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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification initiated on 12/3/2024 and completed on 12/10/2024, the facility failed to ensure, to the extent practicable, the participation of the resident and the resident's representative(s) for the development of the resident's care plan. This was identified for one (Resident #66) of three residents reviewed for Care Planning. Specifically, the facility did not conduct interdisciplinary care plan meetings and did not provide notice of invitation to the resident or the resident's representative to participate in the quarterly assessments. The finding is: A facility policy and procedure titled Care Planning, effective 7/2016, revised 10/2024, documented creating a comprehensive, individualized care plan for each resident based on the assessments performed using the Minimum Data Set and ensuring compliance with Federal and State regulations. Quarterly and annual updates to the care plan, or as required due to significant changes in a resident's condition. The care plan meeting must include an interdisciplinary team. Residents and/or their legal representatives must be actively involved in the care planning process. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of seven, indicating severe cognitive impairment. A five-day Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of 10, indicating moderate cognitive impairment. The medical record lacked documented evidence that Resident #66 or the resident's representative was invited to the care plan meetings. A Social Work progress note dated 10/23/2024 documented resident was reviewed for quarterly assessment. There appears to be no significant change in status at this time. The resident was alert and verbally responsive with some forgetfulness and was able to make needs known to staff. The Resident's Family was involved and supportive. Social Work will continue to provide one-to-one visits for support. A Psychiatry consultation dated 10/17/2024 documented the resident can make their own health decisions. During an interview on 12/04/24 at 9:43 AM Resident #66 stated they did not recall attending a care plan meeting but would want to participate in the process and discuss their care. During an interview on 12/05/24 at 2:36 PM, the Director of Social Work stated the facility invites the resident and their family members to the annual and significant change reviews. The Director of Social Work stated they were not certain if a resident with a Brief Interview for Mental Status of ten should be invited to participate in the care plan meetings. They further stated there was no documented evidence that Resident #66 or their family members were invited to the quarterly care plan meetings. The Director of Social Work further stated for the quarterly assessment, the interdisciplinary team only completes the Minimum Data Set assessment with updates to the care plans; however, the team does not meet. During an interview on 12/5/2024 at 2:54 PM, Social Worker #1 stated for the quarterly review, they complete the Minimum Data Set Assessment and review the care plans. They further stated that for the quarterly assessments, there are no meetings held with the interdisciplinary teams, and the resident or their representatives are not invited. During an interview on 12/5/2024 at 2:59 PM, the Minimum Data Set Coordinator stated that the facility was not having quarterly care plan meetings. The meetings are only held for admissions, annuals, and significant change assessments, and as requested or Ad Hoc meetings. For the quarterly reviews, all disciplines only complete the Minimum Data Set assessments and update the care plans. During an interview on 12/5/2024 at 3:04 PM, the Chief Nursing Officer stated that the social work department is responsible for scheduling the interdisciplinary meetings. The meetings are held for quarterly, significant change, complaints, and annual reviews. They further stated that the residents are invited barring a cognition impairment. The Chief Nursing Officer stated they were not aware that the interdisciplinary care plan team was not holding meetings at all for the quarterly assessments. 10 NYCRR 415. 11(c)(2) (i-iii) | Plan of Correction: ApprovedJanuary 8, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #66 On 12/30/24, the IDCP Team held a meeting with the resident to review his/her plan of care and address any questions or concerns that the resident had. The resident indicated that he/she agreed with the current plan of care. The residents preference to be invited to and attend all care plan meetings was reviewed and documented in the residents record. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents could be potentially affected by the same practice. Effective 12/19/24, the IDCP Team will hold quarterly care plan reviews that includes the resident and/or representative. Residents and/or their representatives will continue to be invited to the other meetings. The IDT will meet with each resident who has had a Quarterly MDS Assessment in the past 3 months to provide an update on their plan of care. For residents who are unable to participate, the residents representative will be provided with an update to the plan of care. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer, and Director of Social Work reviewed the facility policy, ?ôCare Planning,?Ø and revised it to reflect the need to hold quarterly care plan meetings with the IDCP Team and ensure that the resident and/or representative are invited to participate. The IDCP Team was provided with education by the Director of Social Work regarding the revisions to the policy and changes to the facilitys care plan meeting protocol. All Social Workers were educated regarding the care planning process and their responsibility to ensure that residents have the right to participate in planning their care, including attending all care plan meetings. The Social Worker will ensure that all cognitively intact residents, including those who have been evaluated by Psychiatry and have can make their own decisions, and their representatives, as appropriate, are invited to all care plan meetings, including quarterly meetings. If the residents preference is to have a representative attend or be updated on the plan of care, this preference will be documented in the resident record and honored. The Social Worker will ensure that the representatives of residents who cannot or do not wish to participate in planning their care are invited to all meetings. Any resident who declines to participate will be provided with an update on the plan of care after the meeting if this is his/her preference. Members of the IDCP Team will follow up on concerns or questions as needed. The Social Workers were educated to document all care plan invitations and attendance, including for quarterlies, in the resident record. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: An audit tool will be developed to monitor compliance with the facilitys policy to ensure residents and/or their representatives are invited to participate in all care plan meetings, including quarterlies. Director of Social Work and/or Designee will conduct a 100% review of all care plan meeting attendance records to ensure that the resident and/or representative were invited to all care plan meetings, including quarterly meetings monthly for 3 months and then quarterly for an additional two quarters. The Director of Social Work will report all care plan meeting attendance findings to the Administrator. The audit findings will be reported monthly to the QAPI Committee for 3 months and then quarterly for 2 quarters for discussion, evaluation and follow-up action. The QAPI Committee will evaluate the need for continued monitoring at the end of the reporting period. The acceptable level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Director of Social Work |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification and abbreviated survey (NY 065) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident needs, This was identified for one (Resident #73) of six residents reviewed for Accidents. Specifically, Resident #73 required two-person assistance with bed mobility and mechanical lift transfers. On 11/18/2024, Certified Nursing Assistant #14 turned and positioned Resident #14 by themselves and used a mechanical lift transfer to transfer Resident #73 from bed to their wheelchair without assistance. The finding is: The Facility Policy for Hoyer Lift Transfer last revised on 4/2023 documented Lift transfers must be completed by two employees using the following procedure to ensure the safe transfer of residents and protect employees from injury. The procedure documented nursing staff will explain the procedure to the resident, follow the mechanical lift (manufacturer's) instructions for the use of the mechanical lift, and use two employees for safety. The facility employee counseling form dated 1/30/2023 documented that Certified Nursing Assistant #14 received a verbal education on 1/30/ 2024. Certified Nursing Assistant #14 was assigned to a resident who required extensive assistance of two persons for a transfer and Certified Nursing Assistant #14 transferred the resident without a second staff member. The resident became weak, was lowered to the floor, and had no injury. The form documented This is determined to be a failure to follow the resident's plan of care. Any further issues of this nature will require progressive discipline up to and including termination. Corrective Action: The Certified Nurse Assistant was instructed to always check the plan of care before providing care to the resident. If the resident's transfer status is two-person assistance, another Certified Nurse Assistant is to assist. A review of Certified Nurse Assistant #14's facility in-service education records revealed Certified Nurse Assistant #14 did not receive re-education regarding resident transfers in 2024. Resident #73 was admitted with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented the Resident had severely impaired cognition. The resident had functional limitations in the range of motion on both the lower and upper extremities. The resident was dependent on two or more helpers for bed mobility and required the helper to make all the effort. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) effective 6/3/2024 documented Resident #73 was dependent on two or more staff members' physical assistance for bed mobility. The Resident Nursing Instructions effective 11/22/2024 documented that Resident #73 was dependent on two or more staff members' physical assistance for mechanical lift transfers. The transfer instructions dated 11/18/2024 documented to ensure the resident was centered in the mechanical lift pad prior to lifting (the resident tends to lean to the right side) and to assist the resident in crossing arms over the chest for transfers. The physician's orders [REDACTED]. The Fall/Injury care plan dated 5/3/2019 and reviewed on 11/18/2024 documented Resident #73 was at increased risk for falls or injury related to a history of falls and injury, [MEDICAL CONDITION] with right [MEDICAL CONDITION] (weakness), need for assistance with activities of daily living, Dementia, Contractures, and [MEDICAL CONDITION] Disorder. Interventions included but were not limited to keeping the bed in the lowest position and checking the resident frequently to ascertain needs. The care plan note dated 11/18/2024 documented the resident had a bruise on their head that measured 2 centimeters on a round raised area with a 0. 25-centimeter linear small opening to their forehead. The Accident and Incident Report dated 11/18/2024 documented that after showering Resident #73, the assigned Certified Nursing Assistant #14 placed Resident #73 back to bed with a mechanical left with two-person assistance. Certified Nursing Assistant #14's statement documented they were assisted by the nurse for this transfer, and they observed the resident grabbing at the mechanical lift bar and immediately after the event, the Certified Nursing Assistant noticed a lump on the resident's forehead. The Accident and Incident Report concluded that Certified Nursing Assistant #14 did not ask for assistance. The nurses did not assist Certified Nursing Assistant #14 with the mechanical lift transfer and Certified Nursing Assistant #14 performed Resident #73's transfer independently. The facility employee Corrective Action dated 11/18/2024 documented that Certified Nursing Assistant #14 did not follow the plan of care and performed two-person assistance via a mechanical lift without assistance from staff resulting in resident injury. Certified Nursing Assistant #14 was previously warned or suspended for a similar occurrence. During an observation on 12/03/2024 at 11:00 AM, Resident #73 was observed in their room seated in their wheelchair with a faded discoloration on the left upper face. Resident #73 was not able to engage in an interview. During an interview on 12/05/2024 at 12:30 PM, Certified Nursing Assistant #14 stated Resident #73 required two-person assistance for bed mobility and mechanical lift transfers. Certified Nursing Assistant #14 stated they utilized the draw sheet to position Resident #73 in the bed during the morning care and incontinence care. Certified Nursing Assistant #14 stated after they placed Resident #73 on the mechanical lift sling, they hooked the sling to the mechanical lift and left the room to get assistance. Certified Nursing Assistant #14 stated then they transferred Resident #73 alone because they thought a nurse was in the hallway. Certified Nursing Assistant #14 stated no one physically helped them to transfer Resident #73 out of the bed. Certified Nursing Assistant #14 stated the unit was not short of staff on 11/18/ 2024. Certified Nursing Assistant #14 stated they did not observe Resident #73 hit their forehead. Certified Nursing Assistant #14 stated Resident #73 may have put their face on the mechanical lift bar which caused the forehead lump. During an interview on 12/05/2024 at 1:29 PM, Registered Nurse Risk Manager #7 stated Registered Nurse Risk Manager #7 stated they interviewed all staff scheduled on the unit and found out Certified Nursing Assistant #14 did not ask for assistance with the lift transfer and later admitted to transferring Resident #73 without assistance. Registered Nurse Risk Manager #7 stated Certified Nursing Assistant #14 had a previous history of not utilizing two persons and was educated at that time related to the incident. During an interview on 12/10/2024 at 12:29 PM, the Director of Nursing Services stated Certified Nurse Assistant #14 did not follow Resident #73's plan of care to utilize the mechanical lift to transfer with a second person. The Director of Nursing stated the facility would not tolerate such behavior and it was not safe for the resident. The Director of Nursing stated the mechanical lift required two-person assistance and it was not acceptable for Certified Nursing Assistant #14 to transfer the resident without a second staff member. 10 NYCRR 415. 26(c)(1)(iv) | Plan of Correction: ApprovedDecember 31, 2024 I. The following actions were accomplished for the residents identified in the sample: Resident #73 On 11/18/24, the IDCP Team reviewed the residents plan of care related to risk for accidents and determined that the resident continues to require two-person assistance with bed mobility and two-person assistance with a mechanical lift for transfer in and out of bed. CNA #14, who repositioned the resident and completed the mechanical lift transfer without a second staff member providing assistance to complete these tasks was terminated. On 12/30/24, the Chief Nursing Officer met with the Staff Educator to review her responsibility to monitor and ensure that all required CNA annual competencies, including two-person assisting with turning and positioning in bed and mechanical lift transfers are completed by each CNA. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require two-person assistance with turning and positioning and/or require the use of a mechanical lift for transfers have been identified as potentially being affected by the same practice. The Staff Educator will identify all CNAs who have not completed competencies related to two-person assistance for turning and positioning in bed and completing a mechanical lift for transfer during 2024. All identified CNAs will have these competencies completed by 01/31/ 2025. III. The following system changes will be implemented to assure continuing compliance with regulations: The Chief Nursing Officer and Staff Educator will review the facilitys list of annual CNAs competencies and will revise the competency list as needed. Annual competencies will continue to include two-person assistance with turning and positioning/bed mobility and two-person assist mechanical lift transfers. The Staff Educator/designee will schedule and complete annual competency training for all CNAs during 2025 to ensure that all CNAs are able to demonstrate that they are competent to provide care and services as outlined in each residents person-centered plan of care. The RN Supervisors and Nurse Managers will continue to monitor for compliance with the Nursing staff following the plan of care during routine and random rounds and observations of care being provided, staff assistance with bed positioning, and transfers being completed with a mechanical lift and two-person assist to ensure the plan of care is being followed and staff demonstrate care practices consistent with facility policy. Immediate corrective actions, such as staff reeducation on bed mobility assistance, transfer/use of a mechanical lift and responsibility to follow the plan of or revision of the plan of care to meet a residents care needs based on a change in status. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with all CNAs completing the required CNA competency training annually. The Nurse Manager/designee will complete 5 random unannounced competency observation audits to assess compliance with safe provision of care consistent with the ADL/transfer assist instructions weekly x 4 weeks then monthly x 3 months inclusive of all 3 shifts. Residents requiring two-person assistance with bed mobility and/or two-person assist with a mechanical lift transfer will be included in the audit sample. Auditing will begin early 01/ 2025. The Staff Educator/designee will review and summarize all observation audits on a weekly then monthly basis as outlined above and will report all findings to the Chief Nursing Officer and Administrator. Corrective actions will be implemented based on summary information. The Staff Educator will report competency audit findings to the QAPI Committee monthly during the 4-month monitoring period for discussion, evaluation, and follow-up corrective action. At the end of the 4-months a decision will be made regarding the need for ongoing auditing and at what frequency. Completion Date: 01/31/2025 Responsibility: Staff Educator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident to meet each resident's medical and nursing needs. This was identified for one (Resident #152) of one resident reviewed for Accommodation of Needs. Specifically, Resident #152 had a physician's orders [REDACTED]. Resident #152 was observed on multiple occasions sitting in the wheelchair without the leg rests. The finding is: The facility's policy titled Wheelchair Safety, effective (MONTH) (YEAR), documented you must never transport a resident without foot pedals regardless of locomotion status. Make sure feet are on foot pedals when the resident is in the wheelchair. The facility's policy titled Wheelchair Transport, dated (MONTH) (YEAR), documented that foot pedals must be on the chair if staff are pushing a resident. The feet must be on the foot pedals. Resident #152 was admitted with a [DIAGNOSES REDACTED]. The Minimum Data Set assessment documented that the resident used a wheelchair. A physician's orders [REDACTED]. A Comprehensive Care Plan titled Activities of Daily Living-Functional Abilities: Self Care and Mobility Care Plan, effective 10/28/2024, documented the resident has self-care and mobility limitations related to Advanced Dementia. An intervention included providing a standard wheelchair with foam cushion and bilateral elevating leg rests. During an observation on 12/3/2024 at 11:45 AM, Resident #152 was observed in the open recreation area on the Kipp unit (secure dementia unit), sitting in their wheelchair. The wheelchair did not have bilateral leg rests in place, the resident was wearing socks and the resident's feet were resting on the floor. Certified Nursing Assistant #1 was overheard noting Resident #152's wheelchair did not have leg rests. Certified Nursing Assistant #1 left the area and returned moments later with two leg rests and said they were the wrong size for the resident's wheelchair. Eventually, Resident #152 walked to the lunch area with the assistance of another Certified Nursing Assistant. During an interview on 12/3/2024 at 11:50 AM, Certified Nursing Assistant #1 stated they were not regularly scheduled to the resident's unit. When they noticed the resident did not have the leg rests on their wheelchair, they went to check the spare supply area where leg rests are kept but there were no leg rests that fit Resident #152's chair. Certified Nursing Assistant #1 stated they had also checked Resident #152's room for leg rests but there were none in the room. During an observation on 12/3/2024 at 2:30 PM, Resident #152 was observed in the recreation area sitting in their wheelchair with no leg rests on the wheelchair. The resident's feet were on the floor with socks on. During an observation on 12/4/2024 at 12:02 PM, Resident #152 was observed in the lunch area waiting for lunch. The resident was sitting in a wheelchair with no leg rests. During an interview on 12/5/2024 at 9:15 AM, the Rehabilitation Department Director stated most of the residents are provided the leg rests so the residents' legs do not hang down. The leg rests are also needed while transporting residents from one place to another. The Rehabilitation Department Director stated Resident #152 did not self-propel their wheelchair with their feet therefore, the leg rests should always be used on the wheelchair as per the physician's orders [REDACTED]. During an observation on 12/5/2024 at 9:35 AM, Resident #152 was observed at breakfast in the Kipp unit dining area. The resident was sitting in a wheelchair with no leg rests. The resident had socks on and their feet were on the floor. During an interview on 12/5/2024 at 9:46 AM, Licensed Practical Nurse #2 stated a work order was put in yesterday with the maintenance department to get the leg rests for Resident #152's wheelchair. Licensed Practical Nurse #2 stated they just noticed that the resident's wheelchair did not have the leg rests. During an observation on 12/5/2024 at 9:51 AM, while Resident #152 was still in the dining area, a maintenance staff member was observed fitting leg rests to the resident's wheelchair. During a re-interview on 12/5/2024 at 12:30 PM, Certified Nursing Assistant #1 stated staff are not supposed to move residents in a wheelchair without leg rests because of safety issues. Certified Nursing Assistant #1 stated on 12/3/2024 when they were moving residents from the recreation area to the dining area, they noticed that Resident #152 did not have leg rests. Licensed Practical Nurse #3 told them to check the spare supply room and the resident's room, but there were no leg rests for the resident's wheelchair on the unit. During an interview on 12/5/2024 at 1:08 PM, the Director of Nursing Services stated if there is a physician's orders [REDACTED]. The Certified Nursing Assistant should not have been directed to find the spare wheelchair parts. That is not the Certified Nursing Assistant's job. As soon as the staff noticed that the leg rests were not there, they should have called the Maintenance and Rehabilitation department. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedDecember 31, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #152 On 12/5/24 Rehabilitation staff checked the residents wheelchair to ensure that the leg rests placed by the maintenance staff were appropriate for the resident and were consistent with the residents care plan for use of elevating leg rests as per physician order [REDACTED]. The IDCP Team reviewed the overall CCP to ensure that it was person-centered, and no issues were identified. The Nurse Manager reviewed the plan of care with the unit staff to ensure that staff understood the importance of adhering to the facility policy for Wheelchair Safety, physician orders [REDACTED]. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require the use of a wheelchair with leg rests have been identified as potentially being affected by the same practice. The Nurse Managers and Rehabilitation staff will identify all residents who require a wheelchair with leg rests. The IDCP Team will review the plan of care for all identified residents to ensure that an order for [REDACTED]. The IDT will continue to review and revise each residents CCP on a quarterly and as needed basis to ensure that the CCP is person-centered for the individual resident. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer and MDS Coordinator reviewed the policy and procedure for Comprehensive Care Plans, including protocols related to person-centered care plans and staff following the plan of care for individual resident needs, such as providing leg rests to residents who require the use of a wheelchair and leg rests, and determined that the policy is consistent with the facilitys practices. The Staff Educator/designee will provide education to the IDCP Team regarding care planning protocols and the facilitys policy. Education will address the importance of adhering to the plan of care related to person-centered interventions, such as providing a wheelchair with leg rests as ordered. This education will be incorporated into the orientation of new IDCP Team members and will be reviewed on an as needed basis. The Nurse Managers/designee will monitor compliance with the comprehensive care plan policy during review of the comprehensive care plan at care plan meeting discussions and during audits of staff following the person-centered care plan interventions. Immediate corrective actions, such as revision/updating of an individual residents care plan or staff re-education regarding following the person-centered interventions, will be implemented, as needed. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Chief Nursing Officer and MDS Coordinator will develop an audit tool to monitor compliance with the requirements of F-656 including person-centered care plan interventions and staff adherence to following the plan of care. The MDS Coordinator/designee will audit 20% of resident CCPs monthly for the next three months and then quarterly for an additional two quarters. Residents requiring a wheelchair with leg rests will be included in the audit sample. All care plan audit findings will be reported to the Administrator and CNO. Corrective action, such as staff re-education regarding following the plan of care or revision/updating of a residents CCP, will be implemented as indicated. The MDS Coordinator will report all comprehensive care plan audit findings to the QAPI Committee monthly for three months and then quarterly for an additional two quarters for evaluation and discussion. The accepted level of compliance is 95%. At the end of the 3rd quarter a decision will be made by the QAPI Committee regarding the need for ongoing monitoring specific to comprehensive care planning and at what frequency. Completion Date: 01/31/2025 Responsibility: MDS Coordinator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details Based on observation, record review, and interviews during the recertification initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task observation on 12/4/ 2024. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, potato salad, pudding) at the time of meal service. The finding is: A facility policy and procedure titled Food Preparation, documented time/temperature control for safe food (formerly known as potentially hazardous food) means a food that requires time/temperature controls for safety to limit pathogenic organism growth or toxin formation. The Dining Services Director/Cook(s) is responsible for food preparation techniques, which minimize the amount of time food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit or per state regulation. The Cook(s) ensures that all foods are held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulation requires) for hot food holding and less than 41 degrees Fahrenheit for cold food holding. A facility policy and procedure titled Food Storage: Cold documented that frozen and refrigerated food items will be appropriately stored in accordance with the guidelines of the Food and Drug Administration food code. The Dining Services Director/Cook(s) ensures that all perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below except during necessary periods of preparation and service. During an observation of the kitchen on 12/4/2024 at 11:07 AM, a hi-riser food truck was observed with a variety of sandwiches and individual cups of potato salad. The tray line lunch service began at 11:15 AM. There was no documented evidence that cold food temperatures were taken. During an interview on 12/4/2024 at 11:16 AM, the Executive Chef stated cold food temperatures are not obtained because the food is held in the refrigerator, therefore they use the refrigerator temperature for the cold food items. The Executive Chef tested the temperature of several food items not stored in the refrigerator and were being served during the lunch meal service. The temperature findings were: a tuna sandwich was measured at 50 degrees Fahrenheit, a ham sandwich was measured at 48 degrees Fahrenheit, potato salad was measured at 48 degrees Fahrenheit, and pudding was measured at 50 degrees Fahrenheit. The Executive Chef stated that the cold food temperature should be between 30 to 40 degrees Fahrenheit. The Executive Chef stated that with these increased food temperatures, there is an increased risk of foodborne illness for the residents. During an interview on 12/04/2024 at 11:22 AM, Registered Dietitian #1 stated that serving temperatures for cold food items should be kept under 30 degrees Fahrenheit. During an interview on 12/05/2024 at 11:34 AM, the General Manager of the vendor company that provides dietetic services to the facility stated that cold food should never be above 41 degrees Fahrenheit. They further stated that the cold food that was not stored in the refrigerator should have been held on a bed of ice. The General Manager of the vendor company that provides dietetic services to the facility stated if the cold food was stored above the required temperature range, there could be potential for harm/foodborne illness. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedJanuary 10, 2025 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiencies. On 12/4/24, any cold food items that were above 41F degrees were removed from trayline and replaced with new product. The Food Service Director and RDO toured the kitchen to identify any other food item temperature concerns. No other items were identified. 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 being affected by the same practice. Effective 12/4/24, in-service education was provided to Dietary Staff and RDs related to cold food holding procedure on trayline and monitoring of cold food temperatures at every meal. This education included monitoring cold food temperatures on the trayline at each meal, and procedures for holding cold food that is not being held in a refrigerated unit, including holding food on ice or using ice blankets. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Food Service reviewed and revised, as needed, the Food Service policies and procedures related to monitoring of cold food temperatures at mealtimes and holding of cold foods on trayline. Effective 12/4/24, the Director of Food service/Designee will implement system of holding all cold food items on tray line in refrigerator unit, or on other cold source including ice or ice blankets, and monitoring of cold food temperatures at every meal on a temperature log sheet to ensure cold food temperatures are being held appropriately and remain 41F degrees and below daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/Designee will provide additional education to all dietary staff whenever issues related to holding, monitoring and recording of cold food temperatures are identified. The Director of Food Service will review findings with the Administrator monthly for three months then quarterly. Effective 12/4/24, the Food Service Director/Designee will monitor cold food holding and monitoring and recording of cold food temperatures daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/Designee will provide additional education to all food service workers whenever issues related to cold food holding and monitoring and recording of cold food temperatures are identified. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with cold food holding on cold source and monitoring and recording of cold food trayline temperatures on temperature log during meal service. The Director of Food Service/Designee will conduct monitoring of cold food holding and monitoring and recording of cold food temperatures monthly for three months then quarterly for the next three quarters. The Director of Food Service/Designee will conduct competency evaluations of all Food Service workers to ensure they are following established protocols and have a clear understanding of the protocols. On-site education will be provided as necessary to ensure staff compliance. Competency evaluations will be conducted on all new Food service Workers upon completion of orientation and twice yearly thereafter. The Food Service Supervisor/Designee will report cold food holding and monitoring and recording cold food temperatures audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the QAPI Committee. Completion Date: 01/31/2025 Responsibility: Director of Food Service |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification and abbreviated survey (NY 065) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure the resident environment remained as free of accident hazards as possible and the residents received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #73) of six residents reviewed for Accidents. Specifically, Resident #73 required two-person assistance with bed mobility and for a mechanical lift transfer to and from the bed. On 11/18/2024, Certified Nursing Assistant #14 turned and positioned Resident #14 by themselves and used a mechanical lift transfer to transfer Resident #73 from bed to their wheelchair without assistance. The finding is: The Facility Policy for Hoyer Lift Transfer last revised on 4/2023 documented Lift transfers must be completed by two employees using the following procedure to ensure the safe transfer of residents and protect employees from injury. The procedure documented nursing staff will explain the procedure to the resident, follow the mechanical lift (manufacturer's) instructions for the use of the mechanical lift, and use two employees for safety. Resident #73 was admitted with [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented the Resident had severely impaired cognition. The resident had functional limitations in the range of motion on both the lower and upper extremities. The resident was dependent on two or more helpers for bed mobility and required the helper to make all the effort. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) effective 6/3/2024 documented Resident #73 was dependent on two or more staff members' physical assistance for bed mobility. The Resident Nursing Instructions effective 11/22/2024 documented that Resident #73 was dependent on two or more staff members' physical assistance for mechanical lift transfers. The transfer instructions dated 11/18/2024 documented to ensure the resident was centered in the mechanical lift pad prior to lifting (the resident tends to lean to the right side) and to assist the resident in crossing arms over the chest for transfers. The physician's orders [REDACTED]. The Fall/Injury care plan dated 5/3/2019 and reviewed on 11/18/2024 documented Resident #73 was at increased risk for falls or injury related to a history of falls and injury, [MEDICAL CONDITION] with right [MEDICAL CONDITION] (weakness), need for assistance with activities of daily living, Dementia, Contractures, and [MEDICAL CONDITION] Disorder. Interventions included but were not limited to keeping the bed in the lowest position and checking the resident frequently to ascertain needs. The care plan note dated 11/18/2024 documented the resident had a bruise on their head that measured 2 centimeters on a round raised area with a 0. 25-centimeter linear small opening to their forehead. The Accident and Incident Report dated 11/18/2024 documented that after showering Resident #73, the assigned Certified Nursing Assistant #14 placed Resident #73 back to bed with a mechanical left with two-person assistance. Certified Nursing Assistant #14's statement documented they were assisted by the nurse for this transfer, and they observed the resident grabbing at the mechanical lift bar and immediately after the event, the Certified Nursing Assistant noticed a lump on the resident's forehead. Resident #73 was unable to explain the event due to impaired cognition. Resident #73 departed the facility for a scheduled [MEDICAL TREATMENT] appointment and was sent to the hospital Emergency Department for a Computed Tomography scan of the head from the [MEDICAL TREATMENT] Center because the resident receives [MEDICATION NAME] during [MEDICAL TREATMENT]. The Computed Tomography scan results were negative, but the resident was admitted on [DATE] at 5:00 PM with the [DIAGNOSES REDACTED]. The Accident and Incident Report concluded that Certified Nursing Assistant #14 did not ask for assistance. The nurses did not assist Certified Nursing Assistant #14 with the mechanical lift transfer and Certified Nursing Assistant #14 performed Resident #73's transfer independently. During an observation on 11/03/2024 at 11:00 AM, Resident #73 was observed in their room seated in their wheelchair with a faded discoloration on the left upper face. Resident #73 was not able to engage in an interview. During an interview on 12/05/2024 at 12:30 PM, Certified Nursing Assistant #14 stated Resident #73 required two-person assistance for bed mobility and mechanical lift transfers. Certified Nursing Assistant #14 stated they utilized the draw sheet to position Resident #73 in the bed during the morning care and incontinence care. Certified Nursing Assistant #14 stated after they placed Resident #73 on the mechanical lift sling, they hooked the sling to the mechanical lift and left the room to get assistance. Certified Nursing Assistant #14 stated then they transferred Resident #73 alone because they thought a nurse was in the hallway. Certified Nursing Assistant #14 stated no one physically helped them to transfer Resident #73 out of the bed. Certified Nursing Assistant #14 stated the unit was not short of staff on 11/18/ 2024. Certified Nursing Assistant #14 stated they did not observe Resident #73 hit their forehead. Certified Nursing Assistant #14 stated Resident #73 may have put their face on the mechanical lift bar which caused the forehead lump. During an interview on 12/05/2024 at 12:55 PM, Licensed Practical Nurse #4 stated on 11/18/2024 at approximately 12:00 PM, Certified Nursing Assistant #14 brought Resident #73 to the nurse's station and reported that Resident #73 was ready for [MEDICAL TREATMENT] pick up. Licensed Practical Nurse #4 stated they brought Resident #73 to the lunchroom to eat before the [MEDICAL TREATMENT] appointment and observed Resident #73's face with a lump and a small cut. Licensed Practical Nurse #4 stated they administered medication to the resident in the morning and the resident did not have that lump in the morning. Certified Nursing Assistant #14 told them that Resident #73's head was resting on the mechanical lift bar which may have caused the lump. Licensed Practical Nurse #4 stated Certified Nursing Assistant #14 did not ask for assistance with the mechanical lift transfer. Licensed Practical Nurse #4 stated Registered Nurse #3 and Registered Nurse #7 assessed Resident #73 and notified the Physician. Resident #73 was subsequently transported to the [MEDICAL TREATMENT] Center and the [MEDICAL TREATMENT] Center sent Resident #73 to the hospital to rule out a head injury. During an interview on 12/05/2024 at 1:10 PM, Registered Nurse #3 stated on 11/18/2024, they were called to the nurse's station by Licensed Practical Nurse #4 to assess Resident #73's face. Registered Nurse #3 stated they observed the raised area on Resident #73's forehead with a small opening. Registered Nurse #3 stated they reported the injury to Registered Nurse #7 immediately. Registered Nurse #3 stated Certified Nursing Assistant #14 did not ask for help with Resident #73's transfer. Registered Nurse #3 stated Resident #73 required two persons' assistance for bed mobility and transfer. During an interview on 12/05/2024 at 1:29 PM, Registered Nurse Risk Manager #7 stated Registered Nurse Risk Manager #7 stated they interviewed all staff scheduled on the unit and found out Certified Nursing Assistant #14 did not ask for assistance with the lift transfer and later admitted to transferring Resident #73 without assistance. During an interview on 12/09/2024 at 2:31 PM, Certified Nursing Assistant #1 stated that Certified Nursing Assistant #14 did not ask for assistance to transfer Resident #73 on 11/18/ 2024. Certified Nursing Assistant #1 stated Resident #73 required two-person assistance with transfers and bed mobility. Certified Nursing Assistant #1 stated they did not obser | Plan of Correction: ApprovedJanuary 9, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #73 On 11/18/24, the IDCP Team reviewed the residents plan of care related to risk for accidents and determined that the resident continues to require two-person assistance with bed mobility and two-person assistance with a mechanical lift for transfer in and out of bed. The Nurse Manager reviewed that plan of care for two-person assist for bed mobility and mechanical lift transfers with unit staff. CNA #14, who completed the mechanical lift transfer without assistance causing the resident to sustain a head injury that required a CT scan was terminated. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Nurse Managers and IDCP Team will identify all residents who are at risk for an accident through a review of accident risk associated assessments, need for supervision and assistance with ADL care, including all residents who require two-person assist with transfer and a mechanical lift, and have impaired cognitive status. The IDCP Team will review the care plan and CNA Care Instructions for all identified residents to ensure that the care plan and CNA Care Instructions are current and include resident-specific interventions for supervision and assistance , including two-person transfers with a mechanical lift, necessary to prevent an accident. The responsible Nurse Manager/designee will review any changes to the plan of care with the responsible unit staff. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director, Chief Nursing Officer and Risk Manager will review the facilitys policies and procedures for Accident Prevention, including protocols related residents who require the use of a mechanical lift with two-person assist for transfers. The Staff Educator / designee will provide general reeducation to all staff regarding Accident Prevention and resident safety. Education for the Nursing staff will also include following the plan of care for residents who require a mechanical lift for transfer with two-person assist. All CNAs will be reeducated on the requirement to review the ADL/Care instructions prior to providing care or transferring a resident. Accident Prevention education will be included in the orientation of all staff and be reviewed annually and as needed. Nursing-specific education on Accident Prevention will be provided during orientation, annually and on an as needed basis. The RN Supervisors and Nurse Managers will continue to monitor for compliance with accident prevention protocols during routine and random rounds and observations of care being provided/transfers being completed to ensure the plan of care is being followed to prevent accidents. Residents who require two-person assistance with a mechanical lift for transfer will be monitored for staff compliance with two person transfer assist as outlined in the plan of care. The Unit Manager/shift charge nurse will conduct random checks of staff following the plan of care related to two-person assist with a mechanical lift. Immediate corrective actions, such as staff reeducation regarding a two-person transfer/use of a mechanical lift and responsibility to follow the plan of care or updating of the plan of care to prevent an accident when a resident requires a different level of ADL/transfer assistance, will be implemented as needed. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with adhering to the Accident Prevention Policy, including protocols for following the residents individual ADL/transfer plan of care for assistance to be provided to prevent accidents. The Nurse Manager/designee will complete 5 random unannounced observation audits to assess compliance with safe provision of care consistent with the ADL/transfer assist instructions weekly x 4 weeks then monthly x 3 months inclusive of all 3 shifts. The ADL/transfer assist instructions will be audited at the same time for accuracy. Residents who require a two-person transfer assist with a mechanical lift will be included in the audit sample. The Risk Manager/designee will audit 15% of all Occurrence Reports on a quarterly basis to determine compliance with Accident Prevention protocols. All findings will be reported to the Administrator. The Risk Manager/Designee will continue to report accident prevention and supervision audit findings to the QAPI Committee, minimally, on a quarterly basis for discussion, evaluation, and follow-up corrective action. The accepted level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #46) of five residents observed during medication administration. Specifically, during the medication administration observation for Resident #46 on 12/4/2024, Registered Nurse #1 handled the oral medication tablets with their bare hands and administered those medications to the resident. The finding is: The facility's policy titled Medication Pass via Medication Cart, dated 12/2016, documented to follow infection control policies while administering medication. Hold the back of the blister card over the souffle cup and pop the pill into the cup without touching the pill. The facility policy titled Infection Control-Strategy of Investigation, Control, Prevention, last reviewed 4/2023 documented, that the facility will investigate, control, and prevent infections through a structural program of observation, reporting, and education. The purpose is to prevent the spread of infections; to prevent the occurrence and/or spread of contagious or communicable disease; to identify and control nosocomial infections through education and effective treatment; and to increase awareness of staff as to modes of transmission, courses, and treatment of [REDACTED]. Resident # 46 was admitted with [DIAGNOSES REDACTED]. The 9/25/2024 Annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. During the medication pass observation on 12/4/2024 at 8:50 AM for Resident #46, Registered Nurse #1 prepared the following physician-ordered medications for administration: [MEDICATION NAME] (blood pressure medication) 5 milligrams tablet, Vitamin D3 (supplement) 1,000-unit tablet, Eliquis (blood thinner) 5 milligrams tablet, [MEDICATION NAME] (antacid) 20 milligrams tablet, [MEDICATION NAME] (antidepressant) 20 milligrams capsule, [MEDICATION NAME] (diuretics) 40 milligrams tablet, [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 500 milligrams tablet, Memantine (Dementia medicine) 10 milligrams tablet, Potassium Chloride (supplement) 20 milliequivalent (tablet), and Vitamin C (supplement) 500 milligram tablet. The nurse removed each tablet/capsule from their respective blister pack/bottle, without touching the tablets/capsules, and placed them in a souffle cup. Registered Nurse #1 entered Resident #46's room and explained each medication to the resident by pouring the medications from the souffle cup onto the resident's overbed table. The table was not sanitized and did not have a barrier on it. Registered Nurse #1 touched each medication with their bare hand while they explained each medication to the resident. After explaining all the medications to the resident, the nurse picked up all the medications with bare fingers, placed them back in the souffle cup, and then administered the medications to the resident. During an interview on 12/4/2024 at 8:55 AM, Registered Nurse #1 stated the resident said it was OK to place the medications on the overbed table; however, they probably should have placed a barrier on the table and should have used gloves when touching the medications. During an interview on 12/5/2024 at 8:19 AM, the Registered Nurse Inservice Coordinator stated handling medications with bare hands is not acceptable. Nurses can explain what the medication is without handling the medication; nurses should never touch the medication with their bare hands. During an interview on 12/5/2024 at 8:36 AM, the Director of Nursing Services stated handling the medications with bare hands absolutely should not have happened. During an interview on 12/9/2024 at 10:30 AM, the Registered Nurse Infection Preventionist stated the nurse should not touch the medications with bare hands. There are ways to show and teach the resident which medications are being given without touching the medications. 10 NYCRR 415. 19(a)(1-3) | Plan of Correction: ApprovedJanuary 10, 2025 I. The following actions were accomplished for those residents found to have been affected by the deficient practice: Resident #48 On 12/11/24, the resident was evaluated by the Physician who determined that the resident exhibited no signs or symptoms of an infection following consuming medications that the nurse had handled with her bare hands. RN #1 On 12/5/24, the Staff Educator provided education to RN #1 related to general principles of infection control related to medication administration include not touching a residents medication with the nurses bare hands. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. Effective 12/5/24, all licensed nurses, who are responsible for medication administration, will have a medication administration competency, including an assessment of the staff members infection control practices and management of a residents medication without touching the medication with their bare hands during administration, completed by the Staff Educator/designee. III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 12/18/24, the Administrator, Medical Director, Chief Nursing Officer and Infection Preventionist reviewed the policy and procedure for medication administration and associated infection control practices related to medication management and not handling a residents medication during the administration process. The Staff Educator will conduct additional medication administration competency skill evaluations, that includes a review of acceptable infection controls that the nurse must adhere to when administering medication for any licensed nurse who did not successfully pass the initial medication competency completed for all nurses responsible for medication administration as outlined above in Section II. Medication administration competencies will continue to be included in the licensed nurses orientation and will be reviewed on an as needed basis. Inservice education on general infection control practice will continue to be provided annually. Licensed nurses infection control education will include standards of practice associated with medication administration. The Infection Preventionist and Nursing Supervisors will monitor for compliance with general infection control practices including protocols related to medication administration during routine and random rounds on the resident units. Findings will be documented on the Infection Control Rounding audit tool. Immediate corrective actions, such as counselling or reeducating staff, will be implemented as needed. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The Staff Educator/designee will audit 5 licensed nurses during medication administration for compliance with hand hygiene and infection control practices weekly for one month then 10 licensed nurses monthly for the next two months and then on a quarterly basis for the next two quarters. Licensed nurses from all shifts will be included in the audit sample. All audit findings will be reported to the Administrator and Chief Nursing Officer. Additional corrective action, such as staff reeducation or competency retesting, will be implemented as indicated. The Infection Preventionist will continue to conduct routine weekly Infection Control Rounds and will report findings from rounds, infection control rates and other pertinent infection control data to the QAPI Committee, minimally, on a quarterly basis for discussion, evaluation and follow-up corrective actions. Completion Date: 01/31/2025 Responsibility: Infection Preventionist |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that all medications and biologicals were stored properly and labeled in accordance with currently accepted pharmaceutical principles and practices. This was identified for one (Resident #19) of six residents reviewed for Accidents. Specifically, the facility did not ensure that medications were properly labeled and stored. Two tubes of [MEDICATION NAME] cream, which were not labeled with the resident's name or directions of application, were observed in Resident #19's room on their nightstand. There was no staff in the vicinity. The findings are: Resident #19 had a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] documented Resident #19 had a Brief Interview for Mental Status of 15 indicating the resident had intact cognition. The Minimum Data Set documented Resident #19 received scheduled pain medication and did not have any pain in the five days prior to the assessment completion. During an observation on 12/04/24 at 10:47 AM, two unlabeled tubes of [MEDICATION NAME] cream were observed on Resident #19's nightstand. Resident #19 was present in the room and stated they usually apply the cream to their hands. During an observation on 12/05/24 at 9:58 AM, two unlabeled tubes of [MEDICATION NAME] cream were observed on Resident #19's nightstand. Resident #19 was not present in the room at the time of the observation. physician's orders [REDACTED]. There was no documented evidence of a physician's orders [REDACTED]. A Comprehensive Care Plan titled Pain, effective 10/11/2023, documented the resident was at risk for pain due to decreased mobility, muscle weakness, severe [MEDICAL CONDITION], and Spondylolisthesis of the Cervical region. The interventions included administering medications as ordered, observing the effectiveness of the medication, and encouraging the resident to report pain to the caregiver. The care plan was reviewed on 6/28/2024 and documented that the resident was without noted reports of pain. During an interview on 12/6/2024 at 10:40 AM, Licensed Practical Nurse/Patient Care Coordinator #1 stated residents are not allowed to self-medicate without an assessment and physician's orders [REDACTED]. Additionally, the residents' families are advised to not bring medications as the facility will supply them. Licensed Practical Nurse/Patient Care Coordinator #1 stated they were not aware Resident #19 had two tubes of [MEDICATION NAME] cream in their room. During an interview on 12/06/24 at 1:45 PM, the Director of Nursing Services stated medications should not be stored in the resident rooms. The Director of Nursing Services stated that the residents should not be self-administering their medication unless they were assessed for self-administration, and had a physician's orders [REDACTED]. 10 NYCRR 415. 18 (d) | Plan of Correction: ApprovedJanuary 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #19 On 12/5/24, the Nurse Manager met with the resident to discuss the tubes of [MEDICATION NAME] observed in his room and removed the tubes following discussion with the resident and the need for a physician order [REDACTED]. The medicated hand cream was delivered by the provider pharmacy with a label that included the residents name and directions for use. The resident was evaluated for self-administration and a determination was made to keep the medication on the medication cart and allow the resident to self-administer. The Licensed Practical Nurse/Patient Care Coordinator #1 was reeducated by the Chief Nursing Officer on her responsibility to ensure that all medications/ointment/creams are properly labeled and stored for individual resident use. 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 practices. The Chief Nursing Officer directed the unit Nurse Managers to check each residents room for unlabeled medications including medicated creams/ointments that were not ordered by the Physician. Discussions will be held with any resident who has a medication in their room that was not ordered by the Physician, is not appropriately labeled with the residents name and directions for and without an order for [REDACTED]. The Chief Nursing Officer has arranged for all medication storage areas and med carts to be inspected to ensure that there are no outdated or opened items that should be discarded, all medications for discharged residents have been discarded, all medications are properly labeled, and that items that require light sensitive storage are properly stored. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Consultant Pharmacist and Chief Nursing Officer reviewed the facilitys policy and procedure for labeling and storage of drugs and biologicals, including protocols related to parameters for a resident keeping medications in their room and determined that the policies did not require revision. Re-education will be provided by the Staff Educator/designee to all Nurses regarding the appropriate storage of drugs and biologicals and will include the identified survey issue in this education. This education will be included during orientation of licensed nurses and be reviewed on an as needed basis. Weekly monitoring of the medication carts, medication storage areas and refrigerators will be conducted by the Unit Manager/Shift Supervisors to ensure appropriate storage. The nurses responsible for medication administration will be responsible for completing a visual check of the residents room for medications that have not been ordered. Immediate corrective action, such as staff re-education related to proper labeling and storage, or removal of an inappropriately stored item will be implemented as needed. Each nurse will continue to be responsible for the proper storage of medications on their cart and upon receipt of medications from pharmacy deliveries. Pharmacy consultant will continue to reinforce proper storage of drugs and biologicals during routine monthly inspection visit. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with storage of drugs and biologicals, including protocols related to a resident not keeping medication in their room unless there is a Physician order [REDACTED]. The Nurse Manager/designee will audit storage areas and resident rooms on a monthly basis for 3 months and then quarterly for an additional 2 quarters. Storage of drugs and biologicals audit findings will be reported to the Administrator and Chief Nursing Officer monthly for 3 months and quarterly for 2 quarters. Corrective actions, such as removal of improperly stored items or staff re-education, will be implemented as needed. The Chief Nursing Officer will report storage of drugs and biological audit findings to the QAPI Committee monthly for 3 months and then quarterly for an additional 2 quarters for evaluation and follow-up discussion. The accepted level of compliance is 95%. At the end of the third quarter the Committee will decide on the need for additional auditing or a change in the frequency of auditing. Completion Date: 01/31/2025 Responsible Person: Chief Nursing Officer |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
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 initiated on 12/3/2024 and completed 12/10/2024, the facility did not ensure each resident was provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This was identified for one (Resident #79) of three residents reviewed for Food. Specifically, Resident #79 verbalized disliking the food served to them and specified they were not assessed for their food preferences. Finding include: The facility's vendor policy Food Preferences documented that it is the center policy that individual dining, food, and beverage preferences are identified for all residents/patients. Action Steps include that the Dining Services Director or designee will interview the resident or resident representative to complete a Food Preference Interview within the admission process. The purpose of identifying individual preferences for dining location, and meal times, including times outside of the routine schedule, food, and beverage preferences. The Food Preference Interview will be entered into the medical record. Food allergies [REDACTED]. Resident # 79 has [DIAGNOSES REDACTED]. The 11/17/2024 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The resident had no behaviors and had no significant weight loss. During an interview on 12/03/2024 at 02:05 PM, Resident #79 stated they were not assessed for food preferences. The breakfast is served with pork and beef they don't eat. The resident further stated they were never provided a menu to choose their meals. A review of the resident's Dietary assessments dated 11/13/2024 revealed no documentation of an assessment for food preferences. The comprehensive care plan (CCP) for Nutrition revised on 11/11/2024 documented that the resident was on a Therapeutic Diet and was at risk for malnutrition. Interventions include adhering to diet consistency restrictions during recreational programs, and identifying and catering to resident food preferences- no pork/beef. The comprehensive care plan was updated on 12/2/2024 to include the resident's updated food preferences; no pork no beef. The meal ticket was updated and the care plan is ongoing. The food preferences interview form completed on 11/12/24 did not document the resident's food preferences. During an interview on 12/09/2024 at 12:02 PM, Dietician #1 stated the resident did not want to endorse their food preferences on admission, and that is why the food preferences were not documented or assessed upon admission. The Dietician stated on (MONTH) 2, 2024, the resident reported they dislike pork and beef and this was updated on the comprehensive care plan and their meal tracker. The Licensed Practical Nurse # 6 was interviewed on 12/10/2024 at 10:21 AM and stated the resident would refuse their meal and tell me the next day that the meal was not satisfactory. The resident does not receive a menu and am not aware why the resident does not receive a menu. The General Manager from the contract company that provides dietary services to the facility, was interviewed on 12/10/2024 at 10:00 AM and stated Food preferences should be documented in the resident medical record. The dietician should have assessed the resident's food preferences. The meal tracker is updated when food preferences are obtained. A menu is given to any alert and oriented resident. The resident can choose their selections from the menu. The General Manager from the contract company that provides dietary services to the facility stated they did not know why Resident #79 did not receive a menu. The Director of Nursing Services was interviewed on 12/10/24 at 11:45 AM and stated if a resident chooses not to endorse food preferences, the dietician should have documented this in the medical record. The comprehensive care plan should reflect this. 10 NYCRR 415. 14 | Plan of Correction: ApprovedJanuary 10, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #79 On 12/09/24, the Dietitian met with Resident #79 to discuss his/her food preferences and updated his/her food preferences in the meal tracker. On 12/9/24, a full house preference check was completed with information entered into meal tracker and scanned copies of preference sheets kept in binder in RD office. ll. 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 being affected by the same practice. Effective 12/11/24, in-service education was provided to RDs related to obtaining residents food preferences upon admission, and at least quarterly, and appropriate documentation of same by Regional Dietitian. Food preference sheets will be maintained in the RD office in the binder. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Clinical Nutrition reviewed and revised, as needed, the Clinical Nutrition policies and procedures related to completing a comprehensive nutrition assessment, including obtaining residents food preferences and entering same into meal tracker. plus procedure for providing menu to residents. The Chief Nursing Officer reviewed and revised, as needed, policies and procedures related to nursing staff reporting any changes to food preferences identified during meals to RD and food service staff. Effective 12/30/24, the Director of Clinical Nutrition/Designee will implement chart auditing specifically to monitor for obtaining and honoring food preferences as part of clinical nutrition assessment upon admission, at least quarterly, and as preference changes arise, and that this information is up to date and accurate in food preference binder kept in RD office and meal tracker. Dietitians will make meal rounds regularly to obtain feedback from residents at meal time, and this will be monitored by Director of Clinical Nutrition/Designee. The Director of Clinical Nutrition/Designee will also audit to ensure that all residents who meet the criteria to receive menu receives same, and review criteria to ensure it captures all eligible residents. Effective 12/30/24, the Director of Clinical Nutrition will monitor obtaining and provision of food preferences during sample chart reviews and resident interviews on a Monday through Friday basis for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including staff re-education, updating of the CCP or documenting a nutritional progress note, will be implemented as necessary. Residents from all units will be included in the sample. The Staff Educator/Director of Clinical Nutrition/designee will provide additional education to all nursing and dietary staff whenever issues related to residents food preferences are identified. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with obtaining, providing, and updating residents food preferences. The Director of Clinical Nutrition/Designee will monitor that residents food preferences are obtained and provided monthly for three months then quarterly for the next three quarters. The Director of Clinical Nutrition/Designee will conduct competency evaluations of all RDs to ensure they are following established protocols and have a clear understanding of the protocols related to food preferences. On-site education will be provided as necessary to ensure staff compliance. Competency evaluations will be conducted on all new RDs upon completion of orientation and twice yearly thereafter. The Director of Clinical Nutrition will review findings with the Administrator monthly for three months then quarterly. The Director of Clinical Nutrition /designee will report food preference audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the QAPI Committee. Completion Date: 01/31/2025 Responsibility: Director of Clinical Nutrition |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey and abbreviated Survey (NY 655) initiated on 12/03/2024 and completed on 12/10/2024, the facility did not ensure call bells were within reach for each resident at their bedside. This was identified for one (Resident #39) of five residents reviewed for Activities of Daily Living. Specifically, Resident #39, who was assessed to require assistance with transfer and locomotion, was observed on several occasions with a tap call bell out of reach. The finding is: Resident #39 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented no Brief Interview for Mental Status score because Resident #39 was rarely or never understood. The Minimum Data Set documented Resident #39 had impairment to the upper and lower extremities. Minimum Data Set documented Resident #39 used a wheelchair for mobility, and was dependent (helper does all the effort, resident does none of the effort) on staff for wheelchair mobility. A Comprehensive Care Plan titled Communication effective 9/17/2020 and last reviewed on 9/20/2024 documented interventions that included the use of a tap call bell placed on a foam block on either the right or left knee when out of bed for effective use of call bell. During an observation on 12/03/2024 at 11:14 AM, Resident #39 was observed sitting in a wheelchair in their room. A tap call bell was hanging on the wall on a hook to the left of the bed and was out of the resident's reach. During an additional observation on 12/06/2024 at 11:16 AM, Resident #39 was observed sitting in a wheelchair in their room. The tap call bell was placed on the bed and was out of the resident's reach. During observation and interview on 12/06/2024 at 11:19 AM, Registered Nurse Personal Care Coordinator (Nurse Manager) #3 went to Resident #39's room and confirmed the tap call bell was out of the resident's reach. Registered Nurse Personal Care Coordinator (Nurse Manager) #3 stated the tap call bell should be on the resident's right or left knee. Resident #39 is non-verbal and requires the tap bell to be placed on the right or left knee. The resident is dependent upon staff to move them in their wheelchair. Nursing staff should place the call bell within reach when the resident is in bed and on the resident's knee when they are out of bed. During an interview on 12/6/2024, at 12:58 PM, Certified Nursing Assistant #3 stated they placed the tap call bell on the resident's lap after they transferred the resident to the wheelchair on 12/06/ 2024. Certified Nursing Assistant #3 stated they always position the call bell on the lap when the resident is in the wheelchair and on the resident's chest near their hand when in bed. Certified Nursing Assistant #3 stated they did not know how the call bell ended up on the bed on 12/6/ 2024. During an interview on 12/9/ 2024 at 11:48 AM, the Chief Nursing Officer (Director of Nursing Services) stated that the call bell should always be kept within reach of the resident. The Certified Nursing Assistants must ensure the call bell is accessible to the residents. Additionally, the medication nurse is in the room administering medications, they should also make sure the call bell is within reach. 10 NYCRR 415. 29 | Plan of Correction: ApprovedJanuary 13, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #39 Resident #39s tap bell was immediately placed on his knee per the plan of care; no further corrective action was required. The IDCP Team determined that the resident continues to benefit from the use of the tap bell and ensured that this is in the CCP. The Nurse Manager re-educated all unit staff regarding their responsibility to ensure that call bells, including tap bells or other adaptive call bell devices, are within reach of the resident. Licensed staff responsible for administering medications were provided with additional education regarding their responsibility to check if the call bell is within reach when completing medication administration. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who are unable to utilize the facilitys standard call system may be affected by the same practice. The Nurse Managers and Rehabilitation staff will identify any resident who cannot manipulate a standard call bell to determine if the resident would benefit from an adaptive call bell or tap bell. The Nurse Manager will update the plan of care as needed and review the plan of care with the unit staff. The Nurse Manager, licensed nurses and CNAs continue to make rounds and resident observation at various times every shift to monitor residents including their access to their call bell. If a resident is noted not to have their call bell in reach, the situation is corrected by the staff member who identified that the call bell was not accessible. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Chief Nursing Officer reviewed the facilitys policy for Call (NAME) Use, and determined no revisions were necessary. Nurse Managers on all units will re-educate staff regarding their responsibility to ensure that tap bells and other call devices are within reach of the resident while in their rooms. Nurse Managers/Nurse Supervisors/Charge Nurses will conduct routine observations each shift during rounds to ensure residents requiring a tap call bells or adaptive call bell have them in place. Any call bell which is identified to be out of reach will be immediately addressed and responsible staff re-educated as necessary. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with ensuring all call bells including alternative call bells, such as tap bells, are within reach of residents when they are in their rooms. The Nurse Manager/designee will audit a sample of 10 call bells per shift per unit monthly for three months and then quarterly for two quarters, for accessibility and placement as per the plan of care. The sample audit will include residents requiring a tap bell or other adaptive call bell. The Chief Nursing Officer/ designee will report call bell related audit findings monthly to the QAPI Committee for three months and then quarterly for two quarters. The accepted level of compliance is 95%. At the end of the reporting period, the QAPI Committee will determine the need for further auditing and at what frequency. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure each resident was treated with respect and dignity and provided care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified on one (Kipp Unit-secure dementia unit) of seven nursing units observed during the dining task. Specifically, during the lunch meal observation on 12/4/2024 on the Kipp unit, there were 11 dining tables in the room. At least 3 to 4 residents were seated at each table. The lunch meal was being served by the nursing staff from the first meal transport rack. At all of the tables, some residents had received their lunch trays and were eating, while other residents at the same table had not received their lunch trays because the second lunch transport rack and smaller cart had not arrived on the unit from the kitchen. The finding is: The facility's policy titled Resident Rights, dated 6/2024, documented in accordance with the facility's mission and philosophy of care and state and federal regulations and privacy practice, all residents have a right to exercise their rights as residents of the facility in order to continue their lives with dignity, respect, and meaning. During an observation on 12/4/2024 at 11:55 AM on the Kipp unit, all of the residents on the unit were situated by nursing staff in the unit dining area and were seated at tables awaiting the delivery of the lunch transport racks from the kitchen. During an interview on 12/4/2024 at 12:12 PM, Licensed Practical Nurse #2 stated one of the lunch transport racks was due at 11:59 AM and the others (one lunch transport rack and a smaller cart) were due at 12:04 PM as per the lunch delivery schedule. Licensed Practical Nurse #2 stated the transport racks have not arrived yet and they are usually late. During an interview on 12/4/2024 at 12:22 PM, Licensed Practical Nurse #3 stated the meal trays had not yet arrived from the kitchen. The kitchen staff is aware the meals are consistently delivered late from the kitchen because the nurses sign a form that documents the time the lunch racks are delivered to the unit and the form is delivered back to the kitchen manager. All the residents are ready for their lunch meal and the nursing staff is ready to serve the meal; we are just waiting for the kitchen to deliver the lunch. During an interview and observation on 12/4/2024 at 12:27 PM, the first lunch transport rack arrived on the unit. Licensed Practical Nurse #3 stated a second transport rack and a smaller transport cart are still to come from the kitchen because all the lunch trays do not fit on one transport rack. During an observation on 12/4/2024 at 12:29 PM, a smaller lunch transport cart arrived on the unit. Nursing staff were observed distributing the meal trays from the first rack and from the smaller cart to the residents. During an observation on 12/4/2024 at 12:40 PM, there were 11 tables with 3-4 residents seated at each table. Lunch trays were served to some residents on each table and those residents were eating their meals; however, there were other residents at those same tables who had not been served their trays of food yet. During an observation on 12/4/2024 at 12:41 PM, the last lunch transport rack arrived on the unit. During an interview on 12/5/24 at 9:41 AM, Certified Nursing Assistant #2 stated the meal delivery racks are often late and this has been an ongoing issue. The delivery of the meal trays to the residents depends on when the meal transport racks arrive on the unit. The meal transport racks come at different times. Certified Nursing Assistant #2 stated, Maybe dietary can tell us which transport rack is coming first so we can seat residents accordingly and serve those residents all at the same time. During an interview on 12/5/2024 at 11:35 AM, the General Manager for the corporate entity responsible for kitchen and dining operations stated the present meal delivery system is causing delayed meal transportation to the units, and changes need to be made. The General Manager stated they were fully aware that there were meal delivery issues. There needs to be a conversation between nursing, kitchen, and dietary to coordinate when the meal delivery rack is coming so the residents can be seated together and served at the same time. When residents are eating at a table and other residents at the same table are not, that is a dignity issue. During an interview on 12/9/2024 at 10:50 AM, the Director of Nursing Services stated each resident on a table should be served their meal at the same time. Even though the residents on the Kipp unit are confused, the act of eating is something you do not forget and all the residents should eat together rather than watching others eat. 10 NYCRR 415. 3(d)(1)(i) | Plan of Correction: ApprovedJanuary 6, 2025 I. The following actions were accomplished for the residents identified in the sample: No specific residents were identified in the Statement of Deficiencies. On 12/30/24, a seating chart was developed by the Nurse Manager for the Kipp unit and provided to the Dietary Department, so that truck order of trays is consistent with seating chart and all residents at the same table receive their meal at the same time. On 12/4/24 the Staff Educator/designee provided Inservice training to the Kipp unit Nursing staff on meal service, including serving all residents seated at the same table their meal tray at the same time. ll. 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 being affected by same practice. Effective 12/30/24, education was provided to Nursing and Dietary staff related to the facility policy and procedure for the development of seating chart for all units for mealtimes, and dietary developing a system to arrange food trucks in table order so that all meal trays for residents at the same table arrive on the units at the same time by Food Supervisor. This education included staff discussion regarding importance of resident respect, dignity and quality of life as it relates to mealtimes, including concerns for residents at the same table receiving trays at the same time. This education also included the need to review and update seating charts on a routine basis and Nursings responsibility for alerting the Dietary Department of any changes needed to the truck tray order. Nurse Managers and Dietitians will conduct meal observations on a random basis for all meals and shifts weekly to identify any concerns related to meals not being served in table order. Issues identified with the food carts not being loaded in table order for distribution will be addressed by the Food Service Director for all reported concerns. Issues related to a resident being seated at a table that is inconsistent with the seating chart will be addressed by the Unit Nurse Manager. The Manager will update the seating chart, if indicated, or provide staff education regarding their responsibility to adhere to the seating chart during all meals. If a resident must be moved to another table for meals, the Manager will promptly update the seating chart. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Food Service reviewed and revised, as needed, the Food Service policies and procedures related to preparation of meal trucks, including providing trucks in order of residents seating to ensure that all residents receive their meal at the same time at each table. The Chief Nursing Officer reviewed and revised, as needed, policies and procedures related to resident dining and meal service related to resident rights and quality of life and directed the development of resident seating charts for each unit, which will be updated, as needed, and be provided to dietary when updated. Effective 12/10/24, the Director of Food Service/Designee and Chief Nursing Officer/Nurse Managers/designee will monitor meals to ensure all residents at same table are provided with meals at same time daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including Nursing of Food Service staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/designee will provide additional education to all Nursing and Dietary staff whenever issues related to residents receiving meals at same time when seated at the same table are identified. The Director of Food Service will review meal service findings with the Administrator monthly for three months then quarterly. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with Resident Rights related to meal service including residents at same table receiving meals at same time, accuracy of seating charts and accuracy of meal tray order on trucks to ensure meal service promotes resident dignity and respect and quality of life. The Director of Food Service/Designee will conduct monitoring of residents at same table receiving meals at same time monthly for three months then quarterly for the next nine months. The Director of Food Service/Designee will conduct competency evaluations of all Food Service workers to assure they are following established protocols and have a clear understanding of the protocols for proper truck order. On-site education will be provided, as necessary, to ensure staff compliance. Competency evaluations will be conducted of all new Food Service Workers upon completion of orientation and twice yearly thereafter. Chief Nursing Officer/designee will conduct meal service observations of nursing staff job performance during meal service to ensure resident respect and dignity and quality of life concerns are addressed when identified. Observation will include assessing the development and currency of seating charts, communication of updates to the Dietary Department, and residents being in their designated seating area for meals. The Food Service Supervisor/designee will report residents meal service audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. The Chief Nursing Officer will report meal service observation audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. Completion Date: 01/31/2025 Responsibility: Director of Food Service |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 060, NY 385, NY 476, and NY 655) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified for four (Inn, Head Injury Rehabilitation Unit, Muhlenberg, and(NAME)Hall) of seven nursing units reviewed during the Sufficient Nursing Staffing Task. Specifically, during an observation on 12/8/2024 (Sunday) 13 of 15 residents in the Head Injury Unit were still in bed at 11:38 AM due to insufficient staffing. Resident #38, who resided in the Inn unit, did not receive showers as scheduled on 11/28/2024 and 12/2/2024 due to understaffing. On 11/29/2024, the(NAME)Unit had only one Certified Nursing Assistant (#13) assigned for a unit census of 46. Certified Nursing Assistant #13 stated they only took care of 15 residents who were on their original assignments and did not know if any care was provided to the other 31 residents until the morning when additional staff came to get the residents out of bed. Additionally, staff on the Muhlenberg unit stated they were understaffed and were unable to complete their assignment including providing showers to the residents. The findings are: The facility's Staffing policy and procedure dated 11/2024 documented unit staffing needs are determined by taking into consideration case mix index information, unit acuity, number of residents requiring nursing rehabilitation, tube feedings, intravenous therapy, blood glucose monitoring, suctioning, [MEDICAL CONDITION] care, special treatments, special wound care, special equipment, etc. and residents requiring at least two nursing aides for bed care, transfers, and bathing. Replacement of staff is undertaken if there is a call-in. Nurses and Certified Nurse Assistants are replaced with on-call staff or staff who stay overtime, if necessary. When the need arises, residents may be transferred to another unit or staff may be borrowed (from other units). The Facility assessment dated [DATE] documented the facility must ensure there are enough staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in 5483. 35(a)(3). The facility assessment documented the following staffing plan for direct care staff: -Day Shift (7:30 AM-3:30 PM): One Registered Nurse, one to two Licensed Practical Nurses per unit, and two to four Certified Nurse Assistants per unit, except for Muhlenberg which required one to two Certified Nurse Assistants. -Evening Shift (3:30 PM-11:30 PM): One Registered Nurse Supervisor, one to two Licensed Practical Nurses per unit, and two to four Certified Nurse Assistants per unit, except for Muhlenberg which required one to two Certified Nurse Assistants. -Night Shift (11:30 PM-7:30 AM): One Registered Nurse Supervisor, one to two Licensed Practical Nurses per unit, and two to three Certified Nurse Assistants per unit, except for Muhlenberg which required one to two Certified Nurse Assistants. -The daily staffing sheet for 12/8/2024 during the day shift (7:30 AM- 3:30 PM) documented the following: -The Head Injury Rehabilitation Unit had a census of 15 residents with two Registered Nurses and one Certified Nursing Assistant. -The Inn Unit had a census of 40 residents with two Licensed Nurses, a third Licensed Nurse working from 6:30 AM to 10:00 AM, and two Certified Nurse Assistants. -The Kipp Unit had a census of 50 residents with two Licensed Nurses and three Certified Nurse Assistants. -The(NAME)Hall Unit had a census of 46 residents with two Licensed Nurses and three Certified Nurse Assistants. -The Muhlenberg Unit had a census of 17 residents with one Licensed Nurse and one Certified Nurse Assistant. -The Sub-Acute (Livingston Hall) Unit had a census of 22 residents with two Licensed Nurses and two Certified Nurse Assistants. -The Sunset Hall Unit had a census of 40 residents with two Licensed Nurses and three Certified Nurse Assistants. An undated facility list entitled HIRU Ext X 2 Residents, documented 13 residents in the Head Injury Rehabilitation Unit required two-person assistance with care. During an observation on 12/8/2024 at 11:38 AM on the Head Injury Rehabilitation Unit, there was only one Certified Nurse Assistant for 15 residents. There was a total of two residents that were out of bed, the remaining 13 residents were still in bed. During an interview on 12/8/2024 at 11:39 AM, Certified Nurse Assistant #11, who worked at the Head Injury Rehabilitation Unit, stated they were assigned to 15 residents by themselves today (12/8/2024). Certified Nurse Assistant #11 stated all the residents require two-person assistance. Certified Nurse Assistant #11 stated they always work alone and one nurse sometimes helps them to get the residents out of bed. Certified Nurse Assistant #11 stated they were only able to shower one of three residents who were scheduled for a shower today because they were the only Certified Nursing Assistant assigned to the unit and the nurse is too busy to help with providing resident care. Certified Nurse Assistant #11 stated they have to perform bed mobility without assistance when the residents require two-person assistance. Certified Nurse Assistant #11 stated they were responsible for serving breakfast and lunch for all of the residents on the unit and did not have time to provide resident showers or get the residents out of bed. During an interview on 12/8/2024 at 11:49 AM, Registered Nurse #5, who worked at the Head Injury Rehabilitation Unit, stated it is not safe to work with one Certified Nurse Assistant because all the residents on the unit require two-person assistance. Registered Nurse #5 stated all the residents require turning, repositioning, and toileting every two to four hours and it is not done because of short staffing. Registered Nurse #5 stated they try to assist Certified Nurse Assistant #11 as much as possible; however, they are primarily responsible for medication administration and treatments. During an interview on 12/8/2024 at 9:32 AM, Registered Nurse #4, who worked at the Muhlenberg Hall, stated there was only one Certified Nurse Assistant assigned to the unit for 17 residents. Registered Nurse #4 stated the unit has many residents who require two-person assistance, and one Certified Nurse Assistant cannot perform care by themselves. Registered Nurse #4 stated they must help the Certified Nurse Assistant and it takes time away from their responsibilities. During an interview on 12/8/2024 at 9:32 AM, Certified Nurse Assistant #8, who was the assigned Certified Nursing Assistant on the Muhlenberg Hall Unit, stated they were assigned to care for all 17 residents on the unit. Certified Nurse Assistant #8 stated they cannot provide resident showers and are always late with getting the residents out of bed. -Resident #38 was admitted with the [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #38 had a Brief Interview for Mental Status assessment score of 15, indicating the resident had intact cognition. Resident #38 did not have a documented history of rejection of care. Resident #38 was dependent on staff to shower/bathe themselves. A record review of the Inn Unit shower book revealed that in (MONTH) 2024, Resident #38's shower days were Mondays and Thursdays. A review of the Certified Nurse Assistant Accountability Record revealed there was no documented evidence that Resident #38 received a shower on 11/28/2024 and 12/2/ 2024. A review of Resident # 38's Comprehensive Care Plans last revised on 12/10/2024 revealed no documented behaviors or refusals of showers and the resident was dependent on staff for showers. A record review of staffing sheets, assignments, and census logs revealed the following: - On 11/28/2024, the cen | Plan of Correction: ApprovedJanuary 21, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #38 The Nurse Manager for Resident #38 met with the resident to discuss his/her concerns. Resident #38 was provided with a shower. The Nurse Manager provided additional education to unit staff regarding their responsibility for following the residents plan of care, including his/her shower schedule. 