North Westchester Restorative Therapy & Nursing CRT
January 27, 2025 Complaint Survey

Standard Health Citations

FF15 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: § 483. 80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. § 483. 80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: § 483. 80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to § 483. 71 and following accepted national standards; § 483. 80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. § 483. 80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. § 483. 80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. § 483. 80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 27, 2025
Corrected date: March 12, 2025

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 3/28/22-4/4/22, the facility failed to ensure residents were assessed to determine ability to safely self-administer medication when clinically appropriate for 1 of 1 resident (Residents #116) reviewed. Specifically, Resident #116 had an inhaler (hand-held, portable devices that deliver medication to the lungs) at their bedside and there were no physician order for [REDACTED]. The interdisciplinary team will meet and complete assessment form to decide to trial a resident for self-administration of medications. The resident Medication Administration Record [REDACTED]. Resident #116 was admitted with [DIAGNOSES REDACTED]. The 1/10/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with activities of daily living (ADL), and received oxygen. The comprehensive care plan (CCP) dated 4/23/21 documented the resident received oxygen (02) at 3 liters via nasal cannula (NC), used continuous positive airway pressure ([MEDICAL CONDITION]) at bedtime, was monitored for oxygen saturations, and equipment was to be observed with each encounter. The care plan did not include an inhaler or if the resident could safely administer an inhaler. The physician order dated 2/23/22 documented ProAir HFA (short-acting [MEDICATION NAME][MEDICATION NAME] containing [MEDICATION NAME]) was discontinued. The 3/2022 Medication Administration Record [REDACTED]. There was no documented evidence that a self-medication assessment was completed for the resident. Observations of the resident with the ProAir inhaler included: - On 3/28/22 at 12:12 PM, the inhaler was in the bed with the resident. The resident stated they used the inhaler as needed. - On 3/29/22 at 11:51 AM, the inhaler was on the bedside table while the resident was awake in bed. - On 3/30/22 at 10:11 AM, the inhaler was on the nightstand while the resident was asleep in bed. - On 3/31/22 at 9:19 AM, in a bucket of personal belongings next to the resident's bed. During an interview on 3/30/22 at 3:55 PM, the resident stated the inhaler on the table was ordered through the facility's pharmacy. They used the inhaler twice a day, in the morning and the evening, and it could be used in between those times if needed. They had been using an inhaler prior to admission to the facility. They stated they did not tell the nurses how often they used the inhaler and that the nurses did not ask them, either. The resident stated they usually knew when the inhaler was getting low and would tell the nurses. During an interview on 3/30/22 at 4:00 PM, licensed practical nurse (LPN) #7 stated the resident currently used Breztri Aerosphere (long-acting inhalation aerosol medication) 160 mcg/9 mcg/ 4. 8 mcg, 2 puffs twice a day, and it was kept in the medication cart. It could also be used as needed (PRN). The resident had previously used ProAir, but it was discontinued on 2/23/ 22. The LPN stated the resident also received [MEDICATION NAME] nebulizer treatments every 4 hours and PRN. During an interview on 4/1/22 at 9:47 AM, LPN #8 stated they did not know what the process was for residents self-administering medications, but the registered nurse (RN) would do an assessment to determine if the resident was competent to self-administer medications. The nurse stated they were uncertain if the resident was allowed to self-administer medications. During an interview on 4/1/22 at 10:19 AM, RN Unit Manager #9 stated there were residents that could self-medicate. There was an observation check list that the RN would observe and complete the assessment, and then contact the physician to get an order for [REDACTED]. If the self-administration of medication form was completed and there was an order from the physician, then the resident would be allowed to keep the inhaler at the bedside. They were not aware how often the resident was using the inhaler. If a resident did not have a self-medication assessment completed, they should not have any medications at the bedside During an interview on 4/1/22 at 10:37 AM, nurse practitioner (NP) #10 stated the resident would have been able to self-administer their own medications, but they had not received a request for an order to self-medicate. The resident could make their own decisions. During an interview on 4/1/22 at 10:53 AM, the Director of Nursing (DON) stated the resident would need an assessment completed to verify that the resident was able to administer the medication safely and correctly. An order was needed from the provider and the resident's care plan would be updated to reflect that. If a resident did not have the self-administration assessment completed, they should not have any medications at the bedside. They would expect the Unit Manager to complete a self-administration assessment and obtain a physician order if the resident wanted to self-medicate. During an interview on 4/1/22 at 11:46 AM, physician #6 stated if a resident was alert and oriented, able to understand their medications and was assessed by the nurse to be safe to administer their own medications, then they would give an order to self-medicate. They did not recall giving an order for [REDACTED]. 3(e)(1)(vi)

