NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
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, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 (Resident #10) of 25 residents reviewed. Specifically, Residents #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure Titled, Recreational Therapy, revised 9/2024, documented the Department of Recreational Therapy was responsible for providing meaningful leisure time programs for all residents on a seven-day-per-week basis. Each resident, regardless of their physical and cognitive status, would be offered an activities program designed to meet, in accordance with the comprehensive resident assessment, his or her interests and to encourage quality of life, preservation of leisure skills and maintenance of an optimal level of psychosocial functioning among residents. The activities should be designed to promote the physical, social and mental well-being of residents and to maintain contact and interaction with the community. Residents would be encouraged to voluntarily participate in planned group and individual programs of their choice, reserving the right to refuse to participate in any program. Such programs would consist of both individual and group activities at various times of the day, evening and weekends and shall include but would not be limited to animals, children and other community agencies. Resident #10 was admitted with a [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/2024, documented a Brief Interview for Mental Status (BIMS) score of 99- unable to complete. It further documented resident could understand and be understood by others. During observations on 2/10/2025 at 12:45 PM, 2/11/2025 at 10:30 AM, and 2/12/2025 at 11:00 AM, Resident #10 was noted to be in bed, mattress wedges alongside of bed and double mattresses on floor of each side of bed. Resident arousable, but non-verbal. Resident was wearing a hospital gown. Resident had an extremely thin, frail appearance. Resident was observed all three days in same position. The lights and television were off. On 2/13/2025 at 11:00 AM resident was sitting up in bed, more alert on this day, television was on. The Comprehensive Care Plan for Social Work dated 4/29/2024 documented, Resident will continue to have ongoing needs met through next review, Resident/family will recognize need for 24-hour care, to maintain present level of functioning. Encourage resident to voice concerns, encourage participation in activities of choice, encourage interest in daily routine, Encourage participation in activities of daily living. Resident will have increased ability to cope with feelings of anxiety. Encourage activities of resident's choice in and out of their room, Offer 1:1 to provide socialization and support as needed. During an interview on 02/12/2025 at 2:22 PM, Activities Director #1 stated resident #10 was assessed upon admission of likes and dislikes for activities. The Activities Department provided activities 7 days per week, which were posted on announcement board. For those residents who were unable to attend group activities, 1:1 visits were held with resident. Activities Director #1 provided an attendance roster for group activities, but unable to provide any documentation of 1:1 activity visits for Resident #10. Activities Director #1 stated at that time 1:1 visits were not documented, but going forward would document 1:1 visits. Activities Director #1 stated the radio and television are turned on for Resident #10. During an interview on 02/13/2025 at 12:52 PM, Director of Nursing #1 stated they were informed that Activities Department had not been documenting 1:1 activities. They stated going forward each visit would be documented. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h | Plan of Correction: ApprovedApril 25, 2025 Corrective Action for those identified: A progress note regarding the programming offered/implemented was completed on 2/13/25. The resident #10 passed away prior to receiving the statement of deficiencies. Identification of other residents and corrective action All residents have the potential to be affected by the deficient practice. An audit of all recreation care plans for appropriate goals/interventions and appropriate documentation will be completed and any gaps identified will be addressed. Measures and Systemic Changes Implemented policy ?Ç£Recreation Program Development?Ç¥ 3/10/2025. Updated the Recreation Attendance sheet to include the time of a 1 on 1 visit. Education of the Recreation staff related to the new policy and documentation will be completed by 3/31/25. Monitoring A weekly review of residents with a change in condition/status will be completed x30 days and as changes occur. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Supervisor of Recreation, by 3/31 |
Scope: Pattern
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, record review, and interviews conducted during a recertification survey, the facility did not develop and implemented a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 (Residents #s 3, 9, and 19) of 25 residents reviewed for Care Plans. Specifically, (a.) Resident #3 did not have a care plan for falls that documented interventions that were in place including the use of multiple mattresses in their room; (b.) Resident #9's intervention for treatment of [REDACTED].#19 did not have a care plan that addressed their vision problems. This is evidenced by: A facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 documented the plan of care is a working tool that provided a profile of the needs of each resident, identified the roles of each service in meeting these needs, and the supportive measures each service, along with the resident, will use to accomplish the overall goals of care. Each discipline was responsible for identifying a problem/concern if any existed for their discipline and identify an intervention for any problem/concern that was relevant to their discipline. Resident #3 Resident #3 was admitted to the facility with [DIAGNOSES REDACTED].), and coronary [MEDICAL CONDITIONS] (buildup of plaque which causes coronary arteries to narrow, limiting blood flow to the heart). The Minimum Data Set (an assessment tool) dated 12/05/2024, documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. During an observation on 2/11/2025 at 10:21 AM, resident was sitting in a lounge chair in their room. The resident's bed was at its lowest position and has multiple mattresses propped up against the walls in the room. A record review documented Resident #3 has a Care Plan for fall risks developed upon initial entrance to the facility on [DATE]. Resident #3 was discharged to the hospital on [DATE] and returned several days later on 12/05/2024. The resident care plan for falls did not include the use of mattresses in their room. A record review of the Certified Nurse Aide's daily assessment documented the daily safety precautions were to have the bed in the lowest locked position with mattresses next to the bed. During an interview on 2/13/2025 at 10:45 AM, Certified Nurse Aide #2 stated that Resident #3 had the mattresses in their room due to having multiple falls. They stated that the mattresses were there to protect the resident from falls. They stated that their daily plan was to have the bed in the lowest locked position with mattresses next to the bed. Certified Nurse Aide #2 stated that the daily assessment was populated from the resident's care plan. They stated they did not know where in the care plan it was located as they do not deal with care plans. During an interview on 2/18/2025 at 2:33 PM, Nurse Manager #1 stated that the resident had a care plan for falls and that the mattresses on the residence floor were to be care planned. Nurse Manager #1 stated that they could not locate in the care plan where the mattress for the resident was documented. During that time Assistant Director of Nursing #1 was in the office with the Nurse Manager #1 and stated that the care plan was not implemented when the resident returned from the hospital. Resident # 9 Resident #9 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #9 had intact cognition and made decisions regarding tasks of daily life. The Comprehensive Care Plan for [MEDICAL CONDITION] initiated 04/11/2024 documented Resident #9 has chronic bilateral lower extremity [MEDICAL CONDITION]. The outcome with a start date of 04/11/2024 and a target date of 04/08/2025 was Resident #9 would not have an alteration in skin integrity related to [MEDICAL CONDITION] through the next review in 90 days. Intervention for [MEDICAL CONDITION] included: elevate legs as much as possible, avoid tight fitting shoes/socks, monitor skin integrity, medication as ordered, monitor weight, monitor for complaint of pain, and make provider aware of any changes/increases in amount. There was no intervention that included wrapping Resident #9 bilateral lower extremities with ACE bandages daily. Physician order [REDACTED]. The [DIAGNOSES REDACTED]. Nurses progress note dated 01/14/2025 documented Resident #9 was seen by provider regarding bilateral lower extremity [MEDICAL CONDITION]. New order was received to wrap bilateral lower extremities with ACE wraps during the day and off at hour of sleep. Resident #9 was agreeable to this plan. During an interview on 02/10/2025 at 11:27 AM, Resident #9 stated they have a severe case of [MEDICAL CONDITION], and their legs need to be wrapped with ACE bandages. They stated the nurses wrapped their legs when they get situated in the morning, and they come off in the evening. During an interview on 02/14/2025 at 11:29 AM, Licensed Practical Nurse #4 stated ACE bandages were applied to Resident #9's bilateral lower extremities after they were cleaned up in the morning and they were removed at night. Licensed Practical Nurse #4 stated they did not know if it was care planned for Resident #9's legs to be wrapped. During an interview on 02/14/2025 at 11:30 AM, Registered Nurse #2 Charge Nurse stated ACE bandages were applied to Resident #9's bilateral lower extremities in the morning and they were removed at night due to [MEDICAL CONDITION]. The Licensed Practical Nurse was responsible for wrapping the legs in the morning and removing the wraps in the evening. Registered Nurse #2 Charge Nurse stated the use of these wraps should be care planned because Resident #9 has [MEDICAL CONDITION]. They checked Resident #9's care plan for [MEDICAL CONDITION] and skin breakdown and said the intervention for wrapping Resident #9's legs should be on one of those two care plans, but it was not on either of those care plans. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated if a resident had their legs wrapped due to [MEDICAL CONDITION], this intervention should be indicated on their care plan. They would expect to see it on their [MEDICAL CONDITION] care plan for Resident #9 and Director of Nursing #1 acknowledged this intervention was not on Resident #9's [MEDICAL CONDITION] care plan. Resident #19 Resident # 19 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated dated ,[DATE], documented resident was cognitively intact, could be understood, and understand others. The Comprehensive Care Plan dated 12/2024, for Resident #19 did not include a plan for vision and or glasses. During an interview on 2/11/2025 at 11:24 AM, Resident #19 stated they had difficulty with vision. They did not wear their glasses anymore because the glasses really do not help. The glasses were really old, and they had been asking to see the eye doctor, but no appointment had been made. Ophthalmology consult dated 7/27/2020 documented [DIAGNOSES REDACTED]. Recommended follow up in three months. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated resident was seen by ophthalmology in 2020, which was prior to their admission to the facility . They stated Resident #19 had not been seen by ophthalmology since admission. Residents were seen by specialist as needed, but generally once per year. They stated it was the responsibility of the unit manager to coordinate follow up specialist visits. During an interview on 02/14/2025 at 12:47 PM, Registered Nurse #1 stated Resident #19's Comprehensive Care Plan did not include vision and/or glasses. They were not aware resident wore glasses and would update the care plan. 10 New York Code of Rules and Regulations 415.11(c)(1) | Plan of Correction: ApprovedApril 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Resident #3- Identified and implemented a care plan for Falls was identified and implemented. Interventions have been initiated to reflect current approaches in plan to ensure safety. Resident #9- Reviewed and updated care plan for [MEDICAL CONDITION]. Interventions have been added to care plan to reflect approaches currently in place to ensure patient centered care and current needs. Resident #19- Identified and implemented a care plan for Vision. Interventions have been added to reflect current needs. Identification of other residents and corrective action Every resident has potential to be affected by this deficient practice. All care plans for each resident will be audited for accuracy, correct those needed and to ensure all needs are addressed. Measures and Systemic Changes The Interdisciplinary Care Plan Committee Policy was reviewed and updated appropriately. Education will be provided to staff regarding the changes in policy and for the process of completion of the care plan for each resident to ensure the care plan is person centered for each individual. Monitoring All care plans will be audited weekly following the care plan meeting schedule. All care plans will be reviewed at least once within in a 90 day period. This will be audited weekly for 3 months consecutively. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing by 3/31/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in 2 of 2 resident unit nutrition areas and the main kitchen. Specifically, the area of the main kitchen and resident kitchenettes were not clean. This is evidenced by: During the initial inspection in the main kitchen on 2/10/2025 at 11:05 AM, the following observations were made: ?? The manual can open had a build-up of debris in the cutting area of the device ?? The mixer had dirt and debris on and under the device. ?? Dust and dirt were on top of two fire extinguishers in the main kitchen. During an inspection of the East nutrition area on 2/12/2025 at 12:48 PM, the following observations were made: ?? Temperature logs for the refrigerator and freezer for (MONTH) 6, 8, 9, 10, and 12/2025 were missing. ?? There was dirt and grime on the top of the refrigerator/freezer unit. ?? There was dirt, grime, and food particles on the freezer bottom and shelves. ?? There was dirt, grime, and food particles on the refrigerator bottom and shelves. ?? There was dirt and grime on the seals of the refrigerator and freezer. ?? There was dirt, grime, and food particles within the microwave. ?? There was dirt, grime, and food particles built up on the drawers under the microwave. During an inspection of the East nutrition area on 2/12/2025 at 12:58 PM, the following observations were made: ?? Temperature logs for the refrigerator and freezer for (MONTH) 9, 10, and 12 were missing. ?? Dirt and grime on the top of the refrigerator/freezer unit. ?? Dirt, grime, and food particles on the freezer bottom and shelves. ?? Dirt, grime, and food particles on the refrigerator bottom and shelves. ?? Dirt and grime on the seals of the refrigerator and freezer. ?? Dirt, grime, and food particles within the microwave. ?? Dirt, grime, and food particles built up on the drawers under the microwave. During the follow-up inspection in the main kitchen on 2/13/2025 at 11:45 PM the following observations were made: ?? The walk-in refrigerator had a large pool of free-standing water on the floor. ?? The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. ?? The rolling toaster contained a large amount of debris under and behind the apparatus. ?? Dirt and grime on the shelving unit above the grill cooking area. ?? Final rinse pressure on the dishwasher was 13 pounds per square inch. The signage on the device had a recommendation of 20 pounds per square inch. During an interview on 2/13/2025 at 12:22 PM, Director of Food Services #1 stated that their staff were responsible for the cleaning of the equipment being used in the kitchen. They stated they would need to be more diligent in cleaning the equipment and kitchen areas. They stated that they were made aware of the water in the cooler this morning and engineering was working on a potential leak but unsure of what they found or the progress that had been made with it. They stated that the individual who was washing the pots, pans, and containers did not let them dry fully and put them away too soon as it took several hours to fully dry. They stated that they would have to educate the individuals washing the pans on the proper time for drying. Food Service Director #1 stated that the main dishwasher was out of service on Tuesday 2/11/2025 due to a malfunction. The Administrator was made aware, and the service company was called immediately to repair the machine. It was found that a sensor wire corroded away causing the malfunction. Food Service Director #1 stated that they had the service individuals look at the gauges for the dishwashing machine and it was found that the water pressure gauge was not working appropriately and had a faulty sensor. They stated that the service company ordered a new part and would be back to fix it as soon as the part came in. The service individual stated that the recommended pressure on the system was 20 pounds per square inch plus or minus 5 pounds. In observing the rinse pressure of the machine, Food Service Director #1 stated that the final rinse pressure was below the recommended amount. Food Service director #1 stated that the Environmental Services was responsible for the cleanliness of the nutrition areas, but the temperature logs were the responsibility of the dining ambassador. When asked about the missing dates of the temperature logs, Food Service Director #1 stated that people were not doing their jobs, and they would make sure they were completed daily. During an interview on 2/14/2025 at 11:45 AM, Environmental Services Director #1 stated that their staff were responsible for the overall cleaning in the nutrition areas. They stated that the cleanliness of the areas had been lacking. They stated that they were in the process of developing a duty list of responsibilities the environmental service individuals were to complete daily. In showing the areas of concern, Environmental Service Director #1 stated that the areas should have been cleaned and that was the reason they wanted to develop the lists. 10 New York Codes, Rules, and Regulations 415.14(h) | Plan of Correction: ApprovedApril 25, 2025 Corrective Action for those identified: Manual can opener was found to have build-up of debris in the cutting area of the device. Mixer had dirt and debris on and under the device. Dust and dirt were on top of two fire extinguishers in the main kitchen. All three of these items were addressed immediately and cleaned during/after the initial walk through. Staff were reminded during a daily kitchen huddle on (MONTH) 6th that the areas need to be cleaned daily. East Nutrition Area Temperature logs for the refrigerator/freezer in the East Nutrition area were missing dates from (MONTH) 6,8,9,10 and 12, 2025. Dirt and Grime was found on top of refrigerator/freezer unit Dirt, grime and food particles on the freezer bottom and shelves/ Dirt, grime and food particles on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer There was dirt grim and food particles withing the microwave. There was dirt grime and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. West Nutrition Area Temperature logs for the refrigerator and freezer were found to be missing dates for (MONTH) 9,10, and 12 2025 Dirt and Grime was found on top of refrigerator/freezer unit Dirt, grime and food particles on the freezer bottom and shelves/ Dirt, grime and food particles on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer There was dirt grim and food particles within the microwave. There was dirt grime and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. Walk-in freezer was found to have a large puddle of free-standing water on the floor. Eastern Refrigeration was called to come address the puddle. A small water leak was found around the walk in cooler and fixed. The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. Shortly after inspection all pots and pans were pulled and inspected to ensure there was no wet nesting. The staff members responsible for cleaning and putting away dishes were reminded that all pots, pans, and containers need to be fully dried and contain no moisture before they are put away. The rolling toaster contained a large amount of debris under and behind the apparatus. Rolling toaster was moved and counter was thoroughly cleaned. Issue was addressed with staff at a daily kitchen staff huddle on (MONTH) 6th 2025. Responsible staff were reminded that this area needs to be cleaned after each use. Dirt and grime on the shelving unit above the grill cooking area. Shelving unit was wiped down and properly cleaned shortly after inspection. Discussion with the cooks took place on (MONTH) 6th 2025 at daily staff huddle reminding the responsible staff members that the kitchen shelving unit needs to be cleaned each day. Final rinse pressure on the dishwasher was 13psi. The signage on the device had a recommendation of 20psi (+ or ?Çô 5psi). At the time of inspection management was aware that the psi was not correct and a call had been made to Action Service our repair company.(NAME) the Tech from Action Service had come out and determined the machine was functioning as it should but there was a problem with the PSI Gauge and sensor. The part was immediately ordered and replaced/fixed on Tuesday (MONTH) 4th Identification of other residents and corrective action All above listed items will be audited at a frequency of twice per week. Nutrition Management team already conducts a monthly food safety/sanitation audit. The audit frequency will change from monthly to twice per week for a period of 3 months or 90 days. Measures and Systemic Changes Education and In-Servicing will take place with Nutritional Services staff to ensure compliance. Twice a week audits of the kitchen cleanliness to meet standards will be tracked and reviewed at monthly Quality Assurance Performance Improvement meetings measuring compliance of deficient items. Monitoring Twice a week audits will be tracked and reviewed at monthly quality meetings measuring compliance of deficient items. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Manager of Nutrition Services, by 3/31/25 |
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 a recertification and abbreviated survey (Case #sNY 587 and NY 779), the facility did not ensure that residents were free from neglect for 2 (Resident #s 10 and 19) of 25 residents reviewed. Specifically, (a.) Resident #10 was not monitored, turned and positioned or received personal care for at least one full shift on 11:00 PM-7:00 AM, 1/29/2025 - 1/30/2025; (b.) Resident #19 rolled out of bed and hit their head on furniture when receiving care by a Certified Nurse Aide on 1/21/2024 at 10:35 AM. This is evidenced by: The Facility's Policy and Procedure titled, Resident Abuse revised 8/2024, documented the facility would investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment or injuries of unknown origin. Of those cases that the facility found reasonable cause and/or evidence that a resident has been abused, corrective action would take place with those involved: In the case of an employee involvement - the corrective action procedure would be initiated by the employee's immediate supervisor and may result in suspension and/or discharge without prior warning. The term neglect meant failure to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident, while under the supervision of the facility, including, but not limited to: nutrition, medication, therapies, sanitary clothing and surroundings, and activities of daily living. (NY Public Health Law 2803-d). Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (See Older Americans Act, 302 (a) (19)). It may include, but not be limited to, being left to sit or lie in urine or feces, isolating dependent residents by leaving them in their rooms or other isolated locations apart from temporary monitored separation occurring in the context of assessment and care planning, or failing to answer call bells to provide assistance. Resident #10: Resident #10 was admitted with a [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/15/2024, documented the resident could understand and be understood by others. The facility's Investigative Report dated 1/30/2025, documented an aide told Registered Nurse #1 at 7:00 AM on 1/30/2025 that Resident #10 was soaked and there was no way they had been cared for. Two other staff were in the room and changing resident. Resident also had a bowel movement. Investigation revealed that the resident did not receive care by staff on the previous night shift (1/29/2025-1/30/2025). There was no injury related to this incident; however, staff should have recognized that the resident was not attended to. During an interview on 02/13/2025 at 11:11 AM, Registered Nurse #1 stated a Certified Nurse Aide reported to her that Resident #10 had no care during overnight shift. Registered Nurse #1 in turn reported the incident to Director of Nursing #1. Registered Nurse #1 stated they believed it was a miscommunication. Resident #10 was a no male caregiver. The Certified Nurse aide assigned to that hall was a male, Certified Nurse Aide #4. Certified Nurse Aide #3 was fairly new at time of incident, and it was not communicated to them that they were assigned to a resident on the opposites side of the unit. Both Certified Nurse Aides #3 and 4 were educated on the no male caregiver system, which was a pink dot on door of resident to indicate no male caregiver. In addition, Certified Nurse Aide #4 was counseled on documentation. Certified Nurse Aide #4 documented care was provided to Resident #10 on 1/29/2025 through 1/30/2025, when in fact they admitted they did not provide any care to this resident. During an interview on 02/13/2025 at 12:52 PM, Director of Nursing #1 stated the incident was a result of miscommunication. They stated Certified Nurse Aide #s 3 and 4 were 'very good aides,' and the assignment for Resident #10 should have been updated on the assignment sheet. They stated that Registered Nurse #3 wrote out the assignment prior to end of their shift, and at change of shift, Registered Nurse #4 was given a report. Director of Nursing #1 stated they educated both Registered Nurse #s 3 and 4 on the responsibility of making out assignments and in communication. Resident #19: Resident # 19 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was cognitively intact, could be understood and understand others. The Mobility Comprehensive Care Plan dated 1/2024, documented plan of care, Toileting Hygiene, Shower/Bathe, Self-Upper Body Dressing, Lower Body Dressing, Putting On/Taking Off Footwear, Personal Hygiene all Dependent Substantial/Maximal Assistance. Adaptive Equipment used: Mechanical Lift, Geriatric chair. The facility Investigate Report dated 01/21/2024 documented Resident #19 was receiving care (in bed with a soft mattress pad called an overlay). Resident was rolled to their left side and when they moved, the overlay moved causing them to slide to the floor. Resident assessment noted bump on eyebrow/forehead on Right side. Neurological checks completed as per protocol with changes noted. Resident was sent to the emergency department at 11:15 AM. A Computed Tomography Scan (CT) (imaging of the brain) was negative, and resident returned to facility. On 01/22/2024, Resident #19 complained of Left arm and shoulder pain. X-rays were ordered which revealed osteopenia/[MEDICAL CONDITION], and no fracture. The facility Investigative Summary documented Certified Nurse Aide #5 acknowledged that they should have had 2 for turning this resident. Attempts to reach Certified Nurse Aide #5 by phone were unsuccessful. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated Certified Nurse Aide #5 did not state why they did not use a second person when caring for Resident #19. Stated Certified Nurse Aide #5 was no longer employed at the facility, the overly went on top of the mattress, with four ends that tucked underneath the mattress. Director of Nursing #1 further stated that particular type of overlay was no longer in use at the facility following this incident. During an interview on 02/18/2025 at 12:09 PM, Administrator #1 stated they removed the overlay from Resident #19's bed. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i) | Plan of Correction: ApprovedApril 21, 2025 Corrective Action for those identified: For Resident #10, the aide involved was counseled. Care was provided immediately upon discovery. For resident #19, the aide involved was counseled. The resident was transferred to the hospital for evaluation and treatment. Upon return, the care plan was adjusted and the overlay mattress removed from service. Identification of other residents and corrective action All residents requiring assistance are at risk for the deficient practice. Care audits completed by 3/31/25 to ensure care is compliant with policy and completed as per the care plan. Any deviation resulted in counseling of staff and review of the plan of care. Measures and Systemic Changes The abuse policy was reviewed with no changes. Education on the Abuse policy and elements of neglect, specifically related to failure to follow a care plan will be conducted by 3/31/25. The nursing staff were educated, led by the Administrator. Monitoring Random audits of care, to include verification of following the plan of care, will be completed on all shifts weekly x4, then monthly x 3 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Administrator by 3/31/25. |
