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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the Recertification Survey between 01/13/2025 and 01/21/2025, the facility did not ensure that resident's Comprehensive Care Plan was reviewed and revised by the interdisciplinary team after each assessment, including quarterly review assessments. 1) Resident #74 Self care Comprehensive Care Plan was last reviewed 8/1/2024, and not updated quarterly, 2) Resident #187 who was maintained on Oxygen Therapy the Alteration in Cardiopulmonary Care Plan was not updated. This was evident for 1 of 5 residents of reviewed for Activities of daily Living (Resident #74), and 1 out of 3 resident review for oxygen (Resident #187) out of an investigative sample of 37 residents. The findings are: The facility policy and procedure titled Care Plans Comprehensive Person-Centered dated reviewed 7/16/2024 documented the Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Resident #74 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #74 had Short-term Memory and Long-Term Memory Problem, with no memory recall, and is severely impaired-never/rarely made decisions. The Comprehensive care Plan titled Self-Care Deficit dated effective 3/13/2018 and last evaluation note 8/1/2024 with interventions including Dependent of two plus staff, for bed mobility, dressing, locomotion, personal hygiene, toilet use and , transfer with Hoyer lift. The Quarterly Minimum Data Set Assessments were completed on 10/29/ 2024. There was no documented evidence that the care plans were reviewed and revised after each assessment for Resident #74 On 01/21/25 at 01:54 PM, during the Quality Improvement Performance Improvement (QAPI) interview, the Director of Nursing stated, care plans are reviewed quarterly, annually for significant change as needed. The Director of Nursing did not explain why care plans was not completed as least quarterly. On 01/21/25 at 09:43 AM, The Director of Rehab was interviewed and stated the resident who is total care with Activities of Daily Living. Director of Rehab stated the resident is screened quarterly and as needed, Director of Rehab stated the resident is also on passive range of motion which is done during activities of daily living care. Director of Rehab stated this resident had no functional abilities on own and needs staff assistance for everything, and resident cannot follow commands secondary to medical conditions. Director of Rehab stated Rehab goes to each care planning meeting and is part of the care planning process. Director of Rehab stated if a resident is on therapy the Rehab will create own care plan for physical and occupational therapy with goals and interventions. Director of Rehab stated once the goal has been reached Rehab will discharge the care plan. Director of Rehab stated Rehab is not responsible for creating and or updating the Self Care Deficit care plan and stated Rehab creates their own care plans only if the resident is on therapy, and discharged when goals are reached. On 01/17/25 at 10:08 AM, Registered Nurse #7 and was interviewed and stated the resident is total care with all activities of daily living, takes nothing by mouth and gets feeding via GT. Registered Nurse #7 stated the resident is nonverbal and unable to make all needs known, and staff anticipates all needs. Registered Nurse #7 stated all care plan including self-care deficit care plans are updated quarterly, annually, significant changes and as needed. Registered Nurse #7 looked at the Self Care deficit Care plan and stated the last evaluation note was in 8/1/ 2024. Registered Nurse #7 stated Rehab and Nursing are responsible for updating the Self Care deficit care plans. Registered Nurse #7 stated nursing is responsible for overseeing that all the care plans are updated to reflect the status of the resident and if the care plans are not updated Nursing will update the care plans. Registered Nurse #7 stated the care plans are reviewed in care planning meetings and not sure why this care plan was not updated. Registered Nurse #7 stated they will update the care plan now. 2) Resident #187 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 had severely impaired cognition skills for daily decision making. The most recent Annual Minimum Data Set Assessment was completed on 07/05/ 2024. The most recent Quarterly Minimum Data Set Assessment was completed on 10/04/ 2024. The Care Plan Activity Report titled Alteration in Cardio/Pulmonary Status dated active and effective 06/30/2024, documented the last quarterly review done 08/26/2024. Goals that documented that Resident #187 will be free of signs and symptoms of cardiac distress and interventions that documented for nursing to observe for signs/symptoms of cardiac distress were active and effective 06/30/2023 with no review or revision dates entered. There was no documented evidence that the care plans including goals and interventions were reviewed and revised after each assessment for Resident # 187. On 01/21/25 at 1:54 PM, during QAPI interview the Director of Nursing stated care plans are reviewed quarterly, annually for significant change as needed. The Director of Nursing did not explain why care plans was not completed as least quarterly. 10 NYCRR 415. 11(c)(2) (i-iii) | Plan of Correction: ApprovedFebruary 13, 2025 Immediate Corrective Action A care plan review for resident #74 was conducted and the self care deficit care plan was updated on 1/17/ 2025. A care plan review for resident #187 was conducted and the Alteration in Cardio/Pulmonary Status care plan was updated on 1/17/ 2025. RN #7 was in-serviced on 2/3/25 on the importance of ensuring all annual and quarterly care plans are updated in a timely manner. Other Resident with Potential to be Affected The Assistant Director of Nursing and Nursing Supervisors reviewed on 2/5/2025 annual and quarterly self care deficit care plans and Alteration in Cardio/Pulmonary Status care plans for the past 30 days and found the care plans compliant. Therefore, no other residents were identified as being negatively impacted. Systemic Changes The Director of Nursing reviewed the Care Plan policy and procedure and found it to be compliant. The Director of Nursing will re-educate the RN staff on the Care Plan policy and procedure focusing on their responsibility of ensuring care plans are reviewed and revised in a timely manner and reflect the residents most current plan of care. Additionally, this education included all care plans must be reviewed and updated every quarter, annual or any significant change. Quality Assurance The Director of Nursing created an audit tool that will have all the RNs utilizing a care plan checkoff list on all residents upon annual and quarterly review meetings. The completed checklist will be submitted to the DNS/ADNS within 7 days. Checklists will be submitted to the DNS/ADNS for filling & reference. Additionally, audits will be conducted by the Nurse Managers weekly for 3 months and monthly thereafter to ensure compliance. Result of the audit will be reported quarterly by the DON/designee to the QAPI meeting; after such time, the facility will reevaluate the frequency of monitoring. Responsible party for implementation: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that a comprehensive care plan was developed and implemented to meet each resident's needs. This was evident in 1 (Resident #46) out of 38 sampled residents. Specifically, Resident #46 who had [DIAGNOSES REDACTED]. The findings are: The facility policy and procedure titled Care Plans Comprehensive Person - Centered with the last revised date (MONTH) 2023, documented that a comprehensive person-centered care plan that include measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. The facility's policy and procedure entitled Baseline Care Plan, approved 03/2018, states that the care plan will include conditions and risks affecting the resident's health and safety. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. The resident had care plans in place for Cognitive Loss, Hypertension, [MEDICAL CONDITION] Drug Use, Alteration in Neurological Status and Alteration in Respiratory Status. However, there was no care plan reflecting the resident's [DIAGNOSES REDACTED]. On 01/16/2025 at 10:58 AM, Registered Nurse Manager #1 was interviewed and stated that the Registered Nurses are responsible for initiating all care plans. The Nurse Manager stated that the [MEDICAL CONDITION] Care Plan had been put in place for Resident #46 in 2020, but the resident had been hospitalized in 2023 and upon their return in (MONTH) of that year, the [MEDICAL CONDITION] care plan was not reactivated. The Nurse Manager had no explanation for why it had not been done. On 01/21/2025 at 9:52 AM, the Director of Nursing was interviewed and stated that when a resident is admitted to the hospital, they are discharged from the facility and their care plans are discontinued; when they return, all their care plans are reinstated. The Director stated that there was no specific regulation that every physician order [REDACTED]. The surveyor's copy of the plan of care did not mention the [DIAGNOSES REDACTED]. 10NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedFebruary 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action A care plan review was conducted and completed on 1/16/2025 for resident #46 and the [MEDICAL CONDITION] care plan was updated immediately. The RN responsible for this deficient practice was in-serviced on 2/3 on the importance of updating all care plans upon readmission. Other Resident with Potential to be Affected The Assistant Director of Nursing and Nursing Supervisors reviewed on 2/5/2025 readmissions for the past 30 days and found all ADL care plans have been reinstated upon their return in a timely manner. Therefore, no other residents were identified as being negatively impacted. Systemic Changes The Director of Nursing reviewed the Care Plan policy and procedure and found it to be compliant. The Director of Nursing educated the RN's on the importance of following and completing/reactivating all appropriate care plans at the time of readmission. The objectives of the education will be that all Registered Nurses will learn through continuous education regarding initiation, re-evaluation/reinstatement and implementation of care plans on admissions and readmissions to meet the residents clinical/medical, physical/ functional and psychosocial needs. Quality Assurance The Director of Nursing created an audit tool that will have all the RNs utilize a care plan checkoff list on all residents upon Admission and Readmission. The completed checklist will be submitted to the DNS/ADNS within 7 days. Nurse Managers attending the Care Plan meeting will review & ensure that all existing care plans are updated by utilizing a Care Plan Checklist. Negative findings are corrected on site. Checklist will be submitted to the DNS/ADNS for filling & reference. Audits will be conducted by the Nurse Managers weekly for 3 months and monthly thereafter to ensure compliance. Result of the audit will be reported quarterly by the DON/designee to the QAPI meeting; after such time, the facility will reevaluate the frequency of monitoring. Responsible party for implementation: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that the garbage storage areas were maintained in sanitary condition. This was evident during the Kitchen Observation. Specifically, kitchen waste was not disposed of properly and the outside garbage compacter lid was left open and uncovered. The findings are: The facility policy and procedure titled Solid Waste and Pick-up, dated 07/11/2024, documented that the assigned dietary staff removes solid waste from all dietary areas. Solid waste is transported in covered receptacles and disposed of in the compactor. The outdoor compactor side lid must be kept always closed except when emptying trash bins or washing of dumpsters. On 01/15/2025 at 11:26AM During the kitchen observation of lunch preparation with Dietary Supervisor #1, Dietary Aide #1 was observed transporting an uncovered garbage can from the outside trash compactor past the food preparation area while lunch was being prepared. On 01/15/2025 at 11:30AM, an interview was performed with Dietary Aide #1 who stated that anytime they take the garbage out and bring the can back into the kitchen, they are supposed to place the garbage bag inside the can and cover the can with the garbage can lid before they bring the can back into the kitchen from the outside trash compactor. Dietary Aide #1 further stated that they did not put the lid on the garbage can prior to transporting it back into the kitchen from the outside trash compactor because they were in a rush. On 01/15/2025 at 11:49AM, an Interview was performed with Dietary Supervisor #1 who was present during the observation. They stated, that after emptying the trash in the outside trash compactor, the dietary aide is supposed to enter the kitchen from the outside with the garbage can lid covering the garbage can because the garbage can is unsanitary and is passing by the food. Dietary Supervisor #1 further stated that typically, when the dietary staff takes out the trash from the kitchen, they monitor them to ensure a lid is on top of the garbage can before and after disposal. There was no documented evidence of monitoring of trash containment or disposal. 01/21/25 at 9:50 AM, the Food Service Director was interviewed, and stated, I have no comments regarding the garbage disposal and compactor observations findings as it just shouldn't have happened. On 01/15/2025 at 11:55AM, An observation of the outside garbage compactor was conducted with Dietary Supervisor #1 and Dietary Aide #1, The compactor lid was observed to be open and uncovered. Dietary Supervisor #1 stated that the compactor lid is supposed to be kept closed when not in use. On 08/14/24 at 11:15AM, An interview was performed with the facility Administrator who stated that they will clarify and discuss the findings with the Food Service Director. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedFebruary 13, 2025 Immediate Corrective Action The Food Service Director re-educated the dietary employee on 1/16/2025 who violated this alleged deficient practice. The outdoor compactor side lid was immediately closed. Other Resident with Potential to be Affected All residents that reside in the facility have the potential to be affected by the alleged deficient practice. No residents were identified as being affected. Systemic Changes The Administrator reviewed and revised the Solid Waste and Pick-up policy to include a sign to be posted on the compactor door as a reminder to keep the door closed at all times. The Food Service Director will inservice the dietary staff on the importance of transporting waste in covered receptacles when disposing of in the compactor. Additionally, the FSD will inservice the dietary staff on the Solid Waste and Pick-up policy, focusing on the importance and ensuring the dumpster door to be closed after each use. The Director of Environmental Services will inservice the housekeeping staff on the Solid Waste and Pick-up policy, focusing on the importance and ensuring the dumpster door to be closed after each use. Signage will be placed in area of dumpster informing all that the dumpster door must be closed when not in use. The Director of Environmental Services/designee will complete observation rounds daily to ensure dumpster door is closed when not in use. Quality Assurance The Director of Environmental Services developed an audit tool to ensure the dumpster door is closed at all times. This audit with be conducted by the Director of Environmental Services/designee bi-weekly for the first 3 months and then bi-monthly thereafter. Any negative findings will be addressed immediately. The results of these audits will be reviewed at the QAPI committee meeting. The Administrator will be the responsible party for this issue. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from ,[DATE] /2025 to [DATE], the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and pantry observations. Specifically, 1. ) The dairy walk-in refrigerator contained opened and expired loaves of bread and bags of rolls. 