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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the Recertification Survey initiated on 2/12/2025 and completed on 2/20/2025, the facility did not ensure care and services for the provision of [MEDICATION NAME] fluids were consistent with the professional standard of practice for each resident. This was identified for one (Resident #323) of two residents reviewed for Hydration. Specifically, Resident #323 was admitted on [DATE] with a Peripherally Inserted Central Catheter (a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) inserted to the left upper arm. There was no documented evidence the external length of the catheter was routinely measured to prevent migration and the care plan was not updated to include the measurement of the external length of the catheter. The Physician's order did not include monitoring the catheter site for signs and symptoms of infection and measuring the external length of the catheter with each dressing change The finding is: The facility policy titled Peripherally Inserted Central Catheter and revised on 6/2024 documented to measure the length of the external access device with each dressing change or, if catheter dislodgement is suspected, compare with the length documented on initial assessment upon insertion. Healthcare providers should regularly assess the site for signs of infection, complications or dislodgement. Resident #323 was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set assessment was not available because the resident was recently admitted . The hospital record dated 2/4/2025 documented a Peripherally Inserted Central Catheter was inserted into Resident #323's left Basilic vein. A Physician's order dated 2/6/2025 documented to change the catheter site dressing for Resident #323's Peripherally Inserted Central Catheter to the left upper extremity every 72 hours and as needed with transparent dressing, on the day shift every Monday and Thursday. The Physician's order also included to flush the Peripherally Inserted Central Catheter with 10 milliliters of Normal Saline before and after every intravenous medication use. The Physician's order did not include monitoring the catheter site for signs and symptoms of infection and measuring the external length of the catheter with each dressing change. A review of the resident Medication Administration Record [REDACTED] 2025. The resident was hospitalized from [DATE] to 2/18/ 2025. During an observation on 2/12/2025 at 9:30 AM, Resident #323 was observed resting in bed with a Peripherally Inserted Central Catheter in the left upper arm. The site appeared to be intact. A Comprehensive Care Plan dated 2/13/2025 documented the resident had a Peripherally Inserted Central Catheter for the administration of medication. Interventions included assessing the insertion site of the Peripherally Inserted Central Catheter for any redness, tenderness, or swelling, as well as checking that the dressing is clean, dry, and intact. The Nursing Re-Admission Evaluation dated 2/18/2025 documented the dressing for the Peripherally Inserted Central Catheter line to the left upper arm was clean, dry and intact. The resident denied pain at the site. The evaluation did not include the external length measurement of the catheter. During an interview on 2/19/2025 at 4:22 PM, the Assistant Director of Nursing Services stated the Registered Nurses were responsible for flushing the Peripherally Inserted Central catheter and monitoring for blood return, pain, and signs of infection at the catheter site. The Assistant Director of Nursing Services stated they did not know if the facility policy included monitoring the catheter for migration and to measure the external length of the catheter. During an interview on 2/20/2025 at 9:45 AM, Registered Nurse #1 stated during each shift, the Peripherally Inserted Central Catheter line should be monitored to ensure the circumference of the resident's arm does not increase in size. The catheter should also be flushed and the external length should be measured with every dressing change. Registered Nurse #1 stated the Registered Nurses should document their assessment of the site and measurement of the catheter in the Medication Administration Record. Registered Nurse #1 stated upon admission and readmission, the Registered Nurse who completed the assessments should have obtained orders to monitor for signs and symptoms of infection and measure the external length of the catheter. During an interview on 2/20/2025 at 10:09 AM, the Director of Nursing Services stated the medical team, including the resident's medical provider, was responsible for entering and reconciling the orders in the Electronic Medical Record upon admission. The Director of Nursing Services stated after the Physician enters the orders in the medical record, the admitting nurse should ensure all orders are correct. The Director of Nursing Services stated the Registered Nurses were responsible for the dressing change of the Peripherally Inserted Central Catheter, which included measuring the external length of the catheter and checking for signs and symptoms of infection at the catheter site. The Director of Nursing Services stated there were no Physician's orders in place that addressed assessing the site for signs of infection and measurement of the external length of the catheter. The Director of Nursing Services further stated there should have been Physician's orders to monitor Resident #323's catheter for migration and to measure the external length of the catheter. During an interview on 2/20/2025 at 12:28 PM, Physician #1 stated upon admission, the medical team should have ensured that orders were in place for the care of the Peripherally Inserted Central Catheter, including to measure the external length of the catheter. 