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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: March 24, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey from 01/26/2025 to 01/31/2025, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1 (Resident #11) of 5 residents reviewed for Pressure Ulcers out of 38 total sampled residents. Specifically, Resident #11 was observed without a bunny boot, (a pressure-relieving device) on multiple occasions in accordance with the physician's orders [REDACTED]. A resident skin conditions are assessed upon admission, weekly, and as needed. The policy also stated that prevention and treatment include protecting skin against the effects of pressure, friction and shearing reduce pressure over body prominences, assess any appliances, casts or splints as needed to ensure proper fit and avoid increased pressure. Evaluate the basis for the refusal, identify and evaluate the potential alternatives. The policy further stated that pressure ulcer risk factors include but not limited to comorbid conditions diabetes mellitus, impaired diffuse or localized blood flow to an area [MEDICAL CONDITION], resident refusal of aspects of care and treatment. Resident #11 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 assessment dated [DATE] documented that Resident #11 was cognitively intact, required dependent assistance for lower body dressing, and was at risk for development of pressure ulcers. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Podiatrist note dated 1/29/2025 documented Resident #11 seen and history of lower extremity ulceration and pedal pulses non-palpable, sensation lost in both feet and resident is adverse to bathing and no ulcerations noted but does have [MEDICAL CONDITION]. On 01/27/2025 at 03:34 PM, 01/28/2025 at 10:03 AM, 01/29/2025 at 12:23 PM, 01/30/2025 at 11:36 AM, 01/30/2025 at 12:29 PM, 01/31/2025 at 12:29 PM, Resident #11 was observed lying in bed; there was a bunny boot on the left foot and no bunny boot on the right foot. On 01/30/25 at 12:36 PM, Certified Nursing Assistant #3 was observed in Resident #11's room looking for the missing right heel boot and it was not found. The Evaluation Note on 12/24/2024 written by Licensed Practical Nurse #2 documented during rounds, Resident #11 observed with only left bunny boot on, right bunny boot on floor. Resident #11 refused to let Licensed Practical Nurse #2 put bunny boot back on. Teaching performed on importance of bunny boot to prevent pressure injury/skin impairment and Resident #11 verbalized understanding but continue to refuse and the doctor was informed. The Nursing note dated 1/31/2025 written by Licensed Practical Nurse #3 documented during rounds Resident #11 was noted with one bunny boot missing. Searched and found one in the closet, attempted to apply but failed education provided on importance of keeping them on. The Certified Nursing Assistant Monitor for Device for (MONTH) 2025 documented, under General Devices, only bunny boots while in bed. Heel pillows/riser to float feet while in bed. There was missing documentation on 1/29/2025 for the 3 PM shift, 1/30/2025 for the 7 AM, 3 PM and 11 PM shift. There was no documentation in the Medical Record related to the general devices on 1/29/2025 at 3:00 PM and 1/30/2025 at 7:00 AM, 3:00 PM, and 11:00 PM. On 01/30/2025 at 12:33 PM, Certified Nursing Assistant #3 was interviewed and stated that they are currently assigned to care for Resident #11 who uses heel booties, but none were placed this morning, and sometimes Resident #11 refuses both booties. Certified Nursing Assistant #3 also stated that Resident #11 should be wearing both of the heel booties and maybe they refused, and so the booties were not placed on their feet. Certified Nursing Assistant #3 further stated that on 01/29/2025 Resident #11 had only one heel boot on. On 01/30/2025 at 12:36 PM, Certified Nursing Assistant #3 was observed looking around Resident #11's room and dresser drawer and they were not able to locate the missing heel boot. On 01/30/2025 at 12:40 PM, Registered Nurse #4 was observed in Resident #11 room and confirmed that Resident #11 was wearing only one heel boot on the left foot. On 01/30/2025 at 12:48 PM, Registered Nurse Manager #2 was interviewed and stated they do rounding every 1-2 hours, and they look to see if residents are wearing ordered devices. Registered Nurse Manager #2 also stated that Resident #11 is wearing only one heel boot, and they should be wearing both. Registered Nurse Manager #2 further stated that Resident #11 should have on two heel boots which are used to prevent pressure ulcers because they are always in bed. On 1/31/2025 at 01:58 PM, the Director of Nursing was interviewed and stated that assistive devices have not come up in Quality Assurance Performance Improvement meetings. The Director of Nursing also stated that the facility maintains a list of residents with assisted devices, and they do rounds. The Director of Nursing further stated that the charge nurse and Certified Nursing Assistants are responsible to make sure devices are on. 10 NYCRR 415. 12(c)(1) | Plan of Correction: ApprovedFebruary 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident #38 still resides at the facility. The resident did not have any ill effect from the quarterly care plan meeting not being conducted with Resident/Resident Representative. Resident's Plan of Care remained the same. The quarterly care plan meeting was completed with the Resident Representative via phone call. 2) How the facility identified other residents: All residents can be affected by this deficient practice. The Director of Social Services or Designee audited all resident files to assure that all residents care plan meetings have been invited with Resident/Resident Representative. The Director of Social Services or Designee audited the residents Care Plan Meeting Records. As a result of the Audit completed by Director of Social Services no other Residents were affected. 3) Measures put into place/System changes: The Care Plan Policy has been updated to ensure compliance with inviting Resident's representatives to Care Plan Meetings. In the event of Resident's Representative is unreachable via phone call, a mailing invite will be sent. The Social Services Department was re-educated by the Administrator on the process for all Social Workers to ensure Resident/Resident Representatives are invited for all care plan meetings as directed by State and CMS regulations. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring compliance of invitations to Care Plan Meetings with Resident/Resident's Representatives. Every week for a year, the Director of Social Services or Designee will audit all care plan meetings to ensure compliance. The Director of Social Services or Designee will be responsible for the implementation and monitoring of the plan. The results of these audits will be presented to the quarterly QAPI meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: March 24, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification survey from 01/26/2025 to 01/31/2025, the facility did not ensure that residents or their designated representative were afforded the opportunity to participate in their care planning process. This was evident for 1 (Resident #38) of 1 resident reviewed for Care Planning out of 38 total sampled residents. Specifically, there was no documented evidence that Resident #38 or their representative were given the opportunity to participate in the review and revision of their care plan. The findings are: The facility policy and procedure titled Comprehensive Care Plan Meeting revised 5/30/2022 stated that care plan meetings will be scheduled by the Minimum Data Set Coordinator in accordance with the Minimum Data Set schedule set for each resident. The Comprehensive meeting list will be distributed to appropriate disciplines on a weekly basis by the Social Work Department. Care plan meetings are scheduled by the Minimum Data Set department. The policy also stated that Residents/family/responsible parties will be invited to initial, annual and significant change (comprehensive) comprehensive care planning meeting by the Social Work department. Each discipline in attendance will sign a Comprehensive Care Plan Meeting attendance sheet as well as by the resident/family/responsible parties. The Social Work/Nursing representative (designee) will document their attendance in the Comprehensive care planning meeting note. Resident #38 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #38 was severely cognitively impaired and required partial/moderate to dependent assistance on staff for Activities of Daily Living. The Minimum Data Set assessment also documented that resident and family participated in assessment and goal setting. The Social Work progress note dated 07/23/2024 documented annual comprehensive care plan held, daughter invited-no answer. The Comprehensive Care Plan Booklet for Resident #38 documented comprehensive care plan meetings on 07/23/2024, 10/15/2024 and 1/7/2025 documented Resident #38 is confused. The booklet also documented that Resident Representative #3 was contact with no answer on 7/23/2024 for the annual meeting on 7/24/ 2024. There was no documentation in the booklet that Resident Representative #3 was contacted regarding care planning meetings on 10/15/2024 and 1/7/ 2025. The care planning meeting invitation letter dated 06/13/2024 addressed to Resident/Family Member/Designated Representative stated that a meeting would be held on 07/23/2024 at 11:30 AM. The letter stated that Social Work should be contacted in advance to inform whether they would be attending the meeting. No documentation was provided that Resident #38's representative was invited to attend quarterly meetings held on 10/15/2024 and 01/7/ 2025. On 1/30/2025 at 12:51 PM, Registered Nurse Unit Manager #2 was interviewed and stated Resident #38's last comprehensive care plan meeting was held on 01/07/2025 and there was no resident representative present as they live in out of state, but Social Work, Therapy and Nursing were present at the meeting. Registered Nurse Unit Manager #2 also stated that they do not recall when the meeting prior to that one was held. Registered Nurse Unit Manager #2 further stated that they usually do the meetings with family. On 1/30/2025 at 02:00 PM and 01/31/2025 at 10:46 AM, Resident Representative #1 was contacted and voice mail left. On 01/30/2025 at 02:02 PM, Resident Representative #1 was interviewed and stated that they had not been invited recently to any care planning meeting for Resident # 38. Resident Representative #1 also stated that the last care plan invitation they were aware of was in 2024 and was the one sent to Resident Representative #3, and there have been no other invitations received since then. On 01/30/2025 at 02:24 PM, the Social Worker #1 was interviewed and stated that the representative for Resident #38 is invited to care planning meetings. Social Worker #1 also stated that an invitation was sent to the representative who resides out of state for the Annual meeting which was held in (MONTH) 2024. Social Worker #1 further stated that there have been quarterly meetings since then with Social Work, Nursing, Rehabilitation, Dietitian, Recreation present, however Resident #38's representative was not invited to these meetings as representatives are only invited to Annual, Significant Change, and Admission care plan meetings. On 1/30/2025 at 02:33 PM, the Director of Social Services was interviewed and stated that residents, their representative, next of kin, or healthcare proxy are invited to initial, quarterly, Significant Change care planning meetings, and the attendance of those present is documented. The Director of Social Services also stated that Resident Representative #3 for Resident #38 attends care planning meetings and they were invited to the Significant Change, Annual and initial care planning meeting. The Director of Social Services further stated that Quarterly meetings were held for Resident #38, and they did not see Resident #38 or their designated representative at the team meeting, but Rehabilitation, Recreation and Dietary were present. On 01/31/2025 at 01:55 PM, the Director of Nursing was interviewed and stated after the last survey in 2023 care planning was identified as an issue and they had a Quality Assurance Performance Improvement for it. The Director of Nursing also stated that for the Admission, Annual, Significant Change meetings the resident and their representatives are invited, and they do not think that a quarterly meeting invitation is required. On 01/31/2025 at 01:57 PM, the Administrator was interviewed and stated that the facility is in compliance with care planning meetings and if a resident representative has a question they are welcome to speak to staff at any given point. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedMarch 4, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident #238 's Care plan was correctly updated reflecting the appropriate plan of care including Activities of Daily Living Care plan, Mobility care plan and Range of Motion care plan. 2) How the facility identified other residents: All residents can be affected by this deficient practice. The Director of Rehabilitation audited ADL care plan of all residents and no other Residents were affected. 3) Measures put into place/System changes: PT, OT, ST Supervisors and RNs/Nursing Supervisors/Unit Managers received in-service from the Director of Rehabilitation with regards to timely implementing and developing all ADL/Mobility/Range of motion care plans upon admission/readmission/start of care and the policies which includes Activities of Daily Living Care Plan, Mobility care Plan and Range of Motion Care Plan. ADL Functional Abilities Policy and Procedure was reviewed and kept the same. This includes Activities of Daily Living Care Plan, Mobility Care Plan and Range of Motion Care Plan. 4) How the corrective actions will be monitored: An audit tool by the Director of Rehabilitation was developed to monitor compliance in timely implementation of care plans. Director of Rehabilitation/Designee will audit on a weekly basis for a year to ensure compliance and timely establishing and implementing the care plans. The Director of Rehabilitation is responsible for ensuring the corrective action is implemented and is responsible for the implementation and monitoring of the plan. This audit will be submitted to Administrator and presented to the quarterly QAPI meeting. |
Scope: N/A
Severity: N/A
Citation date: January 31, 2025
Corrected date: March 24, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a complaint investigation survey NY 265, the facility did not ensure each resident was free from misappropriation of the resident's property and exploitation. This was identified for one (Resident #1) of three residents reviewed. Specifically, Resident #1's bank card was used by Licensed Practical Nurse #1 to withdraw money totaling 1,000 dollars without the resident's authorization. The findings are: The Facility Policy and Procedure titled Abuse Prohibition and Prevention: Misappropriation of Resident Property, dated 9/1/2016 and last revised on 10/24/2022, defined misappropriation of resident property as the theft, unauthorized use or removal, embezzlement, or intentional destruction of the Resident's personal property, including but not limited to money, clothing, and other possessions belong to the resident, without regard to monetary value. The Facility's Non-Fraternization Policy documented that fraternizing among the employees and resident population on Cold Spring Hills' premises or after hours cannot and will not be tolerated and will subject the employee to discipline up to and including termination. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident had a Brief Interview of Mental Status score of 13, indicating the resident had intact cognition. The Facility grievance form dated 3/27/2024 documented that Resident #1 reported to the Director of Nursing services owing 800 dollars to a staff member. The resident gave their bank card to withdraw 800 dollars, but the following day, the resident learned that Licensed Practical Nurse #1 had withdrawn an additional 200 dollars from their account. The Comprehensive Care Plan dated 2/10/2021 documented that the resident is at risk for abuse/neglect/victimization. Interventions included always maintaining a safe environment. The Social Worker's Progress Note dated 3/27/2024 documented that Resident #1 reported to the Director of Nursing Service and the Director of Social Work on 3/25/2024 that they gave their bank card to the Licensed Practical Nurse #1 asking to withdraw money from their account. The resident alleged that additional funds were withdrawn. The facility called the Nassau County Police Department, but the resident did not wish to file a formal police report. During an interview with the Social Worker on 4/9/2024 at 12:06 PM, the resident reported owing 800 dollars to Licensed Practical Nurse # 1. They stated the debt was incurred when Licensed Practical Nurse #1 bought Chinese food for the resident during the past year. The Social Worker stated they attempted to verify the withdrawal amount by asking Resident #1 to show the bank statements or to call the bank together to confirm the withdrawal. However, Resident #1 refused, citing privacy concerns. The resident expressed significant concerns for Licensed Practical Nurse #1 and did not want any harm to come to the nurse. The Social Worker further stated, when police officers arrived, the resident refused to press charges against Licensed Practical Nurse # 1. During an interview with Resident #1 on 4/9/2024 at 1:13 PM, Resident #1 stated they had been in the facility for four years; the resident had known Licensed Practical Nurse #1 for the whole time and stated, We are good friends. The resident #1 stated Licensed Practical Nurse #1 was going to buy Chinese food, so the resident they gave the bank card and the personal identification number to Licensed Practical Nurse #1 to buy them some Chinese food. Resident #1 stated Licensed Practical Nurse #1 gave back the bank card to them later that day. Resident #1 stated they will not press charges, and stated, I don't want anything to happen to (Licensed Practical Nurse #1); they have a family, and they have been looking out for me. During an interview with the Director of Nursing Services on 4/9/2024 at 2:16 PM, the Director of Nursing Services stated on 3/26/2024, Resident #1 approached the Director of Nursing Services and said they owed money to staff. The resident was hesitant to report further. On 3/27/2024, the Director of Nursing Service interviewed Resident #1 with the social worker. Resident #1 stated they owed Licensed Practical Nurse #1 800 dollars for ordering Chinese food for them during the past year. The resident stated they gave Licensed Practical Nurse #1 their bank card to withdraw 800 dollars. Later, the resident realized that the extra 200 dollars was withdrawn. When asked if the money was given to the resident, the resident refused to answer and refused to show a bank statement. During an interview with, Licensed Practical Nurse #1 on 4/10/2024 at 10:30 AM, Licensed Practical Nurse #1 stated Resident #1 asked them to withdraw 1000 dollars from the bank. However, they were only able to withdraw 200 dollars as the machine did not allow them to withdraw 1000 dollars initially. In response, Resident #1 reached out to the bank to address the issue. Eventually, Licensed Practical Nurse #1 was able to withdraw the additional 800 dollars for the resident. Licensed Practical Nurse #1 stated they used a portion of the withdrawn amount to purchase snacks for Resident #1 and returned approximately 982 dollars to Resident # 1. During an interview with the Administrator on 4/9/2024 at 2:53 and a subsequent interview on 5/16/2024 at 4 PM, the Administrator stated they met with Resident #1 on 3/26/2024 to discuss the incident; however, the resident did not want to reveal any information to the administrator. Subsequently, the facility terminated Licensed Practical Nurse #1 based on Resident#1's report that they owed 800 dollars to the nurse, with an additional unauthorized withdrawal of 200 dollars. 10NYCRR 415. 4(b) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: March 24, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification Survey from 01/26/2025 to 01/31/2025 the facility did not ensure residents' person-centered comprehensive care plans were developed and implemented to meet residents' needs. This was evident for 1 (Resident #238) out of 6 sampled residents investigated for Activities of Daily Living out of 38 sampled residents. Specifically, a care plan to address Activities of Daily Living was not developed and implemented for Resident #238 who required substantial assistance with grooming and personal care. The finding is: The facility policy titled Care Plans - Comprehensive with a revision date of 03/20/2024 stated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policy also stated that each resident's comprehensive care plan is designed to incorporate identified problem areas, reflect treatment goals, and reflect currently recognized standards of practice for problem areas and condition. Resident #238 was admitted to the facility with [DIAGNOSES REDACTED]. The most Admission Minimum Data Set Version 3. 0 (a resident assessment tool) dated 01/13/2025 documented that Resident #238 had moderately intact cognition and required staff assistance when performing grooming. On 01/27/25 at 11:47 AM, during the initial visit Resident #238 stated that they have been asking staff to help them shave their facial hair, but nothing was done about it. Resident #238 also stated that they want their hair trimmed also but the facility was not helping with their request. Resident #238 was observed with ungroomed facial hair. On 01/27/25, a review of the Comprehensive Care Plans was conducted, and there was no documented evidence that a care plan that addressed Activities of Daily Living was developed and implemented for Resident # 238. On 01/31/25 at 11:26 AM, the Registered Nurse Manager #1 was interviewed and stated that part of their responsibility is the completion of a comprehensive assessment, development of care plans and management of the clinical aspect of residents. Registered Nurse Manager #1 also stated that the admitting nurse is supposed to have created the care plans within 48 hours of admission. On 01/31/25 at 11:26 AM, Resident #238's comprehensive care plans were reviewed with Registered Nurse #1 and the Assistant Director of Nursing. A care plan for The Activities of Daily Living care was observed dated 01/28/2025 at the time of review. On 01/31/25 at 11:41 AM, an interview was conducted with the Assistant Director of Nursing who brought a printed copy of an Activities of Daily Living Care Plan to the State Surveyor with the date now changed from 01/28/2025 to 01/03/ 2025. The Assistant Director of Nursing stated that the care plan was created on 01/03/2025 but the person who created the care plan made a mistake by clicking 01/28/2025 instead of 01/03/2025, and they just corrected the date to 01/03/ 2025. On 01/31/25 at 02:15 PM, an interview was conducted with the Director of Nursing who stated the Rehabilitation Department is responsible for developing the Activities of Daily Living Care Plans. On 01/31/25 at 02:59, an interview was conducted with the Rehabilitation Director who stated that they were responsible for the development of Activities of Daily Living Care Plans. The Rehabilitation Director also stated that the Physical Therapist is responsible for creating mobility, and Range of Motion care plans, and the Occupational Therapist is responsible for creating the self-care and functional mobility care plan. The Rehabilitation Director stated that they are supposed to have created and implemented the Activities of Daily Living Care plan for nursing care but it was missed. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedFebruary 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident #6 has since returned to the facility. Resident #12 was discharged to the community with the Discharge/Transfer forms containing the Ombudsman information. Both Resident Families were notified about all the pertinent information with regards to the Ombudsman office. Written Notices for transfer and discharges for Resident # 6 and Resident # 12 were forwarded to the Office of the State Long-Term Care Ombudsman. 2) How the facility identified other residents: All residents can be affected by this deficient practice. The Director of Social Services or Designee audited the residents transferred/discharged to ensure Notice of Discharge/Transfer were issued and were communicated with the Ombudsman Office. As a result of the Audit completed by Director of Social Services no other Residents were affected. 3) Measures put into place/System changes: Transfer and Discharge Notice Policy was reviewed and kept the same. Licensed Nursing Staff and Social Services will be re-educated by Nurse Educator regarding completing the Notice of Transfer/Discharge upon Planned Discharges and upon Emergency Transfers and instructed to keep a copy for facility records. Social Services shall email a copy of the notices to the Ombudsman Office. Social Services shall mail a copy of the notices to the Resident Representative after the transfer/discharge as an additional measure. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring compliance with communication with the Ombudsman Office. The Social Service Director or Designee shall be responsible for oversight of these audits. The Social Service Director or Designee will ensure that all the steps stated in all the elements are implemented. Every week for a year, the Director of Social Services or Designee will audit all discharges/transfers to ensure compliance. The results of these audits will be presented to the quarterly QAPI meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: March 24, 2025
