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: January 3, 2025
Corrected date: March 3, 2025
Citation Details Based on record review and interviews during an abbreviated survey (NY 354, NY 504, NY 121, NY 737), the facility did not ensure a facility-wide assessment was conducted to determine what resources are necessary to care for its residents competently. Specifically, the Facility Assessment did not identify individual staff assignments, systems for coordination, and continuity of care necessary to care for residents during both day-to-day operations including nights and weekends. Findings include: The Facility Assessment provided was last updated 11/7/2024 and last reviewed with the quality assurance and improvement committee on 9/18/2023. The staffing plan documented an example of the evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff is available to meet each residents needs. The table listed the position of staff by title, as well as the total number needed or average or range by position. Review of the Facility Assessment on 12/19/2024 revealed the assessment did not include the staffing plan, the requirements of number of staff needed for each unit per shift to care for residents. During an interview on 12/19/2024 at 4:40 PM, the Administrator stated their facility assessment does list the staff required to care for the residents in the facility but they were not aware that they had to include the staffing requirements by unit to meet the resident's needs, they would include this going forward. 10 NYCRR 415.26 | Plan of Correction: ApprovedFebruary 24, 2025 Immediate Corrective Actions The Administrator/ designee updated the facility assessment to include the par levels necessary to care for residents residents during both day to day operations including nights and weekends. Identification of at Risk Residents All Residents have the potential to be affected by this practice. Systemic Change The facility Policy and Procedure on Facility Assessment has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date. The administrative staff will be in-serviced on the Facility Assessment policy and procedure with a focus on staffing. The updated facility assessment will be reviewed by an ad hoc meeting with the QAPI committee. Quality Assurance The Administrator/ designee created an audit tool to track appropriate completion of the facility assessment. The facility assessment will be audited monthly for 2 months and quarterly for 2 quarters. Audit findings will be presented to the QAPI Committee for evaluation and follow up as indicated. Completion The Administrator/ Designee is responsible for the correction of these practices by 3/03/25. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2025
Corrected date: March 3, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey ((NY 504, NY 121), the facility did not ensure residents right to be free from abuse. This was evident for 6 out of 9 residents (Resident #3, #4, #5, #7, #8, #9). Specifically, (1) on 3/28/2024 Resident #2 hit Resident #5 with their walker after a verbal altercation in the hallway. Resident #5 sustained bruising to their left hand and chest area. (2) On 5/2/2024, Resident #2 and Resident #4 who resided in the same room engaged in a physical altercation. Resident #4 sustained a laceration to their chin and Resident #2 sustained a laceration to their left eyebrow. On 8/23/2024, Resident #2 was witnessed by staff hitting Resident #4 in the arm, while they were in the hallway without being provoked. Resident #4's room was changed after the 5/2/2024 incident, but they remained on the same unit as Resident #2 which increased the chance for another incident to occur; (3) On 11/2/2024, Resident #2 engaged in a physical altercation with Resident #3, witnessed by a staff member. Resident #3 sustained a superficial scratch to their forehead. (4) Resident #6 hit the back of Resident #9's head and stated, now we are even. (5) On 11/7/2024, Resident #6 reached back and hit Resident #7 on the right side of their face. On 11/22/2024, Resident #6 started to approach Resident #7 and aggressively started yelling at them, stating they will show them who they are today, and they are going to kill them. Resident #6 was redirected by staff, but attempts were unsuccessful. Resident #6 then went to Resident #7's room and aggressively and violently pushed Resident #7's belongings off their bed and bedside table to the floor. (6) Resident #6 walked over to Resident #8 and got into their face and told Resident #8 they told them to move, and they did not listen. The witness attempted to separate the residents and Resident #6 reached around with an open hand to slap Resident #8, they moved Resident #6 away from Resident #8 and stood in the middle of them. The facility did not implement any interventions to ensure the safety of the other resident in the facility from Resident #2 and Resident #6 with their known aggressive behaviors. The findings are: The facility Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property policy last reviewed 5/2024 documented it is the policy of the facility that the resident has the right to be free from verbal and physical abuse. The facility prohibits any form of abuse or neglect consistent with the definitions of abuse and neglect of the Federal guidelines. The facility promotes any effort to prevent abuse and neglect. 1) Resident #2 admitted to the facility 12/8/2021 and last readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/23/2024 documented the resident was cognitively intact. No behaviors documented. The resident required a walker for locomotion. The resident requires set-up for eating, supervision for toileting, bed mobility and transfers. A risk to be victimized/involved in resident-to-resident altercations care plan last revised 6/20/2024 documented the resident would be safe and free of harm by peers over the next 90 days. Interventions listed included monitor change in mood or behavior triggered by environmental factors and monitor well-being without environmental restrictions. The Facility Incident note dated 3/28/2024 and Accident report dated 3/29/2024 documented Resident #2 was witnessed on 3/28/2024 picking up their walker and hitting Resident #5 on the left hand. Staff immediately separated the residents. Both residents were assessed. Resident #5 had bruises to the left hand and left side of chest and complained of pain. Physician notified and Tylenol was administered. An Xray of the left hand was completed on Resident #5. Results of the Xray was negative. Resident #2 was transferred to the hospital and returned to the facility and assigned another unit. Resident #5 refused to go to the hospital. The facility investigation concluded that there was cause to believe resident abuse occurred. All staff will be educated to make sure residents are kept away from each other especially if they are off the unit. Review of a risk for harm from/to other care plan last revised 6/20/2024 documented the Resident #2 will not harm other residents x 92 days. Interventions listed included educate resident to report disruptive residents to staff and to not confront them, encourage participation in activities and socialization with others, offer room/floor change and review safety precautions with resident as needed. 2) Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident was cognitively intact. No behaviors noted. The resident required a wheelchair for locomotion and moderate assistance with eating and transferring and maximal assistance with toileting and bed mobility. No behaviors noted. A resident-to-resident altercation care plan last revised 11/4/2024 documented the resident would be kept from Resident #2 at all times. Interventions listed included keep resident within viewing distance for observation as much as possible in activities, day room and nursing station, re-direct and re-focus attention and offer alternatives or engage in 1 to 1 as necessary, remove from other aggressive resident with aggression to a quiet, calm setting to avoid escalation of behavior and reduce incidents of altercation and as of 4/1/2024 resident will be kept away from Resident #2 at all times. 3) Resident #4 admitted to the facility 11/30/2023 with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had moderate cognitive impairment. No behaviors noted. The resident had impairment to the upper extremity on one side and was ambulatory. The resident required supervision for eating, moderate assistance with toileting and bed mobility and was independent for transfers. Review of an incident note dated 5/2/2024 documented Registered Nurse Supervisor was called to the unit and upon arrival observed Resident #2 standing at the doorway of their room alert, oriented and verbally responsive, no apparent distress noted. Resident #2 denied having a fall and was observed with a laceration to their left eyebrow 1 x 0.5 cm with slight bleeding. Resident #2 stated their roommate, Resident #4, accused them of stealing their cellphone and then started hitting them. Resident to Resident altercation resulting in injury to both residents. Physician made aware and 911 called. Resident #4 was moved to another room, social services to follow up. The investigation concluded that there was a cause to believe abuse occurred. Resident #4 was moved to another unit on return from the emergency room , staff would be educated to make sure that Resident #4 and Resident #2 are to always be separated especially if they are off the unit and psychiatry consult and psychology evaluations for both residents. Review of an incident/accident report dated 8/23/2024 documented Resident #2 was witnessed hitting Resident #4 on their arm without provocation in the hallway. The investigation concluded there was cause to believe resident abuse had occurred. Resident #2 hit Resident #4 for no apparent reason. The corrective actions documented staff were educated to make sure the residents are always away from each other especially when they are off the unit. Resident #4's room was changed after the 5/2/2024 incident, but they remained on the same unit as Resident #2 which increased the chance for another incident to occur. Review of a risk for potential verbal/physical abuse care plan last revised 8/26/2024 documented Resident #4 had a physical altercation with Resident #2 on 8/23/2024. Interventions listed included assess for signs and symptoms of physical abuse, encourage resident to seek out staff or assistance if having difficulties with others, ensure resident stays in room with a compatible roommate, monitor mood and behaviors and provide early interventions on any changes, provide support and encouragement for resident to express feelings and ensure resident is free from abuse. Review of risk to be victimized/involved in resident-to-resident altercations care plan last revised 3/6/2024 documented Resident #4 had impaired judgement/confusion. Interventions listed included keep resident within viewing distance for observation as much as possible in activities, day room and nursing station and monitor well-being without environmental restrictions. 4) Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had severe cognitive impairment. No behaviors noted. The resident required a walker or a wheelchair for locomotion. The resident required set up assistance with meals, moderate assistance with toileting, bed mobility and transfers. The corrective action documented in the submission report dated 11/8/2024 documented Resident #2 will not be permitted to visit the unit of Resident #3 unescorted. Staff were educated to make sure Resident #2 and Resident #3 are always away from each other when they are off the unit. Resident #3 was discouraged to verbalize comments to peers. There was no investigative summary attached to the incident/accident file. Review of a peer-to-peer altercation care plan initiated 7/6/2024 documented Resident #3 would not have any further altercations. Interventions listed included deescalate the situation that can potentiate to an altercation, psychiatry consult, and resident relocated to another unit. There was not documented evidence of the care plan being reviewed after 7/6/2024 or revised to reflect the incident that occurred on 11/12/2023. A psychosocial well-being care plan initiated 7/9/2024 documented Resident #3 is a potential for abuse. Interventions listed included allow resident to vent feelings, of being fearful, anxious, as necessary and provided 1 to 1 support as necessary. Review of a risk to be victimized/involved in resident-to-resident altercations care initiated 12/28/2023 documented Resident #3 had impaired judgement/confusion. Interventions listed included monitor for change in mood/behavior and monitor wellbeing without environmental restrictions. Review of an incident/accident report dated 11/2/2024 documented Resident #3 and Resident #2 engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial scratch to their forehead. Resident #3 and Resident #2 were transferred to the emergency room for evaluation. 5) Resident #6 admitted to the facility 6/24/2024 with [DIAGNOSES REDACTED]. A Significant change Minimum (MDS) data set [DATE] documented the resident was cognitively intact. No behaviors noted. The resident required a wheelchair for locomotion. The resident required set up assistance with eating, maximal assistance with toileting and transferring and moderate assistance with bed mobility. A risk for harm to others/from other care plan last revised 11/22/2024 documented Resident #6 was a risk to harm others. Documented on 11/8/2024 Resident #6 had an altercation with Resident #7. On 11/22/2024 Resident #6 slapped Resident #8 on the face unprovoked and threatened Resident #7 to kill them. Interventions listed included educate resident to report disruptive residents to staff and not confront them and offer resident room/floor change and on 11/22/2024 transfer to emergency room and psychiatry consult. 6) Resident #9 admitted to the facility 3/15/2022 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/12/2024 documented the resident had moderate cognitive impairment. No behaviors noted. The resident used a walker and a wheelchair for locomotion. The resident required set up assistance with eating, supervision with toileting, bed mobility and transfers. Review of the incident investigation documented on 8/30/2024 at 5:45 PM Resident #7 and Resident #9 had a verbal argument and were immediately separated by staff. While the staff were wheeling Resident #9 to their room, Resident #6 suddenly hit the back of Resident #9's head and stated, now we are even. Staff immediately intervened and separated the residents. Assessments were conducted for both residents and no injuries were found. The corrective action documented the residents were kept away from each other and safety maintained on the unit. The physician ordered to send both residents to the emergency room for evaluation. Resident #9 was moved to another unit on return from the emergency room . Psychiatry and Psychology follow up in house. Review of a risk to be victimized/involved in resident-to-resident altercations initiated 9/4/2024 documented secondary to impaired judgement / confusion / aggression / behaviors. Interventions listed included monitor for changes in mood and behavior triggered by environmental factors. Review of a risk for potential verbal/physical abuse last revised 10/11/2024 documented Resident #9 was at risk secondary to Dementia. Interventions listed included assess for signs and symptoms of abuse, encourage resident to seek out staff or assistance if having difficulties, ensure resident stays in a room with a compatible roommate, provide support and ensure resident is free from abuse. 