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Scope: Isolated
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, interview, and record review conducted during the Standard survey completed on 1/21/25, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #53) of two residents reviewed. Specifically, Resident #53 had a recent history of urinary tract infection, and the foley drainage bag was not kept below the resident's bladder nor was the drainage tubing kept free of kinks. Additionally, the foley drainage bag and tubing was observed to be placed on the floor by staff. The finding is: The policy and procedure titled Catheter Daily Care (Indwelling) modified on 11/23/22 documented position of the drainage bags should be below the level of the bladder. Collection bags and tubing should not touch the floor. Resident #53 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 12/9/24 documented Resident #53 was understood, understands and was cognitively intact. Resident #53 had an indwelling catheter. Review of the Order Summary Report dated 1/16/25 documented an order starting on 1/12/25 for urinary catheter, change catheter as needed for plugging or leakage. Review of the Kardex Report (tool for staff to provide care) dated 1/14/25 documented Resident #53 had an indwelling foley catheter. Review of the comprehensive care plan dated 12/3/24 documented Resident #53 required an indwelling urinary catheter related to [MEDICAL CONDITION], overactive bladder, and [MEDICAL CONDITION]. Interventions included enhanced barrier precautions, provide catheter care daily and as needed, empty urine and record every shift. Resident #53 had an alteration in bladder/bowel elimination related to decreased mobility, use of catheter and history of urinary tract infection. Interventions included to monitor/document for signs and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, and foul-smelling urine. Review of the nursing progress note dated 1/7/25 at 4:06 PM, Registered Nurse #4 Unit Manager documented a physician assistant was in to assess Resident #53 related to tea colored urine, low urine output, and congestion. New order for bladder scan, flush foley, change foley, chest x-ray, and labs. Resident #53 was made aware of new orders and in agreement. Review of the physician assistant progress note dated 1/7/25 documented Resident #53 was noted by nursing to have decreased urine output from foley and some suprapubic (area in the lower abdomen above the pubic bone) discomfort. Instructed nursing to bladder scan, flush the foley catheter and if no improvement then change the foley catheter. During an observation and interview on 1/13/25 at 9:45 AM, Resident #53 was sitting up in their wheelchair, next to their bed. The foley catheter drainage bag was observed hanging on the right handle of the wheelchair, directly behind Resident #53's right shoulder above the level of their bladder. Resident #53 stated they had a urinary tract infection in (MONTH) 2024, they were unable to reach behind them to move the drainage bag, and they would ask staff to move the drainage bag. During on observation on 1/13/25 at 1:00 PM, Certified Nurse Aide #6 and another staff member entered Resident #53's room stating they were going to boost them in their wheelchair, for better positioning. The wheelchair was alongside the bed and Resident #53's foley drainage bag was hanging on the bedframe. After providing a boost, both staff members asked Resident #53 if they would like their wheelchair pedals attached to the wheelchair, to prevent sliding in the wheelchair. Certified Nurse Aide #6 picked up the right wheelchair pedal, unhooked the foley drainage bag from the bed frame, and placed the foley drainage bag flat, directly on the floor underneath the wheelchair. Approximately eight inches of drainage tubing was on the floor underneath the drainage bag. The urine in the tubing was tea colored. Both staff members left the room, leaving the drainage bag and tubing directly on the floor. During an observation and interview on 1/15/25 at 12:12 PM, Resident #53 was sitting in their wheelchair in their room, with a visitor who stated they were a family member. Resident #53's foley drainage bag was attached and hanging from the left arm of the wheelchair above the level of their bladder. The tubing connected to the top of the drainage bag was bent downwards at a 180-degree angle, completely kinking the tubing. The family member stated Resident #53 was already transferred into the wheelchair with the drainage bag hanging on the armrest prior to their arrival. Resident #53 stated a staff member had hung the drainage bag on the wheelchair. During an observation and interview on 1/15/25 at 12:50 PM, Certified Nurse Aide #5 stated they were responsible for Resident #53's care, and they had transferred Resident #53 to their wheelchair, with help from Certified Nurse Aide # 6. They stated they hooked the foley drainage bag on the left armrest on accident and it should have been hung lower, so the urine could flow into it. During an observation and interview on 1/15/25 at 12:53 PM, Certified Nurse Aide #5 moved Resident #53's foley drainage bag from the left armrest of the wheelchair to an area in front of the left wheel of the wheelchair. The bottom of the foley drainage bag was resting on the floor. Certified Nurse Aide #6 stated they had assisted Certified Nurse Aide #5 to transfer Resident #53 into the wheelchair and the foley drainage bag should not have been hung from the armrest of the wheelchair. Drainage bags were usually hung in a lower position, underneath the wheelchair for both dignity and for the urine to flow into it. They stated the current position of the drainage bag, in front of the wheel, was also incorrect because it was touching the floor, looked like it would drag if the wheelchair was moved forward, and would potentially get caught under the wheel. Certified Nurse Aide #6 stated they remembered helping someone from therapy to boost Resident #53 on 1/13/25 and they remembered unhooking the foley drainage bag from the bed frame so they could add the wheelchair pedal, but they could not recall where they placed the drainage bag. They stated they should not have placed it on the floor for infection control reasons. During an interview on 1/15/25 at 1:03 PM, Registered Nurse #3 stated the foley drainage bags should always be placed below the level of the waist for the urine to drain into it. Hooking the foley drainage bag on the handle of the wheelchair or on the armrest was not considered hanging it below the level of the waist. They stated the foley drainage bag and/or tubing should never be placed on or touch the floor because that would be an infection control problem. During an interview on 1/16/25 at 11:24 AM, the Medical Director stated the foley drainage bag should always be placed in a lower position than the bladder, so the urine was able to drain without any obstruction. They stated, when the urine does not drain properly, there was a higher chance for urinary tract infection [MEDICAL CONDITION] (a severe infection). Resident #53 should have had the foley drainage bag placed lower than where it was observed. The Medical Director stated they recently saw Resident #53 and they did not currently have any signs or symptoms of urinary tract infection. During an interview on 1/16/25 at 11:34 AM, Registered Nurse #4 Unit Manager stated the foley drainage bag should never be placed on the handle of the wheelchair, the arm of the wheelchair or on the floor because it was both a dignity and infection control concern. Certified nurse aides, nurses, or whoever transferred the residents were responsible for hanging the foley drainage bags in the proper place on the wheelchairs. Resident #53 had a recen | Plan of Correction: ApprovedFebruary 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident # 53 was evaluated by the medical provider and noted to free from infection or signs of UTI. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents utilizing a foley catheter are at risk for the same deficient practice. A full house audit was completed on 2/10/25 to ensure all Foley drainage bags were kept below the residents bladder with tubing free of kinks and not placed on the floor.?é-There was no further deficient practice noted.?é- What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The facilitys policy titled Catheter Daily Care (Indwelling) was reviewed and no changes are necessary. All nursing staff will be re-educated by the Infection Preventionist on proper care and placement of foley bags and tubing to ensure residents who have an indwelling (Foley) catheter receive the appropriate care and services to manage catheters. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Unit Mangers will complete weekly observation audits x 4 weeks, then monthly x 2 months ensuring all foley drainage bags are properly placed below the bladder, that the drainage bag is properly secured before and after transfers, that there is no obstructed urine flow from improperly placed tubing and that the drainage bag or tubing is not touching the floor. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Standard survey completed on 1/21/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, issues included a dust laden ceiling, including devices on the ceiling, and a damaged wall. This affected one of one Main Kitchen. The findings are: The policy and procedure titled Kitchen, Dining and Dietary Equipment Routine Cleaning Policy, modified 4/26/19, documented the Director of Dietary Services will plan a regular cleaning schedule for the thorough sanitation of the kitchen equipment, dish room, and staff dining areas. Dietary work areas will be kept clean and in order by designated department staff according to routine schedules established by the Director of Dietary Services. The cleaning procedures will be planned and conducted in conformance with pertinent sections of the State Health Code, Rules and Regulations. 1. Observation in the Main Kitchen on 1/13/25 at 11:32 AM revealed the entire ceiling area was dust laden. This included a visible layer of dark gray dust on the ceiling tiles, the ceiling tile grid, the vents, the sprinkler heads, and the heat detectors located on the ceiling in all areas. At the time of the observation, the Director of Dining Services stated Dietary staff did not clean the ceilings, which should be done by Maintenance staff. The Director of Dining Services stated they personally discussed cleaning the kitchen ceiling with the former Director of Maintenance, but that person left employment at the facility, and they had not spoken to other Maintenance staff about it, and they had not put in a maintenance work order for it. Review of the outside contractor's Fire Alarm and Life Safety System Inspection Certificate dated 1/22/24 revealed the Notes and Recommendations Report detailed additional inspection notes made by the Inspectors during the building inspection. This section included a list of seven heat detectors located in the First Floor Kitchen Area and First Floor Kitchen Dishwashing Area and the note for each was Dirty. Review of the outside contractor's Fire Alarm and Life Safety System Inspection Certificate dated 1/6/25 revealed the Notes and Recommendations Report included the same seven heat detectors and the note for six of them was Dirty and the note for the seventh heat detector was Dirty device is right next to HVAC (heating, ventilation, Air Conditioning) caked in dust needs to be moved. 2. Observation in the Main Kitchen on 1/13/25 at 11:42 AM revealed an area of the wall behind the extinguishment hood was chipped and cracked, with paint and drywall paper peeled. The affected area measured four feet wide by five feet high and a rack of dishes was stored against this wall. At the time of the observation, the Director of Dining Services stated the wall needed to be patched and painted or resurfaced. Additionally, they stated the dishes on the rack against the wall were clean and ready to use. During an interview on 1/13/25 at 11:45 AM, the Director of Facilities Maintenance/ Corporate stated kitchen cleaning should be done by Dietary staff, and deep cleaning of the kitchen was done by Maintenance staff. They stated the ceiling cleaning and wall repair needed to be scheduled for off-hours, when the kitchen was closed. During an interview on 1/17/25 at 2:15 PM, the Director of Dining Services stated they first noticed the dust on the ceiling and the area of wall damage about one year ago. They stated they discussed both issues with the former Director of Maintenance in the Fall of 2024, and the former Director of Maintenance left employment at the facility soon after. The Director of Dining Services stated they would normally submit a maintenance work order to communicate with Maintenance staff, as it was hard to get in touch with them because there were only two staff members and they were all over the building, but they did not submit a maintenance work order for these issues. They also stated the work on the ceiling and wall would need to be done after 8:00 PM, when the kitchen closed for the night. During an interview on 1/17/25 at 3:38 PM, the Administrator stated Maintenance staff would be responsible for cleaning kitchen ceilings. This should be done routinely with preventative maintenance, and as needed. It should be done by Maintenance staff because there would be ladders involved, and cleaning the sprinkler heads was not a task for the Dietary staff. The Administrator stated they were made aware of the status of the kitchen ceiling and the area of wall damage in the kitchen within the last two months, and they thought a plan was made to remedy both. They stated some of the other items that were discussed along with kitchen ceiling and wall damage did get done, so they assumed all items were in the works to be completed. The Administrator stated they saw the kitchen ceiling again this week and realized action was not taken, and it needed to be cleaned. 10 NYCRR 415. 14(h) Subpart 14- 1. 171 | Plan of Correction: ApprovedFebruary 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice All areas of the kitchen were thoroughly cleaned, including walls and ceilings. The areas specifically mentioned as deficient were resolved, the ceiling tile grid, the vents, sprinkler heads, and heat detectors were cleaned prior to conclusion of annual survey. The wall areas noted to be damaged have been repaired. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be impacted by this deficient practice. The cleanliness of the kitchen will be monitored by the director of dining services. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur A cleaning schedule will be developed collaboratively between the director of dining services and the director of maintenance to maintain cleanliness of the kitchen, specifically the ceiling which would be difficult for dietary staff to maintain. The ceiling tiles, sprinkler heads, vents, and heat detectors will be cleaned on a monthly basis and as needed to maintain the sanitary conditions of the kitchen. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Director of Dining services will complete environmental audits monthly x 3 months to identify any dust laden ceiling or damaged walls. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025 |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey and Complaint (#NY 063) with an exit date of 1/21/2025, the facility did not ensure the resident's environment remained free from accident hazards over which the facility had control and provide adequate supervision and assistive devices to prevent accidents for one (1) (Resident #154) of three (3) residents reviewed for accidents. Specifically, on 7/13/2024 Resident #154 identified as severely cognitively impaired wandered off the 2nd floor Memory Care Unit (Unit 3) without staffs' knowledge, exited through the emergency stair-well door, which did not alarm, went down the stairs and exited the building through a second door to the outside. The resident tripped and fell sustaining a 2. 5 cm (centimeter) laceration and hematoma (a collection of blood that forms outside of the blood vessel) to the right side of their head and abrasions to their midback and right knee requiring first aide at the facility. This resulted in actual harm to Resident # 154. The findings are: The policy titled Elopement-Wandering-Missing Resident, last revised 10/08/2018, documented all residents are assessed upon admission, annually, and as needed to determine risk level for unsafe wandering/elopement. Appropriate safety measures were put into place for residents determined to be at risk or if found in an unsupervised/potentially dangerous area within the facility. In the event a resident successfully left the facility undetected and unsupervised, the Missing Resident procedure would be put into place immediately to locate the resident in a timely manner. The policy titled Electronic Wandering Security System, last revised 9/25/2024, documented the nursing staff applied and maintained the bracelet/anklet. Record the date of application and serial number of bracelet/anklets in the resident's medical record. The nurse is to verify the placement of the bracelet/anklet every shift. Functionality would be documented in the resident medication/treatment administration record or maintained in the maintenance department. Resident #154 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool), dated 7/18/2024, documented Resident #154 was severely cognitively impaired, was sometimes understood, and sometimes understands. Resident #154 required supervision or touching assistance of one person for transfers and walking. The comprehensive care plan initiated on 7/12/2024 documented Resident #154 was severely impaired with decision making related to dementia. The care plan was revised on 7/15/2024 and documented Resident #154 was at a high risk for wandering and elopement related to impaired cognition and memory. Nursing interventions to monitor whereabouts due to unsafe wandering/risk of elopement and redirect as needed, Wander alert (a system that monitors and prevents people at risk of wandering) bracelet to right ankle, picture of resident with receptionist and other units as appropriate. The care plan prior to the elopement on 7/13/2024 did not include resident was an elopement risk or include safety interventions. The facility could not provide a Kardex (guide used by staff to provide care) for the resident for the time of the elopement on 7/13/ 2024. Review of Elopement Assessment Admission, initiated on 7/12/2024 by License Practical Nurse #3 and completed on 7/17/2024, documented Resident #154 was a high risk for elopement due to having eloped/attempted to elope/history of elopement. Wander alert placed. The nursing progress note dated 7/12/2024 at 10:36 PM documented the resident was very restless and self-ambulating without assistance several times throughout shift. The resident's gait was very unsteady. The behavior monitoring note dated 7/12/2024 at 10:54 PM documented the resident was restless, paced episodically and continuously, wandered into inappropriate places, had disorganized thinking, frustration and confusion. Interventions documented included: repositioned/seating changed, walking, offering of food and drink, toileting, different staff assist, music, family during meal reassured reapproached. The note documented there was no change in the resident's behavior. The nursing progress note dated 7/13/2024 at 6:45 AM documented the resident was alert and responsive with language barrier. Resident continued with self-transfer and ambulation, out of bed three times. The resident was returned to room and put back to bed twice. Resident was noted self-ambulating down the west hall by a 6:00 AM to 2:00 PM Certified Nurse Aide. Morning care was provided and brought to nurses' station for increased supervision. The behavior monitoring note dated 7/13/2024 at 6:51 AM documented the resident was restless, paced episodically and continuously, wandered into inappropriate places, had disorganized thinking and confusion. Interventions included repositioned/seating changed, walking, offered food and drink, toileting, different staff assist, reassured reapproached. The note documented there was no change in the resident's behavior. The nursing progress notes dated 7/13/2024 at 3:31 PM documented resident alert, pleasant, speaking very little English, communicates with gestures. The resident is non-compliant with getting up from wheelchair and self-ambulating and self-toileting. Family member on site for a visit, resident with increased confusion and anxiety after family member left. The resident was taken to an activity with positive effect. There were no additional behavioral notes or progress notes that documented the resident's behavior after the activity ended, increased monitoring or other interventions prior to the elopement at 7:45 PM. Review of the Work History Report for the last 24 months documented all doors, locks, and alarms were tested and in working order on 7/12/2024 by the Former Director of Maintenance. The Investigation Summary Guide dated 7/13/2024 documented Resident #154 left Unit 3 nurses' station at 7:45 PM, walked through Unit 2 West Hall, and exited into the stairwell by pushing on the emergency exit door. They descended two flights of stairs and reached the southwest exit. Resident #154 managed to open the exit door, lost their footing as they stepped out of the building, fell , and struck their head. Resident #154 was observed on the ground by a visitor at 8:07 PM, who alerted Front Desk Clerk #1, who then alerted Registered Nurse Supervisor # 6. Resident #154 was brought back into the facility but was difficult to understand due to a language barrier. Once the resident was identified, due to being new to the facility, they were then evaluated by Registered Nurse Supervisor # 6. The resident was found to have a 2. 5 cm laceration to their right forehead with a hematoma, an abrasion to their midback and their right knee. Resident #154 was assisted back to Unit 3 and Resident #154's Health Care Proxy and the Physician were updated. Stop signs were placed at doorways and exits on the unit and a wander alert bracelet was placed on Resident # 154. There was no documented evidence the alarms were verified as functioning at the time of the elopement. The Front Desk Clerk #1's witness statement dated 7/13/2024 documented a visitor had reported to them a person was outside near the employee parking lot lying on the ground bleeding. They alerted Registered Nurse Supervisor #6 and together they went out to evaluate the situation. The person had a wristband from a nearby hospital and the hospital was called to determine if they had a missing resident; they did not. The local police were called to see if someone had been reported missing. The person was then transported into the facility and identified as Resident # 154. Review of nursing progress note dated 7/15/2024 at 11:54 AM Registered Nurse #7 documented a wander alert device was applied to Resident #154's right ankle. The Treatment Administration Record dated 7/1/2024 - 7/31/2024 documented a physician's orders [REDACTED]. | Plan of Correction: ApprovedFebruary 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice For Resident #154, the Elopement Risk Assessment was initiated on 7/12/24 and completed on 7/17/ 24. The care plan was revised on 7/15/2024 to reflect that the resident was at high risk for wandering and elopement related to impaired cognition and memory. Nursing interventions were outlined on the care plan. The resident was discharged from the facility on 7/24/24 to a lower level of care. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 7/6/24, 7/13/24, 7/20/24 and 7/27/24 and were documented as functioning. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The QA Committee met on 2/12/25, to complete an assessment of causative factors and to identify an appropriate plan to prevent recurrence. It was determined that all residents have the potential to be affected by the same deficient practice. The Nursing Unit Manger(s) will complete an elopement risk assessment on all residents to identify a baseline for every individual and will be completed by 2/21/ 25. Any resident who is identified at risk for elopement will have their care plan reviewed to ensure their risk is identified and that an adequate care plan has been developed to ensure the residents environment remains free from accident hazards, that adequate supervision and assistive devices to prevent accidents are in place at that time. Preventive Maintenance Checks were completed on all Doors, Locks and Alarms by the Maintenance Staff on 2/1/25 and 2/8/25 and were documented as functioning. All egress doors are equipped with functioning alarming devices that are easily audible by all staff in all areas of the unit, including when in a room with a closed door. The Unit Clerks will verify that all current residents have a facility issued wristband placed on their person and that hospital identification bands are removed by 2/21/ 25. The Administrator verified that an appropriate amount of well-fitting wander alert devices were available in the event any residents were to require this type of intervention on 2/12/ 25. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur To ensure that the residents environment remain free from accident hazards and that adequate supervision and assistive devices to prevent accidents are provided the following measures will be implemented: All licensed nurses will be re-educated on the facilitys policies titled Elopement Risk Assessment, Electronic Wandering Security System and Guidelines for Care Planning Wandering/Elopement High Risk Residents that outlines when elopement risk assessments are to be completed, when appropriate safety measures are to be implemented and documented on the care plan once risk level for unsafe wandering/elopement is identified. The facilitys policy titled Preventative Maintenance Program was reviewed and remains appropriate. Maintenance Staff will be re-educated on the policy and the required weekly functionality verification of egress door alarms and door security devices. The Front Desk Receptionists, Unit Clerks and Medical Records staff will be educated on the facilitys policy titled Resident Identification / Patient Identifiers and their responsibility of placing facility identification wrist bands upon admission to the facility to ensure residents are adequately identified in emergency situations. The facilitys assessment and minimum staffing plan will be reviewed and/or revised by the facility administrator to ensure adequate supervision and to prevent accidents. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Director of Nursing / designee will conduct an audit of all new admissions within 24 hours of admission x 2 weeks, then weekly x 2 weeks, then monthly for a period of 2 months, to ensure Elopement risk assessments are completed as required, that appropriate safety measures have been implemented, that care plans are updated to reflect high risk residents, and that wander guard ankle bracelets have been placed when deemed necessary for residents at high risk. The Administrator, in conjunction with Maintenance staff will conduct a monthly audit x 3 months ensuring that egress door alarms and door security devices have been checked weekly through the Preventive Maintenance Program and that are all functioning as intended. The Unit Clerks will conduct a weekly audit of all new admissions x 4 weeks, then monthly for a period of 3 months, to ensure facility identification bands are present and hospital identification bands removed for all new admissions/readmissions. The Director of Nursing will review daily staffing schedules weekly x 4 weeks, and then monthly for a period of 3 months, to ensure minimum staffing is in place to provide adequate supervision to prevent accidents Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on 3/7/ 25. |
Scope: Isolated
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 interview, observation, and record review conducted during a Complaint investigation (#NY 735) during a Standard survey completed on 1/21/2025, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #51) of two residents reviewed. Specifically, Resident #51 was not ambulated every day as recommended and planned. The finding is: The policy and procedure titled Ambulation Program dated 7/24/2018 documented that residents who need assistance with walking will be placed on a Unit Ambulation Program designed for improving, reinforcing, or maintaining the current status of a resident's ambulation. It also documented that the program is conducted by the unit nursing staff. Resident #51 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/23/2024 documented the resident was cognitively intact, understood and understands others, and required supervision for ambulating 10 feet. The comprehensive care plan dated 12/12/2024 documented Resident #51 was on a nursing rehab ambulation program, required stand by assist of one staff member for 10 to 15 feet with a rolling walker, wheelchair to follow once a day. Review of Resident #51's physical therapy (PT) evaluation and plan of treatment dated 11/8/2024 documented the reason for referral was the resident was an [AGE] year-old resident and was referred to skilled physical therapy for a decline in their transfers and ambulation. The evaluation documented that without skilled physical therapy program, Resident #51 was at risk of further decline with inability to regain independence. Review of Resident #51's physical therapy discharge summary dated 12/8/2024 documented that physical therapy instructed Resident #51 in a functional maintenance program, proper body mechanics, safety sequencing techniques and use of assistive devices to facilitate improved functional abilities, increase safety and decrease need for assistance, prevent decline from current level of skill performance, increase functional mobility skills and facilitate functional independence in the absence of secondary medical complications. Review of Resident #51's nursing rehab ambulation program stand by assist of one staff member for 10 to 15 feet with rolling walker with a wheelchair follow once a day documented from 12/13/2024 to 1/13/2025 documented that the resident was walked 10 to 75 feet on: 12/17/2024,12/18/2024,12/24/2024,12/25/2024,1/2/2025, and 1/3/ 2025. During an interview on 1/16/2025 at 3:37 PM, Resident #51 stated they don't get walked by staff on a regular basis. They stated they need to walk because it was use it or lose it and they do not want to lose the ability to walk. They stated that they try to walk to the bathroom by themselves, but they need help at times. Resident #51 stated it bothered them that they can't walk every day. Multiple observations during the survey period, Resident #51 was in bed and in their nightgown from 7:30 AM to 12:30 PM. During these observations, Resident #51 stated that they have not been ambulated by staff. During an interview on 1/17/2025 at 8:26 AM, Certified Nurse Aide #3 stated that if they have four aides working on the unit, they can walk the residents. They stated with two aides working on most days, it's not possible to walk the residents. They stated that Resident #51 wants to be independent, but the staff can't do their job to help Resident # 51. Certified Nurse Aide #3 stated Resident #51 could lose the ability to ambulate if they were not walked daily. During an interview on 1/17/2025 at 8:34 AM, Registered Nurse Unit Manager #1 stated that they expect their staff to walk residents if residents were care planned to be walked daily. They stated that Resident #51 could lose the use of their legs or the strength in their legs. Registered Nurse Unit Manager #1 stated that it could be that having only two aides working, the nursing ambulation program was not getting completed. During an interview on 1/17/2025 at 8:45 AM, the Director of Rehabilitation stated that residents who were not walked daily could lose strength or range of motion. They stated that they expect the Certified Nurse Aides to walk residents if the residents were care planned for restorative ambulation. During an interview on 1/21/2025 at 8:40 AM, the Director of Nursing stated they expected their staff to follow the care plan and, if the care plan stated the resident should be walked every day, then the resident should be walked every day. They stated they would expect all the staff to help with caring for the residents including nurses and nurse managers. 10 NYCRR 415. 12(e)(1) | Plan of Correction: ApprovedFebruary 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident #51 was reassessed by therapy to ensure there was no decline in residents ROM or abilities which revealed there were not changes in ADL abilities. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents who are care-planned for an ambulation program are at risk for the same deficient practice. All residents with an ambulation program will be reviewed to ensure ambulation programs are appropriate and being completed as planned. Any adjustments required to the plan will be made at that time. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur To ensure residents receive appropriate treatment to prevent decline, the facilitys Ambulation Program policy was reviewed, and no changes were identified to be needed. All nursing staff responsible for implementing and overseeing ambulation programs will be re-educated on the facilities policy. The therapy department will provide a weekly list to the nursing department indicating what residents care planned for an ambulation program. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Unit Mangers will conduct weekly audits x 1 month, then monthly audits for a period of 2 months, verifying that ambulation programs are being implemented. Audits will include documentation review, as well as resident interviews. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 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, interview and record during the Standard survey completed on 1/21/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for five (Unit 1, Unit 2, Unit 3, Unit 4, and Unit 5) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, were not palatable and not attractive. Residents #53, #68, #94, #97, and #131 were involved. The findings are: The policy and procedure titled Food Temperature Requirements and Holding Time last modified on 6/28/2019 documented the Director of Dining Services was responsible for assuring that the proper temperatures and holding times for foods were maintained during the preparation and service of meals. It further documented the steam table thermostat was to be set to maintain hot food between 140-160 degrees Fahrenheit and cold food items were to be held in an appropriate container or bin to maintain the temperature below 41 degrees Fahrenheit. The policy and procedure titled Meal Serving - Resident, last modified 9/24/18 documented that dietary, nursing, and other appropriately trained staff were responsible for assisting with passing trays, serving food, and pouring of hot beverages; ensuring that all items identified on the tray label were in place, and in reach of resident; obtaining substitutes for food items, upon request. It further documented nursing staff were responsible for delivering trays to residents, pouring beverages, and any other eating and feeding assistance as needed. Resident Council Meeting Minutes for 1/9/25 documented that residents were having difficulty changing the alternative items of choice on their meal trays. The meeting minutes also mentioned continued concerns with hot beverages served cold. During a Resident Council Meeting with survey staff on 1/14/25 at 10:35 AM, residents stated that most foods were served cold, and they would like to bring in a celebrity chef who fixes failing restaurants to improve the quality and presentation of their meals. Another complaint residents had was that they did not receive condiments with their food items, even after asking for condiments, and that the food just generally did not taste good. During a lunch meal tray line observation on 1/15/25, the temperatures of food items taken on the steam table in the main kitchen at 11:23 AM were taken by the Cook and Surveyor prior to the start of tray line and were as follows: Salisbury Steak measure 186 degrees Fahrenheit Ground Salisbury Steak measured 160 degrees Fahrenheit Pureed Salisbury Steak measured 194 degrees Fahrenheit Diced Potatoes measured 158 degrees Fahrenheit Peas measured 160 degrees Fahrenheit Mashed Potatoes measured 180 degrees Fahrenheit Carrots measured 194 degrees Fahrenheit Chicken Noodle Soup measured 180 degrees Fahrenheit Tray line commenced at 11:45 AM and drinks such as juice, soda, and nutritional supplements were stored in plastic containers of drained ice. Ice cream cups were stored in plastic containers of drained ice. Single serve milk cartons were stored in plastic milk crates with no form of ice or other refrigeration. Pudding cups, salads, and cottage cheese cups were stored in trays with no ice or any other form of refrigeration. Unit 1 cart left the kitchen at 12:00 PM Unit 2 cart 1 left the kitchen at 12:11 PM Unit 2 cart 2 (containing the test tray for Unit 2) left the kitchen at 12:15 PM Main Dining Room cart left the kitchen at 12:20 PM Unit 5 cart (containing ground food test tray) left the kitchen at 12:35 PM Unit 3 cart (containing pureed food test tray) left the kitchen at 12:47 PM Unit 4 cart left the kitchen at 1:00 PM During an observation of a lunch meal tray on 1/15/25 on Unit 1, the meal cart arrived on the unit at 12:00 PM, all trays were passed at 12:20 PM, and food temperatures on the test tray were taken at 12:25 PM by the surveyor, using a digital thermometer and were as follows: Salisbury Steak with gravy measured at 115. 6 degrees Fahrenheit; was dry and tasted bland; gravy lacked flavor. [MEDICATION NAME] Potatoes measured at 103. 3 degrees Fahrenheit; and the potatoes were shriveled and dry. Coffee measured at 115. 4 degrees Fahrenheit; lacked flavor and tasted like water, and there were no condiments on the tray for the coffee. During an observation of a lunch meal tray on 1/15/25 on Unit 2, the second cart with the test tray arrived on the unit at 12:23 PM, all trays were served at 12:35 PM, and the test tray temperatures were taken with a facility thermometer. Food was tested and tasted with Assistant Director of Dining Services #1 at 12:35 PM and were as follows: Potatoes measured at 121 degrees Fahrenheit and tasted cold. Peas measured at 128 degrees Fahrenheit; tasted bland and were lukewarm. Milk measured at 58. 8 degrees Fahrenheit; tasted warm. During an interview at the time of the test tray, Assistant Director of Dining Services #1 stated the potatoes tasted good but were too cold and that the milk should be colder. They stated there had been some complaints from residents about food being cold and the plate warmer used on the tray line may be the issue. During an observation of a ground meal lunch tray on 1/15/2025 at 12:37 PM on Unit 5, temperatures were measured with a digital thermometer in the presence of Registered Dietician #1 were as follows: Ground Salisbury steak with gravy measured at 114. 5 degrees Fahrenheit; tasted lukewarm and was bland. Diced carrots measured at 111. 3 degrees Fahrenheit; tasted lukewarm and bland. Mashed potatoes with gravy measured at 123. 3 degrees Fahrenheit; tasted warm but bland. Milk measured at 51 degrees Fahrenheit; tasted cool, but not cold. Coffee measured at 108. 5 degrees Fahrenheit; tasted lukewarm. During an interview on 1/15/2025 at 12:37 PM, Registered Dietician #1 stated that the optimal food temperatures on a meal tray should be at least 140 degrees Fahrenheit. They stated that they were not sure how things were done on the tray line, but milk should be kept on ice prior to putting it on trays. They stated that the milk should be at 40 degrees Fahrenheit or below. During a lunch meal tray observation on 1/15/25 at 12:54 PM, the Unit 3 dietary cart arrived at 12:54 PM and meal trays were passed by 1:06 PM. A test tray was completed with Registered Dietitian #1 at 1:06 PM. The temperatures were taken by Registered Dietitian #1 using a digital thermometer. The results were as follows: Puree Salisbury Steak with gravy measured at 131 degrees Fahrenheit; lukewarm and lacked flavor. Mashed Potatoes with gravy measured at 129. 7 degrees Fahrenheit; were lukewarm. 2 % milk measured at 58. 6 degrees Fahrenheit; tasted warm. Coffee measured at 98 degrees Fahrenheit; tasted very bitter and was cold. During an interview on 1/15/25 at the time of test tray Registered Dietitian #1 stated that safe food temperatures should be that cold foods were served below 40 degrees Fahrenheit, and that hot food were to be served at 140-160 degrees Fahrenheit. The Registered Dietician #1 stated, after tasting the food for palatability, that the Salisbury steak could have been hotter. They stated the milk tasted very warm and that the coffee was too cold. During a lunch meal tray observation on 1/15/25 with Licensed Practical Nurse #5 using a facility thermometer on Unit 4, the cart arrived on the unit at 1:02 PM after the last tray passed, the test tray was completed at 1:26 PM and measured as follows: Salisbury Steak measured at 116 degrees Fahrenheit; tasted cold and was dry in the center. Potatoes measured at 101. 1 degrees Fahrenheit; tasted cold and bland, and looked dry and shriveled. Peas measured at 96. 7 degrees Fahrenheit; tasted cold and mushy. Milk measured at 58. 5 degrees Fahrenheit; tasted warm. Coffee measured at 96. 7 degrees Fahrenheit; tasted bitter and cold. During an interview at the time of the test tray, Licensed Practical Nurse #5 stated that if trays sat this long on the cart, they would be cold and they would not want to eat this food. Licensed Practical Nurse #5 tasted all items and stated they agree | Plan of Correction: ApprovedFebruary 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Resident #53, # 68, #94, #97, #131 were the impacted residents ÔÇ£ two residents discharged (#131 & #53). The remaining 3 residents will have the director of dining services interview each of them related to the deficient practice. The director will continue to work with each of these residents to maintain their satisfaction. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be impacted by the same deficient practice. The director/designee will work with all residents. The director of social work/designee will interview all residents to determine satisfaction with their meals. The results of these interviews will be tracked and issues alerted to the dining services director/designee. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The Director of Dining will provide in-service training to all dietary staff, no later than 2/28/25, to include appropriate food temperature requirements and holding time, the palatability of food, and appetizing meals. The director of dining services/designee will in-service the cooks on following the recipe, to ensure foods are prepared according to the appropriate method, ensuring taste and nutritional value. The director of dining services will educate the dietary staff on methods to keep cold food appropriately below 41 degrees, through the use of refrigeration/freezers/or ice. In order to maintain proper hot food temperatures (between 140 and 160), the team will use the newly purchased ?ôhot plate warmer?Ø and maintain food temperatures of hot items in the oven or steam-well. The use of the plate warmer will help to maintain proper hot food temperatures. The dietary staff will be pouring hot beverages just prior to meal service at each meal to ensure proper coffee/tea temperatures. The internal temperature of the coffee machine will be increased to improve temperatures at the time of service. The director of dining services/designee will monitor temperatures when food is ready to serve and at the end of service for resident meals. This will include hot and cold temperature checks to ensure both safe and palatable temperatures are maintained. Appropriate action will be taken if the food is not to proper temperatures ÔÇ£ warmed up for cold food and refrigerated/chilled for items that are not cold enough. All cooks will record food temperatures to discover any variations to the required temperatures. Any issues discovered will reported to the director of dining services/designee and issues will be corrected immediately to obtain proper temperatures. The director of dining services/designee will attend resident council, upon resident request to address any food concerns. Grievances related to food concerns will be reviewed daily in morning report and actions to address any concerns will be implemented. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Test trays will be conducted at each meal for one week, daily for 3 weeks, and then weekly for 2 additional months to observe palatability, temperature, and appearance. These observations will be provided to the Director of dining services/designee. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025 |
Scope: Isolated
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, interview, and record review conducted during a Complaint investigation (#NY 228) completed during the Standard survey on 1/21/25, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Resident #46 and #81) of eight residents reviewed for dignity. Residents #46 and #81 were treated in an undignified manner. Specifically, Certified Nurse Aide #10 pushed Resident #81 while they were in their wheelchair on the back two wheels lifting the front two wheels and pedals off the floor (in a wheelie type of motion). Certified Nurse Aide #10 also made a fist and a boxing jab motion toward Resident #46 and wheeled them into the corner facing the wall in a common area. The findings are: The policy and procedure titled Dignity, date modified 8/19, documented each resident had the right to be treated with dignity and respect. All activities and interactions with residents by any staff must focus on assisting the resident in maintaining and enhancing self-esteem and self-worth and incorporate the resident's goals, preferences, and choices. The policy documented when providing care and services, staff must respect each resident's individuality, as well as honor and value their input. 1. Resident #46 had [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/6/24 documented Resident #46 was usually understood, usually understands, and had severe cognitive impairment. The assessment documented Resident #46 was dependent on staff for wheelchair mobility. The comprehensive care plan revised 8/13/24, documented Resident #46 had a deficit in activities of daily living function and mobility. Interventions included that Resident #46 was a total assist of one staff member for wheelchair mobility. The comprehensive care plan documented Resident #46 had the potential for alteration in mood/behavior related to dementia. Interventions included to approach resident from the front in a calm gentle manner, explain all expects of care and provide support and reassurance. 2. Resident #81 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #81 was sometimes understood, sometimes understands, and had severe cognitive impairment. The assessment tool documented that Resident #81 was a moderate assist for wheelchair mobility. Review of the comprehensive care plan revised 10/9/24, documented that Resident #81 had a deficit in activities of daily living function and mobility. Interventions included that Resident #81 was a moderate assist of one staff member for wheelchair mobility. The comprehensive care plan documented Resident #81 was moderately impaired with decisions making related to dementia. The comprehensive care plan documented Resident #81 had the potential for alteration in mood/behavior related to dementia. Interventions included to provide support and reassurance. The Administrative Services Investigation Summary Guide dated 10/23/24 signed by the Assistant Director of Nursing and the Administrator documented that on 10/21/24 during the 2:00 PM and 10:00 PM shift, video camera footage revealed that Certified Nurse Aide #10 pushed Resident #81 in their wheelchair with the front wheels off the ground doing a wheelie. It was also documented that Certified Nurse Aide #10 was observed to make a fist punching motion toward Resident # 46. It was documented that the Assistant Administrator then started an investigation that included staff and resident interviews. The Incident Investigation Accused Party's Statement obtained by the Human Resource Manager and Former Director of Nursing on 10/23/24 at 10:31 AM documented that Certified Nurse Aide #10 stated that they wheeled Resident #81 with the wheels in the air because Resident #81 had these things on the bottom and it be hard to push the wheelchair (referring to the mounted anti-tippers). It was documented that Certified Nursing Aide #10 stated that they did not push anyone into a corner and that they did not know if Resident #46 was competent enough to know that throwing a fist movement was playing around and they stopped themselves because they did not know that Resident #46 would flinch. The statement documented that Certified Nurse Aide #10 stated it was in the moment; I play around too much. Resident #46 was talking junk. In the moment I put my fist up, like parents do with their kids when they are playing around. On 1/15/25 at 1:35 PM the video footage was reviewed with the Human Resource Manager present. Video footage observed was of the Unit three common area/nursing station area for 10/21/24 between 7:20 PM - 7:38 PM. The following was observed: -7:20 PM Resident #46 was sitting in a wheelchair in the hallway near the nursing station. -7:29 PM Certified Nurse Aide #11 was standing to Resident #46's right side behind their wheelchair. Certified Nurse Aide #10 ambulated an unidentified resident out of the dining room across the common area. Certified Nurse Aide #10 stopped in front of Resident #46, raised a fist as if they were doing a boxing jab and directed it toward Resident # 46. Resident #46 raised their right arm and swatted Certified Nurse Aide # 10. Certified Nurse Aide #10 then walked out of camera view. -7:32 PM Certified Nurse Aide #11 touched Resident #46 hand, appeared as if something was said to Resident #46, then walked out of camera view. Activities Leader #1 enters camera view, approaches Resident #46 and appeared to have a conversation with the Resident # 46. Resident #46 was not combative, agitated and did not appear to be frightened. -7:36 PM Resident #46 self-propelled their wheelchair toward the left hallway and out of camera view. Certified Nurse Aide #10 can be seen wheeling Resident #81 in their wheelchair from the dining room, across the common area, to the left hallway. Certified Nurse Aide #10 tipped Resident #81's wheelchair backwards lifting the front two wheels off the floor as they pushed the wheelchair on the back wheels only in a wheelie. The resident's feet were suspended in air as they were being propelled. -7:37 PM Certified Nurse Aide #10 with slight force pushed Resident #46 in their wheelchair to the common area; let go of the wheelchair handles while the chair was still in motion in the direction of the corner. Certified Nurse Aide #10 then walked out of camera view. -7:38 PM Resident #46 self-propelled themselves out of the corner. During an interview at 1:49 PM (after the video footage was reviewed), the Human Resource Manager stated they would describe Certified Nurse Aide #10's actions as a dignity concern because they cannot treat residents in that manner. The Human Resource Manager stated that Certified Nurse Aide #10 had stated they were just playing around. The Human Resource Manager stated no one should ever raise a hand to a resident regardless of them playing or not. Residents with cognitive deficits were not capable of interpreting playing around. They also stated residents were not children and the should not be treated like children. During a telephone interview on 1/16/25 at 12:56 PM, Certified Nurse Aide #11 stated on 1/15/25 at the time of the incident they were standing with by Resident #46 at the nursing station; Resident #46 was in their wheelchair. Certified Nurse Aide #10 walked by and started to have a joking/sarcastic conversation with Resident # 46. Certified Nurse Aide #10 put their fist in the air and made a boxing jab motion directed toward Resident # 46. They stated that even though the situation occurred in a joking manner it still was inappropriate because the unit was a memory care unit and they residents may not understand it was meant in a joking manner. They stated it was the resident's home and staff shoul | Plan of Correction: ApprovedFebruary 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice Residents #46 and #81 were both interviewed by the Director of Social Services to ensure they are being treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality at the time of the incident. Both residents appeared to have no negative impacts from the facility self-reported occurrences, which include no behaviors that would have implied they had concerns with abuse or dignity. #46 has been discharged . #81 does have cognitive impairment, and their legal representative was notified and interviewed, and no concerns were reported. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be affected by the same deficient practice. The Director of Social Work/designee(s) will interview all residents and/or responsible representatives (if the resident is unable to participate) to ensure they are treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality. Any reports of not being treated with respect and dignity will be investigated and reported as required. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The nurse educator will re-educate all staff on the facilities Resident Rights and Dignity policy to ensure each resident is treated with respect and dignity and receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Monthly at the resident council meeting, the topic of dignity will be reported on, to maintain resident expectations for the treatment received from staff, while a resident within the facility. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Director of Social Work / designee will conduct 15 quality of life/dignity interviews with the residents or resident representatives (3 residents per unit) for a period of 3 months. Any reports of not being treated with respect and dignity will be investigated and reported as required. Results of the interviews will be submitted to the QA committee for review. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025. |
Scope: N/A
Severity: N/A
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey completed on 1/21/25, the Termination Form 105 was not submitted to the New York State Department of Health Criminal History Record Check program within thirty days of an employee being reassigned from the direct care or supervision of residents or terminated from employment. This affected three (Housekeeping Aide #1, Housekeeping Aide #2, and Certified Nurse Assistant #8) of twelve personnel files reviewed for compliance with CHRC regulations. The findings are: The policy and procedure titled Criminal History Record Check last modified 4/18/24, documented that the Human Resources Professional was to complete the Subject Individual Termination Form for Criminal History Record Check Form 105 via Health Commerce System website within 30 days that a staff member was terminated. According to New York State Part 402: Criminal History Record Check, effective 12/2/09, a provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when any prospective employee who is subject to a criminal history record check in accordance with this Part withdraws an application for employment or is no longer being considered as a prospective employee as defined in this Part; or any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provider. Review of the personnel records for Housekeeping Aide #1 revealed Housekeeping Aide #1's Criminal History Record Check result letter was a Pending Denial to provider letter dated 3/7/23, their last day worked in the facility was 3/8/23, and the Criminal History Record Check Termination Form 105 was dated 5/18/ 23. Review of the personnel records for Housekeeping Aide #2 revealed Housekeeping Aide #2's Criminal History Record Check result letter was a Pending Denial to provider letter dated 3/14/23, their last day worked in the facility was 3/17/23, and the Criminal History Record Check Termination Form 105 was dated 5/18/ 23. Review of the personnel records for Certified Nurse Aide #8 revealed Certified Nurse Aide #8 did not work in the facility, their Criminal History Record Check result letter was a Hold in Abeyance letter dated 6/24/24, and the Criminal History Record Check Termination Form 105 was dated 8/15/ 24. During an interview on 1/16/25 at 3:10 PM, Human Resources Manager #1 stated they had been in their position since 5/15/23 and immediately conducted a personnel file review. They did not know why Housekeeping Aide #1 and Housekeeping Aide #2's Criminal History Record Check Termination Form 105 was not submitted until they completed the file review. They stated that Certified Nurse Aide #8 did not work in the facility and their Criminal History Record Check Termination Form 105 should have been submitted by 7/24/ 24. 