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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during the recertification survey from 3/5/25 through 3/12/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 1 resident (Resident #29) reviewed for activities of daily living. Specifically, Resident #29 required staff assistance with personal hygiene was observed on three (3) occasions with long, stained fingernails. Findings include: The facility policy titled nail care revised (MONTH) 2011 documented that routine nail care is to be done following baths and showers whenever possible. The facility policy titled activities of daily living revised (MONTH) 2023 documented that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including hygiene bathing dressing grooming and oral care. Resident #29 was admitted with [DIAGNOSES REDACTED]. The 1/5/25 Significant Change Minimum Data Set assessment documented Resident #29 had severely impaired cognition, required dependent assistance with showers. The 1/2/25 Care Plan documented Resident #29 required maximal assistance with upper body bathing. The Kardex documented showers on day shift Wednesdays & Saturdays, dependent with lower body, maximal assistance with upper body. There was no documented evidence regarding trimming or cleaning fingernails. On 03/05/25 at 12:55 PM and on 03/06/25 08:55 AM, Resident #29 was observed with long fingernails with yellow-brown stains on them. On 03/07/25 at 12:13 PM during an observation and interview, Certified Nurse Aide #7 observed Resident #29's fingernails. Certified Nurse Aide #7 stated they did not pay attention to resident's fingernails when they provided care. They stated they provided care to Resident #29 two days ago and did not notice Resident #29's long fingernails. They stated that fingernails should be clipped when they are long. On 03/07/25 at 12:22 PM during an interview, Licensed Practical Nurse Unit Manager #4 stated the Certified Nurse Aides were responsible for cutting residents' fingernails unless the resident was diabetic. They stated the Certified Nurse Aide should have told the nurse if a resident's nails were long. When Licensed Practical Nurse Unit Manager #4 observed Resident #29's fingernails, they stated the resident's fingernails were long. 10 NYCRR 415. 12 (a)(3) | Plan of Correction: ApprovedApril 4, 2025 Resident #29 was offered nail care and declined nail care. Residents care plan was updated to reflect to encourage nail care per residents preference and as tolerated by the resident. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. Certified nurse aid #7 was educated on the policy of providing nail care to the residents as part of daily ADLs. The CNA has since been re-audited and successfully demonstrated her understanding. All residents on the CNA's assignment had the potential to be affected by the deficient practice. Full house audit by Nurse Managers/designee will be completed to assure all residents nails are clean and trimmed and care planned appropriately. Any instances of dirty nails were immediately rectified. Nurses and CNAs will be educated by the DON/ designee on the process providing nail care during daily ADLs and ensuring residents nails are clean and trimmed as outlined in the residents plan of care. Weekly audits to be completed by the nurse manager/ designee ensure compliance with proper nail care and that residents nails are clean and trimmed per care plan. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review the audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the Monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey from 3/5/25-3/12/25, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 (Resident #68) of 4 residents reviewed for pressure ulcers. Specifically, Resident #68's Skin Integrity at Risk Care Plan dated 11/15/24 and updated 2/12/25 documented to float Resident #68's heels, however it was not updated to include a new intervention when staff observed the resident moving their legs frequently when in bed. The findings are: The facility policy titled Interdisciplinary Care Planning revised 4/15/2024 documented a comprehensive resident centered care plan is developed by the interdisciplinary team upon admission and reviewed/ updated on a regular basis throughout the residence length of stay. The comprehensive care plan is reviewed and updated with changes and minimally on a quarterly basis. Resident #68 had [DIAGNOSES REDACTED]. The 11/20/24 Quarterly Minimum Data Set Medicare 5-day assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed and had two unstageable pressure ulcers present on admission. The 11/15/24 Skin Integrity at Risk Care Plan documented an intervention to float Resident #68's heels in bed. The 2/4/25 Skin Integrity at Risk Care Plan documented intervention to float heels in bed. The 2/15/25 Quarterly Minimum Data Set assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed, and one stage two pressure ulcer present on admission. The Kardex (Certified Nurse Aide instructions) documented to float Resident #68's heels in bed. On 03/05/25 at 10:37 AM, Resident #68 was observed sitting in their wheelchair wearing sneakers, with their right foot on the floor, although their wheelchair footrest was in place. Resident #68 stated their right heel is bruised and it feels better when they are wearing sneaker because the sneaker has padding. They stated their heel hurts at night when they move their foot. Resident #68 stated that nobody offered padded booties in bed. On 03/06/25 at 09:06 AM, Resident #68 was observed in bed with their heels directly on the mattress, and no heel booties or pillow was observed to float their heels, and there was no air mattress in place. On 03/07/25 at 10:45 AM, Resident #68 was observed lying in bed with their heels directly on the mattress, no air mattress was in place, no heel booties or pillow were observed to float their heels. On 03/07/25 at 11:00 AM during an interview, Licensed Practical Nurse #1 stated that Resident #68 moves in bed, and therefore pillows are not effective to float Resident #68's heels, but they never requested another intervention such as heel booties or another device for the resident. They stated they should have told the Nurse Manager. On 03/07/25 at 04:10 PM during an interview, Licensed Practical Nurse Unit Manager stated that nursing staff who was aware that the pillow was not effective for floating the resident's heels should have reported the concern to them or therapy or any nursing management, so that a new intervention could have been implemented. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedApril 4, 2025 Resident # 68 comprehensive care plan was reviewed and revised on 3/8/25 to reflect an air mattress for pressure relief of her heels. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. Unit manager was educated on the requirement to update the resident care plan to accurately reflect interventions Full house audits will be completed by the nurse managers for all residents with wounds and ensure that the comprehensive individualized care plan for wounds is reviewed and revised to accurately reflect the residents' needs All unit managers/supervisors educated by the DON/designee to review and revise comprehensive individual care plan weekly or with noted ineffective interventions. Weekly audits will be completed by the unit managers/designee to ensure all residents with wounds have a comprehensive individualized care plan with effective interventions in place. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ ADON, will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details Based on observation, record review and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16), reviewed for COVID-19 vaccinations. The findings are: The facility COVID-19 policy dated 10/30/24 documented the facility will ensure that all employees and contracted staff will be screened prior to offering the vaccination and prior to immunization, medical precautions and contraindications necessary for determining whether they are appropriate candidates for vaccination at any given time. Documentation will be maintained to reflect that the required education was provided and whether the resident and staff member received the vaccine. During the recertification survey, the facility was asked to provide documentation that COVID-19 vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aide #15 and Laundry Aide #16, but none was provided. During an interview on 3/12/25 at 10:59 AM with Licensed Practical Nurse #17, they stated they were responsible for collecting data for employee immunization status which included eligibility, education and administration of vaccines. They did not have a completed form for Certified Nurse Aide #15 and Laundry Aide #16 which verified they were eligible, educated and consented to or declined the vaccination. Licensed Practical Nurse # 17 stated they did not know the COVID-19 vaccine needed to be offered to staff. During an interview with the Director of Nursing on 03/12/25 at 10:29 AM they stated the Infection Preventionist was new and they delegated the vaccines to the Licensed Practical Nurse #17 to ensure forms were signed by the employee as proof education was provided. The Director of Nursing stated they were not sure why this happened. 10NYCRR 415. 19 (a)(1-3) | Plan of Correction: ApprovedApril 4, 2025 Staff #15 and #16 were both offered and declined COVID vaccinations for the year. Consent form was signed on (MONTH) 12, 2025. Staff #17 has been educated on the importance of completion of vaccination forms in its entirety. That Covid vaccinations are available in the facility throughout the year. A full house audit of all staff vaccination status will be conducted by DON/designee. All staff will be offered the Covid vaccines with education and eligibility information. Education provided to Staff #17 all staff can accept or decline all vaccinations throughout the year. Covid vaccinations are available at any time in the facility. Upon request. Covid vaccinations are offered at time of hire and, throughout the year. All vaccinations are available at any time. House wide audit of vaccinations records will be completed by ADON/designee monthly until 100% compliance is attained for 3 consecutive months. Any abnormal findings will be reported to the DON. These findings will be corrected immediately with education provided. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details Based on observation and interview conducted during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, nursing staff did not perform proper hand hygiene while serving beverages at lunch meal. The findings are: The facility policy last revised 11/2019, Dining Room Service documented dining room meal service is provided in a clean, comfortable and orderly atmosphere. On 3/5/25 at 12:28 PM in the main dining room, the Assistant Director of Nursing was observed serving beverages to multiple residents wearing disposable gloves and not changing gloves between service. The Assistant Director of Nursing touched the beverage cart handle, proceeded to pick up a resident's glass, touched the carafe/pitcher handle and replaced the glass for resident use. The Assistant Director of Nursing did not change their disposable gloves before moving to serve the next resident. This was observed multiple times until the Regional Director of Nursing was observed speaking to the Assistant Director of Nursing, upon which the Assistant Director of Nursing removed the disposable gloves. The Assistant Director of Nursing continued to serve residents without using hand sanitizer or washing their hands between serving residents. The Assistant Director of Nursing touched their own face with their bare hand while taking a beverage order at a table and proceeded to serve Resident #93 hot cocoa in a cup at a separate table. Resident #93 touched the cup to take a drink. The Assistant Director of Nursing touched a resident's walker with their bare hands to move it for a resident and continued to serve a beverage to that resident. After all beverages were served and beverage cart was put away, Assistant Director of Nursing used hand sanitizer. On 3/5/25 at 1:15 PM during an interview with the Assistant Director of Nursing, they stated they wore disposable gloves because they were worried the ice scoop would fall into the ice bin during service and bare hands would contaminate the ice. The Assistant Director of Nursing stated the Regional Director of Nursing asked why gloves were being used, and stated gloves were not needed. The Assistant Director of Nursing stated the disposable gloves were to protect the residents. The Assistant Director of Nursing stated they should have used the sink to wash hands, but the sink was out of soap. The surveyor confirmed no soap at sink. The Assistant Director of Nursing stated if they had no soap and no disposable gloves, they should have used hand sanitizer, which was used after beverage service. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedApril 4, 2025 Resident # 93 had no ill effects from the deficient practice noted during the meal service on 3/5/ 25. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. ADON was educated on proper hand hygiene while serving in the main dining room. She has since been re-audited and successfully redemonstrated understanding. All facility residents have the potential to be affected by the alleged practices. A meal service audit was conducted on all units to verify that disposable gloves were not being used during meal pass and that hand hygiene was performed properly. No further issues were identified. All nursing staff will be in-serviced regarding proper hand hygiene in accordance with professional standards for food service safety while serving meals. Weekly audits will be completed across all 3 meals in each dining room on a rotating basis by DON/designee to assure proper hand hygiene during meal service. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ ADON, will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details Based on observation, record review and interview conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, 1) the facility did not provide documentation of screening, administration, or declination and education provided for 2 of 10 staff (Certified Nurse Aide #15 and Laundry Aide #16) reviewed for pneumococcal vaccination; 2) there was no evidence that a Water Management Plan was reviewed and updated, if needed, annually to prevent and control Legionella; and 3) a Licensed Practical Nurse was observed putting an unsanitized blood pressure cuff into the medication cart before properly cleaning it. The findings are: The facility policy titled Pneumococcal Vaccination Program for employees dated 10/24 documented control of pneumococcal disease is increasingly important due to high morbidity rates. The pneumococcal vaccine will be offered to all employees. During the recertification survey the facility was asked to provide documentation that pneumococcal vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aid #15 and Laundry Aide #16, but none was provided. 1. During an interview on 3/12/25 at 10:59 AM, Licensed Practical Nurse #17 stated they were responsible for collecting data for employee immunization status which included eligibility, education and administration of vaccines. They stated they did not have completed forms for Certified Nurse Aide #15 and Laundry Aide #16 which verified they were eligible, educated and consented to or declined the pneumococcal vaccination. During an interview on 03/12/25 at 10:29 AM, the Director of Nursing stated the Infection Preventionist was new, and they had delegated the vaccines task to the Licensed Practical Nurse # 17. Licensed Practical Nurse #17 was responsible for ensuring forms were signed by the employee as proof that education was provided. The Director of Nursing stated they would make sure vaccines were offered and declinations were on file for staff and was not sure why this happened. 2. , The facility's Legionella binder was reviewed with the Director of Maintenance and the Regional Director of Maintenance. The Water Management Plan was undated, and there was no documented evidence as to when it was completed, reviewed, or updated. On 03/05/25 at 3:45 PM, the Director of Maintenance stated they did not realize the Water Management Plan was undated. 3. During an observation of the medication pass on the second-floor unit that started at 8:58 AM on 3/10/25, Licensed Practical Nurse #18 obtained a blood pressure reading for Resident #40 prior to administering their medications. They used a wrist cuff to obtain the reading. After obtaining the blood pressure, they returned the wrist cuff back into the medication cart without sanitizing the cuff. When asked about the sanitization of the cuff, Licensed Practical Nurse #18 stated it should have been wiped after use. During an interview on 3/10/25 at 11:03 AM, the Director of Nursing stated that all shared equipment should be sanitized between each use. They stated that staff may use either alcohol wipes or the sanitizing wipes with a purple top to sanitize the cuff. 10NYCRR 415. 19 (a)(1-3) | Plan of Correction: ApprovedApril 11, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice Nurse Aide #15 and laundry aide #16 were offered the pneumococcal vaccine on 3/12/25; both declined and signed a declination form Education provided to LPN #17 on the requirements for all employees to have documented immunization status; including eligibility, education and administration of vaccines and that signed consents/declinations are maintained on file The water management plan was reviewed and updated on 3/5/2025 and verbal education was provided to the Maintenance Director on the documentation requirements for the water management plan which includes, at minimum, an annual documented review of the water management plan Licensed practical nurse #18 was educated on the requirement to sanitize blood pressure cuffs after use, prior to being placed in the medication cart Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All Residents have the potential to be affected, however no residents have been negatively impacted Staff Educator/designee completed an audit of all employee vaccination status, and the pneumococcal vaccine will be offered to any employee identified as needing such based off of audit findings Element #3: The following system changes will be implemented to prevent reoccurrence The facility policy and procedure titled ?ôPneumococcal Vaccination Program for Employees?Ø was reviewed and found to be appropriate The staff educator/designee will provide education to all employees upon hire and least annually on the pneumococcal vaccine and will obtain a signed consent or declination for the vaccine. Consent/declination forms will be retained on file. The staff educator/designee will provide education to all licensed nurses on the requirement to properly sanitize blood pressure cuffs after use and prior to placing in medication cart for storage The administrator provided verbal education to the Maintenance Director on 3/5/2025 on the requirement to complete and update the water management plan on an annual basis Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Nursing has created an audit tool to ensure that all employees were offered the pneumococcal vaccine upon hire and annually and that a consent/declination form is signed by the employee The Director of Nursing has created an audit tool to ensure that licensed staff are properly sanitizing blood pressure cuffs after use ADON/Designee will complete a full house audit of employee vaccination records monthly until 100% compliance is attained for 3 consecutive months. Negative findings will be corrected and reported to the Director of Nursing Unit managers/designee will audit once a week to ensure that blood pressure cuffs are properly sanitized in between residents until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected and reported to the Director of Nursing Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency for blood pressure cuffs after 4 weeks of 100% compliance; and for employee vaccinations after 3 months of 100% compliance Element #5: The person responsible for the corrective actions is the Director of Nursing/designee. Date of compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from [DATE]-[DATE], the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for expiration dates and storage. Specifically, 1) one (1) of two (2) medication rooms examined for medication storage, had a box of expired [MEDICATION NAME] 1. 