7) Resident #7 admitted to the facility 6/14/2023 with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident was cognitively intact. The resident exhibited verbal behaviors directed towards others. The resident had impairment to both lower extremities and required a wheelchair for locomotion. The resident required set up assistance with eating, supervision with toileting, bed mobility and transfers. Review of a risk to be victimized/involved in a resident-to-resident altercation last revised on 10/21/2024 documented Resident #7 was at risk secondary to medical and physical status. On 8/3/2024 documented Resident #7 was threatened by Resident #9. Interventions listed from 3/23/2024 documented monitor for changes in mood and behavior triggered by environmental factors. 8) Resident #8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Comprehensive Minimum Data Set (an assessment tool that measures health status) dated 9/17/2024 documented the resident was cognitively intact. The resident exhibited verbal behaviors directed towards others. The resident had impairment to the upper and lower extremities on one side and required a wheelchair for locomotion. The resident required set up assistance with eating, moderate assistance with toileting and supervision with bed mobility and transfers. Review of the investigative summary dated 11/8/2024 documented on 11/7/2024 staff witnessed Resident #7 waiting in line for the smoking session, and Resident #6 rolled ahead of Resident #7 in the line. Resident #7 made a derogatory comment to Resident #6 and Resident #6 turned around and did not say anything. When Resident #7 called Resident #6 a derogatory name again, Resident #6 reached back and hit Resident #7 on the right side of their face. Staff separated the residents immediately and maintained safety. Body checks were completed, and no injuries were noted. Resident #7 had an x-ray ordered and the result came back negative. The physician ordered to send Resident #6 to the emergency room for a psychiatric evaluation. Review of the investigation summary dated 11/25/2024 documented on 11/22/2024 at 5:30 PM Resident #7 was interacting with staff at the nurses' station, Resident #6 started to approach Resident #7 and aggressively started yelling at Resident #7, stating they will show them who they are today, and they are going to kill them. Staff immediately intervened and removed Resident #7 from the situation and Resident #6 was redirected and escorted by staff to their unit. Safety was maintained and 911 was called and police assistance requested. Resident #6 was redirected by staff, but attempts were unsuccessful. Despite multiple attempts to redirect Resident #6 by staff they went to Resident #7's room and aggressively and violently pushed Resident #7's belongings off their bed and bedside table. Resident #6 returned to their unit as the police arrived. The police interviewed both residents and then Resident #6 was transferred to the emergency room due to aggressive behavior. Resident #7 will be seen by psychiatry and psychology in house and reassurance provided. Review of an incident and accident report dated 11/22/2024 documented at 10:58 AM staff witnessed Resident #6 telling Resident #8 to move out of the way. Resident #6 then turned to the witness and stated they asked Resident #8 to move nicely and if they do not move, then they will move them. The witness told Resident #6 that they should leave Resident #8 alone because they were not in their way. Resident #6 then proceeded to walk over to the ice bucket to get ice. After Resident #6 got the ice, Resident #6 walked over to Resident #8 and got into their face. Resident #6 reached around with an open hand to slap Resident #8, they moved Resident #6 away from Resident #8 and separated. Review of a risk to be victimized/involved in a resident-to-resident altercation initiated 10/10/2023 and last updated 12/13/2024. documented Resident #8 was at risk secondary to living in a congregate setting. Interventions listed included monitor for changes in mood and behavior triggered by environmental factors. There was no documented evidence of the care plan being updated with the incident that occurred on 11/22/2024. During an interview on 12/18/2024 at 9:21 AM the Director of Nursing stated when there is a resident-to-resident incident, the residents are immediately separated. The Director of Nursing stated following a resident-to-resident incident all department heads are given a list of the residents involved and instructed to ensure the residents are kept separate. During an interview on 12/19/2024 at 4:40 PM, the Administrator stated the residents with the resident-to-resident situations are separated by unit initially. The Administrator stated they meet with the interdisciplinary team and see what interventions can be put in place and if an intervention is not working then they will change the intervention. The Administrator stated they are always educating the staff to be knowledgeable of which residents need to be closely supervised when they are near each other. The Administrator stated the resident-to-resident incidents are brought up regularly in the quality assurance and performance improvement meetings and they try to have activities on going, so that the residents are always staying busy. The Administrator stated they do their best to try and keep the residents that are more challenging safe and away from each other. 10 NYCRR 415.4(b)(1)(i) | Plan of Correction: ApprovedFebruary 24, 2025 Immediate Corrective Actions Resident #2 was placed on purposeful rounds every hour. Resident #6 was placed on 1:1 monitoring for the duration that the resident is determined to be a risk to the safety of other residents. Identification of at-Risk Residents All Residents have potential to be affected by this practice. All altercations regarding residents #2 & #6 were audited to ensure proper care planning with proper interventions were put in place to ensure the residents' protection. Systemic Change The facility Policy and Procedure on Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date. The facility will in-service all facility staff on the Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property policy with a focus on ensuring that all altercations have appropriate interventions care planned and implemented to prevent reoccurrence. The facility Policy and Procedure on Dementia Clinical Protocol has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date. The facility will in-service all facility staff on the Dementia Clinical Protocol. The facility Policy and Procedure on Care Planning has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date. The facility will in-service all facility staff on the Care Planning policy with a focus on abuse on abuse care plans. Quality Assurance The Director of Nursing/designee created a compliance audit tool to ensure that appropriate care planning with proper interventions were put into place following each altercation. 2 charts will be audited per week for 2 months. Audit findings will be presented to the QA Committee for evaluation and follow up as indicated. Completion The Director of Nursing/designee is responsible for this plan of correction by 3/03/25. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2025
