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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 10/20/22-11/02/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 6 of 7 residents (Residents #99, 101, 160, 163, 221, and 294) reviewed. Specifically, -Resident #294 was not showered and was not assisted with shaving. -Resident #160 was observed in a soiled hospital gown and did not have access to their call bell. - Resident #101 was observed in the same hospital gown for 2 days, had greasy, uncombed hair and was not repositioned for meals. -Resident #99 did not receive assistance getting out of bed as requested when they planned to attend a meeting. -Resident #163 was not properly positioned for and assisted with meals. -Resident #221 was not assisted during mealtime. Findings include: The facility policy, Activities of Daily Living (ADL) Personal Hygiene revised 10/2021, documented nursing staff would meet the residents' individual needs per the plan of care and Kardex (care instructions) on a daily basis. Resident bath or shower would be scheduled per resident preference but at least weekly and a bed bath would be provided on non-shower days. Facial hair would be groomed as needed. Hair care should be provided to resident as needed or by appointment at the hairdresser. The resident's care plan and Kardex would be reviewed for needs of the resident. 1) Resident # 294 had [DIAGNOSES REDACTED]. The 10/3/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not reject care, required extensive assistance of 2 for bed mobility, transfers, dressing, and toilet use, supervision with setup for personal hygiene, and was totally dependent on staff for bathing. The comprehensive care plan (CCP) initiated 5/6/22 documented the resident required assistance with ADLs related to spinal cord injury, neuromuscular dysfunction of the bladder, [MEDICAL CONDITIONS], gout, [MEDICAL CONDITION](gastro [MEDICAL CONDITION] reflux disease). There were no specific interventions addressing the resident's functional ability with individual ADLs. The 7/26/22 Resident #294 grievance documented several care concerns including lack of showering, shaving, and nail care. The grievance was written by the previous Nurse Manager of the unit. The previous Assistant Director of Nursing (ADON #67) documented follow-up dated 7/29/22 and included the resident's nails were to be cut and filed and the resident would be shaved on Tuesday shower day. The Kardex (care instructions) active 10/28/22 documented the resident required physical assistance of 1 with part of bathing activity, not including washing back or hair. The resident was to receive a shower/bath on Fridays on the 3 PM-11 PM shift. The instructions did not include shaving preference. The following observations of Resident #294 were made: -On 10/20/22 at 11:20 AM the resident stated they felt they were being treated like they were in a detention center. They had facial hair approximately 1 inch long and stated they would like to be shaved. They stated it had been about 3 weeks since they were shaved, and they had not received a shower in more than 2 weeks. They stated the CNAs (certified nurse aides) sometimes offered a shower when they were sleeping and if they asked the CNAs to come back when they were awake, they did not. The resident stated the care was based on the CNA's convenience and not the resident's wishes. -On 10/21/22 at 10:49 AM the resident was in bed with a hospital gown on. They stated they did not receive showers as scheduled, and staff would only help with ADLs when it was convenient for them. The resident had beard growth covering their face, approximately 1 inch long and stated they had not been shaved in 3 weeks and would like to be shaved. The facial hair was causing them to itch. -On 10/21/22 at 2:05 PM the resident was observed with facial hair approximately 1 inch long and stated they had not been helped with shaving. -On 10/24/22 at 2:41 PM the resident was in bed in a hospital gown with facial hair approximately 1 inch long. They stated they were not assisted with getting out of bed over the weekend. -On 10/26/22 at 2:10 PM the resident was in bed in a hospital gown with beard growth covering their face, approximately 1 inch long. They stated they received a shower last evening (Tuesday) but was not assisted with shaving. They stated their shower day was Tuesday on the evening shift, and this was their first shower in 3 weeks. The CNA tasks for 10/2022 documented shower/bath day on Friday 3-11. The shower was refused on 10/21 and received on 10/4, 10/10, 10/11, 10/15, 10/16, 10/23, 10/25, and 10/29. During an interview on 10/31/22 at 4:00 PM licensed practical nurse (LPN) Unit Manager #40 stated the resident required assistance with activities of daily living (ADLs). They would minimally need setup for personal hygiene and staff would have to bring shaving supplies to the resident and help. The LPN was not sure when the resident was last shaved or showered, and staff had not reported any refusals of care. During an interview on 10/31/22 at 3:40 PM, CNA #46 stated they were responsible for assisting residents with ADL care. The CNA was assigned to Resident #294 from 10/16-10/22. The CNA did not remember offering to set the resident up for shaving. The CNA stated the resident's shower day was Tuesday on the 3-11 shift and they had not showered the resident during that time frame. The resident should have been showered and shaved on their scheduled day. During an interview on 10/31/22 at 5:34 PM the ADON stated the resident required assistance with ADLs. They would require setup help for personal hygiene, at a minimum. The resident most likely would need assistance also due to physical limitations. Showers were decided by resident preference and should be at least once to twice weekly. Shower refusal should be documented and communicated to the Nurse Manager. During an interview on 11/1/22 at 11:24 AM, CNA #58 stated resident assignments rotated weekly and their assignment from 10/25-10 /28 included Resident #294. They did not remember providing shaving assistance to the resident last week and the resident would usually ask if they wanted to be shaved. The resident's shower was scheduled for evenings they did not provide a shower. During an interview on 11/2/22 at 12:31 PM, the Director of Nursing (DON) stated staff should not be documenting care that was not provided. If a resident did not receive a shower or assistance with shaving, the CNA should let the nurse on the unit know. There should be documentation as to why care was not being done. 2) Resident #160 had [DIAGNOSES REDACTED]. The 9/07/2022 Minimum Data Set (MDS) documented the resident's cognition was severely impaired and they required extensive assistance of 1 for personal hygiene. The comprehensive care plan (CCP) initiated 10/14/22 documented the resident required assistance with activities of daily living (ADLs) related to confusion, dementia, and impaired balance. Interventions included extensive assistance of 1 with bed mobility and dressing, and set-up help only with eating including cutting meat, opening containers, and giving one food at a time. The resident had impaired visual function with interventions including arrange personal items per resident preference and tell the resident where you are placing items. The 10/27/22 Kardex (care instructions) documented Resident #160 required supervision with physical assistance of 1 for dressing, and extensive assistance of 1 for eating. Resident #160 was observed: -On 10/20/22 in bed at 10:44 AM and 10:59 AM with scrambled eggs on their chest and around their mouth. -On 10/24/22 at 03:00 PM lying in bed wearing a gown that was wet and had food on the front. -On 10/25/22 at 1:22 PM lying in bed sleeping with a green gown on with their legs hanging off the bed and a sheet covering only half of their body. The gown had streaks of red liquid down the front. Resident #160's call bell was observed on the floor approximately 2 feet away from the bed under a chair. At 3:44 PM lying in bed in a gown in the same position as 1:22 PM. The front of the resident's gown was observed to be wet and the call bell remained on the floor under the chair approximately 2 feet away from the bed. -On 10/26/22 at 9:10 AM lying in bed with a gown on, with a sheet covering half of their body. The call bell was observed to be under a chair. During an interview on 10/26/22 at 2:58 PM with CNA #5 they stated that Resident #160 needed assistance with their ADLs. The resident required assistance with washing, dressing, grooming, and feeding. CNA #3 stated they rounded on the residents in the morning and afternoon and checked to see if their clothes were soiled and if call bells were in reach. CNA #5 stated that they would change Resident #160's clothes if they were soiled and give them their call bell if it were observed to be out of reach. During an interview on 10/31/22 at 10:21 AM with licensed practical nurse (LPN) #20 on they stated they were responsible to ensure the CNA assignments were completed. They stated that they do rounds on the unit before they started their medication passes and the purpose was to ensure the residents were in clean clothes and call bells were in reach. LPN #20 stated that they did not think it was dignified for a resident to have food on their gown after meals and if they observed it, they would change the gown. During an interview on 10/31/22 at 12:49 PM with LPN #21 they stated they expected staff to give the best care possible to the residents and direct care staff should be rounding on the residents two times in the morning and two times in the afternoon at a minimum. LPN #21stated if a resident had food on their gown, it would not be dignified, and they would expect staff to change the gown. If a call bell was out of reach staff was expected to place it within reach of the resident. 3) Resident #101 had [DIAGNOSES REDACTED]. The 10/4/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 for bed mobility, extensive assistance of 1 for eating, and was totally dependent on 2 for personal hygiene. The 4/28/22 comprehensive care plan (CCP) documented the resident required assistance with ADLs related to MS and [MEDICAL CONDITION]. Interventions included encourage resident to use call bell, extensive assistance of 1 for bed mobility, and total dependence on 2 staff for bathing and dressing. The 10/10/22 physician order [REDACTED]. The following observations of Resident #101 were made: - on 10/20/22 at 12:14 PM, the resident's hair was greasy with dandruff, uncombed, and matted on top of the head. The resident was in a green hospital gown and wearing blue fuzzy socks. - on 10/21/22 at 9:31 AM, the resident observed with their breakfast tray pushed away from the bed, the resident stated, I did not eat my French toast because the staff did not cut it up in smaller pieces, and I can't eat big pieces and/or cut it up myself. The French toast was not cut up and had syrup all over it. - on 10/21/22 at 9:36 AM, the resident was in bed and stated I need my hair cut and washed. I get no attention. Resident was in a green gown and stated, I need some attention and pointed out their nails needed to be cut. Their nails were clean but long and jagged. The resident was wearing the same fuzzy blue socks as 10/20/22. The resident stated they would like to get up and out of bed. - on 10/25/22 at 9:39 AM, the resident was sitting up in bed with their breakfast tray on the table over their lap, at an angle. The resident was leaning to the left. They were wearing a hospital gown; their hair was greasy and uncombed, and they stated they needed to be repositioned to eat. - on 10/25/22 at 12:19 PM, the resident stated they were not washed and wanted their hair washed and cut. Their hair had brown, dry skin on the scalp. The resident was unable to put their hands through their hair. - on 10/26/22 at 8:43 AM, the resident was lying in bed. CNA #53 brought a breakfast tray to the resident, set the tray on the table next to the bed, opened food items, and left the resident. The resident was leaning to left side with the tray table next to the bedside. CNA ADL documentation 10/20/22-10/25/22 revealed there was no documentation of care provided on 10/20/22, 10/21/22 and 10/23/22 during the day shift. On 10/24/22 at 12:18 PM and 10/25/22 at 11:47 AM, care was documented on the day shift and the resident was totally dependent on 2. During an interview on 10/26/22 at 9:26 AM, LPN #87 stated the resident was able to feed themselves and required one person assistance for most care and 2 staff to get out of bed. During an interview on 10/26/22 at 9:46 AM, CNA #52 stated the resident required a full bed bath and received a bath on Monday. The resident had a dry scalp and completed their own oral care. They stated the resident required set-up and opening food items but could feed themselves. During an interview on 10/26/22 at 12:17 PM, CNA #53 stated they had taken care of the resident in the past but was not assigned to them on Thursday 10/20/22 or Friday 10/21/22. The resident required 2 people for care and a nurse should be there because the resident screamed out a lot with pain. The resident did not need assistance with eating, but did need to be repositioned before mealtime, pulled up and moved over. The resident should have a pillow on the left side as this was the side that the resident leaned to, and they needed to be in a good upright position to eat. The resident required total care every day and could only wash their face. CNA #53 stated CNA #90 was assigned to the resident on those dates. During an interview on 10/31/22 at 03:06 PM, RN Unit Manager #4 stated the resident was totally dependent. The expectation was to make sure the resident was comfortable and dry for breakfast. The resident needed to be set up for meals and repositioned. The resident should have their hair washed on shower day, or if the resident asked, they could have hair care with the shampoo shower caps. The staff should have combed hair and be presentable. The resident had very dry scalp and needed lotion for their scalp. The CNAs knew what they were supposed to do for the resident's care as it was on the care instructions. During an interview on 11/01/22 at 1:38 PM, CNA #90 stated they were usually assigned to Resident #101. They stated the resident required total care and 2 people for positioning and to get out of bed. The resident did need help with meals sometimes and could eat alone. They stated the resident needed to be repositioned every 2 hours and needed to sit upright for meals. This was important to make sure the resident did not aspirate. The staff member stated they gave the resident care if they were assigned the resident but was unable to recall if the resident had clothing or a change of socks or if they had washed their hair. They confirmed the resident had bad dandruff. They were unable to recall if they documented the care they had provided to the resident. During an interview on 11/2/22 at 10:22 AM, the DON stated ADL care should be completed for all residents according to the Kardex (CNA care instructions). The staff should be documenting the care as completed. The care should be documented on each shift, this would include bathing, showers, oral care, and hair washing. 10NYCRR 415.12(a)(3) | Plan of Correction: ApprovedDecember 16, 2022 1. ò Resident #294 was showered and assisted with shaving and was evaluated by a Social Worker/ Provider and suffered no ill effects. Care Plan revised to include interventions addressing functional ability and resident's shaving preference documented ò Resident #160 was provided care and a replacement gown. Residents call bell was placed within reach. All staff on unit 10/20/22, 10/24/22, 10/25/22 and 10/26 during the 7am û 3p and 3p- 11p shift educated on providing ADL assistance with emphasis on ensuring residents are dressed and groomed appropriately and call bells remain within reach. Resident #160 was evaluated by a Social Worker/ Provider and suffered no ill effects. CCP and or Kardex reviewed and revised to ensure consistency between the two. ò Resident #101 was provided care and a replacement gown. All staff on duty 10/20/22, 10/21/22, 10/25/22 and 10/26 during the 7am û 3p shift educated on providing ADL assistance with emphasis on ensuring residents are dressed and groomed appropriately and repositioned/set-up for meals evaluated by a Social Worker/Dietician/Provider and suffered no ill effects òResident #99 was evaluated by a Social Worker/ Provider and suffered no ill effects. Facility requested resident council president provide Resident #99 summary of the meeting. Staff on duty educated on the importance and expectation of providing ADL assistance in accordance with resident requests òResident #163 was evaluated by a Social Worker/Dietician/Provider and suffered no ill effects. Care Plan and Kardex reviewed to ensure ADL needs and preference were documented òResident #221 was evaluated by a Social Worker/Dietician/Provider and suffered no ill effects.Care Plan and Kardex reviewed to ensure ADL needs and preference were documented 2. All residents have potential to be affected Rounds conducted on all units to ensure all residents are showered, assisted with shaving and grooming, positioned, call bells within reach, and assisted during mealtimes. 3. The policy on Activities of Daily Living was reviewed. No revisions required All Nursing staff educated on ensuring residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene including: Showers, grooming, ensuring residents are dressed and not left in gowns, assistance and positioning during meals, ensuring call bells being within reach and documenting the care provided in the EMR. All licensed nurses educated on the importance and expectation that Care Plans and Kardex accurately reflect resident status and information is consistent between the two. 4. A rounding audit will be conducted by ADON /Designee on each unit. 5 residents will be observed to ensure Residents are showered, appropriately dressed and groomed, residents receive assistance as requested, residents are positioned and assisted meals and call bells are within reach. The audit will be conducted daily x 7 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met Rounding/Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated surveys (NY 774, NY 007, NY 750, NY 105, NY 718, NY 326, NY 150 and NY 577) conducted from 10/20/22-11/2/22, the facility's administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically; - the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 6 of 7 residents (Residents #99, 101, 160, 163, 221, and 294) reviewed. - the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 4 residents (Residents #57, 222, and 262) reviewed. -the facility failed to ensure the resident environment remained free of accident hazards as possible and residents received adequate supervision to prevent accidents for 6 of 9 residents (Resident #57, 163, 238, 242, 330, and 582) reviewed. - the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 5 of 7 residents (Residents #93, 222, 262, 270, and 294) reviewed, 2 of 4 meals observed, and 2 of 2 meal test trays (1 breakfast and 1 lunch tray) observed. - the facility failed to provide sufficient support personnel to safely carry out the functions of the food and nutrition service for 11 of 11 resident units (Units 1 South, 2 North, 2 South, 3 North, 3 South, 4 North, 4 South, A, C North, C South, and D North) and the main kitchen. - the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 9 of 11 nursing units (1 South, 2 North, 3 South, 4 North, 4 South, A South, C North, C South, D North) observed. - the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen and 10 of 20 unit refrigerators (Units 1, 2, 3, and 4). - the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 6 of 7 units (Units 1, 2, 3, 4, C and D) reviewed. The facility Quality Assurance and Performance Improvement (QAPI) plan 2022 documented the vision of the facility was to create an environment where the residents were valued, respected, and provided the optimal care required to meet their individual needs. The QAPI Program was designed to objectively and systematically monitor and evaluate: the quality and appropriateness of all aspects of the facility's performance and services, identification of opportunities for improvement, compliance with standards and regulations; current standards of practice, actions taken to enhance and improve quality by the facility, resolution of identified problems, sustainability of performance improvement interventions. Documented Responsibility included: The Administrator had jurisdiction and responsibility for the quality of care and service rendered in the facility. The Administrator, in collaboration with Senior Leadership and others as appropriate was responsible for setting expectation and priorities re: safety, quality, rights, choice and respect. The Administrator would also foster a culture of safety, in which staff were urged to identify and report issues that did have or may potentially have a negative impact on residents or staff. In order to fulfill these responsibly, the Administrator would implement and maintain an ongoing QAPI Committee designed to monitor and evaluate the quality of the resident care/service, pursue methods to improve quality care and to resolve identified problems. The facility documented they would use the Plan, Do, Study and Act approach for quality improvement. The 2022 Quality Improvement Prioritization Grid, in Appendix I documented the topic Regulatory Compliance and the rationale included the facility entered into a Special Focus Facility Program in (MONTH) 2022. Additional topics with high risk, high volume and problem prone included Quality of care, Infection Control/COVID 19, unplanned transfers to hospital/hospital admission and meal service. Activities of Daily Living - Resident #294 was not showered and was not assisted with shaving. - Resident #160 was observed in a soiled hospital gown and did not have access to their call bell. - Resident #101 was observed in the same hospital gown for 2 days, had greasy, uncombed hair and was not repositioned for meals. - Resident #99 did not receive assistance getting out of bed as requested when they planned to attend a meeting. - Resident #163 was not properly positioned for and assisted with meals. - Resident #221 was not assisted during mealtime. Refer to citation text in F677 for additional detailed information. Quality of Care - Resident #57 was performing their own wound care and was not assessed and did not have physician orders [REDACTED]. - Resident #222 had a physician recommendation for [MEDICATION NAME] (a diuretic) to treat [MEDICAL CONDITION] and the [MEDICATION NAME] was not ordered. - Resident #262 was performing their own [MEDICAL CONDITION] (small intestine is diverted through an opening in the abdomen) care and dressing changes. The resident was not assessed for their ability to appropriately perform self-care and did not have physician orders [REDACTED].#262 when the skin around the ostomy became raw and macerated due to the resident caring for the ostomy improperly and without medical oversight. Refer to citation text in F684 for additional detailed information. Free of Accident Hazards/Smoking - Resident #163 had physician orders [REDACTED]. The resident was not supervised or assisted during meals and received thin liquids on their meal tray. Additionally, the resident did not have an order to self-medicate and medicated inhalers were left at the resident's bedside. - Resident #238 was on aspiration precautions and a pureed diet and was observed unsupervised eating food items that were not on their prescribed diet. - Residents #57, 242, 330, and 582 were observed smoking on facility grounds. The facility was a smoke-free facility and there were no policies or plans for smoking safety. Refer to citation text F689 for additional detailed information. Provided Diet Meets Needs of Each Resident - Resident #294 did not eat pork due to religious beliefs and received pork on their tray on multiple occasions and did not receive meal items as planned. - Residents #270 and 222 did not receive food items on their meal trays as planned. - Resident #262 had protein malnutrition, required additional calories, and did not receive high protein items on their meal trays as planned. - Resident #93 was not provided a scoop plate with meals as planned. - Hot food temperatures on the meal service line were not monitored and maintained as required. - 1 breakfast tray and 1 lunch tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable. Refer to citation texts F800 for additional detailed information. Sufficient Dietary Support Personnel - Resident #294 did not eat pork due to religious beliefs and received pork on their tray on multiple occasions and did not receive meal items as planned. - Residents #270 and 222 did not receive food items on their meal trays as planned. - Resident #262 had protein malnutrition, required additional calories, and did not receive high protein items on their meal trays as planned. - Resident #93 was not provided a scoop plate with meals as planned. - Hot food temperatures on the meal service line were not monitored and maintained as required. - 1 breakfast tray and 1 lunch tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable. - 9 of 11 nursing units (1 South, 2 North, 3 South, 4 North, 4 South, A South, C North, C South, D North) had resident meal trays delivered up to 1 hour and 31 minutes after the posted scheduled mealtimes. - the main kitchen was unclean and had soiled food preparation equipment, outdated and undated food in the walk-in freezer, improper thawing and storage, dishwashing and sanitization, unsafe food temperatures, improper hand hygiene, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. - the nourishment areas on Units 1, 2, 3, and 4 had unclean equipment, outdated and undated food in refrigerators, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. Refer to citation texts F802 for additional detailed information. Frequency of Meals/Snacks at Bedtime Resident meal trays were delivered to nursing units up to 1 hour and 31 minutes after the scheduled mealtimes. Refer to citation texts F809 for additional detailed information. Food Procurement, Store/Prepare/Serve-Sanitary The main kitchen was unclean and had soiled food preparation equipment, outdated and undated food in the walk-in freezer, improper thawing and storage, dishwashing and sanitization, unsafe food temperatures, improper hand hygiene, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. The nourishment areas on Units 1, 2, 3, and 4 had unclean equipment, outdated and undated food in refrigerators, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. Refer to citation texts F812 for additional detailed information. Resident Call System On Units 1, 2, 3, 4, C, and D resident call bell stations did not function as designed and call bells were not within residents' reach to directly contact caregivers and to be answered timely. During an interview with the Maintenance Director on 10/24/22 at 2:55 PM they stated they had resigned, effective immediately. Refer to citation text F919 for additional detailed information. Interviews During an interview on 11/1/22 at 2:39 PM with the Administrator, they stated they had a high turnover rate with the leadership team. They had to have regional and corporate fill in for the Maintenance Director, Food Service Director, and Clinical Nutrition Director. With no Food Service Director, it impacted the residents with no organization. Most of the major dietary concerns were being handled by the dietetic technicians. Maintenance was having difficulty repairing equipment timely. If there were issues with staffing it would be brought to the attention of the corporation. During a follow-up interview with the Administrator on 11/1/22 at 3:23 PM they stated smoking contracts for new residents started a month ago. They were not sure if new staff were told during orientation if the facility was a non-smoking campus. Smoking in cars or the side lot picnic benches for staff was okay. They were aware staff and residents were smoking by the front fence and it should not be happening. They sent a letter to residents and staff reminding them of the no-smoking policy. If the front lobby receptionist saw residents with smoking materials, they should be reminding them about the no-smoking policy on campus. The receptionist should also make the Nursing Supervisor or Nurse Manager aware of any resident with smoking materials. During the Quality Assurance (QA) interview on 11/2/22 at 11:10 AM with the Director of Nursing (DON) they stated call bell audits were done informally by Unit Managers and Nursing Supervisors. They were not currently doing any call bell audits during resident mealtimes. At one time maintenance was doing formal call bell audits for the facility's previous plan of correction. Meal audits covered the dining experience, adaptive dining equipment, tray accuracy, meal delivery times and food temperatures. The Food Service Director (FSD) used to oversee these audits, but they currently did not have a FSD. The regional dietitian and facility dietitians were overseeing activities in the kitchen. Meal delivery times were changed in (MONTH) (2022) and then revised again. Snack audits were completed on the units by kitchen staff. The facility was a non-smoking campus. Residents were made aware of this on admission. If a resident exhibited smoking behaviors the facility would plan for it in the comprehensive care plan (CCP), offer smoking cessation, or offer an alternative replacement. There were no staff who patrolled the facility grounds to enforce the no-smoking policy. The Unit Managers were responsible for making sure wound care was done on a day-to-day basis, which included ostomy care. They would expect the Nurse Managers visualized wounds and ostomies to make sure they had not digressed. The Assistant Directors of Nursing (ADONs) should be following up with the Unit Managers with wound care concerns. The Unit Managers were responsible for doing rounds on activities of daily living (ADLs). A formal ADL tool was used as part of the P(NAME) (plan of correction) from the last recertification survey, but currently there was no formal audit tool in use. The ADONs were responsible for making sure the Unit Managers were doing ADL rounds. The licensed practical nurse (LPN) Unit Managers were trained by the DON and ADONs with weekly meetings to go over educational topics, roles, and responsibilities. They were expected to contact registered nurses (RNs) if anything was out of their scope of practice. The DON and ADONs touched base with the LPN Unit Managers at least once per day. During an interview on 11/2/22 at 11:47 AM with the Administrator, they stated there were occasional issues with non-functioning call bells on the units. They did not think it was a facility-wide issue. Maintenance should be made aware of any call bell issues and sometimes they could address the problem immediately. They knew there was a call bell issue on the D floor. They had recently received a vendor quote for the D south panel. They were not aware of any training staff received for the different types of call bells the facility had. Without proper training of staff, it could be an issue of the residents' needs not being met timely. During a follow-up interview with the Administrator on 11/2/22 at 12:07 PM they stated some meal delivery times were better than others. There had been times when meals on some units had been received greater than 30 minutes from the actual delivery time and 45- 50 minutes late was not acceptable. Staffing in the kitchen was more of a communications issue and was difficult without a Food Service Director. Some employees were tasked with picking up others' slack. When they changed mealtime delivery a letter went out to residents and their representatives. They were not aware that old mealtimes were posted on the units. Dietary staff should have sent the nursing units the most current schedule. 10NYCRR 415.26(a) | Plan of Correction: ApprovedDecember 16, 2022 Plan of correction not approved or not required |
Scope: N/A
Severity: N/A
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure there was documented supervision while the results of the Criminal History Record Check (CHRC) were pending for 1 of 10 employees (certified nursing assistant, CNA #100) reviewed. Specifically, CNA #100 had direct access to residents and did not have weekly supervision documented while CHRC determination was pending. The facility policy Criminal History Record Check (CHRC) dated 3/2021, documented direct supervision would be provided of the applicant while the applicant was in the facility or with residents. The supervisor would be present on the unit with the applicant at all times during direct care of the residents. Documentation of the supervised time would be maintained in the employee file. Supervision of a provisional employee, for the purpose of meeting the CHRC Regulations, ended when the facility made an employment determination after receipt of the CHRC report. CNA #100's personnel file did not include documentation of supervision while CHRC results were pending. CNA #100's hire date was 8/6/22, a consent form and CHRC submission were dated 8/9/22. On 10/27/22 CNA #100 remained employed at the facility and CHRC results continued to be pending. When interviewed on 10/27/22 at 11:54 AM, the Human Resources Director/CHRC Authorized person stated they did not realize the employee did not have documented supervision until the file was audited with the CHRC review. They stated all employees awaiting a determination letter should have documented supervision. 10 NYCRR Section 402.6(d), 402.4(b)(2)(i) | Plan of Correction: ApprovedDecember 16, 2022 1. Provisional Supervision was implemented for CNA #100 until CHRC results were obtained. 2. All residents have the potential to be affected by the deficient practice. An audit was conducted of all employees hired in the last 4 months to ensure that all CHRC has submitted as required and provisional supervision was in place for all pending determinations 3. The policy on Criminal History Record Checks was reviewed. No revisions required Human resources staff educated on the importance and expectation of ensuring provisional supervision is completed for all pending determinations 4. An audit will be conducted by Human Resources Director /Designee to ensure all persons pending CHRC determination have provisional supervision in place The audit will be conducted weekly x4 weeks, then monthly x 3 months. The audit will continue monthly until substantial compliance has been achieved Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Human Resources |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that residents who required [MEDICAL TREATMENT] received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #177) reviewed. Specifically, Resident #177 did not receive ongoing assessment and monitoring after [MEDICAL TREATMENT] treatments and the facility did not communicate and collaborate with the [MEDICAL TREATMENT] facility regarding care and services. Findings include: The facility document titled Long Term Care Facility (LTCF) Outpatient [MEDICAL TREATMENT] Services Coordination Agreement signed 6/23/21 by the former Administrator, included preparation of residents for [MEDICAL TREATMENT] ensuring residents had received any medications prescribed before going to the [MEDICAL TREATMENT] unit. Resident # 177 has [DIAGNOSES REDACTED]. The 9/8/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not exhibit behaviors, or reject care, required supervision and assistance of 1 with locomotion on and off the unit, toilet use, and personal hygiene. The resident reported frequent pain, had received both routine and as needed pain medications, had no weight gain or loss, and received [MEDICAL TREATMENT]. physician's orders [REDACTED]. - a liberal renal diet, regular texture, with thin liquids. - [MEDICAL TREATMENT] in house every Monday, Wednesday, and Friday (M-W-F) - [MEDICATION NAME] (treats high blood pressure) 50 mg every 8 hours, hold for systolic (top number) blood pressure <120, and [MEDICATION NAME] (used to treat high blood pressure) 0.3 mg/24 hour apply 1 patch every Tuesday and remove per schedule. The Comprehensive Care Plan (CCP) initiated 4/27/22 documented the resident needed [MEDICAL TREATMENT] (HD) related to end stage [MEDICAL CONDITION]. Interventions included AV (arterio venous) fistula (used for HD access) in left arm. Monitor for bruit and thrill (feel and sound of blood flow through fistula) every shift; In-house [MEDICAL TREATMENT] every Monday-Friday; obtain vital signs and weight per protocol, report significant changes in pulse, respirations, and blood pressure immediately. The (MONTH) 2022 Medication Administration Record [REDACTED] - [MEDICATION NAME] 0.3 mg/24 hours, apply 1 patch one time a day every Tuesday for hypertension and remove per schedule. The MAR indicated [REDACTED]. On 10/25 (Tuesday) the MAR indicated [REDACTED]. - on 10/31 at 5 AM [MEDICATION NAME] 50 mg was to be administered. It was marked NA (not available) and there was no blood pressure recorded. The MAR indicated [REDACTED]. The resident was observed at the [MEDICAL TREATMENT] unit on 10/31/22 at 9:30 AM. The [MEDICAL TREATMENT] unit registered nurse (RN) #83 stated the resident did not receive any food or morning medications before [MEDICAL TREATMENT] that morning. The blood pressure check during [MEDICAL TREATMENT] treatment was 199/97 and RN #83 was trying to call the unit for medications to be brought down for the resident. The 10/31/22 [MEDICAL TREATMENT] Hand Off Communication form documented the resident's blood pressure was 195/104 prior to leaving for HD. The resident's post [MEDICAL TREATMENT] blood pressure was 196/86 and morning meds were received at [MEDICAL TREATMENT]. The section to be completed upon return to the facility included presence of bruit (a whooshing sound), presence of thrill (a vibration), signs/symptoms of infection, and signature was blank. During an interview on 10/31/22 at 9:48 AM licensed practical nurse (LPN) # 84 stated they were called by the [MEDICAL TREATMENT] unit due to the resident's elevated blood pressure. The morning medications were on a liberalized schedule timed for 7-10 AM. The resident had not received [MEDICATION NAME] (muscle relaxant), [MEDICATION NAME] (glucocorticoid), carvedilol (antihypertensive), or [MEDICATION NAME] (antihypertensive) that morning before going to [MEDICAL TREATMENT]. The LPN stated they were way behind in their medication pass that morning. The medications could be given by the night shift if the times got moved. Nurse Managers had to change the times in the computer. There was a [MEDICAL TREATMENT] handoff communication form that went to and from [MEDICAL TREATMENT] with the resident and was used to monitor the amount of fluid removed and vital signs. The Unit Manager was to receive it when the resident returned from [MEDICAL TREATMENT] for monitoring purposes. The [MEDICAL TREATMENT] handoff communication forms for (MONTH) and (MONTH) 2022, did not document signoff by nursing upon the resident's return to the unit. During an interview 11/2/22 at 11:28 AM LPN Unit Manager #40 stated the medication times were entered in the MAR by the nurse putting in the order. Resident # 177 went to [MEDICAL TREATMENT] at 7:30 AM. It would be important to have blood pressure medications before going to [MEDICAL TREATMENT]. The resident had hypertension (high blood pressure) and their blood pressure ran quite high. Moving medication times to the night shift could help make sure the resident gets them before going to [MEDICAL TREATMENT]. When a resident comes back to the unit after [MEDICAL TREATMENT], the nurse on the cart should be looking at the communication book. LPN #40 was not aware of the resident's blood pressure of 196/86 when they returned on 10/31/22. The LPN would expect follow-up blood pressures, and notification of the Nurse Supervisor. During an interview 11/2/22 at 11:41 AM nurse practitioner (NP) #16 stated residents should receive antihypertensives before going to [MEDICAL TREATMENT] in the morning. Nursing should schedule the medications in the MAR indicated [REDACTED]. At a minimum a follow-up blood pressure should be obtained by nursing. An elevated blood pressure carries the risk of a stroke or other cardiac event. During an interview 11/2/22 at 12:08 PM the Assistant Director of Nursing (ADON) stated blood pressure medications should be given before [MEDICAL TREATMENT]. Orders are timed by the ordering provider or nursing and could be changed if needed. A [MEDICAL TREATMENT] notebook should be reviewed and signed by the Unit Manager when the resident returned from [MEDICAL TREATMENT]. An elevated blood pressure should be rechecked and reported to the RN supervisor. The risk for stroke or a cardiovascular event was increased with high blood pressure. During an interview 11/2/22 at 12:23 PM the Director of Nursing (DON) stated they would expect morning medications to be administered before [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] communication forms should be signed by a unit nurse on a resident's return from [MEDICAL TREATMENT]. This would document the monitoring of vital signs, and any need for follow-up. An elevated blood pressure should have been reported to a medical provider. The medical provider along with nursing should discuss medication times to see if a more appropriate time could be initiated. 10 NYCRR 415.12 | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #177 was evaluated by provider and medication administration times adjusted to accommodate [MEDICAL TREATMENT] schedule. Resident will be provided a bagged meal on [MEDICAL TREATMENT] days 2. All residents who receive [MEDICAL TREATMENT] have the potential to be affected An audit was conducted of all residents who receive [MEDICAL TREATMENT] to ensure medication administration times were scheduled to accommodate [MEDICAL TREATMENT] scheduled and [MEDICAL TREATMENT] handoff communication forms were completed and signed and information was communicated to providers as indicated. 3. The policy on [MEDICAL TREATMENT] and the LTCF [MEDICAL TREATMENT] Service Coordination agreement reviewed. No revisions required All licensed nurses educated on the importance and expectation of ensuring medication administration times were scheduled to accommodate [MEDICAL TREATMENT] scheduled and [MEDICAL TREATMENT] handoff communication forms were completed and signed and information was communicated to providers as indicated. Dietitian /Designee will obtain/maintain a listing of all residents that receive [MEDICAL TREATMENT] and distribute to the Food Service Director/Designee weekly. Food Service director will ensure that the Food Service staff prepare Bagged meals for [MEDICAL TREATMENT] residents Bagged meals will be delivered to the units the evening before and stored in the unit pantry/refrigerator Nursing staff will ensure that the bagged meal is provided prior to the resident leaving the unit/facility Food Service and Nursing staff educated on the process for ensuring the provision of meals for [MEDICAL TREATMENT] residents 4. DON / Designee will conduct an audit of all residents on [MEDICAL TREATMENT] to ensure medication administration times were scheduled to accommodate [MEDICAL TREATMENT] scheduled and [MEDICAL TREATMENT] handoff communication forms were completed and signed and information was communicated to providers as indicated. Audit will be conducted weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met Diet tech/Designee will conduct an audit of all residents receiving [MEDICAL TREATMENT] to ensure a bagged meal was provided. Audit will be conducted weekly x 12 weeks. Audit will continue weekly until substantial compliance is met. Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation, interview, and record review during the recertification survey conducted 10/20/22-11/2/22, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 kitchen steamtables and 1 of 1 hot boxes (hot food holding cabinet). Specifically, one kitchen steam table and 1 kitchen hot boxes did not maintain proper food holding temperatures. Findings include: The manufacturer's Hot Food Tables steam table manual, revised 11/2009, documented the United States Public Health Service recommended hot foods be held at a minimum of 140 degrees Fahrenheit (F) to help prevent bacteria growth. The manual documented to monitor food temperatures closely for food safety. The facility policy Food Preparation and Service revised 4/2022, documented potentially hazardous foods must be maintained over 135 degrees F. Thermometers would be placed on hot storage areas and checked for accuracy. Temperature of foods held in steam tables would be monitored by food and nutrition staff. During a kitchen observation and interview on 10/21/22 at 1:08 PM, the kitchen had 6 staff members working the tray line. There was a two steam table unit in use for service on the tray line. The first unit had sweet potatoes that were measured at 108 degrees F, ham at 140 degrees F, and pork chops at 108 degrees F. Staff were unaware the food was not at the correct holding temperature (greater than 140 degrees F). Regional registered dietitian (RD) #22 stated the temperatures were checked by the cook at the start of service (today was at 12:00) and again every two hours if service took that long. The sweet potatoes were documented as 163 degrees F and the pork chops were 162 degrees F. At 1:22 PM Regional RD #22 stated food was allowed to be out of temperature for 4 hours. When interviewed on 10/21/22 at 1:20 PM, cook #109 stated the temperatures of the food for the lunch meal were taken around 11:00 AM. Temperatures were taken as the food was coming out of the oven and then moved to the hot boxes to be used on the line. Pork chops needed to be cooked between 160-180 degrees F and sweet potatoes to 130-140 degrees F. They stated no one checked the temperatures once the tray line started. The cook stated food could be out of temperature for 30 minutes. When interviewed at 1:20 PM, dietary aide #107 stated the steam table section under the sweet potatoes was not on when they checked the temperature, but they turned it back on and the section was hot now. That section had a leak, lost water quickly, shut off, and they turned it back on when they noticed. When interviewed on 10/21/22 at 1:35 PM, the Dietary Supervisor #28 and Regional RD #22 stated tray temperatures were not checked as they came off the tray line. During a kitchen observation and interview on 10/25/22 at 11:31 AM, kitchen staff were placing the last items for lunch on the service line. The first unit steam table had first and end lights that were not on. The second unit steam table was plugged into an extension cord. Maintenance aide #111 removed the power strip as one plug was unable to be plugged in. Assistant Administrator #23 entered the kitchen, provided a new extension cord, and stated the old one had electrical problems. Kitchen observations and interviews on 10/25/22 included: - at 11:45 AM, the hot box contained noodles that were 138 degrees F and the unit's light was not on under the noodles; - at 12:15 PM, the temperature log for the kitchen documented the pasta noodles were 129 degrees F when they came off the line, and cook #109 stated they logged the temps when they came out of the oven; - at 12:22 PM, the noodles were 90 degrees F, the unit's light was not on, and the noodle pan contained 25% of the portion left to be served; - at 12:24 PM, dietary aide #107 stated they did not check the noodle temperature, it should be above 130 degrees F, and they measured it at 132 degrees F. The hot box dial was set on 10 and the temperature display did not register. The hanging thermometer in the unit registered 155 degrees F. The unit was warm to touch both in and out of the unit; - at 12:34 PM, noodles were pulled from service; - at 12:35 PM, water beneath noodles measured at 129 F, there was still no light. Service was stopped. Over 100 residents had been served. The noodles were replaced; - at 12:48 PM, cook #109 stated they turned the unit on that morning. The noodles were made around 10:30 AM and placed in the middle hot box. The hot box temperature location had lights but no numbers. The box was hot to the touch and the inside thermometer read 180 degrees F; and - at 1:04 PM, maintenance aide #111 stated the hot box was back on, as a circuit breaker had tripped. When interviewed on 10/26/22 at 2:26 PM, dietary aide #107 stated food temperatures were not checked on the tray line prior to 10/25/22. Food temperatures were to be 140-160 degrees F and they were not documented. The dietary aide had noticed in the past that the steam table was not working and was told the facility was going to replace it. All residents' food was served from the kitchen initially. Proper temperatures were important to prevent the residents from possibly becoming ill from eating food outside of the acceptable ranges. When interviewed on 10/26/22 at 2:53 PM, Dietary Manager #108 stated a kitchen soup well had not been working for 2 weeks, as it had a broken thermostat, and the parts had been ordered. Maintenance was aware. Food should be held at temperatures over 165 degrees F and they were taken after they were cooked and on the tray line. Keeping food at proper temperature was important as it could grow bacteria when left out of temperature, thereby possibly making a resident sick. 10NYCRR 415.29 | Plan of Correction: ApprovedDecember 16, 2022 1. Broken steam table was repaired by in-house maintenance team. Two additional steam wells were purchased for use should there be further steam table issues. Warming box reviewed by the maintenance team for operation. Issues addressed. Maintenance team reviewed electrical supply to the tray line area and determined that additional supply needed. Facility contacted local electrician vendors for proposals to install additional outlets. Soup well to be repaired. The second soup well is in good working order. 2. All residents could have been affected by the deficient practice. Facility nursing and nutrition team to review residents for weight loss and intervene as necessary. House review of dietary equipment to be completed. Any issues will be addressed. 3. Policy related to dietary equipment reviewed with no recommended changes. Dietary staff educated on the requirement that they immediately notify maintenance and leadership of any broken or malfunctioning equipment. Maintenance to be educated on the requirement that issues be immediately addressed and that if issues cannot be immediately resolved, they notify dietary leadership for further advisement. 4. Dietary equipment to be audited for operability monthly x6. Results will be shared with the facility QAPI committee during monthly meetings for review and advisement of further steps and continuance of audits. The Food Service Director is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the recertification survey conducted 10/20/22-11/2/22, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently both during day-to-day operations and emergencies. The facility did not review and update the facility assessment as necessary. Specifically, the facility assessment did not accurately reflect the type of resident being cared for, and clinical nutrition staff, department heads and the medical director were not accurately documented Findings include: The 5/30/2022 Facility Assessment documented the incorrect facility Medical Director. Nutrition was listed under general care areas and documented specific care and practices included individualized dietary requirements, liberal diets, specialized diets, tube feedings, cultural or ethnic dietary needs, assistive devices, and fluid monitoring. The assessment documented the facility resources needed to provide competent support and care for the resident population every day and during emergencies listed Food and Nutrition including Director, registered dietitian (RD), cooks, and dietary aides. Ethnic, Cultural, or Religious Factors did not include Hindu. The registered dietitian listed was not full time or a department head, and the facility did not have a Dietary Director. When interviewed on 10/31/22 at 12:04 PM, RD #29 stated they were not full-time and not the department head and only worked 20 hours a week at the facility. When interviewed on 10/31/22 PM, the Administrator stated the facility assessment was their responsibility to complete and keep updated. They based the assessment information on other lists of staffing. They were not aware the current Medical Director was not correctly listed, and RD #29 was not a full-time employee. They believed the assessment for Dietary was correct. The Food Service Director had recently resigned during the survey 10NYCRR 415.26 | Plan of Correction: ApprovedDecember 16, 2022 1. The facility assessment was updated ot accurately reflect: - The type of residents cared for - Clinical Nutrition staff - Department heads and Medical Director 2. All residents have the potential to be affected. Full review of facility assessment conducted. Assessment revised as indicated to reflect accurate personnel and to identify what resources were necessary to care for residents during day-day operations and in emergencies 3. Policy on facility assessment reviewed. No revisions are required. 4. Administrator /Designee will review Facility assessment to accuracy monthly x 6 months. Review will continue monthly until substantial compliance has been achieved Review Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY 105) surveys conducted [DATE]-[DATE], the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen and 10 of 20 unit refrigerators (Units 1, 2, 3, and 4). Specifically, the main kitchen was unclean and had soiled food preparation equipment, outdated and undated food in the walk-in freezer, improper thawing and storage, dishwashing and sanitization, unsafe food temperatures, improper hand hygiene, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. The nourishment areas on Units 1, 2, 3, and 4 had unclean equipment, outdated and undated food in refrigerators, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. Findings include: Food Preparation Areas and Equipment During an observation on [DATE] at 12:55 PM the Unit 4S breakroom refrigerator and freezer contained food for residents. The interior was soiled with food spills and debris. During an observation on [DATE] at 5:32 PM the Unit 2S breakroom refrigerator was labeled staff food only and contained food for residents. The interior of the refrigerator was soiled with food spills and debris. During an observation on [DATE] at 5:46 PM the Unit 2N nursing station staff breakroom refrigerator contained food for residents and was soiled inside and on the top with food spills and debris. The following observations were made in the main kitchen on [DATE]: - at 11:29 AM the kitchen walk-in cooler had dried food debris on the floor, under the racks, and along the edges. An Avantco cooler located inside and below the compressor was soiled with black smears and debris. - at 11:45 AM the Metro C5 A hot box was soiled with food debris inside the unit. - at 11:56 AM there was partially dried and desiccated food debris and spills behind the cookline equipment. The Buffalo grinder (rotates food in a bowl through spinning blades to chop meats and other ingredients) had food debris on the table below the unit and the blade located on the table was soiled with dried on food debris. The Regional registered dietitian (RD) stated that the Buffalo grinder was used the previous day. The Pot Room had a vent out of place in the ceiling, a sprinkler in the corner was heavily caked with dust and grease, the floor beneath the sinks was soiled with food spills and debris, and the walls behind the sinks were soiled with food splatters and debris. During an interview on [DATE] at 11:29, Dietary Supervisor #110 stated that the Pot Room floors, and sink were cleaned after each meal. During an interview on [DATE] at 12:20 PM, the Food Service Director (FSD) stated the vent out of place in the Pot Room was a make-up air vent, but they were not sure why or how long it was out of place. During an observation on [DATE] at 12:20 PM, there was a hole through the tile wall below the double sink outside of the pot room. This was a potential harborage location for pests and an uncleanable area. During an interview on [DATE] at 12:20 PM the Regional RD stated they used the double sink to soak pots and pans, or dump food in because there was a garbage disposal on the right sink. They were not aware there was a hole through the tile wall below the sinks. During an observation on [DATE] at 12:25 PM the large walk in cooler contained food debris and spills under the shelving, between the shelving and walls, and directly on the shelving. There were double stacked pans of quiche, the Regional RD stated those were leftovers that were pulled from the freezer and would be used for pureed meals tomorrow for breakfast. During an observation on [DATE] at 12:46 PM, the larger dry storage room, located within the kitchen had evidence of rodents (droppings) along the back wall. There was significant amount of debris under shelving along the back and side walls, and on equipment stored on the back walls and racks. During an observation on [DATE] at 12:58 PM the right three-door cooler had a significant puddle beneath the unit, the source of the puddle could not be identified. The Regional RD stated they were not sure of the source of the puddle underneath the three door coolers. During an observation on [DATE] at 11:31 AM there was a large puddle of dirty liquid on the floor in front of the two three-door coolers. Staff were walking through puddles to work the tray line and retrieve drinks, sides, and desserts from the coolers. The rough tile floor was caked with grime, and the floor was sticky. At 12:29 PM the large puddle of liquid crossed the kitchen from the three-door coolers to a large air conditioning (AC) unit, with staff and carts going through the liquid as they worked in the kitchen. At 12:33 PM, the Assistant Administrator moved a floor fan in front of the large AC unit to blow across the puddle flowing across the kitchen floor. At 1:13 PM the source of the water on the floor was seen coming from the right three-door cooler that had a steady drip of water at the top from the compressor at the left end of unit. The Assistant Administrator stated the company was here that morning to service the other set of three-door coolers for the same reason. During an observation on [DATE] at 10:54 AM there was a significant puddle of dirty brown liquid on the floor by the three-door coolers on the side of the tray line. Staff walked through the puddle as they worked. At 11:19 AM the middle door of the leaking cooler on the tray line side had a visibly ripped door seal at the top. During an interview on [DATE] at 11:52 AM, Dietary Manager #108 stated the dishwasher maintained the dish room, the tray setter was responsible to clean the line (the first staff person in the process), and everyone else went to the dish room to do dishes at the conclusion of each service. During an interview on [DATE] at 12:43 PM, cook #109 stated they were responsible for cleaning the equipment in the back of the house located on the cook line. They stated they were not trained how to clean and knew from doing kitchen work for 30 plus years. During an observation on [DATE] at 10:20 AM, the kitchen floors were sticky and soiled with food debris throughout the kitchen. The floors and walls in the three bay sink area were sticky with food debris and discolored black in spots. Outdated/Undated Food in the Refrigerators During an observation on [DATE] at 2:53 PM the Unit 3 day room kitchenette area black refrigerator had a plastic bag with hummus, tzatziki, and cheese curds that were not dated, and each contained visible mold. During an interview on [DATE] at 3:05 PM, licensed practical nurse (LPN) #117 stated the Unit 3 refrigerator was used for all the residents on the third floor. They stated they put the name of the resident and the date on the food and stored it in refrigerator. They stated they believed the food was considered expired after 2 days. They stated they thought the kitchen staff checked the refrigerators on the units for outdated food, but they were not sure. During an observation on [DATE] at 5:32 PM the Unit 2S breakroom refrigerator was labeled staff food only and contained resident food items. The freezer contained individually wrapped white bread and drinks. The refrigerator portion contained a case of creamer, apple juice, and thickened beverages, all unlabeled/undated. During an observation on [DATE] at 9:30 AM, the Unit 1 staff breakroom small refrigerator was soiled with food spills, debris, and a tray full of liquid on the top shelf contained a package of Ensure on its side, a salad dressing packet, and a knotted plastic bag that contained a moldy hotdog and a resident's meal ticket dated [DATE]. There was a strong foul odor coming from the refrigerator. During an interview on [DATE] at 9:45 AM, LPN #49 stated they had worked on Unit 1 since (MONTH) of this year. They stated they thought the small refrigerator was for staff, but they were not sure that it was used for anything. They stated they were unaware of the bag containing the moldy hot dog, the spills, food debris, and puddle in the cooler, or the source of the foul odor coming from the refrigerator. They stated they labelled and dated the food that came from the residents, and after three days it was expired, and they should discard the food. LPN #49 was not sure who was responsible to check the refrigerators for outdated food, or to clean them. They stated that if a resident was to consume something that had expired, or was moldy, they could get sick. During an observation on [DATE] at 9:46 AM, maintenance technician #112 entered the Unit 1 staff breakroom and measured the temperature of the small refrigerator but did not check the taller refrigerator located next to the small refrigerator. During an interview on [DATE] at 9:46 AM, maintenance technician #112 stated that they checked the temperatures of the resident refrigerators and the Med Fridges. They stated that the small refrigerator was for resident food. During an observation on [DATE] at 12:30 PM the main kitchen walk-in freezer contained numerous pans of leftovers including a hotel pan of cookies that was uncovered and not protected, a hotel pan labeled PEI vegetable mix dated ,[DATE] located on a top shelf with ripped plastic wrap, and a hotel pan containing three pans of unlabeled quiche. During an interview on [DATE] at 12:30 PM, the Regional RD stated leftovers that would be reused should be used within a month, that was how often the menu repeated, and if they were not used, they should be discarded. They stated the quiche, cookies, and vegetables observed in the walk-in freezer should have been discarded. During an interview on [DATE] at 1:48 PM the Regional RD stated the food labeling procedure was a team effort. They stated housekeeping should clean any spills in the refrigerators on the units, dietary should check the contents when restocking and remove any outdated items, and nursing should clean if they were responsible for the spills themselves. During an interview on [DATE] at 11:52 AM, Dietary Manager #108 stated dietary staff were responsible for checking the refrigerators in the nourishment rooms, but they did not know who was responsible for the other refrigerators on the units. Hand Hygiene During an observation on [DATE] at 2:53 PM, the Unit 3 day room kitchenette area hand sink had no paper towels and/or heat/air drying methods. During an observation on [DATE] at 10:20 AM, the hand sink located opposite the ice machine in the main kitchen was lacking paper towels. During an observation on [DATE] at 10:26 AM, the hand sink at the end of the prep area of the kitchen was blocked by a large standing fan. Dietary Manager #108 was observed wearing gloves to open the cooler using the door handles, took a bag of shredded cheddar cheese from the walk-in cooler, cut open the bag, and took handfuls of cheese to spread on trays of food (broccoli and cheesy rice casserole) for lunch wearing the same gloves. Other staff who were not wearing gloves were observed touching the same cooler handles with bare hands. There was no glove change or handwashing observed. During an observation on [DATE] at 3:10 PM the Unit 3N medication room hand sink was lacking soap and paper towels and/or heat/air drying methods. During an observation on [DATE] at 4:55 PM the Unit 2 day room kitchenette area hand sink was lacking soap and paper towels and/or heat/air drying methods. During an observation on [DATE] at 11:29, the two rest rooms at the end of the main kitchen were missing paper towels and/or heat/air drying methods. Staff were observed entering each of the bathrooms, exiting, and returning to their workstations. During an observation on [DATE] at 11:52 AM, an unidentified staff working on the tray line placed a cooked hamburger with a gloved hand on a bun. Tongs were present but not used. The same staff handled dessert cups and placed them on trays and handled serving utensils for pureed food without changing gloves. During an interview on [DATE] at 11:52 AM, Dietary Manager #108 stated staff should wash their hands any time they changed gloves, handled food, or they were soiled from touching their face, nose, or mask. They stated that gloves were to be worn when serving or handling food. They stated staff should not be deliberately touching the food on the line, there were tongs for that. They stated that under no circumstances should staff handle the food on the line with gloves, then handle silverware, drinks, dishes, or dishware for service with the same gloves. Dietary Manager #108 stated that staff should change their gloves in between and wash their hands. They stated the sinks should never be without paper towels or soap and that there was usually an extra roll in the kitchen somewhere. Improper Thawing and Storage: During an observation on [DATE] at 10:41 AM, the double sink outside of the Pot Room contained frozen individually packaged drinks consisting of chocolate and vanilla Mighty Shakes, cranberry, orange, and apple juices. The Mighty Shakes were in paper cartons, and the fruit juices were in sealed plastic cups with foil lids. The Mighty Shake packaging documented to thaw under refrigeration. During an interview on [DATE] at 10:41 AM, the Food Service Director (FSD) stated they were thawing the drinks in the sink but was not sure who turned off the water. The FSD turned on the cold water at that time. During an interview on [DATE] at 10:41 AM, the Regional RD stated the Mighty Shakes, which were packaged in paper cartons, should not be thawing under submerged water. During an observation on [DATE] at 9:59 AM, there were two black 6-inch deep rubber tubs with plastic bags of raw frozen/thawing boneless/skinless chicken thighs stored on the second self from the bottom of a 4 shelf bakers rack in the main meat walk-in cooler. There were two black 6-inch deep rubber tubs with plastic bags of raw frozen/thawing pork butts stored directly below the two bins of chicken thighs on the bottom shelf of the 4 shelf baker's rack. During an interview on [DATE] at 10:06 AM, kitchen stocker #142 stated they were responsible for putting the meats in the cooler in the big black tubs to defrost. They did not get any training at the facility and stated they were trained at the last nursing home they worked at on how to properly store and handle food. During an interview on [DATE] at 10:15 AM, Kitchen Manager #31 stated kitchen stocker #142 oversaw putting away food inventory that came in. The way the pork and chicken were being stored was wrong. The food item that should be cooked at a higher temperature (chicken) should be stored on the bottom shelf and the lower cooked temperature food item (pork butts) should be stored above the chicken. Improper Dishwashing and Sanitization: During an observation on [DATE] at 11:29 AM, the Pot Room sanitizer was measured at 400 ppm by Dietary Supervisor #110 who was washing pots. The manufacturer specifications posted on the wall documented the sanitizer needed to be between ,[DATE] ppm. During an interview on [DATE] at 11:29, Dietary Supervisor #110 stated they were not sure of the required sanitizer level, but it was recorded on a log on a clipboard, and they were not sure where the clipboard was. During an interview on [DATE] at 12:17 PM, the Regional RD stated the sanitizer log fell into the sink yesterday and was left to dry somewhere. They were not sure what happened to it since then. During an observation on [DATE] at 12:56 PM, the mechanical dish washer's required wash and rinse temperatures were not listed on machine. The final rinse gauge was reading 180F, and the wash gauge was between ,[DATE] F, but the water going in was measured at ,[DATE] F. Improper food temperatures: During observations on [DATE] between 12:08 PM and 2:22 PM, ,[DATE] pint milk cartons were stored at the end of the tray line 2 cartons deep in each milk crate with blue thermal ice packs under the plastic milk crates. The following internal temperatures were recorded throughout the lunch tray service. - at 12:08 PM, a single ,[DATE] pint carton of regular milk was internally measured by the surveyor using and internal probe thermal couple which measured 41 F. - at 1:35 PM, a single ,[DATE] pint carton of regular milk was internally measured by the surveyor using and internal probe thermal couple which measured 50 F. - at 2:22 PM, a single ,[DATE] pint carton of regular milk was internally measured by the surveyor using and internal probe thermal couple which measured 58 F. During an interview on [DATE] at 2:50 PM, Kitchen Manager #31 stated the blue thermal freezer packs were on top of the table then the milk crates were placed on top of those with milks stacked inside of them. In the morning a stock person put the crates in the reach in coolers on the line. Each cooler had a thermometer as a guide to let them know that the milks were holding refrigeration and were cold enough to hold the items. They stated they thought the milks were going to the residents at the proper temperatures regardless of the time received. Kitchen Manager #31 stated the milk should be held refrigerated at 41 F. Milk temperatures did not get checked throughout the tray line or during test trays, it was assumed they were holding cold enough. 10NYCRR 415.14(h) | Plan of Correction: ApprovedDecember 16, 2022 1. Unclean unit refrigerator in 2S breakroom, 2N nursing station cleaned inside and outside. Kitchen walk-in cooler cleaned and mopped. The Avantco cooler cleaned. Metro C5 A hotbox cleaned. Buffalo grinder and area surrounding cleaned. Pot room vent to be repaired. Sprinkler head above pot sink area cleaned. Floor beneath the pot room sinks cleaned. Walls behind the sinks cleaned. Tile wall below the sink outside of the pot room to be repaired. Large walk-in cooler cleaned. Droppings and debris blow shelving cleared. Pest control vendor notified in-person of this area and will continue his treatment. Water below reach-in trayline cooler cleared. Vendor to assess the source. Rough floor tile cleaned. Cooler door to be reviewed by vendor. Entire kitchen floors cleaned and buffed. Three-bay sink area cleaned. Unit 3 kitchenette refrigerator cleared of expired foods and cleaned. Signage to be placed on all refrigerator noting the safe holding times for the various items that may be stored inside as well as a reminder to staff that all contents must be labeled and dated. Unit 1 staff breakroom refrigerator cleared of expired items and cleaned. Main kitchen walk-in freezer reviewed for uncovered items. All findings immediately addressed. The facility amended the contract with contracted housekeeping vendor to include cleaning of kitchen on a regular basis. There will be housekeepers that are tasked with just kitchen cleaning duties. Hand towel dispensers and soap dispensers in the 3rd-floor kitchenette, 3N medication room, sink opposite the ice machine, 2nd-floor day room nourishment area, and two staff bathrooms in kitchen will be reviewed to ensure they are stocked/filled and in good working order. Kitchenettes will have their refrigerators moved to nourishment rooms to consolidate food storage areas on the units. 2. All residents could have been affected by the deficient practice. Unit resident refrigerators all undergoing review of location and signage. They will be consolidated and marked so that it is clear which refrigerators are for storing resident items, and which are for staff. All unit refrigerators will be reviewed for cleanliness, presence of expired or unlabeled foods. Nourishment rooms and dietary bathrooms to be reviewed for paper towel dispensers and paper towel stock. Kitchen to be reviewed for cleanliness and operability of floors, walls, ceilings, sprinkler heads, vents, equipment, coolers, freezers, and storage areas. Coolers and freezers to be reviewed for improperly stored items and items that are expired or not correctly labelled. All issues will be immediately addressed. 3. Facility policies related to food storage, food safety, hand hygiene while working with food, and dietary cleaning reviewed. Dietary and nursing staff will be educated on the requirements surrounding kitchen and nourishment room cleanliness, food holding safety, the requirement that items e stored using appropriate methods and materials, the requirement that items be clearly dated and discarded past use-by dates, as well as safe food holding temperatures. Dietary staff will be educated on their roles within the department, hand, surface, device, and general kitchen cleanliness standards and processes, three-sink and other documentation, temping trayline items, appropriate holding and storage methods, and to notify maintenance of issues with refrigerators, walls, devices, etc. Signage throughout the department to be reviewed and adjusted. They will also be educated on the new unit stocking process that includes trips to units to maintain par levels, clearing expired food items from refrigerators, and cleaning the refrigerators on a regular basis. Nursing staff will be educated on the requirement that unit refrigerators are kept clean and free of expired food items, that they are maintained to the proper temperature, and that they are frequency reviewed for issues. They will further be educated on the process of notifying the correct parties should issues be found. Housekeeping staff to be educated on the requirement that paper towels remain well-stocked in dietary bathrooms and in nourishment rooms throughout, and the proper dietary cleaning methods. The facility maintenance team is working in conjunction with the dietary leadership team to consolidate unit refrigerators dedicated to resident food to the nourishment rooms on each unit. Facility staff will be provided notice via weekly letter of their new location and the requirements surrounding their use. New facility pest control vendor to continue regular treatments and observations throughout. 4. A full audit of the kitchen that includes food storage, cleanliness of areas, documentation of temperatures and PPM, staff hand hygiene, surface and device hygiene, floor hygiene, cooling rack requirements, maintenance issues, food storage compliance, and the appropriate labeling of nourishments. An audit of unit nourishment rooms will be conducted to review at least four random units for temperature, cleanliness, presence of expired or undated food. These audits will be completed weekly x6 then monthly x3. Audit results will be shared with the facility QAPI team for review and assessment of further actions during monthly QAPI meetings. The Food Service Director is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure the resident environment remained free of accident hazards as possible and residents received adequate supervision to prevent accidents for 6 of 9 residents (Resident #57, 163, 238, 242, 330, and 582) reviewed. Specifically: - Resident #163 had physician orders for a mechanical soft diet with nectar thick liquids and required supervision and assistance during meals. The resident was not supervised or assisted during meals and received thin liquids on their meal tray. Additionally, the resident did not have an order to self-medicate and medicated inhalers were left at the resident's bedside. - Resident #238 was on aspiration precautions and a pureed diet and was observed unsupervised eating food items that were not on their prescribed diet. - Residents #57, 242, 330, and 582 were observed smoking on facility grounds. The facility was a smoke-free facility and there were no policies or plans for smoking safety. Findings include: The facility policy Meal Service revised 4/2022 documented staff should check individual name and diet on the meal identification care/ticket to verify that the meal was served to the correct person, and check items on plate/tray to assure accuracy for therapeutic diets or texture or consistency modifications. The facility policy Aspiration Precautions, revised 2/2109 documented the standard of care for aspiration precautions should include having the resident seated in the upright position, or as possible for any intake. If resident was unable to, refer to any specific positioning in resident's care plan. The resident should avoid use of straws with modified liquids, unless specified otherwise by the speech pathologist. The resident should remain upright for at least 30 minutes after any intake, unless specified in care plan by speech pathologist. The resident must be supervised for all intake, solid or liquid. The CNA should consider the resident must be supervised during any food/fluid intake. The facility policy Medication - Self-Administration revised 7/2019 documented criteria must be met to determine if a resident was both mentally and physically capable of self-administration of medication and to keep accurate documentation of these actions. If the assessment determined the resident could not safely administer medications, all medications would be administered by the nurse from the stored medication in the medication cart. The facility policy Non-smoking effective 3/2021 documented it was the policy of the facility that no resident or visitor would smoke on campus. All residents and visitors were restricted from smoking (real or artificial including electronic cigarettes) anywhere on the property. The facility policy Smoking- Non-smoking facility revised 1/2020 documented the facility had policies and procedures in place to offer the highest quality of care and life for residents. This included but was not limited to the decision to be a smoke free facility. The facility was identified as a smoke free facility and the resident and staff should not smoke on facility property. 1) Resident #163 had [DIAGNOSES REDACTED]. The 8/12/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of two for care/hygiene, extensive assistance of one for eating, and the resident was on a therapeutic diet. The 8/11/22 Nutrition Assessment completed by registered diet technician (DTR) #25 documented the resident was on a mechanical soft, fluid consistency nectar/mildly thickened liquids. The resident did not have chewing problems, had impaired swallowing, and required extensive assistance with feeding. The resident did not use adaptive feeding devices. Diet consistency was downgraded to mechanical soft with nectar/mildly thick liquids per signs and symptoms of mild oropharyngeal dysphagia. The 8/15/22 physician order documented no added salt (NAS) diet, mechanical soft texture, nectar thick /mildly thick consistency, no straws, small bites/sips; sit upright while eating, and no mixed consistencies. The 8/16/22 physician order documented precautions the resident was an aspiration risk. There was no physician order for [REDACTED]. The comprehensive care plan (CCP), dated 8/22/22, documented the resident had actual/potential for aspiration related to [DIAGNOSES REDACTED]. The CCP did not include the resident's ability to self-medicate. The care instructions documented: - Safety: keep maintain resident in an upright sitting position when assisting the resident with meals at least 30 minutes after a meal to help decrease aspiration pneumonia. - Eating: diet and consistency as ordered, mechanical soft, nectar/mildly thickened liquids, no mixed consistencies. - Eating: extensive assistance (staff physically feed one or more bites of food to resident or hold cup and provide one or more sips of liquid at any time). - Swallowing: follow aspiration precaution and no straws, small bites, sips, alternate liquid/solids. Upright for oral intake, and no mixed consistencies. On 10/21/22 at 9:02 AM, Resident #163 was observed sitting up in bed with their breakfast tray on the over bed table and eating alone. The resident stated they had to have thick fluids and mushed food because they choked. There was no staff in the room with the resident. The resident's meal ticket documented no straws mechanical soft, nectar thick liquids. The resident had regular milk and thickened coffee on their tray and was drinking thickened cranberry juice. The resident had 2 medicated inhalers on the tray table, [MEDICATION NAME]/Propionate (Breo) and Salmeterol inhaler ([MEDICATION NAME]). The resident stated the nurses were not supposed to leave them there. On 10/25/22 at 9:02 AM, the resident was observed sitting and leaning to the right side, trying to eat their breakfast meal located on the tray table. There was no staff present. The meal ticket documented no straws- nectar thick and mechanical soft diet. The resident had a plastic container with thin milk on the tray. The resident stated they knew not to drink the milk in the plastic container because they could choke. On 10/25/22 at 1:37 PM, CNA #50 was observed bringing the resident their lunch tray. The CNA set the tray on the bed side table and left the resident. The resident was not repositioned and was leaning to the right side. The resident's meal ticket documented nectar thick, mechanical soft, no straws. There were no fluids on the tray. The resident was trying to feed themself with a fork and dropped their ground beef on their sheet. At 1:42 PM, CNA #50 returned to the room to offer the resident thickened juice. CNA #50 stated they knew the resident and even though the juice was not listed on the meal ticket they knew the resident liked juice with meals. The staff member left the room, the resident was continued to lean to the right, crooked in bed, and feeding themself. The resident stated they were not comfortable eating this way but would manage. During an interview on 10/25/22 at 4:24 PM, licensed practical nurse (LPN) #36 stated the resident had an order for [REDACTED]. The resident should not have inhalers at the bedside without an order because it was an accident hazard. The resident could overuse the inhaler, or a confused resident could walk in the room and take it. During an interview on 10/6/22 at 2:58 PM, CNA #50 stated the resident should have meal tickets that were accurate. The resident was on nectar thick liquids and all the drinks should arrive thickened. The resident was on aspiration precautions. The resident had been on nectar thick liquids for about 4-5 months and was not supposed to have straws either. The resident was on aspiration precautions and could choke if they used a straw. The resident was able to eat by themself and did not need staff help. The resident should be repositioned prior to meals and was always crooked in bed. It was important to reposition the resident for meals so the resident would not choke. During an interview on 10/31/22 at 2:54 PM, RN Unit Manager #4 stated all residents should be repositioned for meals if needed, and Resident #163's orders included the resident should be sitting upright. The staff should be repositioning the resident in bed, before the tray was left in front of them, so they could eat and not aspirate. The resident was on nectar thick, mechanical soft diet related to aspiration. RN Unit Manager #4 stated the resident was not on aspiration precautions. The CNA should look at the name and the diet the resident required, and staff knew which residents required assistance with meals. The resident required set up and staff should check on them frequently. Staff should read the meal ticket and see what the diet was and remove items from the tray that were not appropriate. This should be done before they bring the tray to the resident room. The resident should not have medications on their bed side table. They did not have any residents that self-medicated and all medications needed to be brought to the resident by the nurse. During an interview on 10/31/22 at 4:29 PM, LPN #60 (the nurse assigned to the resident on 10/20/22 and 10/21/22) stated the resident should not have inhalers at the bedside. Medications should not be left at the bedside because the resident may not take them, or they could take more than they were supposed to. LPN #60 stated the resident fed themselves and needed to be repositioned frequently and especially for meals. The resident was on nectar thick liquids and a mechanical soft diet. The resident should not have regular coffee and tea. The staff member who delivered the tray should check for these items and set the resident up. During interview on 11/01/22 at 11:21 AM, physician #54 stated the resident had periods of aspiration, that had prompted a swallow evaluation and the resident was now on mechanical soft, nectar thick liquid diet, the resident was a chronic aspirator and required this diet. The resident should not receive thin liquids. The resident had the capacity to administer medications at the bedside and but there was no formal evaluation for inhalers and no order. During interview on 11/01/22 at 2:52 PM, speech language pathologist #85 stated the resident was currently on the recommended mechanical soft and nectar thick liquids diet. The resident should not have thin liquids on their meal tray. They stated if the resident received thin liquids they could potentially aspirate and could get aspiration pneumonia The resident needed to be sitting upright at meals. The resident's [DIAGNOSES REDACTED]. The resident should not have straws because they did not have the coordination to take a bigger sip of liquids with a straw. 2) Resident #238 was admitted with [DIAGNOSES REDACTED]. The 9/22/22 MDS documented the resident had severe cognitive impairment, required extensive assistance of one for ADLs including eating, had signs and symptoms of a swallowing disorder that included loss of liquids/solids from the mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, complained of difficulty or pain with swallowing and was on a mechanically altered diet. The care instructions documented: - Extensive assistance with eating; staff were to physically feed one or more bites of food to the resident or hold cup and provide one or more sips of liquid at any time or lift residents hand to mouth while resident was holding utensil or cup or finger food. - Provide encouragement and cueing at meals as needed, and for swallowing follow aspiration precautions. - Small bites/sips of food and no straws, upright for all meals, and remain upright for 30 minutes after eating. The CCP initiated on 5/8/22 and updated on 9/19/22 documented the resident had a nutritional problem related to dysphagia, and poor oral intake. The resident was to have puree solids and thin liquids for nutrition. There was an additional notation that documented mechanical soft was unsafe per speech language pathology (SLP) assessment Interventions included diet and consistency as ordered, observe resident for food intolerance and acceptance during meals and provide encouragement and cueing during meals. The 9/15/22 physician order documented regular diet, puree texture, thin liquids, alternate liquids, and solids, sit upright for oral intake. The 9/14/22 SLP #139 progress note documented they had made nursing aware they referred resident for rehabilitation. The resident was observed coughing at a meal by SLP #139. The resident was to be scheduled for a full SLP evaluation. The 9/19/22 registered dietitian (RD) #29 progress note documented the resident was on a regular puree diet and was recently followed by SLP. The 9/27/22 LPN #49's progress note documented the resident refused puree meals, family were aware of the orders, and a family member came and gave the resident an egg salad sandwich. The LPN educated the resident and family on diet instructions and aspiration risks. The resident was currently sitting up with family eating. The 9/28/22 SLP #85's progress note documented the most recent therapy encounter was from 9/15/22 to 9/23/22 with recommendations for pureed solids and thin liquids. Extensive education was provided to resident and family over the course of many encounters with swallow therapy. However, there was no carry over observed. A swallowing evaluation was not recommended as the resident remained at the same level of functioning and to please consult medical provider. The 10/7/22 registered diet technician (DTR) #25's progress note documented on 9/15/22, the resident was seen and had [DIAGNOSES REDACTED]. Due to the [DIAGNOSES REDACTED]. On 10/28/22 at 3:02 PM, Resident #238 was observed eating an egg salad sandwich on white bread in bed unsupervised and unassisted by staff. During interview on 11/02/22 at 9:18 AM, LPN #12 stated the resident had aspiration precautions listed on their diet order. A pureed diet was ordered and would not include an egg salad sandwich. They were not aware the resident was eating an egg salad sandwich. This would put the resident at risk of aspiration. They stated no one had ever mentioned the resident was not following their diet. The resident was not able to obtain food items independently, they needed to bring food to the resident. Sometimes families provided items not on the ordered diet, but they were not aware that occurred with the resident. Residents on aspiration precaution should be sitting up right for meals. During Interview on 11/02/22 at 9:26 AM, CNA #88 there stated they were assigned to resident care on the evening of 10/28/22. They looked up the resident diet type on the care instruction and stated the resident was on aspiration precautions. That meant they could choke and needed to be seated up right for meals and be supervised when eating. They did not recall the resident asking for an egg salad sandwich and/or any family members visiting. They were not aware the resident had eaten an egg salad alone in their room. The resident was on a puree diet and should not have an egg salad sandwich. They were not sure how the resident received an egg salad sandwich because the resident was not able to obtain food independently. During an interview on 11/02/22 at 9:37 AM, LPN Unit Manager #49 stated the resident's diet type/order were listed on the care instructions. If CNAs had questions about diet type, they should ask a nurse before providing items to resident. They stated the resident was on aspiration precautions and this meant the resident needed to be supervised while eating and sitting upright. Egg salad was not appropriate for a pureed diet. The resident's family member worked at the facility and would bring in items. They had been educated and continued to bring these items when they were working. If the staff saw the resident eating items brought in by the family that were not on the ordered diet, they should report to the nurse and document in the record. The resident could aspirate and choke. During an interview on 11/02/22 at 9:46 AM, SLP #139 stated the resident had a recent incident of coughing with a recent [DIAGNOSES REDACTED]. There were a few incidents that the resident required the [MEDICATION NAME] maneuver, food items got stuck when trying to swallow. The safest consistency for the resident was puree. The resident should be seated upright, and an egg salad would not be appropriate. They stated they had provided education to the resident and family. They stated this should be on the resident care plan that the family would bring food in that was not on the diet. During interview on 11/02/22 09:58 AM, SLP #85 stated the resident was on mechanical soft and then the resident had multiple choking incidents that involved staff performing the [MEDICATION NAME] maneuver. They downgraded the resident to puree and then the family reported the resident was not eating. The resident could not safely tolerate mechanical soft diet. The SLP firmly recommend puree. An egg salad sandwich would not be appropriate. Education was provided and documented in the record. The care plan should reflect the family would bring in unsafe food for the resident. The physician and nurse practitioner were made aware. The resident should be supervised while eating. During interview on 11/02/22 at 10:23 AM, Assistant Director of Nursing #51 stated meal consistency and aspiration precautions were listed on the resident's meal ticket. The diet orders were listed on the care instructions. If a resident was on puree diet they were at risk for aspiration. The resident should be seated up right and provided correct food to prevent food aspiration. They stated an egg salad sandwich on a puree diet was not appropriate. They were aware Resident #238 was not compliant with diet and said this should be documented on the care plan. Smoking: The following observations were made: - On 10/20/22 at 5:27 PM and 10/24/22 at 9:05 AM, 4 cigarettes were on the hallway bathroom floor and 1 cigarette was found in the tub within the tub room adjacent to resident room [ROOM NUMBER]. - On 10/25/22 at 2:56 PM, Resident #177 was entering through the main entrance while extinguishing the remainder of a cigarette. The resident was returning from the hospital while being pushed in a wheelchair by a transport worker. During an observation on 10/25/22 at 2:56 PM, CNA #6 who was covering the reception desk, stated to Resident #177 that they should not be smoking, and they knew that. The unidentified transporter stated they hate when the residents smoked because the ashes got all over them while driving. On 10/26/22 the following observations were made: - at 8:50 AM, Residents #242 and #582 were on the sidewalk sitting at a bench smoking on the other side of the front fence entrance leading to the main entrance of the facility. They were seen throwing cigarette butts on the facility sidewalk. There was no approved noncombustible metal container with a self-closing lid available for smokers to use. - at 9:13 AM, there were multiple cigarette butts on the sidewalk around the bench and littered under the fence line and beside the fence gate. Cigarette butts were seen on the walkway and driveway outside the ambulance exit/entrance. Cigarette butts were also seen on the ground around the outside emergency diesel generator for the 918 building next to the front fence. During an interview on 10/26/22 at 8:45 AM, CNA #6 stated residents better not be outside smoking, they knew better. Both residents just went outside when others were coming in and did not have an out on pass form for that day and time. Those residents do what they want, and they smoke. They stated the residents do try to smoke and/or do smoke outside, but they had not seen any smoking inside the facility. The smoking procedures were very confusing, but the staff called and made notes for management and social work to intervene and follow up with residents that were caught smoking. During an interview on 10/26/22 at 9:13 AM, Resident #582 stated they put out their cigarettes in an ashtray. They did not usually smoke but a social worker came out and said there was no more smoking, and they needed to come back inside. The other resident they were with had the cigarettes and a lighter that they bummed off off them. There used to be supervised smoking in the courtyard but that did not happen anymore. The facility said they needed to have staff with them, and they did not check with the front desk when they went outside to smoke. During an interview on 10/26/22 at 9:19 AM, Resident #242 stated they bummed cigarettes and lighters from people on the street. They did not have any smoking materials in their room. They stated staff told residents not to smoke on the property, so they smoked on the public sidewalk. They stated they would sit out front of the fence to smoke. During an interview on 10/26/22 at 9:19 AM, Resident #330 stated they sometimes smoked but did not go out with their oxygen on. They also stated they did not take smoking materials into the facility or their room. It would be dangerous to bring materials inside and they knew better. They stated they get smoking materials from people outside if they smoked. During an interview on 10/26/22 at 10:56 AM, LPN Nurse Manager #49 stated it was a no smoking facility so there should not be smoking at all. They offered nicotine patches for cessation. It had been just over a year since they stopped the smoking in the courtyard. If the front desk told them someone was smoking, they did room checks. They should be documenting room checks in the resident's progress notes. Resident #582 had their room checked today when they came back inside, and nothing was found. They stated they were not sure what to do if any smoking materials were found but would tell the ADON and they could handle it from there. During a combined interview on 10/26/22 at 2:49 PM, CNAs #46 and #47 stated there was no smoking for residents. Reception would call to let nursing staff know if a resident went outside and did not have an out on pass form. They stated if a resident wanted to leave the floor they had to meet with the social worker and the Unit Manager had to sign out on pass agreement, which would be turned into the front desk for receptionists to maintain. Nursing staff offered cessation options and that would be in the residents file if needed. During an interview on 10/26/22 at 2:53 PM, the Administrator stated cigarettes were not allowed to be thrown into the tub within the tub room adjacent to room [ROOM NUMBER]. The facility was a smoke free campus, and they did not know who the resident was that had smoked in this tub room. During an interview on 10/26/22 at 3:09 PM, LPN Nurse Manager #49 stated everyone should have an out on pass order. The two residents did not have out on pass order, so they went out when someone else came in. They were notified by reception that the residents were not on the list and went outside. Any time a resident wanted to go out they would need a new pass. Social Workers and Unit Managers signed off on the passes. They reviewed the records for residents #582 and #242 and identified Resident #582 as supervision status and Resident #242 as independent status. However, both residents would still need to have an approved out on pass order before leaving the building. During an interview on 10/26/22 at 3:14 PM, CNA #6 acting receptionist, stated the charge or medication nurse was responsible to sign the out on pass order/agreement. If a resident came downstairs and wanted to go outside and did not have the pass they were not allowed out and were sent back to their floor. When a resident left and returned to the facility it was the responsibility of the receptionist to log the dates and times the resident left and returned. Receptionists had a blue clip board for out on pass agreements and those were submitted at 8:30 PM each night. Residents #582 and #242 did not have out on pass agreements and snuck out when others were coming into the facility. They knew better and should be checking in at the front desk. When the two residents left, the receptionist got on the phone linked to all management staff and let them know the residents went outside without a current out on pass agreement. The ADON went out to check on them, followed by a corporate social worker, and told them they should not be smoking and to come back inside the building. They also notified management via an app on their cell phone when residents came back inside or refused to come inside. On 10/27/22 at 9:00 AM, Resident #242 was seen outside the facility at the front of the sidewalk outside the front fence entrance on the bench asking the public as they walked by for cigarettes and a light. During an interview on 10/27/22 at 10:12 AM, LPN #44 stated if a resident planned to leave the facility to go outside or go out to an appointment the facility needed a doctor's order. Some residents need a note in their orders if they needed staff supervision. If there were no notes in their file, then they could not go out of the building until that order was completed. Resident #242 was listed in the independent category, and they usually sat outside and came back in. They were not aware they were smoking or trying to smoke when sitting outside. During an interview on 10/27/22 at 10:38 AM, LPN Unit Manager #49 stated Resident #582 was a supervision level resident and should have been with a nurse or social worker when outside. During an interview on 10/27/22 at 10:51 AM, social worker #45 stated social workers do not sign out on pass orders/agreements. The Unit Managers should be signing off if a resident could leave the facility. An out on pass agreement should be in place and signed for each time a resident left the facility. The facility was a non-smoking facility. The residents could be issued warnings and could lead to a 30 day termination notice. There needs to be a physician order if a resident was going to leave the grounds. They stated they would document in the resident's progress notes that the resident went out when they were not supposed to or if they were doing something against facility policy. They would also address the issue with the management team through the group app that the resident was going out to smoke and then social work would issue the warning. They stated they would hope that a room search would be done and documented in the record. During an interview on 10/27/22 at 11:13 AM, the Director of Nursing (DON) stated the facility was a non- smoking facility. If there was a resident smoking or wanted to smoke, they would reiterate to them that it was a non-smoking facility. This would be discussed during care plan meetings as well. Smoking cessation was offered to residents and they would expect there to be behavioral care plans in place if residents go out of the front door without an approved out on pass agreement and especially if they were found smoking. They stated they were now aware that Residents #177, #242 and #582 were found to be smoking outside. They would expect a resident that had gotten outside without a pass or found smoking to have a staff member intervene and to have them come back in. They expected the staff and resident to discuss smoking. Staff should then execute a room search and document that. Those residents should have a care plan that offered a nicotine patch or smoking cessation. When Resident #582 did not have a pass and rushed out the front door the receptionist should have notified staff. The provider should review a resident's level of independence after there was a smoking incident and would also include social work and nursing. On 10/28/22 at 1:01 PM and 10/29/22 at 3:34 PM, there were multiple cigarette butts on the sidewalk around the bench and littered under the fence line and beside the fence gate. Cigarette butts were on the walkway and driveway outside the ambulance exit/entrance. Cigarette butts were also seen on the ground around the outside emergency diesel generator for the 918 building next to the front fence. The garbage can lid had an open ash tray, and there was a vape pen and three cigarette butts observed on the ground opposite the garbage can. There was no self-closing noncombustible ashtray available. During interview on 11/01/22 at 3:23 PM, the Administrator stated new smoking contracts started about a month ago. They were used with new residents moving forward to have them acknowledge and sign off on the facility being non-smoking. The facility had a new welcome packet that they had not used yet which included the smoking agreement. They were aware residents have been found outside smoking even though the facility was a non-smoking facility. The area where the residents were smoking was on facility property and smoking should not be happening at that location. They were not sure if staff were told in orientation about it being a non-smoking facility. Staff locations approved for smoking included their personal vehicles or the side lot that had picnic benches. They had found evidence of smoking on areas of the facility grounds and letters had been put out as reminders. There were no staff disciplinary action in place. The residents could be offered smoking cessation. The Administrator stated it was a violation of policy to smoke. They stated if someone goes out the front door when someone else was coming in and did not have a current out on pass agreement they should be reminded about the policy. The receptionist should be calling supervisors or managers if resident were out without a pass and if they were breaking the facility policy. It had been a difficult topic and working on cessation seemed to be the best avenue so far. On 11/02/22 at 8:21 AM, there were multiple cigarette butts on the sidewalk around the bench and littered under the fence line and beside the fence gate. Cigarette butts were seen on the walkway and driveway outside the ambulance exit/entrance. Cigarette butts were also seen on the ground around the outside emergency diesel generator for the 918 building next to the front fence. 