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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure person-centered comprehensive care plans were developed with objectives and timeframe's to meet the resident's needs. This was evident for 1 (Resident #30) of 5 residents reviewed for unnecessary medications. Specifically, Resident #30 did not have a care plan developed to address antibiotic medication use. The findings are: Resident #30 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3. 0 assessment dated [DATE] documented Resident #30 had mild cognitive impairment, received anticoagulant medication, and received antibiotic medication. The physician's orders [REDACTED]. 25. There was no documented evidence a Comprehensive Care Plan related to antibiotic use was developed and implemented for Resident # 30. On 2/19/2025 at 10:49 AM, Registered Nurse #2 was interviewed and stated the admitting nurse was responsible for initiating care plans for newly admitted residents. Registered Nurse #2 stated they were the charge nurse for the unit and was responsible for reviewing all resident care plans within a few days of their admission to ensure the care plan reflected the resident's medical condition and medication regime. Resident #30 was prescribed antibiotics on a [MEDICATION NAME] basis upon their admission to the facility. Registered Nurse #2 stated they were unsure why the antibiotics were prescribed for Resident #30 and there should be a correlating care plan in place with interventions to monitor the resident for relative side effects. Registered Nurse #2 stated they had not reviewed Resident #30's chart since their admission to the facility and the antibiotic care plan had not been initiated and currently was not in place. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: Director of Nursing or designee updated the person centered comprehensive care plan of resident #30 to address antibiotic medication use. Identification of other residents having the potential to be affected was accomplished by: Residents admitted whom require the development of person-centered comprehensive care plans with objectives and timeframe's to meet the resident's needs have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Nursing or designee will in-service registered nurses on the Comprehensive Care Planning Policy by 3/31/ 25. Clinical Care Manager or designee will ensure person-centered comprehensive care plans are developed with objectives and timeframe's to meet the resident's needs by 4/1/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Nursing or designee will audit 10% of resident Comprehensive Care Plans. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to care for residents competently during day-to-day operations. This was evident during review of Staffing. Specifically, the Facility Assessment did not include the education required by all personnel, a third-party staffing agency contract required to meet staffing needs, and used acuity data from 4/2023 through 6/2023 to determine their resident population staffing needs. The findings are: The Facility assessment dated [DATE] documented the facility had 42 resident beds on the Short Term Rehab Unit with 157 admissions and 42 resident beds on the Long Term Unit with 13 admissions between 4/2023 to 6/ 2023. The Facility Assessment documented the Resident Utilization Group percentages reflected on Minimum Data Set 3. 0 assessments completed between 4/2023 and 6/ 2023. The Facility Assessment did not document the level of staff assistance required to assist residents with activities of daily living. The Staffing Plan did not document the required level of education for all personnel listed and did not include third-party staffing agency contracts used to meet staffing par levels. On 2/18/2025 at 3:18 PM, the Administrator was interviewed and stated they were responsible for creating the Facility Assessment and determining the staffing and equipment necessary to adequately serve residents. The Administrator stated the Facility Assessment staffing plan included nurse staffing par levels reflective of the facility's goals and not the actual numbers of staff required to provide day-to-day care to residents. The Administrator stated the facility identified the 1st Floor as the Short Term Rehab Unit and the 2nd Floor as the Long Term Unit a few years ago. The 2nd Floor was no longer defined as the Long Term Unit because the facility began using beds on this unit to accommodate an increasing number of short-term admissions. The Administrator stated the facility worked with a third-party staffing agency to meet their par levels and address staffing shortages in their schedule. The facility also used a computer application/program to create the nurse staffing schedule, communicate with staff regarding their schedule, and compile staffing data. 10 NYCRR 415. 26 | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: The Administrator reviewed and confirmed that acuity data captured in Quarter 2 of 2024 is included in the Facility Wide Assessment. The Administrator reviewed and confirmed the Facility Wide Assessment includes education required by all personnel. Identification of other residents having the potential to be affected was accomplished by: Residents residing within the nursing facility have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: The Administrator or designee will update the Facility wide Assessment to include third-party staffing agency contracts by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Administrator or designee will audit the Facility Assessment. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based upon record review, observations,and interviews conducted during a recertification survey from 02/12/2025 to 02/19/2025, the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, unmarked undated containers of food were observed in the refrigerator and freezer, and food was not maintained at the proper temperature in the second-floor dining facility's small refrigerator. The findings include: The facility policy Preparation of Potentially Hazardous Foods dated 03/01/2024, states that All potentially hazardous food is to be stored at or 45 degrees Fahrenheit or below and All potentially hazardous foods are to be visibly dated with the date of receipt unless previously dated with or by the manufacturer. Additionally, the facility policy cooling and storage states All storage areas will be inspected daily and weekly by supervisory staff to insure the correct labeling, dating, and storage standards are being met. An initial tour of the kitchen took place on 02/12/2025 at 9:38 AM with the Director of Food Services and the Executive Chef. During the tour of the produce refrigerator, multiple food items were observed unlabeled and undated. One tray containing two salmon fish, one plastic bag of herbs, and boxes of produce (zucchini, brussels, sprouts, and cantaloupe) were undated and unlabeled. During the tour of the freezer, five food items were observed unlabeled and undated while not in their original containers. One bag of pasta large shells, two bags of small pasta, and two bags of hash browns were observed unlabeled and undated. During an interview at the time of observation, the Executive Chef stated thet knew what the unlabeled food was and when it arrived since they did all the ordering. During an observation of the second-floor dining room on 02/13/2025 at 12:08 PM, the small refrigerator, which was stocked with food and snacks for the residents was recorded at an inside temperature of 46 degrees Fahrenheit. During the observation, the Dining Operations Manager stated that refrigerator temperatures were checked every day, and acknowledged the refrigerator was operating at a elevated temperture. 10 NYCRR 415. 14 (h) | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: Executive Chef or designee discarded unmarked and undated food items. Executive Chef or designee labeled produce bins impacted by improper storage techniques Executive Chef marked can goods and other dry goods with ?ôreceived on?Ø adhesive labels Operations Manager or designee placed service call to address the impacted refrigerator Identification of other residents having the potential to be affected was accomplished by: Residents who consume meals prepared in the facilitys kitchen have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Dining Services or designee will in-service Dining Services Staff on Food Labeling Policy by 3/31/ 25. Director of Dining Services or designee will in-service Dining Services Staff on refrigeration Storage Policy by 3/31/ 25. Director of Dining Services or designee will in-service Shift Supervisors on Care & Operation of Refrigerators and Freezers Policy by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Dining Services or designee will audit labeling and dating of stored products weekly x10 beginning on 4/1/ 25. Director of Dining Services or designee will audit refrigerator temperature logs weekly x10 beginning on 4/1/ 25. Audit findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Dining Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Recertification Survey conducted from 2/12/25 to 2/19/2,the facility did not ensure that a resident's representative was informed of the facility's bed hold policy before and upon transfer to a hospital for one of one residents reviewed for hospitalization (Resident #7). Specifically, Resident #7 was transferred to the hospital on [DATE], and the facility did not provide the resident or their representative written information regarding the bed hold. Findings include: The policy and procedure titled Bed Hold last revised 3/24/23, documented the resident and the representative would receive bed hold and return information at admission and before a hospital transfer. The policy further stated that a resident transferred to a hospital would receive written information regarding bed hold and payment amount. Resident # 7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set, a resident assessment tool dated 1/22/25 documented the resident had severe cognitive impairment. The progress note dated 8/22/24 at 5:23 PM, documented Resident #7 experienced shortness of breath and wheezing. The physician was notified, and the resident was transferred to the hospital. The progress note dated 8/23/24 at 9:02 AM, documented Resident #7 was admitted to the hospital with [REDACTED]. The progress note dated 8/29/24 at 11:30 AM, documented Resident #7 returned to the facility in stable condition. review of the resident's medical record revealed [REDACTED].