10 NYCRR 415. 12(k)(2) | Plan of Correction: ApprovedMarch 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #323 discharged home on 3/10/ 25. MD orders for PICC line site dressing was changed to measure the external length of the catheter, the arm circumference, and to monitor the site for redness, swelling or tenderness on 2/19/25 for Resident # 323. II. All residents with PICC lines have the potential to be affected by the same deficient practice. On this date, 3/10/25, there are a total number of 1 out of 223 residents who currently have PICC lines. Residents with PICC line orders have been reviewed to ensure that dressing change orders include monitoring the circumference of the arm, the length of the external catheter, and to monitor for any redness, tenderness and swelling, as well as checking that the dressing is clean, dry and intact. III. The PICC Line and Physician order [REDACTED]. All attending physicians and extenders will be educated to ensure that orders are in place for the care of the Peripherally Inserted Central Catheter, including to measure the external length of the catheter for residents who have orders for PICC lines by the Medical Director. All licensed nursing staff will be re-educated by the Staff Educator regarding PICC Lines and Physician Orders, to include the nurses to document the catheter site monitoring and measurements of the external catheter length and arm circumference with each dressing change. All licensed nurses will also be educated to notify the MD if the measurements vary from the original measurements at time of placement. All licensed nurses will complete a physicians orders administration and PICC line competency post education. IV. All residents who have PICC lines will be audited by the ADNS and/or designee weekly for one month and monthly for 6 months thereafter. The audit will include documentation of the catheter site monitoring and measurements of the external catheter length with each dressing change. Findings will be brought to the DNS weekly and then brought to QAPI monthly for review and discussion by the DNS and/or designee. V. The Director of Nursing will be responsible for compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 20, 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 2/12/2025 and completed on 2/20/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #7) of three residents reviewed for Respiratory care. Specifically, Resident #7, with a [DIAGNOSES REDACTED]. The resident complained of feeling short of breath and was trying to place the nasal cannula to receive supplemental oxygen from the oxygen tank; however, the oxygen tank was empty. The finding is: The Oxygen Administration Policy dated 1/28/2025 documented oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The Policy did not include who was responsible for maintaining and/or monitoring the oxygen tanks. Resident #7 was admitted with the [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The Minimum Data Set documented the resident utilized oxygen therapy. The physician's orders [REDACTED]. The Comprehensive Care Plan for cardiac decompensation related to Hypertension dated 10/16/2024 documented interventions including administering oxygen therapy as ordered by the Physician. During an observation on 2/12/2025 at 11:35 AM, Resident #7 was observed in their bed and was attempting to put the nasal cannula in their nose. The resident stated they felt short of breath and were trying to fix the tubing. The oxygen tubing was attached to the oxygen tank which was placed by the door. The gauge needle was at the red line indicating the tank was empty. The Director of Nursing Services was alerted to check the resident's oxygen saturation level. The Director of Nursing Services came to the resident's room and checked the resident's oxygen saturation level, which was between 88 percent to 91 percent (normal range above 95 percent). The Director of Nursing Services stated the oxygen tank was empty. A new oxygen tank was subsequently connected, and the resident's oxygen saturation level went up to 92 percent. During an interview on 2/12/2025 at 11:48 AM, the Director of Nursing Services stated the resident should use a concentrator for oxygen; however, when the concentrator was broken, the staff used an oxygen tank to administer oxygen therapy. The Director of Nursing Services stated the oxygen tank should have enough oxygen available. Resident #7 is alert and can use the call bell to call for staff assistance. During an interview on 2/13/2025 at 1:38 PM, Licensed Practical Nurse #4 stated Resident #7 has a physician's orders [REDACTED]. Licensed Practical Nurse #4 stated the resident had been utilizing an oxygen tank since the morning. At 9:00 AM, there was a quarter full of oxygen remaining in the tank. The resident made their needs known and had no concerns. Licensed Practical Nurse #4 stated they got busy and did not check the oxygen tank after 9:00 AM. Licensed Practical Nurse #4 stated they should have checked the oxygen tank to ensure there was enough oxygen available. During an interview on 2/20/2025 at 11:57 AM, Nurse Practitioner #1 stated they expected the nursing staff to follow the physician's orders [REDACTED]. Resident #7 has significant [MEDICAL CONDITION], and if they did not receive oxygen therapy as needed, there could be a risk of respiratory distress and [MEDICAL CONDITION] (lack of oxygen to body tissues). 10 NYCRR 415. 12(k)(6) | Plan of Correction: ApprovedMarch 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #7 ?£s oxygen tank was immediately replaced with an oxygen concentrator by the DNS on 2/12/ 25. Resident #7s oxygen saturation level was checked by using pulse oximetry and was between 88-92% (the resident has a [DIAGNOSES REDACTED]. Licensed Practical Nurse #4 was educated to monitor oxygen tank levels. She was educated tanks below ?é?? of a tank should be replaced with a new tank if an oxygen concentrator is not available. LPN #4 was also educated that residents who receive oxygen therapy should have oxygen concentrators placed in their rooms, if available, for their use while in their room. II. All residents with orders for oxygen therapy have the potential to be affected by the same deficient practice. On this date, 3/10/25, there are a total number of 15 out of 223 residents who currently have orders for oxygen. All residents who receive oxygen in their rooms have been provided with an oxygen concentrator. III. The Oxygen Administration policy was reviewed and revised on 3/10/25 by the DNS, Medical Director, and Administrator. The revision includes: 1. licensed nursing staff is responsible to monitor oxygen tanks; 2. oxygen concentrators will be provided in resident rooms, if available, for residents receiving oxygen therapy. All licensed nursing staff will be educated by the Staff Educator on the revision of the Oxygen Administration policy regarding oxygen tank replacement if at a ?é?? of a tank and to provide oxygen concentrators in resident rooms if available to residents receiving oxygen therapy. All licensed nurses will complete an Oxygen Administration competency post education. The Unit Manager and/or designee will round weekly to ensure residents with oxygen administration orders have an oxygen concentrator in their room, if available. IV. 5-7 residents who have oxygen administration orders will be audited to ensure the oxygen tank in use is above a ?é?? of a tank and/or an oxygen concentrator is available bedside by the Unit Manager and/or designee weekly for one month and monthly for 6 months thereafter. Findings will be brought to the DNS weekly and then brought to QAPI monthly for review and discussion by the DNS and/or designee. V. The Director of Nursing will be responsible for compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 20, 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 2/12/2025 and completed on 2/20/2025, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practices, to promote healing and prevent infections. This was identified for one (Resident #11) of four residents reviewed for Pressure Ulcer/Injury. Specifically, Resident #11 had a Stage 4 Pressure Ulcer (full-thickness tissue loss that exposes bone, tendon, or muscle) on the left buttock and sacrum (bottom of the spine). Resident #11 had a physician's orders [REDACTED].#11's left buttock wound during the wound care observation. The wound care team recommended to cleanse the wound with normal saline instead of Dakin's solution on 2/14/2025; hoewever, there was no documented evidence the recommendation was implemented until 2/18/ 2025. The finding is: The facility's policy titled Pressure Injury, last revised on 6/2024, documented the medical provider will authorize pertinent orders related to wound care treatments, including wound cleansing and debridement approaches, dressings (occlusive, Absorptive, etc.), and application of topical agents if indicated for the type of skin alteration. Upon written receipt of recommendations made by the wound care provider/consultants, the primary care providers will review and address the recommendations within 48 hours. Resident #11 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, which indicated Resident #11 had moderately impaired cognition. Resident #11 had unhealed pressure ulcers and used a pressure-reducing device for the chair and bed. A Comprehensive Care Plan titled Left Buttock and Sacrum Unstageable Wound last revised on 2/15/2024 documented interventions including the use of a pressure reduction bed mattress, a cushion to wheelchair, administration of pain medication 60 minutes before treatment, turning and positioning every 2 hours, wound care consultations, and treatments as per the physician's orders [REDACTED]. A physician's orders [REDACTED]. Clean with quarter-strength Dakin's solution (a diluted bleach solution used as an antiseptic to clean and treat wounds), pat dry, apply Santyl followed by normal saline moistened gauze, Zinc Oxide to peri-wound, and cover with a silicone foam dressing daily and as needed. A wound care consultation progress note dated 2/14/2025, written by the Wound Care Nurse Practitioner, documented the left buttock Stage 4 pressure ulcer measuring 5. 7 centimeters in length, 10. 2 centimeters in width, and 0. 2 centimeters in depth. The recommendations included cleansing the wound with normal saline, applying Santyl to the wound, and loosely packing it with saline moist gauze covered with bordered gauze daily and as needed. The Sacral Stage 4 pressure ulcer measurements were 1. 2 centimeters in length, 1. 2 centimeters in width, and 1 centimeter in depth. The recommendations included cleansing the wound with normal saline, protecting the peri-wound with zinc oxide, applying Santyl to the wound, and loosely packing the wound with saline moist gauze covered with bordered gauze daily and as needed. The physician's orders [REDACTED]. During a wound care observation on 2/18/2025 at 1:15 PM, the Wound Care Nurse was assisted by Licensed Practical Nurse #3 and the Nurse Manager for positioning Resident #11 during the wound care treatment. The Wound Care Nurse started cleaning Resident #11's left buttock wound with 0. 9 percent sodium chloride (normal saline). Upon inquiry by the surveyor, the Wound Care Nurse stopped and reviewed the physician's orders [REDACTED]. During an interview on 2/18/2025 at 1:22 PM, the Wound Care Nurse stated that on 2/14/2025, the Wound Care Nurse Practitioner recommended discontinuing the use of the quarter-strength Dakin's solution and using the normal saline for cleansing the left buttock and sacral wounds. The Wound Care Nurse stated that they (the Wound Care Nurse) should have discontinued the quarter-strength Dakin's solution and started normal saline for cleaning as per the recommendations because there were no signs of wound infection. The Wound Care Nurse further stated they should have checked the physician's orders [REDACTED]. During an interview on 2/18/2025 at 2:48 PM, Licensed Practical Nurse #1 stated when they provided wound care treatment for [REDACTED]. Licensed Practical Nurse #1 stated they had never received any order to change Dakin's solution to normal saline. During an interview on 2/19/2025 at 9:10 AM, Licensed Practical Nurse #2 stated they provided wound care treatment on 2/13/2025 and 2/14/2025 for Resident # 11. Licensed Practical Nurse #2 stated the Wound Care Nurse Practitioner was present and assessed the wounds with the Wound Care Nurse on 2/14/2025, but they (Licensed Practical Nurse #2) did not receive any orders to change the quarter-strength Dakin's solution to normal saline for cleaning Resident #11's wounds. Licensed Practical Nurse #2 stated they were using Dakin's solution to cleanse Resident #11's wound per the physician's orders [REDACTED]. During an interview on 2/19/2025 at 9:22 AM, the Wound Care Nurse Practitioner stated they assessed Resident #11 on 2/14/ 2025. The Wound Care Nurse Practitioner stated Resident #11's wounds had no sign of infection. The Wound Care Nurse Practitioner stated they recommended discontinuing the quarter-strength Dakin's solution and using normal saline to cleanse Resident #11's wounds instead. The Wound Care Nurse Practitioner stated prolonged use of Dakin's solution can damage skin. The Wound Care Nurse Practitioner further stated they expected the nurses to relay recommendations to the primary Physicians within 24-48 hours. During an interview on 2/19/2025 at 1:27 PM, the Nurse Practitioner stated they were notified of the recommendation to discontinue the Dakin's solution for Resident #11's wound care by the Wound Care Nurse on 2/18/ 2025. The Nurse Practitioner stated they expected to be notified of recommendations within 24-48 hours of any consultation. The Nurse Practitioner stated they agreed with the Wound Care Nurse Practitioner's recommendation and the physician's orders [REDACTED]. 2025. During an interview on 2/19/2025 at 2:01 PM, the Director of Nursing Services stated they (the Director of Nursing Services) did not know why the Wound Care Nurse did not document the new treatment order for Resident #11 until 2/18/ 2025. 10 NYCRR 415. 12(c)(1) | Plan of Correction: ApprovedMarch 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #11s physicians orders were reviewed by the medical provider on 2/18/ 25. The Medical provider agreed with the wound care providers recommendation to change the Dakins solution for cleaning the wound to normal saline. The physicians order was reconciled and placed in the electronic medical record by the residents MD on 2/18/ 25. The Wound Care Nurse was provided with education regarding following physician orders, prior to start of a pressure injury treatment, that includes a physicians orders administration competency. II. All residents with pressure injury have the potential to be affected by the same deficient practice. On this date, 3/10/25, there are a total number of 14 out of 223 residents who currently have pressure injury. All 14 residents wound care rounds recommendations by the Wound Care team were reviewed by the DNS and reconciled with the medical provider on 3/14/ 25. III. The Pressure Injury and Physician order [REDACTED]. 