402. 9(b)(1)(2) | Plan of Correction: ApprovedFebruary 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice The deficient practice has been corrected as required by regulation. The CHRC active roster review shows compliance at this time. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be affected by the deficient practice. The CHRC active roster review shows compliance at this time and no recent issues have been identified. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The Human resource manager will in-service the recruitment coordinator on the CHRC policy, and the procedure/timing related to removal of terminated employees from the CHRC list. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice An audit of the CHRC active roster will be conducted every 28 days, over the course of the next six months to ensure that only current employees are active. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 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 interview, observation, and record review conducted during complaint investigations (#NY 668, #NY 735, #NY 153, #NY 833, #NY 434) conducted during a Standard survey completed on [DATE], the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not having sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs. Reference: F 688 Increase/Prevent Decrease in range of motion/mobility F 689 Free of Accident Hazards/Supervision/Devices The finding is but not limited to the following: Review of the policy titled Master Staffing Plan dated [DATE] documented the number of staff members, work status, required qualifications of staff members, and overall organization of the department will be determined by the Regional Director of Operations, Chief Operating Officer, Chief Nursing Officer, and Governing Body, in cooperation with the Administrator and Department Manager. The Dear Administrator letter ,[DATE] dated [DATE] sent to nursing home administrators documented starting [DATE] nursing homes were required to to maintain at minimum daily average staffing hours equal to 3. 5 hours of care per resident per day (HPRD) by a certified nurse aid (CNA) and a licensed practical nurse (LPN) or registered nurse (RN). Out of such 3. 5 hours, no less than 2. 2 HPRD shall be provide by a CNA, and no less than 1. 1 HPRD shall be provided by a Licensed Practical Nurses or Registered Nurses. Review of the Federal Register dated [DATE] for the Centers for Medicare & Medicaid Services Medicare & Medicaid programs Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting documented that starting [DATE] long term care facilities are to have 3. 48 hours of care per resident day with 0. 55 hours of a Registered Nurse and 2. 45 hours of a Nurse Aide. The Executive Order 4. 22 from the New York State Governor's office documented that the emergency staffing waivers expired on ,[DATE]/ 2023. The Facility assessment dated [DATE] documented the minimum staffing levels for the day shift for the facility on the weekdays were seven nurses and nine aides; the evening shift six nurses and nine aides; and the night shift five nurses and five aides. It also documented the minimum staffing levels for the weekend on the day shift are seven nurses and nine aides; evening shift six nurses and nine aides; and the night shift five nurses and five aides. Review of the Payroll Based Journal Staffing Data Report Fiscal Year Quarter 4 ([DATE] - (MONTH) 30) 2024 documented that submitted weekend staffing was excessively low for that quarter. A review of ACTS Complaint/Incident Investigation Report #NY 735 dated [DATE] documented staff were not answering call lights. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from [DATE] to [DATE] documented that the average daily resident census was 138 per day and that the hours of care per resident per day was 1. 14 hours. A review of ACTS Complaint/Incident Investigation Reports #NY 153 dated [DATE] and NY 833 dated [DATE] documented the facility was short staffed on all shifts. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from [DATE] to [DATE] documented the average daily resident census was 139 residents per day and that the hours of care per resident per day was 1. 01 hours. A review of the ACTS Complaint/Incident Investigation Report #NY 434 dated [DATE] documented that there was only one nurse on the floor, food trays are not being passed, and residents aren't getting out of bed. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from [DATE] to [DATE] documented that the average daily resident census was 139 and the hours of care per resident per day was 0. 97 hours. A review of the ACTS Complaint/Incident Investigation Report #NY 668 dated [DATE] documented that there was a lack of staffing on the unit and that a resident was not turned or re-positioned in bed for 16 hours. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from [DATE] to [DATE] documented that the average daily resident census was 145 and the hours of care per resident per day was 0. 97 hours. A review of staffing levels from [DATE] to [DATE] documented the facility did not meet minimum staffing levels for the night shift of one nurse per unit on the following dates: [DATE] - four nurses for five units and a resident census of 155 [DATE] - four nurses for five units and a resident census of 157 [DATE] - four nurses for five units and a resident census of 156 [DATE] - four nurses for five units and a resident census of 152 [DATE] - three nurses for five units and a resident census of 152 [DATE] - four nurses for five units and a resident census of 155 A review of acuity levels and average daily census of the facility documented the following from [DATE] to [DATE]: Unit 1 - average daily census 19 residents; acuity rehabilitation unit from subacute unit, colostomies, urostomies, seven residents waiting for long term care beds. Vent Unit - average daily census 17 residents; acuity level 24-hour respiratory therapy services, tube feedings. Unit 2 - average daily census 25 residents; acuity level sub-acute and new admits with short term stays; most have physical or occupational therapy; basic medication passes. Unit 3 - average daily census 30 residents; memory care unit; indwelling catheters (tubing placed inside a resident's bladder to drain urine); some behaviors; very few treatments. Unit 4 - average daily census 40 residents; mostly alert and oriented residents; very few treatments; basic medication passes; there are supposed to be two nurses on this unit. Unit 5 - average daily census 30 residents; long term care unit; three [MEDICAL CONDITION] & [MEDICAL CONDITION] (a machine that treats obstructive sleep apnea by keep the airway open); few treatments. A review of the Resident Council minutes from (MONTH) 2024 to (MONTH) 2025, it documented the following: [DATE] - corporate was looking into hiring agency again to assist with staffing needs and staff are taking breaks at the same time leaving no staff to care for the residents. [DATE] - nurses helping aides caused medications to be delayed. [DATE] - staff ignoring call lights; residents' laundry thrown on the floor and not in laundry basket after care from aides; and call lights being on for two hours. An observation on [DATE] between 11:40 AM to 12:37 PM for call light outside of Resident room [ROOM NUMBER] observed: [DATE] 11:40 AM - call light on. [DATE] 11:59 AM -call light remained on above the doorways above door. No staff in the northeast hall. [DATE] 12:04 PM -call light remained on [DATE] 12:11 PM -Unit Clerk went into janitor closet by room [ROOM NUMBER], left area and did not ask resident in #309 if they needed anything. [DATE] 12:17 PM- call light remained unanswered and still on [DATE] 12:24 PM- Registered Nurse Unit Manager #1 walked down hall, call light remained on and unanswered [DATE] 12:28 PM- Registered Nurse Unit Manager #1 retrieved supplies out of the clean utility room then went back down the hall past room [ROOM NUMBER] call light remained on and unanswered. [DATE] 12:36 PM call light remained on and unanswered [DATE] 12:37 PM Certified Nurse Aide #2 went into room [ROOM NUMBER] after family member went to the nurses' station and asked for help repositioning resident. During an interview on [DATE] at 12:37 PM with Certified Nurse Aide #2 stated that there were only three aides working and they are doing the best they can when answering call lights. Unit 5- observation of a lunch tray pass on [DATE] between 1:08 PM to 1:24 PM observed the following: -[DATE] 1:08 PM trays arrive to unit. There was one Certified Nurse Aide passing out trays. Registered Nurse Unit Manager was i | Plan of Correction: ApprovedFebruary 20, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice The following corrective actions for those residents who were found to have been affected by the deficient practice: Five complaint investigations were conducted (#NY 668, #NY 735, #NY 153, #NY 833, and #NY 434) during annual survey which ended on 1/21/ 25. It was determined that the facility allegedly did not ensure that there was sufficient staffing on multiple dates throughout the [AGE] year, based on the previously referenced complaints and staff/resident interviews conducted during the annual survey. No residents were affected by this deficient practice. The Social Service Director/designee will review with all residents who are alert and oriented in person and/or will contact the responsible parties of those residents with cognitive impairment, to discuss the facilities active plan to recruit and retain staff. The recruitment and retention plan will be reviewed at the next resident council meeting. The Administrator/designee will also discuss the ?ôAmbassador program?Ø that was created to foster relationships between management team members and new staff. The facility also has a ?ôManager on Duty?Ø program to assist on weekends with staffing challenges, this includes the majority of management in the facility. Nursing leadership coverage rotates on a weekly basis, with all members of the nursing leadership team assisting with off-hour and weekend assistance. The Daily Nursing report (BIPA) is reviewed daily to ensure the number of nursing hours worked and the number of nursing staff working each shift based on census met the minimum staffing requirements. The facility will work with the Corporate Recruitment manager to discuss alternative recruitment initiatives. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The Director of Nursing/Assistant Director of Nursing ensure the health and wellbeing of the residents by having responsibility for oversight and operations of the nursing department. The DON and ADON, along with the Unit Nursing Managers, have been present on many shifts over the course of the last year. These include occasions when there were call-offs, weather related issues, and other staffing challenges to help ensure adequate clinical specialists were on-site to provide care to the residents. The facility assessment and minimum staffing plan was reviewed and revised on 2/12/25 to include the use of a supplemental staffing agency. The Emergency Preparedness plan was reviewed on 2/12/25 to address staffing, which includes the use of a supplemental staffing agency. The facility labor disruption policy was reviewed on 2/12/25 to ensure interventions to address insufficient staffing are identified and staff will be re-educated on the process of when to activate the emergency staffing plan. When resident census changes, when staff call off or additional staff are called in to assist with staffing, the number of nursing hours worked, the number of nursing staff working each shift, and census will be updated on the Daily Nursing Report Sheets (BIPA). The Daily Nursing Report sheets along with the Facility Assessment minimum staffing ratios identified in the Facility Assessment will be compared to the daily clinical staffing sheets to ensure clinical daily schedules adequately reflect that staffing minimum hours are being achieved every shift according to the facility assessment. The Administrator, the DON, and the Staffing Coordinator will continue to review staffing daily and implement procedures to ensure sufficient staff are available to meet residents needs. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur To ensure that this deficient practice does not re-occur, the Administrator/Director of Nursing will provide educational training consisting of but limited to: 1. Facility policy and procedures on Facility Wide Assessment Tool consisting of the facilities clinical minimum staffing requirements. 2. Facility policy and procedures on Labor Disruption Policy and when to activate plan 3. Facility policy and procedures on Emergency Staffing Plan and when to activate the plan. 4. Facility policy and procedures on completing and reviewing the Daily Nursing Report Sheet. 5. Nursing Managers and Nursing Supervisors will be re-educated on procedures when to notify the Administrator, Director of Nursing and the Assistant Director of Nursing when there are vacancies and nursing call-offs that impact the facility not meeting minimum clinical staffing requirements as identified on the Facility Assessment. 6. All in-services will be completed by 3/12/ 2025. Nursing Unit Managers, Nursing Supervisors and all other nursing exempt staff will be educated by the Administrator/Director of Nursing on the facility's minimum staffing numbers identified in the facility assessment and what to do if the numbers drop below the minimum requirements. This will include what to do, who to call regarding calls offs/no call no shows, and what other nursing personnel to contact to try and fill the vacancy issues when dropping below minimum staffing requirements. A new on-call schedule was developed to provide to backfill vacancies that are unable to be filled. The on-call schedule does not include the DON as the facility census is above 60. Discussions regarding recruitment and retentions initiatives will be added to the monthly resident council meeting agenda for three months. Grievances will be reviewed daily for staffing concerns during morning report. The Clinical Staffing Coordinator will audit the daily staffing sheets, the daily nursing report sheets (BIPA), the facility assessment minimum staffing ratios and the daily census daily for three months to ensure minimum staffing compliance. The Administrator in conjunction with the Director of Nursing will continue to review the facilities schedules weekly for three months to ensure sufficient staff have been scheduled to attain and maintain the highest practicable physical, mental, and psychosocial well-being of residents. With support from the Corporate Recruitment Team and Chief Operating Officer involvement, continued Recruitment meetings will take place weekly to monitor recruitment initiatives. The facility will continue to provide daily staffing needs updates to the Staffing Agency vendor to try and fill daily open shifts. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Onsite Post-Survey Revisit completed on 3/24/25, corridor doors were not maintained. Specifically, corridor doors did not latch into their door frames and all staff were not educated about corridor doors. This affected all staff and one (basement) of four resident use floors. This is a continuing deficiency from the Life Safety Code survey with an exit date of 1/21/ 25. The findings are: 1. Observation in the basement on 3/21/25 at 10:10 AM revealed the corridor door to the Ladies Locker Room did not latch into its door frame. During an interview on 3/21/25 at 11:15 PM, Maintenance Assistant #1 stated they were aware that the Ladies Locker Room door needed repair, but they had not gotten to it yet. 2. Review of the undated In-Service Program Record titled Corridor Doors - Function - K363 revealed it was signed by the Maintenance Director. Review of the undated In-Service Program Record titled Doors Latched and Closed revealed it was signed by Maintenance Assistant #1 and Maintenance Assistant # 2. During interviews on 3/21/25 from 2:15 PM until 2:47 PM, staff members stated the following: -Licensed Practical Nurse #8 stated they had received no education on doors since the Life Safety Code survey in January, except regarding new alarms on stairway doors. -Licensed Practical Nurse #3 stated they received education about interior and exterior doors recently, specifically not to block doors during a fire drill. -Certified Nurse Aide #17 stated they did not recall any recent education about doors. -Registered Nurse MDS Coordinator #1 stated the topic of not blocking doors was discussed at a Morning Report meeting recently. -Registered Nurse Unit Manager #5 stated they recently received education about the new alarms on stairway doors and a reminder not to prop open the Medication Room door. -Licensed Practical Nurse #4 stated they recently received education to not prop doors open. -Registered Dietician #1 stated there was recent education about new alarms on stairway doors, but they could not recall discussion of interior doors. -Registered Dietician #2 stated they could not recall recent education related to interior doors. Review of the facility's Plan of Correction, with a completion date of 3/7/25, revealed it stated, Corrective action for the deficient corridor doors at the Unit 2 treatment room, unit 2 janitor's closet, unit 1 respiratory therapy office, the ladies locker room, and resident room 222 is completed or in progress by outside contractor. Education will be provided to all staff related to corridor door operation and to the maintenance team on proper operation of corridor doors. Additionally, the Plan of Correction indicated the person responsible for the implementation of the Plan of Correction was the Maintenance Director. During an interview on 3/21/25 at 10:40 AM, the Administrator stated the Maintenance Director was on leave and had not worked since 3/6/ 25. On 3/21/25 at 3:30 PM, the Administrator stated all staff were not educated about corridor doors, only maintenance staff. Additionally, on 3/21/25 at 3:47 PM, the Administrator stated in the absence of a Maintenance Director, they would personally be responsible for the implementation of the Plan of Correction. During an interview on 3/24/25 at 11:25 AM, the Administrator stated they were not aware that some doors that were cited during the recent Life Safety Code survey had not been repaired. They stated they thought the outside contractor was going to return to complete the repairs before the completion date of the Plan of Correction. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 6. 3, 19. 3. 6. 3. 1, 19. 3. 6. 3. 5, 19. 3. 6. 3. 10 | Plan of Correction: ApprovedApril 7, 2025 Corrective action for the deficient corridor door: the ladies locker room door was repaired. The door now functions properly, in the absence of the Maintenance Director, the Asst Administrator and Administrator checked and confirmed this door operated properly. Education was provided to all staff related to corridor door operation and to the maintenance team on proper operation of corridor doors. An ongoing monthly audit will be conducted for all corridor doors to ensure that the doors latch into their door frames for the next 3 months. The results of this audit will be logged monthly into the P(NAME) binder. The results of this audit will be reported monthly at the QA meeting. Responsible Designee - Assistant Administrator. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Onsite Post-Survey Revisit completed on 3/24/25, hazardous areas were not protected. Specifically, hazardous area doors did not self-close and latch into their door frames and all staff were not educated about hazardous area doors. This affected all staff and two (first and third floors) of four resident use floors. This is a continuing deficiency from the Life Safety Code survey with an exit date of 1/21/ 25. The findings are: 1a. Observation on the first floor on 3/21/25 at 9:00 AM revealed the door to the Soiled Utility Room in the center of Unit 1 did not self-close and latch into its door frame. 1b. Observation on the third floor on 3/21/25 at 9:20 AM revealed the door to the Precautions Bins Storage Room in Unit 5 did not self-close and latch into its door frame. Further observation revealed the room was greater than 50 square feet and contained more than 30 precautions bins and more than ten 32-gallon empty garbage cans. The latch was stuck inside the door. 2. Review of the undated In-Service Program Record titled Hazardous Areas - K321 - Interior Doors Close revealed it was signed by the Maintenance Director. Review of the undated In-Service Program Record titled Doors Latched and Closed revealed it was signed by Maintenance Assistant #1 and Maintenance Assistant # 2. During interviews on 3/21/25 from 2:15 PM until 2:47 PM, staff members stated the following: -Licensed Practical Nurse #8 stated they had received no education on doors since the Life Safety Code survey in January, except regarding new alarms on stairway doors. -Licensed Practical Nurse #3 stated they received education about interior and exterior doors recently, specifically not to block doors during a fire drill. -Certified Nurse Aide #17 stated they did not recall any recent education about doors. -Registered Nurse MDS Coordinator #1 stated the topic of not blocking doors was discussed at a Morning Report meeting recently. -Registered Nurse Unit Manager #5 stated they recently received education about the new alarms on stairway doors and a reminder not to prop open the Medication Room door. -Licensed Practical Nurse #4 stated they recently received education to not prop doors open. -Registered Dietician #1 stated there was recent education about new alarms on stairway doors, but they could not recall discussion of interior doors. -Registered Dietician #2 stated they could not recall recent education related to interior doors. Review of the facility's Plan of Correction, with a completion date of 3/7/25, revealed it stated, Corrective action for the deficient doors located on Unit 5 precaution bin storage, Unit 2 oxygen storage area, unit 3 oxygen storage area, unit 1 oxygen storage area, Unit 1 soiled utility room, laundry room rear door, central supply door, and the maintenance shop area are corrected or in progress completion by outside contractor. Education will be provided to all staff related to proper door closure and to the maintenance team on proper technique for checking all interior doors. Additionally, the Plan of Correction indicated the person responsible for the implementation of the Plan of Correction was the Maintenance Director. During an interview on 3/21/25 at 10:40 AM, the Administrator stated the Maintenance Director was on leave and had not worked since 3/6/ 25. On 3/21/25 at 3:30 PM, the Administrator stated all staff were not educated about hazardous area doors, only maintenance staff. Additionally, on 3/21/25 at 3:47 PM, the Administrator stated in the absence of a Maintenance Director, they would personally be responsible for the implementation of the Plan of Correction. During an interview on 3/24/25 at 11:25 AM, the Administrator stated they were not aware that some doors that were cited during the recent Life Safety Code survey had not been repaired. They stated they thought the outside contractor was going to return to complete the repairs before the completion date of the Plan of Correction. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2, 19. 3. 2. 1, 19. 3. 2. 1. 2, 19. 3. 2. 1. 3, 8. 4, 8. 4. 1, 8. 4. 3, 8. 4. 3. 5, 19. 2. 2. 2. 7 | Plan of Correction: ApprovedApril 7, 2025 Corrective action for the two deficient doors: Repaired the doors located at the Soiled Utility Room on Unit 1 and the Precaution Bin Storage Room on Unit 5. The doors now function properly, in the absence of the Maintenance Director, the Asst Administrator and Administrator both checked these doors. Education was provided to all staff related to proper door closure and to the maintenance team on proper technique for checking all interior doors. An ongoing monthly audit will continue for all facility interior doors to verify they self-close and latch properly for the next 3 months. The checks will continue to be logged in a binder for completion. This will be monitored monthly for an additional 3 months in QA. Responsible designee - Assistant Administrator. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Onsite Post-Survey Revisit completed on 3/24/25, a portable electric space heater was plugged-in and ready for use in the facility and there was no documentation that ensured its heating element would not exceed 212 degrees Fahrenheit. This affected one (basement) of four resident use floors. This is a continuing deficiency from the Life Safety Code survey with an exit date of 1/21/ 25. The findings are: 1. Observation in the basement on 3/21/25 at 10:15 AM revealed a portable electric space heater was plugged-in and ready for use inside the Environmental Services Office. Continued observation revealed the space heater was plugged into a power strip. Additionally, the sticker on the side of the portable space heater stated, Keep furnishings and drapery at least three feet away. The unit was six to twelve inches away from a garbage can, disposable sweeper pads, a box of cotton swabs, and reusable cloths. This office was shared by the Director of Environmental Services and the Housekeeping/ Laundry Supervisor, and no one was in the office at the time of the observation. Continued observation revealed a second portable space heater was on the floor about two feet away from the first heater, not plugged in. During an interview at the time of the observation, the Director of Facilities Maintenance/ Corporate stated portable space heaters were not allowed in the facility and at the time of the Life Safety Code survey in January, they personally removed the space heater from this office and delivered it to the Administrator. During an interview on 3/21/25 at 10:17 AM, the Director of Environmental Services stated the space heaters did not belong to them and the Housekeeping/ Laundry Supervisor had been out. The Director of Environmental Services also stated they did not receive formal education regarding space heaters since the Life Safety Code survey, but they recalled discussing space heaters at the time one was found in this office during the Life Safety Code survey in January. During an interview on 3/21/25 at 10:36 AM, the Administrator stated they personally disposed of the portable space heater found in the Environmental Services office during the Life Safety Code survey and were not aware that two new space heaters were brought into the same office. They stated space heaters should not be in the building, and audits should have been done. 2. Review of the undated In-Service Program Record titled Portable Space Heaters - K781 revealed it was signed by the Maintenance Director. Review of the undated In-Service Program Record titled Portable Space Heaters revealed it was signed by Maintenance Assistant #1 and Maintenance Assistant # 2. Review of the facility's Plan of Correction, with a completion date of 3/7/25, revealed it stated, Corrective action for this deficient practice was to remove the portable space heater from the Environmental Services office. An in-service on the prohibition of portable space heaters will be conducted to staff who have offices. Additionally, the Plan of Correction indicated the person responsible for the implementation of the Plan of Correction was the Maintenance Director. During interviews on 3/21/25 from 2:15 PM until 3:22 PM, staff members with offices stated the following: -Licensed Practical Nurse #3 stated they did not recall recent education about space heaters. -Registered Nurse MDS Coordinator #1 stated the topic of space heaters was discussed at a recent quality assurance committee meeting and all department heads attended the quality assurance committee meetings. -Registered Nurse Unit Manager #5 stated they had no recent education about space heaters. -Registered Dietician #2 stated the topic of space heaters was possibly discussed at a recent Morning Report meeting. -Respiratory Therapist #2 stated they could not recall recent education about space heaters. During an interview on 3/21/25 at 3:30 PM, the Administrator stated they did not believe formal education about space heaters was given to all staff who had offices, but space heaters were discussed at the quality assurance committee meeting on 2/27/ 25. They stated most employees with an office would have attended the meeting on that date. Upon review of the meeting's attendance log, the Administrator stated the Director of Environmental Services was out sick on 2/27/25 and the Housekeeping/ Laundry Supervisor attended the meeting in their place. Review of the audit document titled, K781 - Portable Space Heaters revealed weekly checks for space heaters were performed between the weeks of 2/15/25 and 3/22/ 25. The audit document did not indicate which areas were checked or which staff member performed the check. During an interview on 3/24/25 at 10:20 AM, Maintenance Assistant #2 stated the space heater audits were completed by themselves and Maintenance Assistant # 1. They stated when they performed a space heater audit, they checked every room on every floor, including resident rooms and offices. Maintenance Assistant #2 also stated they did not check the Environmental Services office if it was locked during their audits. During an interview on 3/21/25 at 10:40 AM, the Administrator stated the Maintenance Director was on leave and had not worked since 3/6/ 25. Additionally, on 3/21/25 at 3:47 PM, the Administrator stated in the absence of a Maintenance Director, they would personally be responsible for the implementation of the Plan of Correction. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7. 8, 19. 1. 1. 3, 19. 1. 1. 3. 1 | Plan of Correction: ApprovedApril 7, 2025 Corrective action for the deficient practice of portable space heater in the Environmental Services office: the heater was removed. A sign was posted in the Environmental Service office as a reminder that space heaters are prohibited. An ongoing full-house audit will continue to check for portable space heaters. An in-service on the prohibition of portable space heaters was conducted to all staff. Ongoing compliance will be monitored by the Director of Maintenance/ Asst Administrator/Administrator. Ongoing weekly audits will be completed for an additional month and then monthly for 3 months. Audits will be reviewed Monthly in QA for an additional 3 months. Responsible Designee - Assistant Administrator. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 24, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Onsite Post-Survey Revisit completed on 3/24/25, smoke barrier walls were not maintained. Specifically, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating and were not designed to resist the passage of smoke due to open and unsealed penetrations. This affected one (second floor) of four resident use floors. This is a continuing deficiency from the Life Safety Code survey with an exit date of 1/21/ 25. The findings are: 1. Observation above the ceiling tiles on the second floor on 3/21/25 at 9:35 AM revealed two open and unsealed three-quarters of an inch diameter penetrations through the smoke barrier wall in the MDS Office in Unit 2. Review of the facility's Plan of Correction, with a completion date of 3/7/25, revealed it stated, Corrective action for the deficient smoke barrier on unit 4 resident room 333, MDS office on unit 2, resident room 233, and in the wall between the atrium and unit 1 have been sealed. Additionally, the Plan of Correction indicated the person responsible for the implementation of the Plan of Correction was the Maintenance Director. Review of the audit document titled, K372 - Smoke Barrier Check - Weekly Check revealed weekly checks of smoke barrier walls were performed between the weeks ending in 2/15/25 and 3/22/ 25. The audit document did not indicate which areas were checked on each date. The audit document indicated Maintenance Assistant #2 performed the audit in the week ending 3/15/ 25. During an interview on 3/24/25 at 10:20 AM, Maintenance Assistant #2 stated they were unaware of the penetrations through the smoke barrier wall in the MDS Office in Unit 2 and did not personally perform any audits of smoke barrier walls. During an interview on 3/21/25 at 10:40 AM, the Administrator stated the Maintenance Director was on leave and had not worked since 3/6/ 25. Additionally, on 3/21/25 at 3:47 PM, the Administrator stated in the absence of a Maintenance Director, they would personally be responsible for the implementation of the Plan of Correction. During an interview on 3/24/25 at 11:25 AM, the Administrator stated they were told that the penetrations through smoke barrier walls that were identified during the Life Safety Code survey were sealed the same day they were identified. The Administrator also stated the Maintenance Director was in charge of the smoke barrier walls audit sheets, and Maintenance Assistant #2 had told them personally that they performed smoke barrier wall audits. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7. 3, 8. 5, 8. 5. 1, 8. 5. 2, 8. 5. 2. 1, 8. 5. 2. 2, 8. 5. 2. 3 | Plan of Correction: ApprovedApril 7, 2025 Corrective action for the deficient smoke barrier above the MDS office on unit 2 was to seal the opening. The penetration is now sealed, in the absence of the Maintenance director, this was checked by the Administrator and the areas remain sealed. Education will be provided to the maintenance staff on the proper procedure for checking for gaps in smoke barriers. An audit will be conducted to check all smoke barriers in the facility, the results of this audit will be logged in the P(NAME) binder. The results will be brought to the QA committee on a monthly basis. Ongoing Weekly audits of the smoke barriers for 1 month. Then monthly for 3 months. This will also be reviewed monthly for an additional 3 months in QA. Responsibility Designee -Assistant Administrator. |