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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 12/26/2024 and completed on 1/2/2025, the facility did not ensure the comprehensive care plan was reviewed and revised to meet each resident's current needs. This was identified for one (Resident #21) of two residents reviewed for Activities of Daily Living. Specifically, Resident #21 was observed toileting themselves on 12/26/ 2024. Resident #21 required staff assistance for toileting transfer and toileting care as per assessments by the Rehabilitation Department and Certified Nursing Aide Accountability Record. A Noncompliance comprehensive care plan developed in 2023 documented Resident #21 was resistive to Activities of Daily Living assistance; however, the comprehensive care plan did not include interventions to for monitoring the resident's noncompliant behavior related to toileting self. The finding is: The facility's policy and procedure titled Comprehensive Care Plan and Resident/Patient Meeting dated (MONTH) 2024 documented the purpose of the (comprehensive) assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairment(s) in functional capacity and the plan suggested by the comprehensive care plan team for improvement/maintenance for each of the resident's primary care issues. Information including (resident's) ability to perform Activities of Daily Living, and the resident's needs for staff assistance are obtained from the comprehensive assessment and staff interviews to plan care. The Comprehensive Care Plan will be revised quarterly, annually, and as needed, within 7 days of completion of the Minimum Data Set (MDS). Resident # 21 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment documented Resident #21 did not exhibit behaviors and rejections of care. Resident #62 required moderate assistance for toileting hygiene and maximum assistance for toilet transfer. Resident #21 had an ostomy and was continent of urine. A Behavioral Symptoms- Non-Compliance Comprehensive Care Plan related to rejection of Activity of Daily Living assistance dated 1/23/2024 documented Resident #21 required less than half assist for toileting hygiene and more than half assist for toileting transfer. Interventions included but were not limited to provide incontinent care as needed. No new interventions have been developed and implemented since 4/24/ 2023. The current care plan did not include interventions to monitor and supervise Resident #21's non compliance related to toileting themselves. An evaluation note dated 10/29/2024 documented that the resident continued to have periods of noncompliance with the plan of care. Staff continue to educate and encourage the resident to comply with the plan of care, the resident can be adamant about their choices despite ongoing education, and staff to continue to maintain resident's dignity and respect resident's rights. An Activity of Daily Living Comprehensive Care Plan dated 4/24/2024 documented Resident #21 required less than half assist for toileting hygiene and more than half assist for toileting transfer. Interventions included but were not limited to provide incontinent care as needed. The current care plan did not include interventions to monitor and supervise Resident #21's non compliance related to toileting themselves An annual Rehabilitation Screening dated 10/16/2024 documented that Resident #21 continued to require minimal assistance of one person for toileting hygiene and moderate assistance of one person for toilet transfer. Certified Nursing Assistant task instruction for October - (MONTH) 2024 documented Resident #21 was continent of bladder and required more than half assistance (substantial/maximal assistance) for toileting tasks. Resident #21's (MONTH) 2024 Certified Nursing Assistant Accountability records documented that on 21 occasions the resident was not provided assistance with toileting tasks as indicated in the resident's care plan. Resident #21's (MONTH) 2024 Certified Nursing Assistant Accountability records documented that on 15 occasions the resident was not provided assistance with toileting tasks as indicated in the resident's care plan. Resident #21's (MONTH) 2024 Certified Nursing Assistant Accountability records documented that on 43 occasions the resident was not provided assistance with toileting tasks as indicated in the resident's care plan. During the initial tour on 12/26/2024 at 11:28 AM, Resident #21 was observed sitting on the toilet in the bathroom inside their room and the wheelchair was in front of the resident. No staff was observed in the vicinity. Resident #21 stated they went to the bathroom themselves. During an interview on 12/26/2024 at 11:29 AM, Licensed Practical Nurse #1 stated that Resident #1 was allowed and able to toilet on their own. Licensed Practical Nurse #1 stated the resident preferred to transfer and toilet on their own. During an interview on 12/30/2024 at 2:01 PM, Certified Nursing Assistant #1 stated Resident #21 was continent of bladder. Certified Nursing Assistant #1 stated the resident's plan of care indicated that they needed assistance of one person for Activities of Daily Living including toileting but Resident #21 was capable of completing the task on their own and often did not ask for assistance. Certified Nursing Assistant #1 stated many times they observed Resident #21 toileting