Corrected date: March 3, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY 354) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 out of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 who was dependent on staff for all cares including rolling left to right acquired a Stage 3 pressure ulcer to their left hip during their stay at the facility. There was no documented physician order [REDACTED]. It aims to ensure that each individual's basic needs are met while promoting dignity, independence, and comfort. Resident #1 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had severe cognitive impairment and severe impaired vision. Resident #1 had impairment to both upper and lower extremities and was dependent for all cares. The resident had an indwelling catheter and was always incontinent of bowels. Review of an admission nursing assessment dated 1/31/2024 documented Resident #1 was dependent for bed mobility and was bedbound. Resident #1 had wounds present to their coccyx, right and left buttocks and sacrum. Review of Resident #1's Braden scale assessments revealed there was no classification of the resident's risk to develop pressure ulcers. Review of Resident #1's physician's orders [REDACTED]. Review of an activities of daily living care plan last revised 10/13/2024 documented Resident #1 was dependent on staff daily for meeting their needs. Interventions listed included monitor/document and report any changes, and potential for improvement or declines in function. Review of Resident #1's certified nurse assistant accountability for (MONTH) 2024 revealed the resident required maximal assistance with rolling left and right. There was no documented evidence of direct care staff providing assistance with bed mobility on 30 occasions. Review of Resident #1's certified nurse assistant accountability for (MONTH) 2024 revealed the resident required maximal assistance with rolling left and right. There was no documented evidence of direct care staff providing assistance with bed mobility on 32 occasions. Review of a Registered Nurse weekly wound rounds/team assessment note dated 3/12/2024 at 10:30 AM documented Resident #1 had developed a Stage 3 pressure ulcer to the left hip measuring 3 x 1.5 x 0.1 cm. Instructed certified nurse assistants to turn Resident #1 every 2 hours. During an interview on 12/18/2024 at 9:21 AM the Director of Nursing stated if there were orders for turning and positioning, it would be reflected on the certified nurse assistant accountability to turn and position every 2 hours. The Director of Nursing stated a completed Braden scale assessment provides the classification of the resident' risk for pressure ulcers. The resident would be ordered for turning and positioning. The Director of Nursing stated if there is no signature in the box on the certified nurse assistant accountability, it indicates the task was completed. If it is not documented, then it was not done. 10 NYCRR 415.12 | Plan of Correction: ApprovedFebruary 24, 2025 Immediate corrective action Resident #1 is no longer in the facility Identification of at Risk Residents All residents who are dependent on staff for all cares have the potential to be affected by this practice. An audit was conducted on all residents who have pressure ulcers to ensure that appropriate turning and positioning orders in place. Any negative findings were addressed. Systemic Change The facility Policy and Procedure on Pressure Ulcers has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date and ensures that all residents who have pressure ulcers will have appropriate turning and positioning orders. The facility will in-service all Nursing staff on the pressure ulcers policy with a focus on the the importance of skin care for a dependent residents. Quality Assurance The Director of Nursing/ designee created an audit tool to audit residents with pressure ulcers to ensure that appropriate turning and positioning orders, care planning and tasks are in place. 5 residents will be audited weekly for 4 weeks and monthly for 1 month. Audit findings will be presented to the QA Committee for evaluation and follow up as indicated. Completion The Director of Nursing/ Designee is responsible for the correction of these practices by 3/03/25. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2025
Corrected date: March 3, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY 504, NY 121) the facility did not ensure the report of the results of their investigation was submitted to the New York State Department of Health in accordance with State law within 5 working days of the incident for 2 of 3 residents (Resident #2, #6) reviewed for abuse. Specifically, (1) Resident # 2 was witnessed hitting Resident #5 on their left hand with their walker on 3/28/2024. The 5-day investigative conclusion report was not submitted to the New York State Department of Health until 4/11/2024. 2)On 5/2/2024 Resident #2 engaged in a physical altercation with Resident #4 and resulted in injury to both residents. There was no documented evidence that a 5-day investigative conclusion report was submitted to the New York State department of Health. 3) On 11/2/2024 Resident #2 and Resident #3were engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial scratch to their forehead. The 5-day investigative conclusion report was not submitted until 11/8/2024. (4) Resident #6 was witnessed on 11/7/2024 hitting Resident #7 on the right side of their face. The 5-day investigative conclusion report was not submitted until 11/13/2024. 5)On 11/22/2024 Resident #6 reached around with an open hand and slapped Resident #8 in the face. The 5-day investigative conclusion report was not submitted until 12/3/2024. The findings are: 1) Resident #2 was admitted to the facility 12/8/2021 and last readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/23/2024 documented the resident was cognitively intact. No behaviors documented. The resident required a walker for locomotion. The resident requires set-up for eating, supervision for toileting, bed mobility and transfers. Review of the accident/incident report dated 3/28/2024 at 9:10 PM documented Resident #5 sustained bruising to their left hand after Resident #2 hit them with their walker after a verbal altercation in the hallway and the investigative summary dated 3/29/2024 concluded there is cause to believe an alleged resident abuse occurred. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 4/11/2024. 2)A Review of the investigation conclusion dated 5/2/2024 documented a resident-to-resident altercation between Resident #2 and Resident #4. Both residents were transferred to the emergency room and psychiatric evaluation, as Resident #2 sustained a laceration to the chin and Resident #4 sustained a laceration to the left eyebrow. Review of the Aspen Complaint Tracking System revealed no submission of the 5-day investigative conclusion report for the incident that occurred on 5/2/2024. 3) A Review of an incident/accident report dated 11/2/2024 documented Resident #3 and Resident #2 engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial scratch to their forehead. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 11/8/2024. 