Citation Details Based on observation and interview it was determined that faciity did not ensure emergency lighting is provided in the dining area. This is observed on 1 out of 8 units. The Findings include but are not limited to: On 1/27/25 and 1/28/25 between the hours of 9:30 a.m and 2:30 p.m, during the life safety code survey, the following observation(s) was made: - On 1/27/25 at approximately 10:20 am, the dining room located on 7th floor, was observed to have all lighting on manual switches that can be disabled. In an interview with the Maintenance Director, at approximately 10:25 am, they stated it would be corrected. 2012 NFPA 101: 7. 8. 1. 1, 7. 8. 1. 2, 7. 8. 1. 3*, 7. 9. 1. 2, 7. 9. 2 10 NYCRR 711. 2 (a)(1) #43 being fed in a timely manner by Certified Nursing Assistants during mealtimes. On 01/31/2025 at 11:40 AM, Certified Nursing Assistant #2 was interviewed and stated that they typically work every other weekend on the day shift. Certified Nursing Assistant #2 also stated that it is typical for the 8th floor to be staffed with four Certified Nursing Assistants. Certified Nursing Assistant #2 further stated that they are sometimes staffed with 3 Certified Nursing Assistants and that when they are short staffed, it can cause delays in providing morning care, meal tray delivery, and showers. Certified Nursing Assistant #2 stated that they felt like they were able to get their work done most efficiently when the floor is staffed with 5 Certified Nursing Assistants. On 01/30/2025 at 11:17 AM, the Staffing Coordinator was interviewed and stated that they were unsure if the facility had been understaffed between (MONTH) 2024 and (MONTH) 2024. The Staffing Coordinator also stated that the facility receives anywhere from 0-5 callouts per day and that the facility attempts to replace staff members when they call out. The Staffing Coordinator further stated that the facility does not offer incentives to encourage staff to pick up short-staffed shifts. On 01/31/2025 at 11:05 AM, the Director of Nursing was interviewed and stated that they were aware that the staffing levels listed on the Facility Assessment Tool were slightly different than the staffing levels listed on the Certified Nursing Assistants Staffing Par Levels and Nurses Par Levels documents. The Director of Nursing also stated that the facility used the staffing levels listed on the Certified Nursing Assistants Staffing Par Levels and Nurses Par Levels to determine necessary staffing levels. The Director of Nursing further stated that they were aware that the facility was understaffed on the weekends during the summer and attributed it to increased callouts due to staff members going on vacation or taking time off due to the nice weather. The Director of Nursing stated that they believed the facility could improve staffing levels but that compared to other facilities, they felt like they were adequately staffed. The Director of Nursing denied receiving any complaints from residents, resident representatives, or staff members regarding staffing levels. On 01/31/2025 at 12:03 PM, the Administrator was interviewed and stated that they were aware that the facility was not reaching their targeted staffing levels over the summer which was due to scheduled staff members calling out and the facility being unable to replace them. The Administrator also stated that the facility continues to hire staff, and they think that the staffing issue has improved since (MONTH) 2024. The Administrator denied receiving any complaints from staff, residents, or resident representatives related to staffing levels. 10 NYCRR 415. 13(a)(1)(i-iii) | Plan of Correction: ApprovedMarch 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Bensonhurst Center will provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. No negative outcomes were identified for the residents noted in this citation (Resident #120, Resident #3, Resident #36, and Resident #43) as the result of this alleged deficient. All four residents continue to remain in the facility for long term care. None of them had any falls, weight loss or otherwise negative decline due to weekend staffing. 2) How the facility identified other residents: Combination of 20 Family Members/Residents were asked a 3-question survey week of (MONTH) 23rd. 14 Residents and 6 Family Members were surveyed: 1. Have you waited longer for care on weekends? 2. Have you noticed fewer staff on weekends (aside from management that don't work weekends) 3. Do you wish to file any grievance regarding care over the weekends? All responded no to these questions. Copies of these surveys are kept for verification. A review of weekends staffing over the last 2 weeks show that each day fell within the parameters of the updated Facility Assessment. A Resident Council Meeting was held on 3/4/2025 to discuss the weekend staffing. 3) Measures put into place/System changes: 1. Facility Assessment was reviewed, revised, and updated to reflect current resident population acuities and staffing pattern needs on a 7-day basis. 2. A review of master schedule was conducted and facility identified all FT/PT openings. A union required posting for open shifts was posted at facility time clock and was advertised on employment platforms. HR is actively recruiting for these open positions. 3. Two Nursing orientations were conducted since Survey exit. 4. Staffing Coordinator was educated on the appropriate staffing ranges that are required on a daily basis to ensure compliance with Facility Assessment. 5. On a weekly basis, the DON/Admin will review the weekend schedule between Thursday and Friday and devise a plan to ensure compliance with weekend staffing needs. This plan may include offering OT, mandating staff, requiring Management staff to work over weekend or other potential interventions. 6. All nursing supervisors were educated to the above plan which they are empowered to implement (offering OT, Mandating and other interventions). Furthermore, they were educated to notify DON/Admin should staffing fall below the requirements as identified in the Facility Assessment. 4) How the corrective actions will be monitored: An audit tool has been created, which will be completed weekly x8 weeks and then monthly x 6 months. This tool will be retrospective review of weekend staffing to ensure it meets facility staffing needs as indicated in facility assessment. The results of this audit will be presented at QAPI and will be the responsibility of the DON/Administrator. The DON/Administrator is responsible for this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: March 24, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews and conducted during the Recertification Survey and Complaint Survey (NY 691) from 01/26/2025 to 01/31/2025, the facility did not ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing Levels revised on 02/20/2024 stated that the facility will promote resident quality care and safety by ensuring adequate and competent staffing levels that are based on the Facility Assessment. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 to 09/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment Tool last updated 12/16/2024 documented facility capacity of 200 residents with a staffing plan by shift as follows: Day shift: 16 Licensed Nurses providing direct care and 24-31 Certified Nursing Assistants Evening shift: 11 Licensed Nurses providing direct care and 18-24 Certified Nursing Assistants Night shift: 7 Licensed Nurses providing direct care and 12-13 Certified Nursing Assistants Total staffing for 24-hour period: 34 Licensed Nurses providing direct care and 54-68 Certified Nursing Assistants The undated document titled CNAs Staffing Par Levels and Nurses Par Levels documented a staffing plan by shift and unit as follows: Day shift by units: Unit 3: 2 Nurses and 4-5 Certified Nursing Assistants Unit 4: 2 Nurses and 4-5 Certified Nursing Assistants Unit 5: 3 Nurses and 5 Certified Nursing Assistants Unit 6: 3 Nurses and 5 Certified Nursing Assistants Unit 7: 3 Nurses and 5 Certified Nursing Assistants Unit 8: 3 Nurses and 5 Certified Nursing Assistants Day shift total: 16 Nurses and 28-30 Certified Nursing Assistants Evening shift by units: Unit 3: 1 Nurse and 4 Certified Nursing Assistants Unit 4: 1 Nurse and 4 Certified Nursing Assistants Unit 5: 2 Nurses and 4 Certified Nursing Assistants Unit 6: 2 Nurses and 4 Certified Nursing Assistants Unit 7: 2 Nurses and 4 Certified Nursing Assistants Unit 8: 2 Nurses and 4 Certified Nursing Assistants Evening shift total: 10 Nurses and 24 Certified Nursing Assistants Night shift by units: Unit 3: 1 Nurse and 2 Certified Nursing Assistants Unit 4: 1 Nurse and 2 Certified Nursing Assistants Unit 5: 1 Nurse and 2 Certified Nursing Assistants Unit 6: 1 Nurse and 2 Certified Nursing Assistants Unit 7: 1 Nurse and 2 Certified Nursing Assistants Unit 8: 1 Nurse and 2 Certified Nursing Assistants Night shift total: 6 Nurses and 12 Certified Nursing Assistants Total staffing for 24-hour period: 32 Nurses and 64-66 Certified Nursing Assistants Review of the actual weekend facility staffing schedule from 07/01/2024 to 09/30/2024 documented the following: On 07/06/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 07/06/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 4th floor and 6th floor. On 07/07/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 5th floor, and 7th floor, and 2 Nurses on the 8th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 07/07/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor. On 07/13/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th floor, 6th floor, 7th floor, and 8th floor and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 07/13/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 5th floor, and 6th floor. On 07/14/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 6th Floor, 7th floor, and 8th floor, 2 Nurses on the 5th floor, and 1 Certified Nursing Assistant on the 5th floor, and 8th floor. On 07/14/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 3rd floor, 4th floor, and 5th floor. On 07/20/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th floor, 6th Floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 6th floor, and 8th floor. On 07/20/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 3rd floor, 5th floor, 6th floor, and 7th floor. On 07/21/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor, 1 Certified Nursing Assistant on the 5th floor and 6th floor, and 2 Certified Nursing Assistants on the 8th floor. On 07/21/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, and 7th floor. On 07/27/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 6th Floor, 7th floor, and 8th floor and 2 Nurses on the 5th floor and 1 Certified Nursing Assistant on the 5th floor, 6th floor, and 7th floor. On 07/27/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor. On 07/28/2024 on the 7 AM-3 PM shift, there was shortage of 1 Nurse on the 3rd floor, 4th floor, 6th Floor, 7th floor, and 8th floor, 2 Nurses on the 5th floor, and 1 Certified Nursing Assistant on the 6th floor and 8th floor. On 07/28/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 3rd floor and 4th floor. On 08/03/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th Floor, and 8th floor. On 08/03/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 6th floor, 7th floor, and 8th floor. On 08/04/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse and 1 Certified Nursing Assistant on the 5th floor, 6th Floor, 7th floor, and 8th floor. On 08/04/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 8th floor, and 1Certified Nursing Assistant on the 3rd floor, 4th floor, and 8th floor. On 08/10/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 5th floor, 6th Floor, 7th floor, and 8th floor and 1 Certified Nursing Assistant on the 5th floor, 6th Floor, 7th floor, and 8th floor. On 08/10/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 4th floor, 5th floor, and 6th floor. On 08/11/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 5th floor and 8th floor. On 08/11/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 4th floor and 5th floor. On 08/17/2024 on the 7 AM-3 PM shift, there was a shortage of: 1 Nurse on the 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 08/17/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 5th floor, 7th floor, and 8th floor. On 08/18/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th floor, 5th floor, 7th floor, and 8th floor, 2 Nurses on the 6th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 08/18/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, and 8th floor. On 08/24/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th floor and the 8th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, and 8th floor. On 08/24/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 3rd floor, 4th floor, and 6th floor. On 08/25/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 5th floor, 6th Floor, 7th floor and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 08/25/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and the 7th floor, 1 Certified Nursing Assistant on the 4th floor, 5th floor, and 6th floor. On 08/31/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th floor, 6th Floor, 7th floor, and 8th floor and 1 Certified Nursing Assistant on the 5th floor and 6th floor. On 08/31/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, and 4th floor, On 09/01/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 5th floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 6th floor, 7th floor, and 8th floor. On 09/01/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, 1 Nurse on the 6th floor, 1 Nurse on the 7th floor, and 1 Certified Nursing Assistant on the 4th floor. On 09/07/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 6th floor, and 8th floor. On 09/07/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, and 4th floor. On 09/08/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th floor, 5th floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 09/08/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 6th floor, and 1 Certified Nursing Assistant on the 4th floor. On 09/14/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 6th floor, and 8th floor, and 1 Certified Nursing Assistant on the 6th floor. On 09/14/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 1 Certified Nursing Assistant on the 3rd floor. On 09/15/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, and 8th floor. On 09/15/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 1 Certified Nursing Assistant on the 3rd floor. On 09/21/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th floor, 5th floor, 6th Floor, 7th floor, and 8th floor, 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 09/21/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, and 5th floor. On 09/22/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on all floors, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 09/22/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 6th floor, and 1 Certified Nursing Assistant on the 3rd floor and 4th floor. On 09/28/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th floor, 6th floor, and 8th floor and 1 Certified Nursing Assistant on the 5th floor, and 7th floor. On 09/28/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, and 4th floor. On 09/29/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 6th Floor, 7th floor, and 8th floor, 2 Nurses on the 5th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, and 8th floor. On 09/29/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 8th floor, and 1 Certified Nursing Assistant on the 3rd floor and 4th floor. On 01/17/2024, an anonymous complaint (NY 691) was submitted to the New York State Department of Health that alleged that the facility was understaffed on the weekends. Review of the actual weekend facility staffing schedule from 01/01/2024 to 01/31/2024 documented the following: On 01/06/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th floor, 5th Floor, 7th floor, and 8th floor, 2 Certified Nursing Assistants on the 5th floor, and 1 Certified Nursing Assistant on the 6th floor, 7th floor, and 8th floor. On 01/06/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 6th floor, and 1 Certified Nursing Assistant on the 4th floor, and 5th floor. On 01/07/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 6th Floor, 7th floor, and 8th floor, 2 Nurses on the 5th floor, and 1 Certified Nursing Assistant on the 4th floor, 5th floor, 6th floor, 7th floor, and 8th floor. On 01/07/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 6th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, and 8th floor. On 01/13/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th floor, 6th Floor, 7th floor, and 8th floor, 2 Certified Nursing Assistants on the 5th floor, and 1 Certified Nursing Assistant on the 6th floor, 7th floor, and 8th floor. On 01/13/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 5th floor, 6th floor, 7th floor, and 8th floor. On 01/14/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th floor, 6th Floor, 7th floor, and 8th floor, 2 Nurses on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 1 Certified Nursing Assistant on the 5th floor, 6th floor, 7th floor, and 8th floor. On 01/14/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 5th floor, 7th floor, and 8th floor. On 01/20/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 5th Floor, 7th floor, and 8th floor and 1 Certified Nursing Assistant on the 5th floor, 7th floor, 8th floor and 2 Certified Nursing Assistants on the 6th floor. On the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor, 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 5th floor, 7th floor, and 8th floor. On 01/21/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th floor, 6th floor, and 8th floor, 2 Nurses on the 5th floor, 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 5th floor, 7th floor, and 8th floor, and 2 Certified Nursing Assistants on the 6th floor. On 01/21/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 6th floor, and 1 Certified Nursing Assistant on the 3rd floor and the 4th floor. On 01/27/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 4th Floor, 5th floor, 6th floor, 7th floor, and 8th floor and 1 Certified Nursing Assistant on the 3rd floor, 5th floor, 6th floor, 7th floor, and 8th floor. On 01/27/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 1 Certified Nursing Assistant on the 3rd floor, 4th floor, 6th floor, and 8th floor. On 01/28/2024 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th Floor, 6th floor, 7th floor, and 8th floor, 2 Nurses on the 5th floor, 1 Certified Nursing Assistant on the 5th floor, 7th floor, and 8th floor, and 2 Certified Nursing Assistants on the 6th floor, On 01/28/2024 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor and 1 Certified Nursing Assistant on the 3rd floor, and 4th floor. Staffing levels were reviewed during the Recertification Survey conducted between 01/26/2025 and 01/31/ 2025. Review of the actual facility staffing schedule from 01/26/2025 to 01/31/2025 documented the following: On 01/26/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Nurse on the 3rd floor, 4th Floor, 5th floor, and 7th floor, and 1 Certified Nursing Assistant on the 5th floor, 6th floor, 1 7th floor, and 8th floor. On 01/27/2025 on the 7 AM-3 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 7th floor, and 1 Certified Nursing Assistant on the 8th floor. On 01/27/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Nurse on the 5th floor. On 01/28/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 4th floor, and 5th floor. On 01/30/2025 on the 3 PM-11 PM shift, there was a shortage of 1 Certified Nursing Assistant on the 4th floor, and 5th floor. Review of the actual weekend facility staffing schedule from 01/01/2024 to 01/31/2024, 07/01/2024 to 09/30/2024, and 01/26/2025 to 01/31/2025 revealed that the facility had an ongoing pattern of shortage of staff for both Nurses and Certified Nursing Assistants. Resident #120 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #120 was cognitively intact and required dependent level assistance with transfers, and substantial assistance with toileting, bathing, and dressing. On 01/26/2025 at 09:32 AM, Resident #120 was interviewed and stated that the facility is short staffed with the staffing issue being worse on the weekends. Resident #120 also stated that it takes hours to receive incontinence care due to the understaffing. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #3 was cognitively intact and required dependent level assistance with toileting and transfers. On 01/26/2025 at 09:58 AM, Resident #3 was interviewed and stated that the facility is understaffed on all shifts and that it impacts timeliness of care including receiving incontinence care, receiving assistance with getting dressed, receiving beverages, and being repositioned. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #36 was cognitively intact and required dependent level assistance for bed mobility, transfers, eating, dressing, and toileting. On 01/26/2025 at 11:02 AM, Resident #36 was interviewed and stated that the facility does not have enough staff working on the day shift. Resident #36 also stated that they only receive incontinence care one time per shift despite needing to be changed at least twice during the day shift, and that they use the call bell to request assistance, but that staff do not provide the care upon request. Resident #43 was admitted to the facility with [DIAGNOSES REDACTED]. The Comprehensive Minimum (MDS) data set [DATE] documented that Resident #43 had moderate cognitive impairment and required substantial assistance with bathing and partial assistance with toileting, dressing, and personal hygiene. On 01/26/2025 at 01:13 PM, Resident #43's representative was interviewed and stated that the facility is understaffed on the weekends, and it impacts Resident | Plan of Correction: ApprovedFebruary 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident # 11 was examined immediately. No harm was noted. Care Plan was reviewed and kept the same. Resident has a MD order for two bunny boots, reviewed and kept the same. MD orders for bunny boots reflected in Potential for Skin Breakdown Care Plan. Resident was provided with additional bunny boot for right lower extremity. Nurses on unit received one-on-one in-service for Assistive Devices placement and Pressure Ulcers Prevention. 2) How the facility identified other residents: All residents potentially can be affected by deficient practice. The Director of Nursing audited all resident with assistive devices for assistive devices placement. No other residents were affected. 3) Measures put into place/System changes: Policy of Pressure Ulcers Prevention were reviewed and kept the same. All nursing staff were re-in-serviced on proper placement of assistive devices and signing eTAR accordingly as per Assistive Devices placement and Pressure Ulcers Prevention Policy on 02/17/ 2025. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring compliance with placement of assistive devices. All nursing staff in-serviced on proper placement of assistive devices. Each shift medication nurse shall check placement and sign the eTAR. Director of Nursing is responsible to submit results of Quality Assurance Audit to Administrator on weekly basis for a year and presented to QAPI meeting for the next two quarters until compliance is achieved. The Director of Nursing is responsible for the implementation and monitoring of the plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: February 24, 2025
Citation Details Based on observations and interview it was determined that facility did not ensure oxygen tank was secured in accordance with NFPA 99. Specifically, two( 2) oxygen cylinders not restrained. This is observed on 2 out of 8 units. The Findings are: On 1/27/25 and 1/28/25 between the hours of 9:30 a.m and 2:30 p.m, during the life safety code survey, the following observation(s) made: - Two oxygen tank(s) observed not secured (restrained) from falling over on floors 3 and 5. In an interview with maintenance director on 1/28/25 at approximately 11:00 am, stated it will be secured and audit will be conducted. 2012 NFPA 101: 19. 3. 2. 4 2012 NFPA 99: 11. 3. 2. 6 10 NYCRR: 711. 2 (a) | Plan of Correction: ApprovedFebruary 7, 2025 K-0291 (E) NFPA 101- Illumination of Means of Egress This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure all egress paths are properly illuminated. 1. The facility will install emergency lighting in the 7th floor dining room to illuminate the discharge path. The room has ambient lighting, and all residents were free from hazards. 2. All remaining egress path lights have been inspected and found at least one light that is in constant power. Fixtures have been tested and are in full operation as of 2/14/ 2025. All residents are free from hazards and all systems operate as designed. 3. Education is completed with Maintenance staff to confirm proper function and maintenance of all egress path lighting by 2/14/ 2025. 4. Every quarter for a year the Maintenance Director or designee reviews random exit path lights for function. This information will then be entered on a log and will be presented to the QAPI meeting. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: February 24, 2025
Citation Details None | Plan of Correction: ApprovedFebruary 7, 2025 K-0923 (D) Oxygen Storage This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure proper oxygen storage throughout the building. 1. Oxygen cylinder storage rooms on floors 3 and 5 have all been restrained using the appropriate oxygen storage racks and chains. 2. All other oxygen storage rooms have been checked for proper storage. All residents are free from hazards and all systems operate as designed. 3. Education completed with Maintenance staff regarding monitoring oxygen storage locations. 4. Every quarter for a year the Maintenance Director or designee will check oxygen storage areas throughout the facility to ensure storage. This information will then be entered on a log and will be presented to the QAPI meeting. |