#7 or the representative received written information regarding the bed hold policy. During an interview on 2/18/25 at 1:00 PM, the Director of Social Services stated that social workers were responsible for providing bed hold policy notice and it was not completed. 10NYCRR 415. 3 (i) 3(i)(a) | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: No immediate action could be taken for residents found to be affected. Identification of other residents having the potential to be affected was accomplished by: Residents who are placed on leave or transferred out of the facility, planned or unplanned, have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Social Services or designee will identify and implement a compliant Bed Hold Form by 3/20/ 25. Administrator or designee will in-service Social Services Staff on the issuance of Bed Hold Notices before or upon transfer by 3/31/ 25. Director of Nursing or designee will in-service Licensed Nursing Staff on the issuance of Bed Hold Notices before or upon transfer by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Social Services or designee will audit 100% of resident transfers and overnight leaves of absence for written notification of the facility bed hold policy to resident or resident representative. Beginning on 4/1/25 audits will be weekly x4 weeks and then Monthly x 3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Social Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 2/12/25 to 2/19/25, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital for one of one residents reviewed for hospitalization (Resident #7). Specifically, Resident #7 was transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the resident or the resident's representative, and that notification was sent to the Ombudsman Office. Findings include: The facility policy and procedure titled Transfer and Discharge last revised 7/27/2022, documented before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and or representative in a manner and language in which the recipient can understand. The policy also required that a copy of the notice be sent to a representative of the State Long- Term Care Ombudsman's Office. The facility admission agreement documented the resident and their designated representative will be given prior written notice of the transfer or discharge in accordance with applicable regulations. Resident # 7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set, a resident assessment tool, dated 1/22/25 documented the resident had severe cognitive impairment. The progress note dated 8/22/24 at 5:23 PM documented Resident #7 experienced shortness of breath and wheezing. The physician was notified, and the resident was transferred to the hospital. The progress note dated 8/23/24 at 9:02 AM documented Resident #7 was admitted to the hospital with [REDACTED]. The progress note dated 8/29/24 at 11:30 AM documented Resident #7 returned to the facility in stable condition. Review of the resident's record on 2/18/25 revealed no documented evidence the family was notified or that Resident #7's representative received written information regarding transfer. A review of discharges and transfers submitted to the Ombudsman's Office for the month of (MONTH) 2024, revealed no documented evidence the Ombudsman was notified. During an interview on 2/18/25 at 1:00 PM, the Director of Social Services stated that social workers were responsible for providing the transfer/discharge notice and it was not completed for Resident # 7. During an interview on 2/19/25 at 1:03 PM, the Director of Nursing stated the nursing staff and social workers collaborated to ensure that resident representatives were notified of the transfer to the hospital. The Director of Nursing was unable to explain why Resident #7's representative did not receive notification. During an interview on 2/19/25 at 1:10 PM, the facility Administrator stated the resident's family should have received written information regarding the transfer and discharge process. The Administrator further stated that the social worker and nursing staff were responsible for ensuring the notification was provided. During an interview on 2/19/25 at 4:00 PM, the Ombudsman office stated there was no documentation that the facility submitted information regarding Resident #7's discharge on 8/22/ 24. 10 NYCRR 415. 3(i)(1)(iii)(a-c) | Plan of Correction: ApprovedMarch 13, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: No immediate action could be taken for residents found to be affected. Identification of other residents having the potential to be affected was accomplished by: Residents who are transferred and/or discharged from the facility, planned or unplanned have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Social Services or designee will identify and implement a compliant Transfer and Discharge Form by 3/20/ 25. Director of Social Services or designee will establish a transfer and discharge communication protocol with the local ombudsman by 3/31/ 25. Administrator or designee will in-service Social Services Staff on Transfer and Discharge Protocol by 3/31/ 25. Director of Nursing or designee will in-service Licensed Nursing Staff on Transfer and Discharge Protocol by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Social Services or designee will audit 100% of resident discharges and/or transfers for written notification of reason for transfer and/or discharge to resident or resident representative