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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: April 2, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 3/7/25, smoke barrier walls were not properly maintained. Specifically, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating and were not designed to resist the passage of smoke due to open and unsealed penetrations. This affected one (Second Floor) of one resident unit. The findings are: 1a. Observation above the ceiling tiles on the second floor on 3/4/25 at 2:00 PM revealed an open and unsealed penetration through the smoke barrier wall outside of Resident room [ROOM NUMBER], due to a piece of damaged drywall. The piece of drywall was one inch wide by three-quarters of an inch high and hung loosely on the wall by its paper backing. At the time of the observation, the Director of Facilities stated the drywall piece needed to be secured and the area re-caulked with fire-rated caulk. 1b. Observation above the ceiling tiles on the second floor on 3/4/25 at 2:10 PM revealed an open and unsealed one inch by one inch square penetration through the smoke barrier wall outside of the Director of Nursing's Office. The penetration had one blue wire through it and was observed on both sides of the wall. At the time of the observation, the Director of Facilities stated they were not sure what the blue wire was from or when it was installed. During an interview on 3/5/25 at 1:50 PM, the Director of Facilities stated the facility did not currently perform regular smoke barrier audits, but they had performed smoke barrier audits in the past related to the construction project several years ago. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7. 3, 8. 5, 8. 5. 1, 8. 5. 2, 8. 5. 2. 1, 8. 5. 2. 2, 8. 5. 2. 3 | Plan of Correction: ApprovedApril 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 483. 45(e)(4) [MEDICAL CONDITION] Drugs 1. The facility currently has [MEDICAL CONDITION] Medication Use policy that ensures residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is deemed necessary to treat a diagnosed specific condition that is documented in the clinical record. Resident #24s chart was reviewed by the Medical provider and PRN [MEDICAL CONDITION] order was discontinued, and a corrected PRN [MEDICAL CONDITION] order was written immediately with stop date of 14 days. Two (2) separate audits by the Director of Nursing and Pharmacy Consultant on 3/19/25 were completed to ensure [MEDICAL CONDITION] medication use accuracy in all medical records. Audits will continue twice per month for the next 6 months. 2. Nursing Staff were educated immediately by the Director of Nursing with an in-service reviewing Policy and Procedure, Continuing education regarding [MEDICAL CONDITION] Medications and PRN Medication Administration. RN and LPN staff completed this in-service by 3/25/ 2025. The Director of Nursing, Pharmacist Consultant and Social Worker meet once monthly to review resident [MEDICAL CONDITION] use. All residents are reviewed monthly/quarterly and as needed. Residents that need GDRs are determined and reviewed by the Director of Nursing/designee and Medical Director. 3. The Director of Nursing reviewed all Resident Care plans for [MEDICAL CONDITION] drug use. As stated in our [MEDICAL CONDITION] Medication Use policy, residents will not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days except if the attending physician/designee believes that it is appropriate for the PRN order to be extended beyond 14 days. The Physician/designee will document any clinically contraindicated or specific conditions in clinical record along with their rationale and indicate the duration for the PRN order. 5. All (52) current resident's medical records were audited to ensure all active PRN [MEDICAL CONDITION] medications have a 14-day stop date. If the order does not include the 14-day stop date, prescriber will be contacted and a corrected order will be issued. If the prescriber deems it appropriate to extend past 14 days, the prescriber will document rationale in the resident's permanent medical record. An audit of the clinical record for PRN [MEDICAL CONDITION] Medications will continue twice monthly x 6 months by the DON/designee and/or Pharmacy Consultant. All audits will be reviewed quarterly for the next 6 months at QA/QAPI meetings. The Director of Nursing/designee will be responsible for the overall implementation of the plan of correction. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: March 21, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record reviews made during an abbreviated survey(NY 816) the facility failed to allow a resident's designated representative to exercise the resident's rights to the extent those rights are delegated to the representative. This was evident for 2o 5 residents reviewed. Specifically, the facility disenrolled the resident from a Medicare Advantage insurance program into traditional Medicare without the knowledge or consent of their representative. This was true in 2 of 5 residents sampled. The findings are: The facility's policy and procedure entitled Special Rules Regarding Selected Payors (undated) states that residents who are members of a managed care benefit plan that is under a contract with the facility to provide specified services will receive those services with full coverage so long as the resident meets eligibility requirements of the plan. 1) Resident #1 was admitted to the facility on ,[DATE]/ 2021. The Minimum (MDS) data set [DATE] identified the resident's cognitive status as moderately impaired. The Minimum Data Set (MDS, a resident assessment tool) identified the resident with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 10/15 (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). The resident required extensive assist x 1 for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene, and was independent in eating. On 12/15/2021 the resident was discharged to the community. A Cognitive Loss Care Plan was initiated for Resident #1 on 11/17/ 2021. Interventions: assess causative factors, engage resident and provide reality orientation at least once per shift, give simple directions using simple words and short sentences, make eye contact, modify approaches according to resident's ability and response levels, stand in line of resident's vision. A Psychiatry consult dated 11/23/2021 states Resident #1 was seen as a new admission, noted to be oriented x 3 with fair memory, insight and judgment, and had capacity to make medical and financial decisions. A Social Work note dated 12/15/2021 states Resident #1's family member requested resident be discharged back to The Arbors Assisted Living Facility, where the resident had lived prior to admission to the facility. Resident was discharged home the following day. The resident's Physical Therapy discharge summary dated 12/15/2021 states resident had become independent in bed mobility, able to transfer with supervision and able to walk 200 ft. with a Rollator with supervision. Initial authorization was obtained for the resident's stay in the facility from Empire Blue Cross Blue Shield, authorization #UM 755, initial approval level 2 from 11/17-23/ 2021. A handwritten note (undated and unsigned) was obtained from the resident's finance folder and stated that the Finance Coordinator spoke with family member (who was Power of Attorney) regarding copayments after Day 20 of placement, continued authorization process, and wrote, Wants to stay with Blue Cross Blue Shield, not interested at this time in disenrollment. A Notice of Medicare Non-Coverage dated 12/13/2021 (NOMNC) states Resident #1's Medicare coverage in the facility will end on 12/14/2021 and that resident will be discharged on 12/ 15. The NOMNC was signed by the social worker as verbally reviewed with the resident's family member. The NOMNC did not state that the resident had Empire Blue Cross Blue Shield insurance and the NOMNC was issued by the facility, not by Empire Blue Cross Blue Shield. 2) Resident #2 was admitted to the facility on ,[DATE]/ 2021. The Minimum (MDS) data set [DATE] identified the resident's cognitive status as severely impaired. The Minimum Data Set (MDS, a resident assessment tool) identified the resident with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 2/15 (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). The resident required total dependence x 1 for locomotion; extensive assist x 2 for bed mobility, transfers and toileting; and extensive assist x 1 for dressing, eating and personal hygiene. The resident was discharged to another facility on 02/24/ 2022. A Cognitive Loss Care Plan was initiated for Resident #2 on 12/26/ 2021. Interventions: assess causative factors, give simple directions using simple words and short sentences, make eye contact, modify approaches according to resident's ability and response levels, stand in line of resident's sight. A copy of Resident #2's face sheet with a handwritten note (undated and unsigned) states a finance representative spoke with resident's son on 12/27/2021 regarding copayments after Day 20 of placement, Medicaid application, process of obtaining authorizations for managed care insurance. Note stated, Son wants to stay with Blue Cross Blue Shield. A Psychiatric consult dated 12/28/2021 states Resident #1 was seen as a new admission, appeared alert, calm, confused, oriented x 1 with decreased memory, insight and judgment poor, stated that resident had no capacity to make medical or financial decisions at present time. A Social Work note dated 02/23/2022 states family requested transfer packet be sent to another nursing home for long-term care. Social worker documented that transfer packet was sent and Resident #1 was approved medically for transfer but would require authorization from insurance. Family member was notified. Social worker updated new facility that auth was requested and new facility confirmed that bed would be held pending auth. A Social Work note dated 02/24/2022 states authorization for the new nursing home was received and transmitted. Resident #1's family member was notified and agreed with transfer. Resident #1 was discharged to new facility at 7:15 PM. Resident #1's facility bill was reviewed and revealed that Empire Blue Cross Blue Shield covered the resident throughout (MONTH) 2021, (MONTH) 2022 and (MONTH) 2022 without interruption in the facility. The Admissions Director was interviewed on 03/04/2022 at 1:51 PM and stated that when a resident has managed care, authorization must be obtained prior to admission. Each insurance company has its own rules but generally the hospital will get an initial authorization number, the level and the initial approval date through the case manager. After the initial period the facility sends updated Physical Therapy and Occupational Therapy notes to the case manager and are given continued authorizations. With traditional Medicare, authorization is not needed. The facility does not favor one type of admission over the other. Admissions Directed stated to not know which plans had bigger daily rates and stated to have never spoken with any residents or family about disenrolling from a managed plan. The facility accepts a wide variety of plans Blue Cross Blue Shield, Aetna, Humana, Elder Plan, VNS, United Health Care and Oxford. Resident #2's family member was interviewed on 03/04/2022 at 12:27 PM and stated to be familiar with Resident #1's insurance because they were the resident's Power of Attorney. The resident was approved by Blue Cross to be admitted to the facility for subacute rehab, but out of the blue someone phoned and asked to disenroll the resident from Blue Cross into traditional Medicare. Complainant stated to not recall this person's name. Complainant stated that they would not disenroll because the resident had the managed plan through a former employer and paid no premiums. In early (MONTH) someone from the facility phoned regarding a Medicaid application for a supplemental pharmacy plan. The complainant was again unsure of the name of the person who spoke with them. Because the complainant felt the resident would not have needed a supplementary pharmacy plan if they were covered by Blue Cross, they phoned Blue Cross and learned