themselves. Certified Nursing Assistant #1 stated they encouraged the resident to ask for help. During an interview on 12/30/2024 at 2:20 PM, Registered Occupational Therapist #1 stated they assessed and evaluated Resident #21 in (MONTH) 2024 and discharged the resident from skilled occupational therapy. Registered Occupational Therapist #1 stated the resident required minimum assistance of one person (Resident is able to complete 75% of the task and staff help with 25%) for toileting and transfer. During an interview on 12/31/2024 at 10:15 AM, Resident #21 was observed with tremors of bilateral hands. Resident #21 stated they took care of themselves and did not ask staff for help often. During an interview on 12/31/2024 at 1:08 PM, Registered Nurse Supervisor #1 stated they were aware that Resident #21 tried to be independent with their care and did not call staff for help. Registered Nurse Supervisor #1 stated Resident #21 was capable of toileting themselves. Registered Nurse Supervisor #1 stated there was a non-compliance care plan. Registered Nurse Supervisor #1 stated staff continued to provide verbal encouragement but was unable to state different approaches to address the ongoing non-compliance. Registered Nurse Supervisor #1 they expected staff to respond when Resident #21 pressed the call bell. Registered Nurse Supervisor #1 stated that Resident #21 should toilet with one staff present and assisting if they (Resident #21) were care planned to require minimum assistance of one person for toileting. A Nursing referred Rehabilitation Screening dated 12/31/2024 documented that Resident #21 continued to require minimal assist of one person for toileting hygiene and moderate assist of one person for toilet transfer. During a re-interview on 1/2/2025 at 12:20 PM, Registered Occupational Therapist #1 stated that they re-assessed Resident #21 on 12/31/ 2024. Resident #21 had tremors, was unsteady, and had difficulty wiping themselves after toileting and pulling up their pants. Registered Occupational Therapist #1 stated Resident #21 cannot toilet themselves independently and staff must be presented to offer hands-on assistance to complete the toileting care safely. During an interview on 1/2/2024 at 12:41 PM, the Director of Nursing Services stated Resident #21 should be provided one-person staff assistance during toileting as per the assessment and care plan. The D | Plan of Correction: ApprovedJanuary 28, 2025 Plan of Correction FTAG 657 SS:D I. Immediate Action a. Resident #21 is still residing in the facility. resident #21 was affected by this deficient practice. All residents requiring staff assistance with activities of daily living including toileting transfer and toileting hygiene and are non-compliant with activities of daily living have the potential to be affected by this practice No other residents were affected. b. Certified Nurses Aide #1was educated on 1/16/25 by the Assistant Director of Nursing on following all the instructions for providing care to the residents as documented on the Nursing Assistant Accountability Records with emphasis on reporting all non-compliance observed by the resident to the Nurse and rendering the level of assistance as instructed on the residents Accountability Records. Emphasis also reinforcing that a resident noncompliance does not remove the responsibility from the staff member to render the level of assistance documented on the Accountability record to provide the resident care. c. The residents noncompliance care plan was reviewed by the ADNS on 1/15/25 and updated with interventions including staff member offering toileting q 2 hours and prn and must always remain with the resident during toileting hygiene and toileting transfer task to maintain the safety of the resident at all times and to ensure any non-compliance with care is addressed. d. The Residents Activity of Daily Living Care plan was reviewed by the ADNS on 1/15/25 and updated with interventions including offering toileting q2 and prn staff member must remain with the resident at all times for all ADL care requiring staff assistance to monitor and provide assistance and maintain the residents safety at all times. Also updated to include minimal assistance of one person for toileting hygiene and moderate assist of one person for toilet transfer. e. The Nursing Aide Accountability record was reviewed by the ADNS on 1/15/25 and updated to include staff member must render the level of assistance as documented on the residents instructions. Also updated to include offer resident toileting q2 hrs. and prn, minimal assistance of one person for toileting hygiene and moderate assistance of one person for toilet transfer and to report all residents refusal of care and noncompliance to the nurse. f. RN #1 was provided with 1:1 education by the ADNS on 1/16/2025 on updating the Accountability record for the resident care to include intervention for monitoring residents with noncompliance. Ensuring noncompliance behavior has an intervention including interventions for offering toileting to the resident q2 and prn and for staff members to remain with the resident during all tasks requiring assistance and to ensure residents safety is maintained and also to follow up and reevaluate the effectiveness of these interventions with the IDT Team to ensure compliance. g. All LPNs who worked on unit(NAME)on 12/26/24 were provided with 1:1 education by the ADNS on 1/17/25 on following all instructions for care for the residents and reinforcing and ensuring the Aides are following the residents plan of care. If a resident demonstrates non-compliance the RN should be notified and the necessary, follow up be done with the MD and the IDT team. The residents non-compliance does not remove the staff responsibility for rendering the level of care documented on the care instructions. II. Identification of Others: a. An audit was conducted on 1/15/25 by the ADNS for all residents in house with noncompliance care plans related to ADL care including toileting self and requiring staff assistance. There were no negative findings of this audit. III. System Changes a. The Facilitys Policy and Procedure Titled Comprehensive Care Plan and Resident Meeting dated (MONTH) 2024 was reviewed on 1/16/25 by the Medical Director, Director of Nursing, and the Administrator with no changes made. b. All Licensed Nurses will be re-educated by the Inservice Coordinator/designee on the Policy and Procedure Titled Comprehensive Care Plan and Resident/Patient Meeting with emphasis on reviewing and revising the comprehensive care plan with interventions to meet the residents current needs. IV. Quality Assurance a. An audit tool was created by the Director of Nursing to review all residents with new episodes of non-compliance with Activities of Daily Living to ensure there are appropriate interventions to address the residents non-compliance and ensure the Aides accountability record and the residents noncompliance care plan is updated with these instructions and interventions. b. Audits will be completed by the ADNS/Designee on 25 % of all residents on each unit weekly x 4, then monthly x 2 months and quarterly thereafter until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Director of Nursing immediately. All negative findings will be immediately addressed by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4. ( to review and discuss any unfavorable patterns that may prevent achieving 100% compliance) V. Person Responsible. Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews during the Recertification Survey initiated on 12/26/2024 and completed on 1/2/2025, the facility did not ensure that food was served in accordance with professional standards for food service safety. This was identified for one (Madison) of three dining rooms during the Dining Task. Specifically, the facility did not monitor the temperature of cold food items served to the residents during a lunch meal observation on 12/30/2024 at 12:22 PM. The temperature of two yogurt containers measured at 60 and 62 degrees Fahrenheit (normal range: below 41 degrees Fahrenheit.) The finding is: The facility's policy and procedure titled Food Safety/Storage/Distribution/Service/Procurement - General dated 6/2024, documented Danger Zone refers to temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Food Service/Distribution refers to the processes involved in getting food to the resident. This may include holding foods under refrigeration for cold temperature control. Refrigerated Storage: potentially hazardous foods (examples include yogurt) must be maintained at or below 41 degrees Fahrenheit. During the lunch meal service in the(NAME)dining room on 12/30/2024 at 12:22 PM, the Dietary Supervisor measured the temperature of two yogurt containers on the individual resident trays prior to being delivered from the kitchen to the dining room. The yogurt measured 60 degrees and 62 degrees Fahrenheit. The Dietary Supervisor was immediately interviewed and stated there was an increased risk for infection and/or gastrointestinal issues if the food was served outside of the proper serving/holding temperatures. During an interview on 12/30/2024 at 1:03 PM, the Food Service Director stated the temperature of the yogurt and cold food items are checked when the items are placed onto the individual resident trays and the trays are then stored in the walk-in refrigerator unit until the time of service. The Food Service Director stated that the resident trays were delivered to the dining room at approximately 11:55 AM-12 noon. The Food Service Director stated that 60 degrees Fahrenheit is not the proper serving temperature for yogurt or any cold food and should be below 42 degrees Fahrenheit. The Food Service Director the residents can get sick from the cold food served at a temperature above 42 degrees as there is an increased risk of bacterial growth. During an interview on 1/2/2025 at 12:10 PM, the Administrator stated they were not aware of an issue with the cold food items being served above the safe temperature zone prior to notification during the survey process. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedJanuary 28, 2025 Plan of Correction F812 SS:D I. Immediate Action a. All residents' trays in the(NAME)dining room receiving yogurts on 12/30/24 was immediately removed from the trays and replaced with new items from the kitchen transported to the dining room on ice by the Food Service Director. All residents receiving yogurt at meals have the potential to be affected by this practice. No residents were affected. b. The Dietary Supervisor received 1:1 education on 1/16/25 by the Assistant Director of Nursing with the Food Service Director present on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served within the safe temperature. Any items identified outside the safe temperature zone must be immediately discarded. All items requiring refrigeration must be refrigerated. c. The Food Service Director was in serviced on 1/16/25 by the RN (ADNS)on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served to the resident within the safe temperature. All food items requiring refrigeration must be refrigerated and any items identified outside of the safe temperature zone must be immediately discarded. II. Identification of Others: a. All residents receiving yogurt at meal services have the potential to be affected by this deficient practice. No residents were affected. b. An audit was conducted on 1/16/25 by the Food Service Director including temperature check of all yogurts for resident in house receiving yogurt at meals with no negative findings. III. System Changes a. The Policy and Procedure Titled Food Safety/Storage/Distribution/Service Procurement General dated 6/2024 was reviewed on 1/16/25 by the Medical Director, Food service Director and the Administrator with no changes made. b. All Dietary employees will be re-in-service on the Facilitys Policy Titled Food Safety/Storage/Distribution/Service/Procurement by the Food Service Director and the Educator /Designee. IV. Quality Assurance a. An audit tool was created by the Administrator to conduct random temperature checks for all residents receiving yogurt and milk at random meals to identify any unsafe temperature to ensure items are stored and served at a safe temperature. b. Audits will be completed by the Food Service Director daily x 30 days then bi -weekly x 4, then monthly x 2 months and quarterly x 3 quarters until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Administrator immediately and addressed by the Food Service Director/Designee immediately. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable trend that may prevent achieving 100% compliance. V. Person Responsible. Administrator. VI. Completion date: 2/25/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 6. 3. 5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19. 3. 5. 7. 2012 NFPA 101: 19. 3. 6. 3. 10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled. Based on observation and staff interviews the facility did not ensure that corridor doors were provided with suitable means to keep the door open in accordance with NFPA 101:Life Safety Code. Specifically, a corridor door observed held open with an unapproved hold open device. The finding is: On (MONTH) 27, 2024, at approximately 10:50 AM, during the Life Safety Code recertification survey, it was noted that the door to the(NAME)dining room was held open with a hand sanitizer portable stand. The Director of Environmental Services, who was present at the time of observation, acknowledged the finding. On (MONTH) 27, 2024, at approximately 3:45 PM, during the exit interview, the Corporate Environmental Coordinator stated that a magnet tied to the fire alarm will be placed to hold open the door. 2012 NFPA 101: 19. 3. 6. 3. 5*, 19. 3. 6. 3. 10* NYCRR 711. 2(a) (1) | Plan of Correction: ApprovedJanuary 28, 2025 I. Plan of Correction for Affected Residents: The facility respectively states that no Residents were affected by this deficient practice 2) On 12/27/2024 The Director of Maintenance removed the portable hand sanitizer stand that was preventing the(NAME)dining room door from closing. 3) 0n 01/14/2025 The Director of Maintenance contacted the Fire Alarm contractor to provide a proposal to install magnetic hold open devices that are connected to the fire alarm system that will release when the fire alarm is activated. That proposal was received on 01/17/2025 and has been approved. The magnetic hold open devices will be installed by 02/28/ 2025. II. Plan of Correction to identify other Residents Potentially Affected: All residents have the potential to be affected by this deficient practice. On 01/14/2025 The Director of Maintenance inspected all corridors doors and no other areas of noncompliance were noted. III. Plan of Correction for Systems Changes and Measures to Prevent Recurrence: A) On 01/14/2025 The Director of Maintenance in conjunction with maintenance staff reviewed the requirements for K363 to understand and implement the corrective actions. B) Environment rounds will be done for all corridor doors to ensure that they resist the passage of smoke. C) Findings of rounds will be recorded in an audit tool located in the maintenance log book. IV. Plan of Correction for Monitoring Corrective Actions: A) The Director of Maintenance/designee created an audit tool and will conduct quarterly audits of the corridor doors for 12 months to ensure compliance with 2012 NFPA 101: 7. 10. 2, 7. 10. 2. 1, 10 NYCRR: 711. 2 (a) B) The Director of Maintenance/designee will report findings of the audit to Administrator. C) Any negative findings from these audits will be immediately addressed by the Director of Maintenance and Administrator. The findings of these audits will be discussed at the quarterly QAPI meetings to discuss any unfavorable trends and patterns that may prevent achieving 100% compliance. I. Responsible Discipline: The Director of Maintenance is responsible to ensure that all components of the plan of correction have been implemented and that compliance has been achieved. Date of Completion: 02/28/202 |