25. The Wound Care Nurse Practitioner will be re-educated to provide all recommendations timely to the medical provider within 48 hours of consult by the Medical Director. A Wound Care Recommendation form was created by the DNS to facilitate communication between the wound care team and the MD. The DNS and/or designee will monitor pressure ulcer treatment recommendations to ensure all new recommendations have been addressed and reconciled with the attending physician. All licensed nursing staff will be re-educated by the Staff Educator regarding following physician orders [REDACTED]. All licensed nurses will complete a physicians orders administration competency post education. All licensed nurses will receive education regarding the Wound Care Recommendation form by the Staff Educator. IV. The DNS and/or designee will conduct 5-10 treatment observations weekly for four weeks and then monthly for six months. The DNS and/or designee will review the Wound Care Recommendation form weekly for four weeks and then monthly for six months for compliance. Findings from both audits will be brought to QAPI monthly for review and discussion by the DNS and/or designee. V. The Director of Nursing will be responsible for compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 2. 2. 2. 4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (1) Locks complying with 19. 2. 2. 2. 5 shall be permitted. (2)*Delayed-egress locks complying with 7. 2. 1. 6. 1 shall be permitted. (3)*Access-controlled egress doors complying with 7. 2. 1. 6. 2 shall be permitted. (4) Elevator lobby exit access door locking in accordance with 7. 2. 1. 6. 3 shall be permitted. (5) Approved existing door-locking installations shall be permitted. 2012 NFPA 101: 7. 2. 1. 6. 1. 1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9. 6 or an approved, supervised automatic sprinkler system in accordance with Section 9. 7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (1) The door leaves shall unlock in the direction of egress upon actuation of one of the following: (a) Approved, supervised automatic sprinkler system in accordance with Section 9. 7 (b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9. 6 (c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9. 6 (2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism. (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7. 2. 1. 5. 10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. ( 3. 2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS (5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7. 9. Based on observations and staff interview during the recertification survey, it was noted that egress doors that are equipped with delayed egress locking mechanisms were not provided with the required signages in accordance with NFPA 101. The findings are: During the Life Code survey on 02/12/2025 between 9:00 AM to 3:00 PM, it was noticed that egress doors that are equipped with delayed egress locks were not provided with durable signages located on the door leaf adjacent to the release device in the direction of egress. Instead, the egress signages were noted installed on the walls adjacent to the egress doors. In an interview on 2/13/2025 at 2:30 PM, the Director of Maintenance stated that the egress signages will be ordered and installed on the egress doors. 2012 NFPA 101: 19. 2. 2. 2. 4, 7. 2. 1. 6. 1. 1 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 11, 2025 I. Corrective Immediate Action The Director of Plant Operations has ordered ICON construction company that is still under contract, to order and install Emergency Egress signage on newly installed fire exit doors, that is ADA compliant, on all emergency fire doors on all units including the basement to comply with: 2012 NFPA 101: 19. 2. 2. 2. 4, 7. 2. 1. 6. 1. 1 10NYCRR 711. 2(a)(1) II. Identification of Other Areas a. A visual observation has been made by the Director of Plant Operations to identify areas of the facility that may be affected by the same practice. b. All areas that have been affected by the same practice have been noted and communicated to the contractor for immediate remediation. III. Education The Director of Plant operations will in-service the maintenance staff as to the requirements of 2012 NFPA 101: 19. 2. 2. 2. 4, 7. 2. 1. 6. 1. 1, 10NYCRR 711. 2(a)(1) to identify and prevent future practices of this type. IV. QA Monitoring The Director of Plant Operations/Designee will monitor practices and record findings during weekly fire door/emergency egress preventive maintenance/life safety rounds monthly for the next 6 months. Logs will be kept in the Maintenance Directors Office. Any negative findings will be immediately brought to the director of Plant Operations for remediation. The Plant Operations Director will bring any negative findings to the QAPI committee monthly. V. Person Responsible for Corrective Action Director of Plant Operations |