and the ombudsman. Beginning on 4/1/25 audits will be weekly x4 weeks and then Monthly x 3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Social Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification survey from 02/12/2025 to 02/19/2025, the facility did not ensure that a complete preadmission screening was conducted. This was evident for 2 (Resident #169 and Resident # 35) residents reviewed for Preadmission Screening and Resident Review (PASARR) of 16 residents. Specifically, the SCREEN DOH - 695 form was incomplete. There was no documentation of answers to items 21, 24, 25, and 26. The findings are: The facility Policy with Title Preadmission Screening and Resident Review (PASARR) with effective date 01/15/2025 and last review date 01/1/2025 documented It is the policy to screen all potential admissions on an individual basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criteria for mental disorder, intellectual disability, or related condition. Based upon the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. 1) Resident #169 was admitted from acute care hospital with [DIAGNOSES REDACTED]. The SCREEN Form DOH-695 completed for Resident #169 dated 7/25/2024, item # 21 was not answered. 2) Resident #35 was admitted from acute care hospital with [DIAGNOSES REDACTED]. The SCREEN Form DOH-695 completed for Resident #35 dated 01/10/2025, the section Level I Review for Possible Mental [MEDICAL CONDITION]/Developmental Disability (MR/DD) items 24, 25 and 26 were not completed. During an interview on 02/19/25 at 9:06 AM, the Director of Admissions stated they reviewed the screens for all residents prior to admission to the facility admission and ensured they were complete. During the interview, the Screen forms for Resident #169 and Resident #35 were reviewed with the Director of Admissions and they stated the items should have been answered. On 02/19/2025 at 10:43 AM, the Administrator stated the Admissions Department was responsible for reviewing the PASARR SCREEN forms prior to resident admission and they wee unaware they were not complete. 10 NYCRR 415. 11(e) | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: Director of Admissions requested and received completed SCREEN Form DOH - 695 from the hospital of origin for Resident #169 and Resident # 35. Identification of other residents having the potential to be affected was accomplished by: Residents admitted to the nursing facility have the potential to be impacted. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Administrator or designee will in-service Admissions Staff on PASARR Policy and ensuring that complete preadmission screening is conducted by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Admissions or designee will audit 50% of new admissions PASARR Forms. Beginning on 4/1/25 audits will be conducted weekly x4 weeks and then monthly x3 months. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Admissions |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure the posted nurse staffing included the census and total actual hours worked by nursing staff. This was evident during review of Staffing. Specifically, the posted nurse daily staffing did not contain the facility's current census and actual hours worked by Certified Nursing Assistants on each shift. The findings are: The facility Daily Nurse Staffing dated 2/15/2025 documented 7 Certified Nursing Assistants worked on the 7:00 AM to 3:30 PM shift for a total of 52. 5 hours. The Assignment Sheets for the 1st and 2nd Floors dated 2/15/2025 documented 8 Certified Nursing Assistants worked on the Day Shift. There is no documented evidence the 2/15/2025 Daily Nurse Staffing reflected the accurate number of actual working Certified Nursing Assistants on the 7:00 AM to 3:30 PM shift. The facility Daily Nurse Staffing dated 2/16/2025 documented 5 Certified Nursing Assistants worked on the 7:00 AM to 3:30 PM shift for a total of 37. 5 hours and 7 Certified Nursing Assistants worked on the 11:30 PM to 7:30 AM shift for a total of 56 hours. The facility census was not documented. The Assignment Sheets for the 1st and 2nd Floors dated 2/16/2025 documented 1 of 5 Certified Nursing Assistants working on the Day Shift was late and 6 Certified Nursing Assistants worked on the Night Shift. There is no documented evidence the 2/16/2025 Daily Nurse Staffing reflected the accurate number of actual working Certified Nursing Assistants on the 11:30 PM to 7:30 AM shift and total hours worked by Certified Nursing Assistants on the Day Shift. The facility Daily Nurse Staffing dated 2/18/2025 documented 9 Certified Nursing Assistants worked on the 7:30 AM to 3:30 PM shift for a total of 67. 5 hours. The Assignment Sheets for the 1st and 2nd Floors dated 2/18/2025 documented 10 Certified Nursing Assistants worked on the Day Shift. There is no documented evidence the 2/18/2025 Daily Nurse Staffing reflected the accurate number of actual working Certified Nursing Assistants on the 7:30 AM to 3:30 PM shift. On 2/18/2025 at 3:11 PM, the Daily Nurse Staffing was observed posted by the entrance to the facility on the 1st Floor resident unit. There was no documented evidence of the facility census. On 2/18/2025 at 3:18 PM, the Administrator was interviewed and stated the Staffing Coordinator was responsible for posting the Daily Nurse Staffing every day at the beginning of each day. The Administrator stated the Daily Nurse Staffing was not posted at the beginning of each shift, did not account for unforeseen changes to the schedule, and did not reflect the actual hours worked by nursing staff. The Daily Nurse Staffing did not include the facility's daily census, and the Administrator stated they were required to include census information in the daily posting. 10 NYCRR 415. 13 | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: No residents identified as having been affected. Identification of other residents having the potential to be affected was accomplished by: Residents residing within the nursing facility have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Nursing or Designee will develop a procedure to ensure accuracy of Posted Nursing Staffing Information by 3/20/ 25. Director of Nursing or designee will in-service Staffing Coordinator on Posted Nursing Staffing Information to ensure current census and total actual hours worked by nursing staff are included by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Administrator or designee will audit 20% of Posted Nursing Staffing Information. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Recertification survey from 2/12/25 to 2/19/25, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #281) reviewed for respiratory care. Specifically, Resident #281 was receiving supplemental oxygen without a physician's orders [REDACTED]. Findings include: Resident #218 had [DIAGNOSES REDACTED]. The Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident #218 was severely cognitively impaired and did not document the use of oxygen. The facility policy titled Oxygen Therapy and Evaluation effective 03/01/2024 and last reviewed 03/01/2024 documented A Physician/Nurse Practitioner/Physician Assistant order is required for oxygen therapy. The order must include the type of administration system to use, flow rate, and monitoring parameters. A Nurse Practitioner order dated 2/7/25 documented Titrate to maintain sat > 92. There was no documented liter flow rate or route of administration. The (MONTH) 2025 Treatment Administration Record documented to titrate to maintain sat greater than 92% every shift with a start date of 2/7/25 at 3:30 PM. The oxygen saturation was documented every shift however there was no documented Liter flow. The comprehensive care plan, revised 2/12/2025, documented no evidence the resident used oxygen. On 02/12/25 at 12:49 PM, Resident #218 was observed in bed with oxygen via nasal cannula. A bedside oxygen concentrator was delivering oxygen at 4 Liters per minute. On 02/13/25 at 09:25 AM, Resident #218 was observed in their room in in wheelchair, awake, alert, with oxygen via nasal cannula at 4 Liters per minute. During observation and interview on 2/14/25 at 10:45 AM, Licensed Practical Nurse #1 observed the bedside concentrator and stated the oxygen was set at 4 Liters per minute. They stated they documented the oxygen in the Treatment Administration Record. During an interview on 02/14/25 at 10:55 AM, Registered Nurse Manager #2 stated a physician's orders [REDACTED]. Registered Nurse Manager #2, observed the resident's medical record and stated the Nurse Practitioner order dated 02/7/2025 was to Titrate to maintain saturation greater than 92%. Registered Nurse Manager #2 stated they did not see an order that mentioned oxygen. The (MONTH) 2025 Treatment Administration Record documented Oxygen at 2 Liters via nasal cannula to maintain oxygen saturation greater than 92% with a start date of 2/14/25 at 3:30 PM. 10 NYCRR 415. 12 (k) (6) | Plan of Correction: ApprovedMarch 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate action(s) taken for the resident(s) found to have been affected include: Medical Director facilitated in-service education with the provider responsible for entering Resident #281s supplemental oxygen order. Director of Nursing or designee reviewed and updated the physician order [REDACTED]. Director of Nursing or designee conducted an audit of physician orders [REDACTED]. Audit Findings were: Active supplemental oxygen orders contained indication for use, flow rate, and route of administration. Identification of other residents having the potential to be affected was accomplished by: Residents receiving supplemental oxygen have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Nursing or designee will in-service Licensed Staff and Medical Staff on adhering to Oxygen Therapy Policy by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of Nursing or designee will audit 100% of residents receiving supplementary oxygen. Beginning on 4/1/25 audits will be conducted weekly x4 weeks and then Monthly x3 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing |
Scope: N/A
Severity: N/A