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. Between 11/29/24 and 12/10/2024 the Nurse Manager/designee for the Lawrence Hall Unit met with each resident and/or representative to discuss their preferences for related to their out of bed schedule. The Nurse Manager updated the care plan to reflect the residents preference for getting out of bed, updated the CNAs assignment and reviewed the care plan revisions with the unit staff. A comprehensive review of ADL documentation from the last quarter will be conducted by the Nurse Managers/supervisors to identify any potential concerns related to provision of care, including adherence to shower schedules and out of bed preferences. Consideration will be given to redistribution of routine tasks to different shifts, if possible, to assist with staff efficiency and completion of required duties. Effective 12/10/2024, the Unit Managers for all units, including the Muhlenberg unit, were directed by the Chief Nursing Officer to conduct additional observational rounds to ensure each residents plan of care is being carried out consistently as it relates to showers, out of bed and other needs. Any concerns identified will be immediately addressed, such as re-educating staff about the plan of care and ensuring the residents need is met, such as being assisted out of bed at that time or a shower provided. The Nurse Manager/designee will include assessing completion of shower associated documentation as part of the observation rounds. The Unit Managers will review the list of resident shower schedules, out of bed preferences/ schedules and other scheduled ADL assistance with responsible staff to ensure the plan of care is consistently carried out. CNAs who cannot complete all assigned duties during a shift will report this concern to the Unit Manager/ Nurse Supervisor for timely follow-up. The Social Worker for each unit will meet with a random sample of five different interview-able residents monthly to conduct an interview regarding satisfaction and their perception of care and staffing, including as it relates to receiving showers and being assisted out of bed in accordance with their preferences. The results of these structured interviews will be provided to the Director of Social Work for reporting to the Administrator and Chief Nursing Officer. This information will be utilized as appropriate to inform staffing needs for all units and shifts. The Staff Educator/designee will provide additional education to all Nursing staff regarding their responsibility to ensure that the plan of care is followed for all residents, including adhering to shower schedules, assisting residents with getting out of bed, and other care directives. Licensed staff were re-educated regarding their responsibility to assist CNAs, as needed, including for residents who require two-person assistance. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Chief Nursing Officer reviewed the facilitys staffing policy and procedure and Facility Assessment to determine if any revisions were necessary to staffing levels to meet resident care needs The Chief Nursing Officer/designee will educate the Staffing Coordinator, Assistant Director of Nursing and Nursing Supervisors regarding the need to ensure that actual unit-based staffing is based on the staffing levels included in the Facility Assessment. The Chief Nursing Officer/designee will continue to direct responsible staff to immediately attempt to fill any staffing need due to call-ins and document attempts to obtain additional staff, whether it is through advising existing staff of additional shift opportunities or contacting agencies to supplement facility staffing needs. The Administrator and the Chief Nursing Officer will convene routine staffing assessment meetings to review actual staffing levels, call outs, double shifts, retention and use of agency staff and to determine if any staffing level changes are necessary based on the current census. The facility will continue to advertise and actively promote all open roles at the facility through online job postings, on-site job fairs and explore additional opportunities for recruitment and retention, including contacting local nursing schools to identify additional prospective staff. The facility will create an incentivize sign on bonus program for new employees to help with recruitment/retention. The Administrator and Chief Nursing Officer will continue to employ all available tactics to attract and retain staff, including exploring additional staffing agencies to contract with. Attempts to hire additional agency staff are continuously underway. The Administrator and Chief Nursing Officer will continue to explore opportunities to increase staff retention, which is an identified concern. The facility will explore an incentivize Mentorship program by pairing experienced staff with new hires to foster guidance, support and connection. The facility is exploring additional options for weekend shift incentives to increase retention. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor the facilitys compliance with meeting sufficient staffing requirements, as determined by the Facility Assessments staffing plan. The Chief Nursing Officer/designee will audit the facilitys actual staffing daily against the facilitys master staffing plan and report to the QAPI Committee on an on-going, monthly basis regarding staffing status changes. The facilitys recruitment and retention efforts will be reviewed quarterly during QAPI Committee meetings on an on-going basis. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review during an offsite Life Safety Code Post Survey conducted on 01/30/2025,the facility did not submit evidence that the elevator's communication system was repaired. Documents submitted for review included the following: 1. Repair Time Ticket for Elevator# E-3898 (Pass 1 Old Car) dated 01/17/ 2025. Work Performed: Wired phone to controller and tested phone. Phone doesn't work even with active phone line needs new phone. 2. Repair Time Ticket for Elevator# E-3899 (Pass 2 Kitchen Car) dated 01/17/ 2025. Work Performed: Elevator phone needs to be wired properly needs 110 and phone wire ran from [MEDICATION NAME] to phone unit. Need to come back and address issues. Phone line is active. 3. Repair Time Ticket for Elevator# E-3900 (Pass 3 New Car) dated 01/17/ 2025. Work Performed: Has no active phone line. 4. Vendor email dated 01/28/2025, the email states that the phones could not be fixed for various reasons: -Car 1 has an active line but the phone is not working and needs to be replaced. -Car 2 the 110 and phone wire need to be ran from the [MEDICATION NAME] to the phone. The line is active but until we hook up the phone we won't know it the phone itself works. -Car 3 the phone line needs to be activated by your phone provider. On (MONTH) 18, 2025, at approximately 11:54 AM, in an email correspondence, the Senior Director of Operations, stated that they are still waiting on the elevator's service company to get the part; further stating that they will contact them again and let the NYSDOH what they say. No further communication or documentation that evidence the repair of the elevator's communication system was submitted for review. The facility was cited for the following during the 12/10/2024 Life Safety Code recertification survey: 2012 NFPA 101: 19. 5. 3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9. 4. 2012 NFPA 101: 9. 4. 2. 2 Except as modified herein, existing elevators, escalators, dumbwaiters, and moving walks shall be in accordance with the requirements of ASME A 17. 3, Safety Code for Existing Elevators and Escalators. 2012 NFPA 101: 9. 4. 2. 3 Elevators in accordance withASMEA 17. 7/CSA B 44. 7, Performance-Based Safety Code for Elevators and Escalators, shall be deemed to comply with ASME A 17. 1/CSA B44, Safety Code for Elevators and Escalators, or ASME A 17. 3, Safety Code for Existing Elevators and Escalators. 2007 ASME A 17. 1 Safety Code for Elevators and Escalators 2007 ASME A 17. 1: 2. 8. 1 Equipment Allowed. Only machinery and equipment used directly in connection with the elevator shall be permitted in elevator hoist ways, machinery spaces, machine rooms, control spaces, and control rooms. 2007 ASME A 17. 1: 8. 6. 4. 8. 2 Articles or materials not necessary for the maintenance or operation of the elevator shall not be stored in machinery spaces, machine rooms, control spaces, and control rooms. 2007 ASME A 17. 1: 8. 6. 12. 3. 2. 2 The machine room floor shall be kept clean and free from oil or grease. Articles or materials that are not necessary for the maintenance or operation of the elevator shall not be stored in the machine room. Flammable liquids having a flashpoint of less than 44?é??C (111?é??F) shall not be kept in the machine room. 2007 ASME A 17. 1/CSA B44: 8. 6. 4. 15 Car Emergency System. Emergency operation of signaling devices (see 2. 27), lighting (see 2. 14. 7), communication (see 2. 27. 1. 1. 2, 2. 27. 1. 1. 3, and 2. 27. 1. 2) and ventilation (see 2. 14. 2. 3), shall be maintained. Based on observation, document review and staff interviews, the facility did not ensure that an elevator machine room was kept free of storage of items not necessary for the maintenance or operation of the elevator, and that two out of three elevators serving the facility were maintained in accordance with NFPA 101:Life Safety Code and ASME A 17. 1/CSA B44: Safety Code for Elevators and Escalators. The findings are: On (MONTH) 05, 2024, at approximately 10:55 AM, during the Life Safety Code recertification survey, the storage of four TV screens were observed inside an elevator machine room in the basement. The Senior Director of Plant Operations who was present at the time of the observation stated that they will move all items out from the elevator machine room. On (MONTH) 06, 2024, at approximately 11:03 AM, document review of the elevators' inspection records revealed the following: 1. Checklist for inspection of hydraulic elevators dated 11/14/2024: Top of the checklist under General Notes: (b) OK = Meets requirements; NG = no good; NA = not applicable. -Elevator ID No: PASS 3. 1. Inside of Car 1. 6 Car Emergency Signal - Marked as NG Notes: 1. 6 Phone no dial tone. -Elevator ID No: PASS 1. 1. Inside of Car 1. 6 Car Emergency Signal - Marked as NG Notes: 1. 6 Phone no dial tone. 2. Category 1 Hydraulic Elevator Periodic Test Records dated 04/10/2024: - Elevator PE 1(old car): Item #17 - Emergency Communications (alarm, phone & lighting) checked mark on NO, and word Phone circled. Item#19 - Is test satisfactory and in accordance with the code in effect at time of original installation and/or alteration: If no, state reason: Notes - Need to activate phone line. -Elevator PE 3(Kitchen Car): Item #17 - Emergency Communications (alarm, phone & lighting) checked mark on NO, and word Phone circled. Item#19 - Is test satisfactory and in accordance with the code in effect at time of original installation and/or alteration: If no, state reason: Notes - Need to activate phone line. On (MONTH) 06, 2024, at approximately 11:40 AM, the Senior Director of Operations, stated that they are setting up the connection for the phone line in the elevators, and once it is done, they will call the elevator's service company to inspect again, further stating that it will take between one or two weeks to complete the work. 2012 NFPA 101: 19. 5. 3, 9. 4. 2. 2, 9. 4. 2. 3. 2007 ASME A 17. 1: 2. 8. 1, 8. 6. 4. 8. 2, 8. 6. 12. 3. 2. 2, 8. 6. 4. 15 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 4, 2025 Plan of Correction for affected areas The Director of Maintenance secured independent telephone lines for each elevator 1 and 2 and engaged our Elevator vendor to install, test and maintain the emergency telephones in each elevator. Car 3 phone line has always worked and was a type error on elevator company and should state Car 2. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. Elevator vendor is to connect the phone lines. Plan of Correction for system measures to prevent reoccurrence The Director of Maintenance or designee will inspect all Elevator Emergency telephones in each elevator monthly. The Director of Maintenance will utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: March 4, 2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: N/A
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |