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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 a Recertification Survey from 1/02/2025 to 1/08/2025, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for 2 (Resident #36 and Resident #6) out of 23 total sampled residents. Specifically, 1) The Minimum Data Set 3. 0 assessment did not document Resident #36's use of a Wanderguard and 2) The Minimum Data Set 3. 0 assessment inaccurately documented Resident #6 as having clear speech, with ability to make self-understood. The findings are: The facility policy titled, Minimum Data Set Assessment Completion, last reviewed/revised 9/2023 documented, the interdisciplinary team will conduct comprehensive assessments as part of an ongoing process to identify each resident's preferences and goals of care, functional and health status, strengths, and needs, as well as offering guidance for further assessment once problems have been identified. 1) Resident #36 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment dated [DATE] documented Resident #36 had severely impaired cognition and did not use a Wander/elopement alarm. On 1/02/2025 at 3:05 PM, 1/03/2025 at 9:39 AM, and 1/07/2025 at 10:59 AM, Resident #36 was observed with a Wanderguard to their right ankle. The Comprehensive Care Plan related to wandering and elopement initiated 9/20/2024 and last reviewed 12/21/2024, documented Resident #36 had a Wander Alert Bracelet to their right ankle. An Admission Nursing Note dated 9/21/2024 documented Wanderguard on Resident #36's right ankle per history of wandering behavior. The Physician order [REDACTED].#36's Wanderguard placement/function every shift. 2) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Communication Care Plan was initiated for the resident on 09/02/2024 due to impaired ability to make self-understood secondary to slurred speech and was last reviewed 11/29/ 2024. However, the Minimum Data Set booklet dated 09/04/2024 documented the resident as having clear speech with ability to make self-understood. The Minimum Data Set booklet dated 11/29/2024 did the same. On 01/03/2025 at 10:58 AM, Resident #6 was observed seated in a wheelchair at the unit nursing station attempting to communicate with a staff member by rubbing their chin and shrugging their shoulders, then pointing to a passing aide. The staff member told the resident that they did not understand what the resident was trying to say, and the resident appeared frustrated, finally conveying through gestures only that they felt they had been shaved sloppily and would like an aide to go over their unshaven spots. On 01/07/2024 at 10:42 AM, Registered Nurse Supervisor #1 was interviewed and stated that Resident #6 had an unsuccessful trial of speech therapy following their admission but remained essentially nonverbal, able to grunt or scream but not to articulate words. The resident is cognitively intact and was subsequently provided with a communication board but refused to use it. They prefer to use gestures to convey their ideas, and most staff members have become adept at figuring out what their gestures mean. Those who aren't able call upon other staff until the resident's meaning becomes clear. On 01/07/2025 at 11:15 AM, the MDS Coordinator was interviewed and stated that Resident #6 and Resident #36's Minimum Data Set booklets were completed by the MDS Assessor, a Registered Nurse who was currently out on medical leave. The Coordinator stated that the nurse followed the progress notes, physician orders [REDACTED]. In the case of Residents #6 and #36, the Coordinator stated that they did not know how the nurse came to document their booklets so incorrectly as they are responsible for their accuracy but that the nurse is currently not available to discuss their line of thought. On 01/07/2025 at 1:54 PM, the Director of Nursing was interviewed and stated that the Nursing Department collaborates with the MDS Department in ensuring the accuracy of the information documented in the Minimum Data Set booklets. The MDS Coordinator directly oversees the MDS Assessor. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedJanuary 31, 2025 F 641 483. 20 Accuracy of Assessment SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The DNS reeducated the MDS Coordinator submitted a correction of the MDS for Resident #36 and # 6 on 1/7/2025 The DNS reeducated the MDS Coordinator regarding responsibilities to ensure the accuracy of MDS data prior to submission. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. The MDS Coordinator/ Designee will review assessments, progress note and plan of care to ensure accuracy of MDS completion prior to submission. The MDS Coordinator will review the last submitted MDS assessment for all residents to ensure the assessment accurately reflects the resident's status at the time the assessment was completed. A correction MDS will be submitted as needed. III. The following system changes will be implemented to ensure continuing compliance with regulations: The MDS Coordinator/ Designee will develop an audit tool to review all scheduled MDS for accuracy prior to submission. The audit tool will assess residents plan of care, progress notes and assessment to ensure accuracy and the same practice does not recur. The Administrator, DNS, and MDS Coordinator reviewed the policy and procedure entitled ?ôMinimum Data Set Assessment Completion.?Ø No revision is needed at this time. The DNS/ Designee will provide education to the MDS Coordinator regarding the above protocol emphasizing the importance of the MDS including accurate data assessment to ensure the CCP addresses each resident's strengths, care needs, including the use of wander alert devices and resident communication ability as applicable. All IDCPT members responsible for completing sections of the Residents Assessment Instrument (RAI) will be provided with this education and training. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The MDS Coordinator /Designee will monitor the same practice does not recur through weekly audits of scheduled MDS. The audit tool will be utilized to ensure the MDS is accurate prior to submission and monitor compliance with accuracy of MDS data. The audit will occur weekly for six months or until two quarters are at 100% compliance. The RN/ MDS Coordinator will audit 15% of completed MDS assessments monthly for six months. All MDS accuracy audit findings will be reported to the Administrator and DNS on a monthly basis. Corrective actions, such as submitting a correction MDS, will be implemented as indicated. The MDS Coordinator will report MDS accuracy audit findings to the QAPI Committee for six months. Responsible: The MDS Coordinator/ Designee is responsible to ensure regulation compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews made during a recertification survey (BYS411), the facility did not ensure that the Arbitration Agreement was explained to residents or their representatives in a form or manner that they understood. This was true in 3 of 21 residents sampled for Arbitration (Residents #22, 57 and 206). The findings are: The facility's policy and procedure entitled Admission Procedures, last reviewed 07/2019, states that the Admissions Director discusses the Admission Agreement with the resident and/or designated representative after admission to the facility. The facility includes a Binding Arbitration Agreement within its Admission Agreement which is written in legal language. The facility's admission packet was reviewed and revealed a brochure entitled, Your Rights as an ArchCare Resident which included the right to receive an explanation about care in a manner the resident can understand. On 01/07/2025 at 2:20 PM, the Admissions Director was interviewed and stated that when they explain the Arbitration Agreement, they let the resident know who they can talk to for legal advice and refers them to the corporate finance department for any questions. If the resident is unable to understand the legal language of the agreement, the Admissions Director stated that they read it out loud for them but do not paraphrase and stated, It's written for lawyers, but that's what we read. The Admissions Director stated that no one is obligated to sign as a condition of admission and that some residents do opt not to sign. The Surveyor obtained a list of recently admitted residents who had participated on their own or with their families in the admissions process. Resident #22 was admitted to the facility on [DATE] and as per their Minimum Data Set (a resident assessment tool), was mentally intact. On 01/08/2025 at 9:55 AM, Resident #22 was interviewed and stated that they did not know what papers were signed at the time they were admitted but that their family member, who was visiting, was aware. On 01/08/2025 at 9:57 AM, the resident's family member was interviewed and stated that they signed the Admission Agreement but that it was not explained to them. The family member stated, I would know about arbitration because I used to work in the public schools and I was part of the union. I has to do with dispute resolution, but I don't know exactly what it means. The family member stated that they were not told on admission that they had the right to refuse to sign or that if they signed the Arbitration Agreement, they were relinquishing the right to an attorney, and stated, They just told me to sign and I signed. The resident's Admission Agreement had been marked 'signed' but no signature was observed on the copy. Resident #206 was admitted to the facility on [DATE] with a Minimum Data Set documenting that the resident was mentally intact. On 01/08/2025 at 10:02 AM, Resident #206 was interviewed and stated, I remember signing that paper, but I don't know what it said, they didn't talk to me about it. I thought I had to sign or I would have to go back to the hospital, so I signed. The resident's Admission Agreement had been initialed by the resident. Resident #57 was admitted to the facility on [DATE] and was documented on their Minimum Data Set as moderately cognitively impaired. On 01/08/2025 at 10:04 AM, Resident #57 was interviewed and stated, I never sign anything, I won't do it. They wanted me to sign but I wouldn't. I am visually impaired and if I can't read it, I won't sign it. But they didn't even tell me what it was about. The facility submitted a statement that the resident refused to sign and their representative, who had not been present on admission, had also refused. On 01/08/2024 at 10:27 AM, the Administrator was interviewed and stated that the facility has never had any arbitrations. The Administrator stated that the Admission Agreement should be explained to the resident or their representative and that they should be given the opportunity to ask any questions. They should be referred to corporate finance only if there are questions that Admissions is unable to answer. The Administrator stated that the Agreement should be explained in its entirety including the Arbitration Agreement and that they would meet with Admissions to emphasize the need to explain it in simple language, not in legalese. 10 NYCRR 415. 26 | Plan of Correction: ApprovedFebruary 3, 2025 F 847 Entering into Binding Arbitration Agreements SS=E I. The following actions were accomplished for the resident(s) identified in the sample: The Admission Director reviewed the Admission Agreement again with residents #22 and #57 on 1/29/ 25. Resident #206 is no longer at the facility. The residents were clearly advised of the Arbitration Agreement. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents in the facility have the potential to be affected by the same deficient practice. The Policy and Procedure titled, Clinical, Pre-Admission Screening and Resident Review (PASARR) Protocol was reviewed to ensure regulation compliance and revise, no revision needed. The Executive Director/Administrator educated the Admission Director to ensure that the Arbitration Agreement is thoroughly discussed with the resident or representative. All questions are addressed and answered to the satisfaction of the resident or representative, ensuring they fully understand the agreement before signing the agreement. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Admission Director will develop an audit tool to ensure the Arbitration Agreement is discussed, questions were asked and answered to the satisfaction of resident/ designated representative. If the finance department is needed for further clarifications or discussion, the admission Director/ Designee will contact the finance department, for further clarifications or discussion. The Admission Director or Designee will audit all admissions from (MONTH) 2024 and onward. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Admission Director/ Designee will monitor weekly for six months through auditing all new admission from (MONTH) onward utilizing the audit tool developed for six months. The Admission Director/ Designee will report the findings monthly to the quality assurance committee monthly for six months or until two consecutive quarters. Responsible: The Admission Director/ Designee is responsible to ensure compliance. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 [DATE] -[DATE], the facility did not ensure that food was stored and prepared in accordance with professional standards for food service safety. Specifically, (1) there were boxes containing food stored past their use by/best by date. There was an open box containing mirepoix vegetable soup mix, an open box Capi vegetable blend, open box with coleslaw stored. There was also an open box containing expired raw frozen shrimp in the freezer. (2) a dietary staff with a beard and mustache was observed in the process of preparing food without a beard net. This was evident in the kitchen observation. The findings are: The facility policy titled Food and Supply Storage revised ,[DATE] documented all food used for food preparation shall be stored in such a manner as o prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell by, best by enjoy by or use by should proceed the date The 'sell by date is the last date that food can be sold or consumed. Food past the use by, sell-by, best-by or enjoy by date should be discarded. Date and rotate items first in first out. Discard food past the use by or expiration date. The facility policy titled Food Handling Guidelines Hazard Analysis Critical Control Points (HACCP) revised ,[DATE] documented food is handled using Hazard Analysis Critical Control Points process in accordance with regulatory guidelines. Proper handling procedures and techniques are visually monitored on an ongoing basis. The Director of Food and Nutrition Services/Dining Services and The Executive Chef are responsible for the execution and monitoring Critical Control Points and records associated with safe food handling procedures. The individual responsible for maintaining the records should initial the form weekly verifying that proper procedures are been followed. The policy only mentions the use of single use disposable gloves in food preparation and no other uniform items are mentioned for food preparation persons to wear. The facility policy titled Uniform Dress code revised ,[DATE] documented personal cleanliness and a neat appearance are essential for the food service worker. Facial hair must be kept neatly trimmed, hair must be neat and glean, good grooming and personal hygiene is mandatory. Restrain all facial hair with a beard net/restraint. Because everything on this subject cannot possibly be addressed, Associates with questions about the appropriateness of a particular items should speak with the manger before wearing certain articles. The facility in-service on hairnet and beard guards dated [DATE] documented 12 employees and 1 manager attended the training. The facility in-service on food safety and quality assurance dated [DATE] was signed by 9 dietary staff. 1. An initial tour of the kitchen was conducted on [DATE] from 09:44 AM-10:10AM with the Director of Patient Food Services. The following were observed in the refrigerator: mirepoix veg soup mix ,[DATE] inch 4 x 5 pound use by [DATE] lot number 6, 4 bags of veg blend capri 5 way with lot number 7 ,[DATE] pound box with a best if enjoyed by date of [DATE] and the open box dated [DATE], 1 ?é½ bags of coleslaw salad mix G/R cab/car 4 x 5 pound with a use by date of [DATE] lot number WO,[DATE] and the box was dated ,[DATE]/ 24. The following was observed in the kitchen freezer an open box containing frozen raw deveined white shrimp ,[DATE] count with a best if used by [DATE] with product number and purchase order #P 3. During an interview on [DATE] at 10:14 AM, the Food Service Worker was interviewed and stated they did not look at the food items on the shelf. The facility gets food deliveries on Tuesday and Friday and looked at [DATE] with use by date of ,[DATE]/ 2024. They stated the food items mirepoix veg soup, vegetable blend capri 5 way and coleslaw salad mix should not be on the shelf. They look at items in the refrigerator and the cook informs them in they will use the item or not. It is important that food is used timely, so it does not expire and make people sick. We use the older stock first and then we use the newer food items. They stated they have not had training on food safety yet. During an interview on [DATE] at 10:28AM, the Food Service Supervisor stated that they look at the refrigerator and freezer 3 times a day. They also look at the refrigerator and freezer when they get food deliveries on Tuesday and Friday. They did not notice that anything in the refrigerator and freezer were expired. They stated they worked yesterday and did not notice any expired items and they looked at the freezer yesterday and they did not notice the expired food items. The food items should not be in the refrigerator and/or freezer due to food contamination, don't want to create foodborne illness and they had food safety training 1 month ago. On [DATE] at 10:34 AM, Cook #1was interviewed and stated, the shrimp is not cooked and the last time they prepared shrimp was 5 months ago on their shift. Cook #1 stated that the night cook prepares the vegetables for the meals. They look at date on food items daily and they are not aware of any food items that are expired. When the food comes in, it is used up. We don't want to use expired food because we don't want to get residents sick and it is a hazard. On [DATE] at 10:48 AM, the Food Service Manager was interviewed and stated, they look at the refrigerator/freezer when they open the kitchen daily. When they look at food items, they look for the expiration date, food appearance, received date and rotate food items when needed by the food best by date. If the food item is closed item, then the discard date would be based by the foods shelf life. Food stored in the refrigerator is dated for 3 days and anything opened dated 3 days for items start use date. If the food items are in a box we go by the receive date. The mirepoix veg soup mix is in the box and for prepackaged food items received and from the day the food item is open it is labeled for 3 days so it can be discarded on day 3. If the food item is unopened, we go by the receive date and if a food item is closer to date of discard we go by manufacturer date. The best by and use by dates are similar and they are based on manufacturer term. They looked at the freezer yesterday and yesterday shrimp was on the menu and some residents may have an allergy to shrimp and there are alternative foods available for residents with food allergies [REDACTED]. Expired food items could get residents sick, and this is why we keep fresh items in house instead of spoiled that can make residents sick. On [DATE] at 11:23AM, the Director of Patient Food Services was interviewed and stated, that they look at the refrigerator and freezer every morning and also at night. They stated they never noticed the shrimp before, and it is a catering item. We use the raw shrimp right away and the item is used quickly, and they contacted the vendor, and the food item needs to have more shelf life. For food safety of the residents we need to make sure food items are used timely. Last in-service that was done was on food inventory which has to be rotated using first in first out. 2. On [DATE] at 10:47 AM-10:58 AM Cook #2 was observed with a beard and mustache on their face approximately ?é½ inch to 1 inch in length in the kitchen not wearing beard net in kitchen. Cook #2 was observed with a closed box of chocolate brownie mix which was later opened and placed in a silver bowl and grabbing a spatula opposite the stove and going back to the prep area on the office side of the kitchen. On [DATE] at 11:30 AM, Cook #2 was interviewed and stated, they had a beard net on earlier but removed it and they were suppose to have one on their face. They don't want any hair to go in the food. On [DATE] at 11:02 AM, the Food Service Sup | Plan of Correction: ApprovedFebruary 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 812 483. 60 Food Procurement, Store/Prepare/Serve-Sanitary SS=F I. The following actions were accomplished for the resident(s) identified in the sample: All expired food and past due food items were all discarded on ,[DATE]/ 2025. All freezers and fridges were inspected for any additional items that may be past their expiration date and holding. No items found past their expiration date. Provided in-service to dining service staff to ensure proper uniform compliance. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Food Service Director provided in-service to dining service staff, on (MONTH) 3 through (MONTH) 16,2025, on proper food storage procedures including importance of monitoring food expiration dates, including all dates identified as sell-by, best-by, enjoy-by, or use-by. The Food Service Director provided in-service to dining service staff, on (MONTH) 3 through (MONTH) 16, 2025, on proper uniform compliance. III. The following system changes will be implemented to ensure continuing compliance with regulations: Dining Service Managers will conduct daily inspection of all refrigerators and freezers to ensure all items are properly labelled, dated, and within appropriate date ranges. All items that are past proper dates will be discarded. Dining Services Director/Designee will perform weekly Food Safety and Sanitation audits to identify any deficient practices, and ensure corrective actions are implemented as needed. Dining Service Manager will conduct daily huddles, twice a day, to ensure dining service staff follow proper uniform policy. Executive Director and Dining Service Manager reviewed the facilitys policy and procedure entitled ?ôFood and Supply Storage.?Ø No revision is needed at this time. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility's compliance will be monitored weekly for six months utilizing an audit tool to monitor compliance with protocols related to frozen storage. Monitoring will continue until 100% compliance is achieved for six months or two successive quarters. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement committee by the Food Service Director. Responsible: The Director of Food Service is the person responsible to ensure all the above actions are completed. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 [DATE] to [DATE] the facility did not ensure that food was served in accordance with professional standards for food service safety to prevent foodborne illness and ensure that infection control practices were maintained. Specifically, a Certified Nursing Assistant #4 was observed assisting multiple residents with dining room in preparation for dining did not perform hand hygiene between residents. This was evident for 10 residents (of 23 total sampled residents for dining Resident # 7, #18, #19, #38, #39, #49, #52, #70, #72 and #87). (2) the facility did not ensure that disinfecting germicidal wipes, hand sanitizing solution was discarded by the manufacturer discharge date . This was evident for the infection control task. The findings are: The facility policy and procedure titled Uniform Dress Code revised ,[DATE] documented facial hair must be kept neatly trimmed, restrain all facial hair with heard net/restraint associates while working with food. The facility policy and procedure titled Hand Hygiene. Handwashing revised on (MONTH) 27, 2024, documented all personnel will perform hand hygiene appropriately in accordance with current standards of practice and Centers of Disease Control guidelines to prevent he transmission of organisms that cause infections. To reduce the risk of healthcare-associated infection by decreasing the risk of transmission of pathogenic microorganisms to resident and the persons within the health are setting. The facility considers hand hygiene for the prevention of healthcare associated infections. When to employ before and after resident contact, before/after meals of handling food items, after removing gloves. The facility policy and procedure titled Purchasing, Stocking Inventory Control (re-Order Points Procedure was last reviewed /revised [DATE] documented the supply chain manager request that inventory supplies are ordered as they are needed (when reorder point is reached. In addition, The Central Purchasing Office has major input into the inventory control system for establishing reorder points and reorder quantities based on delivery lead times, quantity discount, contract purchases, promotional sales and institutions cash flows. The Central Purchasing in conjunction with the facility Supply Chain Manager is responsible. The policy does not state what specific inventory control measures systems are utilized for the facility purchasing, stocking inventory control. 1. During an observation of dining on the 2nd floor on ,[DATE] from 1143 AM-1149 AM, Certified Nursing Assistant # 4 was observed assisting multiple residents in the 2nd floor dining room in preparation for dining. Certified Nursing Assistant # 4 with bare hands assisted Resident # 52 to clean their hands with a hand wipe, gave a hand wipe to Resident # 39, gave hand wipe to Resident # 87 and assisted Resident # 38 to clean their hands. Certified Nursing Assistant #4 with bare hands assisted Resident #49 to clean their hands then gave a hand wipe to Resident # 19 and then assisted Resident # 7 to clean their hands. Certified Nursing Assistant #4 did not perform hand hygiene between residents. Certified Nursing Assistant # 4 then applied a glove on their left hand and cleaned the hands for Resident # 70 and wipe their hands and they gave a hand wipe to Resident #18 with left glove still on their on hand. Certified Nursing Assistant #4 did not perform hand hygiene between residents. Certified Nursing Assistant # 4 with the same glove on their left hand only cleaned Resident # 72 hands, and then cleaned Resident # 49 hands and then assisted Resident #38 to clean their hands. Certified Nursing Assistant #4 did not perform hand hygiene between residents. Certified Nursing Assistant # 4 then proceeded to wash their hands in the handwashing sink in the 2nd floor pantry area. During an interview on [DATE] at 11:50 AM, Certified Nursing Assistant # 4 was interviewed and stated that before and after a meal they clean their hands. They forgot to change gloves and had a new pair and then stated they did not change gloves between residents. Certified Nursing Assistant # 4 stated they needed to wash their hands to prevent cross contamination and for infection control. Further stated they should have sanitized or washed their hands when they take off gloves and put on a new pair. During an interview on [DATE] at 12:30 PM, the Registered Nurse # 2 was interviewed and stated that when they monitor the dining room at lunch time, they observe staff performing hand hygiene. Staff are supposed to clean their hands before assisting residents, before they touch resident's trays, in-between residents, when they feed residents, assisting a resident in finishing a task and sanitize hands between residents for infection control. During an interview on [DATE] at 11:43 AM, the Infection Preventionist was interviewed and stated they do rounds during the day when they come in to work Monday to Friday. They stated that they observe hand hygiene during meals ,[DATE] times a week. There were no concerns related to hand hygiene that they identified. Hand hygiene is an infection control practice to prevent cross contamination of food. Further stated they did staff inservice on hand hygiene in the last 3 months. 2. On [DATE] at 11:25 AM, in the medication room on the 2nd floor the hand sanitizer was observed to be expired with an expiration date of 08/ 2024. During an observation on [DATE] at 03:58 PM the 3rd floor pantry was observed and in the lower left cabinet facing the nurses station side there was and opened container of disinfecting wipes lot # 3C with expiration date of ,[DATE]/ 2024. During an observation on [DATE] at 12:18 PM to 12:23 PM, the central supply room in the basement was observed and the following was found: antimicrobial skin cleanser antiseptic hand sanitizer at doorway by desk with expiration date of 2/ 2023. There were 3 sealed boxes with disinfecting wipes on the shelf containing germicidal wipes with 150 count sheets and each box contained 24 containers with lot numbers 3 and 3C with expiration date of ,[DATE]/ 2024. On [DATE] at 12:18 PM, the Central Supply Representative was interviewed and stated, that the units are provided supplies daily and as needed. They stated that they did not look at the date on the sanitizer and the wipes and as you can see the boxes were still sealed. The wipes that are expired are the old supply and we have new supply on the shelf. On [DATE] at 12:33 PM, the Infection Preventionist was interviewed and stated if expired hand sanitizer or disinfecting wipes supplies are used they won't be as effective. They stated that they have not looked at the sanitizing wipes, disinfecting wipes or hand sanitizer and that central supplies/housekeeping look at these supplies. On [DATE] at 12:06 PM and 1:01PM, the Director of Plant Operations and Maintenance was interviewed and stated, that the housekeeper changes sanitizer dispensers as needed once they are empty. If they need to be replaced such as if the sanitizer dispenser is not working then maintenance takes a look at the dispenser to see if they need to be replaced. The Central supply in the basement gives out germicidal wipes. Further stated that the central supply person is in charge of the supplies, and they look at it and they will check to see if the supplies are expired. 10 NYCRR 415. 19(a)(1)(b)(4) | Plan of Correction: ApprovedJanuary 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 880 483. 80 Infection Prevention & Control SS=D I. The following actions were accomplished for the resident(s) identified in the sample: On [DATE], the Certified Nursing Assistant #4 who was assigned on the second-floor dining room was re-educated on the Facilities policy entitled ?ôHand Hygiene.?Ø On [DATE], the hand sanitizer with an expiration date of ,[DATE] in the medication room on the second floor was immediately removed and replaced. On [DATE], the disinfecting wipe that was found on the 3rd floor panty room was immediately removed and replaced. On [DATE], the three sealed boxes containing expired disinfecting wipes that were found in the central supply with expiration dates of [DATE] were immediately removed and discarded. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. All Certified Nursing Assistants were educated on the facility policy entitled ?ôHand Hygiene?Ø to ensure proper hand hygiene is practiced in between residents to prevent cross contamination. All hand sanitizer in the entire building were checked by housekeeping staff, including in the central supply, to ensure there were no other expired hand sanitizer. No additional expired hand sanitizer was identified. All disinfecting wipes in the entire building were checked by central supply, including within the central supply department, to ensure there were no other expired disinfecting wipes. No additional expired disinfecting wipes were identified. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Infection Control Preventionist provided an education to all nursing staff on hand hygiene, emphasizing its importance during direct contact with residents in the dining room. This education focused on ensuring the staff members practice proper hand hygiene between residents and when donning or removing gloves, thereby minimizing the risk of cross contamination. The Director of Nursing and the Infection Control Preventionist reviewed the facilitys policy entitled ?ôHand Hygiene?Ø and all regulatory components were outlined with no revision needed. The Infection Control Preventionist will continue to monitor hand hygiene protocols during meals times in the dining room to ensure all staff members adhere to compliance standards. All Housekeeping staff responsible for monitoring and changing hand sanitizers throughout the facility received education on the critical importance of routinely checking expiration dates. This education ensured that all hand sanitizers remain effective and safe for use, thereby maintaining a high standard of hygiene within the facility. All Central Supply staff/representative responsible for distributing supplies and managing procurement and inventory control within the facility received education on the vital importance of routinely checking expiration dates. This education specifically emphasized hand sanitizer and disinfecting wipes, ensuring that these products remain effective and safe for use, thereby supporting the overall health and safety of the facility. The Executive Director/Administrator and the Director of Plant Operations and Maintenance reviewed the facilitys policy entitled Purchasing, Stocking Inventory Control and Order Points Procedure was revised to incorporate comprehensive inventory control measures and monitoring protocols, ensuring that all supplies are routinely checked for expiration dates. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Director of Nursing and Infection Control Preventionist will develop an audit tool to assess compliance with hand hygiene practices during mealtimes in the dining room. This audit tool will specifically focus on ensuring the staff members perform hand hygiene both during direct contact with residents and between residents. Quality Assurance Monitoring will be conducted by the Director of Nursing/Designee using a standardized audit tool titled ?ôHand Hygiene Compliance in Dining Room.?Ø The audits will be conducted weekly for six months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. The Executive Director/Administrator and the Director of Plant Operations and Maintenance will develop an audit tool to monitor compliance with inventory control measures and monitoring protocol ensuring that all supplies are routinely checked for expiration dates. Quality Assurance Monitoring will be conducted by the Director of Plant Operations and Maintenance/Designee using a standardized audit tool titled ?ôSupply Inventory and Monitoring of Expiration Dates.?Ø The audits will be conducted weekly for six months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Plant Operations and Maintenance. Responsible: Executive Director/Administrator, Director of Nursing, Infection Preventionist and Director of Plant Operations are responsible for ensuring all above is in compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted from 01/02/2025 to 01/08/2025, the facility did not ensure that each resident was offered the Pneumococcal immunization. This was observed in 3 of 5 residents (Residents #6, #84, #96) sampled for Immunizations out of a total of 23 sampled residents. Specifically, there was no documented evidence that Residents #6, #84, and #96 were offered or educated on the Pneumococcal immunization. The facility policy titled Resident Immunizations effective 05/2014 documented that all residents will receive immunizations as recommended by the Immunization Practices Advisory Committee (ACIP) of the U.S. Department of Health and Human Resources. The resident's status regarding the Pneumococcal vaccine will be obtained and documented in the electronic medical record. If needed, the resident will be offered the Pneumococcal vaccine unless the resident declines or previously received it. Each resident will receive a fact sheet about the vaccine. If the resident received the vaccine in another facility or in the community, an attempt will be made to obtain that information and it will be documented in the electronic medical record. If the resident refuses the vaccine, the reason for the refusal will be documented in the medical record. Findings include: Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #6 had severe cognitive impairment. It also documented that Resident #6's Pneumococcal vaccination status was not up to date, with no reason documented for why the resident was not up to date on the Pneumococcal vaccination. Resident #84 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #84 had severe cognitive impairment. It also documented that Resident #84's Pneumococcal vaccination status was not up to date, with no reason documented for why the resident was not up to date on the Pneumococcal vaccination. Resident #96 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #96 was cognitively intact. It also documented that Resident #84's Pneumococcal vaccination status was not up to date, with no reason documented for why the resident was not up to date on the Pneumococcal vaccination. On 01/08/2025 at 11:03 AM, Resident #96 was interviewed and stated that they were educated on and received the Pneumococcal vaccine on 01/07/2025 but could not recall if they had been offered the vaccination prior to that. On 01/07/2025 at 11:06 AM, the Infection Preventionist was interviewed and stated that they had stepped into the Infection Preventionist role a few weeks ago after the facility's previous Infection Preventionist was unexpectedly no longer able to fill the position. They stated that the facility's policy was to offer the Pneumococcal vaccination to all residents on admission and annually after that if they declined on admission. The Infection Preventionist stated that after the surveyor requested resident Pneumococcal vaccination records on 01/06/2025, they realized that they did not have recent records reflecting that residents had been offered the vaccination so they immediately began to audit immunization records and offer the Pneumococcal vaccination to those who had not been offered it. The Infection Preventionist was unsure if the previous Infection Preventionist had been offering the vaccination to residents and was unable to produce documentation showing that it had been offered. On 01/08/25 at 10:58 AM, the Director of Nursing was interviewed and stated that the Infection Preventionist is responsible for ensuring residents receive immunizations. The Director of Nursing stated that they oversee the work done by the Infection Preventionist. They stated that the Infection Preventionist verified in the Citywide Immunization Record that it did not look like Residents #6, #84, and #96 had received the Pneumococcal vaccination, and they were unable to find documentation showing that it had been offered and declined. The Director of Nursing stated that the Pneumococcal vaccination should have been offered to these residents during admission and annually if they declined during admission, but based on the lack of documentation, it did not look like the residents had been offered the vaccination. They were unable to provide a reason for why this occurred. On 01/08/2025 at 11:14 AM, the Administrator was interviewed and stated that they believed that the lapse in the Pneumococcal vaccination being offered to residents was related to the unexpected change in staff members in the Infection Preventionist role. They stated that they believed that the previous Infection Preventionist may have been offering the vaccination to residents as per the facility's policy but they were unable to locate documentation reflecting that, because it was not in the electronic medical record. They stated that moving forward, the Infection Preventionist will ensure that residents' Pneumococcal immunization status is tracked and stored in the electronic medical record. 10NYCRR 415. 19 (a) (1-3) | Plan of Correction: ApprovedJanuary 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 883 483. 80 Influenza and Pneumococcal Immunizations SS=E I. The following actions were accomplished for the resident(s) identified in the sample: On (MONTH) 5, 2025, Resident #6 was offered the pneumococcal vaccine. Resident #6 consented to receive the vaccine after receiving education on the vaccine. On (MONTH) 6, 2025, Resident #6 received the Prevnar-20 vaccine. Consent and administration of the vaccine was documented on the electronic medical record. On (MONTH) 5, 2025, Resident #96 was offered the pneumococcal vaccine. Resident #96 health proxy consented on behalf of the resident to receive the vaccine after receiving education on the vaccine. On (MONTH) 6, 2025, Resident #96 received the Prevnar-20 vaccine. Consent and administration of the vaccine was documented on the electronic medical record. On (MONTH) 6, 2025, Resident #84 was offered the pneumococcal vaccine. Resident #84 health proxy consented on behalf of the resident to receive the vaccine after receiving education on the vaccine. On (MONTH) 7, 2025, Resident #84 received the Prevnar-20 vaccine. Consent and administration of the vaccine was documented on the electronic medical record. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Infection Preventionist will complete a [MEDICATION NAME] audit of all in-house residents and the pneumococcal vaccine will be offered to those who have not received it. Documentation of vaccine consent, declination, education, and administration will be completed in the electronic medical record. The audit will include how many residents audited and out of all residents audited, how many residents have already received and how many have not. The audit will also include all residents who have consented to receive the pneumococcal vaccine, and the date administered. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Staff Educator will provide educational in-service to all admission nurses to review immunization history and offer the pneumococcal vaccine upon a residents admission to the facility. The Infection Preventionist will complete weekly audits for six months or until two quarters are at 100% compliance of pneumococcal vaccine for all residents in-house for three months and then on a quarterly basis. Audit results and vaccination data will be reported in the IDT Quality Assurance and Performance Improvement meetings. The Executive Director, Director of Nursing, and Infection Preventionist reviewed the facilitys policy on ?ôResident Immunizations?Ø and made changes to the policy to reflect current recommendations by the Immunization Practices Advisory Committee (ACIP) of the U.S. Department of Health and Human Resources. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Infection Preventionist will develop an audit tool to monitor compliance with resident vaccination status in accordance with current guidelines from the Immunization Practices Advisory Committee (ACIP) of the U.S. Department of Health and Human Resources. Quality Assurance Monitoring will be conducted by the Infection Preventionist or Director of Nursing/Designee using a standardized audit tool titled ?ôResident Vaccination Status?Ø. The audit tool will be initiated for every new admission to ensure up to date vaccination status. The audit will monitor compliance with the facilitys policy on ?ôResident Immunizations?Ø as it relates to ensuring residents receive immunizations as recommended by the Immunization Practices Advisory Committee (ACIP) of the U.S. Department of Health and Human Resources. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Infection Preventionist. Responsible: Director of Nursing/ Infection Preventionist are responsible for ensuring all the above is in compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on interviews and record review conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 2 (Resident #36 and Resident #55) of 3 residents reviewed for Beneficiary Notification out of 23 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made. The findings are: The facility policy titled Advanced Beneficiary Notice of Medicare Non Coverage Benefit Exhaust Letters with effective date 9/14 and last revision date of 12/23 documented the Advanced Beneficiary Notice required by the Centers of Medicare and Medicaid services are distributed to residents within the required time frames. The policy also documented the Benefit Exhaust Letters are sent to Residents/Representatives to inform them that Medicare A is no longer covering the skilled stay. The policy further documented to mail notice if necessary, following phone call under the section of Procedure. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- states that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions also state that when direct phone contact cannot be made, the notice should be sent to the representative by certified mail, return receipt requested. 1) Resident #55 was discharged from Medicare skilled services on 07/17/2024 and remained in the facility. The Notice of Medicare Non-Coverage documented that Resident #55's designated representative was called on 07/15/2024 and a voice message was left. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented Resident #55's designated representative was called on 07/15/2024 and informed that Resident #55's coverage will end on 07/17/ 2024. There was no documented evidence that the notices were mailed to Resident #55's representative on the same day that telephone notification was made. 2) Resident #36 was discharged from Medicare skilled services on 11/4/2024 and remained in the facility. The Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented Resident #36's designated representative was called on 11/1/2024 and informed that Resident #36's coverage will end on 11/4/ 2024. There was no documented evidence that the notices were mailed to Resident #36's representative on the same day that telephone notification was made. On 01/08/2025 at 09:09 AM, Minimum Data Set Coordinator was interviewed and stated they had a utilization review meeting every week to discuss the resident discharge from Medicare Part A. Minimum Data Set Coordinator also stated that residents who will be discharged from Medicare Part A services are given at least 48-hour notice and that their right to appeal is explained. Minimum Data Set Coordinator stated that if a resident is cognitively intact, they ask them to sign the Notice of Medicare Non-Coverage and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage. Minimum Data Set Coordinator also stated that if a resident is cognitively impaired to make decisions, they notify the resident's designated representative by phone call and did not mail them the notices unless the representatives requested the notices. Minimum Data Set Coordinator further stated they mailed the notices with certified mail receipt on same day if they were not able to reach the impaired resident's representative by phone call. Minimum Data Set Coordinator stated they spoke to the representatives of Resident # 55 and Resident # 36 and the representatives stated they did not want to receive the notices. Minimum Data Set had no proof of the refusal to receive the notices. On 01/08/2025 at 09:32 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for providing Notice of Medicare Non-Coverage and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage notices to residents and/or designated representatives to review and sign before discharging them from Medicare Part A. The Administrator also stated they should mail, email, or use other methods so the representative can receive the forms and keep a proof of it. 10 NYCRR 415. 3(g)(2)(i) | Plan of Correction: ApprovedJanuary 31, 2025 F582 483. 10 Medicaid/ Medicare Coverage/ Liability Notice SS=D TAG I. The following actions were accomplished for the resident(s) identified in the sample: The facility mailed the Beneficiary Notification to the designated representatives of resident #36 and # 55. On 1/8/25, the Beneficiary Notification was mailed certified to the designated representative of Residents #36 and # 55. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents on Medicare are potentially affected by the same practice. The MDS Coordinator will audit residents who received Beneficiary Notification for the last six months. If any deficient practice is identified immediate corrective action will be implemented and findings reported to the Administrator and Quality Assurance Committee. The Administrator educated the MDS Coordinator on the facility policy entitled ?ôAdvanced Beneficiary Notice of Medicare Non- Coverage Benefit Exhaust Letters?Ø to ensure compliance with regulations. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Facility reviewed the policy and procedures ?ôAdvanced Beneficiary Notice of Medicare Non- Coverage Benefit Exhaust Letters?Ø to ensure regulation compliance and no revision needed. The MDS Coordinator/ Designee will keep a log of all residents receiving the Beneficiary Notification. The log will indicate the date the resident/ designated representative was notified, and the Beneficiary Notification was mailed to the designated representative. The MDS Coordinator/ Designee will maintain a log for all residents who receive the Beneficiary Notification of Medicare Non- Coverage. The log will also indicate the date of mailing with certified tracking receipt and notification. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The corrective action will be monitored weekly through audits and the findings will be presented to the quality assurance committee for six months to ensure deficient practice will not recur. Compliance with this regulation will be assessed utilizing an audit tool developed by the MDS Coordinator. The findings from the audit will be reported to the Quality Assurance Committee for six months by the MDS Coordinator. Responsible: The MDS Coordinator/ Designee is responsible for compliance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the Recertification Survey from 1/2/2025 to 1/8/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended 4 quarterly meetings. Specificially, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 2 out of the 4 meetings as required. The findings: The policy and procedure entitled Quality Assurance and Performance Improvement dated 08/15 documented Quality Assurance Performance Improvement shall have a committee consisting of, at a minimum, of Executive Director/Administrator, Director of Nursing, Medical Director, Quality Coordinator/Director, and Compliance Director. Each facility shall meet at least quarterly. Review of the Monthly Meeting Attendance Sheets entitled Quality Assurance and Assessment Committee revealed the Medical Director did not sign the attendance sheet for the following Quality Assurance & Performance Improvement meetings on 1/31/2024, 2/16/2024, 3/27/2024, 4/18/2024, (MONTH) 20, 2024, 07/25/2024, 08/15/2024, 09/19/2024, 10/18/ 2024. Clinical Assistant attended the meeting in place of Medical Director on 5/16/2024 and 12/19/ 2024. There is no documented evidence that the Medical Director attended the Quality Assurance & Performance Improvement meeting via Microsoft teams or in person for 2 out the 4 quarterly meetings. On 01/08/25 at 11:14 AM interview with the Attending Physician stated has been working at the facility since 2020 and has not attended any Quality Assurance & Performance Improvement meetings. On 01/08/25 at 11:51 AM interview with the Medical Director stated they attend the Quality Assurance & Performance Improvement meetings monthly, however, does always attend in person. Gets invited via email and attends via Microsoft teams. If cannot attend the meeting, the Clinical Assistant will stand in their place. The Attending Physician does not attend the Quality Assurance & Performance Improvement meetings. On 01/08/25 at 12:23 PM interview with the Administrator stated that the Quality Assurance & Performance Improvement meetings are held monthly and that the Medical Director gets invited via email. The meetings are also held in person, by telephone and via Microsoft teams. The Clinical Assistant to the Medical Director will attend the meetings if the Medical Director cannot attend. The Attending Physician has not attended the meetings. On 01/10/2025 at 3:00 PM an interview with the Clinical Assistant who stated that their role as a Clinical Assistant is more of an Administrative Role. They input documents into the electronic Medical Record, does not give medications, provide care, or medical assistive care to the Medical Director. The Clinical Assistant stated they attend Quality Assurance & Performance Improvement meetings when the Medical Director cannot attend, which is not that many. The Clinical Assistant stated that they do not attend the Quality Assurance & Performance Improvement meetings as much and is not that familiar with the facility's policies, procedures, and practices. 10 NYCRR 415. 15(a) | Plan of Correction: ApprovedFebruary 3, 2025 F 868 483. 75 QAA Committee SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The Medical Director received an Inservice from the Administrator on Regulation Compliance and the importance of attendance at Quality Assurance Committee Meetings. The Medical Director will attend facility QAPI meetings minimally once every quarter. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. The facility reviewed the Quality Assurance Policy and Procedures to ensure regulation compliance. No revision is needed. The Medical Director/ Designee will meet with Quality Assurance Performance Committee at least quarterly to coordinate and evaluate activities such as identifying issues with respect to quality assessment and assurance activities. The Medical Director is required to attend the meeting in person to foster effective communication, collaboration, and engagement with the quality improvement team. If unable to attend in person, the Medical Director/ Designee will attend via TEAMS or Telephonically. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Medical Director / Designee will audit the attendance at Quality Assurance Meeting to ensure compliance of minimally quarterly attendance. The Audit will occur monthly for one year. The Medical Director will be responsible for reporting key data metrics during each meeting. In order to ensure an appropriate quality review for 2024 related to this deficient practice, the Medical Director will review all reports that were presented in the 2024 QAPI meetings. This will develop an understanding of Quality in 2024 in order to continue to improve for 2025 and thereby enhancing quality care for residents at this facility. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Medical Director/ Designee will report findings monthly to the Quality Assurance Committee on the compliance with the regulation for one year. Attendance, along with these reports, will be documented by the Medical Director and provided to the quality improvement coordinator. A log of attendance will be maintained by the administrator. Non-compliance will be reviewed and addressed during performance evaluations with the organizations Medical Director. Responsible: The Medical Director/ Administrator, organizations Medical Director are responsible for audit compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification/Complaint Survey (NY 189) from 01/02/2025 to 01/08/2025, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #96) reviewed for Accidents out of 23 total sampled residents. Specifically, the facility did not report that Resident # 96 was found with injuries of an unknown source to the New York State Department of Health within 2 hours. The findings are: The facility policy titled Clinical, Resident Abuse Reporting and Investigation Protocol, Policy and Procedure with effective date (MONTH) 11, 2010 and last review date 08/01/2024 documented the source of the injury was not observed by any person or the source of the injury could not be explained by the resident, the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made. Resident #96 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3. 0 assessment dated [DATE] documented Resident #96 has moderately impaired cognition and supervision with ambulating. The Nursing Progress note dated 5/23/2024 at 03:31AM documented Resident #96 was assessed to have swelling to left side of face by supraorbital region and scant blood on tip of nose. Resident #96 reported pain 8/10 to left arm with limited movement noted to extremity. The Nursing Progress note dated 5/23/2024 at 02:55 AM documented Resident #96 was found lying on the floor laterally to left side by doorway to room [ROOM NUMBER] with mild swelling to left side of their head with swelling and discoloration to the left supraorbital area, noted with scant bleed from nose, left forehead and supraorbital swelling, inability to move left arm and complaint of pain 6/ 10. Physician was notified and ordered for Resident #96 be transferred to the hospital for further evaluation. The Medical note dated 5/30/2024 documented Re-Admission Note for Resident #96 for status [REDACTED]. The Accident /Incident Occurrence Report/Investigation form documented the occurrence happened at 11:30 PM on 05/22/ 2024. The Webform submission from Nursing Home Facility Incident Report emailed to the Administrator documented the incident was submitted to New York State Department of Health at 23:39 on 05/23/ 2024. During an interview on 1/6/2024 at 03:21 PM, Registered Nurse #5 stated was the nurse on the unit at the time of the incident. Registered Nurse #5 stated was informed by Certified Nurse Assistant #9, Resident #96 is lying on the floor. Upon arrival, observed Resident #96 lying on the floor in the hallway in front of their room. Registered Nurse #5 stated they called for the nurse manager to come to the unit. Resident #96 was assessed with [REDACTED]. The Medical Doctor was called and ordered for Resident #96 be transferred to the hospital. No one witnessed the incident or how Resident #96 came to be lying on the floor. Their roommate at the time was confused and unable to tell what had happened. The bathroom floor was observed to be wet, but when assessing Resident #96, their clothes and socks were dry. Prior to the fall, Resident #96 was on fall precautions such as low bed position and call bell. No known falls since their admission to the facility. No behaviors such as getting up in the middle of the night. Resident #96 was independent with their toileting prior to the incident. Resident #96 is known for sleeping through the night. During an interview on 1/6/2024 at 03:26 PM, Certified Nurse Assistant #9 stated they started their shift on 5/22/2024 around 11:10 PM and saw Resident #96 asleep in their bed. They then went down the hallway to prepare their linen cart for the night shift and when coming down the hall, noticed Resident #96 lying on the floor in the hallway by their room door. Certified Nurse Assistant #9 stated they called for the nurse who came to look at Resident #96 and was taken to the hospital. Certified Nurse Assistant #9 stated that Resident #96 was not able to tell what happened after giving more than one story of what had happened. No one saw how Resident #96 got on the floor. The roommate at the time was unable to tell what happened. Resident #96 did complain of left-hand pain. The bed is always in the low position. The call bell was in her reach, but it was not activated. During an interview on 01/07/25 at 02:36 PM, Minimum Data Set Coordinator stated they were called to file the complaint with the Department of Health. Since they don't have their laptop, the Minimum Data Set Coordinator, who typically completes report submission, is unable to recall what they submitted and when they sent the summary. Additionally, it was mentioned that any occurrence should be reported to the Department of Health within two hours of becoming aware of it. During an interview on 01/06/25 at 10:51 AM, Director of Nursing stated that it was reported that Resident #96 might have gone to use the bathroom and noticed water from the toilet on the floor and went to go to alert the staff and in the process fell and was found by their doorway entrance on the 2nd floor. The incident was unwitnessed. Director of Nursing was interviewed on 01/08/25 at 2:20 PM and stated the process for reporting incidents to the Department of Health is that the Director of Nursing Services will contact the Director of Nursing, who will collect and forward the allegation information to the Department of Health. If it is unwitnessed with injury, falls with major injury are not reportable. After the facility received a report from the hospital that Resident #96 sustained a fracture, the team decided to be safe and report the incident to the Department of Health. On 01/08/2025 at 02:19 PM, the facility Administrator was interviewed and stated, the Director of Nursing obtains the information and/or the supervisor and reports the information to the Department of Health. If it is an abuse case, it gets reported within 2 hours. Falls with injury are reported within 24 hours of the fall. As per the Administrator stated he needs more clarity on the reporting to the Department of Health. Resident #96 was not known to have an injury until the report came back from the hospital that Resident #96 had an injury, and it was then reported to the Department of Health. Stated needs more clarity on reporting of the incidents because not all incidents get reported. The Registered Nurse Supervisor on duty at the time of the incident is no longer employed at the facility and could not be reached for interview. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedJanuary 31, 2025 F 609 483. 12 Reporting of Alleged Violations SS=D I. The Following Actions were accomplished for the residents identified in the Sample: On (MONTH) 23, 2024, Resident #96 was evaluated immediately, assessed from head to toe at the time of the incident, vital signs were taken, and neurological assessment completed, and was transferred to(NAME)Hospital as per Physicians order. The RN Supervisor on duty (MONTH) 23, 2024, who was responsible for assessing Resident #96 after the fall was re-educated on the Facilities policy on ?ôClinical, Resident Abuse Reporting and Investigation?Ø II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. All accident/incident reports related to an unwitnessed incident with residents who are unable to explain the cause and/or with impaired cognition from (MONTH) 1, 2024, to present was reviewed by the Director of Nursing and Administrator to determine if the abuse, mistreatment, neglect can be ruled out immediately. No additional unwitnessed events related to reporting of allegations of abuse were identified. III. The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: The Executive Director and Director of Nursing educated the IDT team of the need to report any unwitnessed events with injury promptly to the Director of Nursing/Designee to ensure a report is completed within 2 hours via HCS. The Executive Director and the Director of Nursing reviewed the facilitys policy on ?ôClinical, Resident Abuse Reporting and Investigation?Ø and all regulatory components were outlined with no revision needed. All facility staff were in-serviced on the facilitys policy on ?ôClinical, Resident Abuse Reporting and Investigation?Ø with emphasis on unwitnessed events with injuries of unknown origin and the requirement to immediately report to the DNS/Designee any allegation/suspicion of abuse, mistreatment or neglect. The Staff Educator/Designee will provide education to all facility staff/all departments on Abuse Reporting protocols and requirements. Emphasis will be given to the Nursing Supervisor regarding responsibilities related to unwitnessed events of unknown source and the need to report promptly to the Director of Nursing/Designee to ensure reporting within the 2-hour time frame to ensure timely reporting to the New York State Department of Health. This education will be provided by the Staff Educator during orientation, on an annual and as needed basis with follow-up monitoring to ensure staff understand these protocols. The Director of Nursing/Designee will continue to review all occurrence reports related to unwitnessed events with injuries of unknown origin, to determine if reporting requirements have been met in all instances. The Director of Nursing/designee will report all reportable events to the Executive Director/Administrator, the State Survey Agency, Local Law Enforcement or other agency as per State Law and regulation, to meet the 2-hr. abuse reporting requirement. IV. The facilitys corrective action will be monitored to ensure the deficient practice does not recur utilizing the following quality assurance practices: The Executive Director/Administrator will develop an audit tool to monitor compliance with investigating unwitnessed events to ensure reporting of alleged abuse, neglect, mistreatment, including injuries of unknown origin. Quality Assurance Monitoring will be conducted by the Director of Nursing/Designee using a standardized audit tool titled ?ôA/I reporting?Ø. The audit tool will be initiated after an unwitnessed incident/event occurs with a resident that has impaired cognition and/or cannot provide a statement as to how the event occurred to rule out any allegation/suspicion of abuse, mistreatment and/or neglect. The audit will monitor compliance with the facilitys policy on ?ôClinical, Resident Abuse Reporting and Investigation?Ø as it relates to immediately reporting allegations/suspicion of abuse to the DNS/Designee and Administrator, with subsequent reporting to HCS within 2 hours of knowledge of an unwitnessed event. The audits will be conducted weekly for 6 months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. Responsible: Director of Nursing is responsible for ensuring all above is completed |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that the last 3 years of facility survey results were posted in a place readily accessible to residents, family members, public, and legal representatives of the residents, where individuals wishing to examine survey results do not have to ask to see them. This was evident for 5 (#15, #49, #96, #29, #42) out of 11 residents attending the Resident Council meeting. Specifically, survey results were posted at the resident courtesy phone located on the left-hand side of the unit, not in plain view. The findings are: The facility policy titled Posting and Availability of Survey Results and Complaint Investigations effective 01/2025 documented the facility is committed to transparency and regulatory compliance by: Posting the results of the most recent survey in a location readily accessible to residents, family members, and legal representatives. Making survey reports, certifications, and complaint investigations from the past three years available upon request. Posting a notice in prominent areas to inform individuals of the availability of these documents. On 01/02/25 at 10:02 AM, The Department of Health Survey results are displayed on the wall adjacent to the security front desk in a blue binder that included the following surveys: 11/2/2023 survey results of Life Safety Code that was done on 9/5/ 2023. 10/3/2023 survey results of Recertification and Complaint Surveys performed on 08/07/023, 06/28/2023 results of Complaint Survey and 03/27/2023 to 3/29/2023 results of Complaint Survey. On 01/02/2025 and 01/03/ 4 between 10:00 AM and 11:00 AM, a sign was posted in a cubby area located near the resident courtesy telephone on the left-hand side coming off the elevator in a non-visible area on Units 2, 3, and 4. Multiple observations were conducted on Units 2, 3, and 4 on 01/02/2025 and 01/03/2025 and there were no documented evidence that the last 3 years of Recertification Survey results were posted. Observed to be posted was survey results from 11/2/2023 of Life Safety Code, 10/3/2023 survey results of Recertification and Complaints, 06/28/2023 survey results of Complaint Survey and 3/27/2023 to 3/29/2023 Complaint Survey results. There was no evidence that the survey results from the year 2022 was posted. A review of the last 3 months of the Resident Council Meeting Minutes revealed there is no documented evidence that the location or the postings of the survey results were discussed at the Resident Council Meetings. On 1/3/2024 at 10:15 AM, a Resident Council Meeting was held with 11 residents. Resident #15, #49, #96, #29, and #42 stated during the meeting they do not know where they can find the survey results without asking. On 01/08/2025 at 11:50 AM interview with the Administrative Coordinator stated you are right, the last 3 years of the results of the survey should have been posted since 2022. On 01/08/25 at 12:20 PM interview with the Director of Nursing stated the survey results are usually posted on all the units. It is usually 3 years of postings. On 01/08/2025 at 02:19 PM the Administrator was interviewed and stated, the survey results are discussed in the minutes in resident council meetings and on admission as well. There is a sign of the posting of the survey results downstairs and near the courtesy phone. 415. 3(1)(c)(1)(v) | Plan of Correction: ApprovedFebruary 4, 2025 F577 483. 10 Rights to Survey Results / Advocate Agency Information SS=C TAG I. The following actions were accomplished for the resident(s) identified in the sample: The social worker met with each resident identified and informed of the facility survey results posting location which is located on the first-floor lobby near the security desk. The facility ensured all 3 years of facility survey results were in the binder readily accessible to residents: #15, #49, # 96, #29, # 42. All residents indicated were informed by the social worker on 1/28/ 25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility identified all residents, families, and legal representatives as having the potential to be affected. The residents will receive information of the location of the facilitys survey posting during resident council, care plan meeting and upon admission which is located on the first-floor lobby near the security desk. The facility has posted the location of the facilitys survey posting on the units, vestibule entrance and lobby. The Staff Educator will provide education of staff re: location of the survey posting. III. The following system changes will be implemented to ensure continuing compliance with regulations: The facility reviewed the Policy and Procedure titled Posting and Availability of Survey Results and Complaint Investigation to ensure compliance with regulations. The policy was revised on 1/8/ 2025. The Administrator provided in-service to the Director of Recreation, Director of Social Service on the facilitys policies and procedures entitled ?ôPosting ad Availability of Survey Results and Complaint Investigation?Ø to ensure compliance. The facility will post the location of the facilitys survey findings on all units, the vestibule entrance of the lobby and by security desk. The residents will be offered to review the facility survey results during Resident Council. The facilitys survey binder will be reviewed quarterly by the Director of Therapeutic Recreation, Director of Social Services or Designee to ensure three years of facilitys survey results are posted and the residents are aware of survey results location. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The corrective actions will be monitored through quality assurance to ensure the same practice will not recur. The Director of Therapeutic Recreation and Social Services or Designee will develop an audit tool to monitor compliance with facility's survey posting results and ensure accessibility to all residents, families/designated representative. The audits will be conducted monthly for six months or until two quarters are at 100% compliance. The Directors of Therapeutic Recreation and Social Services or Designee will monitor monthly for six months ensuring three years of facility survey results are posted and accessible to all residents, families/ designated representative is aware of survey result location on the first-floor lobby near the security desk. The Director of Therapeutic and Social Services/ Designee will utilize an audit tool to assess compliance monthly and report findings to the Quality Assurance Committee for six months. Responsible: Executive Director/Administrator will be responsible for ensuring compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 01/02/2025 to 01/08/2025, the facility failed to maintain a clean, orderly, functional, and sanitary (homelike) environment for the residents. The deficient practice was identified for multiple resident rooms/units inspected: 1) room [ROOM NUMBER] had no hot water supply for about 3 weeks, 2) room [ROOM NUMBER] and shared shower room on Unit 3 were observed in disrepair/damaged/discolored/ dirt and dust accumulation, 3) 2nd floor dining room and rooms 201/202/210/211/212 were observed in disrepair/damaged/discolored. The findings are: The facility policy titled Hot Water Temperature with undated effective date documented the Department of Engineering is responsible for prompt follow-up on any problem, including investigation, repair or other action as appropriate. The facility policy titled Work Order Procedure with undated effective date documented this procedure will govern the insurance of engineering work orders for the safety, preventive maintenance, repair, facility modification and emergency work, indicating on what authority a work order needs to be approved, and prior to being scheduled into the department workload. 1) On 01/02/2025 during the initial pool process around 11:34 AM to 11:43 AM, and subsequent visit on 01/03/2025 around 10:38 AM to 10:43 AM, the surveyor conducted an environmental tour in the room [ROOM NUMBER] and observed there was no hot water coming out when the handle of the hot water faucet was turned on at the sink in the bathroom. On 01/02/2025 at 11:34 AM, Resident # 57 was interviewed and stated there was no hot water from the sink in the bathroom of room [ROOM NUMBER] for 3 weeks. Resident # 57 also stated the sink fell and broke about 3 weeks ago. Resident # 57 further stated the facility installed a new sink the next day and there was no hot water since then. Resident # 57 stated the Certified Nursing Assistant and themselves had to go to the bathing room across the hallway to get hot water when needed and it was very inconvenient. On 01/02/2025 at 11:43 AM, Resident # 95 was interviewed stated there had been no hot water in the bathroom sink of room [ROOM NUMBER] since the facility replaced the broken sink about 3 weeks ago. Resident # 95 also stated the Certified Nursing Assistant and themselves had to go to the bathing room across hallway to get hot water. Resident # 95 further stated they needed hot water supply in the room to wash hands and other purposes in the wintertime. The maintenance book was reviewed and had no documentation about hot water supply problem in the Room # 304. The Maintenance Repair Requisition form documented the sink in room [ROOM NUMBER] became loose on 12/4/ 2024. The form also documented by Maintenance Department on 12/5/2024 that a sink was reinstalled, waterline was tied in, and sink was in working condition. On 01/07/2025 at 09:29 AM, Certified Nursing Assistant # 5 was interviewed and stated they were assigned to Resident # 57 and Resident # 95 in the room [ROOM NUMBER] in December 2024. Certified Nursing Assistant # 5 also stated they were aware there was no hot water supply in the room [ROOM NUMBER] during the morning report meeting from the nurse in (MONTH) 2024 and did not recall the exact date or which nurse gave the report. Certified Nursing Assistant # 5 further stated they thought the hot water issue was known to the nurse already and did not follow up on the repair of hot water issue in Room # 304. Certified Nursing Assistant # 5 stated they should report to the nurse in a few days if there was still no hot water supply in the Room # 304. On 01/07/2025 at 09:52 AM, the Housekeeper was interviewed and stated they recalled there was no hot water in room [ROOM NUMBER] at least since the last week of December 2024. The Housekeeper also stated they did not report the problem to anyone as they saw someone was fixing the sink and was not sure who was fixing the sink. The Housekeeper further stated they thought the hot water problem was taken care by someone already. On 01/07/2025 at 03:40 PM, Certified Nursing Assistant # 6 was interviewed and stated they were newly hired and worked in the evening shift on the unit for a few weeks. Certified Nursing Assistant # 6 also stated they shadowed Certified Nursing Assistant # 7 and were assigned to residents in Room # 304. Certified Nursing Assistant # 6 further stated they recalled the room [ROOM NUMBER] had no hot water supply at least starting the last week of December 2024. Certified Nursing Assistant # 6 stated they did not report the disrepair as they thought Certified Nursing Assistant # 7 was going to report the disrepair. On 01/07/2025 at 10:01 AM, Registered Nurse # 4 was interviewed and stated they made rounds on the floor at least 3 times a day to check if resident's room and bathroom were clean, resident care, and resident safety. Registered Nurse # 4 also stated they did not check water supply in the resident rooms and was not aware nor received any report that there was no hot water in the Room # 304. Registered Nurse # 4 further stated they were not aware the Maintenance Department changed the sink in Room # 304. Registered Nurse # 4 stated they would transfer both Resident # 57 and Resident # 95 to another room if they knew there was no hot water in the Room # 304. Registered Nurse # 4 also stated there were empty rooms on the unit for a transfer if needed. On 01/07/2025 at 03:16 AM, the Maintenance Mechanic staff was interviewed and stated the unit staff called them for urgent repairs and documented non-urgent repair in the maintenance book. The Maintenance Mechanic staff stated they replaced the sink in room [ROOM NUMBER] on 12/5/ 2024. The Maintenance Mechanic staff also stated there was no problem for both hot and cold water supply in the room [ROOM NUMBER] before they left. The Maintenance Mechanic staff further stated they did not receive any report that there was no hot supply in the room [ROOM NUMBER] afterward. On 01/07/2025 at 10:14 AM, Director of Plant Operation and Maintenance was interviewed and stated the sink in the room [ROOM NUMBER] fell on [DATE] and they replaced a new one next morning on 12/5/ 2024. Director of Plant Operation and Maintenance also stated they did not receive any report until 1/3/2025 that there was not hot water coming out in the sink of room 304. Director of Plant Operation and Maintenance stated they checked the issue and found out it was the speedy valve problem in the pipe running hot water to the room 304. Director of Plant Operation and Maintenance also stated they would have the outside plumber to fix the problem if they were notified of the hot water problem in room 304. On 01/07/2025 at 11:52 AM, the Administrator was interviewed and stated they were not aware there was no hot water supply in the room [ROOM NUMBER] until 1/3/ 2025. The Administrator also stated every room should have a hot water supply. 2) During the Unit Tour on 1/3/2024 and 1/7/2025 of Unit 3 the following was observed: room [ROOM NUMBER] the wall behind the resident bed has multiple, deep, scratches with white substance exposed on the wall. The brown headboard has scrapings on it. Panel molding coming off the base of the floor. Located behind the entrance door is a large, white, spot, surrounded by pink colored paint. A review of the Unit 3 Maintenance log found no documented evidence that room [ROOM NUMBER] and the resident shared bathroom was in need of repairs. Resident shared shower room on Unit 3 was observed to have broken yellow tiles in the shower stall, shower head on the floor due to missing clamp holder, brownish to black substance observed in the corners of the shower stall and on the white wall tiles. Brown screen with dust on them, dead bees lying on the floor and brown colored stains observed on the white ceiling tiles. On 1/7/2025 at 12:25 PM interview with Maintenance Technician and stated the office management located on the 5th floor is responsible for doing a walkthrough of the resident rooms. The management staff consist of nursing, directors, and management. They will assign staff to go into the rooms to see what is going on. The maintenance logs are used for the overnight staff wh | Plan of Correction: ApprovedJanuary 31, 2025 F584 483. 10 Safe/Clean/Comfortable/Homelike Environment SS=E I. The following actions were accomplished for the resident(s) identified in the sample: 1. The facility engaged a certified plumber to permanently repair the hot water to the sink in Room 304. Completed 1/9/ 25. 2. The maintenance staff repaired and painted the wall scratches in the wall behind the bed and behind the door in Room 315. Completed 1/23/ 25. The maintenance staff replaced the headboard on the bed in Room 315. Completed 1/26/ 25. The maintenance staff will repair the identified panel molding in Room 315. Completed on 1/30/ 25. In Unit 3 Shared Shower Room the maintenance staff permanently repair the broken yellow tiles. Completed 1/8/ 25. The maintenance staff will replace the shower hose holder assembly and replace the changed stained ceiling tiles. Completed 1/27/ 25. The housekeeping staff completed a deep cleaning of the shower walls, floors and the identified screen. Completed 1/8/ 25. 3. A. The maintenance staff will replace the identified window screen in the 2nd floor Dining Room. Completed on 1/30/ 25. B. The housekeeping staff cleaned the items from within the HVAC unit in Room 211. Completed 1/8/ 25. The maintenance staff will repair or replace the identified cove base in Room 211. Completed on 1/30/ 25. C. The housekeeping staff cleaned the items from within the HVAC unit in Room 212. Completed 1/8/ 25. The maintenance staff will repair or replace the identified cove base and repair and paint the damaged wall in Room 212. Completed on 1/30/ 25. D. The maintenance staff replaced the footboard on the bed in Room 210. Completed 1/26/ 25. Maintenance repaired the bathroom pipe faucet dripping and left faucet not closing to stop water from dripping. Completed 1/24/ 25. E. The maintenance staff will repair or replace the identified cove base, repair and paint the damaged wall (Completed on 1/30/25) and repaired the leaking sink faucet in Room 202. Completed 1/8/ 25. F. The maintenance staff will replace the window screen in Room 201. Completed on 1/30/ 25. The housekeeping staff removed the two round items from the top of the HVAC unit. Completed 1/8/ 25. G. The maintenance staff will replace damaged window screens on the 2nd floor. Completed on 1/30/ 25. The Director of Plant Operations contacted the facilities pest control vendor to provide mitigation plan for flies. Mitigation plan and implementation was completed on 1/30/ 25. H. The housekeeping staff cleaned the 2nd floor Dining Room Pantry shelves and cabinets. Completed 1/24/25 II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be scheduled for correction. III. The following system changes will be implemented to ensure continuing compliance with regulations: All maintenance staff, housekeeping and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483. 10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff and the Director of Plant Operations will report the findings to the QAPI Committee for the period of six (6) months. The Policy & Procedures will be reviewed and updated to include all staff must report issues promptly in the maintenance log. Resident safety issues must be immediately reported to a supervisor in addition to the maintenance log. The Director of Plant Operations/Housekeeping will conduct weekly rounds to identify maintenance and housekeeping issues. The Director of Plant Operations/Housekeeping will each complete documentation of the weekly rounds in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. Responsibility: The Director of Plant Operations/ Designee will be responsible for compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation and interview it was determined that facility did not ensure kitchen lumination is continuous in that manual switches were able to disable lights. This was observed on 1 out of 4 resident units. The Findings are: On 1/6/25 and 1/7/25 between the hours of 9:30 a.m and 2:00 p.m, during the Life Safety Code Survey, manual switches were observed on 1st floor kitchen area wall, when tested , turned off all lumination in the kitchen area. On 1/7/25 at approximately 9:52 a.m. in an interview with facilities director, stated this concern will be corrected. 10 NYCRR 711. 2 (a)(1) 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) | Plan of Correction: ApprovedJanuary 22, 2025 K291 Plan of Correction for affected areas: The facility reconfigured the manual switches on the first-floor kitchen wall allowing for continuous illumination in the kitchen area when switches are turned off. Work completed 01/12/ 24. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Plant Operations inspected all kitchen areas throughout the facility for similar deficiencies. No deficiencies were identified. Work completed by 01/21/ 24. Plan of Correction for system measures to prevent reoccurrence: All maintenance staff will receive additional education, and all participants will understand the life safety issues relating to continuous illumination in the kitchen. The Director of Plant Operations has been assigned the responsibility for the education of staff. The facility will check for continuous illumination in the kitchen on a monthly basis. The Director of Plant Operations will utilize an audit tool to document and report kitchen continuous illumination lighting findings. Plan of Correction for monitoring corrective actions: The Director of Plant Operations or Designee will review monthly Kitchen continuous illumination audit for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of the kitchen continuous illumination lighting audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Plant Operations |