2. ) 2 of 6 pantry unit refrigerators contained expired milk as well as spilled, spoiled, undated and unlabeled food items. The findings are: The facility policy and procedure titled Dry Storage with revision date of [DATE] documented; that all dry goods must be stored in a safe and secure environment. New stock must be stored behind old stock so oldest items will be used first. Products should be dated to ensure First In-First Out. The Food Items Expiration Date Audit Tool documented that all areas must be inspected at least weekly to ensure that there are no expired food items. Any items that are expired must be immediately discarded. The facility's policy and procedure titled Food Receiving and Storage, undated, documented; Food shall be received and stored in a manner that complies with safe food handling practices. Food services or designated staff will maintain clean food storage areas at all times. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. All foods stored in the refrigerator or freezer will be covered, labeled and dated with the use by date. Other opened containers must be dated and sealed or covered during storage. Partially eaten food may not be kept in the refrigerator. Food items and snacks kept on the nursing units must be maintained as indicated: Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Beverages must be dated when opened and discarded after (72) hours. Other open containers must be dated and sealed or covered. The facility's policy and procedure titled Personal Food Safety/Food entering the Facility, undated, documented that it is the policy of the facility to limit entry of food into the facility. Food storage in the units will be monitored by the nursing staff. Quantities should be limited to a reasonable size to prevent spoilage of leftovers. All prepared food stored in the refrigerator will be discarded after 72 hours. Perishable foods must be stored in resealable containers in the refrigerator. Containers will be labelled with the resident's name, room number, and the date. The nursing staff is responsible for discarding perishable food on or before the sell by date, or any food that shows signs of food borne danger, for example mold growth or foul odor. The nursing department will monitor and document the internal temperature of the refrigeration units daily. Units must maintain safe internal temperatures in accordance with the State and Federal guidelines (41 degrees Fahrenheit or below). The refrigerators will be cleaned and defrosted by the Nursing and housekeeping staff will assist as needed. 1) On [DATE] at 9:23AM, an initial kitchen observation was conducted with the Dietary Supervisor. The walk-in dairy refrigerator was found to contain One box of (8) 24 packages of hot dog rolls labeled with the manufacturer's use by date of [DATE], One open/unsealed and undated package of 10 hamburger rolls, originally listed to contain 12 rolls. Two plastic bags torn open/unsealed and undated containing partial loaves of bread. On [DATE] at 9:30AM, the Dietary Supervisor was interviewed and stated, that they inspect all refrigerator and food storage areas weekly for expired food items and would have discarded the expired bread but did not see the items as they were contained in an undated, unlabeled box on the top shelf. On [DATE] at 9:40AM, the Director of Food Service was interviewed and stated that once a week a Dietary Supervisor checks the entire kitchen for the expiration dates of food items, discards expired foods and documents the dates of inspection on an audit tool that they review. The Director of Food Service further stated that the expired bread observed in the walk-in refrigerator was simply missed as the Dietary Supervisor did not notice the box with the expired open items because it was on the top shelf. 2) On [DATE] at 9:19 AM, the 7th floor pantry refrigerator was observed with Registered Nurse #4 the unit manager. A malodourous beige tinged liquid was observed on the bottom of the refrigerator unit. The refrigerator unit was also observed to be overpacked, containing 11 seperate bags of food containers labeled with room numbers only. No bags or containers were observed to be labelled with names or dates. One large bag of contents included a glass bowl of degraded soup and or vegetables. The additional bags were observed to contain multiple cooked food items. On [DATE] at 9:25 AM, Registered Nurse #4, the unit manager was interviewed and stated, that the certified nursing assistants are responsible to have food dated and labeled when placed in the pantry refrigerator, but essentially it is everyone's responsibility. The unit manager also stated that the refrigerator unit temperatures are checked and logged at night by nursing staff, the housekeeping porter is responsible to clean the refrigerator unit daily and the certified nursing assistant is to throw the food out daily that is not labeled, dated and or has been in the refrigerator unit longer than 2 days. Registered Nurse #4 further stated that overall the pantry unit refrigerator is the responsibility of the unit manager and It was an oversight that they did not look at the refrigerator during daily rounds to ensure compliance. 3) On [DATE] at 9:56 AM, the 5th floor pantry unit refrigerator was observed with the Registered Nurse #1, the unit manager. The contents included one half pint of expired milk with manufacturer's expiration date of ,[DATE]/ 2024. (1) 24 oz jar of opened mayonnaise undated and unlabeled with manufacturers expiration date of ,[DATE], (1) 8oz plastic cup of cream cheese unopened with manufacturer's expiration date of [DATE], 4 undated unlabeled bags containing various cooked food items including 1 quart of brown rice, multiple fried shrimp, scoops of collard greens, 2 turkey wings and scoops of yams. The refrigerator shelf was observed with a spilled clear liquid. On [DATE] at 9:45 AM, Registered Nurse #1, the unit manager was interviewed and stated that all contents of the unit refrigerators should be dated and labeled with the resident's name or room number and the items should be discarded within ,[DATE] days by a certified nursing assistant who is assigned to check the unit daily and the housekeeping staff should clean the refrigerator daily. The unit manager further stated that it is their responsibility during daily rounds to ensure that the unit is checked but they became tied up with other issues. On [DATE] at 08:29 AM, The Director of Nursing was interviewed and stated that the pantry refrigerator process includes temperature checking and inside cleaning by the night nurses and the certified nursing assistants. While staff is checking the unit temperatures, the Director of Nursing stated that they should also discard all food items that are not labeled and any that are dated outside of ,[DATE] hours. The Director of Nursing also stated that any staff member who receives food from the outside should label the items with the resident's name, room number and the date prior to placing the items in the pantry unit refrigerator and that external cleaning of the refrigerator unit is the responsibility of the housekeeping porter. The Director of Nursing further stated that the morning shift nurse manager should round daily and make sure the refrigerator unit is clean, that food is discarded and that the temperatures are checked. On [DATE] at 10:20 AM The facility Ad | Plan of Correction: ApprovedFebruary 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action The hot dog rolls that were found after the use-by-date were disposed of immediately. All unnamed and undated food found in the 7th floor pantry refrigerator were immediately discarded. Additionally, the beige tinged liquid observed on the bottom of the refrigerator unit was immediately cleaned. All expired food found in the 5th floor pantry were immediately discarded. All unnamed and undated food found in the 5th floor pantry refrigerator was immediately discarded. Additionally, the spilled liquid observed on the top shelf of the refrigerator unit was immediately cleaned. Other Resident with Potential to be Affected A kitchen walk-thru by the dietary supervisor was conducted on [DATE] to ensure all stored food products were dated and found no other items to be outdated. No residents were identified as having been negatively affected by the findings. The RN Mangers for the other units conducted rounds of the pantries on [DATE] and were all found to be compliant. Systemic Changes The Administrator reviewed and up-dated the Food Receiving and Storage policy and was found to be compliant. The Administrator reviewed and up-dated the Personal Food Safety/Food Entering the Facility policy and was found to be compliant. Dietary Personnel will be educated on the requirements of F812 as it pertains to the requirement to maintain a safe and sanitary environment in which food is prepared, stored, and distributed. Examples from this citation were used within the content of this education. Charge nurses will continue to ensure that a staff is assigned to inspect the pantry fridge Q shift by documenting on the daily Expiration Date and Temperature Audit Tool. The assigned staff will check for outdated & expired food items and discard immediately. Nursing Staff will ensure that packed food brought in from outside is properly labeled with the following: ?