5 feeding that was stored and being used; and expired nicotine patches were stored in 1 of 3 medication carts examined for medication storage. 2) Resident #60 was found with physician ordered [MEDICATION NAME], Carvedilol (blood pressure pills), [MEDICATION NAME] (anti-depressant), Aspirin, Apixaban (blood thinner), Folic Acid (supplement), Levetiracetam ([MEDICAL CONDITION] medicine), [MEDICATION NAME] (stool softener), and [MEDICATION NAME] (anti-acid) in their room on their bedside table. The findings are: The facility policy titled Medication/Treatment Labeling and Storage revised ,[DATE], documented medications/treatments are stored under proper conditions of sanitation, temperature, light, moisture and ventilation. There is no documentation specific to expiration dates in the policy. 1. During an observation of the Medication Room on the First Floor Unit on [DATE] at 11:00 AM, an open box containing six bottles of [MEDICATION NAME] 1. 5 Cal with an expiration date of (MONTH) 1, 2025 was found. During an observation on [DATE] at 11:25 AM with Licensed Practical Nurse #2, a nearly empty bottle of [MEDICATION NAME] 1. 5 Cal was observed in Resident #90's room hanging, but not running or being administered to resident at that time. A handwritten date of [DATE] was written on the bottle. The bottle had an expiration of (MONTH) 1, 2025. During an interview on [DATE] at 11:33 AM, Licensed Practical Nurse #2 stated that the [MEDICATION NAME] 1. 5 Cal hanging in Resident #90's room was stopped by them that morning as their feeding was hung in the evening and taken down in the morning at 10 AM. They stated the [MEDICATION NAME] 1. 5 Cal used did have an expiration date of [DATE] and should not have been hung since it was expired. During an observation on the First Floor Unit on [DATE] at 11:40 AM with Licensed Practical Nurse #1, seven Nicotine Patches with an expiration date of ,[DATE] were loose in the top drawer of the medication cart with no resident label. Licensed Practical Nurse #1 was interviewed during the observation and stated the patches were house stock so that was why there was no label. They stated the patches should not have been in the cart since they were expired. During an interview on [DATE] at 3:57 PM, Licensed Practical Nurse Unit Manager #4 stated that the medication nurse hanging a tube feeding should check the expiration date prior to hanging it. They stated all nurses should check the contents of the medication room for any expired items. Medication nurses should be checking, and are responsible for, the contents of their medication carts. They should dispose of any expired items and let the Unit Manager know. 2. Resident #60 was admitted to the facility with [DIAGNOSES REDACTED]. The [DATE] admission Minimum Data Set assessment documented intact cognition, and required set-up and clean-up assistance with eating. The Physician order [REDACTED]. 12. 5 mg for Hypertension, [MEDICATION NAME] 50 mg for depression, [MEDICATION NAME] 5 mg for Hypertension, Aspirin 81 mg tablet for [MEDICATION NAME] 1 tablet for constipation, Apixaban 5 mg for [MEDICAL CONDITION] Fibrillation, Folic Acid 1000 mcg for supplement, Levetiracetam 1000 mg for [MEDICAL CONDITION], and [MEDICATION NAME] 20 mg for Gastro-[MEDICAL CONDITION] disease. The [DATE] Care Plan had no documented evidence Resident #60 could self-administer medications. On [DATE] at 10:15 AM during an observation, Registered Nurse Unit Manager #6 entered Resident #60's room and left a cup of medication at bed table and instructed Resident #60 to not take the medications until they returned with water. On [DATE] at 10:26 AM, during an observation Resident #60's medications were still sitting on bedside table. On [DATE] at 10:28 AM during an interview, Registered Nurse Unit Manager #6 stated the medications left at bedside were [MEDICATION NAME], Carvedilol, [MEDICATION NAME], Aspirin, [MEDICATION NAME], Apixaban, Folic acid, [MEDICATION NAME], and [MEDICATION NAME]. Registered Nurse Unit Manager #6 stated Resident #60 was alert and would wait for them to bring water to take the medication. Registered Nurse Unit Manager #6 stated they should have left the medications locked in the medication cart while getting water for the resident. Registered Nurse Unit Manager #6 stated this was not normal practice or facility policy. 10 NYCRR 415. 18(e) (,[DATE]) | Plan of Correction: ApprovedApril 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The expired [MEDICATION NAME] feed and nicotine patches were immediately discarded. Resident #60 received appropriate medications on [DATE] and resident has been discharged from the facility. Residents preference was to have all medications administered by the nursing department and not to self-administer medications Resident #90 resident was assessed, and had no negative outcome related to tube feed. MD made aware. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. All nursing staff who administered the expired [MEDICATION NAME] and did not discard the expired nicotine patches were re-educated on checking of expiration dates and discarding as appropriate. Nurse manager #6 was re-educated on med pass policy to not leave residents medications at the bedside and to assure medications are consumed. She has since been re-audited and successfully redemonstrated her understanding. All residents receiving tube feed and medication have potential to be affected by practice. DNS and Maintenance Director completed a Full house audit of tube feeding expiration dates. Additionally, all medication rooms and medication carts were checked to verify that no medications were expired. Any additional medications/feeds that were found to be expired were immediately discarded. All residents who self-administer medications were audited to verify that a Self Administration evaluation was completed and appropriate. Residents that do not have a care plan to self-administering medications will have medications provided by nurses. The nurses will not leave medications unattended. All Nurses and Maintenance Director educated by DON/designee to check expiration dates on all tube feed and medications administered items used. Prior to use, dates will be checked. All Nurses will be reeducated by DON/designee pertaining to proper medication administration. All licensed nurses will be re-educated on the facility procedure for residents that request to self-administer medication Nursing and Maintenance will monitor expiration of Tube feeding and supplies. Weekly audits by Unit Manager/ designee of tube feeding. Medication cart checks will continue to be checked by Pharmacy Consultant monthly. Tube feed will be checked by maintenance before being brought to unit to ensure that tube feeding has not exceeded expiration date. Tube feeding will be checked by nurse prior to hanging it. Audits will be ongoing. Weekly audits on med passes by Unit Managers to ensure medication is not left at bedside. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly.The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is [DATE] |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 725) from 3/5/25 to 3/12/25, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 5 of 5 residents (Resident #50, #202, #203, #68,#69) reviewed for discharge. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the resident or their representatives. The findings are: The facility policy titled Bed Hold and Notice dated 8/24 documented the facility will notify the designated representative and/or the resident of the facility's bed reservation policies, verbally and in writing at the time of admission and at the time of transfer. 1. Resident #50 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool dated 1/4/24 documented the resident had intact cognition and was dependent on staff for all activities of daily living. The Respiratory therapy note dated 12/20/24 at 01:43 AM documented the resident was on assist control ventilator settings, was given a nebulizer for increased work of breathing using accessory muscles and respiratory rate of 36. The physician was notified and ordered the resident to be sent to the hospital for evaluation. The 12/20/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #50 was discharged to the hospital. There was no documented evidence a written notice of the facility Bed Hold Policy was given to the resident or their representative. During an interview on 03/11/25 at 12:04 PM with the Director of Social Work, they stated they could not provide documented evidence that a written notice of the facility bed hold policy was provided to the to the resident or representative. They stated there had been a service gap due to recent changes in administration. During an interview with the Administrator on 03/10/25 at 03:38 PM they stated when they started working at the facility, there was noticeable inconsistency with notices of bed hold policy. Since then, notices have been going out to families and the issue has been added to the facility's Quality Assurance and Performance Improvement plan. 2. Resident #202 was admitted with [DIAGNOSES REDACTED]. The 6/17/24 Minimum Data Set, an assessment tool, documented the resident had moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #202 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of facility bed hold policy. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that a written notice of the facility bed hold policy was provided to the to the resident or representative. 3. Resident #203 was admitted with [DIAGNOSES REDACTED]. The 6/21/24 Modification of Admission Minimum Data Set, an assessment tool, documented moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #203 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the facility bed hold policy. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that a written notice of the facility bed hold policy was provided to the to the resident or representative for their transfer to the hospital. 10NYCRR 415. 3 (i)(3)(i)(a) | Plan of Correction: ApprovedApril 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice Review of identified residents revealed that Residents #50, 69, 68 experienced transfers to the hospital and all were readmitted to the facility after completion of acute hospital stay and are current residents. Resident # 202 was transferred to the hospital for acute needs and expired in the hospital. Resident #203 was scheduled for discharge to ALF prior to hospital admission and was directly discharged to ALF from acute care hospital Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All residents who were transferred have the potential to be affected, however no residents were negatively impacted. An audit of the last 30 days of resident hospital transfers was completed to ensure that a notice of bedhold was given Element #3: The following system changes will be implemented to prevent reoccurrence The facility policy and procedure on ?ôBed Hold and Notice?Ø was reviewed and found to be appropriate Social Work staff, medical records, and admissions will be reeducated on the facility policy and requirement for Bed hold notification for all residents and a record of education will be maintained for reference and validation Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Social Work has created an audit tool to ensure that Notice of Bed Hold documentation is accurately completed for all hospital transfers/discharges and validate that all required documentation is uploaded to the facility eMAR system The Director of Social Work/designee will audit, and Audits will continue until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected immediately and reported to the administrator Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance Element #5: The person responsible for the corrective action is the Director of Social Work/designee. Date of Compliance is [DATE] |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 725) from 3/5/25 to 3/12/25, the facility did not ensure residents and/or representatives were provided written notification in a manner they understood for 5 of 5 residents reviewed for discharge (Resident #50, #202, #203, #68, and #69) who were transferred/discharged to the hospital. Specifically, Residents #50, #202, #203, #68 and #69 were transferred to the hospital and the facility was unable to provide evidence that written notice of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand was provided to the resident and the resident's representative(s). The findings are: The facility policy titled Discharge Notice and dated 3/25 documented; Nursing homes must provide residents with a detailed, written discharge/transfer notice which must include specific information regarding the resident's rights in this process. 1. Resident #50 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool dated 1/4/25 documented the resident had intact cognition and was dependent on staff for all activities of daily living. The Respiratory therapy note dated 12/20/24 at 01:43 AM documented the resident was on assist control ventilator settings, was given a nebulizer for increased work of breathing using accessory muscles and respiratory rate of 36. The physician was notified and ordered the resident to be sent to the hospital for evaluation. The 12/20/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #50 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the transfer to the hospital. During an interview with the Director of Social Work on 03/11/25 at 12:04 PM they stated they were responsible for sending transfer/discharge notices in writing but could not provide documented evidence that it was provided to the resident or representative. They stated there was a service gap with the change of Administration staff and it had not been done for a few months. During an interview with the Administrator on 3/10/25 at 03:27 PM they stated they started at the facility about six weeks ago and during an audit they realized the facility had not been giving discharge notices in writing and began implementing it right away. Thery stated there was a lot of new staff recently and provided education about the process and added it to their Quality Assurance and Performance Improvement program. 2. Resident #202 was admitted with [DIAGNOSES REDACTED]. The 6/17/24 Minimum Data Set, an assessment tool, documented the resident had moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #202 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the transfer to the hospital. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that written notice of reason for transfer to the hospital was provided to the resident or representative. 3. Resident #203 was admitted with [DIAGNOSES REDACTED]. The 6/21/24 Modification of Admission Minimum Data Set, an assessment tool, documented moderately impaired cognition and required staff assistance with activities of daily living. The facility Accident Report/Investigation Report dated 6/28/24 documented Resident #203 was transferred to the hospital for evaluation. The 6/28/24 Minimum Data Set Discharge/Return Anticipated assessment documented Resident #202 was discharged to the hospital. There was no documented evidence the resident and/or resident's representative was notified in writing of the transfer to the hospital. On 03/11/25 at 12:04 PM during an interview, the Director of Social Work stated they could not provide documented evidence that written notice of reason for transfer to the hospital was provided to the resident or representative. 10NYCRR 415. 3 (i)(1)(ii)(a)(b) | Plan of Correction: ApprovedApril 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice Review of identified residents revealed that Residents #50, 69, 68 experienced transfers to the hospital and all were readmitted to the facility after completion of acute hospital stay and are current residents. Resident # 202 was transferred to the hospital for acute needs and expired in the hospital. Resident #203 was scheduled for discharge to ALF prior to hospital admission and was directly discharged to ALF from acute care hospital. Education provided to social workers on the requirement for notice of transfer/discharge to accompany all residents transferred/discharged from the facility Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All residents who were transferred/discharged had the potential to be affected, however no residents were negatively impacted An audit of past 30 days of discharges was conducted to ensure Notice of Transfer/Discharge was provided and to ensure the resident or the resident's representative were notified in writing of the reason for transfer/discharge to the hospital in a language they understood and to notify the Ombudsman for discharge or transfer and hospitalization s. Negative findings will be immediately corrected Element #3: The following system changes will be implemented to prevent reoccurrence The facility policy and procedure on ?ôDischarge Notice?Ø was reviewed and found to be appropriate Social Work staff, medical records and licensed nursing staff will be reeducated on the facility policy and requirement for discharge/transfer notification for all residents and a record of education will be maintained for reference and validation Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Social Work has created an audit tool to ensure that Notice of Transfer/Discharge documentation is accurately completed for all planned and unplanned discharges and validate that all required documentation is uploaded to the facility eMAR system The Director of Social Work/designee will audit, and Audits will continue until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected immediately and reported to the administrator Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance Element #5: The person responsible for the corrective action is the Director of Social Work/designee. Date of Compliance is [DATE] |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REVISED 6/10/2025 IIDR Based on observation, record review, and interview conducted during the recertification survey from 3/5/2025 through 3/12/2025, the facility did not ensure residents received quality of care in accordance with professional standards of practice for one (1) of four (4) residents reviewed for accidents. Specifically, on 12/12/24, Resident #69 was observed ambulating to the bathroom in their room unassisted, as Certified Nurse Aide # 8 assisted the resident their legs became weak, and the resident was lowered to the floor. Certified Nurse Aide #8 left Resident #69 to seek help, upon return Resident #69 was found in a different position, complained of pain to the right side of lower back, and sustained a hematoma (bruise) to the face. Resident #69 was transferred from the floor to the wheelchair and then to the bed by Licensed Practical Nurse #10 and two Certified Nurse Aides (#8 and one unidentified) without being physically assessed by Registered Nurse or Medical Provider. There was no documented evidence of an assessment by a qualified professional (Physician or Registered Nurse) from the time of the fall on 12/12/2024 at 4:00 AM until the resident was transferred to the hospital on [DATE] at 8:32 AM. An X-ray was completed on 12/12/2024 at 6:30 PM which revealed an acute [MEDICAL CONDITION] femur (area in the upper thigh). The hospital discharge summary dated 12/19/2024 documented the resident underwent [REDACTED]. 2024. This resulted in actual harm to Resident #69 that was not immediate jeopardy. Findings include: The facility's policy titled Accident/Incident Investigation and Prevention revised 6/2023, documented the facility will provide an environment that is free from accident hazards over which the facility provides supervision and assistive devices to each resident to prevent avoidable accidents. All residents who have an accident/injury will be assessed by a Registered Nurse. Resident #69 was admitted to the facility with [DIAGNOSES REDACTED]. The 11/05/2024 Quarterly Minimum Data Set (resident assessment) documented the resident had moderately impaired cognition and required maximal assistance with lying to sitting in bed, was dependent with transfers, and was non-ambulatory. The Care Plan for Falls dated 11/18/2024, documented interventions included to monitor for orthostatic [MEDICAL CONDITION] (low blood pressure with positional changes), supervised area when out of bed, remind resident to call for assistance, and to prevent self-ambulation remove wheelchair from bedside while in bed. The Certified Nurse Aide Care Instructions for Resident #69 on 12/12/2024, documented Resident #69 required maximum assist of two (2) people with transfers and toilet transfers, and dependent assist of two (2) people with toileting task, non-ambulatory in corridor and in room. The facility's Witnessed Fall Incident Report dated 12/12/2024, completed by Licensed Practical Nurse Unit Manager #12 (who was not present at the time of fall) documented a fall at 4:00 AM. Certified Nurse Aide #8 called Licensed Practical Nurse #10 into the room. The resident was observed sitting on the bathroom floor in front of the sink, feet were straight out in front of the resident with their back against the wall. The resident had shoes on and was able to move all extremities. The resident had a hematoma to the face. The resident was oriented to person only, not situation, time or place. Neurological checks were not initiated. The resident complained of pain to the right side of lower back. Certified Nurse Aide #8 stated that they found the resident ambulating to the bathroom when they were doing rounds and went to assist the resident to the bathroom. The Certified Nurse Aide stated the resident became unsteady on their feet and the Certified Nurse Aide lowered the resident to the floor. The Primary Care Physician was made aware at 4:30 AM, and orders were received for [MEDICATION NAME] (for pain) as needed, and x-ray of the lumbar spine and right hip. Certified Nurse Aide #8's written statement dated 12/12/2024 documented the resident was last toileted at 3:30 AM, they observed the resident ambulating to the bathroom and assisted the resident to slide to the floor in the bathroom. The resident had complaints of pain, and they went to get help. The resident was safely seated on the floor, leaning against the wall when they left the room to get the nurse. When they returned, the resident was lying under the sink. They documented that the nurse and another unidentified Certified Nurse Aide assisted in lifting the resident from the floor to the bed. Licensed Practical Nurse #10's written statement dated 12/12/2024 documented that Certified Nurse Aide #8 called them to Resident's #69 room, where they observed the resident in the bathroom with their back against the wall near the sink and their feet straight out in front of them. Licensed Practical Nurse #10 documented they asked the resident if they would like to go to the hospital and resident refused. The resident was transferred to the wheelchair with a two (2) person assist and then to the bed. Licensed Practical Nurse #10's progress note dated 12/12/2024 at 6:45 AM documented at approximately 4:00 AM Certified Nurse Aide #8 called them to the resident's room. Resident #69 was observed sitting on the bathroom floor in front of the sink. Their feet were straight out in front of them with their back against the wall. They had shoes on and were able to move all extremities. They complained of pain to the right side of their lower back. Certified Nurse Aide #8 reported that they found the resident ambulating to the bathroom while doing rounds and assisted the resident the rest of the way to the bathroom. The resident became unsteady on their feet and the aide lowered them to the floor. The primary physician was called and ordered to give [MEDICATION NAME] and get an X-ray. Order for x-ray of the lumbar spine and right hip placed. The resident representative was called, and message left. The 12/12/2024 at 10:59 AM Physical Therapy note documented the resident presented with hip and facial bruising and was going to have an x-ray to check for fractures. Licensed Practical Nurse Manager #12's note dated 12/12/2024 at 1:56 PM documented the resident had a hematoma on the lower left eyebrow, purpura/bruise like area on their right mid-back and complained of a lot of discomfort in their right groin and upper thigh area which was swollen. They encouraged the resident to go to the hospital to make sure the hip or pelvis was not broken but the resident declined and would wait for the portable x-ray. Licensed Practical Nurse Unit Manager #12's progress note dated 12/12/2024 at 2:21 PM documented Primary Physician #1 examined Resident #69, and the resident refused to go to the hospital. The resident was informed by the physician if the x-ray results showed a [MEDICAL CONDITION], the resident would have to go to the hospital; the resident agreed to this. There was no documented evidence Primary Physician #1 completed a medical evaluation of Resident #69 on 12/12/ 2024. Licensed Practical Nurse #21's progress note dated 12/13/2024 at 12:21 AM documented an X-ray was done at 6:30 PM (12/12/2024) and the results were pending. The x-ray report signed on 12/13/2024 at 7:44 AM, documented the resident had a [MEDICAL CONDITION] femur (thigh bone). Licensed Practical Nurse Manager #12's progress note dated 12/13/2024 at 8:32 AM documented the Primary Physician was made aware of the x-ray results and ordered to send the resident to the hospital. Licensed Practical Nurse Unit Manager #12's progress note dated 12/13/2024 at 8:52 AM, documented the resident left the facility by ambulance. The hospital discharge summary dated 12/19/2024 documented the resident underwent [REDACTED]. 2024. During a telephone interview on 3/11/2025 at 6:0 | Plan of Correction: ApprovedJune 11, 2025 THIS IS A DIRECTED PLAN OF CORRECTION Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice As part of the DP(NAME); Taconic Rehabilitation and Nursing at Ulster has requested the services of Elizabeth Lange, RN Nurse consultant, employed by RCA HealthCare Management on 3/28/ 25. A directed plan of correction has been developed for Taconic Rehabilitation and Nursing at Ulster by Elizabeth Lange, RN and the Taconic Rehabilitation and Nursing at Ulster facility QA team Resident #69 had a witnessed fall on 12/12/ 24. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. Licensed Practical Nurse #10 was educated on the facility policy that requires an RN to be called when a resident has fallen Element #2: The following actions will be implemented to identify other residents who have the potential to impacted by the deficient practice All residents had the potential to be affected by the deficient practice however no other residents have been identified as having been negatively impacted An Audit was completed by the DON for all residents who had a fall in the past 30 days to verify that an assessment by a qualified professional was completed. No further issues were identified. Elizabeth Lange, RN attended the Taconic Rehabilitation and Nursing at Ulsters QAPI meeting on 3/28/25 to review the deficiency details cited under: Fed - F - 0684 - 483. 25 - Quality Of Care S-S= G listed in the statement of deficiencies. During the facilitys QAPI meeting on 3/28/25, to examine the causative factors of the deficient practice, it was identified that the facility staff did not follow protocol with alerting the nursing supervisor when a resident is found on the floor to complete an assessment of the resident by a qualified professional. The intervention that was put into place to correct the deficient practice were the facility staff will alert the Nursing supervisor when a resident is found on the floor and leave the resident in place until they are assessed by a qualified professional such as a Registered Nurse or Physician. The Nurses were educated on the deficient practice that occurred on 12/12/ 2024. To prevent this deficient practice the Nurses will then be educated on the process that will occur when a resident is found on the floor or has fallen. Element #3: The following system changes will be implemented to prevent reoccurrence Directed In-services will be completed by Elizabeth Lange RN from RCA HealthCare Management on (MONTH) 4, 2025, at 7:00 am and 3:00 pm and (MONTH) 7, 2025 at 7:00 am and 3:00 pm via Zoom conference to all licensed nurses at Taconic Rehabilitation and Nursing at Ulster to discuss the policy and education as it relates to quality of care and the standard of professional practice related to falls. In-services will continue until all licensed nurses have attended The directed in-service course outline includes: 1. The definition of F684-Quality Care 2. General Professional Standards of Practice 3. Expected Professional Standards of practice after a fall which includes a resident assessment by an RN or physician 4. Specific details of the deficient practice cited in the SOD 5. Specific details of the P(NAME) 6. The facility protocol for staff when a resident has had a fall 7. The assessment process: what an assessment entails, including ROM to all joints and full body check 8. How to respond when a resident is non-compliant Weekly Audits will then be completed by the DON/designee to evaluate the effectiveness of the education program to ensure that all residents who were observed on the floor/fallen have an assessment completed by a qualified professional. Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The DON/Designee will complete weekly audits to ensure that all residents who were observed on the floor/fallen have an assessment completed by a qualified professional to evaluate the effectiveness of the education program and to measure whether the efforts are successful or unsuccessful in maintaining compliance Any negative findings from the audits will result in immediate education and correction Audits will continue until 100% compliance is attained for 12 consecutive weeks Audits will be reviewed by DP(NAME) RN consultant and QAPI committee monthly and the QAPI committee will determine ongoing audit frequency after 12 weeks of compliance Element #5: The person responsible for the corrective action is the DON/Designee in conjunction with the DP(NAME) consultant. Date of compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 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 3/5/25-3/12/25, the facility did not ensure that they were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for Resident #30 reviewed for Call Systems/Environment. Specifically, the call system unit at the bedside for Resident #30 was not accessible. Findings include: The facility's policy titled Call Light revised 10/24/22 documented all residents will be provided with a method to communicate requests and needs directly to a staff or a centralized work area from the bedside, bathroom, and bathing areas, and to always place the call light within the resident's reach. The facility policy titled Fall Prevention revised (MONTH) 2023 documented that all reasonable steps will be taken to keep the residents safe from falls and related injuries. Resident #30 was admitted with [DIAGNOSES REDACTED]. The 12/9/24 Minimum Data Set admission assessment documented the resident had intact cognition and required supervision with toileting hygiene, sit to stand and chair to bed and toilet transfers. Resident #30 had a fall in the past month, prior to admission, and a fracture related to a fall in the past 6 months prior to admission. The 3/4/25 Quarterly Minimum Data Set (resident assessment) documented Resident #30 had moderately impaired cognition and required supervision with toileting hygiene and sit to stand and chair to bed transfers and toilet transfers. The Nursing Falls Risk Data Collection Tools dated 12/3/24, 12/31/24, 1/26/25, 1/27/25, 1/30/25, 2/19/25 and the Falls Risk Tool dated 2/22/25 documented the resident was at risk for falls. The 3/5/25 Care Plan for Activities of Daily Living documented Resident #30 required supervision with toileting and transfers and ambulation with rolling walker. The 3/5/25 Care Plan for Falls documented Resident #30 was at risk for falls related to prior fall in the last 90 days prior to admission. Interventions included to remind to call for assistance. The Kardex documented ambulation in room with supervision, fall injury alert-anticoagulant therapy use, remind to call for assistance. On 03/05/25 at 01:02 PM, Resident #30 was observed in their wheelchair in their room. The call bell was observed out of the resident's reach and out of the resident's sight, lying on the stationary chair behind the resident in the corner of the room. When asked, how do you call for help, Resident #30 stated lately it has been difficult because I don't have a call bell. Resident #30 stated they have to yell for the nurse if they need something. Resident #30 additionally stated they take themself to the toilet by wheeling themself into the bathroom, hold onto the grab bar, and transfer themself. On 03/05/25 at 01:25 PM, Resident #30 was observed sitting in their wheelchair, the call bell was still located out of the resident's reach and out of the resident's sight, on the stationary chair in the corner of the room. On 03/05/25 at 01:54 PM Resident #30 was observed lying in bed awake. The call bell was observed on the stationary chair in the corner of the room. When asked, Resident #30 stated they did not know where their call bell was. Resident #30 looked around their room and stated they did not see the call bell. The surveyor gave the resident their call bell. On 03/06/25 at 08:55 AM Resident #30 was not observed in their room. The call bell was observed on the stationary chair in the corner of the room. On 03/06/25 at 10:55 AM and at 11:55 AM, Resident #30 was observed sleeping in bed, the call bell was observed on a stationary chair in the corner of the room, out of the resident's reach and out of the resident's sight. On 03/06/25 at 12:22 PM, Resident #30 was observed sitting in their wheelchair in their room eating lunch. The call bell was observed out of sight and out of reach of the resident, lying on the stationary chair in the corner of the room. On 03/07/25 at 12:30 PM during an interview, Licensed Practical Nurse Unit Manager #4 stated that all residents should have their call bell in reach at all times. They stated they are aware that Resident #30 had a fall prior to admission and is confused. On 03/07/25 at 01:24 PM during an interview with the Director of Nursing, they stated the Certified Nurse Aides and any other staff should place all resident's call bells within resident's reach. 10NYCRR 415. 29 | Plan of Correction: ApprovedApril 4, 2025 Resident #30 was immediately provided with her call bell, and the call bell has been kept within reach. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. All residents had the potential to be affected by the deficient practice. Unit Managers completed a Full house audit of residents to assure call bells are within reach. No further call bells not within reach were found. The Staff educator/Designee provided reeducation for all staff to place call bell within reach for all residents, while in bedroom. Weekly call bell placement audits will be conducted by Unit Manager/ designee and reported to DON. All issues will be corrected immediately. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON, will review audits. For compliance, any negative findings will result in immediate education. The audit's results will be reported to QAPI monthly meetings. Then quarterly, the frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey from 3/5/2025 to 3/12/2025, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was evident for 1 of 1 residents (Resident #65) reviewed for Dignity. Specifically, Resident # 65 was observed ambulating wearing socks that were labeled with the resident's name on the top of the foot clearly visible to other residents, visitors and staff. The findings are: Resident #65 with [DIAGNOSES REDACTED]. The Facility Policy titled Dignity, Respect, and Privacy in Treatment and Care revised 10/2023 documented that the Resident is treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his personal needs. The Annual Minimum (MDS) data set [DATE] documented Resident #65 had severely impaired decision making, memory problem, and required maximal assistance for dressing and footwear. The Care Plan titled Dressing, revised 1/1/2025, documented Resident #65 required maximal assist of 1 staff for dressing. During observations on 03/05/25 at 10:04 AM, 03/06/25 at 11:13 AM, and 03/07/25 at 08:56 AM, Resident #65 was observed ambulating independently in the hallway, wearing socks labeled with their name clearly visible to other residents, staff, and visitors on the top of their foot. During an interview on 03/10/25 at 2:42 PM, Licensed Practical Nurse Unit Manager #14 stated the labels on clothing were so items returned from the laundry went to the appropriate resident. They were not aware that labels on clothing with the resident's name should not be visible to others. During an interview on 03/10/25 at 2:53 PM, the Social Worker stated they did not feel it was a problem having the name label visible to others on items of clothing. During an interview on 03/10/25 at 3:25 PM, the Director of Nursing stated clothing labels should not be in a location visible to others, and it was a dignity issue. They contacted the unit and requested that Resident #65's socks be collected and relabeled so that the name label was not visible to others. 10 NYCRR 415. 5(a) | Plan of Correction: ApprovedApril 4, 2025 Resident #65s socks were immediately removed. Residents #65 was monitored for 5 consecutive days for any emotional distress with no issues noted. The residents care plan was reviewed and is in concert with the residents current needs and a medical record review completed with no abnormal findings. LPN #14, and Social worker reeducated by ADON/ Designee on resident dignity and Privacy as well as policy and procedure for clothing labeling. All residents to have clothing labeled in anon visible area. Both the LPN and Social worker state their understanding. All residents who have clothing labeled had the potential to be affected by the deficient practice. A full audit of each units resident clothing was conducted by unit managers/designee to identify other potential residents affected by deficient practices. Any instances where clothing labels were found to be visible were rectified immediately. The Staff Educator/designee will conduct educational sessions to all nursing and laundry staff on resident dignity and the use of clothing labels, and policy and procedure for labeling clothing for residents, to ensure all residents are treated in a dignified manner keeping labels private. Weekly audits will be completed by unit manager/ designee to assure residents rights are observed and policy and procedure is adhered to No names labels being visible. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ ADON, will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey and abbreviated surveys (NY 643) from 3/5/25-3/12/25, the facility did not ensure residents at risk for pressure ulcers and residents who had pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for 2 of 4 residents (Residents #68 and #352) reviewed for Pressure Ulcers. Specifically, 1) Resident #68's feet were not floated in bed as ordered and there was no documented evidence that wound care treatments were administered 10 of 48 times in (MONTH) and 4 of 18 times in March, and 2) for Resident #352, there was no documented evidence that wound care treatments were administered five (5) times in (MONTH) and (MONTH) 2024 for their Stage 3 pressure ulcers to their coccyx, and left lateral ankle, and Stage 4 pressure ulcer to their left dorsal foot. The findings are: The 6/23 facility policy titled Documentation of Pressure Ulcer and Chronic Wounds documented pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors, all pressure ulcers and chronic wound dressings will be inspected daily, pressure, stasis, and or chronic wounds will be monitored daily with documentation. 1) Resident #68 had [DIAGNOSES REDACTED]. The 11/20/24 Quarterly Minimum Data Set Medicare 5-day assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed and had two unstageable pressure ulcers present on admission. The 11/13/24 Hospital Nursing Wound Summary documented follow-up evaluation for two left lateral heel deep tissue injuries approximately 0. 5-centimeter X 1. 5 centimeter deep, maroon in color, diffuse wound edges, bilateral heels red and slow to blanch. Area cleaned, skin prep applied, and area offloaded with pillow. Dayshift nurse informed. General Care Instructions to continue implementation of the pressure injury prevention bundle. Mattress type recommended-pressure redistribution bed/mattress, schedule regular repositioning and turning. The 11/15/24 Skin Integrity at Risk Care Plan documented intervention to float Resident #68's heels in bed. The 1/15/25 Skin Risk Data Collection Tool documented an unstageable pressure injury to the bottom of right foot. It was not open and there was no drainage. Care Planning interventions included to float heels when in bed. The 2/4/25 Skin Integrity at Risk Care Plan documented intervention to float heels in bed. The 2/12/25 physician's orders [REDACTED]. The 2/15/25 Quarterly Minimum Data Set assessment documented intact cognition. Resident #68 required maximum assistance with rolling in bed, and one Stage 2 pressure ulcer present on admission. The Kardex (Certified Nurse Aide instructions) documented to float Resident #68's heels in bed. The (MONTH) 2025 Treatment Administration Record documented no evidence that skin prep was administered as ordered 10 of 48 times (2/14, 2/18, 2/24, and 2/25 on the evening shift, 2/15 and 2/23 on the day shift, and 2/16, 2/21, 2/22, and 2/24 on the night shift). The (MONTH) 2025 Treatment Administration Record documented no evidence that skin prep was administered 4 of 18 times between 3/1/25 and 3/6/25 (3/2 on the evening shift, 3/3 on the day shift, and 3/2 and 3/6 on the night shift). On 3/05/25 at 10:37 AM, Resident #68 was observed sitting in their wheelchair wearing sneakers, with their right foot on the floor, although their wheelchair footrest was in place. Resident #68 stated their right heel was bruised and it felt better when they were wearing sneaker because the sneaker had padding. They stated their heel hurts at night when they move their foot. Resident #68 stated that nobody offered padded booties in bed. On 3/06/25 at 9:06 AM, Resident #68 was observed in bed with their heels directly on the mattress, and no heel booties or pillow was observed to float their heels, and there was no air mattress in place. On 3/07/25 at 10:45 AM, Resident #68 was observed lying in bed with their heels directly on the mattress, no air mattress was in place, no heel booties or pillow were observed to float their heels. On 3/07/25 at 10:47 AM during an interview, Certified Nurse Aide #3 stated they were responsible for Resident #68 and did not know much about Resident #68's left foot. They stated they did not get report about any specifics on Resident #68's positioning or floating their heels. Certified Nurse Aide #3 stated they looked at the Kardex before providing cares to Resident #68, and did not notice anything about positioning or floating their heels. When they reviewed the Kardex during the interview, they stated they should have put a pillow under Resident #68's calves. On 3/07/25 at 10:54 AM during an interview, Licensed Practical Nurse #2 stated they were responsible for Resident # 68. They stated they were aware of the order to apply skin prep to Resident #68's bilateral heels and Resident #68's heels should be floated in bed. On 3/07/25 at 11:15 AM during an interview, the Assistant Director of Nursing stated they did weekly wound care rounds with the wound care physician. The Assistant Director of Nursing reviewed the resident's care plan and stated the Certified Nurse Aide should have checked the Kardex and floated Resident #68's heels. On 3/07/25 at 11:08 AM during an interview, Licensed Practical Nurse #1 stated they were responsible to apply the Skin Prep to Resident #68's heels on 2/15/ 25. They stated they believed they applied the treatment but forgot to sign and should have signed. On 03/07/25 at 1:27 PM during an interview with the Director of Nursing regarding administration omissions, they stated the nurses were responsible for administering treatments as ordered by the provider and for signing the administration records after completion. 2. Resident #352 had [DIAGNOSES REDACTED]. The Care Plan titled At Risk for Impaired Skin Integrity dated 2/14/24 documented the resident was at risk for impaired skin related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included to apply moisture barrier following incontinence care and as needed, turn and reposition every 2 hours and as needed, and skin and feet check with daily care, document weekly on shower day. The Admission 5 Day Minimum (MDS) data set [DATE] documented intact cognition, maximum assistance with most activities of daily living, at risk for pressure ulcers, and no ulcers present. The Medical Provider Note dated 4/14/24 documented a new Stage 1 to the coccyx. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Wound Care Note dated 4/23/24 documented: - a coccyx Stage 3 pressure injury measuring 4. 5-centimeter x 3. 5 centimeter x 0. 1 centimeter, - a deep tissue injury to the right heel measuring 0. 5-centimeter x 2. 0 centimeter x unable to measure depth, - a deep tissue injury left lateral foot measuring 0. 5 centimeter x 1. 0 centimeter x unable to measure depth, - a deep tissue injury left lateral ankle measuring 5. 6 centimeter x 1. 4 centimeter x unable to measure depth. The physician's orders [REDACTED]. To cleanse the wound at coccyx with wound cleanser and pat dry, apply a thin layer of Santyl and cover with dry protective dressing. The Care Plan titled Impaired Skin Integrity revised 4/26/24 documented resident with impaired skin integrity related to dehydration, impaired mobility, poor nutrition, pressure ulcer. Interventions included administer treatment per physician's orders [REDACTED]. The Significant Change in | Plan of Correction: ApprovedApril 11, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice Resident #68s heels were immediately floated and the attending physician was notified of the missed treatments. The residents care plan and treatment protocol was reviewed and revised to reflect the use of an air mattress. Resident #68 was monitored for 5 consecutive days with no issues noted. A medical record review was completed and no abnormal findings were identified Resident #352 was discharged from the facility on 7/2/ 2024. A medical record review was completed with no additional abnormal findings Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All Residents at risk for skin breakdown as per facility skin risk assessment, have the potential to be affected. All residents identified as being at risk based on documented skin assessment were reviewed with no issues noted and Care plan is in concert with the resident needs. No deficient practice noted. ADON/designee completed an audit of all resident with skin breakdown to ensure all devise and treatments are in place and are being signed for by the licensed nurses Element #3: The following system changes will be implemented to prevent reoccurrence The facility policy and procedure titled ?ôDocumentation of Pressure Ulcer and Chronic Wounds?Ø was reviewed and found to be appropriate The staff educator/designee will provide education to all licensed nurses on documentation of pressure ulcers and chronic wounds policy ; including closely monitoring the effectiveness of treatments, daily documentation of treatments provided, as well as documenting and explanation when a treatment is not completed. Additionally, education will be providing to all licensed nurses on updating the resident(s) careplan to accurately reflect interventions in place; such as floating heels, use of air mattress Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Nursing has created an audit tool to ensure that all residents with pressure ulcers/chronic wounds have proper treatment orders in place that are signed for by licensed nurses and that proper interventions are in place Unit managers/designee will audit once a week until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected and reported to the Director of Nursing Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after 4 weeks of 100% compliance Element #5: The person responsible for the corrective actions is the Director of Nursing/designee. Date of compliance is 4/18/25 |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 13, 2025
Corrected date: N/A
Citation Details Based on documentation review and staff interview, the facility did not ensure that the emergency preparedness facility- based, community based drills were in compliance with the requirements set forth in 483. 73(d). Specifically, a facility- based or a community based drill was not provided. The findings are: On 3/13/25, documentation review of the facility based, or community based drills and tabletop drills were reviewed on at PM and it was noted that table top drills were conducted on 4/23/24 and 8/28/ 24. However, a required facility based, or community based drill was missing and not provided at time of survey. In an interview with the Director of Maintenance on 3/13/25, the Director of Maintenance confirmed that a facility based or community based drill was not conducted. 483. 73 (d)(2) | Plan of Correction: ApprovedMarch 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice A facility based or community based drill will be scheduled and completed by 4/18/2025 Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All residents have the potential to be affected, however no residents were negatively impacted Element #3: The following system changes will be implemented to prevent reoccurrence Maintenance staff and department heads will be in-serviced by the administrator on the requirements for LTC facilities to conduct exercises at least twice per year including unannounced staff drills and participation in an annual full-scale exercise that is either community based, or a facility based functional exercise. Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Administrator has created an audit tool to track dates of disaster drills, type of disaster drill completed to ensure continued compliance The Director of Maintenance/designee will audit 1 x week for 4 weeks then monthly thereafter for 3 months. Negative findings will immediately be reported to the administrator Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 13, 2025
Corrected date: N/A
Citation Details 2010 NFPA 72: 72 National Fire Alarm and Signaling Code 14. 2. 5. 5 Testing shall include verification that the releasing circuits and components energized or actuated by the fire alarm system are electrically monitored for integrity and operates intended on alarm. 14. 4. 5* Testing Frequencies Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14. 4. 5, or more often if required by the authority having jurisdiction. 14. 6. 3. 2 Upon request, a hard copy record shall be provided to the authority having jurisdiction. Based on observation, record review and staff interview, the facility did not ensure that all devices associated with the fire alarm system were maintained and tested annually in accordance with NFPA 101 and NFPA 72. Specifically, documentation that the hold open devices and the magnetic egress locks were tested annually was not provided at time of survey. The findings are: During the life safety recertification survey on 3/12/25 at approximately 9:55 AM, documentation review of the facility's maintenance logs was conducted, and it was revealed that the fire alarm system was last serviced by the vendor on 7/24/2024 and 1/21/25 and 2/4/25 and the service reports did not include the testing of the magnetic fire / smoke barrier doors hold open devices and the magnetic delayed egress locks. In an interview with the Director of Maintenance the same day, the Director of Maintenance stated that the vendor will be contacted. 2012 NFPA 101: 19. 3. 4. 1, 9. 6. 1. 3, 9. 6. 1. 4 2010 NFPA 72: 14. 4. 5, 14. 6. 3. 2 10 NYCRR 415. 29 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice Facility contracted fire alarm vendor was contacted via telephone on 3/14/25 and informed that hold open devices and magnetic egress locks are required to be tested annually as per NFPA 101 and NFPA 72 and such testing was not included as part of the vendor conducted inspections Facility contracted fire alarm vendor was asked to complete a full house test of all hold open devices and magnetic egress locks Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All residents have the potential to be affected, however no residents were negatively impacted Element #3: The following system changes will be implemented to prevent reoccurrence The facility policy and procedure on Fire Alarm System Testing and Inspection was reviewed and revised to include testing of all hold open devices, magnetic fire/smoke barrier doors and magnetic delayed egress locks Maintenance staff will be re-educated on the fire alarm system testing requirements by the administrator and a record of education will be maintained for reference and validation Facility contracted fire alarm vendor will include in all inspection reports the location and inspection of all doors with magnetic egress locks and hold open devices that are released upon fire alarm activation Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Maintenance has created an audit tool to ensure that fire alarm system testing, and inspection documentation is completed and validate that all required doors/magnetic devices are included in the documentation maintained on file The Director of Maintenance/designee will audit monthly x 3 months. Negative findings will be immediately reported to the administrator Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 13, 2025
Corrected date: N/A
Citation Details 2010 NFPA 80 Standard for Fire Doors and Other Opening Protective's Chapter 19 Installation, Testing and Maintenance of Fire Dampers 19. 4* Periodic Testing and Testing. 19. 4. 9. 1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Based on documentation review and staff interview, the facility did not ensure that the heating, ventilation, and air conditioning (HVAC) system was maintained in accordance with NFPA 80. Specifically, a follow up report for deficiencies noted was missing and not provided at time of survey. The findings are: Documentation review of the facility's damper log was conducted on 3/12/25 at 11:05 AM during the life safety recertification survey. The facility's fire damper log revealed that the fire dampers were inspected and tested by a vendor and deficiencies were noted. However, a follow up report of repairs was missing and not provided at time of survey. In an interview with the Director of Maintenance on 3/13/21, the Director of Maintenance stated that repairs were not done and the vendor will be contacted. 2012 NFPA 101: 19. 5. 2. 1, 9. 2 2010 NFPA 80: 19. 4, 19. 4. 9. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice Facility fire damper inspection vendor was contacted on 3/24/25 and was contracted to complete a full house fire damper inspection Fire Damper vendor will provide a written report of any deficient areas, schedule any required repairs identified in the report and provide documentation of such after the completion of repairs Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All residents have the potential to be affected, however no residents were negatively impacted Element #3: The following system changes will be implemented to prevent reoccurrence Maintenance staff will be re-educated by the administrator on the testing and maintenance requirements for fire dampers, including ensuring necessary repairs are completed and documentation of repairs are retained. A record of education will be maintained for reference and validation Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Maintenance has created an audit tool to ensure that fire damper testing, inspection and repair documentation is completed every 4 years as required by 2010 NFPA 80 The Director of Maintenance/designee will conduct an initial audit of fire damper inspection(s) and immediately report any negative findings to the administrator Results of additional inspections or repairs will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency for continued compliance Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 13, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 13, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the linen and trash chutes were maintained in accordance with NFPA 82. Specifically, the self -closing device on the intake door to the linen did not latch when self - closed. This was noted on 1 of 3 resident floors. The findings include: During the Life Safety recertification survey conducted on 3/12/25 at approximately 2:50 PM a tour of the linen chute room on the first floor revealed, that the intake door to the linen chute did not latch when self - closed. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the latching device will be repaired. 2012 NFPA 101: 19. 5. 4. 1; 9. 5. 2, 8. 4 2009 NFPA 82: 5. 2. 3. 3. 1. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMay 2, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice The latches and pistons were replaced on all three laundry chute doors on 3/25/25 by the maintenance director A full house audit of laundry chutes will be completed and any negative findings will be immediately corrected Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice All residents have the potential to be affected, however no residents were negatively impacted Element #3: The following system changes will be implemented to prevent reoccurrence Maintenance staff will be re-educated on the maintenance requirements for rubbish chutes, incinerators, and laundry chutes NFPA 101 to meet code requirements. A record of education will be maintained for reference and validation All staff that routinely use the laundry chutes (nursing, dietary, maintenance, housekeeping) will be educated on the requirements that the linen chute door is required to latch when self-closed and to report negative findings to maintenance director/designee immediately. A record of education will be maintained for reference and validation Element #4: The facilitys compliance with the corrective action will be monitored using the following quality assurance system The Director of Maintenance has created an audit tool to ensure that laundry chute doors are operational and that all chute doors close and latch The Director of Maintenance/designee will audit 2 x week for 4 weeks then weekly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 13, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |