sufficient lighting to the public way. The findings are: During observations on 02/24/2025 between 1:11 PM and 1:24 PM, there was no exterior lighting present to illuminate the following sections of exterior egress pathways to the public way: - An approximately 100-foot-long section of exterior egress pathway between the exits from the A1 and D2 corridors. - An approximately 50-foot-long section of exterior egress pathway between the exits from the D2 corridor and physical therapy. - An approximately 100-foot-long section of exterior egress pathway between the exits from the D1 and C2 corridors. - An approximately 50-foot-long section of exterior egress pathway between the exits from the C2 corridor and the main entrance. During an interview on 02/24/2025 at 1:24 PM, the Environmental Services Director stated they were not aware there was no lighting between exits or that there needed to be more lighting. The Environmental Services Director also stated there was lighting at the exits, but they could add lighting for the pathways. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1), 2012 NFPA 101: 19. 2. 8, 7. 8. 1. 1, 7. 8. 1. 2. 1, 7. 8. 1. 3, 7. 8. 1. 4 | Plan of Correction: ApprovedMarch 19, 2025 K281 Corrective Action- To ensure the facility meets the requirements of illumination of means of egress, including exit discharge, is arranged in accordance with 7. 8 and shall either be continuously in operation or capable of automatic operation without manual intervention. 1) The facility will install lighting: in the 100 foot long section of exterior egress pathway between the exits from A1 and D2 corridors. The 50 foot long section of exterior egress pathway between the exits from D2 and D2 physical therapy. In the 100 foot long section of exterior egress pathway between the exits from D1 and C2 corridors. And the 50 foot long section of exterior egress pathway between the exits from the C2 corridors and the main entrance so that the egress paths are illuminated in compliance with the Life Safety Code. 2) The Director of maintenance will conduct a complete inspection of all means of egress to identify any additional areas that may require increased lighting in compliance with the life safety code. Annual inspection of egress path lighting will be added to the facilitys electronic work order system. 3) The Administrator will oversee in-services to all maintenance department staff in regard to the life safety requirements for means of egress lighting. 4) All means of egress will be audited monthly for 3 months and as needed based on the audits findings. Audits will verify all egress lighting meets the requirement of the life safety code. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K 281. |