Scope: Pattern
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, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 2 (Resident #s 4 and 38) of 16 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 8%. This is evidenced by: The facility's policy and procedure titled Medication Administration last revised ,[DATE] documented, all Registered Nurses and Licensed Practical Nurses must have successfully passed the written medication exam and the medication administration competency to administer medications as outlined below. Registered Nurses and Licensed Practical Nurses have the responsibility to administer medications in accordance with this policy and any other relevant education and/or certification. Right Documentation - Administration is recorded in the electronic Medication Administration Record. If medication is held or refused or not given on time, a reason for such is recorded in the electronic Medication Administration Record. If there are any signs of adverse reaction or change in resident's medical condition, there is documentation in the electronic Medication Administration Record. Check expiration date prior to administration. Verify that the medication selected is stable based on visual inspection for particulates or discoloration and that the medication has not expired. Do not administer single dose vial if seal has been broken. Check expiration date prior to administration. The Registered Nurses or Licensed Practical Nurses would make an evaluation, prior to administering any medication, of the resident's physical condition, lab values, and vital signs as indicated. Any contraindication to administering the medication would be discussed with the physician. Refused/Omitted/ Missed Dose: a. When medication is refused or omitted, select reason in electronic Medication Administration Record, [REDACTED]. State reason for refusal/omission, any communication to physician and action taken in a Clinical Note. A Registered Nurse Supervisor and provider must be notified when a medication was not available. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they have the decision-making capacity to do so safely. Resident #4: Resident # 4 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated [DATE], documented resident had moderate cognitive impairment, could be understood, and understand others. Resident #4's current physician orders [REDACTED]. At 11:17 AM, Resident #4 had a documented blood glucose fingerstick of 347 Milligrams per deciliter. At 12:40 PM, Licensed Practical Nurse #2 administered 10 units of [MEDICATION NAME]based on the sliding insulin scale. Resident #4 had already consumed their lunch at approximately 12:10 PM. During an interview at 12:40 PM, Licensed Practical Nurse #2 stated insulin was ordered to be given before meals and should be given immediately after finger stick had been recorded. They stated it was wound rounds that day and they did not get to give the insulin until 12:40 PM. Licensed Practical Nurse #2 stated they should have prioritized and given the insulin first before passing other resident medications. Licensed Practical Nurse #2 did not obtain another blood glucose fingerstick, and did not report the late medication administration to a Registered Nurse and or physician. During an interview on [DATE] at 02:52 PM, Assistant Director of Nursing #1 stated insulin coverage should be given before meals per physician order. They stated insulin should be given as soon as possible after the blood glucose fingerstick. One hour and 20 minutes was considered an extended time between taking fingerstick and giving insulin coverage. In this case, a repeat fingerstick should have been taken and the physician should have been notified. Resident #38: Resident #38 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated ,[DATE], documented resident had moderate cognitive impairment, could be understood, and understand others. Resident #38's Medication Administration Record [REDACTED]. Nebulized two times daily at 07:30 and 16:30. Administered [DATE] at 07:17 signed by Licensed Practical Nurse #1. During an observation on [DATE] at 11:43 AM, Resident #38 was noted receiving a nebulizer treatment. During an interview on [DATE] at 11:45 AM, Resident #38 stated the medication in nebulizer was left at their bedside that morning [DATE] by Licensed Practical Nurse #1. They stated staff always left the medication at the bedside, and they took it when they were ready. Licensed Practical Nurse#2 stated, resident had the nebulizer applied and turned off nebulizer themselves when done. If the medication was not completed, the resident would restart the nebulizer when ready. Licensed Practical Nurse #2 stated, although the nebulizer was placed that morning by Licensed Practical Nurse #1, they would have done the same thing. During an interview on [DATE] at 11:50 AM, Licensed Practical Nurse #1 stated they signed for Resident #38's nebulizer treatment at 07:30 AM indicating it was administered. They stated they did not go back into resident's room to ensure medication was consumed and or to have resident rinse mouth following nebulizer treatment. During an interview on [DATE] at 12:57 PM, Director of Nursing #1 stated they had no residents at the facility who self-administered medications. They stated if resident wished to self-administer medications, they would have to be assessed for competency along with obtaining an order to self-administer medication by the physician, and a care plan would be put in place. Director of Nursing #1 stated nurses who administer medications should not leave medications at the bedside. Staff were to ensure the medication was consumed. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)) | Plan of Correction: ApprovedApril 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Resident #4 and resident #38 were assessed with [REDACTED]. Nurse #1 was counseled regarding the deficient practice on 3/12/25. Nurse #2 was counseled regarding the deficient practice on 3/12/25. Identification of other residents and corrective action All other residents are at risk for the deficient practice. Random medication administration audits will be audited twice weekly for 5 weeks for accuracy of med pass for a minimum of 3 random residents to ensure timeliness of insulin delivery and glucometer readings. Random medication administration audits will be completed twice weekly for 5 weeks for compliance with medication administration for nebulizer treatments. Disciplinary action will be pursued for non-compliance. Measures and Systemic Changes The Medication Administration Policy and the Self Administration of Medications policy were reviewed with no changes. Education of the Medication Administration policy will be completed to Licensed Practical nurses under the direction of the Assistant Director of Nursing, by 3/31/25. Auditing of medication administration as per schedule listed above. Monitoring Medication Administration will be audited twice weekly for 5 weeks for accuracy of med pass for a minimum of 3 random residents to ensure timeliness of insulin delivery and glucometer readings and for compliance with medication administration for nebulizer treatments. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing, by 3/31/25. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on observation and interviews during the recertification survey, the facility did not designate one or more individual(s) as Infection Preventionist (s) responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have a specified designated individual as their Infection Control Preventionist, and the Director of Nursing had performed a dual role since (MONTH) 10, 2023. This is evidenced by: A Review of the Policy and Procedure titled Infection Prevention and Control created in (MONTH) 1977 and revised in (MONTH) 2024 documented under Mission/Goal of the Infection Control Program: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments. Inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing. The Infection Preventionist implements corrective action plans for infection control in affected problem areas with the assistance of the Chief Executive Officer, Medical Staff, Quality Assurance Performance Improvement Committee, and Nurse Executive. A review of the Infection Preventionist documentation of sufficient training documented that the Director of Nursing #1 completed their nursing home infection prevention training course on 05/10/2023. This was the day they assumed the role of the infection preventionist. A review of key personnel from (MONTH) of 2023 documented that the designated Infection Preventionist listed for the facility was Director of Nursing #1. During the entrance interview conducted on 02/10/2025 at 10:30 AM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated that many staff members have multiple roles due to staffing issues. During an interview on 02/19/2025 at 11:15 AM, Administrator #1 stated that they were unaware that the Infection Control Preventionist was to have their own specific role and could not have a dual role with the Director of Nursing. 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c) | Plan of Correction: ApprovedMarch 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action No residents were affected by the deficient practice. Measures and Systemic Changes The Infection Control Committee policy was reviewed and revised to correctly identify the Infection Preventionist. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring An annual audit will be conducted to ensure that the IP continues to meet the requirements as set forth in F882. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction Director of Nursing by 3/31/25 |
Scope: Pattern
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, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for 1 (West Unit Team 1) of 2 medication carts reviewed. Specifically, (a.) opened medications had no open and or expiration dates (b.) open bottles of eye drops had no label identifying patient and had no open and or expiration dates. This is evidenced by: The facility's policy and procedure last revised ,[DATE] documented, Multiple-Dose Vials a. Multiple-dose vials would not be used beyond the manufacturer's expiration date. Any multi-dose vial that has been opened or punctured would have an expiration date of 28 days-label the container when opened with the date of expiration (28 days from date of opening, or manufacturer's date of expiration if that is sooner) and initials. They must be stored under manufacturer's recommended conditions and discarded if potentially contaminated. Exceptions: Exceptions include when the manufacturer's stability is less than 28 days. For example, [MEDICATION NAME] (Trademark) ([MEDICATION NAME]) vials should be dated upon initial entry. [MEDICATION NAME] expires in 96 hours under refrigeration. [MEDICATION NAME] would be issued with a fill-in-the-blank label for completion and application after the first use. Insulin vials would be dispensed as resident specific. Insulin removed from pyxis would be assigned to the resident for whom it was removed. Check expiration date prior to administration. Verify that the medication selected is stable based on visual inspection for particulates or discoloration and that the medication has not expired. Do not administer single dose vial if seal has been broken. Check expiration date prior to administration. During an observation on [DATE] at 11:34 AM, the West Unit Team 1 Medication Cart contained 1 open vial of [MEDICATION NAME] insulin, and 1 open vial of [MEDICATION NAME]both with no open and or expiration dates. The following open bottle of eye drops had no label identifying resident and had no open or expiration dates: 1 bottle each of [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME] and Alaway. During an interview on [DATE] at 11:23 AM, Licensed Practical Nurse #1 stated medication was labeled when it came from the pharmacy. The label on the eye drops fell off, but they knew which patient the eye drop belonged to. Licensed Practical Nurse #1 stated they did not write the expiration date on the bottles, the pharmacy wrote the expiration date. During an interview on [DATE] at 02:52 PM, Assistant Director of Nursing #1 stated all medications came labeled from the pharmacy. They stated the fill date was different from the open date. The nurse opening the medication should write the open and expiration dates on the medication. When labels fall off, for example on eye drops, it was the nurse's responsibility to re-apply the label or request another medication from the pharmacy. During an interview on [DATE] at 10:45 AM, Director of Nursing #1 stated upon opening a medication the nurse should label the medication with open and expiration dates. Each nurse received medication administration training upon hire. Medication administration training included checking medication expiration dates prior to administration. 