é- Residents Name ?é- Date Received Staff will educate residents and family regarding proper storage of food items brought in from outside in adherence to food safety standards. The Nurse Manager & Supervisor will randomly Check the Pantry Fridge during the shift to ensure compliance. Quality Assurance The Administrator developed an audit tool to ensure pantry food items are inspected daily by checking the daily pantry food audit tool. This audit will be conducted by the Administrator/designee weekly for 3 month and then bi-monthly thereafter. All negative findings will be immediately addressed. The FSD developed an audit tool to ensure all stored food items are not expired. This audit will be conducted by the dietary supervisor weekly for 3 months and the bi-monthly thereafter. All negative findings will be immediately addressed. Results of the audits will be reported by the Administrator/designee to the quarterly QAPI meeting. The Administrator will be the responsible party for the corrective implementation. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review interviews, and record review conducted during the recertification and complaints (NY 658) survey from 01/13/2025 to 01/21/2025, the facility did not ensure a resident remained free of accident hazards. This was evident for 1 (Resident #290) of 3 residents reviewed for accidents out of 38 sampled residents. Specifically, Resident #290 fell out of bed and sustained a 2. 5 cm skin tear to the forehead during care when one staff provided care without a second staff member. The Findings are: The facility policy and procedure titled Accident Prevention Reporting and Investigation, last revised (MONTH) 6, 2021, documented that the purpose is to provide an environment free from accident hazards for the safety of the residents and staff. Identify the cause of an accident and obtain appropriate care for the injury. Resident #290 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #290's cognition as severely impaired and never/rarely made decisions. The resident was dependent and requires one person assistance with personal care and two persons for bed mobility. The Comprehensive Care Plan for Falls/Injury, initiated on 12/31/2020 and last revised on 05/19/2024, documented that while certified nursing assistant #3 was providing care, the unit nurse was alerted that the resident had fallen out of bed. The Resident Nursing Instruction for Certified Nurse Aid dated 09/25/2023 documented that Resident #290 is dependent and requires two-person assistance for bed mobility and one-person assistance for personal hygiene. The Certified Nursing Assistant (CNA) Documentation History Detail dated 05/01/2024 to 05/31/2024 documented personal hygiene support provided one-person physical assistance. The Nursing Note dated 05/20/2024 at 3:37 PM documented that on 05/19/2024 at 9:40 AM, certified nursing assistant # 3 called the writer's attention to Resident #290's room. The writer immediately went to the room and found out the resident was on the floor. Upon assessment, Resident #290 was conscious and alert; a skin tear was noted on the left side of the forehead with slight swelling measuring 2. 5cm x 1. 0cm. The area was cleansed with normal saline, and Steri strips were applied. The nursing supervisor was made aware, and the physician and the family were notified. The facility Resident Incident/Accident Report dated 05/19/2024 at 9:40 AM documented that Certified Nursing Assistant # 3 stated that while giving care to Resident #290, the resident was turned to the left side, and the resident got agitated and fell out of bed. The resident was unable to state what had happened. Resident # 290 sustained a 2. 5 cm x 1 cm abrasion and skin tear to the forehead. The facility Summary of Occurrence concluded that Certified Nursing Assistant #3 did not intentionally harm Resident # 290. However, given the circumstances and information gathered, the incident met the criteria of Department of Health incident reporting for not following the plan of care. On 01/17/2025 at 3:14 PM, Certified Nursing Assistant #3 was interviewed and stated that I was providing care for Resident #290, who was on a ventilator. I turned the resident, and the resident started shaking and then fell . It was only me taking care of the resident. I do not know if they changed it now, but when I looked at the computer, it was one person's assistant for care. I did not get the time to call someone to assist me when the resident became agitated and was shaking. I went to inform the nurse immediately. The nurse and the manager came to see the resident before we put the resident back to bed. On 01/16/2025 at 2:54 PM, Registered Nurse #3 was interviewed and stated that certified nursing assistant #3 called that Resident #290 was on the floor. I assessed the resident; the resident had a small abrasion on the forehead. I called the supervisor and reported to the doctor. We transferred the resident back to bed after the assessment. On 01/21/2025 at 11:40 AM, the Director of Nursing was interviewed and stated that Resident #290 fell during care. They investigated the fall and concluded that there was no intentional harm, but the incident met the criteria for Department of Health reporting for not following the plan of care. Certified Nursing Assistant # 3 was sent home immediately and was suspended for three days. Certified Nursing Assistant # 3 was educated upon return. Resident #290 requires two-person assistance for bed mobility and one person for personal hygiene. Certified Nursing Assistant # 3 was providing care and tried to turn the resident, but the resident became agitated and fell . They will increase the staff for personal hygiene to coincide with the care for bed mobility. 10 NYCRR 415. 12(h)(1) | Plan of Correction: ApprovedFebruary 13, 2025 Immediate Corrective Action The facility failed to prevent a fall from the bed for resident #290 on 5/19/ 24. This resident is no longer in the facility. The Certified Nursing Assistant responsible for this deficient practice was re-educated by the ADON on 5/20/2024 on following the individualized plan of care. Other Resident with Potential to be Affected The Assistant Director of Nursing and Nursing Supervisors reviewed on 2/6/2025 residents with falls for the past 30 days to determine if there were any other residents that experienced accidents as a result of this same practice. No issues were found. Systemic Changes The Director of Nursing reviewed and updated the Accident Prevention Reporting and Investigation policy and procedure and found it to be compliant. The Director of Nursing will re-educate the RNs/LPNs regarding prevention of accident/incident and related injuries and ensure proper instructions into the CNA accountability records related to personal hygiene and bed mobility. The CNA's will be re-educated to emphasize the importance of following the proper plan of care for bed mobility. Quality Assurance The Director of Nursing created an audit tool that will have the RN managers/supervisors conduct an audit on ADL instructions in the CNA accountability records on all admission/readmission and significant changes weekly for the first 3 months and monthly thereafter to ensure that appropriate level of supervision/assistance are in place during personal hygiene care/bed mobility. Result of the audit will be reported quarterly by the DON/designee to the QAPI meeting; after such time, the facility will reevaluate the frequency of monitoring. Any negative finding will be immediately addressed. Responsible party for implementation: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/ , the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #187) of 35 total sampled residents. Specifically, Resident #187 did not receive monitoring and maintenance of the peripheral intravenous site for the infusion of fluids and antibiotics. The finding is: The facility's policy and procedure titled Administration, Monitoring and Maintenance of Intravenous Therapy, undated, documented that the facility shall have a system in place for the administration, monitoring and maintenance of Intravenous therapy. Intravenous tubings shall be labeled with the date and time change. The Intravenous site and dressing shall be labeled with the date and time the needle/catheter was inserted, the gauge of the needle/catheter, and the date and time the dressing was changed. The nurse or physician who changes a dressing after the initial insertion must relabeled the dressing with the date of the initial insertion and needle gauge, and the date the dressing was changed. All must be documented on the medical record. The nurse must notify the physician to change the peripheral intravenous needle/catheter or [MEDICATION NAME] lock after 3 days (72 hours). Transparent dressings shall be changed and relabeled every 72 hours as per procedure. At the time of the dressing change the insertion site is to be observed for signs of phlebitis, infection, or infiltration and the insertion site cleansed per procedure. Resident #187 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 had severely impaired cognition skills for daily decision making. On 01/15/25 at 11:16 AM, Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter. On 01/15/25 at 02:52 PM, Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter. On 01/16/25 at 12:18 PM, Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter. On 01/16/25 at 1:10PM Resident #187 was observed in bed with an undated dressing covering a left upper extremity peripheral intravenous catheter in the presence of Registered Nurse #4, the unit manager. The Physician order [REDACTED]. 0. 45% Sodium Chloride intravenous solution to be infused at 60 cubic centimeters per hour for 72 hours. The Physician order [REDACTED]. 3. 375 grams/50mililiters in [MEDICATION NAME] intravenous piggyback every 8 hours for 5 days. The Physician order [REDACTED]. The Resident Medication Administration Record [REDACTED] 3. 375 grams/50ml in [MEDICATION NAME] intravenous 01/11/2025 thru 01/16/ 2025. The Resident Medication Administration Record [REDACTED] 2025. The Care Plan Activity report dated 01/11/2025, documented that the first dose of [MEDICATION NAME] was administered intravenously 01/11/ 2025. The Care Plan Activity report dated 01/16/2025, documented that the peripheral intravenous line was removed 01/16/ 2025. Prior to 01/16/2025, There is no documented evidence that the peripheral intravenous line dressings were changed nor is there documented evidence that the peripheral intravenous insertion site was assessed. On 01/16/25 at 1:20PM Registered Nurse #4, the unit manager, was Interviewed and stated that the intravenous infusion through the left peripheral line was started on 01/11/2024 for resident #187, but until today the dressing at the insertion site had not been changed. Registered Nurse #4 also stated that the nurse who inserted the peripheral intravenous line was responsible to date the dressing and that the dressing is to be changed and dated every 72 hours per the policy and procedure. Registered Nurse #4 also stated that the intravenous medication was infused three times a day and no one observed that the dressing was not dated and had not been changed. The dressing change should have been documented in the progress notes and the order for the dressing changes should have been entered at the initiation of the IV medication, but neither are in the computer system. Registered Nurse #4 further stated that it is their responsibility to round daily and assess that the Intravenous dressings are changed, dated and that the documentation and orders are entered into the electronic medical record. On 01/17/25 at 10:09 AM, The Director of Nursing was interviewed and stated that regarding peripheral intravenous lines, the insertion site is rotated every 3 days and that collaborates with the dressing change so essentially the dressing should be changed every 3 days. The Director of Nursing also stated that the ideal practice is to date the dressing when it is changed and enter that date in the Treatment Activity Record with documentation of the insertion site assessment. The physician should be made aware if there is difficulty with the insertion and the physician order [REDACTED]. The Director of Nursing further stated that outside of the nurse who changes the dressing, the nurse manager should be looking for evidence of this during their daily rounds and when they run the Treatment Activity Report at the end of each day. 10NYCRR 415. 12 | Plan of Correction: ApprovedFebruary 13, 2025 Immediate Corrective Action Resident #187 was on Intravenous therapy for 5 days. The peripheral intravenous line was removed on day 5, 1/16/ 25. The nurse responsible for this deficient practice was re-educated on 2/3/25 on the importance of changing and dating the intravenous tubings and dressings every 72 hours. Other Resident with Potential to be Affected On 1/16/2025, the Nursing Supervisors reviewed the current residents who were receiving intravenous therapy. There were no other residents identified as being negatively impacted. Systemic Changes The Director of Nursing reviewed the Administration, Monitoring and Maintenance intravenous therapy Care Plan policy and procedure and found it to be compliant. The Director of Nursing will re-educate the RN nurses regarding the Administration, Monitoring, and Maintenance of the IV therapy policy. This education will include that RN nurses will ensure that IV tubings and dressings are being changed and dated every 72 hours. The nurses will ensure with a checklist that peripheral IV tubings and dressings are dated at the time of the initial insertion of IV line and is changed with a date every 72 hours except for end-of-life, ?ôhard stick?Ø and residents with fragile veins per existing acceptable clinical policy. Quality Assurance The Director of Nursing created an audit tool that will have the nurse managers and floor RNs conduct an audit on all IV insertions weekly for 3 months, then monthly thereafter to ensure compliance. Result of the audit will be reported quarterly by the DON/designee to the QAPI meeting; after such time, the facility will reevaluate the frequency of monitoring. Responsible party for implementation: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 2 (Resident # 19 and #187) out of 6 residents reviewed for respiratory care out of 38 sampled residents. Specifically, 1) Resident # 19 was observed using oxygen via the Nasal Cannula (NC) at 2 liters with no Medical Doctor's Order (MDO), and 2) Resident # 187 was observed using oxygen via undated nasal cannula tubing. The findings are: The facility's undated policy and procedure, Supplemental Oxygen, documented that oxygen therapy is administered to residents with medical conditions in which an [MEDICATION NAME] oxygen atmosphere will benefit them. Depending on the residents' inspiratory flow demands, oxygen can be administered using low-flow or high-flow oxygen delivery devices. The procedure is to check the resident chart for a physician's orders [REDACTED]. The facility's undated policy and procedure, Supplemental Oxygen, documented that a nasal cannula will deliver low concentration of oxygen at flow rates of 1-6 liters per minute. Infection Control: disposable equipment should be changed according to the equipment change schedule. The facility's undated policy and procedure titled Supply Change Standards, documented that respiratory supplies must be routinely changed to maintain proper infection control procedure and hygienic standards. Respiratory supplies will be changed according to the schedule listed below to reduce the risk of infection. Nasal Cannula change frequency - Weekly and as needed. 1. Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented Resident # 19 cognition as moderately impaired with a Brief Interview for Mental Status score of 12. On 01/13/2025 at 11:40 AM, Resident #19 was observed out of bed in a wheelchair in their room, using oxygen at 2 liters via nasal cannula. On 01/14/2025 at 9:43 AM, Resident #19 was observed out of bed in a wheelchair in their room, using oxygen at 2 liters via nasal cannula. The Medical Doctor's Orders dated 12/09/2024 to 01/13/2025 have no documented evidence that Resident #19 was receiving oxygen. The Medical Doctor's Order dated 01/14/2025 documented oxygen inhalation via Nasal Cannula at 2-3 liter/minute for oxygen saturation below 95%. The Nursing Note dated 12/16/2024 at 10:41 PM documented that at around 9:00 PM, Resident #19 complained of chest pain and described pain as heavy and in the middle of their chest. The registered nurse supervisor was notified and assessed the resident. I informed the doctor with an order to give a 0. 4 mg of [MEDICATION NAME] sublingual tablet in one dose and administer oxygen. The order was carried out and endorsed. [MEDICATION NAME] was given with relief of the chest pain and oxygen via nasal cannula at 2 liters/minute in progress and well tolerated. The Nursing Note dated 12/19/2024 at 6:21 AM documented that oxygen via nasal cannula was in progress, with oxygen saturation at 98%. The Nursing Note dated 12/23/2024 at 10:20 AM documented Resident#19 on the bed, not in distress, on oxygen inhalation via nasal cannula at 2 liters. On 01/17/2025 at 11:53 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #19 was on oxygen at 2 liters as needed. The resident went to the hospital and returned about three weeks ago with 2 liters of oxygen as needed. The resident did not have oxygen before but has been using it since returning from the hospital. Resident # 19 has an order for [REDACTED]. 2025. On 01/21/2025 at 12:39 PM, Licensed Practical Nurse #4 was interviewed, and stated that that Resident #19 complained of chest pains on 12/16/2024 after 8:00 PM. I took the vitals and reported them to the doctor. The doctor ordered [MEDICATION NAME] and oxygen. I put the resident on oxygen at 2 liters. I forgot to write the order for the oxygen; it skipped my mind. I did not follow up the next day to see if the order was in place. I should have written the order for the oxygen. On 01/17/2025 at 12:51 PM, Registered Nurse #5, the unit manager, was interviewed and stated that Resident # 19 had been on oxygen since the resident was readmitted on ,[DATE]/ 2024. Oxygen 2 liters via nasal cannula was ordered on 01/14/ 2025. There was no order for the oxygen, so I put an order in on 01/14/ 2025. The oxygen was started on 12/16/2024 by the evening nurse. I did not check to see if an order was in place for the oxygen. I missed it because it did not occur on my shift. On 01/21/2025 at 12:03 PM, the Director of Nursing was interviewed and stated that an order for [REDACTED]. There is a note that the doctor was notified and gave an order. It should have been ordered. They will reinforce documentation. 2. Resident #187 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #187 had severely impaired cognition skills for daily decision making. On 01/15/25 at 11:16 AM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute. On 01/15/25 at 02:52 PM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute. On 01/16/25 at 12:18 PM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute. On 01/16/25 at 1:10PM, Resident #187 was observed in bed with an undated nasal cannula tubing inserted that was infusing humidified oxygen at 5 liters per minute, in the presence of Registered Nurse #4, the unit manager. The Physician order [REDACTED]. The Resident Treatment Administration Record dated (MONTH) 2025, had no nursing documentation entries that Resident #187 was administered Oxygen in the month of (MONTH) or that oxygen tubing was dated or changed. On 01/16/25 at 1:25PM, Registered Nurse #4, the unit manager, was Interviewed and stated that the oxygen tubing connected to the nasal cannula should be dated and changed every 7 days but that they observed that there was no date on the tubing today. On 01/21/25 at 10:30 AM, The Director of Nursing was interviewed and stated that the oxygen/nasal cannula tubing has to be dated and changed every 7 days by the night shift staff and documented on an oxygen therapy list. The Director of Nursing further stated that is the day shift nurse manager who is responsible to observe for compliance during rounds and update the oxygen therapy list weekly. There was no documented evidence that the nasal cannula or oxygen tubing used for administration of Oxygen to resident #187 was dated or changed weekly or as needed. 415. 12(k)(6) | Plan of Correction: ApprovedFebruary 13, 2025 1) Immediate Corrective Action A doctors order for oxygen for resident #19 was placed in the medical record on 1/14/ 2025. The LPN responsible for this deficient practice was in-serviced by the ADON on 1/15/2025 on the importance of carrying out MD orders. Other Resident with Potential to be Affected The Nursing Supervisors reviewed on 1/23/2025 all physicians orders with residents who are on oxygen and there were no other residents identified as being negatively impacted. Systemic Changes The Director of Nursing reviewed and revised the Supplemental Oxygen policy and procedure with an effective date of 1/14/ 2025. The Director of Nursing will re-educate the RN nurses and LPN's regarding administration, monitoring, and continuation of O2 therapy to ensure that O2 therapy orders are in place based on order obtained from the physician/NP. Quality Assurance The Director of Nursing created an audit tool for new oxygen orders to ensure orders are appropriately carried out. This audit will be conducted by the Nurse Managers/RNs weekly for the first 3 months and monthly thereafter to ensure compliance. Result of the audit will be reported quarterly by the DON/designee to the QAPI meeting; After such time, the facility will reevaluate the frequency of monitoring. 2) Immediate Corrective Action The RN Unit Manager changed and dated the nasal cannula for resident #187 on 1/16/ 25. The nurse responsible for this deficient practice was in-serviced by the ADON on 1/21/2025 to ensure nasal cannula's are changes and dated on a weekly basis. Other Resident with Potential to be Affected The Nursing Supervisors/Managers reviewed on 2/6/2025 all residents with nasal cannulas. There were no other residents identified as being negatively impacted. Systemic Changes The Director of Nursing reviewed and revised the Supplemental Oxygen policy and procedure with an effective date of 1/14/ 2025. The DON/ADON will re-educate all 11-7 nurses on the Supplemental Oxygen policy and procedure, focusing on the importance of changing and dating nasal cannulas every 7 days. The DON/ADON will in-service all nurses on the day and evening shifts on the importance of observing compliance during daily rounds. Quality Assurance The Director of Nursing created an audit tool for nasal cannula changes and dates. This audit will be conducted by the Night RN Supervisor/designee every Sunday (weekly) as directed for 4 months and monthly thereafter to ensure compliance. Result of the audit will be reported quarterly by the DON/designee to the QAPI meeting; After such time, the facility will reevaluate the frequency of monitoring. Responsible party for implementation: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details Based on interviews and record review conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure that the Medical Director participated in the Quality Assurance and Performance Improvement quarterly meetings. This was evident during review of the attendance sheets for the last four quarterly meetings, and the facility provided list of members of the Quality Assurance and Performance Improvement Committee, and through interview with the Medical Director and other members of the Quality Assurance Committee. Specifically, the Medical Director stated that they do not attend the Quality Assurance quarterly meetings, and the Administrator stated that the Medical Director was too busy to attend the Quarterly Assurance quarterly meetings. The findings are: The undated policy titled Quality Assurance and Performance Improvement Program documented; that the Quality Assurance and Performance Improvement Program is designed to provide an ongoing, coordinated systematic and objective approach to monitor, evaluate, and improve Wayne's performance. The Quality Assurance and Performance Improvement Committee meets at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance and Performance program.(NAME)maintains a QAPI Committee consisting at minimum of the: Director of Nursing, Assistant Director of Nursing, Medical Director/Designee, Infection Preventionist, Administrator, Assistant Administrator, Director of Social Work, and at least two other members of the facility's staff. The undated document titled QAPI Committee documented; that the Quality Assurance and Performance Improvement Committee consisted of the: Administrator, Director of Nursing, Assistant Director of Nursing, Director of Admissions, Director of Social Work, Minimum Data Set Coordinator, Director of Recreation, Director of Rehabilitation, and Dietician. The QAPI Committee document did not include the Medical Director as a member of the Quality Assurance and Performance Improvement Committee. Review of the Quality Assurance and Performance Improvement Committee Meeting Sign-In Sheets documented that the Medical Director did not attend the Quality Assurance and Performance Improvement meetings on 02/06/2024, 05/03/2024, 07/25/2024, and 11/01/ 2024. On 01/17/2025 at 02:20 PM, the Director of Nursing was interviewed and stated that the Medical Director does not attend the quarterly Quality Assurance and Performance Improvement meetings. On 01/21/2025 at 09:33 AM, the Administrator was interviewed and stated that the Medical Director has not attended the last four Quality Assurance and Performance Improvement meetings because the Medical Director is too busy to attend them. The Administrator stated that they send the Medical Director copies of the meeting notes from each Quality Assurance and Performance Improvement meeting after each meeting to inform the Medical Director of what was discussed during each meeting. The Administrator stated that ideally, the Medical Director would attend the quarterly Quality Assurance meetings, but the Medical Director is so busy that it is difficult to schedule a time where they can attend. On 01/21/2025 at 11:58 AM, the Medical Director was interviewed and stated that they do not attend the quarterly Quality Assurance and Performance Improvement meetings. They stated that instead of attending the meetings with the committee, they meet with the Director of Nursing and are briefed on what was discussed in the meetings afterwards. 10 NYCRR 415. 15(a) | Plan of Correction: ApprovedFebruary 13, 2025 Immediate Corrective Action The Medical Director has acknowledged the regulatory requirement of the role and will attend all future QAPI committee meetings as per F 841 guidelines. Other Resident with Potential to be Affected All residents have the potential to be affected by not having the Medical Director present to participate with his medical education and knowledge of patient care. Systemic Changes The Administrator reviewed and up-dated the Quality Assurance and Performance Improvement Program policy. The Administrator reviewed and revised the Medical Director job description to include the QA policy on the importance of attending the quarterly QAPI meetings. The Administrator in-serviced the Medical Director on 2/6/2025 on the importance and obligation to attend the quarterly QAPI committee meeting. In the event the Medical Director cannot attend the QAPI meetings in person, he will attend via zoom or by phone. Quality Assurance The Administrator developed an audit tool that will be conducted monthly by the Administrator to assure appropriate oversight of required duties of the medical director, as well as ensuring the Medical Director attends the quarterly QAPI committee meetings. This audit will continue monthly for 12 months and quarterly thereafter. Any negative findings will be addressed immediately. Responsible party for implementation: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 01/13/2025 to 01/21/2025, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include: The undated facility policy titled Staffing of Nursing Service Personnel documented; each nursing home reports daily staffing hours to Medicare. Medicare calculates a ratio of staffing hours per resident day, the percent of nurse staff that stop working at the facility, and the number of administrators who have left the facility within a given year. These types of staff are included in the nursing home staffing information: Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 - 09/30/2024) documented that excessively low weekend staffing was triggered. The undated Facility Assessment Survey documented facility capacity of 243 residents with a weekend staffing plan by shift distributed as follows: Day shift (7 AM to 3 PM) by units: 2nd Floor (ventilator unit): 3 Registered Nurses, 1 Licensed Practical Nurse, 6 Certified Nurse Aides 3rd Floor: 2 Registered Nurses, 1 Licensed Nurse, 5 Certified Nurse Aides 4th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides 5th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides 6th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides 7th Floor: 1 Licensed Practical Nurse, 4 Certified Nurse Aides Evening shift (3 PM to 11 PM) by units: 2nd Floor (ventilator unit): 3 Registered Nurses, 1 Licensed Practical Nurse, 5 Certified Nurse Aides 3rd Floor: 2 Registered Nurses, 1 Licensed Practical Nurse, 4 Certified Nurse Aides 4th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides 5th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides 6th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides 7th Floor: 1 Licensed Practical Nurse, 3 Certified Nurse Aides Night shift (11 PM to 7 AM) by units: 2nd Floor (ventilator unit): 3 Registered Nurses, 1 Licensed Practical Nurse, 4 Certified Nurse Aides 3rd Floor: 1 Registered Nurse, 1 Licensed Practical Nurse, 3 Certified Nurse Aides 4th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides 5th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides 6th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides 7th Floor: 1 Licensed Practical Nurse, 2 Certified Nurse Aides Review of the actual weekend facility staffing schedule from 07/06/2024 to 09/29/2024 documented the following: On 07/06/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/13/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/13/2024 on the 7 AM to 3 PM shift, there was a shortage of 1 Certified Nurse Aide on the 2nd Floor (ventilator unit). On 07/14/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/20/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/21/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 07/27/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 07/28/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 08/04/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/10/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 08/11/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 08/17/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/18/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/24/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/25/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 08/31/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/01/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse and 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/ 4 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/07/2024 on the 3 PM to 11 PM shift, there was a shortage of 1 Certified Nurse Aide. On 09/08/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/ 4 on the 3 PM to 11 PM shift, there was a shortage of 1 Certified Nurse Aide on the 2nd Floor (ventilator unit). On 09/15/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/21/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 09/21/2024 on the 7 AM to 3 PM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/22/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Registered Nurse on the 2nd Floor (ventilator unit). On 09/28/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). On 09/29/2024 on the 11 PM to 7 AM shift, there was a shortage of 1 Licensed Practical Nurse on the 2nd Floor (ventilator unit). Review of the actual weekend facility staffing schedule from 07/06/2024 to 09/29/2024 revealed that the facility had an ongoing pattern of shortage of nursing staff. Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Minimum Data Set assessment dated [DATE] documented that Resident #98 was cognitively intact. On 01/17/2025 at 12:48 PM, Resident #98 was interviewed and stated that they believed the facility was sometimes understaffed at night. They stated that there had been an incident where it took three hours for a Certified Nurse Aide to provide them with a new gown after they notified the Certified Nurse Aide that they had spilled something on the one they were wearing. They stated that on a separate occasion, it took multiple hours for a staff member to assist them to the bathroom on the night shift. Resident #203 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #203 had moderate cognitive impairment. On 01/17/2025 at 02:33 PM, Resident #203 was interviewed and stated that the facility is very understaffed. They stated that they notice this on all shifts but that it is worse during the night shift and on weekends. They stated that this affects timeliness of receiving food, being cleaned, and being provided incontinence care. Resident #176 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #176 was cognitively intact. On 01/17/2025 at 02:44 PM, Resident #176 was interviewed and stated that the facility is u | Plan of Correction: ApprovedFebruary 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action 1. The Social Services Department re-visited Residents #98, #203, #176, #132, and #157 and assured them that the facility will work diligently to improve the staffing, showers, assistance with ADLs, meal service, and call bell wait times. 2. The Director of Nursing/designee provided support and encouragement regarding the facilitys staffing challenges to CNAs #5 & #4; and reminded them of their responsibility and accountability to assure each residents safety and provision of care, providing ADLs, meals and call bell wait times. 3. The Director of Nursing and Administrator will be re-educated by the facility consultant on their accountability and responsibility to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. 4. The Administrator and the Director of Nursing will revisit current Nursing Agency contracts and called to request additional nursing staff. a. The facility is in the process of reviewing profiles to interview for the upcoming new hire orientation. 5. The Administrator will contact currently contracted Staffing Agencies to request additional days for nurses who had assignments with the facility. 6. The Administrator will contact the 1199 SEIU Workforce Development Manager (Union) requesting recruitment for CNAs and LPNs. 7. The Administrator/designee will contact nearby Nursing Assistant and Practical Nursing Programs to recruit CNAs and LPNs. 8. The staffing coordinator responsible for nursing staffing from 7/1/24 to 09/30/24 will be educated his/her responsibility and accountability to meet the facilitys established par levels, provide incentives as directed by the DNS and continue notification to the Director of Nursing/Administrator when staffing levels are not maintained or fall below established par levels. Other Resident with Potential to be Affected 1. The facility acknowledges that the nursing staffing levels identified by the NYSDOH from 7/1/24 to 09/30/24 had the potential to affect all residents in the facility. 2. An ad hoc Resident Council meeting will be held by the Recreation Director with the interdisciplinary team present, to address any additional concerns that residents may have as it pertains to nursing staffing, showers, assistance with ADLs, meal service, and call bell wait times. a. Any concerns voiced will be addressed by the Administrator and respective department. b. Minutes are filed for reference and validation. Systemic Changes 1. The QAPI Committee will convene to examine the deficiency cited under F725 and a. Perform an assessment of the possible causative factors that may have contributed to the issues identified in the above deficiency. b. Identify the specific steps/interventions that must be initiated to eliminate and correct the causative factors identified during the assessment phase. c. Indicate how this system will be implemented and sustained by the facility. e. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance. f. Identify if the current established nursing staffing par levels align with the resident acuity, profile, PDPM Nursing Case Mix Index, and demographics, and compliance with F725, g. Care Plan meetings will be utilized by the interdisciplinary team as a forum to obtain residents concerns as it pertains to nursing staffing, showers, assistance with ADLs, meal service, and call bell wait times. h. The staffing coordinator will be educated on the updated, reviewed policy titled ?ôNursing Staffing?Ø. Quality Assurance 3. The QAPI Committee developed an audit tool to monitor the Nursing Departments compliance with established staffing par levels, nursing staffing, showers, assistance with ADLs, meal service, and call bell wait times. 1. The Director of Nursing/designee will utilize the audit tool to review staffing patterns, showers, assistance with ADLs, meal service, and call bell wait times weekly for four weeks and monthly thereafter to attain and sustain 100% compliance with F 725. 2. Audits with negative findings will have immediate corrective actions including but not limited to additional incentives and overtime for staff. The Administrator will be notified immediately by the Director of Nursing. 3. The Director of Nursing/designee will summarize the audit findings and present them to the QAPI Committee quarterly for needed revisions to the action plan that will improve our delivery of care services with as it pertains to nursing staffing, assistance with ADLs, meal service, and call bell wait times, compliance with F 725. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 21, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25 5. 2* Inspection. .2011 NFPA 25: Table 6. 1. 1. 2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 Based on observation and staff interview, the facility did not ensure that all components of the building's extinguishing system were tested and maintained in accordance with 2011 NFPA 25. This occurred in three building stairwells, on the 11th floor and the basement. The findings include: During the life safety survey of 1/16/2025, between 9:00 am and 11:30pm, the following were noted: The fire hoses located in the facility's three stairwells, were stamped with a date of 04- 14. There was no indication of the hoses having been tested or replaced within the five years prior to the survey. At the time of this finding, the facility's Administrator stated that the hoses would be replaced. 2012 NFPA 101 2011 NFPA 25 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 23, 2025 Immediate Corrective Action Safety Fire Sprinkler company inspected the stairwell fire hoses on 1/23/2025 and sent a proposal to supply and replace by 2/28/2025, 24 - 1. 5 x 25' rack fire hose with NYFD couplings and 48 - 1. 5 x 50' rack fire hoses with NYFD couplings. Identification of Other Residents All residents were potentially affected by this deficiency. Systemic Changes The Administrator reviewed and revised the fire safety policy to include bi-annual inspections on all stairwell fire hoses. The Director of Environmental Services will to the preventive maintenance schedule a bi-annual inspection on all stairwell fire hoses. The Director of Environmental Services will ensure, as part of the preventive maintenance schedule, to have all fire hoses tested by the fire sprinkler company once every 5 years. Quality Assurance The Administrator will review the fire prevention preventive maintenance book for fire hose inspections every 6 months and will report the findings during the quarterly QAPI committee meeting. All negative findings will be addressed immediately. |