that the resident had been disenrolled into traditional Medicare. The facility denied having done so. Complainant then phoned CMS, which assisted in re-enrolling the resident in Blue Cross Medicare. Resident #1's family member was interviewed on 03/07/2022 at 2:32 PM and stated to be the resident's Power of Attorney. They stated to have never received a disenrollment form from the facility but to have received written notice from Blue Cross on 12/14/2021 that Resident #1 had been disenrolled as of 12/01/ 2021. Complainant then called their Medicare advisor who stated to be able to re-enroll the resident as of 01/01/ 2022. However, complainant decided against this and continued the resident in traditional Medicare. The Finance Coordinator was interviewed on 03/07/2022 at 11:14 AM and stated that Finance reaches out to the resident or family to verify demographics upon admission, then obtains the clinicals to get authorizations from the managed care company. They talk to patients on options for copayments and let them know there will be charges after day 20. They generally also discuss possible application for Medicaid. They do not usually mention disenrollment from a managed plan. Some families want the resident to continue with coverage once the managed program denies coverage, so in that care they guide them through the process of disenrolling from a managed plan if that's what the family wants. The Coordinator stated that there was no disenrollment form for Resident #1 because the resident was admitted under one authorization from Blue Cross and left the facility under the same authorization without interruption, never having disenrolled. There was no NOMNC because the resident was not discharged to the community. The Center for Medicare Services (CMS) Representative was interviewed on 03/21/2022 at 10:46 AM and stated that they had documentation proving that Resident #1 was disenrolled from their Medicare Advantage program as of 12/01/ 2021. The CMS Representative stated that when this change occurs there is potential for a resident to be directly charged a significant copayment. Further contact with the Finance Coordinator was made on 03/21/2022 at 1:04 PM. They stated to have not been aware of the CMS documentation and reaffirmed that they had never disenrolled the resident from a Medicare Advantage program into traditional Medicare. 415. 3(c)(1)(iii) | Plan of Correction: ApprovedMarch 31, 2025 K712 Fire Drills 1. The Facility will ensure fire drills are conducted in accordance with NFPA 101 2. The Director of Facilities and Facilities Supervisor reviewed and revised the policy entitled Conducting Fire Drills. Inservice with Maintenance staff conducted reviewing policy and future schedule. The 2025 fire drill schedule was reviewed to ensure drills are planned for once on each shift per quarter. 3. The Director of Facilities will audit fire drills to ensure they are conducted once on each shift per quarter. 4. Fire drill audit will continue for 12 months and be brought to QA/QAPI meetings on a quarterly basis for review and need for continuance. 5. Overall responsibility to ensure action is implemented and maintained is with the Director of Facilities. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: March 21, 2025
Citation Details Based on interview and record review during the Life Safety Code survey completed on 3/7/25, fire drills were not completed at least once per shift per quarter. This affected one (Second Floor) of one resident unit. The findings are: The policy and procedure titled Conducting Fire Drills, dated (MONTH) 2010, documented fire drills will be conducted according to the established schedule. In the Skilled Nursing Unit, drills will be conducted once per shift, per quarter at varying times. Review of fire drill reports from 2024 revealed no fire drills were conducted during the fourth quarter (October, November, December). During an interview on 3/4/25 at 8:50 AM, the Facilities Supervisor stated they maintained a schedule of fire drills. They stated there were fire drills scheduled for the fourth quarter of 2024, but those fire drills did not get done, it was an oversight. During an interview on 3/4/25 at 8:55 AM, the Director of Facilities stated the responsibility to plan and conduct fire drills belonged both to themselves and the Facilities Supervisor, and the fourth quarter fire drills were missed. During an interview on 3/5/25 at 1:25 PM, the Administrator stated planning and conducting fire drills was the responsibility of the Director of Facilities and the Facilities Supervisor. They stated they were unaware of the missed fire drills until earlier this week, when fire drill records were requested for the Life Safety Code survey. The Administrator also stated they did not normally review the schedule of upcoming fire drills with the Director of Facilities or the Facilities Supervisor. 10NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7, 19. 7. 1, 19. 7. 1. 6 | Plan of Correction: ApprovedMarch 28, 2025 K372 Subdivision of Building Spaces ?ö?ç?ú Smoke Barrier Construction 1. Corrective Action a. The Maintenance Department immediately secured the drywall piece and sealed the penetration using fire caulk in the smoke barrier outside of room 422 and sealed the penetration through the smoke barrier outside of the Director of Nursing's office using fire caulk. b. Maintenance Staff were inserviced on inspection and maintenance of smoke barriers. 2. Identification of other smoke barriers having the potential to be affected The Director of Facilities and Maintenance Staff conducted a 100% audit of smoke barriers to ensure there were not any unsealed penetrations. 3. Systematic Changes The Director of Facilities and/or Maintenance Staff will conduct monthly audits of smoke barriers to ensure compliance. 4. Monitor Performance The Director of Facilities/designee will monitor monthly smoke barrier audits for 12 months. All audits will be reviewed quarterly at QA/QAPI meeting, and need for continuance after 12 months. 5. The Director of Facilities will be responsible for overall completion of the plan with respect to K 372. |