10 New York Codes, Rules, and Regulations 415.18(d) | Plan of Correction: ApprovedApril 25, 2025 Corrective Action for those identified: Immediate inspection of the West Unit Team 1 medication cart was performed and any medications found without label or date were appropriately disposed of and new ones were supplied by pharmacy and appropriately stored, labeled and dated per policy. Identification of other residents and corrective action All residents are at risk for this deficient practice. All medication cart drawers were checked and any medications found without label or dated will be appropriately discarded and new ones will be supplied by pharmacy that are appropriately stored, labeled and dated per policy. Measures and Systemic Changes Medication Administration Policy reviewed with no changes. All nurses educated on policy regarding proper labeling and storage of medication on hire and at least annually. Monitoring Auditing of medication carts and medication labeling will be done twice a week for one month, then weekly for one month, then biweekly for one month. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction 3/31/25 Assistant 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 record review and interviews conducted during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital for 1 (Residents #12) of 1 resident reviewed for notice of bed hold policy before/upon transfer. Specifically, for Resident #12 a written notice of the facility's bed hold policy was not provided to the resident and/or their representative upon transfer to the hospital on [DATE]. This is evidenced by: The policy titled Admission, Discharge and Transfer effective 10/24/2022, last revised 03/2024 documented facilities must develop and implement policies for bed-hold and permitting residents to return following hospitalization or therapeutic leave. When residents were sent emergently to an acute care setting, these scenarios were considered facility-initiated transfers, -not discharges, because the resident's return was generally expected. For facility-initiated transfers or discharge of a resident, prior to the transfer or discharge, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/19/22 documented Resident #12 had severe cognitive impairment. It further documented Resident #12 made decisions regarding tasks of daily life. Physician order [REDACTED].#12 was to be transferred Emergency Department due to a fall and possible fracture. There was no documented evidence that a written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative upon transfer to the hospital on [DATE]. During an interview on 02/14/2025 at 10:57 AM and 12:50 PM, Director of Nursing #1 stated nursing, social work, and the business office were all responsible for making sure the bed hold policy notification was completed. When a resident was transferred to the hospital, the notice of discharge was completed which included the bed hold policy notification. Director of Nursing #1 acknowledged the notice of discharge had not been done consistently and they were working on putting together a better plan to make sure it was completed. 10 New York Codes Rules Regulations 415.3(h)(4)(iii)(a) | Plan of Correction: ApprovedApril 21, 2025 Corrective Action for those identified: A late notice was provided to Resident #12 along with a letter explaining the facility failed to provide this upon transfer to the Hospital, provided on 3/7/25. Identification of other residents and corrective action All residents have potential to be affected by this deficient practice. Daily auditing is being completed to ensure notice has been provided to the resident or designated representative upon transfer/discharge. If this is not completed upon transfer/discharge, a notice is then completed along with a letter informing resident/designated representative that the facility failed to provide upon transfer/discharge. Measures and Systemic Changes Admission, Discharge and Transfer Policy has been reviewed and amended to include that registered nurse staff are to provide the notice at time of discharge or transfer, providing paper copies of The Notice of Transfer/Discharge to residents/designated representatives upon transfer to the hospital. The Notice of Transfer/Discharge has been added to the transfer packet that is utilized by nursing when a resident is being transferred to the hospital. All registered nursing staff will be educated on these changes and the updated policy. Monitoring An audit of Notice of Transfer/Discharge compliance is being completed daily x 2 weeks, then weekly x 4 weeks, then monthly x4 months. This audit will review timeliness of notice to resident/representative and provision of the notice to Social Work for recording. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on record reviews, and interviews conducted during a recertification survey, the facility did not ensure that Quality Assessment and Assurance Committee consisted at a minimum of the Director of Nursing, Medical Director or designee, Administrator, and Infection Preventionist. The failure to meet to coordinate and evaluate the need for performance improvement projects had the potential to affect all residents of the facility. Specially, Director of Nursing was also the Infection Preventionist. This is evidenced by: A review of the facility's undated Quality Assurance and Performance Improvement Plan, revealed that the Quality Assurance and Performance Improvement Plan provides leadership through its committee. The Quality Assurance and Performance Improvement committee shall be comprised of the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Registered Nurse Manager, Registered Nurse Supervisors, Chief Executive Officer, Vice President of Operation, and other ancillary department heads. The Administrator is the chairperson of the Quality Assurance and Performance Improvement committee and is responsible for ensuring that Quality Assurance and Performance Improvement are implemented throughout the facility. The Quality Assurance and Performance Improvement Committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. The overall responsibility of the steering committee is to develop and modify the Quality Assurance and Performance Improvement, identify teams who will problem solve as well as set priorities for the Performance Improvement Projects. A Review of the Policy and Procedure titled Infection Prevention and Control created in (MONTH) 1977 and revised in (MONTH) 2024 documented under Mission/Goal of the Infection Control Program: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments: and, inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing Services. During the entrance interview conducted on 02/10/2025 at 10:30 AM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated that many staff members have multiple roles due to staffing issues. During an interview on 2/19/2025 at 11:15 AM, Administrator #1 stated that they held meetings every month and it was the responsibility of the staff to sign in for the meetings. They stated they were unaware that the Infection Control Preventionist was their own role and could not be a dual role with the Director of Nursing. 10 New York Code of Rules and Regulations 415.27(b)(3) | Plan of Correction: ApprovedMarch 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action No residents were affected by the deficient practice. Measures and Systemic Changes The QAPI policy was reviewed with no changes. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring Audits of QAPI attendance will be completed to ensure the IP is present. This will be completed x 90 days. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction Administrator by 3/31/25 |
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 a recertification and abbreviated survey (Case #sNY 587 and NY 779), the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident # 62) of 25 residents reviewed. Specifically, Resident #62 sustained a fall; 3 Certified Nurse Aides assisted resident from the floor and did not notify a nurse or report the incident, and no assessment or interventions were put into place after the fall and prior to discharge. This is evidenced by: Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/2024, documented resident had mild cognitive impairment, could be understood, and understand others. The facility Investigate Report dated 01/10/2025 documented Resident #62 reported they fell on [DATE] prior to discharge to home on 01/02/2025. It was not report, however staff responded. During an interview on 02/18/2025 at 02:56 PM, Director of Nursing #1 stated the family of Resident #62 called Social Worker #1 on 01/06/2025 and notified them that resident had a fall prior to discharge. Director of Nursing #1 stated they were unaware of fall and at that time they initiated an investigation. They watched the video footage and identified staff who were involved that included Certified Nurse Aides #6, 7, 8 and 9, and Licensed Practical Nurse #3. Certified Nurse Aide #8 lead the other Certified Nurse Aides during the incident. Certified Nurse Aide #6 was seen entering room then left after noting other staff were in the room. They stated they obtained statements from staff involved. The video revealed Certified Nurse Aides #7, 8 and 9 entering into Resident #62's room, and Resident #62 was on floor leaning against the door frame. They placed gait belt around resident and got them up into wheelchair at the direction of Certified Nurse Aide #8. Certified Nurse Aide #8 then informed Licensed Practical Nurse #3 that Resident #62 was short of breath, but did not report resident had been on the floor. Director of Nursing #1 stated Certified Nurse Aide #8 received a final written warning and was still employed at the facility. All staff involved received education and counseling on reporting. Random care audits were now conducted. During an interview on 02/18/2025 at 03:20 PM, Certified Nurse Aide #9 stated they were walking by and heard Resident #62 yelling for help. They went into the room along with two other Certified Nurse Aides #7 and 8. Resident was on the floor sitting on buttocks resting on hands, in the doorway. Certified Nurse Aide #8 told them to get resident up from floor and put them in the wheelchair. Certified Nurse Aid #9 stayed in the room a few minutes with resident and assumed that someone had reported the incident. After they got resident up from the floor resident was a little short of breath, but there was no pain or any signs of bruising. Certified Nurse Aide #9 stated this was their first Certified Nurse Aide job. They were told during orientation that if a resident falls or was found on the floor that it should be reported to a nurse. They were not to move resident until a nurse came to assess resident. They were following the direction of Certified Nurse Aid #8 because they were more experienced aide. During an interview on 02/18/2025 at 03:33 PM, Licensed Practical Nurse #3 stated Certified Nurse #8 reported Resident #62 was short of breath, but never mentioned resident was found on the floor. They stated Resident #62 had a history of [REDACTED].#62 was sitting in wheelchair, but also did not mention they had fallen. Resident #62 was anxious to go home and had been for several days. They attributed the shortness of breath to be related to patient's anxiety, which they had in the past. They noted resident respirations to be 20 and administered nebulizer treatment as orders. They stated resident had good affect and was discharged the following morning. Licensed Practical Nurse #3 stated if they had known resident was found on the floor, they would have notified the Registered Nurse Supervisor. During an interview on 02/18/2025 at 03:42 PM, Social Worker #1 stated they placed a follow up call per protocol to resident who had been discharged on [DATE]. It was at that time Resident #62's wife informed them that resident was in the hospital and that they had a fall the day before discharge. Resident #62 was discharged to home with home care services. The home nurse visited resident, resident had persistent shortness of breath and home care nurse sent resident to the emergency room where resident was admitted . Resident had since been discharged back to home and was in stable condition. Social Worker #1 notified Director of Nursing of the call and reported fall incident. During an interview on 02/18/2025 at 03:58 PM, Certified Nurse Aide #8 stated they heard the sound of a fall and went into Resident #62's room and found them on the floor leaning against the bathroom door. They stated resident had history of shortness of breath and was not wearing their oxygen. They stated because patient had noted shortness of breath, they immediately got resident off the floor so that they could place their oxygen back on. Certified Nurse Aide #8 stated they thought one of the other aides notified supervisor and they did notify Licensed Practical Nurse #3 that resident was short of breath. They were not aware they could initiate the incident and accident report. Certified Nurse Aide #8 stated they were aware that when a resident was found on the floor, they are to call nurse to assess resident. They stated they were just worried about resident's shortness of breath and getting oxygen placed, so they got resident off floor as soon as possible. They acknowledge they should have called for nurse and took full responsibility. 10 New York Codes, Rules, and Regulations 415.12 | Plan of Correction: ApprovedApril 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Resident #62 was discharged on [DATE], prior to the facility becoming aware of the fall. Staff disciplined upon discovery of incident. Identification of other residents and corrective action All residents are at risk for the deficient practice. A review of all Incident & Accident reports will be completed by 3/31/25 to ensure staff follow the policy in relation to fall response protocols. Any deviation from policy standards will result in counseling of staff per protocol. At the time of the incident discovery and follow up reporting, the education of involved staff and discipline of involved staff was completed. Measures and Systemic Changes The Fall Prevention and Response policy was reviewed with no changes. Education of nursing staff regarding responding to a fall and policy will be completed by 3/31. Monitoring Audits of incident reports will be conducted daily x 4 weeks and then weekly x 3 months. Daily staff huddles with unit leaders will be completed and will include review of any falls to ensure all information is reviewed and that all staff are reminded of their duty to report falls. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing by 3/31/25. |
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 a recertification and abbreviated survey (Case #NY 103) , the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency for 1 (Resident #7) of 1 resident reviewed for reportable incident. Specifically, an injury of unknown origin was discovered for Resident #7 on 01/23/2025. This injury of unknown origin was not reported until 01/25/2025 at 10:51 AM. This was evidenced by: The Policy titled Resident Abuse effective 10/24/2022 last reviewed 09/2023 documented resident abuse and/or misappropriation of resident property should not be tolerated by the facility. The facility shall investigate all cases of suspected resident abuse, including allegations of neglect, misappropriation, mistreatment, or injuries of unknown origin. Each covered individual (anyone who is an owner, operator, employee, manager, agent, or contractor of the facility) shall report immediately, but not later than two hours after forming the suspicion, if the events that cause suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. In addition, the facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. In addition, employees are required to immediately report any resident incident, including all suspected cases of resident abuse, mistreatment or neglect including injuries of unknown source and misappropriation of resident property to their supervisor, department head, and/or administrator. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 04/03/2024 documented Resident #7 had severe cognitive impairment, could be understood, and understand others. Skin check work list for Resident #7 dated 01/23/2025 completed by Licensed Practical Nurse #3 documented there was a purple/blue area on the right foot. Nursing home facility incident report submitted to the Department of Health on 01/25/2025 at 10:51 AM by Director of Nursing #1 with incident date of 01/25/2025 and the time of occurrence as 8:56 AM indicated that a Certified Nurse Aide noted during morning (AM) care that Resident #7 had a discolored purplish -blue area on the 4th and 5th toe on the top side of the right foot. An investigation was in progress. No non-residents were accused of abuse, mistreatment, neglect, or misappropriation. There were no witnesses to this incident. Progress note dated 01/25/2025 by Provider #1 indicated Resident #7 was seen due to right foot swelling and discoloration. The resident was not able to recall when they noticed swelling in their foot and could not recall an injury or something that could have occurred to cause the swelling. Assessment included an x-ray to rule out fracture. It was unclear if Resident #7 had an injury as there were no reports of any falls or trauma at that time. Accident and incident form completed on 01/25/2025 stated at incident time of 8:45 AM during AM care, Resident was noted to have an [MEDICAL CONDITION] right foot. Top of the right foot was discolored, and the 4th inner toe and little toe were purple in color. Provider #1 was notified on 01/25/2025 at 10:45 AM and an x-ray of the right foot was ordered. This form indicated this was a reportable incident of quality of care due to an injury of unknown origin. emergency room History and Physical stated Resident #7 was treated in the emergency roiagnom on [DATE] at 3:46 PM for further treatment of [REDACTED]. Resident #7 developed bruising and swelling to right foot which prompted imaging. Resident #7 sustained an impact [MEDICAL CONDITION] and 5th metatarsal (five long bones in the midfoot that connect the ankle to the toes). Follow up undated investigation report completed by Administrator #1 and Director of Nursing #1 documented Resident #7's 4th and 5th toe on the right foot were discolored and [MEDICAL CONDITION] and were x-rayed on 01/25/2025. Impression was severe osteopenia (loss of bone density). Resident #7 sustained a displaced slightly impacted [MEDICAL CONDITION] and 5th metatarsal necks. Resident #7 had moderate [MEDICAL CONDITION] (a [MEDICAL CONDITION] joint disease in which the tissues in the joint break down over time). Provider #1 stated on 1/26/2025 that Resident #7 had fairly significant osteopenia, and the fracture was likely due to minimal impact against the geri chair/bed and Resident #7 continued to be at risk for these kinds of fractures from minimal impact on turning and when sleeping. The report documented it could not be determined how the injury occurred. It was determined that this area was initially found on 01/23/2025 by Licensed Practical Nurse #3 during a routine skin check but Licensed Practical Nurse #3 failed to report the discovery to a Registered Nurse for further assessment. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated they were on call on 01/25/2025 when Resident #7's foot was noted to be purple in color by the 4th and 5th toe. They reported the incident to the Department of Health on 01/25/2025 within 2 hours of them being notified as it was an incident with unknown source and they started the investigative process. Director of Nursing #1 stated Licensed Practical Nurse #3 should have immediately notified a Registered Nurse after completing the skin check work list on 01/23/2025 so the Registered Nurse could have completed an assessment of Resident #7 and determined what to do. Director of Nursing #1 stated this incident should have been reported to the Department of Health two days earlier when it was discovered on 01/23/2025. 10 New York Codes, Rules, and Regulations 483.12 (c) (1) | Plan of Correction: ApprovedApril 18, 2025 Corrective Action for those identified: Resident #7 was assessed upon discovery of the injury. Resident was transferred to the emergency room for evaluation and treatment. An investigation was conducted upon discovery. Identification of other residents and corrective action All residents are at risk for the deficient practice. Audits of skin check worksheets will be reviewed at Interdisciplinary rounds daily and any findings will be addressed immediately. All residents receive a weekly skin check on shower dates, reviewed on the day of or following day. Any findings will be addressed by the Administrator or Director of Nursing to determine if their are reportable elements and then will be reported based upon those findings. The staff involved in the skin check will be counseled if required. Measures and Systemic Changes The Resident Abuse policy was reviewed with no changes. A review of incident report interventions daily at daily rounds will be conducted to evaluate for timely identification and reporting of injuries of unknown origin. Additionally. all injuries of unknown origin are to be immediately reported to the administrator or designee for review for reportability. Monitoring Skin Check audits to be completed weekly x4 weeks and then monthly x2 months to evaluate for timely identification and reporting of injuries of unknown origin. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing by 3/31/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents were observed to be fed by staff wearing gloves in the west dining room and by the east nurses station. This is evidenced by: Policy titled Quality of Life- Dignity effective 05/2020 last reviewed 05/2024 documented each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Interpretation and implementation of this policy included residents should be treated with dignity and respect at all times. Treated with dignity meant the residents would be assisted in maintaining and enhancing their self-esteem and self-worth. During an observation on 02/10/2025 at 12:10 PM in the West dining room, staff wore gloves while feeding residents. During an observation on 02/12/2025 at 12:33 PM in the West dining room, staff wore gloves while feeding residents. During an observation on 02/13/2025 at 12:05 PM in the West dining room, staff wore gloves while feeding residents. During an observation on 02/14/2025 at 12:28 PM in the West dining room, staff wore gloves while feeding residents. During an observation on 02/18/2025 at 12:25 PM in the hall by the East Nurses station, a staff member wore gloves while feeding a resident. During an observation and interview on 02/14/2025, Certified Nurse Aide #1 was feeding a resident in their room and they were not wearing gloves. Certified Nursing Aide #1 stated they do not wear gloves when feeding residents because it was a dignity issue. During an interview on 02/14/2025 at 12:33 PM, Certified Nurse Aide # 2 stated they wore gloves when feeding residents to prevent the spread of germs. They stated they did not think it was a dignity concern, but they did not know how the residents felt about it. During an interview on 02/14/2025 at 12:28 PM, Licensed Practical Nurse #1 stated when they feed residents, they wear gloves to prevent their germs from spreading to the resident. It is a part of facility procedure to wear gloves when feeding residents. Licensed Practical Nurse # 3 stated they did not feel there was a dignity concern to feed residents while wearing gloves. During an interview on 02/14/2025 at 12:50 PM, Director of Nursing #1 stated if a resident needed total assist with feeding, staff should wear gloves. Director of Nursing #1 could not find in a facility policy where it stated staff should wear gloves when feeding a resident and stated it should be written in a policy. Director of Nursing #1 stated staff wearing gloves when feeding a resident was not a dignity concern because they want to keep the residents safe. If the residents had issues relating to dignity while being fed by staff members wearing gloves, they could put it in the resident's care plan so the staff would not wear gloves when feeding the resident. During an interview on 02/18/2025 at 11:37 AM, Nurse Manager #1 stated when a staff member fed a resident, they were to wash their hands and wear gloves. They stated it could be a dignity concern as it could make the residents feel like the staff thought they were dirty, and the residents may not realize they were wearing the gloves to protect the residents. 10 New York Code, Rules and Regulations 415.11 (c)(2)(ii) | Plan of Correction: ApprovedApril 21, 2025 Corrective Action for those identified: Staff were informed to no longer wear gloves during meals, education of staff completed. Identification of other residents and corrective action All resident that are totally dependent for feeding are at risk for this deficiency. Gloves are no longer worn during meals/feeding assistance unless otherwise indicated on the care plan related to infection precautions. Measures and Systemic Changes Policy of How to Assist a Resident at Meal Time was revised 3/2025 to remove the guidance to wear gloves for residents who are totally dependent for feeding. All nursing staff and feeding assistants were educated on the policy change. Monitoring Random audits during all meals will be performed weekly for one month then every other week for two months on residents who are dependent for feeding to ensure staff is not wearing gloves. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing 3/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the recertification survey, the facility did not secure the confidentiality of information contained in Criminal History Record Check (CHRC) records. Specifically, social security numbers were included on the employee information document for criminal history checks that was not requested. This is evidenced by: The document titled, New York State Department of Health Criminal History Record Check Form 103, included the employee's social security numbers and confidential personal information that was not requested. During an interview on 02/18/2025 at 11:43 AM, New Employee Director #1 stated that they received the Department of Health Criminal History Record Check Form 103 during their onboarding process. They noted that this form included newly hired employees' social security numbers. They stated that the information obtained was secured in a locked cabinet after it was sent to the appropriate agency for authentication. They stated that they were the only individual with access to the cabinet. They stated the information obtained stayed in the locked cabinet until a determination letter was received. New Employee Director #1 stated that they realized that confidential information such as social security numbers was not to be disclosed. They stated they did not realize that providing the documents with the private information to the administrator for distribution was an issue and that sending the documentation with the social security numbers was a mistake, inadvertent, and would not be repeated. 10 New York Codes, Rules, and Regulations 402.9(a)(2) | Plan of Correction: ApprovedApril 21, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The paper document with the Social Security Number was destroyed in a secure manner. Identification of other residents and corrective action No residents were affected by the deficient practice Measures and Systemic Changes Policy adjusted to indicate any Criminal History Record Check document which is released will have the Social Security Number rendered illegible by Human Resources prior to the release. Until determination arrives, the documents will be maintained in a locked file accessible only to the assigned Human Resources staff person. Education of the responsible Human Resources staff as to the change in policy, completed on 3/6/25. Monitoring An audit to ensure there is not a recurrence of the deficient practice will be completed if any regulators request copies of Criminal History Record Check documents and we will determine whether the confidential information was rendered illegible in each release. The audit will happen at least semi-annually Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Administrator, 3/31/25 |
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, the facility did not ensure that the resident and resident representative had the right to participate in the development and implementation of their person-centered plan of care by facilitating the inclusion of the resident and resident representative in the planning process for 1 1(Resident #6) of 1 resident reviewed for care planning. Specifically, for Resident #6, their family member was not afforded the opportunity to participate in quarterly care plan meetings. This is evidenced by: Facility policy titled Interdisciplinary Care Plan Committee effective 09/1992 last revised 04/2024 stated a comprehensive care plan was developed within seven days after the completion of a comprehensive assessment by the interdisciplinary team with participation of the resident and revised with significant changes. Care plans were reviewed at the interdisciplinary care plan meeting every three months and as indicated by a significant change or change in condition. The policy also stated the resident and/or their designated representative would be encouraged to participate in the development of initial, significant changes, and annual care plan. Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 05/07/2024 indicated Resident #6 was cognitively intact, could be understood, and understand others. Resident was able to make decisions regarding tasks of daily life. Section Q of the Minimum Data Set documented that Resident #6 participated in the assessment and goal setting. Family did not participate with the assessment and goal setting. During an interview on 02/10/2025 at 3:34 PM, Family Member #1 stated they came to visit Resident #6 every day for five-six hours a day. They stated they came to one care plan meeting when Resident #6 was first admitted to the facility. They have not been made aware of or invited to quarterly care plan meetings. During an interview on 02/13/2025 at 3:49 PM, Director of Social Work #1 stated care plan meetings occur initially when a resident was admitted to the facility, quarterly, annually, and if a significant change occurred or if a family member requested a meeting. Residents and families were invited to attend the meetings initially, annually, and for significant changes. Director of Social Work stated Family Member #1 attended Resident #6's initial care plan meeting on 05/21/2024 and a follow up meeting pertaining to discharge planning on 06/10/2024. Director of Social Work #1 stated family members were not notified of quarterly care plan meetings. If the interdisciplinary team had a concern regarding the resident to discuss with a family member, they could reach out to the family member via phone call to discuss the concern. 10 New York Code Rules & Regulations 415.11 (c)(2)(ii) | Plan of Correction: ApprovedApril 18, 2025 Corrective Action for those identified: Resident #6 and the designated representative have been invited to the next quarterly review and subsequent meetings in the future. Resident #6, residents?ÇÖ husband, as well as resident?ÇÖs daughter were invited and in attendance at the initial care plan meeting on 5/21/24. Also, an interdisciplinary meeting was held on 6/10/24 with resident, residents husband and daughter in attendance to discuss potential discharge. A quarterly meeting was held on 2/19/25 in which resident was invited and declined to attend. Identification of other residents and corrective action All residents have potential to be affected by the deficient practice identified. A review was completed to identify residents affected by the deficient practice. The facility has ensured all residents and designated representatives are invited to all initial, quarterly, annual and significant change care plan meetings, and updates have been provided to anyone identified in the review. Measures and Systemic Changes The Interdisciplinary Care Plan Committed policy was reviewed and amended. A new process was identified to include invitations to all residents and/or designated representatives. When a regulated assessment has been completed (Admission, Quarterly, Annual, Significant change) the care plan meeting invitation will be given to the resident and mailed to the designated representative unless the resident does not wish to involve the designated representative. The social worker will document when invite was provided and/or mailed. Monitoring Audits will be completed weekly x 4 weeks, then monthly to monitor for residents and/or designated representatives invitation to care plan meetings (Initial, Quarterly, Annual, Significant Change). Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Social Work and Admissions- correction by 3/31/25 |
Scope: Pattern
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 and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment and effective housekeeping and maintenance services were maintained for 2 (East and West) of 2 resident units. Specifically, (a.) the floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and West Units; (b.) door frames and doors were in disrepair for multiple resident rooms; walls in the East and West units were in disrepair with scrapes, smudge, chips, and marks; (c.) resident room NH. 44 wall was in disrepair and unfinished; (d.) ceiling tiles in the television rooms had water stains; (e.) shower rooms were soiled with dirt next to walls, and in corners, and (f.) handrails through unit were scuffed and scrapped exposing the underlying wood of the rails. This is evidenced by: The undated Policy &Procedure, titled Maintenance/Housekeeping Work Order Policy, documented that it was the facility's policy to ensure all areas maintained a clean, comfortable, and well-functioning environment. When problems were identified, employees were required to complete a Maintenance/Housekeeping Work Order. During observations on 02/13/2025 at 12:43 PM, the following items were observed; -Floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in the corridors on the East and West Units for room #s 2, 5, 18, 21, 25, 31, 36, 44, and 48. -Door frames and doors were in disrepair with scrapes, chips, and gouges for resident rooms 2, 5, 18, 21, 25, 31, 36, 44, and 48. -Walls in the East and West Units in all corridors were in disrepair with scrapes, chips, and unpainted. -Resident room NH. 44 wall was in disrepair and unfinished. -Several ceiling tiles in the East and West Unit television rooms had water stains -The floors and walls behind fire doors on the East and West Units were soiled with dirt and grime. -Shower rooms in the East and West Units were soiled with dirt next to walls, and in corners and appeared to have a dark black substance on walls. -Handrails through the East and West Units were scuffed and scrapped exposing the underlying wood of the rails. During an interview on 02/14/2025 at 11:45 AM, Environmental Services Director #1 stated that their staff was responsible for the overall cleaning of the facility. They stated that the cleanliness of the areas that had been lacking. They stated that they were in the process of developing a duty list of responsibilities the environmental service individuals were to complete daily. In showing the areas of concern the Environmental Service Director #1 stated that the areas should have been cleaned and that was the reason they wanted to develop the lists. During an interview on 02/18/2025 at 10:22 AM, Engineering Supervisor #1 stated that they oversee the overall appearance of the facility. They stated that they do have staff that worked with them daily and took care of the daily general workload of the facility. They stated their staff were responsible for fixing minor issues on a day-to-day basis such as lighting issues, Call bell issues, and general maintenance. Engineering Supervisor #1 stated that they received approximately 6- 8 work orders per day from staff on issues in the facility. They stated that they did a walk-through each morning to identify issues for repair or maintenance. They stated that approximately a year ago they had staff do a full facility touch-up on walls and door frames. They stated that they had a 3-month plan for renovations on the unit which included but was not limited to fixing the resident room doors, installing kick plates on the doors to protect them from damage, floors in the resident rooms, and general overall appearance. Engineer Supervisor #1 stated that resident room [ROOM NUMBER] had a water pipe break in the wall of the room. They stated that before they could finish fixing the entire wall a resident was moved into the room. They stated they had a work order to finish the wall in the room. 10 New York Codes of Rules and Regulations 415.5(h)(2) | Plan of Correction: ApprovedApril 25, 2025 Corrective Action for those identified: Engineering has begun contractual acquisitions for repairs of all patient rooms 2,5,18,21,25,31,36,44,48, and East/West corridors. The repairs will include door repairs, patch and paint wall coverings, handrail coverings, and ceilings/ceiling tiles. Environmental service has begun cleaning of resident rooms 2,5,18,21, 25,31,36,44, 48, shower rooms on east and west units, along door thresholds and where door frames meet the floor, and floors and walls behind fire doors. Identification of other residents and corrective action Contractual agreements for repairs are in process for the remaining spaces throughout the entire facility. Engineering and EVS have scheduled weekly rounding appointments. This walkthrough will contain a documented audit tool from both departments to ensure continued compliance with the identified deficient practices, specifically including floor condition, ceiling tiles, shower rooms, resident rooms, handrails, door frames, and wall conditions. Any items not meeting standards will be repaired. All the above listed items for Environmental service will be cleaned by 3/31/25. Measures and Systemic Changes Establishment of a new Environment of Care Committee comprised of Engineering, housekeeping, an Executive Sponsor, and nursing home staff will be completed by 3/31, with a policy initiated with education of the committee on the new policy entitled Environment of Care Committee - Nursing Home. Environment of Care meetings will be held monthly as a sub-committee of Quality Assurance Performance Improvement Committee. Agenda items will include rounding, ensuring expectations are met and policies remain appropriate. Policy Environment of Care Committee - Nursing Home was developed on 3/31/25. Nursing home environmental service staff will be re in serviced on 7-step cleaning protocol, including detail cleaning of corners and edges and shower cleaning by 3/31/25. Monitoring Weekly site visit documented on an audit tool from both departments to ensure continued compliance with the identified deficient practices, specifically including floor condition, ceiling tiles, shower rooms, resident rooms, handrails, door frames, and wall conditions. and work order completion reports will be completed weekly x 90 days and filed with the Quality Assurance Performance Improvement Committee. Five Environmental rounding audits will be completed weekly x 90 days. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Chief Operating Officer, by 4/14/25 |
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 a recertification survey, the facility did not ensure that residents received proper treatment and assistive device to maintain vision abilities for 1 (Resident #19) of 1 resident reviewed. Specifically, Resident #19 did not receive an eye exam, glasses, and or a follow up ophthalmology appointment. This is evidenced by: Regulation 483.25(a) Vision and hearing, documented the facility is responsible to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident 83.25(a)(1) In making appointments, and ?º483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of [REDACTED]. Resident # 19 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/2024, documented resident was cognitively intact, could be understood, and understand others. During an interview on 02/11/2025 at 11:24 AM, Resident #19 stated they had difficulty with vision. They stated they did not wear their glasses anymore because they really do not help. The glasses were really old, and they had been asking to see the eye doctor, but no appointment had been made. Ophthalmology consult dated 7/27/2020 documented [DIAGNOSES REDACTED]. Recommended follow up in three months. The Comprehensive Care Plan dated 12/2024, for Resident #19 did not include a plan for vision and or glasses. During an interview on 02/14/2025 at 10:57 AM, Director of Nursing #1 stated resident was seen by ophthalmology in 2020, which was prior to their admission the facility. Resident had not been seen by ophthalmology since admission. They stated residents were seen by specialist as needed, but generally once per year. It was the responsibility of the unit manager to coordinate follow up specialist visits. During an interview on 02/14/2025 at 12:47 PM, Registered Nurse #1 stated Resident #19's Comprehensive Care Plan did not include vision and or glasses. They stated were not aware resident wore glasses and would update the care plan. 10 New York Codes, Rules, and Regulations 415.12(2)(b) | Plan of Correction: ApprovedApril 21, 2025 Corrective Action for those identified: Resident #19 has an ophthalmology appointment scheduled for 3/14/25 at 1500. The care plan for Resident #19 was updated to include vision concerns and use of eye glasses on 2/14/25. Identification of other residents and corrective action All residents are at risk for the deficient practice. An audit of all resident for indication for follow up vision assessments and/or use of eyeglasses will be completed to ensure care planning (inclusive of scheduling of necessary follow up appointment) is completed appropriately. Measures and Systemic Changes A new policy ?Ç£Care of Visually Impaired Residents?Ç¥ was initiated on 3/11/2025. Education of pertinent staff related to the new policy will be completed by 3/31/25. Monitoring An audit of all new admissions will be conducted to ensure vision treatment and assistive devices are appropriately addressed. This will occur weekly x 4 weeks and then monthly x 3 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing, by 3/31/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, corridor doors were not maintained in accordance with adopted regulations. Specifically, corridor doors did not have latching hardware and were not fire resistive as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition section 19.3.6.3.5. This is evidenced by: During observations on 3/24/2025 at 10:00 AM and 3/25/2025 at 2:00 PM, the East dining room was being utilized as a storage space (beds, wheelchairs, tables, chairs), and the corridor double doors separating the East Dining Room from the corridor did not have latching hardware and had a ½-inch space between the double doors. During an interview on 3/25/2025 at 2:04 PM, Director of Engineering #1 stated that they would install latching hardware and an astragal on the double doors. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 19.3.6.3 10 New York Codes, Rules, and Regulations 415.29 | Plan of Correction: ApprovedApril 9, 2025 Corrective Action for those identified: The East dining room has been re-opened as a dining space and all storage items have been removed as of 4/3/25. The space is targeted to return to status as the East Dining Room to accommodate resident dining on 4/14/25. Identification of other residents and corrective action A site tour has been completed to identify spaces used for storage that do not have latching hardware and/or an astragal on the doors as appropriate. Any areas out of compliance were documented and repaired. Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established, to include review for spaces used as storage that do not meet requirements. This has been added to the rounding checklist. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established, to include review for spaces used as storage that do not meet requirements. This has been added to the rounding checklist. Findings will be reported out to quality assurance and performance improvement committee for recommendations and review. Responsible person/title and date of correction 4/18 ?Çô Director of Engineering |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, the facility did not maintain exits in accordance with adopted regulations. Specifically, exit discharges were not marked to make clear the direction of egress travel from the exit discharge to a public way in accordance with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19.2.7 and 7.7. This is evidenced by: During observations on 3/24/2025 at 1:21 PM, the exit discharges from the east and west nursing units did not make clear the direction of egress travel from the exit discharge to a public way. During an interview on 3/24/2025 at 3:51 PM, Director of Engineering #1 stated that they would install directional signage along the exit discharges to make clear the direction to the public way. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 19.2.7, 7.7 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 9, 2025 Corrective Action for those identified: The East and West exit discharges will have exterior signage installed to direct exit to public way by 4/18/25. Identification of other residents and corrective action A site tour was completed on 4/8/25 to identity any other exit discharges that are not in compliance related to exterior signage directing to a public way. Any deficiencies will be corrected Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established, to include compliance with exit discharge exterior signage directing to a public way. The exit discharge exterior signage directing to a public way has been added to the rounding audit tool. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established, to include compliance with exit discharge exterior signage directing to a public way. Findings will be reported out to quality assurance and performance improvement committee. Responsible person/title and date of correction 4/18 ?Çô Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not conduct testing and maintenance protocols on patient care-related electrical equipment in accordance with adopted regulations. Specifically, patient care-related electrical equipment was not tested and/or inspected prior to being put into service as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 10.3. This is evidenced by: There was no documented evidence that pressure relieving mattress (serial number EZ 1525) found in use in room [ROOM NUMBER] was inspected prior to being placed into service. The facility policy titled Alternate Equipment Maintenance Procedure and dated 1/01/2025 documented that all medical equipment is to be assessed upon receipt. During an interview on 3/25/2025 at 10:38 AM, Senior Biomedical Equipment Technician #1 stated that the pressure relieving mattress likely recently arrived, their department was not bust should have notified to inspect the device, and that the nursing staff need to be re-educated on the policy for patient care electrical devices. 42 Code of Federal Regulations 483.70 (a) (1) 2012 NFPA 99 10.3, 10.5.2.1 10 New York Codes, Rules, and Regulations 713-1.1, 711.2 (19) | Plan of Correction: ApprovedApril 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: The pressure relieving mattress in room [ROOM NUMBER] was inspected by our biomedical department on 3/25/25 and a sticker applied to the equipment. Identification of other residents and corrective action An audit of all medical equipment will be conducted to ensure documentation of inspection and any items determined to be deficient will be taken out of service until inspected. Measures and Systemic Changes A new policy ?Ç£Electrical Medical equipment ?Çô testing and maintenance?Ç¥ was initiated on 4/10/25. Education of all components of the new policy, inclusive of the requirement that all medical equipment is to be assessed by the Biomedical department upon receipt and prior to use, will be completed by 4/30/25. Monitoring A random audit of all medical equipment in 4 rooms at a time for proof of inspection will be conducted weekly for 2 weeks, then monthly for 3 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing 4/30/25 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the emergency plan did not provide documentation about the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. This could affect all residents at the facility. This is evidenced as by: There was no documented evidence that the emergency plan documented a description of the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. During an interview on 3/25/2025 at 2:39 PM, Administrator #1 stated that they would start with the facility assessment and add a description of the of the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. 42 Code of Federal Regulations: 483.73(a)(3) | Plan of Correction: ApprovedApril 8, 2025 Corrective Action for those identified: A description of the resident populations that would be at risk during an emergency event were added to the Comprehensive Emergency Management and to the Emergency Disaster Plan, including the service the facility has in place to address the needs. Identification of other residents and corrective action No other residents are at risk with the addition of the information to the policy. Measures and Systemic Changes The policies Comprehensive Emergency Management Plan and Emergency Disaster Plan were amended to include the necessary information on 4/4/2025. Monitoring Audits of emergency plans to ensure appropriateness to the resident population will occur at least annually. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Aimee Rathka, Administrator By 4/12/25 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Standard Life Safety Code Survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include training on and a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Preparedness Program, Training Program included training and a demonstration of knowledge of the following emergency responses identified as the most likely hazards: ?? Broken water main ?? Cyber attack ?? Flood - Internal ?? Blizzard ?? High winds ?? Ice storm ?? Severe Thunderstorm ?? Temp - frigid ?? Civil demonstration ?? Staffing shortage ?? Disruptive person ?? Missing adult ?? Labor action During an interview on 3/25/2025 at 3:17 PM, Administrator #1 stated that they would update the Emergency Preparedness Program, Training Program and quiz to include the most likely hazards. 42 Code of Federal Regulations 483.73(d)(1)(ii) | Plan of Correction: ApprovedApril 10, 2025 CCorrective Action for those identified: The Emergency Plan Training Program was revised on 4/1/2025 to include training on and a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment, including ?Çó Broken water main ?Çó Cyber attack ?Çó Flood ?Çô internal ?Çó Blizzard ?Çó High winds ?Çó Ice storm ?Çó Severe Thunderstorm ?Çó Frigid temperatures ?Çó Civil demonstration ?Çó Staffing shortage ?Çó Disruptive person ?Çó Missing adult ?Çó Labor action Identification of other residents and corrective action No other residents are at risk with the revision of the education plan. Measures and Systemic Changes The Emergency Plan Training Program was revised on 4/1/2025 to include training on and a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment, including ?Çó Broken water main ?Çó Cyber attack ?Çó Flood ?Çô internal ?Çó Blizzard ?Çó High winds ?Çó Ice storm ?Çó Severe Thunderstorm ?Çó Frigid temperatures ?Çó Civil demonstration ?Çó Staffing shortage ?Çó Disruptive person ?Çó Missing adult ?Çó Labor action Staff will be educated using the revised education by 4/30/2025, upon hire and at least annually thereafter. Monitoring Audits of emergency training plan and the risk assessments will be completed at least annually, or at any time the risk assessments are reviewed and/or revised. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Aimee Rathka, Administrator by 4/30/2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the recertification survey, the facility fire-response plan did not address the basic response required of staff as required by adopted regulation. Specifically, the fire response plan did not include a code phrase for fire as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 19.7.2.3. This is evidenced by: The facility policy titled Fire Response and dated 03/2024 documented that upon discovery of fire, staff are to yell Fire and not a code phrase for fire. During an interview on 3/25/2025 at 11:18 AM, Emergency Manger & Security Supervisor #1 stated that the facility had had used Code Red for fire but had switched to the use of plain language. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 19.7.2.3 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 10, 2025 Corrective Action for those identified: The policy ?Ç£Fire Response?Ç¥ was revised on 4/8/2025 to include the use of a code phrase ?Ç£Code Red?Ç¥ to alert to a fire event. All staff will be educated by 4/30/2025 on the change to the policy. Identification of other residents and corrective action Fire drills will be completed once weekly for 4 weeks to determine understanding of the changes to the Fire Response policy, and any identified deficient practice will be immediately corrected. Implementation of quizzes for those that are deficient during a drill to determine where possible weaknesses lie in our training and the subject retention of those we are training. The policy ?Ç£Fire Response?Ç¥ was revised on 4/8/2025 to include the use of a code phrase ?Ç£Code Red?Ç¥ to alert to a fire event. The policy will be reviewed and updated, if necessary, for compliance with the provisions of NPFA 101 section 19.7. Measures and Systemic Changes The policy ?Ç£Fire Response?Ç¥ was revised on 4/8/2025 to include the use of a code phrase ?Ç£Code Red?Ç¥ to alert to a fire event. Education of the policy change to include the change in code phrase to Code Red will be completed with all staff by 4/30/25. Education of the Fire Response Plan and the use of the code phrase Code Red will be completed on hire and annually with all staff. Monitoring Audits of Fire drill responses and the use of the code phrase Code Red will be completed once weekly for 4 weeks, then monthly ongoing, to determine understanding of the changes to the Fire Response policy and code phrase, and any identified deficient practice will be immediately corrected. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction 4/30/25 by the Emergency Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation and interviews during the recertification survey, the facility did not provide effective warning to alert occupants to evacuate in the event of fire in all parts of the building for the outdoor resident courtyard. Specifically, a notification device was not provided in the courtyard as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 9.6.3, NFPA 70 National Electric Code 2011 edition, and NFPA 72 National Fire Alarm Code 2010 edition. This is evidenced by: During observations on 3/24/2025 at 12:04 PM, the outdoor enclose resident courtyard did not have a fire alarm notification appliance. During an interview on 3/24/2025 at 12:05 PM, Director of Engineering #1 stated that they would install a fire alarm appliance in the courtyard. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 19.3.4.1, 9.6.3 2011 NFPA 70 2010 NFPA 72 10 New York Codes, Rules, and Regulations 415.29, 711.2(a) | Plan of Correction: ApprovedApril 9, 2025 Corrective Action for those identified: Installment of 2 audible/visual alarm devices in courtyard. Identification of other residents and corrective action A site tour has been completed to identify any other unalarmed areas. Notification appliances will be installed in any unalarmed areas identified after the site tour. Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established and will include rounding to ensure evaluation of areas missing fire alarm notification devices. Findings will be documented on the checklist and any identified deficiency will be addressed with a work order for correction. Findings will be reported out to quality assurance and performance improvement committee for review and recommendations. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established and will include rounding to ensure evaluation of areas missing fire alarm notification devices. Findings will be documented on the checklist and any identified deficiency will be addressed with a work order for correction. Findings will be reported out to quality assurance and performance improvement committee for review and recommendations. Responsible person/title and date of correction 4/18 ?Çô Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations. Specifically, smoke detectors were not installed relative to ventilation system supply and return ductwork as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition sections 14.4.5.3, 14.6.2.4, and 17.7.4.1. This is evidenced by: During observations on 3/24/2025 at 1:03 PM, smoke detectors were within 3-feet of ventilation ducts in the following areas: Corridor by room #s 19 and 29. Corridor by the timeclock. During an interview on 3/24/2025 at 1:29 PM, Director of Engineering #1 stated that they would have the smoke detectors re-installed to be code compliant. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 14.4.5.3, 14.6.2.4, 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 9, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Remove and re-install 2 smoke heads near room [ROOM NUMBER],29, and the time clock corridor at least 36 inches away from diffusers. Identification of other residents and corrective action A site tour has been completed to identify any other smoke detectors out of compliance. Any identified deficiencies will be corrected and documented. Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established to include inspection of smoke detector heads and installation and maintenance in accordance with NFPA regulations. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established to include inspection of smoke detector heads and installation and maintenance in accordance with NFPA regulations. Findings will be documented and reported out to quality assurance and performance improvement committee. Responsible person/title and date of correction 4/18 ?Çô Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on staff interview and record review during the recertification survey, the facility did not maintain the piped medical gas system in accordance with adopted regulations. Specifically, staff maintaining the piped medical oxygen system did not receive required training and certification or credentialing to the requirements of the Association of Academic Support Educators standards 6030 or 6040 as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 5.1.14.2.2.5. This is evidenced by: There was no documented evidence that staff that change the flowmeters servicing the piped medical gas system received training and certification or credentialing to the requirements of the Association of Academic Support Educators standards 6030 or 6040. During an interview on 3/25/2025 at 3:32 PM, Administrator #1 stated that they would ensure staff that change the flowmeters to the piped oxygen system received the required training and certification or credentialing. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 5.1.14.2.2.5 | Plan of Correction: ApprovedApril 10, 2025 Corrective Action for those identified: All appropriate staff will receive training presented by Respiratory Therapy on 4/24/25 related to safe maintenance of the piped oxygen system and changing of the flowmeters. Identification of other residents and corrective action Documentation of attendance at mandatory trainings for safe maintenance of the piped oxygen system and changing of the flowmeters will be reviewed to determine any staff who have not been trained. Any staff who did not complete the training will be required to complete prior to working the next shift. Staff will complete a test with return demonstration to verify competency. Measures and Systemic Changes Mandatory training on the maintenance of piped medical gas flowmeters will be required on hire and annually of all identified staff, including a test with return demonstration to verify competency. Policy entitled ?Ç£Oxygen Therapy?Ç¥ was reviewed and updated to include the requirement of specialized training for flowmeter maintenance. Education of staff on revised policy will occur by 4/30/25, and on-hire and annually. Monitoring Conduct 2 random audits of qualified staff to evaluate proper technique of flowmeter maintenance will be completed biweekly for 2 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Director of Nursing by 4/30/25 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 3/24/2025 at 1:21 PM, the exit discharges from the west dining room and east unit were not provided lighting fixtures along the path of travel. During observations on 3/25/2025 at 12:17 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention was not provided along the means of egress in the following areas: ?? Corridor outside the West Dining Room. ?? West Dining Room. ?? East Dining Room. ?? Physical Therapy room. ?? Television Lounge. ?? Shower and Tub rooms. ?? Beauty Shop. During an interview on 3/25/2025 at 12:35 PM, Director of Engineering #1 stated that they would install emergency lighting along the path of egress in the areas found. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 9, 2025 Corrective Action for those identified: The East and West exit discharges will have exterior lighting installed to illuminate the path of egress to public way. Also, emergency lockout preventing access to turn the light off or emergency floodlight devices will be installed in the following areas, corridor outside West Dining room, West dining room, East dining room, physical therapy room, East and West tv lounges, shower and tub rooms, and beauty shop. The electrical contractor was onsite 4/8/25 to assess the scope of work and to schedule for installation, to be completed by 4/18/25. Identification of other residents and corrective action A site tour has been completed to identity any other exit discharges or egress paths that are non-compliant completed on 4/8/25. Any identified deficiencies will be placed on the work order for repair/installation. Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established, to include appropriate lighting in areas to meet regulations. Rounding for lights will be added to the rounding auditing tool. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established, to include appropriate lighting in areas to meet regulations. Findings will be placed on a work order for repair/installation and reported out to quality assurance and performance improvement committee. Rounding for lights will be added to the testing rounding auditing tool. Responsible person/title and date of correction 4/18 ?Çô Director of Engineering |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. Specifically, defects in fire-rated doors were not corrected after the required inspections were conducted as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition section 5.1.5. This is evidenced by: The document titled Fire Door and Smoke Door Inspection and dated 11/08/2024 documented that door NB-6 had a 30-minute fire-rating and that a 90-minute rated door was required. There was no documented evidence that the door was replaced with a 90-minute rated door. During an interview on 3/24/2025 at 3:29 PM, Director of Engineering #1 stated that they had ordered the door, but it had not yet arrived. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 8.3.3.1 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 15, 2025 Corrective Action for those identified: The door identified in the citation in B3 storage room was ordered 3/24/25 and will be install as soon as it arrives. A time limited waiver with date of completion of (MONTH) 14 2025. A Safety Plan was developed 4/14/2025 to ensure that all safety measures are in place to ensure resident health and safety during the estimated 3 month waived time period. Identification of other residents and corrective action A site tour has been completed to identify any areas with defects in the fire-rated doors noted to be out of compliance with NFPA 80 2010 edition. Any areas identified as non-compliant will be repaired or replaced immediately and without delay. Monthly inspections of all fire rated doors for compliance with NFPA 80 2010 edition will be completed with areas of non-compliance repaired immediately and without delay. Measures and Systemic Changes Education and training of engineering staff to ensure that doors that fail inspection for defects are repaired immediately and without delay by the Director of Engineering. Weekly rounding for Life Safety and Environment of care committees have been established, to include reviews of fire rated doors for defects as required by NFPA 80 2010 edition. This has been added to the audit rounding tool. Monthly preventive maintenance inspections of all fire rated doors for compliance with NFPA 80 2010 edition will be completed with areas of non-compliance repaired immediately and without delay. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established, to include reviews of fire rated doors for defects as required by NFPA 80 2010 edition. This has been added to the rounding audit tool. Findings will be reported out to quality assurance and performance improvement committee Monthly preventive maintenance inspections of all fire rated doors for compliance with NFPA 80 2010 edition will be completed with areas of non-compliance repaired immediately and without delay. Director of Engineering will submit inspections of the fire doors to ensure all doors are compliant with NFPS 80 2010 edition, and corrections for any non-compliance. The Director of Engineering will report monthly on the status of the door identified at B-3 and any deficient door inspection within the past month to the Quality Assurance Performance Improvement Committee for review and recommendations. Responsible person/title and date of correction 10/14/2025 ?Çô Director of Engineering |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include strategies for addressing each emergency event identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the facility emergency preparedness plan developed plans for cyber-attack, nuclear accident, and reception of mass casualty victims. During an interview on 3/25/2025 at 3:11 PM, Administrator #1 stated that they would update the emergency plan to include the missing policies and procedures. 42 Code of Federal Regulations 483.73(a)(1) | Plan of Correction: ApprovedApril 10, 2025 Corrective Action for those identified: The following policies were initiated on 3/27/2025: Cybersecurity Policy, Mass Casualty Policy, and Nuclear Accident Policy. The policy Surge Capacity was provided during survey and was last updated 9/2024, and remains appropriate at this review. Identification of other residents and corrective action No other residents are at risk at this time due to the updated policies The Emergency Plan and Hazard Vulnerability Analysis will be reviewed and any missing plans will be added to the Emergency Plan. Measures and Systemic Changes The following policies were initiated on 3/27/2025: Cybersecurity Policy, Mass Casualty Policy, and Nuclear Accident Policy. The policy Surge Capacity was provided during survey and was last updated 9/2024, and remains appropriate at this review. The staff will receive education including a demonstration of knowledge, including a quiz, on cyber attack policy, nuclear accident policy, and any new emergency preparedness plans for the review of missing plans. Monitoring Audits of emergency plans and the risk assessments will be completed at least annually, or at anytime the risk assessments are reviewed and/or revised. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Quality Assurance Performance Improvement Committee recommendations. Responsible person/title and date of correction Aimee Rathka, Administrator by 4/30/2025. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview during the recertification survey, the facility did not maintain the electrical system in accordance with adopted regulations in the service area. Specifically, Arc-Flash Hazard Warning signs were not installed on all panelboards as required by the National Fire Protection Association (NFPA) 70 National Electrical Code 2011 edition, Article 110.16. This is evidenced by: During observations on 3/24/2025 at 1:17 PM, Arc-Flash Hazard Warning signs missing on electrical panelboards LP-4 and LP-4X. During an interview on 3/25/2025 at 12:41 PM, Director of Engineering #1 stated that they would contact their vendor and have the Arc-Flash Hazard Warning signs installed and would check all other panelboards for the sign. 42 Code of Federal Regulations 483.70(a)(1) 2011 NFPA 70 110.16 10 New York Codes, Rules, and Regulations 713-1.1, 711.2 (19) | Plan of Correction: ApprovedApril 9, 2025 Corrective Action for those identified: Panels identified as deficient (LP4 and LP4X) have had Arc Fault warning stickers installed. Identification of other residents and corrective action A site tour has been completed to identify areas out of compliance with use of Arc-Flash Hazard Warning signs, and additional stickers have been installed as appropriate. Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established, to include review of panelboards for use of Arc-Flash Hazard Warning signs. This has been added to the rounding checklist. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established, to include review of panelboards for use of Arc-Flash Hazard Warning signs. This has been added to the rounding checklist. Findings will be reported out to quality assurance and performance improvement committee. Responsible person/title and date of correction 4/18 ?Çô Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 25, 2025
Corrected date: N/A
Citation Details Based on observation and interviews during the recertification survey, the facility did not ensure vertical openings were maintained in accordance with adopted regulations. Specifically, the basement floor-ceiling assembly had unsealed penetrations and was not continuous as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 8.6.2. This is evidenced by: During observations on 3/24/2025 at 1:10 PM, 3 unsealed penetrations for piping were found in the floor-ceiling assembly in the Storeroom B-6. During an interview on 3/24/2025 at 1:27 PM, Director of Engineering #1 stated that they would apply fire-stopping materials to the penetrations in the floor. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 19.3.1, 8.6.2 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 9, 2025 Corrective Action for those identified: Installed fireproofing around penetration in B6 storeroom. Identification of other residents and corrective action A site tour has been completed to identify any other unsealed areas in the floor-ceiling assembly. Any deficient areas will be repaired. Measures and Systemic Changes Weekly rounding for Life Safety and Environment of care committees have been established. These rounds will include inspection for unsealed penetrations in the floor-ceiling assembly. This has been added to the rounding auditing tool. Monitoring Weekly rounding for Life Safety and Environment of care committees have been established. These rounds will include inspection for unsealed penetrations in the floor-ceiling assembly. This has been added to the rounding audit tool. Any deficient areas will be repaired and documented. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement Committee monthly. Modification, discontinuation or continuation of audits will be based on Committee recommendations. Responsible person/title and date of correction 4/18 ?Çô Director of engineering |