4) A Review of a Facility investigative summary dated 11/8/2024 documented on 11/7/2024 staff witnessed Resident #7 waiting in line for the smoking session. Resident #6 rolled ahead of Resident #7 on the line. Resident #7 made a derogatory comment to Resident #6 and Resident #6 turned around and did not say anything. Resident #7 called Resident #6 a derogatory name again, and Resident #6 reached back and hit Resident #7 on the right side of their face. Staff separated the residents immediately and maintained safety. Body checks were completed, and no injuries were noted. Resident #7 had an x-ray ordered and the result came back negative. The physician ordered to send Resident #6 to the emergency room for a psychiatric evaluation. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 11/13/2024. 5) A Review of an incident and accident report dated 11/22/2024 documented at 10:58 AM staff witnessed Resident #6 telling Resident #8 to move out of their way. Resident #6 then turned to a staff (witness) and reported they asked Resident #8 to move nicely and if they do not move, they will move them. Resident #6 proceeded to walk over to the ice bucket to get ice and walked over to Resident #8 and got into their face. Resident #6 reached around with an open hand and slapped Resident #8. Resident #6 was moved away from Resident #8, and both were separated. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 12/3/2024. During an interview on 12/18/2024 at 9:21 AM, the Director of Nursing stated the incident that occurred on 3/28/2024 they are not sure who submitted the 5-day conclusion as it states anonymous. The Director of Nursing stated for the incident that occurred on 5/2/2024 they were not aware that a 5-day conclusion was not submitted. The Director of Nursing did not provide and explanation as to why the 5-day conclusion report was not submitted for some of the incidents and why those submitted were late. 10NYCRR 415.4(b)(1)(ii) | Plan of Correction: ApprovedFebruary 24, 2025 Immediate corrective action Residents #2 & #6 reportable incidents were reviewed to determine if follow-up investigation report was submitted. It was determined that Case #NY 504 Submission ID 7 follow-up investigation report was submitted on 4/11/24, Case #NY 504 Submission ID 7 was submitted on 11/8/24, Case #NY 504 Submission ID 3 was submitted on 8/28/24. Identification of at Risk Residents All Residents have the potential to be affected by this practice. An audit was conducted on all reportable incidents going back to 12/3/24 to ensure compliance with the abuse reporting regulations. Any negative findings were addressed. Systemic Change The facility Policy and Procedure on Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date. The facility will in-service all Administrative staff on the Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property policy. Quality Assurance The facility will conduct an audit to ensure reporting summaries are submitted within the regulatory timeline. The Director of Nursing/ designee created an audit tool to track reportable events to ensure timely submission of reporting summaries. This audit will be conducted on all reportable incidents weekly for 4 weeks and then monthly for 2 months. Audit findings will be presented to the QA Committee for evaluation and follow up as indicated. Completion The Director of Nursing/ Designee is responsible for the correction of these practices by 3/03/25. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2025
Corrected date: March 3, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during an abbreviated survey (NY 354), the facility did not ensure the resident's right to a dignified existence. This was evident for 5 out of 6 residents (Resident #4, #12, #13, #14, #15) reviewed for dignity. Specifically, (1) During an observation on 12/13/2024, the 6th floor unit hallway had 4 residents (Resident #4, #12, #13, #14) dressed in hospital gowns; (2) During an observation on 12/13/2024 on the 5th floor dining room, Registered Nurse #1 was standing over Resident #15 while assisting them with their meal. The findings are: The Facility Resident's Rights Policy last reviewed 5/2024 documented the purpose was to provide general guidelines for resident rights while caring for the resident. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on residents' rights including resident dignity and respect. During an observation on the 6th floor on 12/13/2024 between12:34 PM to 12:54 PM, Residents were noted to be seated along the hallways and there were 4 residents (Resident #4, #12, #13, #14) dressed in hospital gowns. 1) Resident #4 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 3/4/2024 documented the resident had moderate cognitive impairment. No behaviors noted. The resident had impairment to the upper extremity on one side and was ambulatory. The resident required supervision for eating, moderate assistance with toileting and bed mobility and was independent for transfers. Review of an activities of daily living care plan last revised 9/3/2024 documented Resident #4 required staff assistance daily in meeting their needs due to a [DIAGNOSES REDACTED].#4's needs would be met by staff as evidenced by being well groomed and dressed appropriately daily. 2) Resident #12 had [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had severe cognition impairment. The resident was ambulatory and required set up assistance with eating, bed mobility and transfers, and moderate assistance with toileting. Review of an activities of daily living care plan last revised 11/18/2024 documented Resident #12 was dependent on staff for meeting their daily needs due to a [DIAGNOSES REDACTED]. 3) Resident #13 was admitted with [DIAGNOSES REDACTED]. A Comprehensive Minimum (MDS) data set [DATE] documented the resident had moderate cognitive impairment. The resident had impairment to the upper extremity on one side. Resident #13 required supervision with eating, maximal assistance with toileting, transfers, and bed mobility. Review of an activities of daily living care plan last revised 12/3/2024 documented Resident #13 was dependent on staff daily in meeting their needs related to their history of a [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions listed included monitor/document/report as needed any changes, reasons for self-care deficit or decline in function. 4) Resident #14 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had moderate cognitive impairment. The resident had impairment to both upper extremities. Resident #14 required maximal assistance with eating, toileting and bed mobility and was dependent for toileting. Review of an activities of daily living care plan last revised on 12/17/2024 documented the resident was dependent on staff daily for meeting their needed related to their history of Dementia and [MEDICAL CONDITION]. During an observation on the 5th floor dining room on 12/13/2024 at 1:07 PM, Registered Nurse #1 was standing next to Resident #15 while assisting them with their meal. 5) Resident #15 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum (MDS) data set [DATE] documented the resident had moderate cognitive impairment. The resident had impairment to both upper and lower extremities. The resident required moderate assistance with eating, toileting and bed mobility, and maximal assistance with transfers. Review of an activities of daily living care plan last revised 7/31/2024 documented the resident was dependent on staff for meeting their daily needs. During an interview on 12/13/2024 at 1:10 PM, Certified Nurse Assistant #1 stated the residents on the 5th floor that are dressed in hospital gowns, either do not have clothes or it is a housekeeping issue. Certified Nurse Assistant #1 stated a lot of the residents on their unit do not have families or any clothing and sometimes when the laundry is sent down to housekeeping it does not get sent back to the correct resident. Certified Nurse Assistant #1 stated there was a housekeeping/laundry person, but they do not think they have one anymore. Certified Nurse Assistant #1 stated there is a lot of clothing that is donated to the residents in the facility, but the clothing gets misplaced, because it is not labeled for the residents. Certified Nurse Assistant #1 stated there is clothing down in the laundry room that the residents can wear, but some of the certified nurse assistants do not want to go down and get the clothing for the residents so they leave them in hospital gowns. During an interview on 12/13/2024 at 1:07 PM, Registered Nurse #1 stated they observed the other residents at the table assisting Resident #12 with their meal, so they went and tried to assist the resident. Registered Nurse #1 stated they were aware they are not supposed to stand over residents when assisting them with meals. During an interview on 12/18/2024 at 9:21 AM, the Director of Nursing stated they instructed the certified nurse assistants to inform them if a resident has no clothing, so they can get the social worker involved to provide clothing for the residents. The Director of Nursing stated the facility process when residents have no clothing will be to inform the residents' family of the need for clothing and also make them aware there is clothing for donation in the facility, and they will ask for permission to dress the resident in the donated clothing. During an interview on 12/18/2024 at 11:09 AM, Registered Nurse #2 (unit manager 2nd floor) stated some of the residents are adamant about wearing the hospital gowns. Registered nurse #2 stated a few of the residents on their unit stay in their room or go in and out of their rooms and they do not want to wear clothing. Registered Nurse #2 stated they ask the residents if they want to wear clothes, and they also have to care plan the residents for not wanting to wear clothes. During an interview on 12/18/2024 at 12:40 PM, Certified Nurse Assistant #2 stated Resident #13 came to the facility without any clothing and the clothing the resident had on when they arrived at the facility were soiled with urine. Certified Nurse Assistant #2 stated they were told there is clothing for the residents in the facility which is stored on the second floor. Certified Nurse Assistant #2 stated they weent to the second floor and there was no clothing and the staff on the staff on the second floor stated they do not know what they were talking about when they asked about cloyhing for residents. They asked one of the housekeepers about clothing and were sent to the basement and they found clothing, but it looked dirty. Certified Nurse Assistant #2 stated when they wash their residents and they do not have clothing they put a clean gown on them which they obtain from the clean utility room. Certified Nurse Assistant #2 stated they found out yesterday that they need to speak to the the Director of Housekeeping when they need clothes for their residents, and the Director of Housekeeping will them the clothing and label them for the resident. During an interview on 12/19/2024 at 10:27 AM, the Director of Housekeeping stated they have donated clothing for residents in the building. The Director of Housekeeping stated they have 2 large blue bins with shelving, designated for men and women. The Director of Housekeeping stated when a resident has no have clothing the certified nurse assistant is expected to contact them, or they meet with the resident directly with an inventory sheet to document their size and preferences for clothing. The Director of Housekeeping stated bring the resident clothing from the laundry room, and label the clothing with the resident name and the facility name. During an interview on 12/19/2024 at 4:40 PM, the Administrator stated they try to ensure there is clothing available for the residents in the facility and they receive clothing donations from the community. The Administrator stated the clothing that is donated is labeled with the resident's name after the resident makes their selection. No resident should have to be dressed in hospital gowns. 10 NYCRR 415.3(d)(1)(i) | Plan of Correction: ApprovedFebruary 24, 2025 Immediate Corrective Actions Director of Nursing/ Designee ensured that residents #4, #12, #13, #14, #15 have access to clothing. Nurse #1 was educated on the faciality Resident's Rights policy with a focus on resident dignity. Identification of at-Risk Residents All Residents who do not have clothing and that require assistance while eating have potential to be affected by this practice. The Director of Nursing/ Designee conducted an audit to ensure that all residents have access to clothing. Any negative findings were addressed. An audit was conducted for all that require assistance while eating to ensure resident dignity was maintained during mealtime. Any negative findings were addressed. Systemic Change The facility Policy and Procedure on Resident's Rights has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date. The Facility Policy and Procedure on Resident Clothing has been reviewed and updated to include the facility process for accessing donated clothing. All nursing staff will be in-serviced on facility policy on Resident's Rights. All nursing, Social Services and Housekeeping staff will be in-serviced on facility policy on Resident Clothing. Quality Assurance The Director of Nursing/ designee created an audit tool to ensure compliance with facility policy on Resident's Rights to ensure that residents have access to clothing. The Director of Nursing or their designee developed an audit tool to ensure compliance with the facility's Resident Rights policy, specifically focusing on proper feeding assistance for residents The Director of Nursing or designee will conduct an audit on 4 random residents weekly for 4 weeks, then monthly for 1 month, and then as needed. Any issues identified will be referred to the DNS and QA for review and corrective action. Audit findings will be presented to the QA Committee for evaluation and follow up as indicated. Completion The Director of Nursing/designee is responsible for this plan of correction by 3/03/25. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2025
Corrected date: March 3, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during an abbreviated survey (NY 354, NY 737), the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, on every unit in the facility there were multiple areas of chipped paint, scuff marks, visible dirt and stains on the walls and floors, base boards chipped and coming off the wall, holes in the walls, chipped tiles, caving ceiling tiles and foul odors. The findings are: The facility Resident Environmental Quality policy last revised 10/2024 documented it is the policy of the facility to be designed, constructed, and maintained to provide a safe, functional, sanitary, and comfortable environment for resident's staff and the public. During rounds on the units on 12/13/2024 from 12:34pm to 2:41pm the following was observed: On the 2nd floor there was chipped paint on the walls along the hallway. On the 3rd floor there was a light bulb out on the high side hallway, the walls were dirty and had chipped paint. The bathroom in room [ROOM NUMBER] had visible dirt on the walls and the radiator had chipped paint. The base boards were off and peeling along the hallways in many areas. By room [ROOM NUMBER] the paint was chipped on the wall and the baseboard was coming off. On the 4th floor dining room, there was chipped paint and large scuff marks on the walls, the baseboards were chipped and coming off the walls. There was an improper ceiling tile repair, and a portion of the tile was caving. The plaster was chipped off the wall at the nurse's station. The wall behind the bed in room [ROOM NUMBER] was visibly dirty and stained. The bathroom in room [ROOM NUMBER] had a hole in the wall around the plumbing and duct tape holding the paper towel dispenser together. On the 5th floor there was chipped paint along the walls on the low side of the hallway and well as on the doorways to the rooms. The door to the medication room in the nursing station was chipped. There were some tiles coming up and cracked in the nurse's station. There were holes in the wall by room [ROOM NUMBER]. The panel under the water fountain at the end of the low side hallway had a screw missing and was protruding from the wall, the baseboard by the water fountain was chipped along the entire corner. In the dining room there was a large, scuffed area along the entire bottom section of the wall. On the 6th floor the walls had chipped paint along the hallway and visibly soiled walls and doors. Multiple areas of the base boards were chipped and coming off the walls. During an interview on 12/17/2024 at 9:45 AM, the Director of Maintenance stated they are responsible for everything that breaks down in the facility, maintaining the equipment, some engineering tasks and dealing with the boiler room. The Director of Maintenance stated they currently have 2 staff members under them, and they have a lot of experience in construction, and they have to assist their staff who are not as experienced. The Director of Maintenance stated the staff then write a note as to what repair is needed and then they complete the task and sign off and close the ticket with a note. The Director of Maintenance stated they have the app on their cellphones and the computer and daily they review to see if there are issues that need to be addressed. The Director of Maintenance stated most tasks are completed in a day but if additional items are needed to complete the task, then it may take longer and if the task cannot be completed the next day, then they try to address it within 48 hours. The Director of Maintenance stated they make environmental rounds in the morning if they are not available then they will ask their employees to make the rounds. The Director of Maintenance stated the Administrator is only on rounds if necessary or if they find something they need to have addressed. The Director of Maintenance stated they are trying their best with completing the painting and patching in the facility, the work is overwhelming at times. The Director of Maintenance stated they will patch holes and they have to go back and paint the area and they are trying to hire someone with the skills needed to repair things like painting and patching holes. The Director of Maintenance stated they have spoken with the Administrator about hiring additional staff and they are working on it and it is their responsibility to maintain the building and not to fix it. During an interview on 12/16/2024 at 9:03 AM, the Administrator stated they have been working in the facility since (MONTH) 2024 and they do environmental rounds in the facility at least weekly, but they try to do rounds daily. The Administrator stated when they make rounds, they focus on making sure the hallways are free of clutter, no items on the carts, observe for chips in the paint, holes in the walls, ensure no doors are propped open and ceiling tiles are intact. The Administrator stated they also spot check to ensure the call bells are working and the resident's televisions are working. The Administrator stated if something is found they reach out to the maintenance department and if it is a nursing issue they reach out to nursing. The Administrator stated depending on the item that is being requested to work on, they timing requirement for expected repairs differs. The Administrator stated if it is a remote control then they would expect it to be addressed in an hour or two, if it is a hole in the wall then within 48 hours, they would expect it to be addressed. The Administrator stated they try to be reasonable so if they request several things at one time then they will allow them more time. The Administrator stated they do not usually use an outside vendor for cosmetic needs in the building. The administrator stated they were working on hiring more staff for maintenance. 10 NYCRR 415.29 | Plan of Correction: ApprovedFebruary 17, 2025 Immediate corrective actions All environmental issues referenced in survey were promptly addressed and repaired. Rounds were conducted on nursing unit. All environmental issues noted have been rectified. Identification of at risk residents All Residents have the potential to be affected by this practice. Corrective action The facility Policy and Procedure on Resident Environmental Quality has been reviewed and determined that no change was needed, and the policy is consistent with state and federal requirements and up to date and ensures that environmental concerns will be promptly noted and remediated. All maintenance staff will be in-service on the facility policy and procedure Resident Environmental Quality. The director of maintenance will conduct weekly environmental rounds to ensure that and environmental finings are identified and addressed. Quality Assurance The facility Director of Maintenance/ representative created an audit tool to ensure that weekly environmental rounds are being conducted and issues identified are being addressed. The weekly environmental rounds will be audited weekly for 4 weeks and monthly for 1 month. Audit findings will be presented to the QA Committee for evaluation and follow up as indicated. Completion The Director of Maintenance/ Designee is responsible for the correction of these practices by 3/03/25. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 3, 2025
Corrected date: March 3, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY 737) the facility did not ensure sufficient nursing staff to attain or maintain the well-being of each resident as determined by the facility staffing grid as necessary to meet the needs of the residents for 35-40 residents on the 3rd floor Dementia Unit. Specifically, review of the facility scheduled data sheets for (MONTH) 2024, (MONTH) 2024 and (MONTH) 2024 revealed staffing was not adequate across various shifts based on the unit needs and Provider Average Ratio (PAR) levels documented on the staffing grid. The findings are: The facility Staffing policy last revised 5/2024 documented the facility must have sufficient nursing staff with the appropriate competencies and skill sets to: provide nursing and related services to assure resident safety. Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. As determined by resident assessments and individual plans of care. Considering the number, acuity, and [DIAGNOSES REDACTED]. The Staffing Grid documented as of (MONTH) 12, 2024, the certified nurse assistant Provider Average Ratio levels for the 3rd floor were as follows: Day shift: 5 certified nurse assistants, Evening shift: 4 certified nurse assistants, Night shift: 2 certified nurse assistants. Review of the facility staffing schedule for the 3rd Floor Dementia Unit for (MONTH) 2024 revealed the following: Day shift-2 certified nurse assistants on 1/1/2024, 1/8/2024, 1/9/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/21/2024, 1/23/2024, 1/25/2024, 1/28/2024 3 certified nurse assistants on 1/2/2024, 1/4/2024, 1/6/2024, 1/7/2024, 1/10/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/20/2024, 1/22/2024, 1/24/2024, 1/29/2024, 4 certified nurse assistants on 1/3/2024, 1/5/2024, 1/17/2024, 1/18/2024, 1/19/2024, 1/27/2024, 1/30/2024, 1/31/2024. Evening shift-2 certified nurse assistants on 1/1/2024, 1/3/2024, 1/13/2024, 1/14/2024, 1/16/2024, 1/20/2024, 1/21/2024, 3 certified nurse assistants on 1/2/2024, 1/4/2024, 1/5/2024, 1/6/2024, 1/7/2024, 1/8/2024, 1/9/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/17/2024, 1/18/2024, 1/24/2024, 1/25/2024, 1/27/2024, 1/29/2024, 1/30/2024, 1/31/2024. Night shift-1 certified nurse assistant on 1/13/2024, 1/25/2024, 1/28/2024 Review of the facility staffing schedule for the 3rd Floor Dementia Unit for (MONTH) 2024 revealed the following: Day shift-2 certified nurse assistants on 2/5/2024, 2/9/2024, 2/11/2024, 2/12/2024, 2/13/2024, 2/14/2024, 2/22/2024, 3 certified nurse assistants on 2/1/2024, 2/4/2024, 2/8/2024, 2/10/2024, 2/19/2024, 2/20/2024, 2/21/2024, 2/26/2024, 4 certified nurse assistants on 2/2/2024, 2/3/2024, 2/6/2024, 2/7/2024, 2/16/2024, 2/23/2024, 2/25/2024, 2/27/2024, 2/28/2024, 2/29/2024, Evening shift-2 certified nurse assistants on 2/4/2024, 2/9/2024, 2/11/2024, 2/17/2024, 2/18/2024, 2/23/2024, 2/26/2024, 3 certified nurse assistants on 2/1/2024, 2/3/2024, 2/6/2024, 2/8/2024, 2/10/2024, 2/12/2024, 2/13/2024, 2/14/2024, 2/18/2024, 2/20/2024, 2/21/2024, 2/24/2024, 2/25/2024, 2/27/2024, 2/28/2024. Night shift-1 certified nurse assistant on 2/3/2024, 2/4/2024, 2/16/2024, 2/22/2024, 2/25/2024 Review of the facility staffing schedule for the 3rd Floor Dementia Unit for (MONTH) 2024: revealed the following-Day shift-2 certified nurse assistants on 3/16/2024, 3/17/2024, 3/18/2024, 3/21/2024, 3/26/2024, 3 certified nurse assistants on 3/2/2024, 3/3/2024, 3/4/2024, 3/5/2024, 3/7/2024, 3/10/2024, 3/25/2024, 3/31/2024, 4 certified nurse assistants on 3/1/2024, 3/6/2024, 3/8/2024, 3/9/2024, 3/11/2024, 3/12/2024, 3/13/2024, 3/14/2024, 3/15/2024, 3/19/2024, 3/22/2024, 3/23/2024, 3/24/2024, 3/27/2024, 3/28/2024, 3/30/2024, Evening shift-2 certified nurse assistants on 3/1/2024, 3/4/2024, 3/11/2024, 3 certified nurse assistants on 3/2/2024, 3/3/2024, 3/5/2024, 3/6/2024, 3/7/2024, 3/8/2024, 3/10/2024, 3/12/2024, 3/13/2024, 3/15/2024, 3/16/2024, 3/17/2024, 3/19/2024, 3/21/2024, 3/22/2024, 3/24/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, 3/30/2024, 3/31/2024.Night shift-1 certified nurse assistant on 3/19/2024 During an interview on 12/19/2024 at 1:55 PM the Staffing Coordinator stated they have been working in the facility since March. The Staffing Coordinator stated staffing during the morning and evening shifts, have a lot of call outs and they try to have additional staff scheduled just in case, but sometimes they call out as well. The Staffing Coordinator stated if the census on a unit is 30 residents or below then they will schedule 3 certified nurse assistants. The Staffing Coordinator stated if a unit has a 1 to 1 then they schedule 3 certified nurse assistants and 1 extra. The Staffing Coordinator stated if they do have extra certified nurse assistants then they will schedule them to work on the Dementia units. Staffing for the facility is as follows as per the Staffing Coordinator: morning and evening shifts all units- 4 certified nurse assistants, night shift-2 certified nurse assistants. The Staffing Coordinator stated they also use agency staff when there is an opening and the regular or the per diem certified nurse assistants do not pick up the shift. During an interview on 12/19/2024 at 2:28 PM Certified Nurse Assistant #3 stated they have been working in the facility for a longtime and the staffing is really bad. Certified Nurse Assistant #3 stated sometimes they start the shift off with 4 certified nurse assistants on the unit and then they end up with 2 or 3 certified nurse assistants. Certified Nurse Assistant #3 stated sometimes when they arrive to the facility in the morning, there is only 1 certified nurse assistant and the nurse for the entire unit with 35 to 40 residents. That is too much for the 3rd floor dementia unit where the residents wander around. Certified Nurse Assistant #3 stated when they arrive in the morning the residents on the unit are saturated with feces and urine from head to toe. Certified Nurse Assistant #3 stated the staffing shortage occurs every week and the facility's response to them is that they reach out to agency staff, but they never come in. During an interview on 12/19/2024 at 2:37 PM Certified Nurse Assistant #4 stated they have been working in the facility since the beginning of the year. Certified Nurse Assistant #4 stated they are now assigned to the 3rd floor. They work double shifts about 2-3 times/week. Certified Nurse Assistant #4 stated the staffing in the facility is bad and there have been times when they are the only certified nurse assistant on the unit with the nurse. Certified Nurse Assistant #4 stated there have been times when there is only certified nurse assistants on the unit with no nurse. Certified Nurse Assistant #4 stated sometimes on the weekend they work with 2 certified nurse assistants on the 3rd floor, and it is not easy. This is another reason a lot of staff do not want to work on the 3rd floor. During an interview on 12/19/2024 at 2:50 PM Certified Nurse Assistant #5 stated they have been working in the facility for [AGE] years and the staffing has gotten better compared to earlier in the year, the staffing was bad. Certified Nurse Assistant #5 stated the facility uses agency staffing to fill gaps and now the staffing is better, but before it was horrible. During an interview on 12/19/2024 at 5:03 PM the Director of Nursing stated when they came to the facility the staffing was done according to the census and there was a back and forth about the acuity and type of residents they had. The Director of Nursing stated staffing is a challenge in the facility, with the lateness and the call outs. The Director of Nursing stated although the documented Provider Average Ratio (PAR) for the day shift is 5 certified nurse assistants, most days they have 3 or 4. The Director of Nursing stated if the residents on the units have appointments, the certified nurse assistants are pulled from the units to accompany the residents to the appointments. The Director of Nursing stated they must meet the needs of the residents and staffing has improved from where it used to be. 10NYCRR 415.13 (A)(1)(i-iii) | Plan of Correction: ApprovedFebruary 24, 2025 Immediate Corrective Actions The facility reviewed PAR levels to ensure that they are in line with unit needs. The facility assessment was revised and reviewed accordingly. The schedule was immediately adjusted to be match the facility needs. The Director of Nursing/Designee educated the Staffing Coordinator on the importance of proper staffing levels. Identification of at Risk Residents All Residents have the potential to be affected by this practice. Systemic Change The facility will ensure that the staffing levels are in line with the facility needs and will be reflected on the daily schedule. Recruitment bonuses will be offered for staff referrals to help recruitment efforts. Sign-on bonuses will be offered in order to attract new staff members. Quality Assurance The Director of Nursing/ Designee created and audit tool to ensure proper scheduling. 2 daily schedules will be audited weekly for 4 weeks and monthly for 1 month. The Director of Nursing/ Designee created an audit tool to track all new hires. This audit will be conducted weekly for 4 weeks and then monthly for 2 months. Audit findings will be presented to the QAPI Committee for evaluation and follow up as indicated, for the duration of the audit. Completion The Director of Nursing/ Designee is responsible for the correction of these practices by 3/03/25. |