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on interview and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure notification of the New York State Department of Health when a subject employee was no longer employed by the facility. This was evident for 4 (Employee #7, #8, #9, and #10) of 6 subject employees with Negative Determination Letters during review of the Criminal History Record Check. Specifically, Employee #7, #8, #9, and #10 were not removed from the Criminal History Record Check system within 30 days of their Final Denial letters issued to the facility. The findings are: The facility policy titled Fingerprinting dated 9/19/2019 documented the facility will submit terminations to the Criminal History Record Check system in a timely fashion to ensure all records are up to date. A Final Denial letter for Employee #7 was dated 2/21/ 2024. Form 105 for Employee #7 was dated 2/13/2025, more than 30 days after the Final Denial letter. A Final Denial letter for Employee #8 was dated 11/08/ 2024. Form 105 for Employee #8 was dated 2/13/2025, more than 30 days after the Final Denial letter. A Final Denial letter for Employee #9 was dated 1/17/ 2023. Form 105 for Employee #9 was dated 2/13/2025, more than 30 days after the Final Denial letter. A Final Denial letter for Employee #10 was dated 1/24/ 2024. Form 105 for Employee #10 was dated 2/13/2025, more than 30 days after the Final Denial letter. On 2/14/2025 at 11:35 AM, the Human Resources/Authorized Person was interviewed and stated Employee #7, #8, #9, and #10 were never hired by and did not start working at the facility prior to receiving Final Denial letters from the Criminal History Record Check system. Form 105 was not submitted on Employee #7, #8, #9, and #10 until 2/13/ 2025. The Authorized Person stated the facility audited their Criminal History Record Check roster quarterly based off of a list of active employees that were terminated by the facility. The audit list did not include prospective employees submitted to the Criminal History Record Check system but never hired by the facility. | Plan of Correction: ApprovedMarch 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: Vice President of Human Resources or designee sent notification of termination to the New York State Department of Health for Employee #7, #8, #9 and # 10. Vice President of Human Resources or designee reviewed entire Criminal History and Record Check roster to ensure all termination notifications were sent to the New York State Department of Health for applicable staff. Identification of other residents having the potential to be affected was accomplished by: No potential for resident impact identified. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Vice President of Human Resources or designee will complete in-service education with Human Resources Staff on provider notification requirements by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Vice President of Human Resources or designee will audit 100% of the Criminal History and Background Check roster for compliance. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Vice President of Human Resources |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details Based on observation, documentation review and staff interview, the facility did not ensure that the emergency preparedness (EP) plan was reviewed and updated at least annually in accordance with Emergency Preparedness 483. Specifically, the emergency preparedness binders indicated that the plan was last reviewed in the year 2017. This was noted on 2 of 2 resident floors. The findings are: During the Life Safety recertification survey conducted on 2/20/25 at 11:50 AM, documentation review of the facility's emergency preparedness (EP) plan on the first floor revealed that the emergency binder was last reviewed in the year 2017. This same situation was observed in the emergency binder on the second floor. In an interview with a nursing staff member at the time of finding, the staff member stated that the EP binder is used as a reference. In a subsequent interview with the Director of Nursing the same day, at approximately 12 Noon, the Director of Nursing stated that the staff can access the information from the computer. 483. 73 (a) | Plan of Correction: ApprovedMarch 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Facilities discarded outdated hard copies of Emergency Preparedness Plan noted on 2 out of 2 resident floors and replaced them with updated hard copies of the Emergency Preparedness Plan last revised in (MONTH) of 2024. Director of Nursing will complete in-service education with Licensed Staff on accessibility of Emergency Preparedness Plan by 4/15/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 3/31/25 Director of Facilities will conduct monthly reviews of the Emergency Preparedness Binders on Pavilion 1 and 2 as well as electronic versions to ensure continued regulatory compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99 Health Care Facilities Code 10. 5. 3 Servicing and Maintenance of Equipment. 10. 5. 3. 1 The manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer. 10. 5. 3. 1. 1 The documents specified in 10. 5. 3. 1 shall include the following, where applicable: (1) Illustrations that show the location of controls (2) Explanation of the function of each control (3) Illustrations of proper connection to the patient or other equipment, or both (4) Step-by-step procedures for testing and proper use of the appliance (5) Safety considerations in use and servicing of the appliance (6) Precautions to be taken if the appliance is used on a patient simultaneously with other electric appliances (7) Schematics, wiring diagrams, mechanical layouts, parts lists, and other pertinent data for the appliance (8) Instructions for cleaning, disinfection, or sterilization (9) Utility supply requirements (electrical, gas, ventilation, heating, cooling, and so forth) (10) Explanation of figures, symbols, and abbreviations on the appliance (11) Technical performance specifications (12) Instructions for unpacking, inspection, installation, adjustment, and alignment (13) Preventive and corrective maintenance and repair procedures 10. 5. 3. 1. 2 Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. Based on observation, documentation review and staff interview, the facility did not ensure that the service manuals for the patient care-related electrical equipment and a policy and procedure for testing the patient care related electrical equipment was available in accordance with NFPA 99. Specifically, service manuals for patient care related equipment for the air mattress pumps (Span, IPS Signa Relief, and Direct Supply), oxygen concentrators (Invacare Platinum XL) and nebulizer (McKesson) were missing and not provided at time of survey and a policy and procedure for testing the patient care related electrical equipment was not readily available. The findings are: During the Life Safety Code survey on 2/19/25 and 2/20/25 between the hours of 9:30 and 3:00 PM documentation review of the facility service manuals for the patient care related electrical equipment (PCREE) revealed that service manuals were missing for air mattress pumps (Span, IPS Signa Relief, and Direct Supply), oxygen concentrators (Invacare Platinum XL) and nebulizer (McKesson) that were noted in use at time of survey were missing and not provided at time of survey. In addition, a policy and procedure for inspecting and testing the patient care related electrical equipment was not provided at time of survey. In an interview with the Director of Facilities on 2/20/25 at 11:25 AM, the Director of Facilities stated that the service manuals were provided by central supply and a policy and procedure for the frequency of testing the patient care related electrical equipment will be provided. 2012 NFPA 99: 10. 5. 3. 1, 10. 5. 3. 1. 1, 10. 5. 3. 1. 2, 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Facilities will secure service manuals for noted patient care related electrical equipment by 3/18/ 25. Clinical Educator or designee with review and update the Patient Care Related Electrical Equipment Policy by 4/15/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 5/1/25 the Clinical Educator or designee will audit 5 patient care related electrical devices per month x12 months. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Clinical Educator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 20, 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. 2010 NFPA 110: 8. 4. 6 Transfer switches shall be operated monthly. 8. 4. 6. 1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position. 2012 NFPA 99 6. 4. 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. 10 and 6. 4. 3. 1. Based on observation, documentation review and staff interview, the facility did not ensure that all required tests for the generator were conducted in accordance with NFPA 101, NFPA 110 and NFPA 99. Specifically, the time power is transferred to the generator during the monthly test for the transfer switch was missing for the monthly generator logs for the year 2024 and 2025. The findings are: During the life safety recertification survey on 2/19/25, at approximately 11:00 AM documentation review of the facility generator logs was conducted and revealed that the time power is transferred to the generator was not included on the monthly generator load test reports for the months of May, (MONTH) and (MONTH) for the year 2024 and (MONTH) 2025 and was not documented on the generator service reports. In an interview with the Director of Facilities at approximately 11:40 AM, the Director of Facilities stated that during the months in 2024, the generator was serviced by the vendor and will ensure the time power is transferred to the generator will be documented. 2012 NFPA 101: 9. 1. 3. 1 2010 NFPA 110: 8. 4. 6, 8. 4. 6. 1 2012 NFPA 99: 6. 4. 4. 1. 1. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will develop and implement a standardized log for generator load tests that includes transfer switch timeframes by 4/1/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 4/1/25 the Director of Facilities or designee will audit the Generator Log monthly through (MONTH) 31, 2025 and report findings to QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 4. 1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9. 6. 2012 NFPA 101: 9. 6. 1. 3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2010 NFPA 72: 14. 2. 5. 5 Testing shall include verification that the releasing circuits and components energized or actuated by the fire alarm system are electrically monitored for integrity and operates intended on alarm. 14. 4. 5* Testing Frequencies Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14. 4. 5, or more often if required by the authority having jurisdiction. 14. 6. 3. 