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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
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 Survey, initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for one (Resident #234) of four residents reviewed for Pressure Ulcers. Specifically, Resident #234 had a physician's orders [REDACTED]. On 1/5/2025 while the resident was in bed, the wedge cushion was observed against the bed's side rail and was not being used for providing pressure relief. The direct care staff were unaware of the reasons for the positioning wedge cushion use. The finding is: The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 11/13/2024 documented that the nurse shall describe and document/report the following: full assessment of pressure sore, including location, stage, length, width and depth, presence of exudate or necrotic tissue; pain assessment; resident mobility status; current treatments, including support surfaces, and all active diagnoses. The Physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical treatments. 1) Resident #234 was admitted with [DIAGNOSES REDACTED]. The 10/22/2024 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 6, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented that the resident was dependent on staff for bed mobility and transfers, had no pressure ulcers, was at risk for pressure ulcer development, and required pressure-reducing devices for the bed and chair. The Braden score (a scale for predicting pressure ulcer risk) dated 10/15/2024, documented a score of 16, indicating the resident was at mild risk for developing pressure ulcers. A nursing progress note dated 12/18/2024, written by Registered Nurse Unit Manager #2, documented the assigned Certified Nursing Assistant reported an open area to the resident's right buttocks. Wound Care Registered Nurse #1 determined the area as a Stage 3 pressure ulcer. Treatment was initiated. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Reposition every 2 hours for pressure relief. A progress note dated 1/3/2025, written by Physical Therapist #1, documented the resident was provided with a positioning wedge for pressure relief, to be placed on the right/left side of the trunk/hips while in bed. Reposition the resident every 2 hours. The Certified Nursing Assistant assigned to the resident was informed and educated. A Comprehensive Care Plan titled Open Area to Right Buttock, Retitled to Sacral Stage 3, initiated on 12/18/2024 and last updated on 1/5/2025, documented an intervention to administer treatments/medications as ordered and monitor for effectiveness; the care plan did not include an intervention for the Positioning Triangle Wedge. A review of the Certified Nursing Assistant Accountability Record for (MONTH) 2025 revealed that Certified Nursing Assistants started using the triangle wedge on 1/6/ 2025. During an observation on 1/7/2025 at 8:45 AM, Resident #234 was observed in their room with facial grimacing and was complaining in profane language that their buttocks were hurting and they wanted to die. The resident was lying flat on their back. The positioning wedge was observed against the side rail and did not provide pressure relief to the resident. Registered Nurse Unit Manager #2 entered the resident's room and stated the positioning wedge was to prevent the resident from falling out of bed. Registered Nurse Unit Manager #2 stated they had to check with the Rehabilitation Department to see if the positioning wedge was meant to provide pressure relief. During an observation and interview on 1/7/2025 at 9:00 AM, Registered Nurse Unit Manager #2 returned to Resident #234's room and stated they spoke to the Rehabilitation Department and stated the positioning wedge was meant to offload the sacral area and to provide pressure relief. Registered Nurse Unit Manager #2 and Licensed Practical Nurse #1 (who was also in the room to administer medication to the resident) then left the resident's room without repositioning the resident or placing the positioning wedge under the resident. The resident continued with facial grimacing and complaints of pain in the buttock area. During an observation and interview on 1/7/2025 at 9:04 AM, Certified Nursing Assistant #5 (assigned to Resident #234) entered the resident's room after being alerted of the resident's pain complaints. The resident was complaining in profane language of pain in the buttock area. Certified Nursing Assistant #5 repositioned a pillow under the resident and stated the positioning wedge was to keep the resident safe. During an interview on 1/7/2025 at 09:14 AM, the Rehabilitation Department Director stated the triangular positioning wedge was meant for pressure relief for Resident #234 and should be placed under the resident's hip to offload the wound. The positioning wedge is not used to prevent the resident from falling out of bed. During an interview on 1/7/2025 at 1:53 PM, Physical Therapist #1 stated the positioning triangle wedge was meant to be placed on either side of the resident's hips/trunk and switched every 2 hours for pressure relief and was meant to keep the resident off their back. Physical Therapist #1 stated they spoke to the Certified Nursing Assistant assigned to the resident (could not recall the name) and to the Registered Nurse Unit manager # 2. During an interview on 1/8/2025 at 9:37 AM, Registered Nurse Unit Manager #2 stated they did not recall Physical Therapist #1 telling them about the positioning wedge. During an interview on 1/8/2025 at 02:27 PM, the Director of Nursing Services stated the nursing staff taking care of Resident #234 should have known what the positioning wedge was for and should have utilized the wedge cushion to offload the would area. 10 NYCRR 415. 12(c)(1) | Plan of Correction: ApprovedFebruary 6, 2025 I. Resident #94 received immediate personal hygiene care, including fingernail trimming and cleaning, by a certified nurses aide's (CNA). The resident was assessed by the nurse for any discomfort or issues related to long, untrimmed fingernails, and no injuries or skin integrity concerns were noted. The resident's care plan was reviewed and updated to include routine nail care as needed. Licensed nursing staff and nursing assistants involved in resident #94 were educated regarding necessary services to maintain good grooming, and personal hygiene. II. All residents that are dependent on ADL care will have potential to be affected A facility-wide audit of all dependent residents was conducted to identify any other residents requiring nail care and any finding was addressed accordingly. III. The facility's policy titled Activities of Daily Living Care??ÿ was reviewed by Director of Nursing and no revision was required Licensed nursing staff and certified nurses aides will receive re-education on the importance of proper ADL care, including nail trimming as part of routine hygiene. Unit Mangers will be responsible to oversee ADL care provided to ensure residents who are unable to carryout activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene. IV. The Director of Nursing / Designee will conduct audits of 10 dependent residents nail care weekly x 4 then monthly x3 to ensure their finger nails are trimmed, cut and clean, which are necessary services provided to maintain good grooming. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Director of Nursing/Designee The correction date is 3/5/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that the Quarterly Minimum Data Set assessments were completed within the prescribed time frames. This was identified for three (Resident #6, Resident#113, Resident #13) of six residents reviewed during the Resident Assessment Task. Specifically, Resident #6, Resident#113, and Resident #13 Quarterly Minimum Data assessment was not completed within 14 days of the Assessment Reference date. The finding is: The facility policy titled MDS Assessments, dated 12/10/2024, documented all Minimum Data Set assessments are to be completed and submitted to Centers for Medicare and Medicaid Services as per the guidelines provided in the Resident Assessment Instrument Manual. The Minimum Data Set Coordinator will assume the leadership role to ensure that all Minimum Data Set Assessments are completed and submitted as per the guidelines. Resident #6's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 8/23/2024, was completed on 9/9/ 2024. This was three days beyond the required time frame. Resident #113's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 8/2/2024, was completed on 8/21/ 2024. This was five days beyond the required time frame. Resident #13's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 8/30/2024, was completed on 9/17/ 2024. This was four days beyond the required time frame. During an interview on 1/10/2025 at 9:19 AM, the Minimum Data Set Director stated the Minimum Data Set should be completed 14 days from the Assessment Reference Date. The Minimum Data Set Director stated they knew that Resident #37's and Resident #67's Annual Minimum Data Sets were completed late. They further stated that the Director of Nursing and Administrator were aware. During an interview on 1/10/2025 at 9:51 AM, the Director of Nursing Services stated they were aware the Minimum Data Set assessments were completed late. The Director of Nursing Services stated the late assessment completion was because of staffing turnover. 10 NYCRR 415. 11 (a)(4) | Plan of Correction: ApprovedFebruary 10, 2025 I. The Interdisciplinary Team (IDT) reviewed both resident #67 and resident #37 medical records to ensure that residents' plan of care was not negatively impacted due to the delayed MDS. No adverse effects were noted. MDS team members were educated to ensure Minimum Data Set Assessments to be completed within 14 days of the Assessment Reference date. II. All residents have potential to be affected. A facility-wide audit of all residents with scheduled comprehensive MDS assessments was conducted by the MDS Director to identify any additional cases of late assessments. Any findings were addressed accordingly. III. The facility policy titled MDS Assessments, was reviewed by the Director of Nursing and Director of MDS. No revision was required. The MDS staff and Interdisciplinary Team (IDT) including Rehab, Social Work, Dieticians, and Recreation will be re-educated on the regulatory timeframes for MDS completion to ensure Minimum Data Set Assessments to be completed within 14 days of the Assessment Reference date. Weekly MDS reports using PCC (EHR) will be generated and reviewed by the MDS Director to ensure timely completion. The Interdisciplinary Team (IDT) including Rehab, Social Work, Dieticians, and Recreation will review the MDS completion schedule during weekly care plan meetings and morning meetings. Any assessments at risk of delay will be escalated to the Administrator and Director of Nursing for immediate action. The MDS director will develop a tracking system to create reminders for quarterly assessments and alerts for assessments that are approaching the due date. The MDS director will review the tracker daily and distribute the list of all residents with an approaching due date at the morning meeting. The MDS Director will provide a report to the administrator weekly. IV. Administrator/Designee will conduct an audit of MDS assessment completion weekly x 4 then monthly x3 to ensure Minimum Data Set Assessments to be completed within 14 days of the Assessment Reference date. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Administrator/Designee Correction date is 3/5/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
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 initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was identified for one (Resident #94) of one resident reviewed for Activities of Daily Living. Specifically, Resident #94 was observed on multiple occasions with long, untrimmed fingernails on both hands. Resident #94 stated they were unable to trim their fingernails on their own and wanted them trimmed. The finding is: The facility's policy titled Activities of Daily Living Care, dated 10/2024, documented the nursing home shall provide Activities of Daily Living care that promote and maintains residents' health, safety, independence, and dignity. Activities of Daily Living care include assistance with tasks such as bathing, dressing, grooming, eating, toileting, mobility, and transferring. Assist with grooming tasks such as shaving, hair care, oral hygiene, and nail care. Resident #94 was admitted with [DIAGNOSES REDACTED]. The 11/26/2024 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident was dependent on facility staff for personal hygiene. A Comprehensive Care titled Resident requires assist with activities of daily living related to [MEDICAL CONDITION] with metastasis to spine, initiated 11/20/2024, documented personal hygiene: dependent on one staff member. The KARDEX (Certified Nursing Assistant care instructions), as of 1/5/2025, documented that the resident was dependent on one staff member for personal hygiene. Resident #94 was observed in bed on 1/5/2025 at 9:58 AM. Their fingernails on both hands were long and untrimmed. The resident stated they would like their fingernails trimmed, but they cannot trim the fingernails themselves because their hands are numb. Resident #94 was observed in bed on 1/6/2025 at 8:20 AM and their fingernails had not been trimmed yet. During an interview on 1/6/2025 at 8:25 AM, Certified Nursing Assistant #1 stated they were not the regularly assigned Certified Nursing Assistant and had not worked with Resident #94 before. Certified Nursing Assistant #1 observed Resident #94's fingernails and stated the nails were long and needed to be trimmed. Certified Nursing Assistant #1 stated they were not sure if the Certified Nursing Assistants were allowed to trim fingernails. During an interview on 1/6/2025 at 8:30 AM, Licensed Practical Nurse #1 stated if the resident is diabetic, the Certified Nursing Assistant can file the resident's fingernails and if the resident is not a diabetic, then the Certified Nursing Assistant can cut the fingernails. A nursing progress note dated 1/6/2025 at 12:28 PM, written by Registered Nurse #2, documented fingernails cut/trimmed/filed this morning. During an interview on 1/7/2025 at 10:41 AM, the Registered Nurse Staff Educator stated the Activities of Daily Living care include keeping fingernails clean. The Certified Nursing Assistants are allowed to cut the resident's fingernails. During an interview on 1/8/2025 at 10:40 AM, the Director of Nursing Services stated that Certified Nursing Assistants are expected to trim and clean the resident's fingernails. 10 NYCRR 415. 12(a)(3) | Plan of Correction: ApprovedFebruary 6, 2025 I. Resident #233: A comprehensive care plan was immediately developed to address the resident's IV hydration needs, including monitoring parameters and potential complications. Resident #68: The medication order was corrected to reflect the prescribed dosage of Calcium Vitamin D 600- 200. The resident's care plan was updated to include this medication regimen and monitoring for efficacy and potential side effects. Resident #285 care plan was developed to address the resident's UTI, including antibiotic therapy, monitoring for effectiveness, and prevention strategies. A medication error report was initiated for the near missed dose on sampled resident # 68. LPN #2 was also educated in the policy of medication administration. Licensed nursing staff involved with the care of resident 285 were immediately educated to ensure they understand their responsibility in developing and implementing a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. II. All residents with IV therapy and ABT therapy have potential to be affected. An audit of all residents with IV therapy was conducted to ensure that a comprehensive care plan was developed and implemented for each resident including measurable objectives and timeframe to meet each resident's medical and nursing needs. An audit of all residents receiving supplements Calcium-Vitamin D 600 milligrams-200 to ensure they receive the correct medication with correct dosage. Any findings were addressed accordingly. III. The facility's policy titled Care Plans, Comprehensive Person-Centered, and Medication Administration, were reviewed by Director of nursing and no revision was required. Licensed nursing staff will be educated on the above policies to ensure: A comprehensive care plan will be developed and implemented for each resident including measurable objectives and timeframe to meet each resident's medical and nursing needs. Timely updating of care plans in response to residents change of conditions. Medication administration competency and Ensuring accuracy in medication administration as per MD order. Unit Manager/Designee will be responsible to oversee developing and implementing a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. IV. The Director of Nursing (DON) or designee will conduct an audit of 10 residents weekly x 4 then monthly x3 to ensure that a comprehensive care plan was developed and implemented for each resident including measurable objectives and timeframe to meet each resident's medical and nursing needs. Their care plans Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Director of Nursing/Designee The correction date is 3/5/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025 the facility did not ensure Intravenous antibiotics were administered consistent with professional standard of practice and in accordance with physician's orders and the comprehensive person-centered care plan. This was identified for two (Resident #336 and Resident #285) of two residents reviewed for Urinary Tract Infection. Specifically, 1) Resident #336 had a Midline Intravenous Catheter (a type of peripheral intravenous access, flexible tube inserted into a vein in the upper arm) on the left arm. There were no physician orders for monitoring and flushing the Midline Intravenous Catheter. 2) Resident #285 was observed with a peripheral intravenous catheter (Midline Intravenous Catheter ) in their right arm. There were no physician orders for monitoring and flushing of the Midline Intravenous Catheter. The findings are: The facility's policy titled Intravenous Infusion, last revised on 12/10/2024 documented that intravenous sites are checked every four hours and as needed for signs and symptoms of infection or inflammation. The Nurse will assess associated risks due to intravenous fluid administration such as infiltration (when fluids leak out into the tissue under the skin) and infection. The intravenous documentation is recorded in the Nurses' notes and/or Medication Administration Records. Flush vascular access device with normal saline. Resident #336 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severely impaired cognition. The Minimum Data Set (MDS) assessment documented Resident #336 was incontinent of urine. A Physician's order dated 12/31/2024 documented [MEDICATION NAME] Injection Solution (an antibiotic that treats bacterial infection) three grams intravenously every eight hours for Urinary Tract Infection for seven days. There were no documented Physician's Orders to monitor and flush the Midline Intravenous Catheter until 1/8/ 2025. There was no Physician's Order to insert the Midline Intravenous Catheter and Midline Intravenous Catheter site dressing until 1/13/ 2025. A review of Resident #336's Electronic Medical Administration Record (EMAR) revealed there was no documentation that Resident #336's Midline Intravenous Catheter site was assessed for infiltration ( when some of the fluid leaks out into the tissues under the skin where the tube has been put into the vein) and flushed with saline before 1/8/2025 per the facility policy. A review of Resident #336's Progress notes from 12/31/2024 to 1/7/2025 revealed that the Medication Nurses were not consistently documenting that Resident #336's left arm Midline Intravenous Catheter site was assessed for any infiltration and signs of infection. A Comprehensive Care Plan (CCP) dated 12/31/2024 and revised on 1/8/2025 documented that Resident #336 had a Midline Intravenous Catheter on the left arm. The intervention included an assessment of the Midline Insertion site for redness, tenderness, and swelling. Resident #336 was observed on 1/5/2025 at 9:45 AM in bed. Resident #336 was receiving medication intravenously via the left arm Midline Intravenous Catheter. There was no redness or swelling around the Midline Intravenous Catheter site. During an interview on 1/8/2025 at 8:48 AM, Registered Nurse #3, Unit Supervisor stated they forgot to obtain an order to assess and flush Resident #336's Midline Intravenous Catheter. Registered Nurse #3 stated there should have been an order for [REDACTED].#3 stated there should have been an order for [REDACTED].#3 stated they (Licensed Practical Nurse #3) must have forgotten to document the assessment in Resident #336's Progress Notes. During an interview on 1/8/2025 at 12:08 PM, the Director of Nursing Services stated an intravenous catheter site should be assessed for signs of infiltration and signs of infection every shift as per facility policy. The Director of Nursing Services stated they expected the nurses to document the assessment in the resident's Progress Note every shift while the resident was receiving intravenous fluids or intravenous antibiotics. 2) Resident #285 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #285 had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The Minimum Data Set did not document that Resident #285 was admitted to the facility with an intravenous catheter. A Physician's order dated 1/02/2025 documented Midline Intravenous Catheter insertion. A Physician's order dated 1/02/2025 documented [MEDICATION NAME] Sodium Solution (antibiotic) 1 gram intravenously every 12 hours for 7 days for infection. The Medication Administration Record [REDACTED]. There was no documentation regarding the assessment, monitoring, or flushing of the Midline Intravenous Catheter. The Treatment Administration Record for (MONTH) 2025 did not include documentation related to an assessment monitoring, or flushing of the Midline Intravenous Catheter. During an observation on 1/5/2025 at 9:35 AM, Resident #285 was sleeping in bed with a Midline Intravenous Catheter in their right arm. The site appeared clean and dry. During an observation on 1/7/2025 at 10:51 AM, Resident #285 was sleeping in their bed with the midline intravenous catheter in their right arm. The site appeared clean and dry. During an interview on 1/7/2025 at 10:24 AM, Registered Nurse Unit Manager #4 stated the nurses were expected to assess the Midline Intravenous Catheter site and flush the catheter before and after administering intravenous medication each shift and document their findings in the medical record. Registered Nurse Unit Manager #4 stated there should be physician's orders to assess the site and to flush the intravenous catheter before and after intravenous medication administration. During an interview on 1/08/2025 at 12:01 PM, the Director of Nursing Services stated they expected nursing staff to ensure a physician's order for placement and the assessment of the intravenous catheter was present for residents with intravenous catheters in place. The Director of Nursing Services stated nurses on all shifts must assess the intravenous catheter site including flushing of the intravenous catheter and document in a progress note or the Medication Administration Record [REDACTED]. 12(k)(2) | Plan of Correction: ApprovedFebruary 6, 2025 I. Resident #54 was promptly assessed by the dietitian to evaluate the extent of weight loss and informed the NP who evaluated the resident on 1/7/ 25. The dietitian developed a personalized nutrition care plan to address the residents' weight loss, which included: Changing supplements to higher calories and higher protein. Modifying the resident's meal pattern as per preference to include sweeter foods. Aiding and encouragement during meals to enhance intake. On 1/7/25 an Interdisciplinary Team Meeting with the family was conducted and interventions for weight loss was discussed. The family requested DNR, DNH and Comfort Measures with no weights. II. All residents with weight loss have the potential to be affected. An audit of all residents' weights over the past 30 days was conducted to identify others experiencing significant weight changes. Residents identified with a weight loss of 5% or more within one month were referred to the dietitian for further evaluation and intervention. The facility's current weight monitoring protocols were reviewed to ensure compliance with established guidelines. III. The facility's policy titled Management and Prevention of Significant Weight Loss was reviewed by Director of Nursing and Registered Dietitian and no revision was required. Registered Dietitian, Licensed Nursing staff and Certified Nurses Aides will be educated on: - The facility's policy titled Management and Prevention of Significant Weight Loss - Importance of placing residents on a weekly weight when there is unplanned or undesirable weight (loss/gain) - Involvement of the Interdisciplinary Team (IDT) - Notification of primary provider - Initiate and update nutritional patient centered care plan that meet each resident nutritional needs with the goal of achieving the desired outcome. - On time reporting significant weight changes by RD to IDT and physicians - Proper procedures for obtaining and documenting weights. - The importance of timely communication with the dietitian and physician regarding residents' nutritional status. - Communicate with the Physician and Charge Nurse about any nutritional recommendations based on residents 'assessments. The facility's weekly weight committee will ensure that residents at risk of nutritional status will be monitored closely, and all interventions will be followed accordingly. IV. The Chief Registered Dietician/Designee will conduct weekly audits of residents with weight loss weekly X 4 then monthly x 3 to ensure their nutritional needs will be addressed accordingly including weekly weight, communication to primary physician, Updating nutritional plan of care according to the facility policy and procedures. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Chief Registered Dietician/Designee The correction date is 3/5/25 |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19. 1. 6. 1 limits existing health care occupancies to the building construction types shown in Table 19. 1. 6. 1 Construction Type Limitations. Table 19. 1. 6. 1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation, document review, and staff interviews, the facility did not ensure that the three-story building was in accordance with NFPA 101 Life Safety Code. Specifically, it could not be verified that the building was at least Type II (111) construction type or that the building had a fire resistance rated ceiling assembly. These was observed in three of three stories within the facility. The findings are: On (MONTH) 08, 2025, at approximately 9:30 AM, during the Life Safety Code recertification survey, observations of the floor/ceiling assembly above the drop ceiling revealed the following: -On the third floor, the smoke barrier by the nurse station revealed fire proofed steel structural members (e.g., joists and beams). It could not be verified that the steel structural members above the smoke barrier by resident room [ROOM NUMBER] were fire proofed. - On the second floor, the smoke barrier by the nurse station revealed fire proofed steel structural members (e.g., joists and beams). It could not be verified that the steel structural members above the smoke barrier by resident room [ROOM NUMBER] were fire proofed. -On the first floor, the smoke barrier by the elevators revealed unprotected steel structural members (e.g., joists and beams) not provided with fire proofing. In addition, a fire resistance rated ceiling assembly could not be verified for the building. The lack of a complete fire proofing on steel structural members or not having a full fire resistance rated ceiling assembly indicates that this building can not be considered of at least Type II (111) protected, non-combustible structure. On (MONTH) 08, 2025, at approximately 9:50 AM the Regional Director of Building and Environmental Services stated that they will seek to conduct a Fire Safety Evaluation System (FSES) using the 2001 values. On (MONTH) 08, 2025, at approximately 3:00 PM, a contractor letter was provided for review. The letter dated 10/16/2023, stated the proposal for a Fire Safety Evaluation System (FSES) service for the facility. A document that evidence that the facility is of at least Type II (111) construction type was not provided for review. On (MONTH) 08, 2025, at approximately 3:45 PM, during the exit interview, the Administrator stated that they will conduct an FSES. 2012 NFPA 101: 19. 1. 6. 1 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The facility obtained the services of a Registered Nurse consultant, not employed by the facility, to develop in implement a plan of correction. Resident #234 was promptly assessed for pain using a standardized pain assessment tool. The attending physician was notified, and appropriate pain management interventions were initiated, (ordered Tylenol 2 tabs) including pharmacological and non-pharmacological approaches on 1/6/25 The staff involved with resident #234 were identified and educated on the facilities pain management protocols. Resident #234 is no longer a resident of the facility as of 1/09/ 25. II. All residents with wounds have the potential to be affected. An audit of all residents with wounds was completed to ensure that pain management was provided to each resident consistent with professional standards of practice. Any finding was addressed accordingly to ensure residents identified were assessed for pain, and their care plans were reviewed to ensure appropriate pain management interventions are in place. III. The facility's policies titled Pain Management and Pressure Ulcers/Skin Breakdown-Clinical Protocol, were reviewed by Director of Nursing and no revision required. Providers, Interdisciplinary Team (IDT) and nursing staff will be educated on: - The above policies, - Recognizing signs and symptoms of pain and possible behavioral signs of pain include negative verbalizations and vocalizations such as groaning, crying, and screaming; facial expressions such as grimacing, frowning, clenching of the jaw, behavior changes such as resisting care, irritability, depressed mood; be aware the residents may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness, or tingling, burning and etc. - Monitor the residents for the presence of pain and need for further assessment when there is change in condition. - Assess the resident whenever there is a suspicion of new pain or worsening existing pain. - Review the residents' clinical record to identify conditions or situations that may predispose the resident to pain, including pressure, venous, or arterial ulcers and etc. - identify any situations where an increase in pain may be identified, such as treatment for [REDACTED]. - documenting correct pain level especially in residents with communication challenges. - Proper assessment when giving pain medications. - Documentation requirements for pain assessments and interventions. - Implementing both pharmacological and non-pharmacological pain management strategies. - Ensure providers assess pain and ensure patient is on proper pain medication management regimen according to resident plan of care and goals of care - Communication between IDT to ensure residents' level of pain is addressed according to their plan of care to ensure that pain management was provided to each resident consistent with professional standards of practice. - Ongoing communication between the prescriber and staff is necessary for the optimal and judicious use of pain medications. - Informing the prescriber of the residents' pain or pain medication side effects. If pain has not been adequately controlled, the Physician, shall reconsider approaches and make adjustments as needed. The facility wound nurse/designee will monitor that all residents with wounds will be assessed for pain and they have an effective pain management care plan to ensure that pain management is provided to each resident consistent with professional standards of practice. Any resident with change of condition will be reviewed during morning meeting to identify conditions or situations that may predispose the resident to pain, including pressure, venous, or arterial ulcers, etc. A pain assessment and plan of care will be initiated accordingly. Unit Managers will monitor residents with behaviors and cognitive impairment to ensure pain assessments are completed and any behavior that could be a result of residents pain will be addressed accordingly by medical provider. IV. The Director of Nursing (DON) or designee will conduct an audit of 10 residents with wound weekly x 4 then monthly x 3 to ensure that pain management was provided to each resident consistent with professional standards of practice. The Director of Nursing (DON) or designee will conduct an audit of all new admissions with wound weekly x 4 then monthly x 3 to ensure that pain management was provided to each resident consistent with professional standards of practice. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Director of Nursing/Designee The correction day is 3/5/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
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, initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (1) (Resident #234) of four (4) residents reviewed for Pressure Ulcers. Specifically, Resident #234 had a Stage 3 pressure ulcer to the sacrum (a large, triangular bone at the base of the spine). The resident was heard from the hallway loudly complaining of pain and they wanted to die. The resident did not have a physician's orders [REDACTED]. This resulted in actual harm that is not Immediate Jeopardy. The finding is: The facility's policy titled Pain Management, dated 10/2024, defined pain management as the process of alleviating the resident's pain based on their clinical condition and established treatment goals. Possible behavioral signs of pain include negative verbalizations and vocalizations such as groaning, crying, and screaming; facial expressions such as grimacing, frowning, clenching of the jaw; behavior changes such as resisting care, irritability, depressed mood; be aware the resident may avoid the term pain and use other descriptors such as throbbing, aching, hurting, cramping, numbness, or tingling; monitor the resident for presence of pain and need for further assessment when there is change in condition; assess the resident whenever there is a suspicion of new pain or worsening existing pain; review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including pressure, venous, or arterial ulcers; identify any situations where an increase in pain may be identified, such as treatment for [REDACTED]. Assessing pain includes the medical conditions and pain medications, the resident's goal for pain management, and their satisfaction with the current level of pain control. The medication regimen is implemented as ordered. The results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and staff is necessary for the optimal and judicious use of pain medications. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. If pain has not been adequately controlled, the multidisciplinary team, including the Physician, shall reconsider approaches and make adjustments as indicated. The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 11/13/2024 documented the nurse shall document and report pain assessment; the physician will help identify medical interventions related to managing pain related to the wound or wound treatment. Resident #234 was admitted with [DIAGNOSES REDACTED]. The 10/22/2024 Admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 6, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident had occasional, moderate pain and had received scheduled and as needed pain medications. The resident was able to make self understood and understands. The resident was dependent on staff for bed mobility and transfers and had no pressure ulcers. A Comprehensive Care Plan titled, at risk for pain related to a decrease in mobility, recent hospitalization , effective 10/15/2024, documented to monitor, record, and report to the nurse any signs and symptoms of non-verbal pain including but not limited to vocalizations (grunting, moans, yelling out, silence), mood and behavior changes, more irritable, restless, aggressive, squirmy, constant motion, sad face, crying, worried, scared, grimacing, and thrashing, etc.; and to administer medications as ordered by the Physician. The physician's orders [REDACTED]. The order was discontinued on 10/22/ 2024. A nursing progress note dated 12/18/2024, written by Registered Nurse #2 (the Unit Manager), documented the assigned Certified Nursing Assistant reported an open area to the resident's right buttocks. The resident was assessed by the wound nurse (Wound Care Registered Nurse #1) as a Stage 3 pressure ulcer-(full-thickness tissue loss indicating significant damage to the underlying tissue beneath the skin) to the right buttocks. Treatment was initiated. A Comprehensive Care Plan titled Open Area to Right Buttock, (Retitled to Sacral Stage 3), initiated on 12/18/2024, and last updated on 1/5/2025, documented an intervention to administer treatments/medications as ordered and to monitor for effectiveness. There was no documented evidence the resident was assessed for pain or was provided pain management related to the wound. A progress note dated 12/19/2024, written by Occupational Therapist #1, documented the resident was issued a pressure relieving cushion for the wheelchair to prevent skin breakdown and help alleviate pain from the wound on the right buttocks. A review of the Comprehensive Care Plan for the Sacral Wound revealed the pressure relieving cushion was not included. Nurse Practitioner #1's progress note dated 12/31/2024 documented the resident was seen for a medical follow-up. The resident was complaining that their buttocks burn. The resident had a sacral wound and was being managed by the wound care team and the plan was to continue [MEDICATION NAME] for pain management. A review of the medical record revealed there was no current order on 12/31/2024 for [MEDICATION NAME]. A physician's orders [REDACTED]. Reposition every 2 hours for pressure relief. During an initial tour observation on 1/5/2025 at 10:39 AM, Resident #234 was in their room and was heard from the hallway complaining in profane language that their buttocks hurt and saying, I want to die. During an interview on 1/5/2025 at 10:40 AM, Certified Nursing Assistant #4 stated Resident #234 complained of pain because of the wound. The resident also verbalized that the [MEDICAL CONDITION] the nurse puts the dressing on it. A physician's orders [REDACTED].#2) documented to obtain a Psychiatry consult related to resident yelling on/off, and constant banging on their table. There was no documented evidence the physician was aware of the resident's complaint of pain. The pain level documented in the Medication Administration Record for the 7:00 AM-3:00 PM shift on 1/5/2025 was 0 (no pain). The Medication Administration Record did not indicate a specific time when the pain assessment was completed. A physician's orders [REDACTED]. During an observation on 1/7/2025 at 8:45 AM, Resident #234 was observed in their room with facial grimacing and was complaining in profane language that their buttocks was hurting and they wanted to die. The resident was lying flat on their back. The positioning wedge was observed against the side rail and did not provide pressure relief to the resident. Registered Nurse Unit Manager #2 entered the resident's room and stated the positioning wedge was to prevent the resident from falling out of bed. Registered Nurse Unit Manager #2 stated they had to check with the Rehabilitation Department to see if the positioning wedge was meant to provide pressure relief. During an observation on 1/7/2025 at 8:57 AM, Licensed Practical Nurse #1 (the medication nurse) entered the room and administered two tablets to Resident # 234. Licensed Practical Nurse #1 stated the tablets were 325 milligrams of Tylenol each. Licensed Practical Nurse #1 stated the positioning wedge was in place to prevent the resident from falling out of bed. Licensed Practical Nurse #1 did not ask the resident about their level of pain prior to providing the Tylenol and there was no documented follow up if the Tylenol was effective. During an observation and interview on 1/7/2025 at 9:00 AM, Registered Nurse Unit Manager #2 returned to Resident #234's room and stated they spoke to the Rehabilitation Department and the positioning wedge was meant to offload the sacral area and to provide pressure relief. Registered Nurse Unit Manager #2 and Licensed Practical Nurse #1 then left the resident's room without repositioning the resident or placing the positioning wedge under the resident. The resident continued with facial grimacing and complaints of pain in their buttock area. A review of the medical record indicated no documented follow-up regarding the resident's pain level after the Tylenol was administered on 1/7/2025 at 8:57 AM. The pain level documented on the Medication Administration Record, by Licensed Practical Nurse #1, for the 7:00 AM-3:00 PM shift on 1/7/2025 was 5 out of a scale of 10, with 0 being no pain and 10 being the worst possible pain. The Medication Administration Record did not indicate a specific time when the pain assessment was completed. During an observation and interview on 1/7/2025 at 9:04 AM, Certified Nursing Assistant #5 (assigned to Resident #234) entered the resident's room after being alerted of the resident's pain complaints. The resident was complaining in profane language of pain in the buttock area. Certified Nursing Assistant #5 repositioned a pillow under the resident and stated the positioning wedge was to keep the resident safe. During an interview on 1/7/2025 at 2:10 PM, Occupational Therapist #1 stated during their therapy session with the resident on 12/19/2024, the resident was expressing pain and stated in profane language that their buttocks hurt. Occupational Therapist #1 stated they notified Registered Nurse Unit Manager #2 of the resident's complaint of pain. A nursing progress note, written by Registered Nurse Unit manager #2 , dated 1/7/2025 at 3:20 PM documented resident's family visited the resident and insisted on having stronger pain medication. A telephone order was received from the Physician for [MEDICATION NAME] (a narcotic pain reliever) 50 milligrams every 12 hours and Tylenol 650 milligrams by mouth every 6 hours. Review of the (MONTH) 2025 Medication Administration Record revealed that a one-time dose of [MEDICATION NAME] 50 milligrams was ordered and administered on 1/7/2025 at 2:46 PM. The first standing dose was administered on 1/7/2025 at 9:00 PM. During an interview on 1/8/2025 at 9:26 AM, Certified Nursing Assistants #4 and #6 stated the resident always says in profane language that their buttocks hurt. The resident has been complaining of pain since they were admitted . Certified Nursing Assistants #4 and #6 stated the nurses and the supervisor were aware because they provided wound care and medications to the resident. During an interview on 1/8/2025 at 9:37 AM, Registered Nurse Unit Manager #2 stated the Certified Nursing Assistants never told them that Resident #234 was having pain. Occupational Therapist #1 ordered the pressure relieving cushion for Resident #234; however, they were not informed the resident was having pain. During a re-interview on 1/8/2025 at 10:19 AM, Wound Care Registered Nurse #1 stated Resident #234 did not have orders for pain medication before the treatment changes until 1/6/2025 Wound Care Registered Nurse #1 stated they assessed Resident #234 when the resident was first identified with a Stage 3 pressure ulcer on 12/18/2024; however, they did not get an order for [REDACTED]. Wound Care Registered Nurse #1 could not recall if the resident was complaining of pain. Wound Care Registered Nurse #1 stated residents with a Stage 3 or Stage 4 pressure ulcer should have orders for pain medications to be administered before a wound care treatment. A Pressure Injury Investigation and Audit Form dated 12/18/2024 prepared by Wound Care Registered Nurse #1 documented no entry for Date of Last Pain Evaluation and no entry for Was there any immobility related to pain status? During an interview on 1/8/2025 at 11:05 AM, Certified Nursing Assistant #7 stated the resident always verbalized that they were always in pain. Resident #234 often stated they want to die and help me. A review of the (MONTH) 2024 Medication Administration Record revealed the resident's pain level ranged from 0 (no pain) to 2 (mild pain) out of 10 on a pain scale (a score of 0 indicating no pain and a score of 10 indicating the highest amount of pain one can experience). The Medication Administration Record did not indicate a specific time when the pain assessment was completed. During Resident #234's wound care observation on 1/8/2025 at 1:15 PM, Licensed Practical Nurse #5 performed the wound care and they were assisted by Wound Care Registered Nurse # 1. When Licensed Practical Nurse #1 started the sacral wound care treatment, Resident #234 appeared very sensitive to touch. The resident flinched, grimaced, pulled their body away from the nurse, and stated the treatment hurt. The resident was yelling You are burning me when the wound was touched and cleansed. The resident was saying they wanted to die. The nurses stopped the treatment because of the resident's discomfort. Licensed Practical Nurse #5 stated they gave the resident Tylenol at 12:30 PM. Wound Care Registered Nurse #1 stated they would have to call the Physician for additional pain medication. A review of the Medication Administration Record for 1/8/2025 for the 7:00 AM - 3:00 PM shift revealed a pain level of 2 out of 10 entered by Licensed Practical Nurse # 5. The Medication Administration Record did not indicate a specific time when the pain assessment was completed. A nursing progress note written by Wound Care Registered Nurse #1 dated 1/8/2025 at 3:09 PM documented the resident was seen today for a dressing change at 1:15 PM; they were premedicated with pain medication (Tylenol), 30 minutes before the dressing change. The resident complained of pain during repositioning and repeatedly stated I want to die. During the dressing change, the resident complained of burning when (the wound was) cleansed with normal saline and repeated, I want to die. The treatment was stopped, and the Physician was notified that the resident was complaining of pain during positioning and burning during the treatment change. [MEDICATION NAME] immediate dose was ordered and given. The resident was revisited at 2:35 PM for a dressing change; they still complained of burning during treatment. Treatment was completed. During an interview on 1/8/2025 at 1:47 PM, Nurse Practitioner #1 stated they saw the resident for a medical follow-up on 12/31/ 2024. The resident complained of pain to their buttocks area. Nurse Practitioner #1 stated at the time of the assessment they did not realize the [MEDICATION NAME] order was discontinued and that the resident did not have any other pain medication orders. The resident should have had pain medication management because they had pain per their assessment. Nurse Practitioner #1 further stated the resident had a Stage 3 pressure ulcer and should be medicated prior to wound treatment, as per the facility protocol. During an interview on 1/8/2025 at 2:27 PM, the Director of Nursing Services stated the nursing staff should have reported the resident's pain to the Nurse Manager, who should then have called the Physician for pain medication orders. Additionally, the staff should have utilized the positioning wedge to offload the wound as per the Rehabilitation Department's recommendation to minimize pain. The Director of Nursing Services stated the medical provider should have initiated pain medication orders when the wound was first identified, and the nurses should assess for pain prior to providing treatment and routinely due to the Stage 3 sacral ulcer. During an interview on 1/10/2024 at 9:24, Physician #2 (the resident's Attending Physician) stated when a resident expresses verbal or non-verbal complaints of pain, the medical provider should have ensured the pain medication orders were put in place and the facility staff should have reported the resident's pain complaints to the Physician. 10 NYCRR 415. 12 | Plan of Correction: ApprovedFebruary 6, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The attending physician was immediately contacted for Resident #336 and Resident #285, and appropriate orders were obtained for monitoring and flushing of their intravenous catheter sites. The nurses responsible for these residents were re-educated on the importance of obtaining and following physician orders [REDACTED]. II. All residents with IV therapy have the potential to be affected. A facility-wide audit of all residents with intravenous catheters was conducted to ensure Intravenous therapy will be administered consistent with professional standard of practice and in accordance with physician's orders [REDACTED]. III. The facility's policy titled Intravenous Infusion, was reviewed by the Director of Nursing and no revision was required. Licensed Nursing Staff will be educated on the above policy to ensure Intravenous therapy will be administered consistent with professional standard of practice and in accordance with physician's orders [REDACTED]. Unit Managers/Supervisors will oversee the residents with IV therapy to ensure Intravenous therapy is administered consistent with professional standard of practice and in accordance with physician's orders [REDACTED]. IV. The Director of Nursing/Designee will conduct an audit of residents receiving IV therapy weekly x 4 then monthly x 3 to ensure Intravenous therapy is administered consistent with professional standard of practice and in accordance with physician's orders [REDACTED]. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Director of Nursing/Designee The correction date is 3/5/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that a comprehensive care plan was developed and implemented for each resident including measurable objectives and timeframe to meet each resident's medical and nursing needs. This was identified for one (Resident#233) of one resident reviewed for Hydration; one (Resident #68) of seven residents reviewed during the Medication Administration Task; and one (Resident #285) of two residents reviewed for Urinary Catheter or Urinary Tract Infection. Specifically, 1) Resident #233 had a physician's orders [REDACTED]. 2) Resident #68 was administered Calcium 500 milligrams with Vitamin D 3 instead of the Physician ordered Calcium-Vitamin D 600 milligrams-200 milligrams. 3) Resident #285 received antibiotic therapy intravenously; however, there was no comprehensive care plan developed for the insertion, care, and use of the Peripheral Intravenous Catheter. The findings are: A facility's policy titled Care Plans, Comprehensive Person-Centered, documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided. 1) Resident #233 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. A physician's orders [REDACTED]. 9 percent at 100 milliliters per hour every shift for Hydration for two days. A nursing progress note dated 1/6/2025 documented the resident was started on Sodium Chloride Solution 0. 9 percent at 100 milliliters per hour intravenously, every shift for hydration until 1/7/ 2025. There was no documented evidence that a comprehensive care plan was developed for the use of intravenous fluids. During an interview on 1/8/2025 at 9:49 AM, Registered Nurse Unit Manager #2 stated Resident #233 received intravenous fluids related to their elevated blood sugar levels starting 1/4/2024 for two days. Registered Nurse Unit Manager #2 further stated that whoever picked up the physician's orders [REDACTED]. During an interview on 1/10/2025 at 10:06 AM, the Director of Nursing Services stated there should have been a care plan developed for the use of intravenous fluids. 2) The facility's policy and procedure titled Medication Administration, last revised on 10/18/2024 documented that medications are administered in accordance with the prescriber's orders, including the required time frame. Resident #68 was admitted with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #68 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #68 had no [MEDICAL CONDITION] (bones become weak and brittle) or Arthritis (joint inflammation). A Comprehensive Care Plan (CCP) dated 10/19/2024 documented Resident #68 was at risk for pain related to contractures (when muscles, tendons, joints, or other tissues tighten or shorten causing deformity). The intervention included administering medication as ordered by the Physician. A physician's orders [REDACTED]. Resident #68 was observed in their room on 1/5/2025 at 9:10 AM. Licensed Practical Nurse #2 was observed during the Medication Administration Task administering two tablets of Calcium 250 milligrams with Vitamin D3 ( 3. 1 micrograms) to Resident # 68. The resident refused to take the medications. During an interview on 1/5/2025 at 9:12 AM, Licensed Practical Nurse #2 stated they did not have the Calcium with Vitamin D 600 milligrams-200 International Unit available in their medication cart. Licensed Practical Nurse #2 stated the Calcium 250 milligrams with Vitamin D3 ( 3. 1 micrograms) was the closest dose they had in their medication cart. Licensed Practical Nurse #2 stated they would have documented in Resident #68's Electronic Medication Administration Record [REDACTED]. During an interview on 1/5/2025 at 11:33 AM, Registered Nurse #3, the Unit Manager stated that Licensed Practical Nurse #2 should never have given a different dose of Calcium with Vitamin D to the resident. Registered Nurse #3 stated that Licensed Practical Nurse #2 should have checked with Central Supply for the medication availability. Licensed Practical Nurse #2 should have also called the Physician to get a different order if Calcium with Vitamin D 600 milligrams-200 International Unit was not available. During an interview on 1/8/2025 at 12:34 PM, the Director of Nursing Services stated Resident #68 should not have been given any medication except for what the Physician had ordered. The Director of Nursing Services stated Nursing staff should follow the orders given by the Physician. 3) Resident #285 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #285 had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Additionally, while there was a Comprehensive Care Plan for a Urinary Tract Infection dated 12/28/2024, the care plan did not include interventions related to the placement or care of an Intravenous Midline Catheter. During an observation on 1/5/2025 at 9:35 AM, Resident #285 was observed in bed with an Intravenous Catheter in their right arm. During an observation on 1/7/2025 at 10:51 AM, Resident #285 was in bed with the Intravenous Catheter in their right arm. During an interview on 1/7/2025 at 10:24 AM, Registered Nurse Unit Manager #4 stated a Care Plan should be developed for the Intravenous Midline Catheter when the peripheral intravenous catheter was ordered and placed. During an interview on 1/8/2025 at 12:01 PM, the Director of Nursing Services stated staff is expected to confirm that a physician's orders [REDACTED]. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedFebruary 10, 2025 I. The Interdisciplinary Team (IDT) reviewed Resident #113, #13 and #37's medical records to ensure that residents' plan of care was not negatively impacted due to the delayed MDS. No adverse effects were noted. MDS team members were educated on Quarterly MDS assessments to ensure the facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months. II. All residents that are in the facility for more than 90 days have potential to be affected A facility-wide audit of all residents with scheduled Quarterly MDS assessments was conducted by the MDS Director to identify any additional cases of late assessments. Any findings were addressed accordingly. III. The facility policy titled MDS Assessments??ÿ, was reviewed by administrator, Director of MDS and Director of Nursing and no revision was required The MDS staff and interdisciplinary team (IDT) including Rehab, Social Workers, Dieticians, and Recreation staff will be re-educated on the above policy and regulatory timeframes for MDS completion. Weekly MDS reports using PCC (EHR) will be generated and reviewed by the MDS Director to ensure timely completion. The Interdisciplinary Team (IDT) including Rehab, Social Workers, Dieticians, and Recreation staff will review the MDS completion schedule during weekly care plan meetings and daily at morning meetings. Any assessments at risk of delay will be escalated to the Administrator and Director of Nursing for immediate action. The MDS Director will implement a reminder system by compiling a weekly list of MDS that are due for comprehensive assessments and will distribute the list at morning meeting to the involved Interdisciplinary team members to ensure timely assessment and timely completion. The MDS Director will submit a weekly report to the administrator to ensure compliance with the above. IV. The Administrator/Designee will conduct weekly audits on MDS quarterly assessments weekly X 4 then monthly 3 to ensure quarterly assessments are completed and submitted within the required timeframe of 90 days. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Administrator/Designee Date of correction is 3/5/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the Recertification Survey initiated on 1/5/2025 and completed on 1/10/2025, the facility did not ensure that comprehensive assessments of residents were conducted within 14 calendar days after admission and not less than once every 12 months. This was identified for two (Resident #67 and Resident #37) of six residents reviewed during the Resident Assessment Task. Specifically, Resident #67 and Resident #37's annual Minimum Data Set Assessment was not completed within 14 days of the Assessment Reference date. The finding is: The facility policy titled MDS Assessments, dated 12/10/2024, documented all Minimum Data Set assessments are to be completed and submitted to Centers for Medicare and Medicaid Services as per the guidelines provided in the Resident Assessment Instrument Manual. The Minimum Data Set Coordinator will assume the leadership role to ensure that all Minimum Data Set Assessments are completed and submitted as per the guidelines. Resident #67's Annual Minimum Data Set assessment with an Assessment Reference Date of 8/30/2024 was completed on 9/20/ 2024. This was 7 days beyond the required time frame. Resident 37's Annual Minimum Data Set Assessment with an Assessment Reference Date of 8/22/2024 was completed on 9/11/ 2024. This was 6 days beyond the required time frame. During an interview on 1/10/2025 at 9:19 AM, the Minimum Data Set Director stated the Minimum Data Set should be completed 14 days from the Assessment Reference Date. The Minimum Data Set Director stated they knew that Resident #37's and Resident #67's Annual Minimum Data Set was completed late. They further stated that the Director of Nursing and Administrator were aware. During an interview on 1/10/2025 at 9:51 AM, the Director of Nursing Services stated they were aware the Minimum Data Set assessments were completed late. The Director of Nursing Services stated the late assessment completion was because of staffing turnover. 10 NYCRR 415. 11 | Plan of Correction: ApprovedFebruary 6, 2025 I. Resident # 283 # 284 # 335 who were observed with Foley catheters lacking privacy bags were immediately provided with appropriate catheter bag covers to maintain dignity and privacy. Each resident's care plan was reviewed and updated to include the use of privacy bags for their Foley catheters. The certified nurses aide's and nurses on the units were educated on the importance of maintaining resident privacy and dignity by ensuring all urinary bags are covered appropriately. II. All residents with urinary catheters have potential to be affected. A comprehensive audit was conducted to identify all residents with indwelling catheters. The audit ensured that each identified resident had a privacy bag in place and that their care plans reflected this intervention. III. The facility's policy and procedure titled Foley Catheter Care and Privacy was reviewed by the Director of Nursing and no revision was required. Nursing staff will be educated on the above policy, importance of urinary privacy bags and proper application and maintenance of catheter privacy bags to promote resident's rights and privacy and to ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. Unit Mangers/Supervisors will be responsible to monitor the application urinary privacy bags during their daily rounds to ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of their quality of life. IV. The Director of Nursing/Designee will conduct audits of all residents with urinary bags weekly x 4 then monthly x 3 to ensure privacy covers are in place. Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Director of Nursing Date of correction is 3/5/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
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 initiated on 01/05/2025 and completed on 01/10/2025, the facility did not ensure that each resident was offered a therapeutic diet when there is a nutritional problem, and the healthcare provider ordered a therapeutic diet. This was identified for one (Resident #54) of six residents reviewed for Nutrition. Specifically, Resident #54 experienced a 10% weight loss over one month, decreasing from 99 pounds on (MONTH) 5, 2024, to 89 pounds by (MONTH) 12, 2024. Registered Dietician #1 recommended weekly weights; however, there was no documented evidence the resident's weights were obtained weekly to monitor further weight loss. Subsequently, Resident #54 had an additional 7% weight loss from 12/12/2024 to 1/7/ 2024. The finding is: The facility's policy titled Management and Prevention of Significant Weight Loss, revised on 11/01/2023 documented that the Clinical Dietitian will place the resident on a weekly weight if a resident's weight (loss/gain) is unplanned or undesirable. The Physician will be notified of any weekly or monthly significant weight changes or as needed. Care plans will be under continuous revisions to meet the resident's needs with the goal of achieving the desired outcome. Communicate with the Physician and Charge Nurse about any nutritional recommendations based on assessment. Monitor resident's progress and document weekly or sooner in the medical record until weight status resolves. Resident #54 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview could not be completed due to Resident #54's severe cognitive impairment. Resident #54 was on a mechanically altered therapeutic diet and required supervision or touching assistance (the helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completes the activity. Assistance may be provided throughout the activity or intermittently) for eating. The resident's height was 60 inches and weight was 99 pounds. The resident did not have a weight gain or weight loss of 5% in one month or 10% in six months of the assessment period. The Comprehensive Care Plan effective 8/05/2024 last reviewed 11/19/2024 documented the resident had a high nutritional risk secondary to chewing difficulty. The interventions included monitoring weights monthly/weekly and monitoring oral intake of food and fluids. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Dietician progress note dated 11/05/2024 documented Quarterly nutritional assessment. The resident was on a no-salt added diet with puree consistency and nectar thick liquids and was on weekly weights. The resident's weights were: on 8/3/2024 the resident weighed 105. 2 pounds; on 10/7/2024 the resident's weight was 99. 2 pounds; on 10/23/2024 the resident weighed 98 pounds; and on 11/5/2024 the resident weighed 99 pounds. The resident's weight increased by one pound in 2 weeks and was stable in 30 days; however, there was a 6. 2 pounds ( 5. 8%) weight loss in 90 days. The weight loss was not desirable. The resident was receiving additional food items for weight stability/weight gain. The recommendation was to monitor weights and oral intake. The Weights and Vitals Sign Summary documented on 11/17/2024 the resident weighed 132 pounds; however, the weight was crossed off and no reweigh was documented for (MONTH) 2025. On 12/12/2024 the resident weighed 89 pounds which was a 10% weight loss in one month since 11/5/ 2024. The resident's weight on 1/07/2024 was recorded as 83 pounds which was an additional 7% weight loss since 12/12/ 2024. A dietary progress note dated 12/16/2024, written by Registered Dietitian #1, documented the resident's weight decreased by 10 pounds in 30 days (10%). Registered Dietitian #1 documented they observed the resident on meal rounds. The resident was consuming only a few bites of lunch and a few sips of nectar thick liquids. The plan was to continue monitoring the weekly weights, oral intake, and tolerance of supplements. The medical record lacked documented evidence of weekly weights in (MONTH) and (MONTH) 2024. A physician progress notes [REDACTED].#1, documented Resident #54 was seen and examined. The resident's weight was 89 pounds on 12/12/ 2024. The resident was at risk for Malnutrition. A physician's orders [REDACTED]. Administer into a 500-milliliter bag of normal saline daily for 3 days. A physician's progress note dated 1/03/2025, written by Nurse Practitioner #1 documented staff requested to evaluate Resident #54 for poor appetite. A Calorie Count was ordered for 3 days. The resident would continue to receive Ensure supplement. Nurse Practitioner #1 documented they will reevaluate the resident at the end of the calorie count and will discuss the goals of care with the family. The Calorie Count was not initiated until 1/6/ 2025. The Certified Nursing Assistant Accountability Record for Resident #54's meal intake in (MONTH) 2024 documented that Resident #54 consumed 0-75% of their meals. For (MONTH) 2025, Resident #54 consumed 25-75% of their meals. During an observation and interview on 1/08/2025 at 11:52 AM, Resident #54 was observed sitting in a Geri chair. Certified Nursing Assistant #2 was feeding Resident #54 their lunch meal. The resident fell asleep during the meal and ate less than 25% of their lunch. During an interview on 1/07/2025 at 2:59 PM, Registered Dietician #1 stated Resident #54 had a 10% weight loss in one month in (MONTH) 2024. Registered Dietician #1 stated the resident was diagnosed with [REDACTED]. Registered Dietician #1 stated the resident lost 10 % of weight in one month; however, they did not change the resident's plan of care. They stated they should have changed the Ensure Clear from twice a day to three times a day on 12/12/2024 when they first identified the weight loss. Registered Dietician #1 stated the Dieticians are responsible for monitoring the resident's weight, assessing the resident for weight loss, notifying the Physician, and providing nutritional interventions to prevent further weight loss. During an interview on 1/07/2025 at 3:40 PM, Chief Dietician #1 stated Resident #54 had a significant weight loss in (MONTH) 2024. Registered Dietician #1 was expected to make changes to the resident's nutritional plan of care and should have provided increased protein and calories. Resident #54's weekly weights should have been obtained as recommended by Registered Dietician # 1. During an interview on 1/10/2025 at 9:24 AM, Primary Physician #1 stated they stated, they were made aware of Resident #54's weight loss. Resident #54 had a COVID-19 infection and was treated with intravenous fluids and intravenous antibiotics. Primary Physician #1 stated they follow the the Dietician's recommendations to increases and decreases the diet and supplements. Primary Physician #1 stated stated they did not documented a weight change in their notes; however, they provided orders to administer intravenous fluids to Resident #54 for hydration. 10 NYCRR 415. 12(i)(1) | Plan of Correction: ApprovedFebruary 6, 2025 I. On 1/5/25 the triangle wedge cushion for Resident #234 was properly repositioned to ensure appropriate pressure relief as intended in the care plan. On 1/5/25 Resident #234 was assessed for any signs of skin breakdown or pressure injuries due to improper positioning. No adverse effects were noted. The certified nurses aide assigned to the resident was immediately re-educated on the purpose and proper use of the wedge cushion in preventing pressure injuries. II. All residents with pressure injuries/wounds have the potential to be affected. A facility-wide audit of all residents with pressure injuries/wounds was conducted to identify preventive measures such as pressure relief positioning devices are being used correctly. No additional findings were identified III. The facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol??ÿ was reviewed by Director of Nursing and no revision was required. Licensed nursing staff and Nursing assistants will be educated on the above policy and the purpose and correct use of pressure relief and positioning devices. The importance of pressure relief measures for at-risk residents. How to identify and report improper use of positioning devices. The Wound nurse or designee will perform random spot checks to ensure compliance with proper positioning and use of positioning devices during wound rounds. Any incorrect use of positioning devices will be corrected immediately, and staff will receive education. Unit Managers will oversee the care of residents with pressure injuries to ensure each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. IV. The Wound Nurse/designee will conduct weekly audits of residents with pressure relief/ positioning devices weekly x 4 then monthly x 3 the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing Results of these audits will be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings for 3 months or until compliance is sustained. V. Responsible party: Director of Nursing/designee The correction date is 3/5/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 1. 3. 1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2012 NFPA 99: 6. 5. 4. 1 Maintenance and Testing of Essential Electrical System. 2012 NFPA 99: 6. 5. 4. 1. 1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 2012 NFPA 99: 6. 5. 4. 1. 1. 1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6. 4. 1. 1. 7 and 6. 4. 3. 1. 2012 NFPA 99: 6. 4. 3. 1 Source. The life safety and critical branches shall be installed and connected to the alternate power source specified in 6. 4. 1. 1. 4 and 6. 4. 1. 1. 5 so that all functions specified herein for the life safety and critical branches are automatically restored to operation within 10 seconds after interruption of the normal source. 2012 NFPA 99: 6. 5. 4. 2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 2012 NFPA 99: 6. 5. 4. 1. 1. 2 Inspection and Testing. Generator sets shall be inspected and tested in accordance with 6. 4. 4. 1. 1. 3. 2012 NFPA 99: 6. 4. 4. 1. 1. 3 Maintenance shall be performed in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 8. 2010 NFPA 110: 8. 4. 1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. Based on document review and staff interviews, the facility did not ensure that the generator was inspected and tested in accordance with NFPA 99 Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Specifically, there was no evidence that the generator was capable of supply service within 10 seconds, and that the generator was inspected weekly and exercised under load at least monthly. This was noted for the only generator serving the facility. The findings are: On (MONTH) 08, 2025, at approximately 2:25 PM, during the Life Safety Code recertification survey, the generator inspection logs were provided for review, the document review revealed the following: -For the past 12 months, there was no evidence that the generator was inspected every week. -The records did not specify when the generator was exercised under load. The last documented load test was performed on 10/23/23; as a result, it could not be verified that the generator was exercised under load 30 minutes 12 times a year in 20 -40 day intervals. -The generator logs did not include the transfer time, as a result, it could not be verified that the generator was capable of supplying service within 10 seconds. On (MONTH) 08, 2025, at approximately 2:35 PM, the Director of Building Services, stated that the generator starts within 8 seconds, the monthly load test is done every four weekly inspections, and that the generator is inspected weekly. On (MONTH) 08, 2025, at approximately 3:45 PM, during the exit interview, the Director of Building Services stated that they will submit the missing weekly generator's inspection reports. No other document that evidences the weekly inspections for the past 12 months was provided for review. 2012 NFPA 101: 9. 1. 3. 1 2012 NFPA 99: 6. 5. 4. 1, 6. 5. 4. 1. 1, 6. 5. 4. 1. 1. 1, 6. 4. 3. 1, 6. 5. 4. 2, 6. 5. 4. 1. 1. 2 , 6. 4. 4. 1. 1. 3 2010 NFPA 110: 8. 4. 1* 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 20, 2025 The Grand Pavilion is requesting a continuing waiver under a passing FSES 2013 Edition conducted by the design professional. The building was cited for not being the proper construction type. The facility contracted an outside vendor to complete the initial evaluation of the Fire Safety Evaluation System (FSES) for the Grand Pavilion On 01/20/2025 the initial evaluation will be completed for the FSES based on the NFPA 101A 2013 Edition to determine if the facility as it stands, is equal to the life safety requirement through strict compliance with the Life Safety Code. 1. No residents were affected by the deficient practice. 1a. All residents have the potential to be affected by the deficient practice. The Medical Director is in agreement there is no additional risk to the residents. 2a. The facility contracted an architectural/engineering firm to conduct an FSES in January 2025. No additional work is required to pass the FSES. 2b. The FSES was completed, and the facility received a passing score. The facility is requesting a continuing waiver under a passing FSES 2013 Edition conducted by the design professional. 3. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The Director of maintenance/designee will implement the following additional measures to mitigate the risks to residents and staff: 1. fire watches 2. additional fire drills 3. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are electronically supervised hold opens and doors will shut when alarms are activated. 6. provide additional extinguishers 7. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not exceeded. Ensure corridors remain unobstructed to allow for evacuation when required.??ÿ 8. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily round tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Staff will be trained and educated regarding all new life safety measures and their importance. 11. The Emergency Preparedness plan was reviewed in conjunction with the FSES results, no additional precautions are required. 4. Administrator will report any updates at the next quarterly QA meeting. 5. The Administrator/designee is responsible for the correction of this deficiency by 02/14/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details None | Plan of Correction: ApprovedFebruary 5, 2025 I. The Director of Maintenance (1) was in-serviced by the administrator on properly testing and documenting the generator weekly and monthly under load (2) updated the log sheet to include transfer time. The administrator will verify all generator testing has been completed. Audits will be completed quarterly to monitor. All other required generator testing was reviewed; no other testing requirements were missing. All testing and documenting will conform with all applicable NFPA standards. II. 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. III. The Director of Maintenance will conduct a quarterly audit to ensure generator testing has been completed as per NFPA standards. IV. 1. The Director of Maintenance/designee will report the findings of audit to administrator. 2. Administrator will report findings of this audit at the next quarterly QA meeting. V. 1. Date of correction is 2/14/2025 2. The Director of Maintenance is responsible for the correction of this deficiency. |