Plan of Correction: ApprovedMarch 6, 2025

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Plan of Correction FTAG 880 I. Immediate Action a. Resident #1 expired in the facility on [DATE] Resident #2 is no longer residing in the facility and has been discharged to home on [DATE] The Facility acknowledges that all residents on contact precautions/Isolation have the potential to be affected by this practice. b. The Director of Nursing received 1:1 re- education on [DATE] by the Regional Nurse on the Policy Infection Prevention and Control Program with emphasis on ensuring that all residents with a communicable infection, contact isolation are isolated immediately to prevent further spreading of the infection, utilizing all means, including room changes and cohorting as appropriate to ensure all residents optimum health is maintained. II. Identification of Others: a. An audit was conducted on [DATE] by the Infection Preventionist for residents on contact precautions/isolation to ensure all residents requiring contact isolation was in place and room placement was appropriate. No negative findings. III. System Changes a. The Policy and Procedure Titled Infection Prevention and Control Program dated ,[DATE] was reviewed on [DATE] and [DATE] by the Medical Director, Director of Nursing, Infection Preventionist and the Administrator with no changes made. b. The Administrator, Assistant Administrator, Nursing Administration, Social Workers, Admissions personnel and all nursing staff will be educated by the Educator/Designee on the Policy Titled Infection Prevention and Control Program dated ,[DATE] with emphasis on infection control, ensuring all residents with a communicable infection are isolated immediately to prevent further spreading of the infection utilizing cohorting and room change as appropriate to ensure all residents optimal health is maintained. c. Registered Nurse #1 will be reeducated upon return to the facility [DATE] by the Staff Educator/designee on the Policy Infection Prevention and Control Program with emphasis on ensuring that residents with a communicable infection, contact isolation are isolated immediately to prevent further spreading of the infection, utilizing room change and cohorting to ensure all residents optimum health is maintained. IV. Quality Assurance a. An audit tool was created by the Director of Nursing to review all residents placed on contact precautions to ensure staff are following infection control techniques, including isolating residents immediately, cohorting, and initiating room change when appropriate and completing patient specific care plan with completed goals and interventions. b. Audits will be completed by the Infection Preventionist weekly x 8, then monthly x 2 months and quarterly thereafter until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Director of Nursing immediately. All negative findings will be immediately addressed by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4. (to review and discuss any unfavorable patterns that may prevent achieving 100% compliance) V. Person Responsible. Director of Nursing Completion Date: (MONTH) 12th, 2025

FF15 483.10(g)(2)(i)(ii)(3):RIGHT TO ACCESS/PURCHASE COPIES OF RECORDS

REGULATION: § 483. 10(g)(2) The resident has the right to access personal and medical records pertaining to him or herself. (i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); and (ii) The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of: (A) Labor for copying the records requested by the individual, whether in paper or electronic form; (B) Supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media; and (C)Postage, when the individual has requested the copy be mailed. § 483. 10(g)(3) With the exception of information described in paragraphs (g)(2) and (g)(11) of this section, the facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information described in paragraph (g)(2) of this section may be made available to the patient at their request and expense in accordance with applicable law.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 27, 2025
Corrected date: March 12, 2025

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY 900), the facility did not ensure a resident with a communicable infection was isolated to prevent further spread of infection for 2 out of 3 (Resident #1, #2) residents reviewed for infection control. Specifically, on [DATE] the facility identified Resident #2 as having a suspected case of Norovirus during a facility outbreak. Resident #2 was the roommate of Resident #1, who did not display any symptoms of the infection on ,[DATE]/ 2024. Resident #1 remained in the same room with Resident #2 on the south unit, and Resident #1 subsequently acquired symptoms of the infection on ,[DATE]/ 2024. Facility open bed census reviewed revealed available beds on the South unit on [DATE], [DATE] and ,[DATE]/ 2024. Resident #1 expired in the facility on [DATE] from acute [MEDICAL CONDITION]. The findings are: The facility Infection Prevention and Control Program policy last reviewed (MONTH) 2024 documented the purpose is to prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. When the Infection Preventionist/Physician or current acceptable standards determines that a resident requires isolation/contact precautions to prevent the spread of infection, the facility must isolate the resident in the least restrictive way possible. Private rooms, if available may be used at the Administrator's discretion, followed by cohorting if available. If neither of the above options are possible, then the resident may be placed in the room with an unaffected resident. Cohorting is having two residents infected with the same organism share a room with each other. 1) Resident #1 had [DIAGNOSES REDACTED]. A 5-day Minimum Data Set (an assessment tool that measure health status) dated [DATE] documented the resident was cognitively intact. The resident had no functional limitations and required supervision for eating, maximal assistance with bed mobility and was dependent for toileting and transfers. The resident was always incontinent of bladder and bowel. The resident exhibited shortness of breath when lying flat. A Review of a contact precautions care plan initiated [DATE] documented Resident #1 had a suspected gastrointestinal infection. Interventions listed included contact precautions, infectious disease follow up as needed and maintain infection control practices through proper handwashing. Review of a suspected infection gastrointestinal infection care plan initiated [DATE] documented Resident #1 had nausea and diarrhea. There were no documented goals or interventions noted on the care plan. Review of a physician's orders [REDACTED]. 2) Resident #2 had [DIAGNOSES REDACTED]. A Modified 5-day Minimum (MDS) data set [DATE] documented the resident was cognitively intact. The resident required a wheelchair for locomotion and had impairment to the lower extremity on one side. The resident required set up assistance for eating, supervision for bed mobility, moderate assistance for transfers and maximal assistance for toileting. Review of a contact precaution care plan dated [DATE] documented Resident #2 had a suspected gastrointestinal infection. Interventions listed included contact precautions and to maintain infection control practices through proper handwashing. Review of an infection care plan dated [DATE] documented Resident #2 had a suspected gastrointestinal infection. Interventions listed included encourage oral fluids as indicated, encourage rest periods, maintain precautions as needed and monitor labs as ordered and report any abnormalities to the physician as necessary. Review of a physician's orders [REDACTED]. Review of the facility line list revealed Resident #2 developed symptoms of Norovirus (vomiting), on [DATE] and their symptoms resolved on ,[DATE]/ 2024. Resident #2 was Resident #1's roommate. Resident #1 developed symptoms of Norovirus (diarrhea, vomiting, nausea) on [DATE] and expired on ,[DATE]/ 2024. Review of the open bed census list revealed there were available beds on the South unit on [DATE], [DATE] and [DATE] where Resident #1 or Resident #2 could have been moved to prevent the spread of Norovirus. During an interview on [DATE] at 12:37 PM, the Director of Nursing stated they followed the isolation guidelines from New York State Department of Health regarding cohorting/isolation which indicated to separate the resident with no symptoms of the Norovirus from a room with a resident that was exhibiting symptoms or was identified as infected with [MEDICAL CONDITION]. The Director of Nursing stated room changes would not occur if they had a bed lock or if all the beds were filled. In such a situation, the resident's room would not be changed. The Director of Nursing stated the ideal way to cohort is to keep the positive resident in the room and move the exposed resident which means exposed residents can room together and positive residents can remain in the same room together. During an interview on [DATE] at 2:14 PM, Registered Nurse #1 stated on the line list a C indicate a case and they were informed if a resident was suspected and had symptoms of Norovirus, then it is a case. Registered Nurse #1 stated the residents that were suspected were treated as if they were positive for [MEDICAL CONDITION]. Registered Nurse #1 stated they did not see any cross contamination occurring with residents that were cohorted. As far as they can recollect if they were able to change the residents' room, they were moved. Registered Nurse #1 stated the residents were monitored by their symptomology. During an interview on [DATE] at 1:25 PM, the Director of Nursing stated during the period of the suspected Norovirus outbreak in the facility, there were about 30 residents that were suspected to have Norovirus. The Director of Nursing stated [MEDICAL CONDITION] was moving rapidly in the facility and as per Center for Disease Control guidance suspected and confirmed cases are treated the same. The Director of Nursing stated they did not move resident's room at the time of the outbreak. The Director of Nursing stated they agree that Resident #1 would have gotten Norovirus anyway at the pace at which it was moving in the facility, but they probably should have just moved Resident #1's room. The Director of Nursing stated they will speak with the interdisciplinary team to prepare them for future incidents. 10 NYCRR 415. 19(b)(1)

Plan of Correction: ApprovedFebruary 20, 2025

Plan of Correction F573 I. Immediate Action a. Resident #3 is no longer residing in the facility and was discharged to NYP(NAME)Valley on 5/1/ 24. b. The Director of Nursing received a 1:1 education on 2/19/25 by the Regional Nurse on the Facility Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident/resident legal representative within 2 working days advance notice to the facility is followed. c. The Medical Record Personnel received a 1:1 education on 2/19/25 by the Regional Nurse on the Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident / resident legal representative within 2 working days advance notice to the facility is followed. d. The Facility Administrator received a 1:1 Inservice on 2/19/25 by the Regional Nurse on the Facility Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident resident/legal representative within 2 working days advance notice to the facility is followed. II. Identification of Others: a. An audit was conducted on 2/19/25 by the Administrator for all request for medical records by the resident/resident legal representative within the last 14 days with no negative findings. b. The facility acknowledges that all resident who request for medical record has the potential to be affected by this practice. III. System Changes a. The Facility Medical Record Policy dated 9/2024 was reviewed on 2/19/25 by the Medical Director, Administrator, Director of Nursing with no changes made. b. The Administrator, the Assistant Administrator, DNS, ADNS and Medical Record Personnel will be reeducated on the Facility Medical Record Policy. IV. Quality Assurance a. An audit tool was created by the Administrator to audit all medical record request to ensure they are sent out timely. b. Audits will be completed by the Medical Record Personnel weekly x 4, monthly x 2 months and quarterly x 3 quarters. c. All negative findings will be brought to the attention of the Administrator immediately. All negative findings will be immediately addressed by the Administrator /Designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. V. Person Responsible. Administrator Completion date: (MONTH) 12, 2025