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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 (Resident #10) of 3 residents reviewed. Specifically, Resident #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The facility's Policy and Procedure titled, Activities, effective 9/30/2023, documented, the purpose was to provide structured and engaging activities that promoted the physical, mental, and emotional well-being of all participants, ensuring compliance with New York State Department of Health and Centers for Medicare & Medicaid Services regulations. Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/2024, documented the Brief Interview for Mental Status was not completed, and that the resident could understand and be understood by others. The Comprehensive Care Plan dated 10/2024, documented Resident #10 needed 1-to-1 structured multi-sensory activities to stimulate cognitive functioning through religious visits, conversation, tactile therapy, music therapy, and light hand massage. They were unable to develop meaningful routine daily, staff must anticipate all activity needs and interventions. Interventions: Turn on animated cartoons daily. Weekly 1-to-1 visit to promote sensory, cognitive, and social stimulation. During observations on 12/30/2024 at 1130 AM, 12/31/2024 at 10:00 AM, 1/02/2025 at 2:40 PM, 1/03/2025 at 1:00 PM, and 1/06/2025 at 9:45 AM, Resident #10 was observed in their room, in bed alone with the television on. . During an interview on 1/07/2025 at 11:11 AM, Director of Activities #1 stated residents who did not attend group therapy had 1-to-1 activities once per week. They stated there were multiple staff members in and out of resident room daily such as medication nurse, respiratory therapists, certified nurse aides that were considered part of daily activity. A barber service visits the facility twice per month to give haircuts and shave. Director of Activities #1 stated they had 5 Activities Staff members for their department. In order to provide more frequent 1-to-1 activity sessions, the Activities Department would need an additional 10 staff members. Resident #10's (MONTH) 2024 Activity Log for 1-to-1 sessions was blank with the exception of 12/28/2024 and 12/31/2024. During an interview on 1/07/2025 at 12:07 PM, Director of Activities #1 stated Resident #10 did not tolerate sitting in wheelchair. Director of Activities #1 also stated for ventilator-dependent residents to attend group therapy, they must be able to tolerate out of bed to chair, and respiratory therapy and or family member must be present during activity. During an interview on 1/07/2025 at 12:09 PM, Licensed Practical Nurse #2 stated Resident #10 did not attend group activities. They stated not every resident got up and out of bed daily. It depended on staffing, and if an aide had them frequently, sometimes the aide would get them up. Licensed Practical Nurse #2 stated some residents had daily routines where they got up daily and some did not. Licensed Practical Nurse #2 stated that it was also related to staffing for the day. They stated Resident #10 had not gotten out of bed in a week and did not attend group activities. During an interview on 1/07/2025 at 12:32 PM, Director of Respiratory Therapy #1 stated all residents at this facility could attend group activities; Ventilator dependent residents who attended activities would use the same ventilator that they used while in their room; When leaving the room, the ventilator would be disconnected from the outlet and then function on its battery; The ventilator also had a portable monitor that went along with it. Director of Respiratory Therapy #1 further stated residents who were ventilator dependent did not have any restriction for getting out of bed or leaving their rooms. Director of Respiratory Therapy #1 stated they were never informed of Resident #10 having respiratory difficulty when out of bed. During an interview on 1/07/2025 at 12:45 PM, Director of Nursing #1 stated some residents did not get out of bed daily because they could not tolerate it clinically. For those cases, residents would receive 1-to-1 therapy and or activities. Residents who were ventilator dependent had no restrictions for getting out of bed or engaging in activities. During an interview on 1/07/2025 at 3:17 PM, Administrator #1 stated the facility conducted group activities daily and 1-to-1 individual activity as frequently as possible; The Activities Department was recently changed with a new director; Staffing was increased to meet demands for staff to patient ratio. Administrator #1 stated they were currently working on new ideas to enhance all activities. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h | Plan of Correction: ApprovedFebruary 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents: The facility immediately addressed the deficiency regarding the lack of meaningful, accommodating 1-to-1 activities for Resident #10 as follows: Resident #10 was picked up immediately for 1-to-1 activities during the survey. Ensure that all interventions, such as multi-sensory activities, religious visits, tactile therapy, music therapy, and other specified activities, are scheduled and documented. Increase the frequency of 1-to-1 activities for Resident #10, with clear documentation of participation and resident response. Identification of Other Residents Potentially Affected: The facility will: Audit the activity schedules and logs for all residents, with a focus on those identified as requiring 1-to-1 by 2.20.2025, Residents found to be non compliant will be pick up for more 1-to-1 activities. Identify any additional residents whose activity preferences or needs are not being met and develop corrective action plans to address identified gaps. Systemic Changes to Prevent Recurrence: To ensure ongoing compliance and meaningful activity engagement, the following systemic changes will be implemented. Staffing and Scheduling: Evaluate current activity staffing levels and, if necessary, hire additional staff to ensure adequate coverage for group and 1-to-1 activities. Develop and implement a scheduling system to ensure all residents requiring 1-to-1 activities receive them consistently. Staff Training: Provide training by activities director and education to the Activities Department on best practices for engaging residents in individualized and group activities. Emphasize the importance of accurate and thorough documentation of all activity interventions. Policy: policy was reviewed and found to be compliant. Monitoring Performance for [MEDICATION NAME] Solutions: Activity Log Audits: The Activities Director/designee will conduct weekly audits of activity logs to verify that scheduled activities are being completed and documented. Quality Assurance and Performance Improvement Oversight: Findings from activity log audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, with corrective actions implemented as needed. Designee assigned: Activities Director Completion Dates for Corrective Actions: (MONTH) 11th 2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) an opened medication had no open and/or expiration date; (b) 3 medications were passed expiration dates; (c.) medication requiring refrigeration were stored in the medication cart unrefrigerated, and (d.) shift change narcotic count signatures were missing on several dates, for 3 out of 3 medication carts reviewed. This is evidenced by: The Facility's Policy and Procedure titled, Medication Storage, revised 1/03/2017, documented, Medications listed in Schedules II, III, IV, and V would be stored under double locked conditions. The access key to the controlled medications was not the same key that allowed access to other medications. The medication nurse on duty would maintain possession of a key to the controlled medications and does not relinquish the key until a count has been completed and thus, the transfer of responsibility for the key and controlled medications has been completed. Controlled medications would be counted every eight hours (at change of shift 7:00 AM, 3:00 PM, and 11:00 PM) and as needed with the nurses beginning and ending a tour of duty with assignment of medication administration for a particular patient grouping. The oncoming nurse handled and counts the remaining controlled medications and the outgoing nurse records the amount noted. The actual amount of the controlled medication present would be compared to the remaining amount Indicated on the Controlled Substance Record and the amount remaining would be recorded on the Controlled Medication Change of Shift Audit form. Both nurses Involved in the count would sign the Controlled Medication Change of Shift Audit form verifying the integrity of the Information represented. The Facility's Policy and Procedure titled, Insulin Administration and Safety, revised (MONTH) (YEAR), documented, Storage in of insulin Vials and [MEDICATION NAME]: The individual manufacturer's storage recommendations and expiration dates must be followed. These usually suggest that o Insulin vials and [MEDICATION NAME] pen must never be frozen. o Direct sunlight or warming (in hot climates) damages insulin. o Unused insulin vials and [MEDICATION NAME] should be stored in a refrigerator. o After opening, an insulin vial and [MEDICATION NAME] should be discarded per manufacturer recommendation. MIX insulin-[MEDICATION NAME] 70/30=14 days; Rapid acting- [MEDICATION NAME] R =28 days and Long acting- [MEDICATION NAME]/ [MEDICATION NAME]= 42 days. The Facility's Policy and Procedure titled, Medication Administration, revised 3/19/2018 documented, pre-mixed medications from pharmacy with a label 'Refrigerate' should be kept in the refrigerator at all times. Never give a medication that has expired. During an observation on 1/02/2025 at 10:36 AM on the [MEDICAL CONDITION] Unit, the Shift Change Narcotic Count for Cart B was noted to have missing signatures on the following dates: 12/23/2024 7-3 PM and 3-11 PM shifts; 12/25/2024 7-3 and 3-11 PM shifts; 12/27/2024 3-11 PM shift; 1/1/25 3-11 PM shift. The Ventilator Unit, Cart B was noted to have no signatures for 1/2/2025 7-3 PM shift. There were no discrepancies in the medications. During an observation on 1/02/2025 at 10:40 AM on the [MEDICAL CONDITION] Unit, Medication Cart B contained 1 bottle of artificial tears with an expiration date of 12/08/2024. At the time of observation, Registered Nurse #1 stated they were unaware the medication had expired 30 days after opening, and they were not aware of medication that had shortened expiration dates after opening. During an observation on 1/02/2025 at 11:00 AM on the [MEDICAL CONDITION] Unit, Medication Cart A, contained an opened bottle of [MEDICATION NAME] liquid medication labeled 'keep refrigerated.' At the time of observation, Registered Nurse #2 stated this was an oversight and immediately placed medication in medication room refrigerator. During an observation on 1/02/2025 at 11:30 AM on the Ventilator Unit, Medication Cart B contained 1 bottle of [MEDICATION NAME] eye drops with an expiration date of 11/30/2024; 1 bottle of [MEDICATION NAME] 0.1% eye drops with an expiration date of 12/30/2024, and 1 [MEDICATION NAME] pen with no open and expiration date. At the time of observation, Licensed Practical Nurse #1 stated expired medications should be discarded and not used. During an interview on 1/02/2025 at 10:54 AM, Nurse Educator #1 stated there was a grid of medications with shortened expiration dates posted in the medication room; All nursing staff received training upon hire on the administration of medication including checking expiration dates; During orientation each nurse was observed and signed off on proper shift change narcotic count; During shift change narcotics were counted and signed by two nurses, the outgoing and oncoming nurse. During an interview on 1/2/2025 at 10:56AM, Director of Nursing #1 stated all clinical staff received Inservice training upon hire and annually on medication shortened expiration dates after opening. In addition, each nurse was observed and signed off on proper shift change narcotic count. During shift change narcotics were counted and signed by two nurses, the outgoing and oncoming nurse. This included nurses who we worked double consecutive shifts. Director of Nursing #1 stated they were not aware there were missing signatures in the narcotic signoff sheets; It was the responsibility of the unit manager to monitor narcotic signoff sheets daily. 10 New York Codes, Rules, and Regulations 415.18(d) | Plan of Correction: ApprovedFebruary 11, 2025 Immediate Corrective Action: The facility immediately removed and discarded the identified opened medication without open and expiration date and was replaced with a new one properly labelled with open and expiration date. The medications that were identified to have expired or passed the expiration dates were immediately replaced by the unit staff/manager despite not being expired by manufacturers recommendation. The medication that needs refrigeration that was noted on the medication cart was promptly returned to the medication room refrigerator. The facility educator immediately gave an Individualized on-site in-service/education to the identified Licensed Nurses as relates to missing signatures on Narcotic Shift Change Count Sheet, labeling of medication when opened, storing medication requiring refrigeration and Medication storage as relates to expiration specified by the manufacturer on the product label unless the manufacturer indicated shortened expiration when opened. IDENTIFICATION OF OTHER RESIDENTS POTENTIALLY AFFECTED: The facility fully recognizes all residents have the potential to be affected by the deficient practice. However, there were no negative outcomes identified from the said deficiency. All units- Medication carts were inspected for; expired medications, medications missing appropriate label including opened and expiration dates, medications improperly stored like; requiring refrigeration and narcotic shift change count sheet completion. SYSTEMIC CHANGES TO PREVENT RECURRENCE: The facility Policy and Procedure on: Insulin Administration and Safety, Medication Storage, Medication Administration were reviewed and found to be compliant with regards to labeling and storage standards. -Training and Education for all licensed nursing staff will be conducted by Educator as it relates to Medication Administration/Storage and Labeling with emphasis on: Labeling medications with open and expiration dates, Proper Storage of medications, including refrigeration, Medication expirations review- all medications shall expire on the date specified by the manufacture on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself, dfNarcotic Shift-Change Count procedures and documentation requirements Update/Enhance signage in medication rooms and carts to include: Guidelines for medications with shortened expiration dates, Visual aids to identify proper storage requirements for specific medications including labeling, Visual aids to remind on completion of Narcotic Shift Change Count Sheet. All completed by 3.11.2025 MONITORING ?Çô HOW THE CORRECTIVE ACTIONS BE MONITORED -The facility-Director of Nursing will develop and implement an Audit and Monitoring Tool to ensure compliance. * Unit Managers, Supervisors or Designee will perform audits of Medication Carts to verify compliance with labeling and storage requirements and Narcotic Books to ensure completion and accuracy of signatures on Shift Change Count Sheet Audits will be done daily x 2 weeks then weekly thereafter until compliance is determined. Audits with negative findings will have corrective actions implemented promptly. Audit results and compliance trends will be reviewed by Director of nursing or Assistant Director of Nursing and will be presented to Quality Assurance and Performance Improvement monthly meetings. The date for correction ?Çô 3/11/2025 The person responsible ?Çô Director of Nursing or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 (Resident # ' s 30 and 64) of 24 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was incomplete for Residents #30 and 64. This is evidenced by: The facility Policy titled, Assessment Prior to Admission, last revised (MONTH) 2011 documented recipient was to be admitted without an assessment prior to admission of the need for the intended level of care using New York State mandated forms. The screen must be completed and signed by a qualified professional. Resident #30 Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 12/05/2024 documented that the resident was in a persistent vegetative state. The Preadmission Screening and Resident Review dated 10/30/2024 for Resident #30 was incomplete, with questions 23 through 26 (level 1 review for mental illness, mental [MEDICAL CONDITION], and developmental disability) unanswered. Resident #64 Resident #64 was admitted to the facility with [DIAGNOSES REDACTED]. The minimum Data Set (an assessment tool) dated 10/24/2024 documented that the resident could understand, be understood, and was cognitively intact. The Preadmission Screening and Resident Review dated 07/12/2021 for Resident #64 was incomplete, with questions 31, 32 (danger to self or others), and 33 (level 2 referrals) unanswered. During an interview on 01/03/2025 at 12:21 PM, Admissions Staff #1 stated the screen was completed at the hospital and reviewed by Admission staff for completion, dates and signature. During an interview on 01/03/2025 12:30 PM, Director of Nursing #1 stated the Screen forms should have been reviewed by the Admissions department and sent back to the hospital if it they were incomplete. 10 New York Code of Rules and Regulations 415.11(3) | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents: The facility will immediately address the deficiencies identified in the Preadmission Screening and Resident Review (PASARR) process as follows: Resident #30: The PASARR form was replaced with a completed PASARR from the hospital, including responses to questions 23 through 26. Resident #64: The PASARR was reviewed and the form did have responses to questions 31, 32, and 33. A Level 2 referral was made and was not needed. Identification of Other Residents Potentially Affected: The facility will: Audit all current residents?ÇÖ most recent PASARR admission records to identify any additional incomplete PASARR forms with be completed by 2.20.2025. If found non-compliant facility will initiate new screening to be complete. Ensure that any identified deficiencies are corrected promptly by completing the forms and submitting them to the appropriate State authority for review. Systemic Changes to Prevent Recurrence: To prevent recurrence of incomplete PASARR screenings, the facility will implement the following changes: Policy Revision: Reviewed policy and found to be compliant. Staff Training: Admissions and Social Work will Verification of receiving PASARR from the hospital, identifying and addressing incomplete or missing sections and Steps for submitting forms back to the hospital for correction. Admission will will receive training from education and Social Work LMSW. Communication with Hospitals: Establish clear communication protocols with referring hospitals to ensure PASARR forms are completed accurately before transfer. Monitoring Performance for [MEDICATION NAME] Solutions: Ongoing Audits: The Admissions team will conduct weekly audits of new admission files for the next 90 days to ensure PASARR forms are complete and accurate. Quality Assurance and Performance Improvement Review: Findings from audits will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings, and corrective actions will be taken as needed. Designation to be completed by: Admissions and Social Service Completion Dates for Corrective Actions: (MONTH) 11th 2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for 2 (Resident #s 39 and 65) of 106 residents reviewed. This is evidenced by: The Policy and Procedure titled, Resident Rights and Dignity, revised 11/2018, documented it was the facility's policy to ensure that all residents' rights were ensured and respected. In addition, the facility would maintain strict adherence to state and federal guidelines with regards to granting residents' rights, maintaining resident dignity, and ensuring a pleasant and home-like environment for residents and their families. Resident #39: Resident #39 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/23/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The Care Plan fo Activities of Daily Living documented the following: Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, revised 10/24/2024, with a goal that the resident would be clean, dry, and groomed daily. Care plan interventions documented to check and change incontinent briefs every 2-4 hours and as needed. During an interview on 12/30/2024 at 2:57 PM, Resident #39 stated that the night before, 12/29/2024, they had to wait 5 or 6 hours during the evening shift to get changed when their brief was wet. During a subsequent interview on 1/08/2025 at 12:46 PM, Resident #39 stated they were offended by staff who were always angry and would scold them. Resident #39 stated they had asked a Certified Nurse Aide to put their medicated powder on them and was told it was in an angry tone it was not their job; it was the nurse's job. Resident #39 stated, 'The Certified Nurse Aides make it look like I am being taken care of when I am not.' Resident #39 stated that it 'seemed to be a policy here.' They further stated they would activate their call light, for the Certified Nurse Aide to come in and turn it off, and would not help them. Resident #39 stated Certified Nurse Aides 'leave them wet half the night.' During an interview on 1/7/2025 at 11:45 AM, Licensed Practical Nurse #2 stated Resident #39 was dependent on 1 staff for their personal care needs. Stated they were not aware the resident had been left in a wet brief for 5-6 hours on 12/29/2024. Stated Certified Nurse Aides should be checking the resident's brief as care planned. Stated Certified Nurse Aides should be answering the resident's call light in a timely manner and assisting the resident at that time. Resident #65: Resident #65 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The assessment documented impairment to upper extremities on both sides and impairment to lower extremity on one side. The resident required partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathing, and upper body dressing. The resident required substantial/maximal assistance with lower body dressing and personal hygiene. The resident was frequently incontinent of bowel and bladder. During an interview on 1/08/2025 at 1:41 PM, Resident #65 stated they had problems with some of the Certified Nurse Aides. Stated their regular aide was good, but some of the aides were very rude and short with them. Stated they were often left in a wet bed for hours. Resident #65 stated they wait all night to get assistance. Stated they would put their call light on, and the aide would come into the room and turn the light off. Stated they would leave the room and never come back. Stated they had to ask for assistance with activities of daily living such as washing up and toileting. Stated the aide would tell them to do it yourself. Stated they could not do it alone all the time secondary to having the [MEDICAL CONDITION] and shortness of breath. Stated the aides were very abrupt and then leave the room. Resident #65 stated they had spoken to the nurse manager and there has been no resolution. Stated that one aide told them it was the nurse manager's problem. Resident #65 could not identify the Certified Nurse Aides but said some of them still worked in the facility and some have left. Stated they thought they were Certified Nurse Aides who were from a travelling agency. During an interview on 1/08/2025 at 1:48 PM, Registered Nurse #2 stated there was a turnover of staff, specifically Certified Nurse Aides. Stated Certified Nurse Aides would stay for a few months and then leave. Stated it was mostly the travel Certified Nurse Aides that would leave. Stated they had not received any complaints from residents. Stated Resident #65 preferred certain staff. Stated that in the past, Resident #65 had a problem with a Certified Nurse Aide, stating they were rude. They stated they talked to the aide at that time and provided them with an onsite in-service. Stated it was a female Certified Nurse Aide and they did not notify Administrator #1 or Director of Nursing #1. During an interview on 1/08/2025 at 1:53 PM, Director of Nursing #1 stated they did not recall a staff member reporting a Certified Nurse Aide that was being inappropriate. Stated they had addressed an issue in the past with another resident who had a preferred Certified Nurse Aide because they felt they had to argue with Certified Nurse Aide staff. 10 New York Code Rules and Regulations 415.5(a) | Plan of Correction: ApprovedFebruary 11, 2025 Immediate Corrective Action: The facility Social Service department immediately spoke to identified residents to verify concerns on wait time for care and staff attitude. Resident #39 did not confirm the wait times of 5 to 6 hours but did state could take 2 hours. Resident #39 is also now aware to voice concerns in regards to their care in a timely manor to any staff member or unit manager. Resident #65 was spoke to by social service as well in regards to concerns. -The facility educator immediately gave an Individualized on-site in-service/education to all Certified Nursing Assistants who worked on 12/29/24 11-7 shift regarding residents?ÇÖ rights as relates to ADL?ÇÖs-prompt response to resident?ÇÖs needs, conduct at work and customer service- proper attitude in dealing with residents. IDENTIFICATION OF OTHER RESIDENTS POTENTIALLY AFFECTED: The facility fully recognizes all residents have the potential to be affected by the deficient practice. Thus, the Social Service Department conducted an interview with residents that were able to voice concerns and family members who were visiting on a regular basis regarding waiting time for care and staff attitude. However, there were no negative outcomes identified from the said deficiency SYSTEMIC CHANGES TO PREVENT RECURRENCE: The facility Policy and Procedure on: Resident?ÇÖs Rights and Dignity was reviewed and found to be compliant. Training and Education for all Certified Nursing Assistants will be conducted by Educator as it relates to Resident?ÇÖs Rights and Dignity and Utilizing Video presentation with emphasis on: residents?ÇÖ needs and Proper conduct in workplace and dealing with residents. Place signage on CNA carts to include: Visual aids to remind residents needs and conduct in the workplace and dealing with residents. MONITORING ?Çô HOW THE CORRECTIVE ACTIONS BE MONITORED: The facility director of nursing will develop and implement an Audit and Monitoring Tool to ensure compliance. Social Service Staff, Unit Managers, Supervisors or Designee will perform audits to interview residents who can voice concerns and to families who are visiting. Audits will be done to 2 residents and 1 families daily x 2 weeks then weekly thereafter until compliance is determined. Audits with negative findings will have corrective actions implemented promptly. Audit results and compliance trends will be reviewed by Director of nursing or assistant director of nursing and will be presented to Qaulity Assurance Performance Improvement monthly meetings. The date for correction ?Çô 3/11/2025 The person responsible ?Çô Director of Nursing or Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing level of Certified Nurse Aides was not consistently met every day on 3 of 3 Nursing units from 12/07/2024 to 1/08/2025. This is evidenced by: Upon entrance to the facility on [DATE], there were 106 residents residing on 3 units. The Policy and Procedure titled, Nursing Services and Sufficient Staff, revised 5/2023, documented it was the facility's policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and [DIAGNOSES REDACTED]. The facility would supply services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans except when waived, licensed nurses and other personnel, including but not limited to nurse aides. The Facility assessment dated [DATE], documented the average daily census was 109. The number of residents dependent on assistance with activities of daily living documented: 95 residents for both bathing and dressing 90 residents for transfer 69 residents for eating 102 residents for toileting 99 residents who were in a chair most of the time were dependent for mobility The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the [MEDICAL CONDITION] unit: -- 4 for the 7:00 AM to 3:00 PM day shift, -- 4 for the 3:00 PM to 11:00 PM evening shift, and -- 2 for the 11:00 PM to 7:00 AM night shift. The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Sub-Acute/Ventilator unit: -- 4 for 7:00 AM to 3:00 PM day shift, -- 4 for the 3:00 PM to 11:00 PM evening shift, and -- 2 for the 11:00 PM to 7:00 AM night shift. The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Pediatrics unit: -- 3 for the 7:00 AM to 3:00 PM day shift, -- 3 for the 3:00 PM to 11:00 PM evening shift, and -- 1 for the 11:00 PM to 7:00 AM night shift. A review of the Facility Scheduling Worksheets (daily staffing sheets) dated from 12/07/2024 to 1/08/2025 documented the following units were short Certified Nurse Aides: Saturday, 12/07/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift, 2 on the evening shift, and 1 on the night shift until 5:15 AM. Sunday, 12/08/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 2 Certified Nurse Aides on the day shift, 2 on the evening shift, and was short 1 on the night shift until 5:15 AM. -- The Sub Acute/Vent had a census of 33 and was short 2 Certified Nurse Aides on the day shift, 2 on the evening shift, and 1 on the night shift. Wednesday, 12/11/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift, 1 at the start of the evening shift at 3:00 PM and was short 2 as of 3:50 PM. Saturday, 12/14/2024: -- The [MEDICAL CONDITION]) unit had a census of 39 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. Sunday, 12/15/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 1 Certified Nurse Aide on the day shift, 1 on the evening shift, and 1 on the night shift until 5:30 AM. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift, and 1 on the evening shift. -- The Pediatrics unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. Monday, 12/16/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. Tuesday, 12/17/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 2 Certified Nurse Aides on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 12/18/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Thursday, 12/19/2024: -- The [MEDICAL CONDITION] unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift and 1 on the night shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Friday, 12/20/2024: -- The [MEDICAL CONDITION] unit had a census of 38 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Saturday, 12/21/2024: -- The [MEDICAL CONDITION] unit had a census of 38 and was short 1 on the day shift and 1 on the night shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day, evening, and night shifts. Sunday 12/22/2024: -- The [MEDICAL CONDITION] unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Monday 12/23/2024: -- The [MEDICAL CONDITION] unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 12/24/2024: -- The [MEDICAL CONDITION] unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 12/25/2024: -- The [MEDICAL CONDITION] unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift, 1 on the evening shift, and was short 1 on the night shift, as of 12:30 AM. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. Saturday, 12/28/2024: -- The [MEDICAL CONDITION] unit had a census of 38 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Sunday, 12/29/2024: -- The [MEDICAL CONDITION] unit had a census of 37 and was short 3 Certified Nurse Aides at the start of the day shift at 7:00 AM and as of 10:00 AM was short 2 Certified Nurse Aides. At the start of the evening shift at 3:00 PM, was short 2 Certified Nurse Aides and at 8:00 PM was short 3 Certified Nurse Aides. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift as of 7:18 AM. At the start of the evening shift at 3:00 PM, the unit was short 2 Certified Nurse Aides, and as of 8:00 PM, was short 3 Certified Nurse Aides. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. On the evening shift at 3:00 PM, was short 1, and at 5:00 PM was short 2. Monday, 12/30/2024: -- The [MEDICAL CONDITION] unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 12/31/2024: -- The [MEDICAL CONDITION] unit had a census of 37and was short 2 Certified Nurse Aides on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 1/01/2025: -- The [MEDICAL CONDITION] unit had a census of 36 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Pediatric unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Thursday, 1/02/2025: -- The [MEDICAL CONDITION] unit had a census of 35 was short 1 Certified Nurse aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Friday, 1/03/2025: -- The [MEDICAL CONDITION] unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. Saturday, 1/04/2025: -- The [MEDICAL CONDITION] unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. On the night shift, was short 1 until 5:00 AM. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. Sunday, 1/05/2025: -- The [MEDICAL CONDITION] unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Monday, 1/06/2025: -- The [MEDICAL CONDITION] unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 1/07/2025: -- The [MEDICAL CONDITION] unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 1/08/2025: -- The [MEDICAL CONDITION] unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. -- The Pediatrics unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift. Census data for the [MEDICAL CONDITION], Sub Acute/Ventilator, and Pediatrics units for (MONTH) 2024 and (MONTH) 2025 provided by the facility documented the following: CENSUS DECEMBER 2024 Day-Month, [MEDICAL CONDITION] Unit Census, Sub-Acute/Ventilator Unit Census, Pediatrics Unit Census, Total Census 1-December 39 33 36 108 2-December 39 33 36 108 3-December 39 33 36 108 4-December 39 33 36 108 5-December 39 33 35 107 6-December 39 34 35 108 7-December 39 33 35 107 8-December 39 33 35 107 9-December 39 33 35 107 10-December 39 33 35 107 11-December 39 33 35 107 12-December 39 33 35 107 13-December 39 34 36 109 14-December 39 34 36 109 15-December 39 34 36 109 16-December 39 34 36 109 17-December 39 33 35 107 18-December 39 34 35 108 19-December 39 34 35 108 20-December 38 34 35 107 21-December 38 34 35 107 22-December 37 34 34 105 23-December 37 34 34 105 24-December 37 34 34 105 25-December 37 34 34 105 26-December 37 34 35 105 27-December 38 34 35 107 28-December 38 34 35 107 29-December 37 34 35 106 30-December 37 34 35 106 31-December 37 34 35 106 CENSUS JANUARY 2025 Day-Month, [MEDICAL CONDITION] Unit Census, Sub-Acute/Ventilator Unit Census, Pediatrics Unit Census, Total Census 1-January 36 34 35 105 2-January 35 34 35 104 3-January 35 34 35 104 4-January 35 34 34 103 5-January 34 34 34 102 6-January 35 34 34 103 7-January 35 34 33 102 8-January 36 34 33 103 During an interview on 12/30/2024 at 2:55 PM, Resident #64 stated they stayed in bed all when there was not enough staffing because they required the assistance of 2 staff and a mechanical lift for transfers out of bed. During an interview on 12/30/2024 at 12:07 PM, Family Member #1 stated there were times when the facility was short staffed. During an interview on 12/30/2024 at 2:57 PM, Resident #39 stated the facility was 'severely' understaffed on a regular basis and was short staffed on all shifts. They stated that last night, 12/29/2024, they had to wait 5 or 6 hours during the evening shift to get changed when their incontinence brief was wet. The resident stated there had been recent turnover with staff. During an interview on 12/30/2024 at 3:59 PM, Resident #52 stated there was a staffing problem. They stated the 3:00 PM to 11:00 PM shift was the worst and stated there was usually 1 Certified Nurse Aide on the unit. Resident #52 stated they could not get their shower on the 3:00 PM to 11:00 PM shift because the aide stated they could not handle the shower without another staff member to assist. They stated the evening shift did follow the care plan for brushing their teeth and changing them because they were short staffed. The resident stated they usually had to wait 30 minutes to one hour for care. During an interview on 12/31/2024 at 10:21 AM, Resident #260 stated that every time they needed to go to the bathroom, they were told to wait. During an interview on 12/31/2024 at 11:24 AM, Family Member #2 stated they were concerned there were not enough staff to correctly turn and position the resident. They stated there was often only 1 to 2 Certified Nurse Aides on the unit. During an interview on 1/08/2025 at 10:12 AM, Staffing Coordinator #1 stated they were also a Certified Nurse Aide and helped in many areas of the facility. They stated they looked at the facility census when they assessed the staffing needs and stated they had to 'balance' staff; They gave the units what they required and was aware of the number of nursing staff required for each unit. They stated the facility had been very good about staffing, but the gastrointestinal illness effected staffing on the (Pediatrics) unit. [MEDICATION NAME] staff came and then they went back home to their home states. Stated staffing was bad this past week. Stated supervisors call them about weekend staffing. Staffing Coordinator #1 stated they would come in on Sunday to work. Stated they worked closely with supervisors, especially with staffing. Surveyor asked specifically about staffing on 12/29/2024. They stated that on the Sub Acute/Vent unit, a Certified Nurse Aide left at 7:18 AM due to a personal issue and another aide that was scheduled from an agency cancelled, leaving 2 aides on unit for the shift. They stated the Agency would just cancel and would not give a reason. They stated for 3-11 shift, there were 2 Certified Nurse Aides but 1 left at 8:00 PM, leaving 1 aide on the unit. On the [MEDICAL CONDITION] unit during the 3-11 PM shift, there were 2 aides and then 1 left at 8:00 PM to accompany a resident to the hospital. Stated the facility utilized Agency staff and had a sheet of agencies/staff/phone number they provide to the supervisors. The facility had 5 contracted agencies but only 3 were providing nursing staff. The facility requires 3 days of training for agency staff. Staffing Coordinator #1 was called when by staff when they were not coming in or staff would call the off-shift supervisor. Stated (MONTH) staffing was 'hit or miss' due to flu or flu-like symptoms. Stated the facility did float staff to other units. During a subsequent interview on 1/08/2025 at 12:46 PM, Resident #39 stated there was a lot of staff in the building today. They stated when the unit was short staffed, they had to wait for care. They stated The Certified Nurse Aides would come into the room after they (the resident) puts their call light and then is told by them to give them a minute but then they do not come back for 2 hours. They stated it was a problem during the weekend more than the week when sometimes they only had 1 person (aide) on the unit who had 18-20 people to provide care to. During an interview on 1/10/2025 at 10:27 AM, Administrator #1 stated there was turnover from out of state staffing in December. Stated several staff left with no notice: 4 in early December, and then 2 in the week of 12/30/2024. Stated the out-of-state Certified Nurse Aide staff were not contracted and were facility employees. Stated that during the sudden staff shortage in December, the facility brought in agency staff for the short term. Stated the facility had new hires as of 1/7/2025 and were orienting 7 new Certified Nurse Aides. The biggest issue was Criminal History Record Check which took 'months.' Stated the facility did not bring in staff without clearance due to the vulnerable population. The facility currently offered a sign on bonus, had increased the base rate of pay, and offered a shift differential. Stated there was continuous overtime pay. Stated that although the facility had stressed to new hires that it was a 'different' facility, staff often state they were not aware of the heavy patient care load and then resign. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents The facility will address the deficiency related to insufficient staffing and the facility assessment as follows. Residents Directly Affected: Conduct a full review of staffing levels during the time of the identified deficiency to determine specific impacts on resident care and outcomes. Address any unmet needs of residents by ensuring adequate staffing to support their physical, emotional, and psychosocial well-being. Provide immediate interventions for residents requiring additional care, including increased staff presence. Identification of Other Residents Potentially Affected: The facility will: Conduct a comprehensive review of all residents to identify those who may have been affected by staffing inadequacies. Implement immediate corrective measures, such as temporary staffing adjustments, to ensure all residents receive timely and appropriate care. Systemic Changes to Prevent Recurrence: To ensure sufficient staffing levels and a complete facility assessment, the following systemic changes will be implemented. Facility Assessment Revision: Update the facility assessment to reflect a fluid census, acuity levels, and the required competencies of staff to meet the specific needs of the resident population. Staffing Plan Development: Revise the staffing plan to align with the updated facility assessment and ensure adequate staff-to-resident ratios. Recruitment and Retention Efforts: Review retention programs, such as: No callout bonus and Sign-on Bonus to ensure competitiveness in the field. Completed by 3.11.2025 Monitoring Performance for [MEDICATION NAME] Solutions Ongoing Facility Assessment Reviews: Conduct quarterly reviews of the facility assessment to ensure it remains accurate and reflective of resident needs. Staffing Audits: Perform weekly audits of staffing levels to verify compliance with the staffing plan. Monitor call light response times, incident reports, and resident satisfaction surveys as indicators of staffing adequacy. Quality Assurance and Performance Improvement Oversight: Review findings from staffing audits and facility assessment updates during monthly Quality Assurance and Performance Improvement (QAPI) meetings. Implement corrective actions as needed based on data trends and feedback. Responsible party: Director of Nursing and Administrator/designee Element 5: Completion Dates for Corrective Actions: (MONTH) 11th 2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations. Specifically, the emergency generators test logs did not document engine performance such as the percentage of the nameplate under which the monthly full load test was conducted, and the generator transfer times; the 4-hour load test records did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: Document titled Standby Generator Monthly Preventative Maintenance Checklist and dated from (MONTH) 2024 through (MONTH) 2024 did not record: Percentage of the nameplate under which the monthly full load test was conducted. Generator transfer times. Document titled 3-Year 4-Hour Load Test dated 06/17/2023 recorded one hundred percent of the load for the three-year four-hour load bank test with the test amperages consistent and not incremental. During an interview on 01/17/2025 at 12:43 PM, Environmental Services Director #1 stated that they would add the transfer times and the percentage of the nameplate to the record of the monthly load tests, and they would conduct another 4-hour load test wherein the amperages and generator performance would be recorded at one-hour increments. 42 Code of Federal Regulations 483.70 (a) (1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents: The facility will immediately address the deficient practice by ensuring that generator testing records meet all regulatory requirements. Specifically: Update the Standby Generator Monthly Preventative Maintenance Checklist to include, The percentage of the nameplate under which the monthly full load test was conducted. Generator transfer times. Conduct a new 4-hour load test for the only emergency generator and accurately documented. This test will record generator performance, including amperages, incrementally at one-hour intervals as required. Identification of Other Residents Potentially Affected: All residents, staff, and visitors may be affected by deficiencies in emergency power system testing. To ensure compliance: The facility will review generator maintenance and testing records for the past 12 months to identify any additional deficiencies. Immediate corrective actions will be taken for any identified issues. Systemic Changes to Prevent Recurrence: The following measures will be implemented: Record-Keeping Improvements: Testing records will be standardized to ensure all required information is documented consistently. Training for Maintenance Staff: Staff responsible for generator maintenance will receive updated training on record-keeping and sign off on the training. New staff will be trained as on-boarded. Monitoring Performance for [MEDICATION NAME] Solutions: The Maintenance Director/designee will review generator testing logs monthly to ensure accuracy and completeness. Monthly and then quarterly audits of generator maintenance and testing records will be presented to the Safety Committee. Findings from these audits will be reviewed during the facility?ÇÖs Quality Assurance and Performance Improvement (QAPI) meetings, and corrective actions will be implemented promptly. Element 5: Completion Dates for Corrective Actions: 3.22.2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Standard Life Safety Code Survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Plan, Training Program included a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment: emerging infectious disease, supply chain problems, severe thunderstorms, blizzard/snow problems, communications failure. During an interview on 01/21/2025 at 2:06 PM, Administrator #1 stated that they would update the quiz section of the emergency plan to include questions on the top 5 hazards facing the facility. 42 Code of Federal Regulations 483.73(d)(1)(ii) | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents: The facility will immediately address the deficient practice by revising its Emergency Plan Training Program to ensure staff demonstrate knowledge of responses to the most likely hazards identified in the risk assessment. Training materials will be updated to include specific instructions and scenarios for the following hazards: Emerging infectious diseases, Supply chain disruptions, Severe thunderstorms, Blizzard/snow-related issues, Communications failure. All staff, individuals providing services under arrangement, and volunteers will participate in updated training sessions within 60 days and have a post test on the materials. Affected residents?Çöall individuals currently residing in the facility?Çöwill benefit from improved staff preparedness during emergencies. Identification of Other Residents Potentially Affected: The facility acknowledges that all residents are potentially affected by this deficient practice. Therefore, corrective actions and updated training will encompass all staff roles and responsibilities to ensure comprehensive coverage for the safety of every resident. Regular reviews of the risk assessment and hazard response plans will be conducted to confirm that all relevant hazards are addressed effectively. Systemic Changes to Prevent Recurrence: The following measures will be implemented to ensure the deficient practice does not recur: Policy and Procedure Updates: The Emergency Preparedness policies and procedures will be revised to incorporate detailed responses for the identified hazards. Enhanced Training Program: The Emergency Plan Training Program will include: Initial and annual training focused on hazard-specific responses. Post test to verify staff understanding. Documentation Protocols: Attendance records, training content, and performance evaluations will be maintained and reviewed regularly to ensure compliance. Monitoring Performance for [MEDICATION NAME] Solutions The Education/designee will conduct monthly audits of training documentation for six months to ensure consistent participation and understanding by staff. Findings from audits will be shared during monthly Quality Assurance and Performance Improvement meetings Completion Dates for Corrective Actions Initial Audit Cycle: Completed by 3.22.2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations on 2 of 3 units and the core area. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 01/17/2025 at 11:16 AM, the light switches that supplied normal and emergency lighting for the means of egress and exit access had no normal and emergency lighting when the switch was in the off position in the following areas: ?? [MEDICAL CONDITION] unit corridor ?? [MEDICAL CONDITION] unit dining room ?? Sub-Acute unit dining room ?? Therapy Gym ?? Main dining room ?? Classroom ?? Pediatric unit corridor ?? Day Room During an interview on 01/17/2025 at 11:43 AM, Administrator #1 stated that they would install emergency lighting in the areas found as required by the Life Safety Code. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents: The facility will immediately address the deficient practice by ensuring emergency lighting is installed and functioning in all identified areas. Emergency lighting that operates automatically without manual intervention will be provided along the means of egress, including the exit discharge, in the following areas: [MEDICAL CONDITION] unit corridor, [MEDICAL CONDITION] unit dining room, Sub-Acute unit dining room, Therapy Gym, Main dining room, Classroom, Pediatric unit corridor, Day Room. These actions will ensure the safety of all residents, staff, and visitors in the event of an emergency. Identification of Other Residents Potentially Affected: The facility recognizes that all residents, staff, and visitors may be affected by this deficiency in emergency lighting. A comprehensive inspection of the entire facility will be conducted to identify and address and correct any additional areas where emergency lighting may be inadequate or non-compliant with NFPA 101 Life Safety Code, Sections 19.2.8 and 7.8 with compliant lighting. Systemic Changes to Prevent Recurrence: The following measures will be implemented to ensure the deficient practice does not recur: Installation of Emergency Lighting: Emergency lighting that meet NFPA 101 standards will be corrected in all identified areas. Routine Inspections: The facility will conduct quarterly inspections with audit tool of all emergency lighting systems to verify functionality and compliance with NFPA 101 code by the maintenance director and will provide education to maintenance staff regarding the monthly/quarterly inspections. Monitoring Performance for [MEDICATION NAME] Solutions: The facility?ÇÖs Maintenance Director/designee will oversee monthly testing of emergency lighting systems to ensure compliance with NFPA 101 standards. Results from these tests will be documented and reviewed by the Safety Committee during monthly meetings. Any deficiencies identified during testing will be addressed immediately, and corrective actions will be implemented to prevent recurrence. Completion Dates for Corrective Actions: 3.22.2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews during the Standard Life Safety Code Survey, the automatic sprinkler system was not installed and maintained in accordance with adopted regulations. Specifically, the sprinkler heads in compartmented spaces that have at least one quick response sprinkler head did not have all quick response sprinkler heads as required by the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.3.3.4. This is evidenced by: During observations on 01/17/2025 from 1:44 PM through 2:00 PM, at least one quick response sprinkler head and at least one standard response sprinkler head were in the following compartmented spaces: ?? Pediatric Unit shower room ?? [MEDICAL CONDITION] Unit shower room During an interview on 01/21/2025 at 2:47 PM, Environmental Services Director #1 stated that they would have the standard response sprinkler heads replaced with quick response sprinkler heads. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.7.5 2010 NFPA 13: 8.3.3.4 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for Affected Residents: The facility will immediately address the deficient practice by replacing all standard response sprinkler heads with quick response sprinkler heads in the identified compartmented spaces, ensuring compliance with NFPA 13 standards. The specific areas where replacements will occur are: Pediatric Unit shower room, [MEDICAL CONDITION] Unit shower room. This corrective action ensures that all sprinkler systems in the facility function as required to protect residents, staff, and visitors during an emergency. Identification of Other Residents Potentially Affected: The facility recognizes that all residents, staff, and visitors may be affected by this deficiency in sprinkler system compliance. An inspection of the entire facility will be conducted to identify any additional areas where sprinkler heads are not uniform in response type, and immediate corrective actions will be taken to replace the wrong sprinkler head with the correct one. Systemic Changes to Prevent Recurrence: The following measures will be implemented to ensure the deficient practice does not recur: All sprinkler heads identified during the facility inspection will be replaced with quick response sprinkler heads to maintain uniformity. Routine Inspections: Quarterly and then annual inspections of the sprinkler system will be conducted to verify compliance with NFPA 13 standards with an audit tool that will track compliance. New policy and procedure will be implemented as well as training to all maintenance staff Monitoring Performance for [MEDICATION NAME] Solutions: The facility?ÇÖs Maintenance Director/designee will oversee monthly reviews of the sprinkler system with the vendor, to ensure compliance with NFPA 13 and NFPA 25 standards. Results from these reviews will be documented and presented to the Safety Committee during monthly meetings. Any deficiencies identified during reviews will be addressed immediately, and corrective actions will be implemented to prevent recurrence. Completion Dates for Corrective Actions: Facility-Wide Sprinkler System Inspection: Completed by 3.22.2025 |