2 Upon request, a hard copy record shall be provided to the authority having jurisdiction. Based on observation, record review and staff interview, the facility did not ensure that all devices associated with the fire alarm system were tested annually in accordacne with NFPA 101. Specifically, the inspection and testing report for the fire alarm system did not include the inspection and testing of the magnetic hold open devices, and the service report for these devices was not provided at time of survey. The findings are: During the life safety recertification survey on 2/19/25 at 10:45 AM, documentation review of the facility's maintenance logs was conducted and it was revealed that the fire alarm system was last serviced by the vendor on 9/24/2024 and did not include the inspection and testing of the magnetic hold open devices and the vendor service report for these devices was not provided at time of survey. In an interview with the Director of Facilities the same day, the Director of Facilities stated that the vendor will be contacted. 2012 NFPA 101: 19. 3. 4. 1, 9. 6. 1. 3 2010 NFPA 72: 14. 4. 5, 14. 6. 3. 2 10 NYCRR 415. 29 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Facilities or designee will contact the appropriate vendor to conduct testing of the magnetic hold open devices by 3/15/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 3/15/25 the Director of Facilities or designee will audit vendor reports monthly through (MONTH) 31, 2025 and report findings to QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details 2010 NFPA 13 8. 15. 3. 2. 1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. 8. 15. 10. 3 Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. Based on observation and staff interview, the facility did not ensure that sprinkler coverage was installed throughout in accordance with NFPA 101 and NFPA 13. Specifically, sprinkler coverage was not provided under the first accessible landing in stairwell B and in the electrical switch gear room located in the enclosed garage. The findings are: During the life safety tour conducted on 2/19/25 and 2/20/25 between 9:30 AM and 2:30 PM, a tour of stairwell B revealed that sprinkler coverage was not provided under the first accessible landing in the stairwell. In addition, a tour of the electrical switch gear room located in the enclosed garage revealed that the room lacked sprinkler coverage and two ladders and 2 chairs were in the room. In an interview with the Director of Facilities, the Director of Facilities stated that sprinkler coverage will be installed under the first accessible landing in the stairwell and the ladders and chairs will be removed. 2021 NFPA 101: 19. 3. 5. , 19. 3. 5. 1, 9. 7 2010 NFPA 13: 8. 1, 8. 15. 3. 2. 1, 8. 15. 10, 8. 15. 10. 1, 8. 15. 10. 3 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Facilities immediately removed noted ladders and chairs from electrical switch gear room. Director of Facilities or designee will conduct in-service education with Facilities Staff on the prohibition of combustible storage in the electrical equipment room by 3/20/25 The Director of Facilities or designee will obtain quotes and will select an appropriate vendor to install an automatic sprinkler in the first accessible landing of Stairwell B by 3/31/ 25. Once an appropriate vendor is identified the Director of Facilities or designee will schedule sprinkler installation and permit process for Stairwell B, work expected to be completed by 4/21/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Director of facilities will conduct audit of electrical equipment room weekly x4 and then monthly x 5. Updates will be provide during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Facilities |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 7. 1. 10 Means of Egress Reliability. 7. 1. 10. 1 * Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency. Based on observations and staff interview, the facility did not ensure that the emergency exit stairwell was maintained free of all obstructions or impediments to full instant use in case of fire or other emergency in accordance with NFPA 101. Specifically, a radiator and a unsecured mat was observed in stairwell C. This was noted in 1 of 3 stairwells on 2 of 2 resident floors. The findings are: During the Life Safety recertification survey on 2/19/25 between the hours of 9:30 and 2:30 PM and it was noted that a radiator was placed in the stairwell near the emergency exit door within the stairwell. The radiator was attached to an extension cord and the mat was not secured to the floor. In an interview with the Director of Facilities at the time of the finding, the Director of Facilities stated that the radiator was placed in the stairwell to keep the sprinkler pipe at the bottom of the landing from rupturing and the radiator and mat will be removed. 2012 NFPA 101: 7. 1. 10. 1, 7. 2. 1. 8, 7. 2. 1. 8. 1* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 18, 2025 Identification of other residents having the potential to be affected was accomplished by: All residents have the potential to be affected. Action taken/ systemic change put into place to reduce the risk of future occurrence include: Director of Facilities immediately removed radiator, unsecured mat and extension cord from Stairwell C. Director of Facilities or designee will complete in-service education with Facilities Staff members on Preventing Obstruction of Means of Egress by 3/31/ 25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: Beginning on 4/1/25 Director of Facilities or designee will complete audits to confirm unobstructed means of Egress for 3 out of 3 stairwells weekly x4 and then monthly x 5. Date of Completion and Person Responsible: 4/20/25, Director of Facilities |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |