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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 11, 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 3/5/2025 and completed on 3/11/2025, the facility did not ensure it implemented a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #260) of two residents observed for Medication Administration. Specifically, on 3/6/2025, during the medication pass observation for Resident #260, Licensed Practical Nurse #1 did not rinse the resident's mouth after administering a [MEDICATION NAME] inhaler (a medication that helps reduce inflammation and keep airways open; the inhaler contains a steroid medication that increases the risk of oral fungal infection) as per the physician's orders [REDACTED]. The finding is: The facility's policy titled Medication Administration, last revised 2/2023 documented that it is the responsibility of each licensed nurse to be aware of drug classifications, actions/interactions, standard dosages, standards of administration, side effects, and the reason the drug is being given to the resident. Licensed nurses are expected to demonstrate competency in medication administration. Steroidal inhalation medications require the resident's mouth to be completely rinsed after administration. Resident #260 was admitted with [DIAGNOSES REDACTED]. The 1/17/2025 Significant Change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. A physician's orders [REDACTED]. 4. 5 microgram inhaler ([MEDICATION NAME]/[MEDICATION NAME]) two inhalations every 12 hours (9:00 AM and 9:00 PM); Rinse Mouth After Use! Diagnosis: [REDACTED]. During the medication administration observation on 3/6/2025 at 8:18 AM, Licensed Practical Nurse #1 administered two inhalations of the [MEDICATION NAME] inhaler to Resident #260 and did not rinse the resident's mouth after the [MEDICATION NAME] inhalation treatment. During an interview on 3/10/2025 at 8:55 AM, Licensed Practical Nurse #1 stated they were nervous, which is why they missed rinsing the resident's mouth after the [MEDICATION NAME] treatment. Licensed Practical Nurse #1 stated [MEDICATION NAME] is a steroid and can cause oral thrush (fungal infection in the mouth). During an interview on 3/10/2025 at 9:17 AM, Registered Nurse Educator #1 stated [MEDICATION NAME] is a steroid medication and can cause oral thrush. The resident's mouth should be rinsed with water after the inhalation administration. The resident should spit the water out after the rinse. During an interview on 3/10/2025 at 9:25 AM, the Director of Nursing Services stated the nurse should have rinsed the resident's mouth after administering the [MEDICATION NAME] inhaler, It says so in the physician's orders [REDACTED]. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedMarch 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Upon notification from the NYS Surveyor that the Licensed Practical Nurse (LPN) failed to rinse resident # 260s mouth, as per the physician order, the LPN immediately rinsed resident # 260s mouth as ordered. Resident # 260 was seen and examined by the attending physician (MD) on 3/10/2025 at 1:22 pm. The MD documented that there was no evidence of thrush or oral plaques noted. In addition, beginning on 3/10/2025, the nurse who was observed, as well as all other medication administration nurses, were re-educated regarding the need to rinse residents mouths after administering steroid inhalation medications. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have an order for [REDACTED]. The facilitys Director of Pharmacy (DOP) will generate a list of all residents who have active orders for all inhalation type of medications by 03/28/ 2025. The DOP will indicate which of these residents have an inhalation medication that is in the steroidal drug class. Beginning on (MONTH) 31, 2025, the Nursing Informatics Coordinator will review all MD orders for steroidal inhalers to ensure that the order includes directives to rinse the residents mouth after administration. Beginning on (MONTH) 1, 2025, the Nursing Educators will conduct medication administration competencies on all facility nurses who are administering steroidal medications to residents to ensure that they are following physician orders, and rinsing the residents mouths after administration. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The Interdisciplinary Team (IDT) reviewed the policy and procedure titled ?ôMedication Administration?Ø on 03/20/ 2025. There were no necessary changes to the Policy and Procedure upon review. The policy and procedure titled ?ôMedication Administration?Ø was further reviewed by the Director of Nursing, Medical Director and Facility Administrator on 03/24/2025 and approved on 03/24/ 2025. Beginning on (MONTH) 7, 2025, the Nursing Educators will conduct re-education sessions regarding aspects of medication administration to all facility licensed nursing staff (RN and LPN). The education will include, at minimum, the rights of medication administration, reviewing the MD orders prior to administering medications, a brief review of different types of drug classifications and the importance of rinsing residents mouths after administering steroidal inhalation medications. This education will be completed by (MONTH) 2, 2025. IV. The facilitys compliance will be monitored using the following quality assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that nurses administering steroidal inhalation medications are correctly following MD orders to rinse residents mouths after administering the medication. Each month the pharmacist will generate a list of residents who are currently receiving a steroidal inhalation medication. These residents will be added to the developed audit tool to ensure compliance. The Nurse Educators, or designees, will complete a competency assessment on all licensed nurses responsible for medication administration on a monthly basis, based on the list of residents identified by the pharmacist. Deficient practices will be corrected immediately, and nurses who fail to adhere to the MD orders for steroidal inhalation medication will be directed to the nursing education classroom for formal re-education and competency before they are permitted to administer any type of medication to facility residents. These audits will be completed monthly for three (3) months and quarterly for three (3) consecutive quarters, and will be conducted across all shifts. All audit findings will be reported to the facility Administrator and Director of Nursing (DON) following completion. The DON will report results of the audits at the facilitys quality assurance and performance improvement committee meeting. The compliance standard will be set to 100%. At the end of the third quarter, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits and at which frequency. Corrective action will be implemented as needed after the QAPI review of the audits. Responsibility: Director of Nursing |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 11, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 3/5/2025 and completed on 3/11/2025, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for one (Resident #25) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #25's Significant Change Minimum Data Set (MDS) assessment was not electronically submitted to the Center for Medicare and Medicaid Services (CMS) until 35 days after the completion of the assessment. The finding is: The facility's policy and procedure titled MDS 3. 0 Completion last revised on 12/2022, documented the Minimum Data Set Coordinator submits the Minimum Data Set to both the Center for Medicare and Medicaid Services (CMS) database. The policy did not include the timeframe for the completion and transmission of the Minimum Data Set assessments. Resident #25 was admitted with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated that Resident #25 had moderate cognitive impairment. The Minimum Data Set was completed on 1/16/ 2025. A review of the Minimum Data Set (MDS) 3. 0 Nursing Home Validation Report revealed the following: Resident #25's Significant Change Minimum Data Set (MDS) assessment with the reference date of 1/10/2025 was completed on 1/16/2025 and was submitted to the Center for Medicare and Medicaid Services (CMS) on 3/6/2025, 35 days late. During an interview on 3/6/2025 at 1:32 PM, the Minimum Data Set Director stated the facility used a software system that tracked the Minimum Data Set (MDS) assessment schedules. The Minimum Data Set Assessors entered the Minimum Data Set (MDS) start date and completion date in the system. The software system generated a list of the resident assessments due for transmission; however, Resident #25's name did not appear on the list and they did not know why. The Minimum Data Set Director stated that Resident #25's Minimum Data Set was submitted today, 3/6/ 2025. During an interview on 3/7/2025 at 12:47 PM, the Minimum Data Set Assistant Director stated they are responsible for generating the Minimum Data Set assessments transmission due date reports daily. The Minimum Data Set Assistant Director stated they had completed the Significant Change assessment for Resident #25 on 1/16/2025 and did not transmit the assessments upon completion because they relied on the system to generate a report and provide the due dates. During an interview on 3/10/2025 at 1:36 PM, the Director of Nursing Services stated all Minimum Data Set assessments should be completed and transmitted timely. During an interview on 3/10/2025 at 2:24 PM, the Administrator (Executive Director) stated all Minimum Data Set (MDS) assessments should be completed and submitted on time. The Administrator stated they relied on the fact that the software system they use for tracking the assessments is accurate. 10NYCRR 415. 11(a)(3)(i) | Plan of Correction: ApprovedMarch 28, 2025 I. The following actions were accomplished for the residents identified in the sample: The Minimum Data Set (MDS) for Resident #25 dated 1/10/25 and completed on 1/16/2025 was supposed to be submitted by 1/22/ 2025. The MDS director submitted this MDS on 3/6/2025, and it was accepted by the system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have MDS assessments completed have the potential to be affected by the same deficient practice. On (MONTH) 27, 2025, the MDS director generated a report of all MDS assessments that have not been submitted to ensure that there were no assessments that were late to be transmitted. There were no assessments (MDS) that were late to be transmitted. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The interdisciplinary team (IDT) reviewed the policy and procedure, on 03/24/2025, titled ?ôMDS 3. 0 Completion?Ø. The IDT recommended adding to the responsibilities of the MDS director the following statement: Submit the MDS to both the CMS database as well as the state veterans home (SVH) databases within the timeframes established within the Resident Assessment Instrument guidelines as well the regulation under 483. 20 (f)(1)-(4). In addition, the following statement was added: The MDS director, or designee will, generate the list for submission for all MDS assessments that are completed at a minimum, on a weekly basis. This list will be compared to the MDS calendar which contains all resident assessments that are scheduled, and is prepared by the MDS staff after reviewing the previously completed assessments. This will ensure that all MDS assessments which are due to be completed are submitted timely. The Facility Administrator, Director of Nursing and Medical Director reviewed the policy on 03/24/2025 and approved the addition. Beginning on 03/25/2025, the Director of Nursing(DON) re-educated all MDS staff members regarding the policy and procedure for MDS completion, including the change to the submission guidelines. This education will be completed by 03/28/ 2025. IV. The facilitys compliance will be monitored using the following Quality Assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that all completed MDS assessments are transmitted as per the RAI guidelines as well as the regulations under 483. 20 (f) (1)- (4). Each week the MDS Director, or designee, will generate a list of all completed MDS assessments. They will compare the list of completed assessments to the MDS calendar to ensure that all scheduled assessments due for completion are completed and ready for transmission. Residents that have a completed MDS will be added to the audit tool to ensure compliance with transmittal. If MDS assessments are found to be past the required deadline for transmittal, the facility administrator, Director of Nursing, and Chief Financial Officer (CFO) will be notified immediately. Re-education will be provided to the MDS staff member, by the DON, if any MDS assessments are found to be past the required deadline for transmittal. The MDS director or designee will transmit all MDS assessments that are required to be transmitted. Following transmittal, the MDS director or designee will review the ?ôMDS 3. 0 NH Final Validation Report?Ø to ensure that there were no assessments that contained errors or rejections. Any assessments that do contain errors or rejections will be reviewed and transmitted the same day as the original transmittal. These audits will be completed weekly for six (6) months, and then quarterly for two (2) consecutive quarters. The compliance standard will be set to 100%. At the end of the second quarterly audit, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits, and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: MDS Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 11, 2025
Corrected date: N/A
Citation Details Based on record review and staff interviews during the Recertification Survey initiated on 3/5/2025 and completed on 3/11/2025, the facility did not ensure that a Criminal History Record Check (CHRC) 105 Form was submitted within the required 30-day time frame to the New York State Department of Health (NYSDOH). This was identified for one (Employee #6) of six employee records reviewed for Criminal History Record Check. Specifically, the facility received a negative determination Hold in Abeyance letter from Criminal History Record Check dated 1/8/2025 for Employee # 6. Employee #6 was removed from their position on 1/8/2025 and did not return to work as of 3/10/2025; however, the facility did not submit a Criminal History Record Check 105 Form to the New York State Department of Health within 30 days as required. The finding is: The policy titled, Criminal Background Checks last revised 7/24/2023, documented that it was the responsibility of the facility's Human Resources Department to report in a timely manner all terminations to the New York State Department of Health using the Criminal History Record Check 105 Form. The policy did not indicate a timeframe for submitting the Criminal History Record Check 105 Form. A review of Employee #6's file revealed that the facility received a Hold in Abeyance letter on 1/8/2025; however, there was no documented evidence that a Criminal History Record Check 105 Form was submitted to the New York State Department of Health to terminate the employee from the Criminal History Record Check system. During an interview on 3/6/2025 at 1:55 PM, the Director of Human Resources stated when they received the Hold in Abeyance letter for Employee #6 on 1/8/2025, they informed Employee #6 that they would not be able to work again until they provided the requested documentation to the Criminal History Record Check the information necessary to clear their Criminal History Record. The Director of Human Resources stated since Employee #6 did not receive a Denial letter, a Criminal History Record Check 105 Form was not submitted because when Employee #6 gets cleared by Criminal History Record Check they could be put back on duty. During an interview on 3/10/2025 at 2:45 PM, the Administrator stated the Director of Human Resources should have submitted the Criminal History Record Check 105 Form within 30 days of receiving the negative determination letter for Employee # 6. The Administrator also stated the Criminal History Record Check policy would be updated to include when to submit the 105 Form. | Plan of Correction: ApprovedMarch 28, 2025 The following actions were accomplished for the residents identified in the sample: There were no residents identified by this deficient practice. A Criminal History Record Check (CHRC) form 105 for employee #6, who received the Hold in Abeyance letter, was submitted to CHRC on 03/06/2025 which removed them from the CHRC system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents may be affected by this deficient practice if employees who receive hold in abeyance letters are not removed from the CHRC system. On 03/27/2025 the Director of Human Resources reviewed all employees who are pending clearance for employment on the CHRC roster. There were zero (0) employees who have received a negative determination letter from CHRC requiring removal from employment at the Long Island State Veterans Home, and from the CHRC system. III. The following system changes will be implemented to assure continuing compliance with the regulations, and that the same deficient practice does not recur: The policy and procedure titled ?ôCriminal Background Checks- Non-Licensed Personnel?Ø was reviewed by the Interdisciplinary team (IDT). The IDT recommended that the policy be revised to contain language specifying the required time frame for employee removal from the CHRC system as per the regulations under 402. 9(b)(2). Specifically, the policy was revised to state ?ôLISVH Human Resources must immediately, but not later than 30 calendar days after the event, notify the Department when an individual is subject to CHRC via 103 submissions; and an individual is no longer subject to CHRC via 105 termination. Terminations include when an employee is no longer subject to CHRC; is no longer employed by the provider; employee death; or when a prospective employee is no longer being considered by the provider. In addition, all employees who receive a ?ôHold in Abeyance Letter?Ø will be removed from the CHRC system within 30 days. In addition, the policy was revised to include a change in procedure, that no person who is offered employment at the LISVH will be permitted to commence employment without a favorable CHRC legal determination. The facility administrator, Director of Nursing and Medical Director reviewed the revised policy and approved the additional language on 03/26/ 2025. Beginning on 03/26/2025, the Director of Human Resources educated all Human Resources staff on the revised policy and procedure titled ?ôCriminal Background Checks- Non-Licensed Personnel?Ø. This education will be completed by 03/28/ 2025. IV. The facilitys compliance will be monitored using the following quality assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that employees have a favorable CHRC legal determination in their employee record prior to commencing employment. The Director of Human Resources, or authorized Human Resources staff member prior to each orientation class will review the roster of scheduled new hires to ensure that all individuals have a favorable CHRC legal determination. Individuals who do not have favorable CHRC legal determinations will not be permitted to commence employment. The compliance standard will be set to 100%. This audit will be completed for each orientation for 12 calendar months. The Human Resources staff will report audit findings during the facilitys QAPI committee meetings. At the end of the audit period the QAPI committee will review the results of the completed audits and discuss the need for further audits and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: Director of Human Resources |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 11, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 5. 2 Heating, Ventilating, and Air-Conditioning. 2012 NFPA 101: 19. 5. 2. 1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9. 2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19. 5. 2. 2. 2012 NFPA 101: 9. 2 Heating, Ventilating, and Air-Conditioning. 2012 NFPA 101: 9. 2. 1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 90A: 5. 3. 4 Shafts. 2012 NFPA 90A: 5. 3. 4. 1 Air ducts that pass through the floors of buildings that require the protection of vertical openings shall be enclosed with partitions or walls constructed of materials as permitted by the building code of the authority having jurisdiction, as indicated in 5. 3. 4. 2 or 5. 3. 4. 3, unless otherwise permitted by 5. 3. 4. 3. 1. 2012 NFPA 90A: 5. 3. 4. 2 The shaft enclosure shall have a minimum fire resistance rating (based on possible fire exposure from either side of the partition or wall) of 1 hour where such air ducts are located in a building less than four stories in height. 2012 NFPA 90A: 5. 3. 4. 3. 1 Where an air duct penetrates only one floor or one floor and an air-handling equipment penthouse floor, and the air duct contains a fire damper located where the duct penetrates the floor, an air duct enclosure shall not be required. Based on observation, staff interviews and document review during the recertification survey, the facility did not ensure that vertical ventillation duct penetrations that passed through floors were protected in accordance with NFPA 101 and NFPA 90A. Specifically, resident toilet exhaust ducts that extend vertically from the first floor through the third floor, were not enclosed with a minimum fire resistance rating of at least 1- hour. A Time Limited Waiver to meet the prescriptive requirement is set to expire on (MONTH) 10, 2026. The findings are: During the Life Safety Code survey on 03/05/2025-03/06/2025 between 9:00am and 3:00pm it was noted that resident toilet room vertical ventilation ducts which passed through the floor/ceiling assemblies, were not enclosed in at least 1- hour fire resistance rated construction. In an interview on 03/05/2025 at 10:00am the facility's Engineering, Support, Administration and Life Safety Personnel stated that the a project to remedy this issue is in the planning phase that included capital procurement, design, and permit application to install fire rated dampers at the floor penetration of the vertical ventilation ducts. A review of NYSDOH records indicated that the facility received an approved Time Limited Waiver from CMS to come into compliance with the prescriptive code requirement that is set to expire on (MONTH) 10, 2026. 2012 NFPA 101: 19. 5. 2, 19. 5. 2. 1, 9. 2, 9. 2. 1 2012 NFPA 90A: 5. 3. 4, 5. 3. 4. 1, 5. 3. 4. 2, 5. 3. 4. 3. 1 10 NYCRR, 711. 2 (a) (1) | Plan of Correction: ApprovedMarch 28, 2025 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiencies. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. III. The following measures and / or systemic changes will be implemented to ensure the deficient practice identified does not recur: Long Island State Veterans Home (LISVH) continues to utilize the Time Limited Waiver approved by CMS on (MONTH) 3, 2025, to address deficiency K- 521. Listed below is the project update related to deficiency K-521: LISVH has secured an approved Veteran Affairs Construction Grant to fund the corrective actions required to address the K-521 HVAC bathroom exhaust deficiency. LISVH completed the bidding process to select a consultant to facilitate the design to correct the K-521 deficiency. The design was completed and sent to DOH for CON approval. The DOH approved the project CON on 1/14/ 2024. LISVH has generated the bid package and selected a construction contractor as well as the electrical vendor for the project. The electrical vendor contract has been awarded. LISVH purchasing department is preparing the construction contract for submittal to the NYS Office of Attorney General (AG) and NYS Office of State Comptroller (OSC). Upon receipt of approval from the NYS Office of Attorney General (AG) and NYS Office of State Comptroller (OSC), LISVH will finalize contract award and work to commence construction. Construction is estimated to begin October 2025. LISVH Building Safety Features: The building is fully sprinklered with quick action heads throughout the facility. The building is protected by smoked detection and fire alarm pull stations. Each floor is separated into multiple smoke compartments in the event of an emergency and relocation is required. LISVH additional fire safety protocols: Staff are trained on Fire Safety upon hire, additional departmental Fire safety training will be conducted annually by the safety specialist and staff will undergo additional training on environment of care and safety, utilizing the facilities electronic education system. Increase frequency of fire drills for all shifts. Conduct training related to emergency management and evacuation drills. Areas under construction will be assessed daily to ensure combustibles are removed and the area is neat an organized, prior to leaving the site each day and more frequently if necessary. Fire protection system impairment policy shall be implemented in the event of a fire system impairment. Require a Hot Work Permit. In the event a partial or full evacuation is necessary, the facility in coordination with the fire department would initiate the necessary facility evacuation plan. This evacuation would occur with evacuating the Residents closet to the fire and then the floors above and below where the fire is located followed by the residents further away from the fire. The residents with higher acuity will be relocated within our facility or nearest hospital and then residents with lower acuity will be evacuated to alternate locations or facilities until the fire department is able to give further direction on the scope and severity of the fire. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: The facility will provide updates on the Bathroom Exhaust Project to the LISVH QAPI Committee. V. Responsibility: Director of Support Services |