10NYCRR 415.12 (h) | Plan of Correction: ApprovedDecember 16, 2022 Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation, record review and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 9 of 11 nursing units (1 South, 2 North, 3 South, 4 North, 4 South, A South, C North, C South, D North) observed. Specifically, resident meal trays were delivered to nursing units up to 1 hour and 31 minutes after the scheduled mealtimes. Findings include: The facility Meal Services Policy revised 4/2022 documented individuals would be encouraged to receive their meals in the dining room. Each resident shall receive meals with preferences accommodated, prompt meal service and with appropriate feeding assistance. Meals would be served promptly to maintain adequate temperature and appearance. A letter addressing the residents and family members of the facility dated 9/21/22 documented that starting on 9/28/22 there would be a new meal delivery schedule starting with the lunch meal. Those times included: 4 North: Breakfast at 7:20 AM, Lunch 11:20 AM, Dinner 4:20 PM 4 South: Breakfast at 7:35 AM, Lunch 11:35 AM, Dinner 4:35 PM 3 North: Breakfast at 7:50 AM, Lunch 11:50 AM, Dinner 4:50 PM 3 South: Breakfast at 8:05 AM, Lunch 12:05 PM, Dinner 5:05 PM 2 North: Breakfast at 8:20 AM, Lunch, 12:20 PM, Dinner 5:20 PM 2 South: Breakfast at 8:35 AM, Lunch 12:35 PM, Dinner 5:35 PM 1 South: Breakfast at 8:50 AM, Lunch 12:50 PM, Dinner 5:50 PM D North: Breakfast at 9:05 AM, Lunch 1:05 PM, Dinner 6:05 PM C North: Breakfast at 9:20 AM, Lunch 1:20 PM, Dinner 6:20 PM C South: Breakfast at 9:35 AM, Lunch 1:35 PM, Dinner 6:35 PM A South: Breakfast at 9:50 AM, Lunch 1:50 PM, Dinner 6:50 PM The mealtime schedule documented please note that meals may be up to 20 minutes early or late. During an observation on 10/20/22 at 10:22 AM staff were still serving breakfast from the main kitchen. They were assembling the C North meal trays. The scheduled breakfast time for C North was documented to be 9:35 AM (49 minutes late). During an interview on 10/20/22 at 10:27 AM, Resident #582 stated it took 3 hours to get the lunch meal on Sunday 10/16/22. They were told there were only 3 people in the kitchen. The following observations were made on 10/20/22: - at 12:32 PM, the second meal cart arrived on 4 South. The scheduled time for lunch delivery was 11:35 AM (57 minutes late). - at 1:16 PM, Resident #262 was served their lunch tray in their room on 2 North. Lunch trays were scheduled for 12:20 PM (56 minutes late). - at 1:38 PM, Corporate Administration personnel were observed passing meal trays on 1 South. At 1:47 PM, meal trays were still being passed on 1 South. Lunch trays were scheduled on 1 South at 12:50 PM. - at 1:49 PM, the D North first lunch cart was delivered to the unit. The schedule delivery time was 1:05 PM (44 minutes late). - at 2:19 PM, C North lunch trays were delivered. The scheduled delivery time for C North was 1:20 PM (59 minutes late.) - at 5:16 PM, the first dinner meal cart arrived on 4 North and at 5:22 PM, the second dinner meal cart arrived. The scheduled dinner delivery time was 4:20 PM. The first cart was 54 minutes and the second cart was1 hour and 2 minutes late. - at 5:34 PM, the 4 South dinner meal carts arrived at the unit and last meal tray was passed at 6:03 PM. The scheduled time for 4 South dinner delivery was 4:35 PM (59 minutes late). The following observations were made on 10/21/22: - at 10:04 AM, the C North breakfast trays arrived at the unit. The scheduled delivery time was 9:20 AM (44 minutes late). - at 10:41 AM, the C South breakfast trays arrived. The schedule delivery time was 9:35 AM (54 minutes late). - at 1:07 PM, the lunch trays arrived on 3 South. The scheduled time for lunch was 12:05 PM (one hour and 2 minutes late). - at 1:40 PM, lunch trays arrived at 2 North. Lunch trays were scheduled for delivery at 12:20 PM (1 hour and 20 minutes late). Registered nurse (RN) Unit Manager #4 stated Oh, there goes the lunch carts. At 1:47 PM, Resident #290 was the 1st resident to be served their meal after the carts had been on the unit for 7 minutes and untouched by staff. The following resident interviews were conducted on 10/22/22: - at 10:33 AM, Resident #76 stated breakfast time was either 8:30 AM, 9 AM or 10 AM, and there was no routine at the facility for meals. - at 11:06 AM, Resident #315 stated the meals were really late. - at 11:57 AM, Resident #329 stated the meals were always late. During an observation on 10/21/22 at 7:44 AM, the first breakfast meal cart arrived on 4 North (24 minutes later than scheduled) and the second meal cart arrived at 7:46 AM (26 minutes later than scheduled). During a telephone interview on 10/21/22 at 8:16 AM, the facility's Ombudsman stated the biggest complaints were missing items and late meals. During an interview on 10/21/22 at 9:58 AM, Resident #292 stated they wished to have a choice in mealtimes and meals were too late. During a resident group meeting on 10/21/22 at 11:06 AM, an anonymous resident stated staffing shortages were the main reason for the delay in meal tray arrivals. During an observation on 10/24/22 at 2:39 PM, C South lunch trays arrived. The scheduled delivery time was 1:35 PM (1 hour and 4 minutes late). The first tray was passed at 2:41 PM to Resident #294. The following observations were made on 10/25/22: - at 9:29 AM, the D North breakfast trays arrived on unit. The scheduled delivery time was 9:05 AM (24 minutes late). - at 10:00 AM, the C South breakfast trays were delivered 25 minutes late. - at 12:04 PM, the first lunch meal cart arrived at 4 North. Lunch for 4 North was scheduled for 11:20 AM (44 minutes late). - at 12:15 PM, the first meal cart arrived at 4 South (40 minutes late) and at 12:21 PM the second meal cart arrived (46 minutes late). LPN Unit Manager #72 stated, Hello, trays are here. - at 1:07 PM, lunch trays arrived at 2 North. Trays were scheduled to arrive at 12:20 PM (47 minutes late) and meal tray passing did not commence until 1:27 PM. - at 1:29 PM, the meal trays arrived at 3 North. The scheduled time was 11:50 AM (1 hour and 39 minutes late). - at 1:32 PM the D North lunch meal trays had not yet arrived at the unit. The scheduled delivery time was 1:05 PM. - at 1:53 PM, the lunch meal cart arrived at 1 South. Lunch trays were scheduled to arrive at 12:50 PM (1 hour and 3 minutes late). - at 2:51 PM, the C North lunch meal cart arrived on the unit. Several residents were overheard stating that it was too late for lunch. The scheduled time for lunch was 1:20 PM (1 hour and 31 minutes late). During an interview on 10/25/22 at 3:34 PM, certified nurse aide (CNA) #7 stated dinner trays came anywhere from 7 PM to 10 PM on A South. The CNA stated at night there were only like 3 staff working in the kitchen so the trays were always late. The following observations were made on 10/26/22: - at 9:20 AM, the D North breakfast tray cart was delivered to the unit 15 minutes late. - at 9:58 AM, the C North breakfast trays were delivered. The schedule time for C North was 9:20 AM (38 minutes late). - at 2:10 PM, the C South lunch trays were delivered. The scheduled lunch time was 1:35 PM (35 minutes late.) The following observations were made on 10/31/22: - at 10:03 AM, the breakfast meal carts arrived on 1 South. The schedule delivery was 8:50 AM (1 hour and 13 minutes late). - at 2:40 PM, the lunch trays arrived on C South unit. The scheduled delivery time was 1:35 PM (1 hour and 5 minutes late). During an interview on 10/31/22 at 12:35 PM, the Administrator stated the recent mealtime changes were recent and the previous times were later. They stated they changed the order of the meal trays based on the units served. The 4th floor was the first and used to be the last. The A unit was last and used to be first. They stated that 8 PM was not on the schedule for meal delivery. During an interview on 11/1/22 at 1:41 PM, the Director of Nursing (DON) stated they were aware meals were coming to the resident units late. They stated they had no idea why they were coming late and may have to do to with lacking management and staff turnover. Specifically, the Food Service Director position was vacant. The DON stated they were aware of residents complaining about late meals. These complaints were brought from Nurse Managers and resident council meetings. They stated that it was not acceptable to have residents wait so long for food and when meal carts arrived on the units, staff should assist with passing them immediately During interview on 11/1/22 at 5:20 PM, the Assistant Direct of Nursing (ADON) #51 stated they were aware that meals were late occasionally. Nurses had to go downstairs to the kitchen to get food items and this should not have to happen. They stated it was not acceptable for meals to be late. Late meals were discussed as an interdisciplinary team, and it was known there were issues at times with late meals. They stated they did not think late meals affected the residents' quality of life. During a second interview with the Administrator on 11/2/22 at 12:07 PM, they stated some mealtimes were better than others. There had been times meals that were over 30 minutes late. They stated 45-50 minutes late was not okay, but this was not a regular occurrence. The staff had 20 minutes before and after scheduled mealtime to deliver the meals. When there was a Food Service Director (FSD) there were no issues with mealtimes. During an interview with Regional RD #22 on 11/2/22 at 9:40 AM, they stated they were aware of resident meals being late over the last couple weeks. They stated they attributed the late mealtimes to the recent changes to the meal schedule. They seemed to have enough dedicated staff to get meals out on time. Not having a FSD was affecting how the kitchen ran. They were not involved in changing the mealtimes, the postings and/or family and resident notification. 10NYCRR 415.14(f)(3)(4) | Plan of Correction: ApprovedDecember 16, 2022 1. Registered Dietitian or Diet technician met with residents #262, #76, #315, #329 #290 and #292 to ensure they have no negative impact associated with meal deliveries Resident #582 was discharged . Supervisor checklist and meal schedule logs were reviewed by the Assistant Administrator director to ensure meals were delivered as scheduled. A new Food Service Director (FSD) was hired, and will begin working 11/28/2022. The assistant administrator has been appointed to oversee the food service department to provide guidance and oversight until a new director was found A senior level food service director will facilitate training and support department All food service employee vacancies are actively being filled, cross-training roles are being developed, and per diem positions have been posted, and interviews are underway. Administrator notified residents and families via weekly newsletter of meal schedule and cart delivery on 11/18/2022 2. All Residents have the potential to be Affected The facility meal times were reviewed and determined to not require changes. Meal cart and delivery will be audited for all units by the Assistant Administrator or designee daily x 7 days on nursing floors to ensure timely delivery of meals. The asst administrator or designee will meet with the resident body monthly at food council to review their meal times to ensure meets needs, requests and plan of care. Any issues or concerns will be immediately addressed Directed Plan of Correction: ò Survey Findings: 10/20/22-11/2/22, the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 9 of 11 nursing units (1 South, 2 North, 3 South, 4 North, 4 South, A South, C North, C South, D North) observed. Specifically, resident meal trays were delivered to nursing units up to 1 hour and 31 minutes after the scheduled mealtimes During an observation on 10/20/22 Breakfast Late C North was 49 minutes late. Resident #582 reports lunch on 10/16/22 3 hrs late. 4S Received lunch 57 min late; Resident #262 received lunch 56minutes late, D North care arrived 44minutes late C North arrived 59minutes late; Dinner on D North arrived 54 minutes late with the 2nd cart 1hr and 2 minutes late; 4S Dinner cart arrived 59 minutes late On 10/21/22 Breakfast and Lunch meals late as much as One hour and 20 minutes late; Resident #290 1st to receive tray (7minutes untouched by staff) Resident interviews with #76, #315, #329 report meals late Ombudsman office on 10/21-22 report complaints of late meals and missing items. During an interview on 10/21/22 at 9:58 AM, Resident #292 stated they wished to have a choice in mealtimes and meals were too late The following observations of late trays noted on 10/24- CS Lunch; 10/25- D North, 4S, 2N,3N Breakfast and Lunch: 10/26/22-Breakfast and Lunch; 10/31/22-1S Breakfast and CS Lunch Five æWhysö ò Assessment of Causative Factors: ò Lack food service department leadership to provide oversight and guidance ò Dietary staff lack understanding of need to ensure meals are delivered timely ò Dietary employees not familiar with scheduled meal service policy ò Lack of adequate oversight of the tray line and tray pass ò Insufficient cross trained staff to carry out timely delivery of meals to units ò Lack sufficient nursing staff support to address needs of units and serve meals timely and efficiently ò Poor communication between facility supervisors and administration as it relates to timely service of meals. ò Steps/Interventions Undertaken; Systemic Changes ò QA committee convened on 11/22/2022 to identify root cause and analysis on systemic changes with interventions necessary to effect changes for compliance. ò A food service director has been hired and will start on 11/28/2022. The assistant administrator has been appointed to oversee the food service department to provide guidance and oversight until a new director was found. A senior level food service director will facilitate training and support department ò Implement and complete staff competency for meal assembly and timely service of meals ò All new hires will be crossed trained within the department ò The Asst Administrator or designee will notify the Corporate / Regional Director of Food Services for guidance and directions related to meal service and delivery. ò The Asst Administrator or designee will be responsible for providing oversight related to meal service and delivery ò The Asst Administrator or designee will be responsible for providing oversight on tray assembly. ò The Asst Administrator and their designee initiated a re-education of all dietary employees on (MONTH) 22, 2022. ò All dietary employees are required to be educated on the following items before working at the facility: Meal service Policy Meal service logs and audit tools Assigned task and schedules ò Evaluation/audit tool will be developed to monitor effectiveness of these interventions ò The Asst Administrator will oversee effectiveness of above interventions until food service director shows competency. Triggers/Parameters to signal an evolving problem: ò Administrator / Director of nursing services will oversee deviation from the following established guidelines: ò ò Observing of practice to ensure compliance with meal service and delivery. ò Monitor scheduled meal times and staffing patterns ò Monitoring effectiveness and compliance to meal schedule and delivery ò Clinical leadership oversight and performance. Monitoring: Approaches to Ensure palatable food temperatures and tray accuracy are maintained will include: ò The Regional Director of Food Nutrition will conduct kitchen rounding to ensure dietary staff is adhering to proper food holding processes and tray accuracy protocols. ò Ad hoc education will be provided to persons who are not correctly following established food holding processes and tray accuracy protocols. ò Such monitoring will continue until the facility are in compliance as determined through auditing. ò Regional Director of food and nutrition will review tray accuracy and test tray evaluation audits How the facility will measure the success of its efforts: ò Center will utilize systemic reviews such as Audits/Monitoring/Observations ò The Corporate / Regional Dietitian Services Feedback ò QAPI Committee review and follow up. ò 3. The policy and procedure titled Meal Service was reviewed and no revision was necessary. Meal time has been posted on all units and communicated with resident and resident contacts via weekly letter. All food service employees will receive in service related to meal schedules. All dietary staff will receive education on adherence to shifts and time management to ensure tasks are completed to ensure trays are assembled and delivered to units on schedule. All food service employees will have competency completed to ensure tray assembly and meal times are followed All units will be stocked with snacks and fluids to offer residents between meals upon request or need. Nursing leadership and unit managers will be in serviced on corrected meal times schedule and location to ensure resident are served promptly. The Assistant Administrator or designee will review and sign the daily meal delivery log to ensure regular timely delivery of meals to units. Directed In-Service: Fed - F - 0809 - 483.60 û Frequency of Meals/Snacks at Bedtime S-S= F ò All facility administrative staff, Dietary staff, dietitians, diet technicians, RN and nursing staff will understand the contributing factors to the deficiency ò All facility administrative staff, dietary staff, dietitians, diet technicians RN and nursing staff will have understanding of their responsibilities in regards to contributing factors to the deficiency. ò A new food service director will start on 11/28/2022 to provide oversight and guidance related to timely delivery of meals ò All food service and nursing staff will be able to verbalize importance to adherence to meal time schedule to ensure resident quality of life is maintained ò Food service staff will understand their role as assigned to ensure meals are delivered to units timely ò Food Service Professionals (Food Service Director and Registered Dietitians) and administrative leadership (Administrator, Assistant Administrator and DON) will understand their role to ensure meals are served as timely and efficiently to residents according to schedule ò All new food service employees will be oriented to their assigned and posted schedule. ò Food Service Director will understand their responsibility relating to departmental meal service and production oversight ò All above staff will understand policy and procedures related to Meal service ò New food service Director will receive training and competency assessed by Senior Director Fed - F - 0809 - 483.60 û Frequency of Meals/Snacks at Bedtime S-S= F ò Review of regulation ò Review of Statement of Deficiency: ò Root Cause and Contributing Factors ò Review of Policy and Procedure: o Meal Service Policy and Cart Delivery Log ò A new Food Service Director (FSD) was hired, and will begin working full time on 11/28/2022 ò All Food Service employee vacancies are actively being filled, cross-training roles are being developed, and per diem positions have been posted, and interviews are underway. ò Asst Administrator will conduct audits and provide corrective action on meal tray service and delivery. ò New Food service staff will be oriented to assigned work schedules and meal time schedules to ensure timely delivery to units. ò New food service staff will be cross trained to dietary tasks and job flows to ensure tray line schedule is followed ò Asst Administrator will oversee effectiveness of above interventions. ò Corrective action will be initiated upon identification ò Evaluating/ auditing tool will be utilized to monitor effectiveness of these interventions ò Review of audit processes will be completed by facilityÆs Assistant Adminstrator ò Administrator will conduct random meal delivery audits ò The Regional Dietitian will perform review of above implementation and provide feedback on plan of correction. ò Evaluation/auditing tool will be utilized to monitor effectiveness of these interventions. Quality Assurance/Triggers - Observing of practice to ensure compliance with meal time and cart delivery schedule - Monitor documentation of food delivery schedule - Nursing and resident feedback to ensure positive outcomes achieved - Clinical leadership oversight and performance. 1. Evaluation of Program Effectiveness - Verbal feedback / discussion - Results of scheduled audits - DOH approval - Staff understanding of centerÆs policies and procedure relating to: Task assignments and schedules Meal service policy - Regional Clinical DirectorÆs Feedback - QI committee feedback 4. The Assistant Administrator or designee will audit 3 carts per week x 4weeks the monthly x6mths to ensure meals are delivered to units as scheduled. Any issues noted will be immediately addressed. The Assistant Administrator will report outcomes from audits with interventions to QAPI committee monthly. The need for continued reporting will be determined by the QAPI committee The Assistant Administrator or designee will complete rounding to ensure staff knowledge of meal time schedules Assistant Adminstrator will report outcomes from audits with interventions to QAPI committee monthly. The need for continued reporting will be determined by the QAPI committee Responsible Party Food Service Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: January 19, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 10/20/22-11/2/22, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #288 and 290) reviewed. Specifically; - Staff did not utilize appropriate personal protective equipment (PPE) while caring for Resident #288 who was on transmission based precautions for COVID-19. - Resident #290 was observed with their urinary catheter drainage bag uncovered and resting directly on the floor without a barrier. Findings include: The facility policy Catheter Guidelines dated 8/2019, documented to prevent catheter associated urinary tract infections (UTIs) ensure the catheter tubing and drainage bag were kept off the floor. The facility policy Isolation Precautions revised 12/2019, documented: - droplet transmission occurred when droplets traveled 3-10 feet by air when a resident coughed, sneezed, or talked; - contact transmission occurred through direct contact with the organism and then contact with another person or surface; - appropriate signage would be placed on the resident's doorway identifying the type of infection and type of precautions required; - wear a gown if body/clothing contact was likely; - wash hands before entering room, after removing PPE, and after removing gloves. Soap and water only to be used if the resident had [MEDICAL CONDITION]; - wear eye protection if within 3 feet of a resident on droplet precautions; and - wear appropriate mask prior to entering room (mask for droplet precautions and/or N95 mask depending on the disease specific recommendations). The facility COVID-19- Prevention policy, revised 10/14/22, documented the facility would: - provide healthcare personnel education about COVID-19 and how it spreads, hand hygiene guidance, and personal protective equipment (PPE) uses and competencies; - follow local and/or state guidance for additional infection prevention and control practices; - schedule dedicated employees to the extent possible to care for COVID-19 residents and provide staff training; and - provide supplies to ensure correct use of PPE. 1) Resident #288 had [DIAGNOSES REDACTED]. The 10/7/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 with bed mobility and toilet use, extensive assistance of 1 with dressing and personal hygiene, supervision after set-up with eating, and was frequently incontinent of bowel and bladder. During the entrance conference interview with the Administrator and Director of Nursing (DON) on 10/20/22 at 10:16 AM they stated there were 2 residents, including Resident #288, in the facility that were COVID-19 positive and on precautions. Staff were expected to wear a gown, gloves, eye protection, and either a KN95 or N95 mask prior to entering the room. The 10/20/22 updated comprehensive care plan (CCP) for Resident #288 documented the resident had COVID-19. Interventions included 6 feet social distancing unless providing care, use appropriate personal protective equipment (PPE), and maintain hand hygiene. During an observation on 10/24/22 at 9:41 AM, licensed practical nurse (LPN) #36 was in Resident #288's room standing at the bedside within 3 feet of the resident and was wearing a surgical mask. The LPN was not wearing an N95 mask, gown, gloves, or eye protection. The room had a sign on the doorway indicating the room was a red zone and that an N95 mask, gown, gloves, and eye protection were required when entering the room. The room also had a PPE station hanging from the door that contained N95 masks, gowns, and gloves. The LPN exited the room wearing the surgical mask. The LPN sanitized their hands at the medication cart located outside of the room, entered the hallway, and went into room [ROOM NUMBER] without changing their surgical mask. When interviewed on 10/25/22 at 4:01 PM, LPN #36 stated they had received infection control training recently that included COVID-19 protocols. The LPN stated Resident #288 had a sign on their doorway indicating the room was a red zone, meaning the resident was COVID-19 positive. The LPN stated the facility had an adequate supply of PPE to use when caring for a COVID-19 positive resident. They had worked on Resident #288's unit on 10/24/22 and knew that there was a COVID-19 positive resident on that unit. Staff were required to don a gown, gloves, eye protection and KN95 or fitted N95 mask prior to entering that room. A surgical mask was not appropriate to wear in a COVID-19 positive room. The LPN stated PPE was to be worn when in the COVID-19 positive room for infection control purposes so that the infection was not spread to other residents in the facility. The LPN did not recall if they put on appropriate PPE when in Resident #288's room and would inform the charge nurse if there was no PPE available. When interviewed on 11/1/22 at 2:48 PM, LPN Unit Manager #130 stated Resident #288 had tested positive on 10/12/22 and was still on red zone precautions. The resident had an isolation caddy on the door of their room that included required supplies needed to provide the resident care. Staff were required to wear gown, gloves, eye protection such as goggles, and a KN95 or N95 mask when providing care to any COVID-19 positive resident. Staff should don all the PPE even when passing medications. The LPN Manager was not aware the medication LPN did not wear the required PPE. The purpose of the PPE was to prevent the spread of the disease. When interviewed on 11/2/22 at 9:19 AM, Infection Preventionist #120 stated each floor had a COVID-19 binder containing facility policies and procedures that staff had to sign when read. They stated they were doing constant rounding on the units and hanging signs informing staff how to wear the appropriate masks. The expectation was staff were to wear a N95 mask, gown, gloves, and eye protection when going into a COVID-19 positive room. There should be a PPE caddy station hanging from the resident's door. There should be signs on the doorway displaying the type of precautions the resident was on and what PPE was needed to enter the room. The resident's room should contain separate isolation bins for linen and garbage. PPE should be donned outside the doorway and taken off just inside the door to the room. Hands should be washed with soap and water and not just hand sanitizer. Gloves should not be worn in the hallway. They stated the facility's focus was preventing infectious outbreaks. 2) Resident #290 had [DIAGNOSES REDACTED]. The 10/1/22 quarterly MDS documented the resident had a [DIAGNOSES REDACTED]. The 12/22/21 medical order by nurse practitioner (NP) #119 documented indwelling catheter, 16 French (size), 10 milliliter (ml) retention balloon, non-silicone, change every 30 days, on day shift, every month starting on the 22nd for urine retention. The 10/8/22 comprehensive care plan (CCP) initiated on 5/12/22, documented the resident was at risk for infection related to diabetes and [MEDICAL CONDITION]. Interventions included monitor labs and monitor output for signs and symptoms of infection. The resident had an indwelling catheter related to neuromuscular dysfunction of bladder. Interventions included catheter care every shift, change catheter as ordered, indwelling catheter 16 French, 10 ml balloon, maintain bag below bladder level, monitor and record urine, report to the physician for signs and symptoms of urinary tract infection. The 10/26/22 resident care instructions documented catheter care every shift, the resident had an indwelling catheter, ensure to manage catheter, and maintain urine collection bag below the level of the bladder. Observations of Resident #290 included: - on 10/20/22 at 3:53 PM, the resident was lying in bed and the uncovered urine collection bag was directly on the floor without a barrier; - on 10/21/22 at 8:39 AM, 12:28 PM, and 1:19 PM, the resident was sitting in a reclined chair near the nurse's station with the uncovered urine collection bag resting directly on the floor; - on 10/25/22 at 8:58 AM, the resident was in bed eating breakfast and the uncovered urine collection bag was directly on the floor; - on 10/25/22 at 11:30 AM, the resident was in bed with the uncovered urine collection bag directly on the floor; - on 10/25/22 at 1:50 PM, the resident was sitting in a reclined chair with the uncovered urine collection bag directly on the floor; and - on 10/25/22 at 4:03 PM, the resident was sitting in reclined chair in the hallway outside of their room with the uncovered urine collection bag resting on floor. During an interview on 10/26/22 at 2:49 PM CNA #50 stated the urine collection bag should not be on the floor to prevent germs from entering the bag and causing an infection. During an interview on 10/31/22 at 2:36 PM, registered nurse (RN) Unit Manager #4 stated they did not think the resident currently had a urinary tract infection but had a history of [REDACTED]. They had told the CNAs multiple times that leaving the urine collection bag on the floor was a breeding ground for infection and germs from the floor could enter the bag. During an interview on 11/01/22 at 10:57 AM, physician #54 stated the resident had a [DIAGNOSES REDACTED]. The urine drainage bag should not have been left directly on the floor. The physician stated there was deficits with nursing staff and infection control practices. During interview on 11/2/22 at 9:19 AM, the Infection Preventionist RN #120 stated appropriate catheter care/infection prevention education was provided to all nursing staff. The staff should make sure the catheter was patent and the urine collection bags should be changed when they appeared unclean. The urine collection bag should never be on the floor as this was a means of getting an infection. The Preventionist stated the facility's focus was preventing infectious outbreaks. 10NYCRR 415.19(a)(1-2)(b)(1-4)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification post survey review conducted 1/4/23-1/6/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #501) reviewed. Specifically, staff did not utilize appropriate personal protective equipment (PPE) while caring for Resident #501 who was on transmission based precautions for influenza (flu). Findings include: The facility policy Influenza-Vaccination/Control revised 4/2019 documented the facility followed current guidelines and recommendations for the prevention and control of seasonal influenza. Staff would adhere to Droplet Precautions including gowns, gloves, and hand hygiene. Droplet Precautions would be implemented for residents with suspected or confirmed influenza for 7 days after onset or until 24 hours after resolution or respiratory symptoms. In some cases, Droplet Precautions may be applied for longer periods. The facility policy Isolation Precautions revised 12/2019, documented: - droplet transmission occurred when droplets traveled 3-10 feet by air when a resident coughed, sneezed, or talked; - contact transmission occurred through direct contact with the organism and then contact with another person or surface; - appropriate signage would be placed on the resident's doorway identifying the type of infection and type of precautions required; - wear a gown if body/clothing contact was likely; - wash hands before entering room, after removing PPE, and after removing gloves; - wear eye protection if within 3 feet of a resident on droplet precautions; and - wear appropriate mask prior to entering room (mask for droplet precautions and/or N95 mask depending on the disease specific recommendations). Resident #501 had [DIAGNOSES REDACTED]. The 12/13/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 1 with most activities of daily living (ADLs) and received oxygen therapy. The MDS did not document if the resident received the influenza vaccine for the current flu season. The 11/18/22 comprehensive care plan (CCP) documented the resident had an alteration in respiratory system and was at risk for cross contamination to potential COVID-19 exposure. Interventions included nebulizer (aerosol medication machine) treatments as ordered, provide supplemental oxygen as ordered, observe for poor airway clearance and gas exchange, and vital signs as ordered. The CCP did not include influenza [DIAGNOSES REDACTED]. The 12/30/22 test for flu by nasopharyngeal polymerase chain reaction (PCR, a highly accurate test to determine presence of flu and type of strain) documented the resident was positive for Flu A. The 12/31/22 at 12:16 PM registered nurse (RN) #16 progress note documented the resident's flu swab resulted positive for flu A. Nurse practitioner (NP) #28 was made aware and ordered Xofluza ([MEDICAL CONDITION] medication) and take vital signs every 4 hours. The resident was placed on isolation. During an observation on 1/4/23 at 12:07 PM, Resident #501's room had a sign on the doorway documenting the resident was on droplet/contact precautions. The sign documented staff were to put on a N95 mask, gown, gloves, and eye protection at the door prior to entering the room. There was only 1 resident assigned to that room. The room door had a PPE caddy hanging from the door and the door was open about 12 inches. Assistant Director of Nursing (ADON) #15 stated the resident was on droplet precautions due to having the flu. During an observation on 1/4/23 at 3:34 PM, licensed practical nurse (LPN) #18 entered Resident #501's room with gloves and a surgical mask on. The LPN did not don a gown or eye protection prior to entering the room. The resident was not wearing a mask. The LPN talked to the resident briefly, exited the room, went to a medication cart by the nursing station, went back into the room without donning a gown or eye protection, closed the door most of way, came back to the door 10 seconds later, grabbed a gown from the door caddy and began donning the gown in the entryway to room. The LPN then closed the door to the room. When interviewed on 1/4/23 at 3:45 PM, LPN #18 stated staff needed to put on a gown, gloves, and mask prior to entering Resident #501's room. The LPN was unsure why the resident was on precautions. The LPN stated infection control education was recently done. The LPN stated they did not put on a gown initially as they only entered to ask the resident a question. The LPN stated they did not don a gown the second time entering the room as the LPN's hands were full. They donned a gown when they had to provide care to the resident. When interviewed on 1/4/23 at 4:45 PM, certified nurse aide (CNA) #19 stated staff were to wear a surgical mask throughout the building, don gloves prior to providing hands on care, don a gown if there was a PPE caddy on the outside of the resident's door, and a N95 mask if they were in that same caddy. All staff were to wear eye protection for anyone on droplet precautions. All PPE was to be put on in the hallway prior to entering the room. Staff recently received PPE education. The CNA did not think PPE needed to be worn if just delivering or picking up a meal tray in the room. During an observation on 1/4/23 at 4:54 PM, CNA #19 delivered a meal tray to Resident #501's room wearing only a surgical mask for PPE. The CNA set the meal tray on an overbed tray table, asked if the resident wanted something else, exited the room, sanitized their hands, and went to pass a meal tray to another resident. CNA #19 was not observed changing masks after exiting Resident #501's room and before entering another resident room. During an observation on 1/5/23 at 10:08 AM, the door to Resident #501's room was open and the droplet/contact precautions sign on the door was in place. The resident was lying in bed in a hospital gown. Certified occupational therapy assistant (COTA) #20 was in the room at the bedside about 2 feet from the resident. The COTA had a N95 mask and gloves on and was not wearing a gown or eye protection. The resident did not have a mask on. There were no gowns or eye protection observed in the PPE caddy hanging from the room door. The COTA pulled the curtain in the room and began assisting the resident with care and dressing while standing about 2 feet or less from the resident. At 10:17 AM, the COTA moved the overbed table and walker in the resident's room, got a wheelchair from across the room and assisted the resident to self-transfer from the bed to the wheelchair. The resident was observed coughing twice. Once in the wheelchair, the resident removed an oxygen nasal cannula from their face, handed it to the COTA, and the COTA placed it on the bedside stand. At 10:23 AM, the COTA wheeled the resident to the bathroom and closed the door about ¾ of the way. Through the partially opened bathroom door the COTA was observed assisting the resident. The resident continued to occasionally cough and did not have a mask on. At 10:41 AM, the COTA assisted the resident out of the bathroom via a wheelchair. The COTA then entered the bathroom, removed the N95 mask and gloves and washed their hands. The COTA exited the room and donned a surgical mask from the PPE caddy. When interviewed on 1/5/23 at 10:43 AM, COTA #20 stated they had facility orientation around 8/2022 and had not received infection control education recently. The COTA stated the resident was on droplet precautions as they recently had the flu. The COTA stated a nurse informed them the resident no longer had the flu but could not remember which nurse had told them. The COTA stated they did not don a gown prior to entering the room as there were none in the caddy. There was a sign on the doorway specifying what PPE was to be donned prior to entering the room and if the sign was on the doorway, staff should don the appropriate PPE. The COTA stated they did not ask unit staff if the resident was still on precautions prior to entering the room and did not get a gown from another PPE station or ask unit staff for more gowns. The COTA stated the resident was not wearing a mask and had coughed a few times while the COTA was within 2-3 feet of the resident. PPE should be worn to prevent staff from becoming infected with the resident's illness when the resident coughed. During an observation on 1/6/23 at 10:05 AM, Resident #501's room continued to have a Droplet/Contact Precautions sign and a PPE caddy on the doorway. During an observation on 1/6/23 at 10:19 AM, housekeeper #21 entered Resident #501's room wearing an N95 mask and gloves. The housekeeper was not wearing a gown or eye protection. The housekeeper exited the room, gathered cleaning supplies, reentered the room, cleaned the bathroom, exited the bathroom, exited the room, went to the cleaning cart outside the doorway, removed the gloves and donned new gloves. The housekeeper did not perform hand hygiene prior to donning the new gloves. The housekeeper reentered the room, LPN #22 told CNA #23 to hand the housekeeper a gown. The CNA took a gown from the door caddy, handed it to the housekeeper, and the housekeeper put on the gown. When interviewed on 1/6/23 at 10:40 AM, housekeeper #21 stated they were not sure when they were last educated about PPE and had difficulty understanding English. The housekeeper stated they had only worked in the facility about 3 weeks and had facility orientation when starting employment. The housekeeper stated they could read the words on the Droplet Precautions sign on the doorway but was unable to describe the meaning. The housekeeper did not know why they were supposed to wear PPE in the room and did not understand the purpose of precautions. The housekeeper knew what each picture of the individual PPE on the sign was but was not sure what PPE was required prior to entering the room. When interviewed on 1/6/23 at 10:50 AM, LPN #22 stated staff were educated a couple of weeks ago regarding infection control and wearing of PPE was included. Staff were to wear a N95 mask, gown, gloves, and eye protection when entering room Resident # 501's room as the resident had the flu. Corporate staff audited PPE use, and the LPN was unsure how often that was done. The LPN stated unit staff were to immediately educate and ensure other staff member don the appropriate PPE if they were seen not wearing appropriate PPE. When interviewed on 1/6/23 at 11:02 AM, LPN Unit Manager #17 stated Resident #501 was positive for flu and staff recently had infection control in-services given by the Director of Nursing (DON) and both Assistant Directors of Nursing (ADONs). The LPN Manager stated all nursing staff received the education. Prior to entering Resident #501's room, staff were to don a N95 mask, gown, gloves, and eye protection as indicated on the sign on the room door. The ADONs were performing PPE wearing audits, but the LPN Manager was unsure of the frequency. If staff were unsure of what PPE to don, they were expected to ask other unit staff. If a staff member was observed not wearing the correct PPE, other staff were to immediately reeducate and ensure the correct PPE was put on. The LPN Manager stated they monitored appropriate wearing of PPE when doing hourly unit rounds. Additional PPE was to be obtained from central supply by the LPN Manager or supervisor if there was none in the caddy. When interviewed on 1/6/23 at 11:27 AM, the Director of Therapy stated therapy staff received Infection Control education during facility orientation and during the contract agency's orientation. All therapists in the facility worked for a contract agency. The last infection control education their department received was on 12/21/22. When interviewed on 1/6/23 at 11:35 AM, ADON #15 stated recent infection control education was provided by themselves, the other ADON, the Infection Control RN and off-shift supervisors. All staff received the education either in person or via telephone call from the end of 11/2022 through 12/2022. Staff were required to complete the sign in sheets. Staff knew what PPE was required as there was a sign on the doorway to the resident's room informing them and there was a PPE caddy on the door with supplies. The ADONs were performing PPE wearing audits every week for 12 weeks. Staff were to wear a N95 mask, gown, gloves, and eye protection for a resident that had the flu. Additional PPE supplies were to be obtained from central supply by the Unit Manager or Nursing Supervisor. Staff were to don the appropriate PPE before they entered the room. The purpose of the PPE was to prevent cross contamination of germs, especially if the resident was coughing. The resident on precautions was not required to wear a mask in their room. When interviewed on 1/6/23 at 11:47 AM, Infection Control RN #24 stated infection control education, including PPE wearing, was begun after the recertification survey and was continuous. All staff received the education. Those with language barriers brought a partner who was able to explain the training to those that had difficulty understanding. Internet pictures were also used. Required PPE for droplet precautions were N95 mask, gown, gloves, and eye protection. Eye protection consisted of goggles or a face shield. PPE was to be donned in the hallway prior to entering the room and taken off just inside the hallway door. Hand hygiene was to be performed each time after removing gloves either by washing with soap and water for 20 seconds or using hand sanitizer. All staff were to correct and educate any staff member not performing infection control procedures appropriately. When interviewed on 1/6/23 at 12:26 PM, the DON stated staff should wear PPE into a room based on the signage outside the doorway to that room. Education for those with language barriers was done using a translator, through lectures, and there was no posttest. The staff with language barriers were only required to state that they understood the education. Staff were required to wear N95 mask, gown, gloves, and eye protection in rooms for residents on droplet precautions. Each precaution room had signage and a PPE caddy on the hallway door. Staff were to immediately correct and reeducate other staff not in compliance. PPE was worn to prevent cross contamination of germs to other residents, staff, and those outside the facility. Influenza was highly contagious. At 2:00 PM, the DON stated everyone on isolation precautions was supposed to have an order for [REDACTED]. When interviewed on 1/6/23 at 12:44 PM, the Medical Director stated the flu was highly contagious in the facility setting, most residents were immunocompromised, and the flu was spread via airborne means. 10NYCRR 415.19(a)(1-2)(b)(1-4) | Plan of Correction: ApprovedFebruary 9, 2023 1. The facility retained the services of an outside Consultant to perform the services of developing a plan of correction addressing the cited deficiency. Resident #288 was evaluated by the provider and suffered no ill effects. All licensed nurses on duty 10/24/22 on unit 4 South were educated on infection control with emphasis on required PPE for COVID isolation Resident #290 was evaluated by provider and suffered no ill effects. All nursing staff on duty on 2 North on 10/20/22, 10/21/22 and 10/2522 during the 7a-3p and 3p û 11p shift were educated on Infection Control with emphasis on the importance and expectation od urinary collection bags being covered and not resting on the floor 2. The Quality Assurance Committee convened to examine the deficiencies under F880 All residents on isolation precautions have the potential to be affected A Full house audit was conducted of all residents on Isolation precautions to ensure staff entering the resident room donned the required PPE All residents with indwelling catheters have the potential to be affected ò A Full house audit was conducted of all residents with indwelling catheters to ensure urinary catheter collection bags were not uncovered, and/or resting directly on the floor 3. Polices on Catheter guidelines Isolation precautions reviewed. No revisions required All nursing staff educated on the requirement, importance, expectation and steps to providing a safe, sanitary and comfortable resident care environment to help prevent the development and transmission of communicable diseases and infection, including use of PPE and management of urine collection bags 4. Director of Nursing/Designee will conduct rounds to audit infection control practices on units. (2) staff per unit and all residents with indwelling catheters will be observed. The audit will be conducted weekly x 12 weeks. Audit will continue weekly until substantial compliance is achieved Consultant will review audits for completion and ensure any required corrective action was conducted. Consultant will complete a report of findings Consult will conduct audit review and report of findings weekly x 4 weeks then monthly x3 months. Monthly review will continue until substantial compliance is met Audit findings and Consultant report will be submitted to the facility QAPI committee monthly for review and recommendations. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated (NY 577) surveys conducted 10/20/22-11/2/22, the facility failed to complete a thorough investigation for 1 of 1 residents (Resident #239) reviewed. Specifically, Resident #239 reported missing personal property and cash contained in a suitcase, the suitcase and its contents went missing, the facility did not thoroughly investigate the allegation and there was no evidence the resident was reimbursed for the missing personal property. Findings include: The facility policy Personal Property revised 8/2019, documented the facility would inventory resident personal possessions upon admission and the facility would promptly investigate any complaints of misappropriation or mistreatment of [REDACTED]. The undated facility Clothing Label Request form was in triplicate, with one copy distributed to laundry, one copy distributed to the resident's family, and another copy distributed to the social worker. The form documented to retain for your records and the facility would not replace lost clothing unless the yellow slip was produced. Resident #239 had [DIAGNOSES REDACTED]. The 9/23/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance of one for most activities of daily living (ADLs). There was no inventory list for personal belongings or a Clothing Label Request form in Resident #239's electronic health record. A facility Missing Item Report filed on 2/10/22 by social worker (SW) #80 (no longer employed at facility), documented Resident #239's had missing items contained in a black suitcase. A black suitcase, 7 tops, PJs, 7 boxers, white socks, toiletries, and $100 cash in a black pouch. Next to these missing items was a note that documented wrote their name on everything. The SW included a note on the Missing Item Report documenting they were notified by the family that the resident was missing a suitcase and the SW had never seen a black suitcase when the resident moved to another room in the facility. The Missing Item Report was signed off by a former facility Administrator on 2/22/22. Nursing progress notes dated 1/21/22-11/1/22 did not document any missing personal property. A social worker progress note dated 2/10/22 at 2:36 PM by SW #80 documented an initial care plan meeting with the resident's spouse present. There was no documentation regarding the resident's missing personal property. During an interview on 11/1/22 at 11:30 AM with front lobby receptionist #78 they stated if a family representative brought in clothing for a resident, they would fill out a Clothing Label Request form available at the front lobby desk, then laundry would pick up the clothing to mark with the resident's name. Food could go right to a resident's room. Money would be put into a resident's account at the front lobby desk. On 11/1/22 at 11:36 AM there was no black suitcase observed in the resident's room. An unidentified medication nurse and CNA nearby stated they had never seen a black suitcase in the resident's room. During an interview on 11/1/22 at 11:46 AM with SW #45 they stated they were not aware of any missing property for Resident #239. The resident had a care plan meeting in (MONTH) (2022) and the topic was not brought up in the meeting. They were not aware of the Clothing Label Request form or of any inventory form used for residents upon admission. Since the resident had moved to another unit recently (Unit 4 to Unit 1) the resident's new SW was the Director of Social Work. During an interview on 11/1/22 at 11:56 AM with the Director of SW, they stated they were not aware of any missing personal property or money for Resident #239 from 2/10/22. If a resident was missing any personal property, they would fill out a misappropriation of belongings form. They knew the resident had reported a missing TV remote control recently, but that was replaced. They thought the facility concierge might know how to keep track of resident personal belongings when they were brought in on admission, but they would check with the assistant administrator first. During an interview on 11/1/22 at 12:00 PM with Assistant Administrator #77, who handled resident grievances, they stated this was the first time they heard about Resident #239 missing any personal property or cash. The resident did not have any grievances filed. During an interview on 11/1/22 at 4:47 PM with Resident #239 they stated they had never been reimbursed for the missing suitcase containing the personal belongings or the cash. They stated the facility had lost it. During the interview on 11/1/22 at 4:47 PM with Resident #239's spouse, they stated that a family member had brought a black suitcase with clothing and money for the resident. They had left it at the front lobby desk at the end of (MONTH) (2022) when the resident was admitted from the hospital. The family member did not take the suitcase to the resident's room, and they were not asked to inventory the items. The resident's spouse then stated the next time they came to visit the resident on 2/10/22 they did not see the suitcase with the personal belongings and cash, so they reported it missing to a SW who no longer worked at the facility. The resident's spouse stated they had never filled out a grievance form and the missing items and cash were never reimbursed. During an interview on 11/2/22 at 8:55 AM with Business Office Manager #81 they stated they had only been in this role for a few days. They looked up the resident's name to see if there was a resident account and there was none. A copy of the Missing Items Report was provided to the Business Office Manager who stated they would look into it and speak with the higher-ups. 10NYCRR 415.4(b)(3) | Plan of Correction: ApprovedDecember 16, 2022 1. An investigation was conducted for the reported missing personal property of Resident #239 and reimbursement to be provided 2. All residents with reported missing property have the potential to be affected. An audit was conducted of all grievances in the past 30 days to ensure that a thorough investigation was completed and residents were reimbursed if indicted. Audit conducted of all residents with room changes that occurred in the past 30 days to ensure no personal belongings were missing. An investigation will be conducted of any identified missing items. 3. The policy on Person Property was reviewed. Revisions made to include other times that inventory is to be taken such as when items are delivered to the facility and when room change occurs Director of Social Work assigned to be facility Grievance Officer Members of the interdisciplinary team educated on the grievance process including investigation and reimbursement Inventory of items will be taken when personal belongings are dropped off at the front desk, Housekeeping staff will collect belongings from the front desk for Labeling and return items to the front desk. Nursing staff will retrieve items from the front desk. Confirm the inventory and deliver to resident. All Nursing, Housekeeping and Front Desk staff educated on the process 4.An audit will conducted of by Director of Social Work/Designee of all grievances to ensure that a thorough investigation was completed and residents were reimbursed if indicted. The audit will be conducted weekly x 12 weeks and continue weekly until substantial compliance has been me. An Audit will be conducted on all resdients who have room changes to ensure that all personal belongings are present. Audit will be conducted weekly x 12 weeks and continue weekly until substantial compliance is met Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Social Work |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: January 19, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 10/20/22-11/02/22, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 6 medication carts (2 North) and 1 of 9 medication rooms (the 2 North clean storage/medication room) reviewed. Specifically: - prescribed controlled drugs on the 2 North unit were stored in an untethered (free moving) medication cart and not in a permanently affixed compartment as required; and - controlled substance medications including liquid [MEDICATION NAME] syringes, discontinued [MEDICATION NAME] ([MEDICATION NAME] with [MEDICATION NAME], an opioid pain reliever) and [MEDICATION NAME] (contains opioid) were stored in single locked cabinet in the clean storage/medication room. Findings include: The facility policy Medication Storage revised 1/2019 documented the facility's medications were stored in a manner that maintained the integrity of the product, ensured the safety of the residents, and was in accordance with the Department of Health guidelines. And except for Emergency Drug Kits, all medications would be stored in a locked cabinet, cart or medication room that was accessible only to authorized personnel, as defined by facility policy. The facility policy Medication, Narcotic Management revised 4/2019 documented all narcotic and Schedule II drugs would be maintained in a medication cart in a locked drawer. During an observation on 10/25/22 at 3:58 PM, the 2 North clean storage/medication room door was open. A single locked medication storage cabinet contained 114 [MEDICATION NAME] concentrate 5 milligram (mg)/0.25 milliliter (ml) syringes, 2 tablets of discontinued [MEDICATION NAME] 10-325mg and 2 tablets of discontinued [MEDICATION NAME]. During an observation on 10/25/22 at 4:05 PM, the 2 North medication cart was not tethered to a fixed area, was sitting behind the nursing station, and contained 45 blister packages (a total of 1,051 tablets) of controlled substance medications for the entire unit. The blister packages were not in a double locked compartment and permanently affixed as required. The medication cart contained the following controlled substances: -167 tablets of [MEDICATION NAME] (an opioid pain reliever) 50 milligrams (mg) -345 tablets of [MEDICATION NAME] (an opioid pain reliever) 5 mg instant relief (IR) -40 tablets of [MEDICATION NAME] with Tylenol 10/325 mg -1 tablet of [MEDICATION NAME] with Tylenol 7.5/325 mg -21 tablets of Briviact (anti-[MEDICAL CONDITION]) 50 mg -163 tablets of [MEDICATION NAME] with Tylenol 5/325 mg -28 tablets of [MEDICATION NAME] (anti-anxiety) 0.5 mg -30 tablets of [MEDICATION NAME] 1 mg -36 tablets of [MEDICATION NAME] (anti-anxiety) 0.5mg -70 tablets of [MEDICATION NAME] 1 mg -150 tablets of [MEDICATION NAME] (an opioid agonist)10 mg During an interview on 10/25/22 at 4:20 PM, licensed practical nurse (LPN) #36 stated the medication cart needed to be locked in safe secure medication storage. The medication cart contained all the narcotics for the unit except for 2 or 3 people. All staff had access to the clean storage/medication room, and once the keys were accepted the nurse was responsible for the medication storage room and the medication cart. During an interview on 11/02/22 at 10:22 AM, the Director of Nursing (DON) stated narcotic medications should be stored under a double lock and if not in use they should be locked in the cabinet. The DON stated discontinued medications should be stored in the narcotic cabinet in the storage room, which also doubled as the clean storage room, had a keypad for entry, contain narcotic boxes and all staff had access to the clean storage rooms. They stated they were recently made aware that the cabinet did not have a lock and it was fixed. They stated that narcotics were controlled substances and should not be accessible to unauthorized people. 10NYCRR 483.45(h)(2)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the on-site post survey review (PSR) conducted 1/4/23-1/6/23, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 2 of 11 medication carts (2 North and 4 North) reviewed. Specifically, prescribed controlled drugs on the 2 North and 4 North units were stored in untethered (free-moving) medication carts and not returned to the double-locked medication room cabinets after the medication passes were completed as required. Findings include: The facility policy Medication Storage, revised 1/2019, documented the facility's medications were stored in a manner that maintained the integrity of the product, ensured the safety of the residents, and was in accordance with the Department of Health guidelines. Except for emergency drug kits, all medications would be stored in a locked cabinet, cart or medication room that was accessible only to authorized personnel, as defined by facility policy. Staff training on medication storage dated 11/30/22 signed by licensed practical nurse (LPN) #3 and an orientation checklist dated 12/22 signed by LPN #4 included education on understanding the importance and expectation that narcotic medication was stored according to regulations. No signature was documented for registered nurse (RN) #2. During an interview on 1/4/23 at 1:22 PM, licensed practical nurse (LPN) #4 stated their medication pass was completed on 2 North. They stated their medication cart contained all the unit's controlled medications. LPN # 4 stated they were a new LPN as of December. The LPN stated they had an orientation checklist to complete that included medication administration and medication storage of controlled medications and they had a preceptor. They stated controlled medications were supposed to be locked in the medication room cabinet at the conclusion of a medication pass. LPN #4 stated they should have locked up their controlled medications in the medication room when they went to lunch. During an observation on 1/4/23 at 1:43 PM the 2 North medication cart was located against a wall in the hallway untethered and unattended. Upon return to the medication cart at 1:45 PM, LPN #4 opened the locked drawer of the medication cart. The drawer contained the entire inventory of controlled medications for the unit for all administration times and shifts. Controlled medications observed included: - [MEDICATION NAME] (pain relief) 50 milligrams (mg) - 14 tablets - Briviact (anti-[MEDICAL CONDITION]) 50 mg - 29 tablets - [MEDICATION NAME] IR (opioid pain relief) 5 mg - 203 tablets - [MEDICATION NAME] (anti-anxiety) 0.5 mg- 65 tablets - [MEDICATION NAME] (opioid pain relief) 5/325 mg - 119 tablets - [MEDICATION NAME] (sedative, anti-[MEDICAL CONDITION]) 0.5 mg- 59 tablets - [MEDICATION NAME] (opioid) 10 mg - 46 tablets - Xtampra ER (opioid pain relief) 9 mg - 17 capsules - [MEDICATION NAME] sulfate IR (opioid pain relief) 15 mg- 60 tablets - [MEDICATION NAME] ER (extended release opioid pain relief) 10 mg - 8 tablets - pregabalin (nerve pain medication) 75 mg - 59 capsules - [MEDICATION NAME] (sedative) 5 mg -16 tablets - [MEDICATION NAME] 10/325 mg- 53 tablets - [MEDICATION NAME]/apap ([MEDICATION NAME] with Tylenol) 7.5/325 mg - 29 tablets During an observation on 1/4/23 at 2:15 PM on unit 4 North (4N), registered nurse (RN) #2 opened the medication room controlled drug storage cabinet and there were no controlled drugs inside. The low side medication cart contained all controlled medications for the residents who resided on that side of the hall. RN #2 stated there were no residents scheduled to receive controlled medications for that medication pass and the medication pass for the shift was completed. The RN stated all the low side controlled medications were in the medication cart, and they did not return them to the double-locked, affixed cabinet in the medication room. Controlled medications in the low side cart included: - [MEDICATION NAME] IR 5 mg - 109 tablets - pregabalin 100 mg- 7 capsules - [MEDICATION NAME] ER 10 mg- 11 tabs - [MEDICATION NAME]/apap 325mg- 40 tablets During an observation on 1/4/23 at 4:16 PM on unit 4 North, LPN #3 was the evening medication nurse and was passing medications. The medication cart for the low side was not in use and contained all the controlled medications for the low side rooms 421-430. Controlled medications in the low side cart included: - [MEDICATION NAME] IR 5 mg- 109 tablets - pregabalin 100mg- 7 capsules - [MEDICATION NAME] ER 10 mg- 11 tablets - [MEDICATION NAME]/apap 5/325mg - 39.5 tablets LPN #3 stated the controlled medications were in both medication carts for the entire unit (low side and high side) and they did not have any controlled medications locked in the medication room. They were passing medications for the high side of the hall at that time and were not passing medications for the low side. During an interview on 1/6/23 at 10:15 AM, the Director of Nursing (DON) stated all licensed nurses were educated on medication administration and storage. The Unit Managers who were both LPNs and RNs were responsible for rounding on the units to observe medication storage. It was not acceptable that controlled medications were in the medication carts after medication passes were completed, or medication carts containing controlled medications were left unattended. The controlled medications should be returned to the medication room cabinet when not in use. During an interview 1/6/23 at 11:09 AM with RN Unit Manager #13, they stated they were the Unit Manager for both 2 North and 2 South. They stated they were responsible for rounding on the units and had not done any auditing or rounding regarding controlled medications on the 2 North unit. They stated the risk of leaving a medication cart unattended with controlled medications would be that any person could take the medication cart out of the building. Controlled medications should be returned to the medication room when the medication passes were completed. During an interview on 1/6/23 at 11:30 AM with RN Unit Manager #14, they stated they were responsible for the oversight of the 4 North unit, including the medication carts. RN Unit Manager #14 stated the controlled medications should be returned to the narcotic cabinet in the medication room when the medication passes were complete. The medication nurses were ultimately responsible because they were the sole holders of the medication cart and medication storage room keys. During an interview on 1/6/23 at 2:00 PM with the DON, they stated they expected staff to be compliant with medication storage policy. The Assistant Directors of Nursing (ADONs) and RN Unit Managers did rounds three times per week and audits to ensure compliance with medication storage. Morning report included ongoing conversations regarding accessibility for the medication nurses with the keypads on the medication carts and storage rooms. They stated the only controlled medications that should be in the medication carts were for the current medication pass only. The rest of the controlled medications should be locked in the narcotic cabinets in the medication storage rooms. All nurses had been educated on this topic. 10NYCRR 483.45(h)(2) | Plan of Correction: ApprovedJanuary 27, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Narcotic medication removed from medication cart at the conclusion of the medication pass. And placed under double lock in affixed cabinet. Narcotic cabinet lock repaired and all narcotic medication, including [MEDICATION NAME] placed under double lock. 2. All residents have the potential to be affected. Rounds conducted on all untis to ensure Prescribed controlled drugs were not stored in an untethered (free moving) medication cart when not in use and all narcotic medication is stored in a double locked cabinet 3. F 761 Label/Store Drugs and Biologicals SS=D The facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 6 medication carts (2 North) and 1 of 9 medication rooms (the 2 North clean storage/medication room) reviewed. Specifically: ò Prescribed controlled drugs on the 2 North unit were stored in an untethered (free moving) medication cart and not in a permanently affixed compartment as required; and controlled substance medications including liquid [MEDICATION NAME] syringes, discontinued [MEDICATION NAME] ([MEDICATION NAME] with [MEDICATION NAME], an opioid pain reliever) and [MEDICATION NAME] (contains opioid) were stored in single locked cabinet in the clean storage/medication room. Narcotic medication removed from medication cart at the conclusion of the medication pass. And placed under double lock in affixed cabinet. Narcotic cabinet lock repaired All residents have the potential to be affected. Rounds conducted on all untis to ensure Prescribed controlled drugs were not stored in an untethered (free moving) medication cart when not in use and all narcotic medication is stored in a double locked cabinet Polices on Medication storage Medication: Narcotic Management reviewed. No revisions required All licensed nurses educated on the importance and expectation that Prescribed controlled drugs are not stored in an untethered (free moving) medication cart when not in use and all narcotic medication is stored in a double locked cabinet On units 1S, 2N, 2S ,3N, 3S, 4N and 4S All non-medication clean storage supplies relocated to alternate storage space on units and locks changed to transition the room to Medication rooms with licensed nurses having sole keyed access. 4. DON/Designee will conduct an audit on all units to ensure Prescribed controlled drugs are not stored in an untethered (free moving) medication cart when not in use and all narcotic medication is stored in a double locked cabinet. The audit will be conducted weekly x12 weeks and continue weekly until substantial compliance has been met Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Nursing |
Scope: N/A
Severity: N/A
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to properly maintain documentation of quarterly reviews of emergency supplies under Public Health Law 2803-12. Specifically, there was no documented evidence the facility conducted quarterly inventory of the emergency 72-hour food and water supply as required by New York State. Findings include: On 10/24/22 at 11:00 AM, the facility Emergency Preparedness and Disaster Plan did not include documentation of quarterly reviews of 72-hour supply inventories for emergency food or water for 2022. During an interview on 10/24/22 at 11:00 AM, the Food Service Director stated that the emergency food was checked quarterly but was not documented. They had been completing this task weekly. They stated they were not sure the last time the emergency water had been checked. During an interview on 11/2/22 at 9:45 AM, the Assistant Administrator stated they could not find the prior quarterly emergency food and water inspections for 2022 and an inspection was completed on 10/24/22. During an interview on 11/2/22 at 1:30 PM, the Administrator stated that they were aware that emergency food and water was required to be inspected quarterly and was last completed on 10/24/2022. They expected quarterly inspections to be completed since the last federal survey, which was 6 months ago. PHL 2803-12(a) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility conducted an audit of the emergency food supply against the emergency menu. The audit was documented. Deficient items were addressed. 2. All residents could have been affected by the deficient practice. No residents were affected. 3. Facility policy related to Emergency Food Supply was reviewed with no recommended changes. The Food Service Director and the Administrator were educated on the requirement that an emergency food supply audit be conducted and that the review be documented and stored in an accessible area. 4. An audit of the emergency food supply and documented audits will be conducted by the Food Service Director of designee quarterly x2. Results of the audit will be shared with the QAPI committee during monthly QAPI meetings for review and advisement. The Food Service Director is the responsible party. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: January 19, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification survey conducted 10/20/22-11/1/22, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 5 of 7 residents (Residents #93, 222, 262, 270, and 294) reviewed, 2 of 4 meals observed, and 2 of 2 meal test trays (1 breakfast and 1 lunch tray) observed. Specifically: - Resident #294 did not eat pork due to religious beliefs and received pork on their tray on multiple occasions and did not receive meal items as planned. - Residents #270 and 222 did not receive food items on their meal trays as planned. - Resident #262 had protein malnutrition, required additional calories, and did not receive high protein items on their meal trays as planned. - Resident #93 was not provided a scoop plate with meals as planned. - Hot food temperatures on the meal service line were not monitored and maintained as required. - 1 breakfast tray and 1 lunch tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable. Finding include: The facility policy Food Preparation and Service revised 4/2022 documented the longer foods remained in the danger zone, above 41 degrees Fahrenheit (F) to below 135 F the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained below 41 F or above 135 F. Potentially hazardous foods held in the danger zone may cause foodborne illness. The facility policy Recording Food Temperatures revised 6/2022 documented that food temperatures of cold and hot food items would be recorded on all menu items and substitutions for meal service to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal regulations thus ensuring that foods were provided in a safe, palatable manner. Meal temperatures would be recorded at the beginning of meal service to ensure proper temperatures and repeated midway through at point of service if meal service exceeded 2 hours. Temperatures would be recorded using the food temperature log and maintained for 1 year. All employees were responsible to notify their supervisor of any food item that did not meet the regulated safe acceptable service ranges, below 41 F or above 140 F. The facility policy Food and Nutrition Services revised 4/2019 documented staff should check individual name and diet and meal identification care/ticket to verify that the meal was served to the correct person, and check items on the plate/tray to assure accuracy for therapeutic diets or texture or consistency modifications. The facility policy Tray Assembly Identification and Service Policy revised 1/2022, documented there would be a means of identifying resident meals and trays for therapeutic requirements and resident preferences. Tickets were used to identify correct items for resident diets. Nursing staff would check each food tray for the correct diet before serving the residents. Resident Meal Trays 1) Resident # 294 had [DIAGNOSES REDACTED]. The 10/3/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required supervision and setup for eating. The comprehensive care plan (CCP) initiated 5/18/22 documented the resident had nutritional problem or potential nutritional problem related to multiple food concerns, and no pork related to religious beliefs. Interventions included regular diet with regular texture and thin fluids, Food Service Director follow-up with multiple food issues, and meal tickets marked to avoid pork. A physician order [REDACTED]. The 7/26/22 Resident #294 grievance documented several care concerns including lack of meat on their meal tray. The grievance was written by the previous Nurse Manager of the unit. The previous Assistant Director of Nursing (ADON #67) documented follow-up dated 7/29/22 and included dietary to address meal concerns and lack of meat selection on meal trays. The following observations were made: -On 10/20/22 at 11:20 AM the resident was in bed in a hospital gown. They stated the food was always cold, and they had specific diet needs due to their religion. They felt that when their tray contained beef or pork it was a direct attack on their religion and race. They stated it happened about once or twice a month since admission. -On 10/24/22 at 2:41 PM certified nurse aide (CNA) #131 delivered the lunch tray to the resident. There was no juice on the tray, and the resident had requested juice and creamer for the coffee. At 3:16 PM juice was delivered from the kitchen and taken to the resident. During an interview on 10/24/22 at 2:57 PM, CNA #131 stated the delivery of trays, proper positioning, opening containers, making sure trays matched the ticket were all part of meal setup. They had delivered the lunch tray to Resident #294 and the resident did not get their juice as listed. The ticket documented 8 ounces (oz) of both cranberry juice and orange juice. The CNA stated it was only their 3rd day on the job and they were unsure of where to find things, and they should have asked. There was no juice on the unit, so the kitchen was called, and juice was requested. During an interview on 10/31/22 at 4:00 PM licensed practical nurse (LPN) Unit Manager #40 stated the resident did not like pork and thought it might be a religious preference. The resident had complained in the past of pork being on their tray. When that happened, the staff obtained a replacement item. During an interview on 10/31/22 at 3:40 PM, CNA #46 stated the resident did not eat pork or beef due to their religion. The CNA had seen mistaken tray items sent to the resident including pork. When that happened, they called the kitchen and got something else. During an interview on 11/1/22 at 11:24 AM, CNA #58 stated the resident did not want pork or beef and was not sure if it was because of their religion. There had been mistakes made on the resident's trays and they received meat they did not want. When that happened, substitutes were requested. During an interview on11/2/22 at 9:10 AM, CNA #56 stated they had worked when the resident had received pork or beef on their tray, and they requested a substitute from the kitchen. The resident got upset when meat was on their tray. 2) Resident #270 had [DIAGNOSES REDACTED]. The 10/7/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required limited assistance of one for eating, and coughed or choked during meals. The comprehensive care plan (CCP) reviewed 10/21/22 documented the resident had a potential nutritional problem related to altered meal consistency with a history of a need for altered solids and fluids. Their diet was house regular, mechanical soft consistency with nectar thick fluids. On 10/24/22 at 9:45 AM the resident was observed sitting in their room with a breakfast tray on their overbed table. The meal ticket documented nectar thick milk to moisten cereal, nectar thick chocolate milk, nectar thick apple juice, nectar thick coffee, peaches, a slice of bread, and blueberry yogurt. The resident's breakfast tray included an unopened carton of regular consistency 2% milk the resident stated they refused to drink. The thickened apple juice was replaced with thickened orange juice. The tray was missing thickened chocolate milk and coffee, peaches, a slice of bread and blueberry yogurt. The resident stated they frequently were missing items on their tray, they never got a slice of bread, and showed the surveyor a stack of meal tickets they kept in the nightstand drawer. The resident had red checks next to the missing items on the meal tickets. They stated they had told the CNAs and charge nurse about the missing food items. The charge nurse told the resident there was nothing they could do about it. On 10/26/22 at 9:05 AM the resident was observed sitting in their room with their breakfast tray in front of them on the overbed table. There was no slice of bread on the tray as documented on the meal ticket. On 10/31/22 at 9:28 AM the resident was observed in bed with their breakfast tray in front of them on an overbed table. The resident had not eaten anything yet. The meal ticket documented gravy, a slice of bread, margarine, 1/2 cup canned fruit, 1/2 cup applesauce, and jelly. None of these items were on the resident's breakfast tray. During an interview on 10/31/22 at 9:35 AM CNA #35 stated they were assigned to care for Resident #270 today but had not delivered the breakfast tray to the resident's room. They stated CNAs were supposed to check meal tickets with what was on the residents' trays. If a food item was missing, they would call down to the kitchen or tell the nurse. During an interview on 10/31/22 at 9:45 AM Assistant Director of Nursing (ADON) #51 stated the CNAs should be checking the meal tickets for accuracy. They stated the Nurse Manager or themself would retrieve a missing food item from the kitchen. They were short-staffed in the kitchen. The Food Service Director had quit, and the Assistant Administrator had been in the kitchen recently overseeing the mealtime process. 3) Resident #93 had [DIAGNOSES REDACTED]. The 8/17/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition and ate with supervision of 1 after set-up. The 10/11/22 updated comprehensive care plan (CCP) documented the resident had weight loss, [MEDICAL CONDITION], contractures, limited use of the left arm, left hand limited movement, and right arm immobility. Interventions included provide assistance with all meals, cut food into small bites, open containers, scoop plate, no plastic silverware, supervision/aspiration precautions, feed resident, eat with supervision, no set-up help required, occupational therapy (OT) referral as needed, and evaluate needs and eating habits as needed. The 10/12/22 diet technician (DTR) #25 progress note documented the resident needed supervision and tray set-up. The resident had been observed with self-feeding difficulties at meals. The resident benefited from increased meal assistance. The resident was to have a scoop plate and no straws. The care instructions as of 10/31/22 documented the resident ate with supervision and no set up help was required. Provide assistance with all meals (opening containers, feeding resident, cutting up food into small bites, supervision/aspiration precautions), assist with hand hygiene, and adaptive devices. The instructions did not specify what the adaptive devices were and included contradictions with feeding level assistance. During a meal observation on 10/21/22 at 2:07 PM, Resident #93's meal ticket documented ADAPTIVE EQUIPMENT, NO STRAWS, NO PAPER PRODUCTS along the right side, with scoop plate and no plastic silverware on the bottom of the ticket. The resident did not have a scoop plate or silverware. The meal was not cut up and the resident ate using their fingers. The resident held up, in their fingers, a slice of ham while talking with the surveyor. During an observation on 10/25/22 at 9:19 AM, Resident #93's breakfast tray was on an overbed table with a regular plate. There was no scoop plate observed. Certified nurse aide (CNA) #52 stated the resident never received a scoop plate, adaptive silverware was routinely missing, and the resident used their fingers to eat. The CNA stated they would get the resident a plastic spoon from the medication cart if the resident requested one. When interviewed on 11/1/22 at 11:32 AM, physician #54 stated the resident was a functional quadriplegic and only had one hand that worked effectively. The resident needed built up silverware and rim plate per their medical history. When interviewed on 10/26/22 at 11:51 AM, CNA #53 stated the resident needed assistance of 1 with little help for meals and the tray table should be slanted at an angle for them to reach the tray. The resident was supposed to have a special plate and spoon. Kitchen staff were to send the adaptive equipment. The resident had not received utensils and no special plate for a long time. When interviewed on 10/25/22 at 9:20 AM, CNA #52 stated Resident #93 was supposed to have special utensils and a special plate that never came with their tray. When interviewed on 11/1/22 at 3:07 PM, occupational therapist (OT) #73 stated the resident should have the adaptive equipment at each meal if it was recommended. The scoop plate gave the resident the needed support to scoop the food off the plate as the resident was very weak on their right side. The resident did not like staff assistance for meals. Weighted or built up silverware could also assist with getting food to the mouth, and the OT was unsure if the resident used those. When interviewed on 11/1/22 at 5:29 PM, RD #74 stated the kitchen staff working shorthanded was leading to meal accuracy issues. The RD stated they completed tray audits and residents were complaining about a lot of missing items. Missing items and late meals could affect the resident's quality of life, including weights and other areas of care. Food Temperatures on Meal Service Line During an observation on 10/21/22 at 1:08 PM with the Regional RD present, the first of two steam table units in use for service at the tray line contained the following items and temperatures measured by the surveyor: ham 140 F, sweet potatoes 108 F, yellow wax beans 174 F, tuna melt 150 F, pork chops 108 F, and carrots 147 F. At that time the service line was paused, and the items identified out of temperature were removed from service. During an interview on 10/21/22 at 1:08 PM, dietary aide #107 who was serving the food from the steam table, stated that they did not check the temperatures of the food on the line, the cook monitored those. Once the tray line was started, nobody checked the temperatures. Dietary aide #107 stated the steam table section under the sweet potatoes was not on when the surveyor checked the temperature. That section had a leak and lost the water real fast, then shut off, so they turned it back on. They stated they were not sure if the section under the pork chops worked. During an interview on 10/21/22 at 1:08 PM, Regional RD #22 stated the temperatures were checked by the cook at the start of service at 12:00 PM and again every two hours if service took longer. They stated they were unable to serve the pork because they were left out of temperature, and not monitored for more than two hours, they were going to substitute hamburger patties or fish. During an interview on 10/21/22 at 1:20 PM, cook #109 stated they took the temperature around 11:00 AM as they removed the items out of the oven, then moved each item to the hot boxes to be used on the line. Cook #109 stated they believed the pork chops needed to be cooked between 160 F and 180 F and the sweet potatoes to 130-140 F. They stated they did not check the temperature of the food on the line before, or during service, only when it initially came out of the oven. Cook #109 stated that food could be out of temperature and in the danger zone for up to 30 minutes. The pork chops and sweet potatoes were voluntarily discarded. Review of the Food Temperature Log dated 10/21/22 and untimed, documented sweet potatoes were 163 F (starch 2), pork chops were 162 F (entree 2). These items were not identified under the menu items column, cook #109 identified each from memory. The following was observed during the lunch service line on 10/25/22: - at 11:45 AM, the lunch service line's first steam table contained the following items and temperatures measured by the surveyor: beef 172 F; noodles 138 F; yellow wax beans 190 F; gravy 180 F. The light was not on under the noodles located in the second section of the unit. There was nothing located on the end in section 5 of the unit at that time. - at 11:48 AM staff started to plate food for service. No temperature checks were completed. - at 12:22 PM the surveyor measured the noodles at 90 F and the light beside the knob for that section was not on. - at 12:24 PM dietary aide #107 pulled a new pan of noodles from hot box A located beside the steam table. Dietary aide #107 stated they did not check the temperature, but it should be above 130 F. The surveyor measured the pan of noodles at 132 F. The hot box was set at 10, the temperature display did not show anything, the hanging thermometer in the unit read 155 F, but it was only warm to the touch inside and outside of the unit. - at 12:34 PM the noodles were pulled from service - at 12:40 PM noodles were returned to the line and service resumed, cook #109 stated they measured the noodles at 168 F. A 2-inch hotel pan of noodles was set in the 2-inch pan of water beneath. During an interview on 10/25/22 at 1:00 PM, cook #109 stated they made noodles around 10:30-10:45 that morning. They boiled the noodles, then rinsed them under lukewarm water, put them in a pan, wrapped, and placed them in the middle hot box, it was hot to the touch and the thermometer inside read 180 F. They stated they recorded the temperature of the noodles that morning before putting them into the hot box. Cook #109 stated the noodles that were out of temperature were voluntarily discarded because they were out of temperature, and they were not sure for how long. A pan in the back was used to keep service going and a pot of water was put on to make more noodles at that time. Review of the Food Temperature Log dated 10/25/22 documented the noodles were listed as cold item #1 and the temperature recorded was 129 F. The form documented that hot food must be held at 140 F or more, cold food at 41 F or less, and to contact the supervisor if the item did not meet those requirements. During an interview on 10/26/22 at 2:26 PM, dietary aide #107 stated they would check to make sure the food was at least between 140 and 160 F, and if not in that range they were supposed to tell a supervisor and replace that item. They would report that to the cook, who would replace it, or if there was one in the hot box, they would get that one. They stated that as of yesterday, they checked the temperatures before they started serving and before putting a new tray on the line, but they did not record the temperatures they measured. Dietary aide #107 stated they received training yesterday on how to measure temperatures, and again this morning. They stated that it was important to serve food at the right temperature so that the residents would not get sick. During an interview on 10/26/22 at 2:53 PM, Dietary Manager #108 stated the duties of a cook were to make sure the product was out on the line in a timely manner, temperatures were correct, and that the line had everything that it needed. They stated they checked the temperatures of the food after they cooked it, and then after it was on the line and they were looking for temperatures of 165 F and above, for meat, potatoes, starch, and vegetables, and 45 F and below for cold holding. They stated that was recorded on the day's production sheet and they did one every day for each meal. Dietary Manager #108 stated if something was out of temperature, they had to dispose of it, and make fresh. They tried not to do that because it was a waste, and the residents had to wait. It was important to serve food at the right temperatures because the food could grow bacteria when left out of temperature. During an interview on 10/27/22 at 12:43 PM, cook #109 stated they had worked in the kitchen at the facility for seven months. They stated they were not trained how to check temperatures. They stated the required temperatures for hot holding were 150 or 155 F, but they were not sure. They stated temperatures were checked when they cooked, before they put the food on the line, and then again on the line. They stated they only did that 50-60% of the time. They stated they recorded yes on the day's production sheet for temperature checks. They were aware the steam table was not working properly in the second spot, and they tried to keep bacon there, or something that did not need to stay hot. Cook #109 stated that if food was not at the right temperature bacteria could cause illness. They added it was important to serve food that was been properly prepared for the quality of the food. Test Trays 1) Unit C Lunch Tray During an observation on 10/25/22 at 2:50 PM, lunch carts left the kitchen and arrived at 2:51 PM on Unit C South. At 2:58 PM the tray for Resident #316 was selected as a test tray as it was being delivered and a replacement tray was ordered from the kitchen. The contents of the tray were measured as following: orange juice 63 F, milk 47 F, beef and noodles 117 F, yellow wax beans 101 F, apple strudel 76 F, yogurt 58 F, and chocolate ice cream 18 F. All items on the ticket were received. The beef, noodles, strudel, and ice cream tasted acceptable, but the beans were cold to taste. 2) Unit D Breakfast Tray During an observation on 10/26/22 at 9:12 AM, the breakfast tray line was in progress with 6 staff plating trays. At 9:20 AM the meal cart was brought to the Unit D floor and residents started being served. At 9:40 AM the last regular food tray for Resident #87 was selected as a test tray and a replacement ordered. There was no super cereal received as documented on the ticket. The following items temperatures were measured: bread and sausage gravy at 104 F, Mighty Shake was 54 F, and orange juice was 41 F. The sausage gravy was not warm, too thick, and was not palatable. During an interview on 10/20/22 at 10:27 AM, Resident #582 stated all their meals were cold. During an interview on 10/20/22 at 5:05 PM, Resident #222 stated that the food was late, and it did not taste good. During an interview on 10/21/22 at 1:35 PM, Dietary Supervisor #28 stated that staff who worked the end of the tray line would check the trays for accuracy and make sure the residents received everything on the tickets, or they would get a stamp for a substitution. They stated that they were able to make substitutions and did not need approval. Dietary supervisor #28 stated that they did not check the temperature of the food coming off the line, or the trays as they completed them and put them on the carts for delivery. During an interview on 10/27/22 at 11:36 AM, dietary aide #106 stated they had worked at the facility for about a year and worked in the same position the entire time. They stated that as the runner they took the carts up to the units, brought them back down, and made sure they had coffee on the carts. They stated they took the carts up to the units. Sometimes there were staff waiting for them, if staff were not there, they would notify an LPN. Dietary aide #106 stated they did not check the temperature of the food on the carts because there were no temperature gauges, and they did not have a thermometer. The staff on the floor that received the cart did not measure the temperature either, usually the cook checked the temperature of the foods. They stated they heard the residents complain that the food was cold, or not cooked properly. They stated they did not receive training for this position, but they had worked a similar job at another facility in the past, so they already knew how to do the job. 10NYCRR 415.14**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the onsite post survey review (PSR) conducted 1/4/23-1/6/23, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 3 meals observed. Specifically, Resident #267's lunch meal tray was not served to the resident until 41 minutes after the meal cart was delivered to the unit, resulting in unsafe and unappetizing food temperatures. Findings include: The facility policy Food Preparation and Service revised 4/2022 documented the longer foods remained in the danger zone, above 41 degrees Fahrenheit (F) to below 135 F the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained below 41 F or above 135 F. Potentially hazardous foods held in the danger zone may cause foodborne illness. The facility's 12/14/22 Directed Education for Frequency of Meals for Nursing Leadership and Nurse Managers documented attendees understood corrected mealtimes schedule and location to ensure residents were served promptly. The facility's undated Meal Cart Delivery Schedule documented Unit 4 North would receive their lunch cart delivery at 11:20 AM +/- 20 minutes. The facility's undated Meal Service Delivery and Test Tray Evaluation documented the temperature standard of food on the tray line in degrees Fahrenheit (F): - Hot entree 140 degrees F or above. - Hot starch 140 degrees F or above. - Hot vegetable 140 degrees F or above. - Cold dessert cool/ firm. - Cold fruit cool - Cold beverage less 41 degrees F or below. Resident #267 had [DIAGNOSES REDACTED]. The 10/28/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required set-up assistance at meals. The following observations were made on 1/4/23 on Unit 4 North: - At 11:31 AM, the meal cart was delivered from the kitchen to the unit near the nursing station. - At 11:41 AM, registered nurse (RN) #2 was standing at the medication cart located at the nursing station approximately 10-12 feet from the meal cart. RN #2 stated there were 4 staff members assigned to the unit, 2 certified nursing assistants (CNAs), 1 RN (themself) who was passing medications, and the RN Unit Manager. - At 11:48 AM, RN #2 was standing at the medication cart at the nursing station and the facility's Administrator was behind the nursing station conducting a walk through with another surveyor. The meal cart remained in the hallway, untouched. - At 11:50 AM, RN Unit Manager #7 walked by the meal cart near the nursing station and told RN #2 that they needed to go downstairs. RN Unit Manager #7 did not acknowledge that the meal cart was on the unit near the nursing station. - At 11:52 AM, (21 minutes after the meal cart arrived to the unit) CNA #5 passed the 1st meal tray. - At 12:11 PM, (40 minutes after the meal cart arrived to the unit) CNA #6 passed the last meal tray on the cart to Resident #267. Resident #267 agreed to have their meal tray used as a test tray and a new meal tray was ordered for the resident. Food item temperatures from the tray were taken in the presence of the Assistant Director of Nursing (ADON). The ground braised beef was measured at 123 degrees Fahrenheit (F), peas were 115 degrees F, rice was 116 degrees F, peaches were 62 degrees F, and apple juice was 65 degrees F. - At 12:34 PM, Resident #267's replacement meal tray arrived at the unit and was brought to the resident. During an interview with CNA #5 on 1/4/23 at 2:27 PM, they stated the lunch meals would come to the unit between 11:00 AM and 11:40 AM. There were only 2 CNAs and 2 RNs assigned to the unit. They stated they were providing care for residents and when they were done with care, they started passing meal trays. They had received education about making sure the food consistency was correct and all items on the tray matched the meal ticket. They did not receive any education on how soon the meal trays should be passed once the cart arrived on the unit, but they stated 20 minutes was a long time for trays to sit and could lead to cold food. They also stated any nursing staff could pass trays if the CNAs were busy providing care. During an interview with CNA #6 on 1/4/23 at 2:30 PM, they stated the lunch meals would come to the unit between 11:00 AM and 11:40 AM. There were only 2 CNAs working on the unit and when they had finished providing care to the residents, they observed the meal cart on the unit, and CNA #5 had just started passing meal trays. They had received education within the last month to ensure all items matched the meal tickets and the resident received the correct food consistency. They stated all nursing staff could help pass trays. They were unaware how long the meal trays were on the unit before they were passed, but 20 minutes was a long time for the meal trays to sit and the food might get cold. On 1/5/23 at 9:23 AM, the Director of Nursing (DON) stated nursing leadership and Unit Managers received additional education on meal trays being served promptly after the meal cart arrived at the unit. On 1/5/23 at 10:02 AM, RN Unit Manager #7 stated they had received education, about a month ago, on the importance of passing meal trays timely. The lunch meal cart arrived on the unit between 11:00 AM and 12:00 PM. They stated once the meal cart arrived on the unit it was expected that staff start passing meal trays. They stated they were responsible for supervising that meal trays were distributed in a timely manner and the meal cart should not sit in the hallway unattended. They stated on 1/4/23 they were helping RN #2 complete their medication pass and was unaware what time the meal cart arrived at the unit or what time tray passing began. Any nursing staff could pass meal trays. They stated 20 minutes was a long time for the meal trays to sit prior to being passed. They stated if meal trays sat on the cart for a long period, it could affect the temperature of the food and residents might not want to eat cold food. During a follow up interview on 1/5/23 at 10:56 AM, the DON stated RN Unit Manager #7 attended and signed the facility's Directed Education for Frequency of Meals for Nursing Leadership and Nurse Managers on 12/15/22. That meant they understood the information explained and that they would implement the education they received on their unit. They stated 20 minutes was a long time for the meal trays to sit before being passed. If the meal trays were not passed timely, it could impact the temperature of the food and could also impact the resident's intakes due the palatability of food. During an interview with the Food Service Director on 1/5/23 at 11:14 AM, they stated served promptly meant that nursing staff should pass trays once the meal cart arrived at the unit. 20 minutes too long for the meal trays to sit on the meal cart. Food temperatures would drop and could result in cold food being served. They stated hot food should be served at 130 degrees F or higher on the units and cold food should be served 40 degrees or below on the units. They stated the test tray temperatures taken were not acceptable. During an interview on 1/5/23 at 1:45 PM, with the Regional registered dietitian (RD) #12 they stated all nursing leadership and Unit Managers received education regarding prompt meal tray delivery. Prompt delivery meant once the meal cart arrived at the unit, nursing staff should start passing the meal trays. The RD stated 20 minutes was a long time for a meal cart to sit prior to the trays being passed. It was the responsibility of the Unit Managers to make sure the meal trays were passed timely. If the meal trays were not passed timely, it could affect the temperature and palatability of the food and could affect the resident's intakes at meals. Ideally, hot food should be served at 140 degrees F and cold food should be served 41 degrees F or below. During an interview on 1/5/23 at 4:03 PM, the facility Administrator stated all of nursing leadership and Unit Managers received directed education about passing trays in a timely manner. The Unit Managers should know what time their meal carts arrived at the units and ensure staff were passing trays as quickly as possible. They stated 20 minutes was a long time for the meal cart to sit on the unit prior to passing trays. During a telephone interview on 1/6/23 at 12:28 PM, the Senior Director of Food and Nutrition Services stated they provided the directed plan of correction education to the nursing leadership and Unit Managers regarding the frequency of meals and prompt delivery of meal trays. They stated prompt meant that once the meal cart arrived at the unit, unit staff should start passing trays. It was the responsibility of the Unit Managers to ensure the trays were passed. They stated 20 minutes was a long time for the meal trays to sit and was not prompt service. They stated the test tray temperatures obtained were not acceptable. 10NYCRR 415.14 | Plan of Correction: ApprovedJanuary 27, 2023 Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification and abbreviated surveys (NY 150) conducted 10/20/22-11/2/22, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 4 residents (Residents #57, 222, and 262) reviewed. Specifically: - Resident #57 was performing their own wound care and was not assessed and did not have physician orders to complete the wound care independently. - Resident #222 had a physician recommendation for [MEDICATION NAME] (a diuretic) to treat [MEDICAL CONDITION] and the [MEDICATION NAME] was not ordered. - Resident #262 was performing their own [MEDICAL CONDITION] (small intestine is diverted through an opening in the abdomen) care and dressing changes. The resident was not assessed for their ability to appropriately perform self-care, did not have physician orders to perform care independently, and the active ostomy site was not regularly assessed. Findings include: The facility policy Ostomy Care ([MEDICAL CONDITION], jejunostomy, [MEDICAL CONDITION]) last revised 5/2019 documented staff should verify the physician orders and nursing care plan. Gently wash skin around the stoma (opening to allow body excretions to collect in an external pouch) with soap and water or designated cleaner, do no scrub, check skin for signs and symptoms of breakdown, observe the stoma site and surrounding skin for sing and symptoms of bleeding. Staff should report any concerns to the licensed nurse immediately. Apply appliance per manufacturer recommendations, and ensure appliance was secured properly. Facility staff should educate the resident and provide assistance so the resident could be as independent as possible with stoma care. The facility policy Medication-Self Administration reviewed 7/2019 documented the resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident was both mentally and physically capable of self-administering medications and to keep accurate documentation of these actions. The staff and practitioner would assess each resident's mental and physical capabilities to determine whether self-administering medications was clinically appropriate for the resident. The nurse would perform a more specific skill assessment. The policy did not include treatment self-administration. The facility policy Medication Orders' revised 9/2020, documented each resident must be under the care of a licensed physician authorized to practice medicine and must be seen by the physician at least every 60 days, a current list of orders must be maintained in the clinical record. When recording treatment orders, specify the treatment, frequency, and duration of the treatment. The facility policy Wound Care reviewed 10/2021 documented wound care documentation should include the type of wound care given, the date and time the wound care was given, the position the resident was placed in, the name and title of the individual performing wound care, and change in the resident condition, all assessment data, how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused treatment and why, and signature and title of person recording the data. 1)Resident #262 had [DIAGNOSES REDACTED]. The 9/29/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of one for personal hygiene and toilet use, including management of the ostomy, had an ostomy, and received application of nonsurgical dressings. The 4/7/22 hospital discharge summary documented the resident was admitted with [MEDICAL CONDITION] of the abdominal wall [MEDICAL CONDITION] without acute organ dysfunction and peri-[MEDICATION NAME] (area around ostomy opening) [MEDICAL CONDITION] (inflammation of the skin) associated with moisture. Physician orders documented: - on 4/7/22 nurse skin observations weekly on Thursday. Empty the [MEDICAL CONDITION] bag every shift and replace as needed; ostomy drainage pouch- 2 pieces with a pouch and seal every shift. - on 4/11/22 change the wafer (a ring used to hold the ostomy pouch in place) weekly on Monday and as needed (prn), change [MEDICAL CONDITION] pouch every 3 days and as needed (prn), ostomy wafer, 2 piece and a pouch, apply stoma powder and skin prep (protectant) to peri-[MEDICATION NAME] area with a piece of Eakin seal at the creases located at 3 and 9 o'clock for protection and treatment of [REDACTED]. Physician orders did not document the resident's ability to independently care for their ostomy. The 4/22/22 Readmission History and Physical completed by physician #55 documented the resident was in the hospital for rash and [MEDICAL CONDITION] stoma with surrounding [DIAGNOSES REDACTED] (redness). The resident was diagnosed with [REDACTED]. The plan included [MEDICAL CONDITION] care per nursing policy and procedure and wound care consult for assistance with ostomy and skin care. The 5/12/22 comprehensive care plan (CCP) documented the following: - the resident had impaired gastrointestinal (GI) function related to constipation and ostomy bag x2 (one non-working). Interventions included administering medications per physician orders, after 3 days of no documented bowel movement evaluate the resident for abdominal distention, bowel sounds and abdominal discomfort, evaluate bowel status with any change in behavior and mental status. There were no documented interventions for the care of the residents two ostomy sites. - the resident had an ostomy. Interventions included to maintain the ostomy device, empty as needed, monitor stoma site for any sign and symptoms of infection including redness, tenderness, drainage, fever, and pain, ostomy care every shift and prn (as needed) and ostomy bag care. -The resident exhibited behavior symptoms such as compulsive/fixation upon ostomy site resulting in multiple dressing changes throughout the day. Interventions included initiate psychology evaluation as needed, provide the resident an opportunity to express themself, and behavior symptoms. -The resident required assistance with ADLs. The resident was independent with personal hygiene with no assistance required. The 7/4/22 physician #54 progress note documented the resident was seen for an acute visit to follow up on the recurrent [MEDICAL CONDITION] of the abdominal wall. The resident was started on [MEDICATION NAME] (antibiotic) 19 days ago. The resident continued to pull off the wafer/bag and blamed staff for not having it affixed correctly in the first place. With the resident's dementia, it was likely a combination of staff and the resident's behaviors causing the difficulty. The 7/9/22 physician order documented cleanse lower abdomen with normal saline pat dry with gauze, and apply Xeroform (petroleum dressing) over old stoma site and cover with boarder gauze, change every day and prn every day shift for skin integrity. On 7/12/22 wound consultant physician #9 documented the resident was seen at the request of physician # 54, and a thorough wound care assessment and evaluation was performed. Wound #1 was documented as post-surgical failed ostomy site with recommendation to apply Xeroform sterile gauze once daily for 30 days. There was no documentation about the active left sided ostomy. The 8/18/22 weekly skin monitoring by licensed practical nurse (LPN) #59 did not include documentation of the active left sided ostomy and surrounding skin. A 9/14/22 wound consult physician #9 progress note documented the resident presented with a wound on their abdomen. The resident was seen at the request of the referring provider, physician #54, and a thorough wound care assessment and evaluation was performed. The resident had a failed ostomy on the right lower quadrant (RLQ), and a functioning ostomy on the left lower quadrant (LLQ). The wound, failed ostomy wound to the RLQ measured 2 centimeters (cm) x 2.8 cm with moderate serous exudate (clear drainage), granulation tissue 100%, and there was no change to the wound progress. The treatment plan was Xeroform sterile gauze apply once daily for 30 days, gauze island with border to apply once daily for 30 days, skin prep applied once daily to the peri-wound. The care was discussed with a nursing staff member and the clinical documentation was made available for access in the medical record. Continue with present skin care and breakdown prevention. There was no further assessment of the functioning ostomy or surrounding skin. The 9/15/22 weekly skin monitoring LPN #59 did not document the left sided ostomy and surrounding skin area. During an observation and interview on 10/20/22 at 12:52 PM, Resident #262 was sitting up in a wheelchair and had an active ostomy intact with a collection bag on the left abdomen. The resident stated they took care of their own ostomy daily. The resident demonstrated the placement of the ostomy was low on the abdomen and when they were sitting their left thigh would push against the intestines (stoma) area and this would cause the wafer seal of the ostomy to leak. The skin would fold, and it would leak. The resident stated since they were admitted the nurses were supposed to change it, but when they waited for nursing staff to complete the ostomy care, they appeared to not know how to do it, they wanted to do it their way. The resident said they knew how to do it from reading the instructions on the ostomy products. They stated the nurse's way was not the correct way. The resident stated some of the nurses did not know how to do anything with their ostomy. The ostomy pouch (stool collection bag) was observed clean and intact. The resident stated they preferred to take care of the ostomy themselves. The resident had a dresser drawer full of supplies. The resident stated the bandages did not seem to fit very good, the stoma should have a tight seal. When the bag was full and it sometimes leaked, they applied extra tape. Sometimes the stoma bled a little bit. The resident stated they were in the hospital in (MONTH) 2022 for an infection to the stomach area and then readmitted to facility with ostomy supplies from the hospital. The resident pointed out they had a right sided abdomen stoma that was not active with a bandage covering it dated 10/17/22. The resident stated that was the last day the nurses changed it. The resident stated their skin was reddened around the active stoma and it was irritated from the stomach acid. The resident stated they managed the ostomy themselves because they lost faith in the nurse's ability to do it. The resident stated they were not supposed to be doing it, the staff were supposed to do it. During the interview, the resident's family member was present and stated the resident needed assistance from staff. The non-active stoma was supposed to be changed daily and it was dated 10/17/22. The 10/20/22 weekly skin monitoring by LPN #59 documented abdomen -old stoma site with no new skin alteration noted. There was no documentation on the active left sided ostomy and surrounding skin area. During observation and interview on 10/25/22 at 9:09 AM, the resident's ostomy with bag was in place. The resident stated the bag, and the wafer came off yesterday (10/24/22) because it had leaked. They stated the nursing staff did not help them and they reapplied the wafer and collection bag themself and used a mirror to see how the wafer was placed. The dressing over the non-active ostomy on the right lower abdomen was dated 10/24/22, the dressing appeared dirty. The bandage was green, brown in color and there appeared to be old stool on outer part of dressing. The resident said they did not change the dressing on the old site. The 10/26/22 care instructions (Kardex) included toileting ostomy bag care, maintain [MEDICAL CONDITION] device, empty as needed, and assist resident with personal hygiene. During an interview on 10/26/22 at 3:18 PM, certified nurse aide (CNA) #50, stated the nurses were supposed to manage the ostomy, but the resident was able to empty the bag and preferred to empty it. They stated the bag seemed to fall off every single day and the resident was not able to get it to stay intact. During observation and interview on 10/27/22 at 10:16 AM, licensed practical nurse (LPN) #3 stated ostomy care was the responsibility of the LPN, and they were to document this on the TAR (treatment administration record) when completed. The LPN stated the resident just reported they would prefer to do the dressing themselves. LPN #3 was observed notifying RN Unit Manager #4 about the resident's preference to do the dressing themself. RN Unit Manager #4 instructed LPN #3 to follow the orders in the computer for the treatment. LPN#3 stated they went to clarify with RN Unit Manager #4 because they had had never taken care of this resident and the orders did not match what the resident was doing. During a dressing observation on 10/27/22 at 10:36 AM, LPN #3 removed the old dressing to the right non-active stoma and applied a new dressing to the area and told the resident. The active ostomy was not leaking, and the appliance was taped down and there was an ostomy belt securing the device. LPN #3 removed the ostomy dressing and the active stoma cite was dark pink and irritated. The outer aspect of the wound skin was bleeding and was raw and macerated. The resident stated it hurt like a stabbing/burning pain. The resident stated they cut out the ostomy appliance already and it was not big enough to go over the entire stoma cite. LPN #3 stated they should have been updating the resident record with appropriate orders to ensure the ostomy-wafer was the correct size. LPN #3 stated the current wafer would not go over the entire stoma and could cause skin break down if the sticky part was placed on the stoma. During the observation LPN #3 left the room to get RN Unit Manager #4 to assess the stoma. The resident stated the site was not bleeding at first, but they had been experimenting with different products to get it to not leak and burn. The resident stated it was hard to do it alone because they felt they needed a third hand. The resident again stated the skin around the stoma felt like stabbing and burning. At 10:59 AM RN Unit Manager #4, entered the room to assess the resident and stated the stoma was very irritated from the wafer sitting on the skin and surrounding area and instructed LPN #3 to use skin prep around the outside of the skin. RN Unit Manager #4 stated they were going to call the nurse practitioner (NP) to come up and see the wound. LPN #3 cleansed the area around the stoma and gave the resident gauze pads to put over the stoma. During an observation on 10/27/22 at 11:12 AM, NP #16 entered the room to assess Resident #262. NP #16 stated the area around the stoma looked fungal and smelled yeasty. NP #4 stated they would need to heal the outer aspect of the wound, and they would order [MEDICATION NAME] (antifungal) for treatment of [REDACTED]. NP #16 stated they had not seen the resident in a while but would order antifungal for the skin and try healing the skin around the stoma. They stated the stoma site looked good but the skin around it was macerated and this is going to take a while to heal. On 10/27/22 at 3:04 PM, there were no new orders for the resident's ostomy care. There was a pending order from NP #16 for antifungal cream. There were no nursing or provider notes documenting an assessment of the ostomy and the surrounding skin. During interview on 10/31/22 at 9:47 AM, Resident #262 stated the nursing staff did not take care of the ostomy over the weekend, they completed their own ostomy care and that included emptying the bag, changing the bag and on Friday they replaced the wafer that was placed by the LPN on Thursday because it leaked. They stated the wafer that was placed by the nurse on Thursday had tape that was cut smaller around the cite to leave skin exposed and to air out the fungal infection. They said the small tape was what caused the dressing/wafer to leak. They stated the non-working right side ostomy was changed on 10/30/22 by nursing staff and was due to be changed. During an interview on 10/31/22 at 10:08 AM, NP #16 stated, they were the only NP in the building and never went back on Thursday 10/27/22 to see the resident and left a message to the wound team to see the resident. NP #16 stated if there was a problem the wound team LPN #63 would report it. NP #16 stated the abdominal area was over taped and the area needed to be aired out. NP #16 stated they ordered the [MEDICATION NAME] cream for the resident and this was a delay in resident care. The resident picked at the ostomy site since they were admitted and had some behaviors with the ostomy. Nursing should be assisting the resident with the ostomy and the resident should not have to care for their own ostomy. NP #16 stated they had not been notified prior to Thursday that the resident needed to be seen. During an interview on 10/31/22 at 2:14 PM, RN Unit Manager #4 stated the resident's skin issues appeared to be related to the adhesive from the ostomy appliance and it was fungal. The resident was using a different kind of tape to reinforce the ostomy cite, the tape was not something the facility routinely carried. They called the NP because the skin looked like it needed attention the rash looked like it had spread, and it smelled yeasty. Even if the resident was doing the ostomy care the LPNs should be checking on the resident's ostomy. There should be an order that they could self-manage the ostomy and there was not. The resident was cooperative and would allow the nurses to do it, but the nurse should be checking on the resident to see if they needed assistance. The LPN should write a note if the resident refused their assistance and notify the RN Unit Manager. They stated they did not know much about the non-active site on the right side of the abdomen, and the area around the active stoma was macerated and should demonstrate the resident was not able to manage the area. They stated the area had worsened since the last time they saw it the week before. The LPN would be responsible to change the adhesive ostomy wafer and assist with changing of bag. The wafer should be changed weekly on Monday and prn, they were not sure when it is changed because the resident was doing it. During a telephone interview on 10/31/22 at 4:24 PM, LPN #60 stated that they had helped the resident with their ostomy care every now and again and stated sometimes the resident's skin appeared red and irritated. They stated if the skin appeared to have a rash it should be reported to the supervisors for assessing. They stated an LPN's responsibility included resident ostomy care and if they were unsure how to do the ostomy care they should tell nursing administration. During a telephone interview on 11/01/22 at 11:02 AM, physician #54 stated the resident had been asked repeatedly by nursing and by medical not to do their own ostomy care. The resident's judgment was off. The resident messed with the [MEDICAL CONDITION] frequently during the day and made it hard to manage the ostomy. Currently the resident's ostomy had fungal and moisture issues. They stated they spoke with RN Unit Manager #4 yesterday and the resident may be developing [MEDICAL CONDITION] there. The resident had [MEDICAL CONDITION] in the past due to their poor self-care of the ostomy. The area around the ostomy could be erosion of the skin and nursing staff should be assessing and documenting this. It would be reasonable to have an assessment of the resident's ability to care for the ostomy. If the resident was able to manage the ostomy site safely, they should have a physician order to do so. This would cover the resident to ensue no development of infection or [MEDICAL CONDITION]. They stated Lotrisome cream was ordered by the NP #16 last week. 2) Resident #57 was admitted with [DIAGNOSES REDACTED]. The 8/3/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not reject care, required extensive assistance of 1 with dressing, supervision of 1 for personal hygiene, received surgical wound care, and received applications of nonsurgical dressing. The 7/22/22 admission assessment by Assistant Director of Nursing (ADON) #51 documented the resident had a skin impairment of [DIAGNOSES REDACTED] on their left front thigh, on their front left lower leg, and left hip. There was no assessment for self-care of the wounds. The 7/22/22 physician orders documented to ensure the Wound Vac/Negative pressure (vacuum assisted closure used to treat wounds) was set at 125 millimeters of mercury (mmHg) to left leg wound, change 3 times a week and as needed for soilage and displacement. A 7/23/22 admission progress note by physician #55 documented the resident was admitted with chronic non-healing legs wounds The 7/23/22 physician orders documented to change the Wound Vac/Negative pressure canister weekly and as needed every day shift for 7 days. The 7/24/22 physician orders documented: - cleanse the left medial mid leg with normal saline, do not wipe away, gently pack the wound with [MEDICATION NAME] (absorbent wound dressing), cover with dry dressing, and change daily and as needed. - cleanse the left posterior calf with normal saline, place [MEDICATION NAME] to wound bed, cover with border gauze, change daily every other day shift, and as needed. - Apply Dakins 1/4 strength external solution 0.125 % sodium hypochlorite (wound cleanser) to left lateral thigh topically every day shift and evening shift for wound care, cleanse with normal saline, apply Dakins moistened gauze to wound bed, cover with ABD pads (a heavy gauze pad), change daily on day and evening shifts. On 7/24/22 licensed practical nurse (LPN) #103 documented the resident was a new admission to the facility and had a wound vac that was placed post-operation, had multiple wounds to the left lower extremity due to significant uncontrolled diabetes, peripheral [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. The left ankle wound was attributed to venous stasis (poor blood flow) and the left lateral lower leg wound was related to previous surgeries for [DIAGNOSES REDACTED]. LPN #103 documented the resident had changed their dressings prior to the writer entering the room. The resident was unwilling to allow the writer to redo their dressings. The dressing to the left leg appeared to be clean, dry, and intact. The resident was able to verbalize wound care dressing correctly. The 7/25/22 weekly wound evaluation by licensed practical nurse (LPN) #63 (signed by LPN #59 on 10/14/22) documented the resident had 3 wounds. Wound #1 was a surgical incision on the left lower front leg that measured 26 centimeters (cm) x 8 cm x 0.5 cm. The wound had moderate serosanguineous (watery blood tinged fluid) drainage, 95% granulation (new tissue), 5% slough (moist dead tissue), treatment was in place, the wound had improved, the wound was present on admission, and the wound vac was changed Monday, Wednesday, and Fridays. Wound #2 was a left lower leg abscess that measured 4 cm x 3 cm, had moderate serosanguineous drainage, had 100% granulation, had improved, and was present on admission. Wound #3 was a left lateral leg surgical incision that measured 15 cm x 5 cm, had moderate serosanguineous drainage, had large exudate (drainage), 90% granulation, 10% slough, had improved, and was present upon admission. On 7/26/22 LPN #63 documented the resident completed their own dressing changes to left posterior and left lateral leg in the presence of Wound Team Nurses. The Wound Vac dressing to left anterior lower leg was intact. Wound Vac unit was operating effectively at 125mmHg. The wound vac dressing was changed 7/25/22. There were no documented physician orders the resident was assessed and approved to complete their own dressing changes. The 7/26/22 comprehensive care plan (CCP) documented the resident had impaired skin related to [DIAGNOSES REDACTED] to their left lower front leg. Interventions included provide medications as ordered for pain, report any signs and symptoms of deterioration, significant changes to area of impairment, apply moisturizer as needed to skin, and use mild cleansers for peri care and washing. The resident had impaired skin related to wounds. Interventions included to apply treatments per medical orders, evaluate wounds, monitor, document, report to physician any signs and symptoms of infection, and refer to appropriate medical specialist. There was no documentation the resident was assessed to perform wound care independently. The 8/19/22 physician orders documented update to ensure placement of Wound Vac/Negative pressure at (-125) mmHg to left leg and apply collagen powder and [MEDICATION NAME] Non-Adhering Dressing (Protects the wound) to wound bed prior to sponge. The orders did not document self-performance of wound care by the resident. On 9/9/22 Registered Nurse (RN) #120 documented the resident completed their dressing change to the leg independently. Upon assessment of the wound minimal scant serosanguinous drainage was noted on old dressing. The updated 9/14/22 physician orders did not document self-performance of wound care by the resident. The treatment administration record (TAR) documented on 9/14/22 by LPN #102 under wound care see nurse note. There were no documented nursing progress notes for the resident's wound care. The updated 9/16/22 physician orders did not document the resident was able to self-perform wound care. On 9/17/22 at 1:15 PM, LPN #103 documented the resident was provided supplies as the resident completed their own dressing change. On 9/19/22 LPN #102 documented on the TAR, see nurse note. There was no documented nursing note. The updated 9/21/22-9/23/22 Physician orders included: -discontinue the Wound VAC/ Negative pressure. -cleanse the left lateral thigh with normal saline, pat dry with sterile gauze, apply collagen powder and Maxsorb to wound bed; Cover the area with Abd pad and wrap with kerlix; Change the dressing daily and as needed. There were no documented orders for the resident to complete their own wound care. On 9/24/22 - 9/26/22 LPN #102 documented on the TAR see nurse note under the section wound care. There was no documented nursing note. On 9/27/22 LPN #103 documented the resident had been completing own dressing changes since admission. On 10/5/22 LPN #102 documented the resident's bandage was soaked through with blood, the resident began yelling at staff that it was not done right yesterday, and they had to do the dressing themselves, as per normal. On 10/5/22 LPN #103 documented the resident completes own dressing change when they feel like it. During an interview with Resident #57 on 10/20/22 at 11:51 AM, they stated they did their own dressing changes on their left leg, staff did not observe them when they did their dressing changes, and they had never received any wound dressing training from the facility. They knew what how to change the dressing from watching the staff at the hospital prior to their admission at the facility. The resident then pulled off their sock and pulled up their pant leg, which revealed 2 areas that had bandages on their left leg. The bandages were not dated, and their foot bandage had some discoloration on it. The resident also had a clear plastic 12 x 12 tote in their room with wound dressing supplies. On 10/21/22 at 9:24 AM and 1:49 PM, the resident stated they completed their own dressing changes again without staff, the bandages were observed to not be dated. On 10/24/22 at 10:43 AM, the resident's left foot and leg bandages were observed to not be dated. During an interview with Consultant Wound Care Physician #9 on 10/26/22 at 9:43 AM, they stated Resident #57's wounds were healing. The resident did do their own dressing changes at times and sometimes they allowed staff to do it. They had not watched the resident do their dressing changes. During an interview on 10/26/22 at 2:01 PM, LPN #36 stated they were unsure if residents needed an order or assessment to complete their own wound care dressing changes. If a resident was able to complete their own wound care dressings the facility's wound care team would let the Nurse Manager know. Resident #57 told them that they did their own dressing changes, the resident did not want staff changing their dressings, and they did not watch the resident complete their dressing changes. When they were assigned to the resident, they wrote a progress note to document the resident did their own dressing changes. During an interview with physician #55 on 11/1/22 at 11:45 AM, they stated Resident #57 had complex wounds and they were followed by the facility's Consultant Wound Care Physician. They were unaware the resident was completing their own wound care dressing changes, but they would need to be assessed by a registered nurse (RN) and they would also need a medical order to complete their own dressing changes. During a telephone interview with LPN #102 on 10/31/22 at 1:10 PM, they stated wound dressing orders were written on the TAR. Residents could complete their own dressing changes if they could show them, they can do it. Resident #57 was followed by the Wound Care team. The resident verbally told them they could do their own dressing changes and they would bring the resident the supplies needed for their dressing changes. They said it was hit or miss if they watched the resident complete their own dressing changes, as they had a plastic container in their room with supplies. They were unsure where they obtained the supplies that were in the plastic container. They stated it would be important to watch the resident complete the dressing change to ensure it was done properly. They had never told anyone that the resident completed their own dressing changes. During an interview with LPN Unit Manager # 49 on 10/31/22 at 2:02 PM, they stated Resident #57 was able to complete their own dressing changes with the supplies they had in their room. They were unsure how the resident obtained the supplies in their room. They stated the LPNs should have told them that the resident was refusing to allow them to do the dressing change. If the resident was able to do their own dressing changes, they needed a medical order, an assessment, and it would be listed on their CCP. It would be important to know if the resident was following the orders and using proper technique. If staff were not completing the dressing changes, they should be documenting a nursing note. During an observation on 10/31/22 in the presence of ADON #5, LPN Unit Manger #49, and LPN #63, Resident #57 completed their wound dressing changes independently. The resident stated the box of supplies came from the hospital. The resident needed two reminders to perform hand hygiene during the dressing change. During an interview on 10/31/22 ADON #57 stated the resident should have had a self-performance competency assessment done by either a RN or a physician to determine if they could complete their own wound dressing changes. There should have been weekly wound evaluations completed and they were unaware this was not occurring. They were told by the previous ADON that the resident completed their own dressing changes, and they were unaware until today that the resident did not have orders, or an assessment completed to do their own dressing changes. They stated if a resident was able to complete their own dressing changes it should also be listed on their CCP. Staff should have reported to the nurse that the resident was doing their own dressing changes and there were no orders for them to do it themselves. The resident needed some queuing for hand hygiene. During a follow up telephone interview with Consultant Wound Care Physician #9 on 10/31/22 at 6:21 PM, they stated they were aware the resident wa | Plan of Correction: ApprovedDecember 16, 2022 Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 6 of 7 units (Units 1, 2, 3, 4, C and D) reviewed. Specifically, on Units 1, 2, 3, 4, C, and D resident call bell stations did not function as designed and call bells were not within residents' reach to directly contact caregivers and to be answered timely. Findings include: The facility policy Call (NAME)s dated 8/2019 documented providing timely response to residents in need was essential to ensuring high quality resident outcomes. All defective call lights should be reported to the nursing supervisor promptly. Answer the resident's call as soon as possible. On 10/21/22 the following observations were made: - At 9:02 AM, the call bell unit at the toilet within resident room A10 was out of the wall and on the floor. The call bell unit at the bedside in resident room A10 was loose from the wall. - At 9:45 AM, overhead call bell system audible tone for the unit was going off on D-south. The call bell panel behind the nursing station indicated cross hall repeaters were in fault as of 9/10/22 at 12:12 PM. - At 9:45 AM, the D-south panel indicated the current time was 6:45 AM and not 9:45 AM. This was confirmed when testing call bell in D13 at 9:45 AM and the panel indicated 6:45 AM. - At 9:50 AM, the bedside call bell for Resident #267 was out of the residents reach and pinned to itself on the wall behind the left side of the headboard. During an interview on 10/21/22 at 9:02 AM, Resident #100 stated call bells were not answered timely, and they had to wait a long time especially at night. During an interview on 10/21/22 at 9:05 AM, licensed practical nurse (LPN) #64 stated they were not aware the call bell unit in the bathroom of room A10 had come out of the wall. They stated if they did see something a resident could let them know and they would report it. During an interview on 10/21/22 at 9:45 AM, patient liaison #62 stated the overhead tone was always going off. Maintenance would come and fix it and it would come back. They were not aware the call bell panel was showing the wrong time and did not know how long it had been that way. During an interview on 10/21/22 at 9:50 AM, D-south LPN Unit Manager #21 stated they did not know the panel was showing the wrong times. There were maintenance log books that were checked daily, and staff could put that information in the book for maintenance. On 10/25/22, the following call bell observations were made: - At 11:44 AM, the C south unit call bell system was a phone panel with room lights on it. The panel indicated rooms C28, C26, and C18 were activated. Observation of rooms showed only C28 was activated at the bedside, but the corridor light did not function for the room. The Patient Liaison #62 picked up the receiver and hung it up which cleared C26 and C18 leaving C28 activated. - At 11:50 AM, the bedside call bell (paddle style) was tested for resident room C20 and did not function with tone or light. There was a second plunger style call bell plugged into the same wall unit that was not within the resident's reach. The connection jacks were bent and the corridor light outside the room did not work. - At 12:03 PM, the bedside call bell was tested for resident room C17. The call bell was out of reach and on the floor under the bed. The corridor light for the room was not functioning and the cover was hanging from the ceiling. The light on the unit was not functioning and the faceplate was broken. No cancel button was visible, and it required putting a finger inside the unit to access the plunger. - At 1:25 PM on Unit 1 south Resident #121's call bell was alarming. The resident was yelling from their room for the remote control. Resident #121 then called the nursing desk on the unit, and an unidentified CNA answered the call bell at 1:37 PM. During an interview on 10/25/22 at 11:44 AM, patient liaison #62 stated they were not sure why the tone was not going off on the unit. They had not noticed the call bell panel was never clear when picking up and hanging up the receiver. They stated they went what was on the panel. The panels were always being worked on. C28 and the light outside the room in the corridor did not work. During an interview on 10/25/22 at 12:00 PM, LPN #40 stated there should be an audible beep with an activated call bell. The call bell system had been an issue on and off for a while. It worked sometimes and other times it did not. They stated maintenance would fix something and then something else would go wrong. During an interview on 10/25/22 at 12:13 PM, D-South LPN Unit Manager #21 stated certified nurse aides (CNAs) and nurses should make sure call bells were within reach for residents especially after making beds. Call bell placement was everyone's responsibility. If staff were in a resident's room and see them in the wrong spot they should be fixed. During an interview on 10/25/22 at 2:54 PM CNA #6 stated Resident #267 should not have had their call bed behind them because it needs to be by their side. Everyone was responsible for making sure the call bells were within reach but especially CNAs. The CNAs would clip them to blankets or near their hands. On 10/27/22, the following call bell observations were made: - At 10:01 AM on Unit 3 south Resident #109 in room [ROOM NUMBER] was yelling can somebody help me? The call bell was on the floor on the opposite side of the bed. The resident was sitting in their chair next to the window. When the call bell was handed to the resident and activated at 10:02 AM the corridor light outside the room did not activate. The red light on the wall unit was on. The resident continued to yell somebody help me please I want to go back to bed! At 10:09 AM the resident continued yelling, Can somebody help me please? I'm gonna fall, oh my God! - At 4:30 PM the call bell panel for 3 south indicated both bed stations within room [ROOM NUMBER] were activated on 10/25/22 at 5:51 PM. At 4:32 PM in resident room [ROOM NUMBER] the call bell stations at the bedside were not activated and the corridor light outside the room was not activated. Call bells were not within the resident's reach and no tap bells were observed for either resident's use. - At 4:42 PM the bedside call bell for room [ROOM NUMBER] would not go off when addressed. The panel at the nurse's station showed it was activated on 10/27/22 at 12:58 PM. - At 4:52 PM there was a fault on the 2 south call bell panel indicating the shower room east was in fault as of 10/26/22 at 8:22 PM. During interviews on 10/27/22 at 10:13 AM, CNA #101 stated the lights above the rooms in the hallway should come on when the call bell was activated and should also show on the call bell panel at the nurse's station. CNA #41 stated call bell lights above the doors in the hallway were supposed to come on and they were not sure that the lights always came on when activating the call bell. During an interview on 10/27/22 at 10:27 AM, LPN #2 stated if the light in the corridor did not come on it meant the battery was dead and maintenance was alerted. They were unsure if anyone was checking call bells. During an interview on 10/27/22 at 4:35 PM, CNA #39 on Unit 3 south stated they were per diem and did not know about the call bell system. They went by the call bell panel. They did a lot of rounding with residents. The CNA stated they had never been briefed or trained on the call bell system differences unit to unit. During an interview on 10/27/22 at 4:40 PM, LPN #38 on Unit 3 south stated the call bell system did go down and maintenance would come up on evening shifts to try and address it. room [ROOM NUMBER] had been an issue and maintenance had tried to fix it. Residents got tap bells until they it was addressed. During an interview on 10/27/22 at 4:42 PM, CNA #70 stated the call bell in room [ROOM NUMBER] never went off and they could not cancel them. During an interview on 10/27/22 at 4:52 PM, CNA #71 stated the overhead tone was always going even if no call bells were activated. They had been at the facility a year and the tone had never stopped. During an interview on 10/27/22 at 4:57 PM, CNA #37 stated they had not been informed about the call bell systems or differences. On 10/28/22, the following call bell observations were made: - At 1:31 PM, room [ROOM NUMBER] on Unit 3 south continued to show bedside call bells were activated on the panel and not at the stations. The corridor light outside the room was not activated. Call bells continued to not be within resident's reach and no tap bells were observed for either resident's use. - At 3:36 PM, room [ROOM NUMBER]'s call light was missing the button to push (the red piece of plastic). During an interview on 10/28/22 at 1:15 PM, LPN #36 on Unit 4 stated they were never trained or briefed on the call system function when working on different units. During an interview on 10/28/22 at 1:33 PM, CNA #35 on Unit 3 south stated the facility had been trying to fix call bells for some time now. If they heard a call bell going off, they checked the sides of the corridors for lights. They would not know if room [ROOM NUMBER] was going off. Tap bells should be used for the short term if call bells were not functioning but they had not seen tap bells in room [ROOM NUMBER]. Nurses had them at the station and could give them out if needed. They had never been trained on different units call bells. If there was an issue with a call bell, they would tell the Nurse Manager. During an interview on 10/28/22 at 3:36 PM on Unit 3, Resident #169 stated they were transferred from the 4th floor today. With call bell in hand they stated it does not work. Upon further inspection of the call bell, it was observed to be missing the red button used to press which activated the call light. During an interview on 10/28/22 at 3:44 PM, Resident #109 stated the call bell still did not work. On 10/29/22, the following call bell observations were made: - At 1:50 PM, the call bell panel in the 3 South Unit nursing station showed five faults. Pull station in room [ROOM NUMBER] as of 10/26/22 at 12:43 PM, bed station in room [ROOM NUMBER] as of 10/26/22 at 12:43 PM, bed station (1) in room [ROOM NUMBER] as of 10/27/22 at 10:24 AM, bed station (2) in room [ROOM NUMBER] as of 10/27/22 at 10:24 AM, and bed station in room [ROOM NUMBER] as of 10/27/22 at 12:31 PM. - At 1:51 PM on Unit C north the call bell for the resident in room [ROOM NUMBER] was on the floor to the left of the bed. - At 1:52 PM, room [ROOM NUMBER] on 3 South showed bedside call bells were activated on the panel and not at the stations and the corridor light outside the room was not activated. Call bells continued to not be within resident's reach and no tap bells were observed for either resident's use. - At 1:54 PM on Unit C north the call bell for the resident in room [ROOM NUMBER] was under their bed. - At 1:56 PM on Unit C north the call bell cord for the resident in room [ROOM NUMBER] was pinned to the wall behind the bed, unreachable to the resident. - At 1:59 PM on Unit C north an unidentified nurse was observed in Resident #142's room (35.) The call bell was hanging from the wall. The nurse exited the room without making the call bell within reach of the resident. - At 2:04 PM on Unit C north the resident in room [ROOM NUMBER]-W was observed in bed, with the call bell hanging from the wall out of reach. - At 2:09 PM, room [ROOM NUMBER] Unit 3 south bedside call station was not activated, the overhead light in the corridor was on and the panel at the nursing station showed the pull station was activated at 11:14 AM. - At 2:09 PM, the overhead corridor light for room [ROOM NUMBER] Unit 3 south was activated, the call bell stations inside the room were not activated and the room was not showing activation at the nursing station panel. - At 2:19 PM, the call bell was not in reach of the resident in room [ROOM NUMBER] Unit 3. - At 2:19 PM on Unit C south the resident in room [ROOM NUMBER]-D was sitting in their wheelchair and the call bell was lying in the middle of the bed, out of reach. - At 2:22 PM, the call bell was not in reach and under the bed on the floor in room [ROOM NUMBER] Unit 3. - At 2:29 PM on Unit C south the resident in room [ROOM NUMBER]-W was in their bed; the call bell was on the floor. - At 2:31 PM on Unit C south the resident in room [ROOM NUMBER], who was lying in bed, stated their call bell did not work and they were asking for help. The call bell was pressed but it did not activate in the room or in the corridor. There was also a second call bell behind the resident's bed and out of reach, which also was non-functioning. - At 2:33 PM, the 2 south call panel had a fault for East shower room as of 10/26/22 at 8:22 PM. - At 2:36 PM, call bells were not in reach and on the floor under the beds in room [ROOM NUMBER] Unit 2. - At 2:40 PM on Unit C south the resident in room [ROOM NUMBER]-W was asking for help with their call bell which was behind their headboard. - At 3:04 PM on Unit D the resident in room [ROOM NUMBER]-W was lying in bed. Their call bell was hanging behind their bed. - At 3:17 PM on Unit D the resident in room [ROOM NUMBER]'s call bell was draped over the head of the bed, out of reach. - At 3:18 PM, the call bell panel behind the D-south nursing station had a fault for the cross hall repeater as of 9/10/22 at 12:12 PM. Overhead tone was going off. - At 3:21 PM, during a call bell test for both bed side units in room D46 the overhead corridor light did not activate, and the panel did not show an activation for ether bed in the room. The call bell was not in reach for Resident #267 as it was pinned on the wall behind the headboard. - At 3:23 PM, during a call bell test for both bed side units in room D45 the overhead corridor light did not activate, and the panel did not show an activation for ether bed in the room. During an interview on 10/29/22 at 3:25 PM, CNA #82 stated they were not trained on how to respond to call bells when entering the floor. They stated they thought it would be like normal when a sound or light comes up, they answered that room. They did not know the call bell for both resident rooms D45 and D46 did not activate to the panel. During an interview on 10/29/22 at 3:40 PM, CNA #32 stated resident rooms D45 and D46 were tied into the closed D-north unit. The new system was supposed to include those two rooms and ring to the panel on D-south. The residents in D45 knew staff names and would call out to them. They were rarely in their room. Resident #267 should be up each day, so they were checked on regularly. Resident #267's roommate was checked on each time they were in the room for Resident #267. They relied on frequent checks to make sure residents did not need anything. The new system should have been installed around (MONTH) and was supposed to ring to the correct side of the unit. During an interview on 10/29/22 at 2:02 PM, CNA #76 stated the call panel did not work and they did not go by it but would respond to the sound overhead. They mainly used frequent room checks to see if residents needed anything. It was mainly from experience that they knew what worked and what did not for call bells. They knew room [ROOM NUMBER] did not sound but the hallway light would light up. On 10/31/22 the following call bell observations were made: - At 9:32 AM on Unit 2 north Resident #163 in room [ROOM NUMBER] was observed leaning to their right side in bed, with their call bell alarming. At 10:02 AM the call bell was answered by unidentified staff. - At 9:37 AM on Unit 2 north there was an overhead call bell announcement for room [ROOM NUMBER]'s bathroom. At 9:41 AM an unidentified staff member was observed sitting at the nurse's station. At 9:56 AM room [ROOM NUMBER]'s bathroom alarm was again announced in an overhead page. At 10:02 AM the call bell for room [ROOM NUMBER] was answered. - At 10:36 AM on Unit D the resident in room [ROOM NUMBER]-D was lying in bed with their call bell behind the bed. - At 10:43 AM on Unit D the resident in room [ROOM NUMBER]-W's call bell was hanging over the head of their bed, out of reach. During an interview on 10/31/22 at 12;35 PM with the Administrator, they stated call bells were checked by maintenance occasionally to make sure they were functioning. Sometimes the call bell systems needed batteries. If call bell problems were not addressed residents would not be able to call for assistance and that would be problematic. During an interview on 11/01/22 at 1:41 PM, the Director of Nursing (DON) stated they understood there were some issues with the call bell system and had service providers in to check them. They had recently talked with Units D and C about call bells not working. Call bells not working could impact residents and the care being rendered to them. If they knew about a call bell not working, there were manual tap bells that could be provided for residents to use. Residents could also have a room change when a problem persisted. Nurse supervisors had tap bells if needed on each unit. Staff were expected to call maintenance or document issues into the maintenance work log on the units. Nursing staff that floated to different units did not receive any training or re-education when being assigned to various units. They expected the base function of any call bell system to work the same way and to be addressed in the same way. All call bells should be within resident reach and this topic was covered during orientation. On 11/02/22, the following call bell observations were made: - At 1:14 PM, the call bell panel in the 3 South Unit nursing station showed five faults. Pull station in room [ROOM NUMBER] as of 10/26/22 at 12:43 PM, bed station in room [ROOM NUMBER] as of 10/26/22 at 12:43 PM, bed station (1) in room [ROOM NUMBER] as of 10/27/22 at 10:24 AM, bed station (2) in room [ROOM NUMBER] as of 10/27/22 at 10:24 AM, and bed station in room [ROOM NUMBER] as of 10/27/22 at 12:31 PM. - At 1:15 PM, room [ROOM NUMBER] on 3 South continued to show bedside call bells were activated on the panel and not at the stations, and the corridor light outside the room was not activated. Call bells continued to not be in residents' reach and no tap bells were observed for either resident to use. - At 1:28 PM, the 2 North call bell panel clock showed the current time was 10:28 AM and a call bell activation was in place for room [ROOM NUMBER] as of 10:04 AM. - At 1:52 PM, fault identified on D-South panel for D45 as of 11/1/22 at 10:48 AM and cross hallway repeater as of 10/31/22 at 4:48 PM. During an interview on 11/02/22 at 11:47 AM, the Administrator stated call bells had occasional issues with batteries or errors that came up. They did not think there was a facility-wide issue. If any component of the call bell system was not working a tap bell was a good solution. If there was an immediate issue that needed to be addressed maintenance staff had a cell phone. Non-emergency issues could be put in the maintenance log books on the units. Maintenance should tell staff when and if a unit was fixed. The expectation should be to look at the call bells and they should be responded to regardless of the time of the call bell pull. They were not aware of any current areas with faults not being addressed on a unit. Maintenance should be aware. They stated they knew that rooms D45 and D46 were not being used because they rang to the D north panel instead. Those residents were moved this week due to that issue. D-south was an anomaly. It was not optimal, but replacement parts were needed. They had not gotten a vendor quote yet for the D south panel to include the missing rooms [ROOM NUMBERS] that go to the North side. They stated they would expect the call bell system to be addressed as issues arose. There were no system replacements in the works they were aware of. The call bell system issues could be a problem for residents if call bells were not being attended to and residents' needs were not met. During an interview on 11/02/22 at 12:52 PM, the HMO Coordinator/IT/Assistant Director of Maintenance they stated there were a couple of issues that had been brought to their attention with the call bell system. Room C25 and C20 had been sent into the call bell vendor to get addressed. On D south the vendor came in to fix the issue of not alarming to the panel in D-south but going to D-north. On Monday (10/31/22) it was changed and fixed. They were not sure if there were work orders on the completion of the work done. Outside hall lights for D45 and D46 were hard-wired to the other side so the replacement receiver needed to be changed for that. They asked staff to log things that needed assistance on the floors using the logbooks. Maintenance should be called immediately for a call bell malfunction. Time and time again they had tried to fix the systems. When they found faults, they tried to address them and asked nursing staff to let them know of any issues that arose. Any issues with overhead tones not coming up could be an issue with the volume control of the audio since they could turn it down and then may not turn it back up. The maintenance logbooks were checked each day on the units. Call bells were audited quarterly and visually every 2-3 days. 10NYCRR 415.29 | Plan of Correction: ApprovedDecember 16, 2022 1. The facility engaged the services of a call system vendor to review and advise on the status of the call bell system. Results of their review will be immediately addressed. All staff on duty on 10/29/22 on 3 South , C South and D south during the 7a-3p shift and 11/2/22 on 3 South during the 7a-3p shift were educated on the importance and expectation of call bells being within residentsÆ reach 2. All residents could have been affected by the alleged deficient practice. An audit was conducted on the facility call-light system to ensure that all resident rooms on open units have full operable call systems. All identified issues to be addressed by the vendor and maintenance team. Rounds conducted on all units to ensure residents call bells were within reach. 3. Facility policy related to call system has been reviewed. No revisions required . Maintenance will be educated on the requirements surrounding resident call systems and the importance of having a full operable system in every occupied resident room and throughout operable resident areas. They will further be educated on the requirement that call bell system issues are immediately addressed. Routine inspections will be implemented on the call bell system. This will include regular audits on the operability of individual call-system components as well as a review of the software dashboard for alerts. All Nursing staff will be educated on the importance and expectation of ensuring call bells are placed and kept within resident reach and reporting call bell issues to maintenance. 4. A random sample of 20 call bells in various locations will be audited for functionality Audits will be conducted weekly x12 and continue weekly until substantial compliance has been met A rounding audit will be conducted by DON /Designee on each unit. 5 residents per unit will be audited to ensure residentsÆ call bells are within reach The audit will be conducted daily x 7 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met Rounding/Audit findings will be submitted to the QAPI committee monthly for review and recommendation. . Person Responsible: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey conducted 10/20/22 - 11/2/22, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life, recognizing each resident's individuality for 4 of 5 residents (Residents # 93, 110, 290, and 294) reviewed. Specifically: - Resident #110 was visible from the hallway, in bed not wearing clothing, eating their meal while incontinent of stool, and with their roommate eating their meal in close proximity. - Resident #290's urinary catheter collection bag was uncovered, and the contents was visible on multiple days. - Resident #294 was transported out of the facility to medical appointments wearing only a hospital gown and received food items they had asked to avoid due to religious beliefs. - Resident #93 was observed spoken to by staff in a disrespectful manner. Findings include: The facility policy Quality of Life/Dignity, revised 10/2021, documented each resident shall be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Treated with dignity meant the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. Demeaning practices and standards of care that compromise dignity were prohibited. Staff shall promote dignity and assist residents as needed by helping resident to keep urinary catheter bags covered. 1) Resident #110 had [DIAGNOSES REDACTED]. The 8/16/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required total assistance for toileting, two-person physical assistance for personal hygiene and dressing, and one-person limited assistance with eating. The comprehensive care plan (CCP) with a review date of 8/22/22 documented the resident required assistance with activities of daily living (ADLs) related to limited range of motion (ROM). The resident was encouraged to use the call bell for assistance. The resident required supervision with set-up help only for eating. The resident had bowel incontinence due to chronic constipation and interventions included incontinence would be managed daily in a timely manner and that perineal care was to be provided after each incontinent episode. The resident had target behaviors which included disrobing and staff were to monitor and record the occurrence. There was no documentation for the resident's meal preference location (in or out of bed) and no documentation regarding specific interventions for behaviors of not wearing clothing. The resident care instructions as of 10/26/22 documented the resident was totally dependent on staff for toileting, and perineal care was to be provided after each incontinent episode. The following observations of Resident #110 were made on 10/25/22: - at 1:14 PM the resident's call light was alarming over their doorway. The resident was in their bed in the high position, turned onto their left side with no clothing on, eating their lunch. There was an incontinent pad covered with stool on the bed. The resident had a trapeze bar over their bed for turning and positioning. The resident's roommate was sitting in a chair eating their lunch three feet away from Resident #110's bed and at eye level to the soiled pad. Housekeeping was across the hall from the resident's room opening a utility closet. Resident #110 stated they had turned the call light on an hour-and-a-half ago and whenever they turned on their call light staff never came, or they would say they would be right back but never returned. The resident stated staff had brought in their lunch tray while they were incontinent of stool. - at 1:19 PM an unidentified staff entered Resident #110's room and asked them if they were okay. The resident stated they needed to be changed and they thought the certified nurse aide (CNA) taking care of them for the day was CNA #1. The unidentified aide stated they would let CNA #1 know, but they thought they were currently assisting with feeding other residents. The call light remained on. - at 1:32 PM the resident was holding onto the trapeze bar above their bed attempting to reposition and distance themselves from the stool covering most of the incontinent pad. During an interview on 10/25/22 at 1:41 PM licensed practical nurse (LPN) Unit Manager #2 stated CNA #1 was Resident #110's assigned caregiver for the day. It was not easy to manage all the call lights alarming during mealtimes. They shrugged their shoulders and stated, we have a lot of feeders; we have 8 feeders and walked away. On 10/25/22 at 1:42 PM CNA #1 was observed entering Resident #110's room. During an interview with CNA #1 on 10/26/22 at 10:19 AM they stated they knew when a resident needed assistance by the call light alarming above a residents' door and on the computer screen in the nursing office. They could not remember who passed Resident #110's lunch tray on 10/25/22. They stated if a resident had stool in their bed when passing meal trays, they would leave the tray in the room then come back later to provide incontinence care. CNA #1 stated it was not right to leave the tray in a Resident #110's room if they were incontinent of stool, but they had 2-3 CNAs passing meal trays and a lot of feeders on the unit. They stated CNAs were in some resident rooms assisting with feeding. It was not appropriate for Resident #110's roommate to have to sit next to them eating their meal while Resident #110 was incontinent of stool. They stated they did not routinely tell LPN Unit Manager #2 if they needed more assistance on the unit for resident care. During an interview with LPN Unit Manager #2 on 10/27/22 at 10:27 AM they stated staff should be looking for call lights alarming during mealtimes. They had more feeders on the unit lately. LPN Unit Manager #2 expected staff to notify them if they needed more assistance during mealtimes. If they needed more help on the unit, they would first see if they could pull staff from the other side of the unit. If they could not find more staff from the other side of the unit, they would let Assistant Director of Nursing (ADON) #51 know. If a resident was incontinent of stool, they would expect staff to provide incontinence care prior to them getting their meal tray. It was not appropriate or dignified for Resident #110 to be receiving their meal tray while incontinent of stool and with their roommate sitting nearby eating their meal. During an interview with ADON #51 on 10/31/22 at 9:40 AM they stated staff should be monitoring call lights during mealtimes. If staff was not able to assist a resident immediately when their call light was alarming, they should tell the resident they would be right back. No resident should get their meal when incontinent and Resident #110 should have been provided incontinence care first before receiving their meal tray. It was not dignified for Resident #110 to be eating while unclothed and incontinent of stool and it was also not appropriate for Resident #110's roommate to be put in that situation. If a unit was running short on help the Unit Manager should be notifying the ADON or Director of Nursing (DON). It was not dignified to refer to residents as feeders; they should be called by their individual names. 2) Resident #290 had [DIAGNOSES REDACTED]. The 10/1/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was totally dependent for activities of daily living (ADL) and had an indwelling catheter. The following observations of Resident #290 were made: - on 10/21/22 at 8:39 AM, 11:39 AM, 12:28 PM, and 1:19 PM, sitting in a chair near the 2N nursing station with their urine collection bag resting on the floor not covered and visible to visitors and other residents on the unit. - on 10/25/22 at 8:58 AM, 11:30 AM, 1:50 PM, and 4:03 PM, sitting in a chair in the hallway outside of room [ROOM NUMBER] with their urine collection bag uncovered and resting on the floor in plain sight. - on 10/26/22 at 2:46 PM, sitting in a chair in the hallway near the nursing station with their urine collection bag on their lap, uncovered. During an interview on 10/26/22 at 2:46 PM, certified nurse aide (CNA) #50 acknowledged the resident was sitting in the hallway with their urine collection bag in their lap. CNA # stated there should be a privacy bag over the urine collection bag but was unsure where to get one and would have to ask the nurse or central supply staff. During an interview on 10/31/22 at 2:36 PM, registered nurse (RN) Unit Manager #4, stated the urine collection bag should be covered with a blue privacy bag when the resident was out of their room for dignity purposes and resident privacy. During interview with Assistant Director of Nursing (ADON) #51 on 11/2/22 at 8:44 AM, they stated a urine collection bag should be covered with a privacy bag for resident dignity. 3) Resident # 294 had [DIAGNOSES REDACTED]. The 10/3/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive staff assistance for bed mobility, transfers, dressing, and toilet use, and supervision and setup for eating. The mood severity score was 21, with the resident reporting feeling down, depressed, or hopeless, feeling bad about themselves, trouble with sleep, and trouble with appetite or overeating nearly every day. An initial psychological assessment dated [DATE] by psychologist # 65 documented a referral was made due to depression, frustration, and agitation. The mental status exam documented the resident was calm and cooperative, agitated, alert, with good judgement. The resident expressed discontent with being in care and did not feel they received appropriate services. The resident mentioned they would like to pursue a lateral transfer. Recommendations included no medication changes, safety precautions per facility protocol, and to follow-up in 1-2 weeks for supportive psychotherapy The comprehensive care plan (CCP) initiated 5/18/22 documented the resident had a nutritional problem related to multiple food concerns and no pork related to religious beliefs. Interventions included the Food Service Director would follow up with multiple food issues, and meal tickets marked to avoid pork. On 7/26/22 the resident filed a grievance which documented several care concerns including menu choices. On 8/2/22 the interventions implemented included dietary was to address meal concerns and lack of meat selections on trays. A social work progress note dated 8/8/22 by social worker #68 (SW) documented the resident asked their primary care office to call the facility to assist with retrieving clothing items from their previous residence. The SW explained that the resident had an estranged relationship with their spouse and was seeking a divorce. The resident's primary care social worker indicated they would provide the resident with pro-bono information regarding obtaining their personal clothing items from their previous residence. The SW would continue to provide ongoing support. The 8/29/22 physician orders [REDACTED]. Resident # 294 was observed and interviewed: - on 10/20/22 at 11:20 AM the resident was observed in bed in a hospital gown. The resident stated they felt they were being treated like they were in a detention center. The food was always served cold, and they had specific diet needs due to their religion that were often not honored. They felt that when their tray contained beef or pork it was a direct attack on their religion and race. This had happened about once or twice a month since their admission. They had been taken out of the facility for appointments in a hospital gown and covered with a sheet. They felt embarrassed and ashamed going to medical appointments this way. The resident had very few items of clothing and no shoes observed in their closet or dresser. Their closet contained a jacket, and a yellow mesh bag with 2 shirts and one pair of sleep pants. They stated their house was right down the road and no one had offered to help them get clothing. They stated it had been about 3 weeks since they were shaved and had not received a shower in more than 2 weeks. - on 10/21/22 at 2:05 PM the resident stated they had no shoes or clothing available since admission, and this was not how they wished to live. The resident stated they felt they were in a detention center, and the facility was making money from them being there and they would expect better treatment be provided. - on 10/25/22 at 9:30 AM the resident stated they had an outside appointments today and was upset they had no clothing or shoes to wear. - on 10/26/22 at 9:30 AM the resident stated they went out for an appointment on 10/25 and staff were able to provide a T-shirt and hospital pants for them to go out in, but they still had no shoes. - on 10/27/22 at 10:56 AM the resident was dressed in a shirt with the facility logo and hospital type pants. They were not wearing shoes. They stated they were going out for an appointment. During an interview on 10/31/22 at 3:40 PM, certified nurse aide (CNA) #69 stated the resident had no clothing available other than the donated items provided by the facility. The resident did not eat pork or beef due to their religion. The CNA had seen mistaken tray items including pork. When that occurred, they called the kitchen and ordered something else. They were not aware of the resident feeling treated differently because of race/religion. During an interview on 10/31/22 at 4:00 PM licensed practical nurse (LPN) Unit Manager #40 stated the resident did not like pork and they thought it might be a religious preference. The resident had complained in the past of pork being on their meal tray. When that happened, the staff was supposed to obtain a replacement. The LPN was aware the resident had no clothing. The LPN stated they had never heard the resident complain about not having clothing. The facility provided clothing for appointments this past week. If the resident stated they wanted clothing, the LPN would notify social work. During an interview on 10/31/22 at 5:34 PM, ADON #51 stated they were aware the resident had complained about feeling they were treated differently because of their race and religion. The care plan should include personal preferences as well as religious beliefs. The facility was looking into the resident's concerns. Residents should be clothed to go out of the facility for appointments. If a resident did not have clothing it could be provided by the facility. During an interview 11/1/22 at 11:24 AM, CNA #58 stated the resident did not want pork or beef and was not sure if it was because of religious preference. There have been mistakes made on their tray receiving meat they did not want. When that happened, substitutes were requested. The resident only had a couple of shirts and pants, and only gets dressed for appointments. If they needed clothing, the CNA would get some from laundry. Residents should not go to appointments in hospital gowns. During an interview on 11/02/22 at 9:10 AM, CNA #56 stated they had worked when the resident had received pork or beef on their tray and staff were to request something the resident wanted from the kitchen. The resident got upset when meat was on their tray and did not like it if the kitchen did not have a suitable replacement. During an interview on 11/2/22 at 12:31 PM, the DON stated the facility should provide clothing if the resident did not have any. The DON stated there were definite tray accuracy issues in the kitchen but does not feel they were racially motivated. They were aware the resident was upset when their tray mistakenly received meat they did not want. 10NYCRR 415.5 (a) | Plan of Correction: ApprovedDecember 16, 2022 1. ò Resident #110 was provided incontinent care and was evaluated by a Social Worker/ Provider and suffered no ill effects. All staff on duty 10/25/22 during the 7am û 3p shift were educated on resident dignity with emphasis on residents being clothed and providing assistance/ incontinent care timely and prior to residents having their meal ò Resident #290 was provided a privacy bag and was evaluated by a Social Worker/ Provider and suffered no ill effects. All staff on duty 10/21/22 during the 7am û 3p shift 10/25/22 during the 7am -3pm and 3p- 11p shift and 10/26/22 during the 7am û 3pm shift were educated on resident dignity with emphasis on the importance and expectation of providing privacy bag covering to all resident with urinary collection bags and proper placement of urinary collect bags. . ò Resident #294 provided clothing and shoes by the facility. Resident was evaluated by a Social Worker/ Provider and suffered no ill effects. Dietian met with resident to review/update dietary preferences. Care Plan updated to reflect religious based preferences ò Resident #93 was evaluated by a Social Worker/ Provider and suffered no ill effects 2. All residents have potential to be affected ò All residents reviewed to ensure cultural/religious food requests are being honored -Rounds conducted at mealtime on all units to ensure no residents were visible from the hallway, in bed not wearing clothing and eating their meal while incontinent and/or with their roommate eating their meal in close proximity ò A Full house audit was conducted of all residents with indwelling catheters to ensure urinary catheter collection bags were not uncovered, and/or with the contents was visible. ò A audit was conducted of all residents with appointments scheduled in the next 30 days to ensure resident have appropriate clothing to attend appointments ò Rounds were conducted on all units to ensure no residents are/were observed ot be spoken to in a disrespectfull manner 3. The policy on Quality of life /Dignity reviewed. No revisions required All facility staff educated on Residents Rights /Dignity including to not refer to residents as feeders or other undignified names All Nursing staff educated that Privacy bags may be located in clean utility rooms and/or Central Supply Unit assignments revised to include assigned person for rounding /answering call lights during meals 4. ò A rounding audit will be conducted by ADON /Designee during 1 meal per unit to ensure no residents were visible from the hallway, in bed not wearing clothing and eating their meal while incontinent and/or with their roommate eating their meal in close proximity. The audit will be conducted daily x 7 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met ò DON/Designee will conduct and audit of all residents with indwelling catheters to ensure urinary catheter collection bags were not uncovered, and/or with the contents was visible. The audit will be conducted daily x 7 days. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met ò DON /Designee will conducted an audit of all residents with appointments to ensure resident have appropriate clothing to attend appointments. The audit will be conducted daily x 7 days then weekly x 12 weeks and continue weekly until substantial compliance has been met ò Social Worker/Designee will conduct interviews on 3 residents per unit to ensure that no residents report or is observed being spoken to in a disrespectful manner. The audit will be conducted weekly x 12 weeks and continue weekly until substantial compliance has been met Rounding/Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #140) reviewed. Specifically, Resident #140 was administered oxygen without a medical order. Findings included: The facility policy Oxygen Administration, revised 10/2019, documented oxygen was administered by licensed nurses with a physician's orders [REDACTED]. Orders should specify the oxygen equipment and flow rate, or concentration required as routine or as needed. Check the physician order. If the order was unclear, clarification must be obtained. The facility policy Oxygen Therapy, revised 1/2020, documented oxygen should be regarded as a drug and therefore required physician prescription in all but emergency situations. Failure to administer oxygen appropriately could result in serious harm to the patient. Oxygen was administered according to physician order. Oxygen orders should include liter flow, delivery mode (nasal cannula, mask etc ), oxygen equipment checks, and frequency. Oxygen use would be documented on the electronic Medication Administration Record [REDACTED]. Flow rate must be adjusted only by a licensed nurse. Resident #140 had [DIAGNOSES REDACTED]. The 10/5/22 Minimum Data Set (MDS) assessment documented the resident received oxygen therapy and had a bilevel positive airway pressure ([MEDICAL CONDITION]-noninvasive respiratory ventilation). The 5/2/22 comprehensive care plan (CCP) documented the resident had an alteration in respiratory system. Interventions included assess oxygen needs and provide as ordered by the physician; monitor vital signs and report any abnormalities to the physician; monitor/document/report to the physician as needed any difficulty breathing or cough; monitor signs of shortness of breath; provide oxygen per physician orders [REDACTED]. The CCP was continued upon the resident's return from the hospital. The 10/4/22 hospital discharge summary documented the resident was admitted for [MEDICAL CONDITION] (brain disease) and palliative care. The 10/5/22 at 3:21 PM licensed practical nurse (LPN) Unit Manager #40 progress note documented the resident returned from the hospital at 12:00 PM, physician orders [REDACTED]. The 10/5/22 admission physician orders [REDACTED]. - [MEDICATION NAME]-[MEDICATION NAME] Solution ([MEDICATION NAME][MEDICATION NAME]) 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) give 3 ml inhale orally via nebulizer three times a day for antiasthma tic; and - [MEDICATION NAME] (steroid) 1 milligram (mg)/2 ml every morning and bedtime for [MEDICAL CONDITION]. The admission orders [REDACTED] The 10/5/22 LPN Unit Manager #40 admission/readmission evaluation documented the resident was admitted from the hospital, had oxygen on via nasal cannula, had shortness of breath while lying flat, lung sounds were clear, and the resident received breathing treatments per orders. The 10/7/22 at 10:56 AM LPN #57 progress note documented the resident denied shortness of breath and had oxygen on while lying flat during the MDS interview. The resident was observed on 10/30/22 at 9:33 AM, 10/30/22 at 11:50 AM, 10/31/22 at 9:53 AM, 10/31/22 at 11:14 AM, and 10/31/22 12:45 PM lying on their back in their bed wearing oxygen at 2 liters per minute (LPM) via a nasal cannula supplied through an oxygen concentrator. The resident was observed on 10/31/22 at 1:07 PM sitting on the edge of the bed with oxygen on at 2 LPM via nasal cannula and 2 female therapists were in the room performing therapy with the resident. The resident was observed on 11/1/22 at 10:30 AM and 2:00 PM lying on their back in bed with oxygen supplied at 2 LPM via nasal cannula connected to an oxygen concentrator. When interviewed on 10/31/22 at 1:30 PM, certified nurse aide (CNA) #58 stated they were assigned the resident on 10/31/22 and was very familiar with the resident. The CNA stated the resident received oxygen routinely, was not sure how much, and only checked that the humidification bottle was full, and the concentrator was on. If the bottle was not full or the concentrator was not on, they would notify the nurse on duty. CNAs knew if the resident needed oxygen by reading the care instructions. When interviewed on 10/31/22 at 3:10 PM, LPN Unit Manager #40 stated the resident was on supplemental oxygen. After looking at the resident's orders, the LPN Unit Manager stated the resident did not have oxygen or [MEDICAL CONDITION] orders. The LPN Manager stated the resident did have those orders prior to going to the hospital. They stated orders should include LPM flow, the times of administration, and tubing change frequency as well as humidification bottles. Those orders could be entered into the electronic medical record by any nurse, the physician or nurse practitioner, and a respiratory therapist. The Unit Manager was responsible for ensuring the resident had the appropriate oxygen orders and was not sure why the resident did not. The admission nurse was initially responsible upon the resident's return from the hospital. On 11/1/22 at 11:37 AM, the LPN Unit Manager stated the admission nurse received the admission packet, reviewed the hospital discharge orders, and contacted the physician to obtain admission orders [REDACTED]. The orders were then inputted into the medical record and verified by the physician on their next visit. When interviewed on 10/31/22 at 4:36 PM, Assistant Director of Nursing (ADON) #51 stated oxygen orders included frequency of oxygen saturation levels, frequency of changing humidification bottles, frequency of oxygen administration, liters of administration, and method of administration. The ADON stated any nurse was able to obtain oxygen orders from the physician and enter them into the medical record. The Unit Manager was responsible for ensuring the resident had oxygen orders. The ADON stated the nurse assigned to admit the resident received the discharge packet, discharge orders were to be verified with the physician by the admitting nurse, and then inputted into the medical record. The off-shift night supervisor was responsible for double checking the orders the night of admission. 10 NYCRR 415.12(k)(6) | Plan of Correction: ApprovedDecember 16, 2022 1. ò Resident #314 was evaluated by a Social Worker/Respiratory therapist /Provider and suffered no ill effects. Order for oxygen entered. Care plan reviewed/revised to reflect resident status 2. All residents have the potential to be affected. Rounds were conducted on all units to identify residents utilizing oxygen. Provider orders and Care plans of residents identified will be reviewed and revised accordingly to reflect resident status 3. Polices on Oxygen Administration and Oxygen Therapy reviewed. No revisions required All Nursing staff educated on the importance and expectation that residents utilizing oxygen have provider orders and Care Planning in place 4. A rounding audit will be conducted by ADON /Designee on each unit. 5 residents per unit will be to ensure residents utilizing oxygen have Provider orders and Care plans in place The audit will be conducted daily x 7 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Nursing |
Scope: N/A
Severity: N/A
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure termination forms (Form 105e used to deactivate the employee in the CHRC, Criminal History Record Check) were submitted to the New York State Department of Health (NYS DOH) within 30 calendar days of termination/separation for 3 of 10 prospective employees (prospective Employees #91, #92, and #93) reviewed. Specifically, Prospective Employees #91, #92 and #93 were not terminated from Criminal History Record Check (CHRC) within 30 days of their separation/termination from the facility. Findings include: The facility policy Criminal History Record Check (CHRC) dated 3/2021 documented once an employee was terminated from employment the Authorized Person would then submit the DOH CHRC 105 Termination form in a timely manner. Personnel folders documented the following: - Prospective Employee #91 never worked at the facility due to a negative determination letter from CHRC dated 5/19/2022. They were not terminated in the CHRC system using the 105e form until 10/26/2022, and not within 30 calendar days as required. - Prospective Employee #92 was terminated from employment with the facility on 12/8/2021. They were not terminated in the CHRC system using the 105e form until 10/26/2022, and not within 30 calendar days as required. - Prospective Employee #93 was terminated from employment with the facility on 7/12/2022. They were not terminated in the CHRC system using the 105e from until 10/26/2022, and not within 30 calendar days as required. When interviewed on 10/27/22 at 11:54 AM, the Human Resources Director stated they did not realize the three employees were not terminated from CHRC. They stated they were aware of the requirement to have employees terminated in CHRC within 30 calendar days after separation from employment. 10NYCRR 402.9(b)(2) | Plan of Correction: ApprovedDecember 16, 2022 1. Prospective Employees #91, #92 and #93 were terminated from Criminal History Record Check (CHRC) 2. All residents have the potential to be affected by the deficient practice. Audit conducted of all employees terminated in the past 30 days to ensure removal from CHRC 3. The policy on Criminal History Record Check was reviewed. No revisions required All Department Heads educated on the importance and expectation of timely notification to Human Resources of any staff terminations Human resources staff educated on the importance and expectation of terminating persons from CHRC who do not and no longer work for the facility. 4. An audit will be conducted by Human Resources Director /Designee to ensure all persons separated from employment at the facility have been terminated from CHRC. The audit will be conducted weekly x4 weeks, then monthly x 3 months. The audit will continue monthly until substantial compliance has been achieved. Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Human Resources |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 10/20/22-11/2/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 13 resident rooms (Resident rooms A10, A12, C17, C24, C29, D15, 136, 139, 227, 231, 249, 431, and 444), for 10 resident common rooms (Shower room adjacent to room [ROOM NUMBER], 136, 139, 222, 248, 427, 436, 448, 457, and the 2nd floor day room), and the main kitchen. Specifically, there were multiple unclean, stained, and damaged floors and walls throughout the facility and fruit flies were present in the main kitchen. Findings include: Review of Bathroom Cleaning procedure date 9/5/17, noted how to mop floors and what chemicals to use. The intervals were not listed for how often the bathroom cleanings are done. According to the blank deep cleaning schedule, also dated 9/5/17, resident rooms are deep cleaned once a month by conducting a few rooms each day throughout the month. Review of the requested past 6 months of maintenance work order records noted there was no dates and little information for the location of issues that needed to be addressed. There was also no evidence listed for the status of the issues in need or repair (e.g fixed, ongoing, etc.). Resident Rooms: On 10/25/22 the following observations were made: - at 11:12 AM, there was a 8 inch x 11 inch hole in the wall covered by a piece of fiber wall paneling (FRP) screwed to the wall adjacent to the bed in resident room A10. In addition, the bed side call bell unit was loose from the wall. - at 11:16 AM, the walls were scraped and marred adjacent to the resident's bed within resident room A12. - at 11:56 AM, there was a spilled can of soda on the floor under the bed with a plastic spoon and fork under the PTAC (heating/air conditioning) unit within resident room C24. In addition, the window screen on the right side was bent and broken and hanging loose from the window frame. - at 12:03 PM, the call bell unit at bedside had a broken faceplate with a hole in it inside the wall of resident room C17. There was no cancel button or labeling on it to turn it off. In addition, the walls around the residents bed were scraped and marred all along the length of the bed. - at 1:21 PM, the linoleum flooring in front of the door to the resident bathroom was chipped and missing 3-4 inch sections within resident room [ROOM NUMBER]. - at 2:18 PM, there was a large single window pain with large cracks through the glass that was taped over with blue painters tape within resident room [ROOM NUMBER]. There was sign on the opposite window pain that stated do not open. - at 3:28 PM, the walls are scraped and marred all along the wall behind the bed within resident room C29. During an interview on 10/25/22 at 11:15 AM, licensed practical nurse (LPN) #64 stated maintenance should be addressing work orders that get put into the log books at the nursing stations. The pages are taken each day, but not sure when things get worked on. There are plenty of things still waiting to be addressed and fixed. During an interview on 10/25/22 at 11:38 AM, LPN #21 stated nursing staff will make beds and bring laundry to the soiled rooms. If there was anything not working or damaged in a residents room nursing staff should make note of those things in the maintenance log books at the nursing stations. Maintenance checks them daily and then addresses the issues. We do not know when things get addressed. During an interview on 10/25/22 at 12:15 PM, maintenance technician #112 stated the log books were checked on each unit daily. The logs sheets were collected and then staff worked on them. The logs were not saved and should be entered into our system. The technician was not sure about specific resident rooms but there were a lot of rooms that needed finishing and painting. During an interview on 10/25/22 at 3:28 PM, Resident #308 stated the walls had been scraped for a long while. On 10/26/22 the following observations were made: - at 9:43 AM, there was a large crack in the window pain on the left side within resident room [ROOM NUMBER]. - at 9:46 AM, the cable television outlet box was hanging loose from the wall with exposed wires within resident room [ROOM NUMBER]. - at 10:22 AM, there were scrapes and peeling paint all along the wall next to the door side resident's bed within resident room [ROOM NUMBER]. In addition, there were blue fleece blankets covering the windows and kept in place with clothes pins on the right and taped to the window pain on the left side. The towel bar within the bathroom was loose from the wall. - at 10:33 AM, Resident #99 had a Geri (positioning) chair in their room that was unclean on the arms and seat. - at 10:45 AM, there were three large basketball sized unsanded and unfinished sections of joint compound roughly put on the wall next to the resident's bed within resident room [ROOM NUMBER]. - at 2:39 PM, the cable television outlet box was coming loose from the wall and held in place with a piece of red duct tape within resident room D15. During an interview on 10/26/22 at 9:55 AM, certified nurse aide (CNA) #43 stated maintenance should be handling any things that were broken or needed to be painted. They were not sure how long the window was cracked in room [ROOM NUMBER]. During an interview on 10/26/22 at 10:22 AM, Resident #163 stated their family put up the blankets years ago. They told staff they wanted shades on the windows as the sun was to much coming through the window. During a combined interview on 10/26/22 at 10:24 AM, CNA #41 and CNA #42 stated the resident's family put the blankets up on the windows. They brought a lot of items from the resident's home that staff were unaware of. There were blinds up on both windows but the resident's family took one down when they put up the blankets. They were not sure if the blankets were ever taken down or laundered. During an interview on 10/26/22 at 10:33 AM, Resident #99 stated their Geri chair never got cleaned and the chair looked like that all the time. During an interview on 10/26/22 at 10:36 AM, LPN #42 stated resident wheel chairs and Geri chairs should be getting cleaned and wiped down every evening. The LPN was not sure if the cleaning got documented when completed. Therapy would swap a broken chair for a new one. Deep cleanings should be done weekly. During an interview on 10/26/22 at 11:33 AM, laundry supervisor #140 stated they were not aware of the blankets being washed. Resident Common Rooms: On 10/25/22 the following observations were made: - at 12:55 PM, the shower was unclean with pink staining on the shower wall. Silicone caulk was discolored and peeling all around the floor level shower drain pan in the shower room adjacent to resident room [ROOM NUMBER]. - at 12:59 PM, there were excessive amounts of discolored silicone caulk peeling all round the floor level shower drain pan in the shower room adjacent to resident room [ROOM NUMBER]. - at 1:01 PM, the shower drain pan was unclean and discolored black and pink stains. There were large amounts of discolored silicone caulk peeling all around the floor level shower drain in the shower room adjacent to resident room [ROOM NUMBER]. - at 1:04 PM, the shower drain pan was unclean and discolored with brown stain. There was excessive loose accumulations of silicone caulk peeling all around the floor level shower drain pan in the shower room adjacent to resident room [ROOM NUMBER]. In addition, the overhead light was not working. -at 1:10 PM, the shower drain pan was unclean and discolored pink and black in the shower room adjacent to resident room [ROOM NUMBER]. There was black stained loose silicone caulk coming up around the floor level shower drain pan. In addition, the floor drain was missing creating a 2 inch open hole in the shower drain pan. - at 1:12 PM, the shower drain pan was unclean and discolored with black and brown stains in the shower room adjacent to resident room [ROOM NUMBER]. The shower cartridge and controls were missing, creating an 8 inch round hole in the tile wall. In addition, the sink was leaking into a bed pan under the sink on the floor. On 10/26/22 the following observations were made: - at 10:06 AM, the floor level shower drain pan was unclean and discolored with black and pink staining, chipped and broken floor tiles with black grout around the pan, and excessive black silicone caulk peeling in the shower room adjacent to resident room [ROOM NUMBER]. - at 10:13 AM, there was a large 4 foot (ft) x 8 ft piece of unfinished drywall screwed into the ceiling within the 2nd floor day room. - at 10:16 AM, there were cracks inside the toilet bowel and on the front of the pedestal portion of the toilet bowel within the 2nd floor shower room adjacent to resident room [ROOM NUMBER]. - at 10:19 AM, there were cracks in the sink basin within the common bathroom adjacent to resident room [ROOM NUMBER]. In addition, there was black mold like substances under the sink at the floor level on the tile wall. Main Kitchen: During an observation on 10/20/22 at 10:14 AM, there were multiple fruit flies present visibly flying around in the dirty meal cart return room. During an observation on 10/25/22 at 1:10 PM, multiple fruit flies were flying around tray line. During an interview on 10/27/22 at 11:36 AM, dietary aide #106 stated that the facility used to have flies, but the third party pest control vendor had come and put treatment chemicals around. During an observation on 10/31/22 at 01:12 PM, there were 3 fruit flies noted over the trays on the meal tray line during lunch service. During an interview on 10/31/22 at 12:35 PM, the Administrator stated the Director of Maintenance had resigned on 10/24/22 during survey and had only been employed by the facility for 6 weeks. They were aware that there were lots of maintenance issues. Maintenance concerns were taken care of, although not done quickly, effectively, or thoroughly. There was no coordination in the maintenance department without an effective leader. 10 NYCRR 415.29(j)(1) | Plan of Correction: ApprovedDecember 19, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. FRP paneling in room A10 will be adjusted so that it is no longer a homelike environment issue. IN A12, the walls that were marred and scraped in the same room to be corrected. Spill and cutlery under PTAC unit in C24 have been cleaned. The bent and broken screen in the same room to be repaired. C17 broken faceplate and marring and scraping on wall to be fixed. room [ROOM NUMBER] chipped bathroom floor to be repaired. Broken window in room [ROOM NUMBER] to be repaired. Scraped and marred walls in room C29 to be fixed. Window in room [ROOM NUMBER] to be repaired. Cable outlet box in room [ROOM NUMBER] to be repaired. Scrapes and peeling paint in room [ROOM NUMBER] to be repaired. Window shades to be installed in room [ROOM NUMBER] and the towel bar to be tightened. Resident 99Æs geri chair to be cleaned. Unsanded and unfinished walls in room [ROOM NUMBER] to be fixed. TV outlet box in room D15 to be fixed. Shower room adjacent to room [ROOM NUMBER] caulking around drain to be repaired. Shower room adjacent to room [ROOM NUMBER] caulking around drain to be redone so that it is not excessive or discolored. Shower room adjacent to room [ROOM NUMBER] drain pan to be cleaned or replaced and light repaired. Shower drain pan in shower room adjacent to room [ROOM NUMBER] to e cleaned and holes repaired. Sink leak to be repaired. Shower room adjacent to room [ROOM NUMBER] to be cleaned and caulking adjusted. 2nd floor day room ceiling has been repaired. 2nd floor shower room adjacent to room [ROOM NUMBER] to be repaired or replaced. Sink in common bathroom adjacent to room [ROOM NUMBER] to be repaired and tile wall to be cleaned. Pest control vendor made aware of fruit flies in kitchen (this is a non-resident area). 2. All residents could have been affected by the deficient practice. Residents 308, 99, and 163 as well as others in deficient areas to be interviewed to ascertain whether they were affected by the areas of non-compliance. Immediate actions will be taken to remedy should there be negative effects. 3. Policies related to facility cleaning and repairs have been reviewed with no recommended adjustments. Facility maintenance, housekeeping, dietary, and nursing staff to be educated on the requirements related to homelike environment and the various processes involved in reporting areas of non-compliance and remedying them. Maintenance team to be educated on the proper usage of the TELS maintenance requisition software, that requisitions from the unit binders are entered into the system and appropriately marked when completed. Cleaning schedule to be reviewed to ensure adequacy. Negative findings to be immediately addressed. Staff to be educated on the frequency of cleanings of bathrooms and other areas. Contract with contracted housekeeping vendor adjusted to increase the staffing pattern to ensure better cleaning is completed throughout. Facility leadership team to conduct weekly rounding on units utilizing ôDaily Audit Checklistö that includes areas related to the homelike environment. They will address non-compliant areas immediately. 4. Audits to be completed on at least five random facility resident environment areas to ensure that they remain in good repair, clean, and free of pests weekly x4 then monthly x5. Results of the audits will be shared with the facility QAPI committee during monthly meetings for review and further action. They will further determine the need for audit continuance and make recommendations on plan of correction efficacy. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification survey conducted 10/20/22-11/1/22, the facility failed to provide sufficient support personnel to safely carry out the functions of the food and nutrition service for 11 of 11 resident units (Units 1 South, 2 North, 2 South, 3 North, 3 South, 4 North, 4 South, A, C North, C South, and D North) and the main kitchen. Specifically, concerns were identified with the effectiveness of meal preparation and other food and nutrition services including: - Resident #294 did not eat pork due to religious beliefs and received pork on their tray on multiple occasions and did not receive meal items as planned. - Residents #270 and 222 did not receive food items on their meal trays as planned. - Resident #262 had protein malnutrition, required additional calories, and did not receive high protein items on their meal trays as planned. - Resident #93 was not provided a scoop plate with meals as planned. - Hot food temperatures on the meal service line were not monitored and maintained as required. - 1 breakfast tray and 1 lunch tray had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable. - 9 of 11 nursing units (1 South, 2 North, 3 South, 4 North, 4 South, A South, C North, C South, D North) had resident meal trays delivered up to 1 hour and 31 minutes after the posted scheduled mealtimes. - the main kitchen was unclean and had soiled food preparation equipment, outdated and undated food in the walk-in freezer, improper thawing and storage, dishwashing and sanitization, unsafe food temperatures, improper hand hygiene, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. - the nourishment areas on Units 1, 2, 3, and 4 had unclean equipment, outdated and undated food in refrigerators, and lack of access to proper hand washing facilities with available soap and disposable towels and/or heat/air drying methods. Findings include: Refer to: F 800 Provided Diet Meets Needs of Each Resident F 809 Frequency of Meals/Snacks at Bedtime F 812 Food Procurement, Store/Prepare Serve- Sanitary The Resident Census and Conditions of Residents (CMS-672) dated 10/20/22 documented the resident census was 322. The undated Dietary Employee list documented there were 15 dietary aides, 1 pots/porter, 1 stocker, 4 cooks, 1 Dietary Manager, 1 Food Service Director, 6 dietitians, 3 Dietary Supervisors, and 1 Assistant Administrator. During an observation on 10/20/22 at 10:39 AM, Regional registered dietitian (RD) #22 was washing pots and pans. The Regional RD #22 stated a person had called off and they were filling in to help wash pots and pans. During an observation on 10/25/22 at 12:15 PM, there were 3 dietary aides, 1 Regional Administrator, and 2 Regional RDs working on the tray line. During an interview on 10/26/22 at 11:07 AM, the Food Service Director (FSD) stated they normally had three cooks on each day, but today there were only two. They stated the early cook was scheduled 6 AM to 2 PM, and the later shift was 11 AM to 7 PM. The following observations were made on 10/26/22: - at 11:09 AM, Regional Administrator #142 was starting to set up trays for lunch service. - at 11:13 AM, Assistant Administrator #23 stated they would be the runner and delivering meal carts today. - at 11:14 AM, dishwasher #116 was the only staff washing dishes. They stated they only worked during the week and was typically by themselves. - at 11:16 AM, dietary aide #115 began to assist with dishes in the dish room. They stated they worked at another facility owned by the same company but were told to report to this facility today to help with dishes. - at 11:20 AM, Regional RD #22 was observed working on the main steam table for lunch service. During an interview on 10/26/22 at 2:26 PM, dietary aide #107 stated that they had been employed in the kitchen for 3 months and the kitchen had been short staffed. They stated their task was to serve the breakfast and then go to the dish room to wash the dishes, and then repeat the same process for lunch. During an interview on 10/26/22 at 3:14 PM, Dietary Manager #108 stated the Food Service Director (FSD) quit today and that was confirmed by Regional RD #22. During an interview on 10/27/22 at 11:36 AM, dietary aide #106 stated that they had been employed in the kitchen for over a year and the kitchen had been short staffed for the about 6 1/2 months. They stated as a food cart runner they would bring the carts onto the floors and there were times when the residents were waiting for their food. Dietary aide #106 stated Administration had started working in the kitchen a couple of weeks ago. The regional staff had not shown up until the survey started on 10/20/22. During an interview on 10/27/22 at 11:52 AM with Dietary Manager #108 they stated there were typically 10-12 dietary staff working in the kitchen during the day. Evening staff came in at 3:45-4 and there were 5 with the night supervisor. They stated the Regional staff and Administration would come if they needed help. Assistant Administrator #23 worked in the kitchen almost every day, making sure things were running smoothly. If the Assistant Administrator was needed, they would not leave. They stated that there were not enough staff in the kitchen to complete the work required. During an interview on 10/31/22 11:02 AM, RD (#29) stated that they had helped on the tray line at times. During an interview with the Administrator on 10/31/22 at 12:35 PM they stated the FSD had quit on 10/26/22 and there was currently no Director. They stated there were many issues with food service from top to bottom, including kitchen staff, tray accuracy and meals times. The residents were not happy. The facility had been attempting to hire more kitchen staff. They stated staff needed to be more diligent with their duties and to be held accountable and follow up with any issues that were found. During an interview on 10/31/22 at 1:37 PM, dietary runner #114 stated they were typically a runner and prepared the [MEDICAL TREATMENT] orders, but because they were short staffed, they were serving on the tray line to help. During an interview on 10/31/22 at 2:50 PM, Dietary Supervisor #28 stated they ran out of food items and dinnerware regularly, and they needed more staff. During an interview on 11/01/22 at 11:33 AM, Assistant Administrator #23 stated they had culinary experience and were being leaned on to fill in as the FSD. They had started working in the kitchen in September. They stated the typical staffing they would expect was at least 2 cooks, 7-8 people on the line, and 1-2 two cleaning, and that would also include food cart runners. During an interview with RD #74 on 11/01/22 at 5:29 PM they stated the kitchen had been running short staffed and felt this was causing issues with meal accuracy and late meals. 10NYCRR415.14(b)(1)(2) | Plan of Correction: ApprovedDecember 16, 2022 1. Dietary staff hiring ads were reviewed and adjusted as needed so that they were more attractive to potential candidates. Facility tasked agency to hire out of state traveling staff. At the time of this writing, three were successfully hired (on 11/9, 11/11, and 11/16) and are currently working. Rates reviewed and adjusted for facility cooks to increase retention and attraction of additional staff. Jr Cook role was created in the department to assist both cooks and dietary aides to fill in where there may be staffing ôholesö. New food service director hired and started on 12/23. New assistant food service director hired with projected start date of 12/28. Since 11/2, through the date of the writing of this plan of correction, a total of nine dietary aides, three Jr. Cooks, three cooks, and two dishwashers were hired and started. 2. All residents could have been affected by this deficient practice. All residents that eat via facility delivered meals were affected. Residents with documented weight loss being followed by nutrition, medical, and nursing teams for intervention. Current dietary staffing levels will be reviewed and issues immediately addressed. 3. Policies related to sufficient staffing reviewed with no recommended changes. Policies related to hiring reviewed with no recommended changes. Dietary department staffing patterns adjusted to increase total positions. Staff to be cross-trained on various roles so that they can be slotted into holes should they arise. Human resources staff and dietary leadership to be educated on the importance of maintaining strong candidate flow and to communicate with facility leadership should flow diminish. 4. Dietary staffing to be reviewed/audited against the schedule by the Food Service Director during their weekly meeting with the administrator weekly x8 then monthly x4. Results of the review to be shared with the facility QAPI committee for review and advisement during monthly QAPI meetings. The Food Service Director is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 10/20/22-11/3/22, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to dehydration for 2 of 2 residents (Residents # 314 and 583) reviewed. Specifically, - Resident #314 received enteral feedings (feeding by a tube in the stomach), and the enteral feeding was observed not infusing as ordered. - Resident # 583 received enteral feedings, the enteral feeding was observed not infusing as ordered, the resident's weight was not obtained as ordered, and a re-weight was not obtained to confirm weight loss so the plan of care could be reassessed to ensure if was meeting the resident's nutritional needs. Additionally, the resident's enteral feedings were not labeled and dated for 2 days of survey. Findings include: The facility policy Enteral Feeding revised 4/2020 documented intermittent enteral feedings were delivered over a specific period of time or until a specified volume of formula was delivered. Staff were to verify physician order [REDACTED]. The facility policy Weight Assessment and Intervention revised 5/2022 documented: - Nursing staff would measure the resident's weight upon admission, weekly for four (4 weeks), and then monthly. - Weights were to be recorded in the electronic medical record. - Weight changes of 5 pounds (lbs.) in one month or 3 lbs. in one week since their last weight assessment would be retaken within 48 hours and verified by nursing. - The reweight should be reviewed by licensed nurse and the licensed nurse would notify the dietitian of weight change once reviewed. Notification should be documented in the resident's medical chart. - The registered dietitian (RD) or diet technician (DT) would respond to receipt of notification within 72 hours. - Threshold for significant unplanned weight changes were 5% or greater at 1 month, greater than 5% was severe, 7.5% at 3 months, greater than 7.5% was severe, and 10% at 6 months, greater than 10% is severe. - Assessment information would be analyzed by the multidisciplinary team and conclusions regarding current medical or clinical condition and whether weight stabilization or improvement can be anticipated. 1) Resident #314 was admitted with [DIAGNOSES REDACTED]. The 10/1/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, was totally dependent for eating, weighed 109 pounds (lbs.), had significant weight loss of 5% at 1 month or 10% at 6 months, had a feeding tube, received greater than 51% of their calories through their feeding tube, and received 501 milliliter (mls) or more of fluid daily through their feeding tube. The 5/30/22 comprehensive care plan (CCP) documented the resident required a feeding tube related to [DIAGNOSES REDACTED]. Interventions included administer tube feeding and water flushes per RD recommendation and physician orders, provide [MEDICATION NAME] 1.5 (tube feeding formula) at 55mls an hour for 20 hours a day and auto water flushes of 100 mls every 2 hours while tube feeding was infusing, check for tube placement and gastric contents and residual volume per facility protocol and record, hold tube feeding if greater than 100 mls, keep head elevated 30 degrees at all times, monitor, document, report to physician any aspiration, fever, shortness of breath, and tube dislodgement. The 10/2022 physician orders [REDACTED]. Provide [MEDICATION NAME] 1.5 infused via: pump at 55mls/ hour for 20 hours, total volume in 24 hours was 1100 mls. Administer 100 mls of water via auto flush every 2 hours via J-tube during tube feeding administration run. The undated certified nursing assistant care instructions (Kardex) documented the resident was to receive nothing by mouth (NPO) and received tube feedings. The following observations of Resident #314 were made on 10/31/22: - at 9:37 AM, the resident was lying in bed. Their tube feeding formula was not hung and the pump was not on. - at 9:48 AM licensed practical nurse (LPN) #130 brought the medication cart to the resident's doorway. - at 9:59 AM, LPN #130 administered the resident their medications. - at 10:12 AM, LPN #130 completed their medication administration, turned on the resident's tube feeding pump, and attached the tube feeding tubing to the resident's feeding and began administering the tube feeding. During an interview with LPN #130 on 10/31/22 at 1:49 PM, they stated the resident's tube feeding orders were listed in the electronic medication administration record (eMAR) system. Nurses could administer medications and tube feedings 1 hour before and 1 hour after their scheduled time. If medications or tube feedings were administered outside of that timeframe, they needed to let the Nurse Manager know and the Nurse Manager would notify medical. They could also notify the physician themselves if they were running behind. They stated the resident's tube feeding should have been administered between 7 AM and 9 AM and they did not let the nurse manager know they were late administering the resident's tube feeding. They should have told the Nurse Manager and they should have documented in a progress note at that time. During an interview with LPN Nurse Manager #49 on 10/31/22 at 1:56 PM, they stated the resident's medication and tube feeding orders were in the eMAR, nurses could provide medications and tube feedings 1 hour before and 1 hour after their scheduled time. They expected staff to let them know if they were running behind and were unable to provide the medications and tube feedings as ordered. If they were unavailable the nurse should have told Assistant Director of Nursing (ADON) #51, the registered nurse (RN) who covered the unit. They stated it was important for the resident to receive their tube feeding as ordered because it was their only source of nutrition. If they were made aware they would have notified the physician. They stated LPN #130 documented at 10:24 AM, they administered the resident's tube feeding and it was late. During an interview ADON #51 on 10/31/22 at 3:20 PM, they stated they were not aware the resident's tube feeding had been administered late. The LPN should have notified the Nurse Manager or themselves if they were running behind. It was important to notify the physician and the RD if the tube feeding was not administered timely in case the run time needed to be adjusted. It was important for the resident to receive their tube feeding as ordered since it was their sole source of nutritional support. During an interview with RD #74 on 11/1/22 at 5:29 PM, they stated it would be important for them to be notified if a resident's tube feeding was not administered timely. If they were made aware they could have adjusted the resident's tube feeding order. They were not aware the resident's tube feeding was administered late. It was important to follow the medical orders especially when administering tube feeding because it was the resident's source of nutrition and could affect the resident's weight. 2) Resident #583 had [DIAGNOSES REDACTED]. The 10/8/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, was totally dependent on 1 for eating, weighed 162 pounds (lbs), had a feeding tube, received 51% or more of their calories from their feeding, received 501 milliliter(mls) or more of fluid daily through their feeding tube, and did not have any significant weight changes in the last month or 6 months. The 10/4/2022 physician order [REDACTED]. Administer 30 mls of water before and after medications and 30-60 mls when starting and stopping the tube feeding. The 10/4/22 Comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADLs) and was totally dependent on staff for feeding. On 10/4/22 the resident's weight was documented as 163.2 pounds (lbs.). The 10/4/22 Admission/ Readmission Evaluation documented the resident was admitted from the hospital, weighed 162.8 pounds (lbs.) via mechanical lift scale, had no noted [MEDICAL CONDITION], and had resided at a group home. The 10/5/22 physician orders [REDACTED]. The 10/7/22 revised CCP documented the resident received nothing by mouth (NPO) and required a feeding tube. Interventions included obtain weights as ordered and provide [MEDICATION NAME] 1.0 at 70 mls an hour for 22 hours for a total volume of 1540 mls. Staff were to keep the head of the bed elevated at least 30 degrees at all times, the registered dietitian (RD) was to evaluate quarterly and as needed to estimate nutritional needs and make recommendations as needed. The 10/7/22 Admission Nutrition Assessment completed by RD #57 documented the resident was NPO, received [MEDICATION NAME] 1.0 at mls an hour from 7:00 AM-5:00 AM via pump for a total volume of 1540 mls, with 30 mls water flushes before and after medications, and 90 mls of water flushes 4 times daily. This provided 1632 calories, 68 grams of protein, and 1646 mls of fluids daily. The resident weighed 162.8 lbs on 10/4/22 via mechanical lift, on 9/22/22 the resident weighed 142 lbs at their group home, and their current body mass index (BMI) was 29.8 (considered overweight). The resident's estimated daily nutritional needs were 1480-1850 calories (calories were estimated lower due to their medical [DIAGNOSES REDACTED]. The RD questioned the admission weight of 162.8 lbs as it was an outlier when compared to the resident's usual body weighed reported from by the group home. Weekly weights were to continue to obtain a baseline weight. On 10/10/22 physician #55 documented an admission and history examination progress note. The resident was admitted to the hospital from a group home and was hospitalized [DATE]-10/4/22 when they were admitted to the facility for post-acute care. The resident was NPO (nothing by mouth) and received all their nutrition, hydration, and medications through their feeding tube. The resident was totally dependent for all care. The resident weighed 162.8 lbs, The 10/12/22 physician orders [REDACTED]. Weights were to be obtained by the 7th of the month. The undated care instructions (Kardex) documented the resident was NPO and received tube feedings. On 10/19/22 the resident's weight was documented as 137 lbs. There was no documentation of a reweight and there were no further weights documented. On 10/21/22 at 5 AM licensed practical nurse (LPN) #134 documented on the medication administration record (MAR) 1540 mls of [MEDICATION NAME] 1.0 was provided via the pump and at 7 AM they documented the tube feeding was started and running at 70 mls an hour. On 10/21/22 at 8:51 AM, licensed practical nurse (LPN) #72 Unit Manager documented the resident was out of the facility to a medical appointment. The resident was observed in bed on 10/21/22: - at 10:42 AM, the bag of tube feeding was unlabeled and contained 550 mls of brown liquid, the water flush bag contained 600 mls of clear liquid was unlabeled, and the tube feeding pump had an error message on it. - at 12:09 PM, the bag of tube feeding was unlabeled and contained 550 mls of brown liquid, the water flush bag contained 600 mls of clear liquid and was unlabeled, and the tube feeding pump had an error message on it. - at 12:50 PM, the bag of tube feeding was unlabeled and contained 550 mls of brown liquid, the water flush bag contained 600 mls of clear liquid and was unlabeled, and the tube feeding pump had an error message on it. LPN Unit Manager #72 and a unidentified staff member entered the resident's room and positioned the resident higher in their bed and did not address the tube feeding. - at 12:55 PM, the bag of tube feeding was unlabeled and contained 550 mls of brown liquid, the water flush bag contained 600 mls of clear liquid and was unlabeled, and the tube feeding pump had an error message on it. - at 2:46 PM, the bag of tube feeding was unlabeled and contained 550 mls of brown liquid, the water flush bag contained 600 mls of clear liquid and was unlabeled, and the tube feeding pump had an error message on it. - at 4:35 PM, the tube feeding bag and water flush bag were unlabeled, the tube feeding pump was on and was not infusing the feeding formula into the resident. The tube feeding formula was observed pooling on the floor in a 4-inch puddle. On 10/22/22 at 9:19 AM, the resident's tube feeding was observed infusing at 70 mls, the tube feeding bag was unlabeled and contained 850 mls of a brown substance. The water flush bag contained clear liquid and was unlabeled. On 10/24/22 RD #29 electronically crossed out the resident's 10/4/22 weight of 162.8 lbs in the medical record. They noted the 10/4/22 weight documented incorrectly. There was no documentation of a reweight and no further weights were documented. During a telephone interview on 10/25/22 at 8:21 AM, the Group Home RN Nurse Manager stated the resident's weight of 142 lbs on 9/1/22 was within the resident's usual body weight range of 135-145 lbs while they resided at the group home. During an interview with certified nursing assistant (CNA) #135 on 10/26/22 at 9:56 AM, they stated monthly weights started on the 1st of the month. The Nurse Manager provided a list of residents who needed to be weighed. If a resident had an order for [REDACTED]. If a resident needed to be weighed via mechanical lift, they made sure the scale was at zero, if they were weighed in a wheelchair, they made sure there were no additional items on the chair and weighed the chair, they then would weigh the resident in the wheelchair, and subtract the weight of the wheelchair from the weight they obtained with the resident in the wheelchair. They did not enter the weights into the computer and provided the weights to the LPN Unit Manager. If they thought the weight did not seem correct, they would also let the LPN Unit Manager know so a reweight could be obtained. During an interview with RD #29 on 10/31/22 at 12:19 PM, they stated new admissions were weighed weekly for 4 weeks to obtain their baseline weight, then the resident would be weighed monthly unless there was a medical order. They stated nursing staff should have obtained the resident's weight weekly since admission and there were a couple weeks of missing weights. They stated the diet technicians were responsible for tracking the new admission's weekly weights. They crossed out the 10/4/22 weight of 163.2 lbs because the resident weighed 142 lbs at their group home in 9/2022. They did not reassess the resident's nutritional needs when they crossed out the 10/4/22 weight and did not adjust their tube feeding because they did not have all the resident's weekly weights. They were unaware the resident's tube feeding was not running on 10/21/22 and they should have been notified. They stated residents should receive their tube feeding as ordered because it was their source of nutrition and if they did not receive their tube feeding as ordered it could lead to weight loss. During an interview with LPN #134 on 10/31/22 at 3:49 PM, they stated they started the resident's tube feeding at 7 AM on 10/21/22. They had worked the night shift on 10/20/22 from 11 PM to 7 AM on 10/21/22. Their next shift was 3 PM - 11 PM on 10/21/22. They stated a CNA told them the resident's tube feeding was leaking on the floor, but LPN #134 did not remember the time. They observed the tube feeding leaking on the floor and let the LPN Unit Manager know the tube feeding was not infusing. The LPN Unit Manager told them to connect the tube feeding so it would infuse into the resident's feeding tube. They did not document the tube feeding was found disconnected. During an interview with LPN #133 on 11/1/22 at 1:34 PM, they stated they were unaware the resident went out to an appointment on 10/21/22. They started their shift at 8 AM on 10/21/22. When a resident went on an appointment staff usually told the nurse the resident was back, but sometimes CNAs would put the resident back into their bed without telling the nurse the resident had returned. They were unaware the resident's tube feeding was not labeled and was not infusing as ordered. During an interview with LPN Unit Manager #72 on 11/1/22 at 2:25 PM, they stated if a resident went out for an appointment their tube feeding would be put on hold and a medical order was needed for that. They stated it was their responsibility to notify the physician that the resident was going out and their tube feeding needed to put on hold. They did not know who disconnected the resident's tube feeding prior to the appointment. Staff should have notified the nurse when the resident returned so their tube feeding could be reconnected. They were unaware the resident's tube feeding was not infusing and staff should have documented it was not connected when they observed it. The nurses should label the tube feeding bags and water flushes each time they hang a bag and other nurses should be checking to ensure they are labeled as well. It was important for residents to receive their tube feeding as ordered since it was their source of nutrition. If they were made aware the resident's tube feeding was not connected and infusing as ordered, they would have informed medical and the RD. They stated new admission weights were obtained weekly for 4 weeks and then once monthly unless there was a medical order. The nutrition staff sent the unit a list of residents that needed to be weighed weekly. The CNAs obtained the resident's weights, and the LPN Unit Manager recorded the weights into the computer. They were unaware the resident was not weighed weekly. During an interview with Nurse Practitioner (NP) #16 on 11/1/22 at 2:48 PM, they stated they were not made aware the resident's tube feeding was not connected or infusing per orders on 10/21/22. They stated they should be made aware when things like this occurred. They stated it was important to get weekly weights for new admissions, so staff knew their baseline weight. During an interview with registered diet technician (DTR) #138 on 11/1/22 at 4:33 PM, they stated weights were obtained weekly for 4 weeks and then monthly unless there was a medical order. The new admission's weight orders were on the MAR so nursing staff should obtain the weight as indicated. They did not know who reviewed the new admission's weekly weights, but it was important to obtain the weights as ordered. They stated there were issues with admission weights because staff did not clear the scale or remove all the items from the resident's wheelchair prior to weighing them. Staff should not cross out weights unless a reweight was obtained. During an interview with Assistant Director of Nursing (ADON) #51 on 11/1/22 at 5:17 PM, they stated they were the registered nurse (RN) responsible for the resident's unit. If a resident went out for a medical appointment there should be an order to hold their tube feeding. The LPN Unit Manager was responsible for communicating with the provider. Staff should have made the nurse aware the resident had returned to the facility so they could connect their tube feeding. The resident's tube feeding bags should also be labeled, and staff should document if they find a resident's tube feeding disconnected or not infusing per medical orders. Staff should have notified a nursing supervisor and made both medical and the RD aware. If the resident's tube feeding was not infusing as ordered, it could lead to weight loss. They were not aware the resident's tube feeding was not infusing on 10/21/22. They stated staff should be obtaining weights as ordered. The RDs communicated with nursing staff via an electronic communication board to let them know which residents needed weights obtained. They were unaware the resident's weekly weights were not obtained as ordered. 10 NYCRR 415.12(g)(2) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. ò Resident #314 evaluated by a Social Worker/Dietician/Provider and suffered no ill effects ò Resident # 583 discharged [DATE] 2. All residents who are fed by enteral means have the potential to be affected. An audit will be conducted of all residents fed by enternal means to ensure The feeding is infusing as ordered and feedings are labeled and dated. All residents have the potential to be affected. An audit conducted of all residents to ensure that a current weight was obtained and re-weights were obtained within 48hrs if indicated 3. The policies on Enteral feedings Weight Assessment and Intervention were reviewed. No revisions required All licensed nurses educated on the importance and expectation of ensuring all enteral feedings are labeled, dated and infused as ordered and notifying provider and documenting if tube feeding is administered late, as well as obtaining a provider order if tube feeding is to be held for any reason, All CNA staff educated on the importance and expectation of notifying the licensed nurse if Tube Feeding pump is alarming and/or tube feeding is observed on bed/floor and not infusing into resident. All CNA staff educated on the importance of notifying the licensed nurse when residents return from appointments Dietitians and Diet techs educated on reassessing resident needs following a significant weight change All nursing staff educated on how and when to obtain resident weights 4. DON /Designee will conduct an audit of all residents fed via enteral means to ensure the feeding is labeled /dated and infusing as ordered The audit will be conducted daily x 7 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met Audit findings will be submitted to the QAPI committee monthly for review and recommendation. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure a corridor wall was smoke tight for 2 isolated areas (918 building first floor south nursing office, and 918 building third floor south nursing office). Specifically, a wall within the 918 building first floor south nursing office was a corridor wall and it had an unsealed data wire penetration, and a wall within the 918 building third floor south nursing office had a window built into it and there was data wires passing through it. Findings include: During an observation on 10/21/22 at 9:42 AM, the 918 building first floor south nursing office had an unsealed data wire passing through a corridor wall into the corridor behind the nursing station. During an observation on 10/27/22 at 11:58 AM, the 918 building third floor south nursing office had a few unsealed data wires passing through an open window within a corridor wall into the corridor behind the nursing station. During an interview on 10/31/22 at 3:30 PM, the Administrator stated that they were not aware of the unsealed data wires passing through the walls of the 918 building first floor south nursing office and the 918 building third floor south nursing office. They stated that they would have expected the data wires being passed through the wall to be sealed immediately after installation. 2012 NFPA 101 19.3.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Unsealed data cables passing through wall from behind nursing station to be sealed using appropriate methods and materials. Wires passing through window on 3rd floor south nursing area were removed. 2. All residents could have been affected by the deficient practice- none were. The facility maintenance team or designee will perform an audit on corridor walls to ensure that there are no other areas of non-compliance. Negative findings will be immediately addressed. 3. Facility policy related to corridor walls has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all corridor walls remain penetration free and that they are reviewed regularly for issues. All issues are expected to be addressed upon finding. 4. The facility maintenance team or designee will conduct audits on at least five random areas of corridor walls monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code recertification survey conducted from 10/20/22-11/2/22, the facility failed to ensure electrical installations were maintained for 7 isolated locations (906 building [MEDICAL TREATMENT] storage room, 918 building third floor south nursing office, 918 building first floor nursing station, resident room [ROOM NUMBER], resident room A36, resident room [ROOM NUMBER], and resident room C29). Specifically, the 906 building [MEDICAL TREATMENT] storage room, the 918 building third floor south nursing office, the 918 building first floor nursing station, and resident room [ROOM NUMBER] had adapters plugged into another adapter (daisy-chained); resident room A36 and resident room [ROOM NUMBER] had patient care related electrical equipment (PCREE) and resident owned electrical equipment (non-PCREE) plugged into the same adapter; resident room A36, resident room [ROOM NUMBER], and resident room C29 had unapproved adapters/extension cords. Findings include: During an observation on 10/20/22 at 11:22 AM, the 906 building [MEDICAL TREATMENT] storage room had a 6 prong adapter plugged into a UPC adapter that was plugged into a 6 prong adapter that plugged into the wall (daisy-chained). A lift battery charger was plugged into the 6 prong adapter. During an observation on 10/20/22 at 2:40 PM, the 918 building third floor south nursing office had a 6 prong adapter plugged into a UPC adapter that was plugged into the wall (daisy-chained). Miscellaneous computer equipment was plugged into the 6 prong adapter. During an observation on 10/21/22 at 9:20 AM, the 918 building first floor nursing station had a 6 prong adapter that was plugged into a 6 prong adapter that was plugged into a 20 prong adapter that was plugged into the wall (daisy-chained). Miscellaneous computer equipment was plugged into the 6 prong adapter. During an observation on 10/21/22 at 10:48 AM, resident room [ROOM NUMBER] had a coffee maker that was plugged into an unapproved extension cord that plugged into a 6 prong adapter that was plugged into the wall (daisy-chained). During an interview on 10/26/22 at 11:32 AM, the Administrator stated that staff had been educated not to use extension cords or unapproved adapters after the last federal survey and during staff orientation. They stated that if staff had seen an unapproved adapter they should have reported it to the maintenance department, or just removed it themselves. The Administrator stated that in the last six months they had seen unapproved adapters in resident rooms, and those residents and families were educated on why those were not allowed. They stated that the daisy-chained adapters, the unapproved adapters, and the unapproved extension cords found during the tour of the facility were not acceptable. During an observation on 10/31/22 at 10:10 AM, resident room A36 had the following extension cord issues: - an electric bed was plugged into the same UL1363A 6 prong adapter as a fan, a phone charger, and a laptop. PCREE and non-PCREE electrical items were not allowed to be plugged into the same adapter. - a coffee pot and a coffee pot warmer were plugged into an unapproved 3 prong adapter. - a mini-fridge was plugged into an unapproved 3 prong adapter. During an observation on 10/31/22 at 10:20 AM, resident room [ROOM NUMBER] had the following adapter issues: - an electric bed and oxygen concentrator were plugged into the same UL1363A 6 prong adapter as a cell phone charger and a fan. PCREE and non-PCREE electrical items were not allowed to be plugged into the same adapter. - a box fan, a mini-fridge, a TV, and an alarm clock were plugged into an unapproved 4 prong adapter. During an observation on 11/1/22 at 4:50 PM, resident room C29 had the following extension cord issues: - a window side electrical bed was plugged into an unapproved UL1363 adapter. - a wall side electrical bed was plugged into an unapproved 16 foot extension cord. During an interview on 11/2/22 at 9:35 AM, HMO Coordinator #34 stated that they were not aware of the unapproved adapters in resident room C29, and that extension cords were not allowed in resident rooms. They stated that both of the resident electrical beds located in resident room C29 should have been directly plugged into the wall. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents and family members were reminded of the rules surrounding power cords in resident care areas via administrator letter. [MEDICAL TREATMENT] storage room unapproved adapter removed during survey. 3rd floor south nursing office unapproved adapter removed during survey. 1st floor nursing unapproved adapter removed during survey. room [ROOM NUMBER] unapproved adapter and coffee machine removed during survey. A36 unapproved extension cord removed. PCREE and non-PCREE devices plugged into the same adapter were remedied . Unapproved adapters were also removed. room [ROOM NUMBER] devices plugged into same adapter were adjusted. Unapproved adapter in the same area was removed. C29 unapproved adapter removed. Unapproved extension cord removed. 2. All residents could have been affected by the deficient practice- none were. An audit of the facility will be conducted to determine if there are other areas that are deficient. Negative findings to be immediately addressed. 3. Facility policy related to power cords reviewed with no recommended changes. Maintenance staff to be educated on the requirements surrounding power cords and the requirement that the facility be regularly inspected for non-compliant items. Residents, resident contacts, and all other facility staff will be reminded which items are disallowed in resident areas via letter. 4. An audit will be conducted on at least 10 random resident care areas for the presence of unapproved cords, adapters or the incorrect usage of approved cords or adapters by the maintenance department or designee monthly x5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code recertification survey conducted from 10/20/22-11/2/22, the facility failed to ensure patient care related electrical equipment (PCREE) was maintained in accordance with National Fire Protection Agency (NFPA) 99 for 3 of 5 PCREE reviewed (resident room [ROOM NUMBER] electrical bed, 906 building A floor north day room CD player, and 906 building A floor north day room floor lamp). Specifically, the resident room [ROOM NUMBER] electrical bed was not maintained as per the user manual; and the 906 building A floor north day room had a CD player and a floor lamp that lacked electrical inspection labels. Findings include: The facility Electrical Equipment policy, last revised 5/2019, stated that equipment would be maintained At least annually or sooner if recommended but the manufacturer all resident medical equipment will be inspected for safety and function. This policy was unclear and did not include the requirements for maintenance. 1. Electrical Beds A surveyor had requested an electrical bed user-service manual for any bed within the facility and was provided the manual for an electric bed located in resident room [ROOM NUMBER]. The manual documented: - The maintenance required would be dictated by the bed's usage and care - a thorough inspection should be conducted monthly. During an interview on 11/1/22 at 3:15 PM, HMO Coordinator #34 stated that the electrical bed user service manual stated that the electrical bed in resident room [ROOM NUMBER] was required to be electrically inspected monthly, and that they could not find any documentation that an inspection had been completed since (MONTH) 2022. During an interview on 11/2/22 at 10:20 AM, the Administrator stated that the electrical bed user service manual was just a recommendation, and that they felt the facility policy of annual electrical inspection for the beds was acceptable. They stated that the electrical bed manual monthly electrical inspection was to ensure maximum life of the product, and the manual did not require that monthly inspections be completed. 2. Other Facility Owned Equipment During an observation on 10/24/22 at 9:40 AM, the 906 building A Floor north day room had a CD player and a floor lamp that lacked electrical inspection labels. During an interview on 10/31/22 at 9:20 AM, the HMO Coordinator #34 stated that the CD player and the floor lamp, located within the 906 building A floor north day room, lacked inspection labels. They stated that there was no documentation to verify that either piece of equipment had been electrically inspected, and these items appeared to be facility used electrical equipment. 2012 NFPA 99: 10.5.3 10NYCRR 415.29(a)(1&2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. CD player and lamp located in A floor day room were inspected and stickered appropriately. Resident bed in room [ROOM NUMBER] was inspected and stickered appropriately. 2. All residents could have been affected by the deficient practice- none were. Facility devices to be reviewed for correct frequency of inspections. Negative findings to be immediately addressed. 3. Facility policy related to equipment inspections reviewed and adjusted to clarify the requirements. Facility maintenance staff to be educated on the adjusted policy as well as the requirements related to electrical testing and maintenance. 4. An audit will be conducted on at least 10 random facility devices for appropriate frequency of inspections by the maintenance department or designee monthly x5 Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the Life Safety Code survey conducted on 10/20/22-11/2/22, the facility failed to ensure that the essential electric system was maintained for 1 isolated area (906 building C south floor between resident room C23 and resident room C28), and that 1 of 2 diesel emergency generators was not maintained in accordance with NFPA 110 (918 building temporary 300 KW diesel generator). Specifically, the red emergency outlets and the white outlets, located between the 906 building C south floor resident room C23 and resident room C28, had no power supplied to them; and an annual fuel test for the 918 building temporary 300 KW diesel generator had not been completed for 2020 and 2021. Findings include: 1. Electrical Outlets With No Power During an observation on 10/2522 at 10:30 AM, a surveyor plugged their work laptop into the red emergency outlet located on the wall between resident room C27 and resident room C28, and the laptop did not charge. During an observation on 10/26/22 at 4:10 PM, the red emergency outlet and the white outlet, located on the wall between resident room C27 and resident room C28, had no power. A staff owned cell phone charger, a facility owned hoyer lift battery charger, and facility owned portable fan were plugged into these outlets and they did not charge or turn on. During an observation on 10/26/22 at 4:20 PM, the red emergency outlet and the white outlet, located on the wall between resident room C23 and resident room C24, had no power. A staff owned cell phone charger, a facility owned hoyer lift battery charger, and facility owned portable fan were plugged into these outlets and they did not charge or turn on. During an interview on 10/27/22 at 10:00 AM, HMO Coordinator #34 stated that the breakers for the red emergency outlets and the white outlets, located between the C south resident room C23 and resident room C28, had been tripped, or shut off. They stated that the white outlets were on a separate electrical panel from the red emergency outlets. HMO Coordinator #34 stated that once the breakers within these two electrical panels had been reset, the electrical outlets had power, and this was verified and tested by a voltmeter. They stated that they had not received any work orders reporting the loss of power on the C south floor within the last month, and were not sure how long the breakers had been off. During an interview on 11/1/22 at 1:50 PM, the Administrator stated that they were not sure what electrical device had tripped the C floor breakers, or how long the power had been turned off to these electrical outlets. The Administrator stated that they were aware the red emergency electrical outlets and the white electrical outlets were on separate electrical panels. 2. Annual Generator Fuel Test Not Completed The third party vendor Fuel Sample Analysis for the 918 building's temporary 300 KW diesel generator stated that an annual diesel fuel test was completed on 11/4/19. The facility could not provide an annual fuel test for 2020 and 2021. During an interview on 10/31/22 at 2:25 PM, the Administrator stated that they were not aware that the last annual fuel test for the 918 building's temporary generator was completed in 2019, and that they were aware that diesel generators were required to have an annual fuel test. 2012 NFPA 101: 9.1.3.1, 19.5.1 2012 NFPA 99: 6.5.1 2010 NFPA 110: 8.3.8 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Outlets located on C floor between rooms C23 and C28 were returned to normal operation via resetting of flipped breaker in nearby breaker panel during survey. Annual generator fuel test to be completed for both generators. 2. All residents could have been affected by the deficient practice- none were. Facility emergency outlets to be inspected determine if there are other deficiencies. Negative findings to be immediately addressed. 3. Facility policy related to essential electrical systems reviewed with no recommended changes. Maintenance staff to be educated on the requirements surrounding inspection frequency and requirements. 4. An audit will be conducted on at least 10 random emergency outlets by the maintenance department or designee monthly x5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview conducted during the Life Safety Code survey from 10/20/22-11/2/22, the facility failed to ensure that remote annunciator panels were properly installed as required in NFPA 99 for 1 of 2 emergency generators (906 building temporary diesel generator). Specifically, the 906 building temporary diesel generator was not wired to the 906 building B floor remote annunciator panel. Findings include: During an observation on 10/20/22 at 10:00 AM, there was no lights on the 906 building B floor remote annunciator panel, and it looked like there was no power going to this panel. During an interview on 10/25/22 at 3:35 PM, HMO Coordinator #34 stated that the 906 building temporary diesel generator was wired to the disconnected and non-functioning permanent 906 diesel generator, that was located on the 906 building S floor. They stated that a third party vendor would need to run an extended wire from the temporary generator to the 906 building B floor remote annunciator panel. During an interview on 10/26/22 at 3:05 PM, the Administrator was not aware that the 906 building temporary diesel generator was not connected to the 906 building B floor remote annunciator panel, and stated that the third party generator vendor had not made him aware of this. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. 906 generator annunciator panel located at the B unit nursing station to be hooked up to temporary generator. 2. All residents could have been affected by the deficient practice- none were. Generator annunciator panels to be inspected to determine if there are other deficiencies. Negative findings to be immediately addressed. 3. Facility policy related to electrical systems reviewed with no recommended changes. Maintenance staff to be educated on the requirements that facility generator annunciator panels be properly connected to the generators and that they are regularly reviewed for trouble- acting swiftly should issues be found. 4. An audit will be conducted on facility generator annunciators by the maintenance department or designee monthly x5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to maintain the fire alarm systems in accordance with the requirements of National Fire Protection Association (NFPA) 72 for 1 fire alarm system (918 building). Specifically, the 918 building had smoke detectors that were not annually inspected as required by NFPA 72. Findings include: The 918 building semi-annual third party inspection fire alarm inspections were completed on 1/13/2021, 6/30/2021 and 2/8/2022, and the second semi-annual inspection for 2022 had never been completed. The fire alarm inspections dated 6/30/2021 and 2/8/2022 had smoke detectors that were not tested . 100% of the smoke detectors within the the 918 building had not been annually tested as required by NFPA 72. Specifically: - there were 20 resident room smoke detectors that were not tested during the 6/30/2021 inspection, and these were skipped because there was no access due to patients changing/with doctor, etc. - there were 29 resident room smoke detectors that were not tested during the 2/8/2022 inspection, and these were skipped because no rooms in yellow or red status were tested . During an interview on 10/27/22 at 3:45 PM, HMO coordinator #34 stated that the fire alarm third party vendor had not addressed the smoke detectors that were skipped during the 6/30/22 and 2/8/22 918 building inspections. They stated that a third party vendor had came onsite on 10/26/22 to complete a semi-annual fire alarm inspection. HMO coordinator #34 stated that they were aware that the components of the fire alarm system had to be inspected annually. During an interview on 11/1/22 at 12:20 PM, the Administrator stated that they could not find which resident room smoke detectors were skipped during 2/8/22 third party vendor 918 building fire alarm inspection, and could not verify if some of these resident room were also skipped during the 6/30/21 third party vendor fire alarm inspection. They stated that they would have expected the third party fire alarm vendor to test all required devices annually and maintain the semi-annual inspection schedule. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility contracted a new vendor to complete required regular inspections on facility fire alarm system. Vendor to inspect all resident room devices in 918 building to ensure that all missed devices are inspected. Deficient items to be immediately addressed. 2. All residents could have been affected by this deficient practice- no residents were. Inspection reports will be reviewed for other potential areas of deficiency. Deficient findings to be immediately addressed. 3. Facility policy related to fire alarm testing has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all devices are appropriately inspected at the required interval and how to read the post-inspection report to ascertain this information. Further, they will be educated on the requirement that should inspections not be able to be conducted for specific areas at the time of an inspection visit that the inspector schedule a subsequent visit within the required timeframe to complete. 4. The facility maintenance team or designee will conduct audits on facility fire alarm inspections bi-yearly x2. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure fire drills were completed as required for 1 of 3 night shift fire drills (third quarter of 2022). Specifically, a night shift fire drill was not competed for the third quarter of 2022. Findings include: The facility fire drill reports documented that a night shift fire drill was not completed for the third quarter of 2022. During an interview on 10/26/22 at 2:30 PM, the Administrator stated that there were two night shift fire drills completed for the second quarter of 2022; and that the last night shift fire drill for the second quarter, dated 6/21/22 should have counted as the missing night shift fire drill for the third quarter of 2022. 2012 NFPA 101: 19.7.1, 4.7 10NYCRR 415.29(a)(1&2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Facility to conduct night shift fire drill. 2. All residents could have been affected by the deficient practice- none were. Facility fire drill documentation to be reviewed to determine if there are other deficiencies in frequency. Negative findings to be immediately addressed. 3. Facility policy related to fire drills reviewed with no recommended changes. Administrator and maintenance staff to be educated on the requirements surrounding the frequency of fire drills. 4. An audit will be conducted on fire drill documentation to review appropriate frequency by the administrator or designee quarterly x3. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility did not ensure oxygen tanks were stored properly for 3 of 7 resident floor oxygen storage rooms (918 building fourth floor oxygen storage room, 918 building second floor oxygen storage room, 918 building first floor oxygen storage room). Specifically, the 918 building fourth floor oxygen storage room door and door frame were painted over, the 918 building second floor oxygen storage room had an unsealed hole in a fire rated rated wall, and the 918 building first floor oxygen storage room had unapproved ceiling materials. Findings include: During an observation on 10/20/22 at 12:01 PM, the 918 building fourth floor oxygen storage room had 17 full oxygen tanks and the access door and door frame were painted over. During an observation on 10/20/22 at 6:15 PM, the 918 building second floor oxygen storage room had 19 full oxygen tanks and there was an unsealed 1/2 inch hole in one of the one-hour fire rated walls. During an observation on 10/21/22 at 9:45 AM, the 918 building first floor oxygen storage room had 14 full oxygen tanks, and there were two unapproved sections of ceiling material that were screwed into the ceiling, and one section of this material was 18 inch x 18 inch and the other was 18 inch x 10 inch. During an interview on 10/26/22 at 2:45 PM, the Administrator stated that they were not aware that oxygen storage rooms containing over 12 oxygen tanks were required to have one-hour fire rated walls and ceilings, and 45 minute fire rated doors. They stated that they were not aware that the 918 building fourth floor oxygen storage room door and door frame were painted over, that the 918 building second floor oxygen storage room had an unsealed hole in a fire rated rated wall, or that the 918 building first floor oxygen storage room had unapproved ceiling materials. The Administrator stated that the extra oxygen tanks from the resident floors would be moved to the larger oxygen storage room located in the 918 basement. 2012 NFPA 99: 11.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Oxygen rooms located on floors 1, 2, 3, 4, A, C, and D were adjusted to remove full cylinders exceeding the 12-bottle capacity that would then require the rooms to be specially designed for hazardous storage. 2. All residents could have been affected by the deficient practice- none were. Facility oxygen rooms to be reviewed to ensure that they are meeting storage requirements. Negative findings to be immediately addressed. 3. Facility policy related to oxygen storage reviewed and adjusted to clarify the requirements. Facility maintenance and central supply staff to be educated on the requirements related to oxygen storage. 4. An audit will be conducted on at least five random facility oxygen rooms for appropriate frequency of inspections by the maintenance department or designee monthly x5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that hazardous areas were maintained for 11 isolated areas (resident room B10, resident room B11, 918 building fourth floor laundry shoot room, 918 building second floor laundry shoot room, 918 building third floor PPE closet, 918 building north elevator machine room, 918 building third floor medical storage room, 906 building S floor kitchen lounge, 918 laundry room, 906 building D floor clean utility room, and 906 building D floor soiled utility room). Specifically, resident room B10 and resident room B11 access doors and door frames lacked fire rated labels; the 918 building fourth floor laundry shoot room, the 918 building second floor laundry shoot room and the 918 building north elevator machine room access doors and door frames fire rated labels were painted over; the 918 building third floor PPE closet access door and door frame fire rated labels were painted over and the access door was not self closing; the 918 building third floor medical storage room and the 906 building S floor kitchen lounge access doors were not latching; and the 918 laundry room, the 906 building D floor clean utility room, and the 906 building D floor soiled utility room access doors had unsealed holes in them. Findings include: 1. Fire Rated Labeling During an observation on 10/20/22 at 11:10 AM, resident room B10 and resident room B11 had been converted to storage rooms, and both access doors lacked a fire rated label. During an observation on 10/20/22 at 12:40 PM, the 918 building fourth floor laundry shoot room access door and door frame fire rate label was painted over. During an observation on 10/20/22 at 5:15 PM, the 918 building second floor laundry shoot room access door and door frame fire rate labels were painted over. During an observation on 10/20/22 at 3:17 PM, the 918 building third floor PPE closet was approximately 48 square feet, and it contained 25 boxes of face shields and 5 boxes of masks. Due to the storage in this room it had been converted to a hazardous area and the access door and door frame fire rated labels were painted over. The access door to this room was not self closing, and one of these walls was shared by an adjoining tub room and this wall had only one layer of sheetrock. The walls within hazardous areas were required to have two layers of sheetrock. During an observation on 10/24/22 at 11:45 AM, the 918 building north elevator machine room had a section of wall with only one layer of one 3 foot by 18 inch section of sheetrock. The 918 building north elevator machine room access door and door frame fire rated labels were painted over. The walls within hazardous areas were required to have two layers of sheetrock. 2. Door Not Latching During an observation on 10/20/22 at 2:35 PM, the 918 building third floor medical storage room access door latch was taped open and would not latch. During an observation on 10/24/22 at 10:20 AM, the 906 building S floor kitchen lounge access doors did not latch and three attempts were made. This room was over 100 square feet and had the following items in the room: - a pallet with 7 boxes of dinner napkins; - 59 boxes of disposable trays; and - kitchen equipment, multiple empty boxes, and miscellaneous debris. 3. Unsealed Holes In Doors During an observation on 10/24/22 at 12:00 PM, the 918 laundry room clean side metal access door had five 1/16 inch() sized holes on both sides of the door. During an observation on 10/26/22 at 9:32 AM, the 906 building D floor clean utility room fire rated access door had six 3/16 holes at the top of it. During an observation on 10/26/22 at 9:34 AM, the 906 building D floor soiled utility room fire rated access door had six 3/16 holes at the top of it. During an interview on 10/31/22 at 2:50 PM, the Administrator stated they were not aware that the hazardous area access doors and door frames fire rated labels had been painted over, but was aware that the labels were required to legible. They stated that they were not aware that the wheelchair storage inside resident room B10 and resident room B11 had converted these rooms into hazardous areas, and would consider the 906 building S floor kitchen lounge a hazardous area. The Administrator stated that it was not acceptable for the ceilings and doors within hazardous areas to have unsealed holes, and that hazardous area doors were required to be self-closing. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Resident room B10 and B11 will have storage items removed and placed in approved storage areas. 4th floor chute room door label with be adjusted so that the rating label is visible. 2nd floor chute room door will be adjusted so that the rating label is visible. 3rd floor PPE closet will have combustible storage removed and the door label adjusted so that the rating label is visible and a self-closing device installed on the door. 918 elevator room wall repairs will be adjusted so that it is completed using the correct methods and materials. The same elevator room door label will be adjusted so that the rating label is visible. 3rd floor medical storage room access door will be adjusted so that is properly latches. 906 employee lounge door will be adjusted so that it positively latches. Laundry room middle door will be adjusted so that the holes are properly sealed using approved methods and materials. D floor clean utility room access door will be adjusted so that the holes are properly sealed using approved methods and materials. D floor soiled utility room door will be adjusted so that the holes are sealed using approved methods and materials. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of rooms for hazardous material storage and their enclosures and access doors. Any adverse findings will be immediately addressed. 3. Policy related hazardous material areas enclosures has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that hazardous material area enclosures remain in good working order and that access doors function appropriately and are easily identified as being properly rated. They will further be educated on the importance of ensuring that appropriate methods and materials are used in their repair. 4. The facility maintenance team or designee will conduct audits on at least five random hazardous materials areas and their enclosures and access doors monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on record review and interview conducted during the Life Safety Code survey from 10/20/22-11/2/22, the facility failed to ensure that the fire doors throughout the facility were tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Specifically, the annual fire door inspection was not completed for 2022 and it had been one year and three months since the last annual inspection. The findings include: The facility provided documentation that the NFPA 80 Fire/Door Inspection was last conducted on 8/17/21. The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This form did not include a specific breakdown of the facilty fire rated doors, and there was no documented evidence that annual fire door inspections were being conducted according to NFPA 80 requirements. During an interview on 10/26/22 at 2:35 PM, the Administrator stated that they were not aware of the specific NFPA 80 fire door inspection requirements. They stated that the K363 corridor door audit done in (MONTH) 2022 after the last federal survey should count as the annual fire door inspection. The Administrator stated that all doors located within the corridors, including the fire rated doors, were inspected. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 42 CFR 483.70 (a)(1) NYCRR 415.29, 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility will inspect all fire doors in accordance with NFPA 80 requirements. 2. All residents could have been affected by the deficient practice- none were. Fire door inspection documentation to be reviewed to determine if there are other deficiencies in frequency. Negative findings to be immediately addressed. 3. Facility policy related to fire door inspections reviewed with no recommended changes. Administrator and maintenance staff to be educated on the requirements surrounding inspection frequency and requirements. Facility inspection documentation to be reviewed to determine if they meet NFPA 80 requirements. Negative findings will be immediately addressed. 4. An audit will be conducted on fire door inspection documentation to review appropriate frequency by the administrator or designee bi-yearly x2. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation, record review and interview during the Life Safety Code survey conducted on 10/20/22-11/2/22, the facility failed to ensure that one-hour fire rated doors were maintained for four isolated doors observed (kitchen dishwasher area access door, 918 building first floor two-hour fire barrier separation door, 906 building D floor fire barrier door and lobby fire barrier door), did not ensure that one-hour fire rated enclosures was maintained for one isolated enclosure (918 building emergency PPE storage room/ 918 building human resource office/918 building south stairwell), and did not ensure that two-hour fire rated building separation doors was maintained for one isolated door (918 building first floor two-hour fire barrier separation door). Specifically, the one-hour fire rated kitchen dishwasher area access door and the lobby fire barrier door would not latch, the one hour fire rated Unit 1 barrier door would not open, the one hour fire rated 918 building south stairwell enclosure had an emergency PPE storage room wall hatch that was open and an access door to the human resources office would not self close, and the two-hour fire rated 918 building Unit 1 separation barrier door would not latch. Findings include: The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This audit documented that all corridor doors were inspected. 1. Fire Doors During an observation on 10/20/22 at 10:15 AM and on 10/24/22 at 10:15 AM, the one-hour fire rated kitchen dishwasher area access door was part of a one-hour fire rated barrier and the door lacked a self closure device. Three attempts were made. During an observation on 10/21/22 at 10:35 AM, 1 of the one-hour fire rated 918 building first floor fire barrier double doors would not open and three attempts were made. Also, the fire rated label on the double doors and door frame were painted over. During an observation on 10/21/22 at 12:05 PM, 1 of the one-hour fire rated 906 building D floor fire barrier double doors would not latch and three attempts were made. Also, the miscellaneous hardware on this door was loose. During an observation on 10/27/22 at 9:34 AM, 1 of the one-hour fire rated lobby fire barrier double doors would not latch and three attempts were made. Also, the fire rated label on the double doors and door frame were painted over. During an interview on 11/1/22 at 3:00 PM, the Administrator stated that the facility one-hour fire rated barrier doors were last checked during the 6/22 corridor door audit. They stated that they were not aware that the 918 building first floor fire barrier door would not open, and was not aware that the lobby fire barrier door and the 906 building D floor fire barrier door would not latch. The Administrator stated that they were not aware that the kitchen dishwasher area access door lacked a self closure device, and that they were aware that fire rated doors were required to be self-closing. 2. Fire Rated Enclosures During an observation on 10/24/22 at 12:40 PM, the 918 building emergency PPE storage room shared a section of wall that was part of the 1 hour fire rated 918 building south stairwell enclosure and this wall contained a fire rated wall access hatch which was open. There was an adapter cord and two data wires passing through it, and there were two punch card computers plugged into the adapter. The cord and data wires prevented the self-closing device on the wall access hatch to close and latch. During an observation on 10/24/22 at 1:55 PM, the 918 building human resource office shared a section of wall that was part of a 1 hour fire rated 918 building south stairwell enclosure and one of two fire rated human resource office doors would not self-close as required. Both doors had self-closure devices and three attempts were made. During an interview on 11/1/22 at 3:00 PM, the Administrator stated that they were not aware that there were wires passing through the one-hour fire rated emergency PPE storage room wall access hatch, and that they were not sure how long that had been there. They stated that they were not aware that the human resource office door had a malfunctioning self-closure device. The Administrator stated that fire rated enclosure doors and wall hatches were required required to be self-closing. 3. Building Separation Barrier Doors During an observation on 10/27/22 at 11:05 AM, 1 of the two-hour fire rated 918 first floor building separation barrier double doors would not latch and three attempts were made. During an interview on 11/1/22 at 3:00 PM, the Administrator stated that the facility one-hour fire rated barrier doors were last checked during a 6/6/22 K363 Corridor Doors Facility Audit. They stated that they were not aware that the 918 building first floor fire barrier door would not latch, but were aware that fire rated doors were required to be self-closing. 2012 NFPA 101 19.2.1, 7.2.15.2 2010 NFPA 80 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Kitchen dish room door will be adjusted so that it positively latches upon closure. 1S east fire door was repaired during survey. The paint over the label will be stripped so that it can be easily read. D floor fire barrier doors will be adjusted so that it positively latches upon closure. The hardware will be tightened. The lobby fire separation doors will be adjusted so that they positively latch upon closure. The painted over label will be stripped so that it is easily read. Cords passing through the wall access hatch outside the HR office area to be moved to a dedicated hole in the wall that is appropriately sealed per life safety requirements. HR office double door to be adjusted so that it closes automatically. 918 building separation barrier doors to be adjusted so that they positively latch upon closure. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of other means of egress to ensure that there are no similar issues. Negative findings will be immediately addressed. 3. Policy related to means of egress were reviewed with no recommended changes. The facility maintenance department will be educated on the importance of conducting regular audits of facility fire barriers, fire doors, smoke doors, and other means of egress areas and the importance of ensuring that they remain in compliance and in good working order. 4. The facility maintenance team or designee will conduct audits on at least five random means of egress areas for presence of non-working doors/obstructions as well as painted over rating labels monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that the two-hour fire rated building separation barriers were maintained for 1 of 2 barriers observed (906 building A floor bridge barrier). Specifically, the 906 building A floor bridge barrier had unsealed and improperly sealed penetrations. Findings include: The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This audit documented that all corridor doors were inspected, but did not address building separation barriers. During an observation on 10/28/22 at 12:45 PM, the two-hour fire rated 906 building A floor bridge barrier had the following: - there were multiple data wires passed through multiple holes on both sides of this barrier; - the gap between the top of the sheetrock and the metal ceiling deck was not sealed in the section of the barrier located over the two A unit bridge fire rated doors; - there was an unapproved material (red tape) used to seal the gaps between the two separate pieces of sheetrock within this barrier; and - there were gaps between the two separate pieces of sheetrock within this barrier that were not sealed. During an interview on 10/28/22 at 12:55 PM, HMO Coordinator #34 stated that they were not sure when the facility's two-hour fire rated barriers had last been inspected, and was not sure of the frequency of these inspections. They stated that they had assisted the surveyor with a ladder and a flashlight, and had never looked above the ceiling tiles to check the fire barriers prior to the observations made on 10/28/22. They stated that they assumed that data wires would have been sealed after the wires had been installed. During an interview on 10/31/22 at 11:10 AM, the Administrator stated that the two-hour fire rated building separation barriers were last inspected on a 6/6/22 K363 Corridor Doors Facility Audit, and had expected the 906 building A floor bridge barrier to have been properly sealed and smoke tight. 2012 NFPA 101 19.1.3.5 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility maintenance team will inspect the 906 Building A floor bridge barrier area to plan for remediation. Once an appropriate repair is determined, they will fix the non-compliant penetrations so that the barrier maintains itÆs required 2-hour rating. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of facility 2-hour barriers. Any adverse findings will be immediately addressed. 3. Policy related to facility fire barriers reviewed with no recommended changes. The facility maintenance department will be educated on the importance of conducting regular audits of facility fire barriers and the importance of ensuring that vendors that install wiring or otherwise need to penetrate fire barriers are appropriately sealing penetrations behind themselves so that the barriers remain sealed smoke-tight. 4. The facility maintenance team or designee will conduct audits on at least two random areas of 2-hour barriers for presence of penetrations monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure fire extinguishers were maintained for 10 of 10 floors (918 building fourth floor, 918 building third floor, 918 building second floor, 918 building first floor, 918 building basement, 906 building D floor, 906 building C floor, 906 building B floor, 906 building A floor, and 906 building S floor) in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers. Specifically, the annual fire extinguisher inspections were not completed for the above mentioned floors. Findings include: Review of the most recent third party fire extinguisher annual inspection documented that was completed on 7/1/2021. During observations on 10/20/22, between 11:40 AM and 12:00 PM, the following areas within the 918 building first floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - the DON nursing suite; and - the main lobby. During observations on 10/20/22, between 12:01 PM and 1:15 PM, the following areas within the 918 building fourth floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - hall near room [ROOM NUMBER]; - fourth floor pantry; and - hall near room [ROOM NUMBER]. During an observation on 10/20/22 at 3:30 PM, the hall near room [ROOM NUMBER] had a fire extinguisher that was last annually inspected on (MONTH) 2021. During observations on 10/20/22, between 5:10 PM and 6:14 PM, the following areas within the 918 building second floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - second floor pantry; - hall near room [ROOM NUMBER]; and - hall near room [ROOM NUMBER]. During observations on 10/21/22, between 10:14 AM and 10:25 AM, the following areas within the 918 building first floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - hall near room [ROOM NUMBER]; - hall near room [ROOM NUMBER]; and - first floor pantry. During an observation on 10/21/22 at 11:10 AM, the 906 building penthouse had a fire extinguisher that was last annually inspected on (MONTH) 2021. During observations on 10/21/22, between 11:28 AM and 11:59 AM, the following areas within the 906 building D floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - D floor pantry; and - hall near D15. During observations on 10/21/22, between 12:40 PM and 12:48 PM, the following areas within the 906 building C floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - C floor pantry; and - hall near C15. During an observation on 10/21/22 at 1:40 PM, the 906 building B floor occupational therapy storage room had a fire extinguisher that was last annually inspected on (MONTH) 2021. During an observation on 10/21/22 at 2:56 PM, the hall near A11 had a fire extinguisher that was last annually inspected on (MONTH) 2021. During observations on 10/24/22, between 9:50 AM and 10:10 AM, the following areas within the 906 building S floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - S floor general storage room; - S floor maintenance shop; and - S floor mechanical room. During an observation on 10/24/22 at 11:50 AM, the 918 building basement laundry room had a fire extinguisher that was last annually inspected on (MONTH) 2021. During an observation on 10/24/22 at 1:55 PM, the 918 building basement human resources office had a fire extinguisher that was last annually inspected on (MONTH) 2021. During an interview on 10/24/22 at 2:20 PM, the Administrator was not aware that the facility fire extinguishers had not been inspected annually as required, and stated that they were aware of this requirement. They stated that the facility had a fire extinguisher vendor to complete this fire extinguisher annual inspection. 2012 NFPA 101 19.3.5.12, 9.7.4.1 2010 NFPA 10 10 NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility contracted a new vendor to perform annual fire extinguisher inspects. All facility fire extinguishers were inspected by new vendor during survey. 2. All residents could have been affected by the deficient practice- none were. The facility maintenance team or designee will perform an audit on all fire extinguishers to ensure that they were addressed during the most recent vendor inspection. 3. Facility policy related to fire extinguishers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all fire extinguishers are inspected at the required intervals. They will further be educated on the requirement that they review inspection tags on all extinguishers during routine monthly inspections to ensure that they remain in compliance with annual testing requirements. 4. The facility maintenance team or designee will conduct audits on annual testing on at least 10 random facility fire extinguishers bi-yearly x2. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation and interview conducted during the Life Safety Code survey on 10/20/22-11/2/22, the facility failed to ensure the building was properly maintained and protected throughout by an approved automatic sprinkler system for 1 isolated area (the laundry room). National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, there were 14 quick response sprinkler heads and 20 standard response sprinkler heads installed in the laundry room. Findings include: During an observation on 10/24/22 at 12:18 PM, there were 14 quick response sprinkler heads and 20 standard response sprinkler heads installed within the laundry room. During an interview on 10/26/22 at 10:55 AM, the Administrator stated that they were not aware of the mixed quick response sprinkler heads and the standard response sprinkler heads, and that they were not aware that a smoke zone/room could not contain both types of sprinkler heads. They stated that they expected the third party sprinkler vendor to identify this issue during the facility quarterly sprinkler inspections. NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Standard response sprinkler heads in the clean laundry room area to be swapped for quick response type sprinkler heads of the same temperature rating. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of rooms for incorrect mixing of sprinkler head types. 3. Facility policy related to fire sprinklers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all sprinkler areas that contain quick response heads have only quick response sprinkler heads within that smoke compartment. They will further be educated on the requirement to report findings of non-compliance immediately to facility management for follow up. 4. The facility maintenance team or designee will conduct audits on facility fire sprinkler system in at least 5 random areas bi-yearly x2. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/02/22, the facility failed to ensure the automatic sprinkler system was maintained for 6 isolated rooms in 906 building (906 building occupational therapy storage room, 906 building south penthouse, 906 building penthouse level south stairwell, the 906 building north penthouse, 906 building D floor electrical room and 906 building S floor female locker room) and for 11 isolated rooms in 918 building (918 building third floor shower room across from room [ROOM NUMBER], 918 building third floor north social workers office, 918 building administrator office, 918 building second floor day room, 918 building first floor hallway near the soiled utility room, 918 building first floor soiled utility room, 918 building first floor staff bathroom, 918 building first floor shower room across from room [ROOM NUMBER], 918 laundry room, 918 building emergency PPE storage room, and 918 building human resources office). Specifically, the above mentioned rooms had missing ceiling tiles and unsealed data wire penetrations that could allow smoke and heat to rise past the sprinkler head, not allowing the sprinkler head to function as designed. Findings include: 906 Building: During an observation on 10/20/22 at 11:15 AM, the 906 building occupational therapy storage room had a 1 foot x 1 foot section of missing ceiling tile. During an observation on 10/21/22 at 11:10 AM, the 906 building south penthouse had a 2 foot x 6 inch section of missing ceiling tile, and a 4 foot x 4 foot missing section of ceiling tile. During an observation on 10/21/22 at 11:15 AM, the 906 building penthouse level south stairwell had a 2 foot x 4 foot section of missing ceiling tile. During an observation on 10/21/22 at 11:19 AM, the 906 building north penthouse had three 2 foot x 4 foot sections of missing ceiling tile. During an observation on 10/21/22 at 11:35 AM, the 906 building D floor electrical room had a 2 foot x 3 foot section of missing ceiling tile. During an observation on 10/24/22 at 9:57 AM, the 906 building S floor female locker room had a 1 foot x 1 foot section of missing ceiling tile. 918 Building: During an observation on 10/20/22 at 3:14 PM, the 918 building third floor shower room across from room [ROOM NUMBER] had a loose ceiling light enclosure in the shower room and this was not smoke tight. During an observation on 10/20/22 at 3:24 PM, the 918 building third floor north social workers office had an unsealed wire that passed through a hole in the corridor wall, passed over the solid ceiling tile, and into a corridor wall into resident room [ROOM NUMBER]. During an observation on 10/20/22 at 4:50 PM, the 918 building administrator office ceiling had a 6 inch x 12 inch unsealed rectangular hole. During an observation on 10/20/22 at 5:00 PM, the 918 building second floor day room had a 4 foot x 6 foot section of missing ceiling tile. During an observation on 10/21/22 at 9:10 AM, the 918 building first floor hallway near the soiled utility room had an unsealed data wire passing through solid ceiling. During an observation on 10/21/22 at 9:15 AM, the 918 building first floor soiled utility room had an unsealed data wire passing through solid ceiling. During an observation on 10/21/22 at 9:40 AM, the 918 building first floor staff bathroom had a gap around the ceiling sprinkler head and this was not smoke tight. During an observation on 10/21/22 at 10:10 AM, the 918 building first floor shower room across from room [ROOM NUMBER] had a 4 inch x 4 inch ceiling hole. During an observation on 10/24/22 at 11:55 AM, the 918 laundry room cage area ceiling had a 1 1/2 inch hole. During an observation on 10/24/22 at 12:15 PM, the 918 building dirty side of the laundry room ceiling had a 5 foot x 10 foot section of missing ceiling tiles, and there was a 1 foot x 1 foot section of missing ceiling tile located over the handwashing sink. Also, there was an open ceiling hatch in this area. During an observation on 10/24/22 at 12:40 PM, the 918 building emergency PPE storage room ceiling had a 1 foot x 1 foot missing section of ceiling tile. During an observation on 10/24/22 at 1:55 PM, the 918 building human resources office ceiling had three 2 foot x 4 foot sections of missing ceiling tile. During an interview on 10/26/22 at 11:10 AM, the Administrator stated that in the last month there was a burst pipe over the 918 building second floor day room ceiling that affected this room and the 918 laundry room, that this was an active leak, and were not aware of the other missing ceiling tiles observed during survey. They stated that a fire or smoke event could happen at any time and the ceilings in the facility should always be smoke tight. The Administrator stated that in the last 6 months a third party vendor had installed wanderguard and door mag-locks, and the vendor should have sealed the vertical penetrations through the solid ceiling tiles after they were installed. They stated that the sprinkler heads installed within this facility could be negatively affected by unsealed holes in the ceiling. The Administrator stated that if an employee would see a hole in a ceiling that it should be reported to a supervisor and recorded in the work order log book located at each nursing station. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Missing ceiling tile in OT storage room locate on the B floor to be replaced using appropriate methods and materials. 906 south penthouse missing ceiling tiles to be replaced using appropriate methods and materials. South penthouse stairwell missioned ceiling tile to be replaced using appropriate methods and materials. North penthouse missing ceiling sections to be replaced using appropriate methods and materials. D floor electrical room missing ceiling sections to be replaced using appropriate methods and materials. Loose light fixture in 3rd floor shower room across from room [ROOM NUMBER] to be adjusted using appropriate methods and materials so that it is smoke tight. 3rd floor social worker office unsealed wire into corridor and resident room [ROOM NUMBER] to be sealed using appropriate methods and materials. Administrator office hole in ceiling has been repaired using appropriate methods and materials. 2nd floor day room ceiling has been repaired using appropriate methods and materials. 2st floor hallway near the soiled utility room unsealed data wire to be filled using appropriate methods and materials. 1st floor staff bathroom gap around sprinkler head to be sealed using appropriate methods and materials. 1st floor shower room across from room [ROOM NUMBER] hole in ceiling to be repaired using appropriate methods and materials. Laundry room hole in ceiling to be repaired using appropriate methods and materials. Holes above washing machines and handwashing sink to be repaired using appropriate methods and materials. Ceiling roof hatch in same area to be closed. PPE storage room ceiling to be repaired using appropriate methods and materials. Human resources ceiling to be repaired using appropriate methods and materials. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of ceilings in sprinklered areas to ensure that they are intact and are not in a condition that would impact the efficacy of the facility sprinkler system. 3. Facility policy related to fire sprinklers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all sprinkler have a ceiling that is maintained in a way that it would not hinder the efficacy of the sprinkler system They will further be educated on the requirement to report findings of non-compliance immediately to facility management for follow up. 4. The facility maintenance team or designee will conduct audits on facility fire sprinkler areas for intact ceilings in at least five random areas monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 10/20/22-11/02/22, the facility failed to ensure 1 of 3 smoke barriers observed were constructed to a 1/2 hour fire resistance rating (smoke barrier located near room A14). Specifically, the smoke barrier located near room A14 had unsealed conduit penetrations. Findings include: The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This audit documented that all corridor doors were inspected, but did not address building smoke barriers. During an observation on 10/28/22 at 12:25 PM, the smoke barrier located near room A14 had an unsealed data wire passing through both layers of sheetrock. Also, there were two data wires passing through the gap between the top of the sheetrock and the metal ceiling deck and the packing material that filled the space was loose. During an interview on 10/28/22 at 12:55 PM, HMO Coordinator #34 stated that they were not sure when the facility's smoke barriers had last been inspected, and was not sure of the frequency of these inspections. They stated that they had assisted the surveyor with a ladder and a flashlight, and had never looked above the ceiling tiles to check the smoke barriers prior to the observations made on 10/28/22. They assumed that data wires would be sealed after had been installed. During an interview on 10/31/22 at 11:10 AM, the Administrator stated that the smoke barriers were last inspected during the 6/6/22 K363 Corridor Doors Facility Audit, and had expected the smoke barrier located near room A14 to have been properly sealed and smoke tight. 2012 NFPA 101 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Penetrations in smoke barrier near A14 and loose packing between floor decking and the top of the smoke barrier to be repaired using appropriate methods and materials in a manner that ensures the area remains smoke tight. 2. All residents could have been affected by the deficient practice- none were. The facility maintenance team or designee will perform an audit on smoke barriers to ensure that there are no other areas of non-compliance. Negative findings will be immediately addressed. 3. Facility policy related to smoke barriers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all smoke barriers remain penetration free and that they are reviewed regularly for issues. All issues are expected to be addressed upon finding. 4. The facility maintenance team or designee will conduct audits on at least five random areas of the facility smoke barriers monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: December 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that the facility had no vertical penetrations for 3 isolated areas (resident room [ROOM NUMBER], 918 building north stairwell, and the 906 building A floor south nursing station), and did not ensure that proper ceiling material was in use for 7 isolated areas (918 building third floor restroom across from resident room [ROOM NUMBER], 918 building third floor restroom across from resident room [ROOM NUMBER], resident room [ROOM NUMBER], 918 building first floor oxygen storage room, 918 building fourth floor south hallway, 918 building third floor south hallway, 918 building second floor south hallway). Specifically, resident room [ROOM NUMBER] and in 906 building A floor south nursing station had vertical unsealed penetrations, the 918 building north stairwell had an unsealed wall pipe penetration; the ceiling material was not acceptable for 918 building third floor restroom across from resident room [ROOM NUMBER], 918 building third floor restroom across from resident room [ROOM NUMBER], resident room [ROOM NUMBER], 918 building first floor oxygen storage room, 918 building fourth floor south hallway, 918 building third floor south hallway, and the 918 building second floor south hallway. Findings include: 1. Vertical Penetrations During an observation on 10/20/22 at 12:16 PM, resident room [ROOM NUMBER] had an unsealed cable that passed through a hole through the concrete flooring into the floor below. During an observation on 10/20/22 at 2:05 PM, the penthouse level of the 918 building north stairwell had an unsealed 1 1/2 inch pipe going through an outside wall. During an observation on 10/21/22 at 2:50 PM, the 906 building A floor south nursing station had a two inch circular unsealed hole in the floor, and this hole went through the concrete flooring into the floor below. There were three data wires passing into the floor below. During an interview on 10/31/22 at 3:05 PM, the Administrator stated that in the last 7 1/2 months vendors have ran additional data wires through the ceiling and had expected those to be properly sealed after the wires had been installed. They stated that they were not aware of the floor penetration by resident room [ROOM NUMBER] and the 906 building A floor south nursing station. The Administrator stated that they did not feel that the penetration in the stairwell to the outside was an issue due to the fact that this penetration was through an outside wall. 2. Unapproved Ceiling Tiles During an observation on 10/20/22 at 3:35 PM, the 918 building third floor restroom across from resident room [ROOM NUMBER] had a section of damaged ceiling that was patched with a sheet of paper (8.5 inch() x 11). During an observation on 10/20/22 at 3:41 PM, the 918 building third floor restroom across from resident room [ROOM NUMBER] had a 2 foot(') x 2' section of ceiling that was covered with an unapproved plastic material. During an observation on 10/20/22 at 3:45 PM, the resident room [ROOM NUMBER] had a 3' x 3' section of ceiling that was covered with an unapproved plastic material, and a 1' x 4' section of ceiling that was covered by an unapproved unknown material. During an observation on 10/21/22 at 9:45 AM, the 918 building first floor oxygen storage room had an 18 x 18 section of unapproved ceiling material, and a 18 x 10 section of approved sheetrock material that was screwed onto the ceiling over a hole (not smoke tight). During an observation on 10/27/22 at 11:45 AM, the 918 building fourth floor south hallway ceiling near the soiled utility room had an approximate 1' x 1' section of an unknown plastic material. This unknown plastic material was also found on a section of ceiling near the south pantry. During an observation on 10/27/22 at 11:51 AM, the 918 building third floor south hallway ceiling near the soiled utility room had an approximate 1' x 1' section of an unknown plastic material. This unknown plastic material was also found on a section of ceiling near the south pantry. During an observation on 10/27/22 at 12:20 PM, the 918 building second floor south hallway ceiling near the soiled utility room had an approximate 1' x 1' section of an unknown plastic material. This unknown plastic material was also found on a section of ceiling near the south pantry. During an interview on 10/31/22 at 1:50 PM, HMO Coordinator #34 stated that they were not aware of the unknown ceiling materials found during tour of the facility, and that they were not sure if those were approved ceiling materials. During an interview on 10/31/22 at 1:50 PM, the Administrator stated that the unapproved ceiling tile materials found during the tour of the facility was not allowed, and proper ceiling material should have been used. 2012 NFPA 101: 19.3.1, 8.6 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Unsealed cable passing through the floor in room [ROOM NUMBER] will be sealed with appropriate methods and material. 918 north penthouse unsealed pipe through outside wall will be sealed with appropriate methods and materials. A Floor nursing station hole was patched with fire-stop material. 3rd floor restroom across room [ROOM NUMBER] unapproved ceiling hatch to be remedied with appropriate methods and materials. Resident room [ROOM NUMBER] ceiling repairs with unknown and unapproved material will be remedied with approved methods and materials. 918 1st floor oxygen storage room ceiling unapproved material and repair will be remedied with approved materials and methods. 4th floor south hallway ceiling near soiled utility room with unknown material repair with be remedied with approved materials and methods. 3rd floor south hallway ceiling near soiled utility room and near soiled utility room unknown plastic material (access hatch) will be remedied with approved methods and material. 2nd floor south hallway ceiling near soiled utility room unknown plastic material (access hatch) will be remedied with approved methods and materials. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of ceiling and floor penetrations and openings. Any adverse findings will be immediately addressed. 3. Policy related to vertical openings has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of conducting regular audits of ceilings and floors and the importance of ensuring that appropriate methods and materials are used in their repair. 4. The facility maintenance team or designee will conduct audits on at least five random ceiling or floor areas for vertical opening issues monthly x5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committeeÆs determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |