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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident in 1 (Resident #142) of 2 residents reviewed for Personal Funds out of 39 total sampled residents. The findings are: The facility Policy and Procedure titled Resident Funds Accounts with a last revision date of 07/2024 documented that the facility will provide on request, and at least quarterly to the resident or resident's designated or legal representative, a statement showing the account balance including funds deposited and withdrawn and interest accrued. This will be documented in resident's chart. On 02/05/25 at 11:20 AM, Resident #142 was interviewed and stated they have an account with the facility, but they have not been getting copy of their account statement from the facility. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #142 had intact cognition and participated in assessment and goal setting. Resident #142's Fund Ledger dated 04/15/2024 for the period of 01/01/2024 - 03/31/2024 documented an open balance of $ 75. 00 and a combined current total balance of $ 100. 00. Resident Fund Ledger dated 10/29/2024 for the period of 07/01/24 - 09/30/24 documented an open balance of $ 75. 00 and a combined current total balance of $ 25. 00. Resident Fund Ledger dated 01/20/25 for the period of 10/01/2024 - 12/31/2024 documented an open balance of $ 25. 00 and a combined current total balance of $ 25. 00. There was documentation on the statements that resident was unable to sign. There was no documentation in any of the resident's medical record that a copy of the statement has been provided to the resident or that the Resident declined to receive the copy and requested that the copy be mailed to their family On 02/10/2025 at 09:51 AM, Registered Nurse #7, who was the Unit Manager, was interviewed and stated that the Social Worker is responsible for giving residents their account statement. They stated nursing is not in charge of keeping or monitoring the residents' funds. On 02/10/2025 at 09:59 AM, Social Service Director was interviewed and stated they distribute copy of the statement to the alert and oriented residents quarterly and mail copy to the family of the residents that are not alert and oriented, residents signed the copy when they are given, and the copies of the signed statement are kept on file. They stated that Resident #142 was seen about a week ago and was verbally informed of the account balance, copy of the statement mailed to the family because resident is unable to sign the copy. On 02/10/2025 at 02:14 PM, the Financial Controller was interviewed and stated the statement is printed out and given to the Social Worker to give to the residents or mail to the resident's family, and the statement should be signed for, by the resident, or resident's family when they receive the copy. The Controller stated they are not aware that Resident #142 is not being given the statement. The Controller further stated that residents that are alert and oriented should be given the statement, even if they cannot sign for it. The Controller stated if a copy is not given to cognitively intact residents, then the staff are not following directions. On 02/12/2025 at 02:43 PM, the Administrator was interviewed and stated that they were not aware that Resident #142 was not provided a copy of their quarterly statement. They stated they were informed by the Social Worker that Resident #142 does not want to have a copy of the statement and that it should be mailed to the family. 10 NYCRR 415. 26(h)(5)(iii) | Plan of Correction: ApprovedMarch 5, 2025 I. Immediate Corrective Action 1. On 1/28/2025, Resident #142 was provided with an account statement for October, (MONTH) and (MONTH) by the Director of Social Service. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Work reviewed all other residents' accounts. The residents who have funds, were provided with a quarterly account statement and/or a copy is sent to the resident representative. 3. No other issues were identified. III. Systemic Changes 1. The Administrator, Medical Director, Director of Social Service and the Controller reviewed the policy on ?ôResident Funds Accounts and found it to be compliant. 2. Social Workers and the Controller will be inserviced on the above policy with emphases on the residents and residents representative receiving quarterly account statements. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quarterly Assurance 1. The Director of Social Service developed an Audit tool to ensure compliance with residents and residents representatives receiving quarterly statements. 2. Audits will be done by the Director of Social Service / Designee on 10 random residents weekly x 4 weeks, 10 random residents monthly x 3 months and 10 random residents quarterly thereafter. 3. Audits with negative findings will have immediate corrective action taken by the Director of Social Service & reported to the Administrator for review and follow up. 4. Audit results will be presented to the QA committee by the Director of Social Service quarterly for evaluation and follow-up. V. The Director of Social Service will be responsible for overseeing this corrective action plan by 4/7/ 2025. |
Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: February 12, 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 conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident in 1 (Resident #84) of 39 total sampled residents. Specifically, the Minimum Data Set assessment for Resident #84 did not accurately reflect the Resident's psychiatric/mood disorder status. The findings are: The undated facility policy titled Minimum Data Set, Version 3. 0 documented the interdisciplinary team members will communicate with resident and resident's family, and review resident's medical record to perform an accurate and comprehensive assessment. Resident #84 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #84 was severely impaired in cognition, had no behavior symptoms, and had active [DIAGNOSES REDACTED]. The Minimum Data Set assessment also documented Resident #84 and their representative participated in the assessment. The hospital Patient Review Instruction dated 08/06/2019 documented that Resident #84 had [DIAGNOSES REDACTED]. The Trauma/[MEDICAL CONDITION] Screening dated 03/06/2020 documented Resident #84 was admitted to the facility with a [DIAGNOSES REDACTED]. It also documented Resident #84 and their representative stated they were never told that Resident #84 had or was treated for [REDACTED]. The psychiatry notes dated 04/28/2022 and 01/04/2024 documented Hospital Patient Review Instruction mentioned Resident #84 had [MEDICAL CONDITION]. It also documented the representative stated they were not aware of Resident #84's diagnosis. It further documented [MEDICAL CONDITION] was not confirmed as per chart. There was no documented evidence that the facility medical provider diagnosed Resident #84 with [MEDICAL CONDITION]. On 02/10/2025 at 12:52 PM, the Minimum Data Set Coordinator was interviewed and stated they did the Minimum Data Set assessment for Resident # 84. Minimum Data Set Coordinator also stated they reviewed Resident # 84's medical chart, spoke to the resident, and talked to staff to collect data for assessment. Minimum Data Set Coordinator stated Resident # 84 had the [DIAGNOSES REDACTED].# 84. Minimum Data Set Coordinator reviewed Resident # 84's medical record and stated the facility's [MEDICAL CONDITION] assessment and psychiatrist evaluation documented the [DIAGNOSES REDACTED]. Minimum Data Set Coordinator also stated the facility medical provider did not give [DIAGNOSES REDACTED].# 84. Minimum Data Set Coordinator stated it was an error to code the [DIAGNOSES REDACTED].#84 if the facility medical provider did not diagnose it for Resident # 84. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedMarch 5, 2025 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. Acknowledged and corrected to be in compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that infection control practices were maintained. This was evident in 11 (Residents # 1, # 8, #26, #31, #39, #44, #54, #82, #102, #145 and #157) of 24 total sampled residents during the Dining Task. Specifically, Certified Nursing Assistant #7 failed to clean their hands in between residents while assisting multiple residents with hand hygiene before meal service. The findings are: The facility policy titled Dining Meal Service with a reviewed date of 01/2025 documented the Certified Nursing Assistant provide residents with hand wipes to perform hand hygiene or assist with performing hand hygiene prior to the meal service. The facility policy titled Handwashing and Hygiene with a reviewed date of 09/2024 documented staff will perform hand hygiene in accordance with Centers of Disease Control guideline and facility policy. Hand hygiene will be performed between providing direct care to residents and before moving from one resident to another resident to provide direct care. During dining observation conducted on the 3rd Floor on 02/05/2025 between 12:02 PM - 12:20 PM, Certified Nursing Assistant #7 was observed assisting Residents #1, #8, #26, #31, #39, #44, #54, #82, #102, #145, and #157 in preparation for meal service. Certified Nursing Assistant #7 failed to perform hand hygiene in between residents, was observed picking up used hand wipes with bare hands, get clean wipes, and proceeded to clean the residents' hands. During an interview on 02/05/2025 at 12:54 PM, Certified Nursing Assistant #7 was interviewed and acknowledged they did not perform hand hygiene between residents. They stated they were not thinking. During an interview on 02/05/2025 at 2:04 PM, Registered Nurse #2 stated Certified Nursing Assistants must perform hand hygiene in between residents to prevent cross contamination. During an interview on 02/12/2025 at 3:14 PM, the Assistant Director of Nursing stated staff are required to provide hand hygiene to residents before meals and must perform hand hygiene themselves in between residents to prevent spread of infection. 10 NYCRR 415. 19 (b)(4) | Plan of Correction: ApprovedMarch 5, 2025 I. Immediate Corrective Action 1. Resident # 1 had no ill effects from the CNA who did not conduct proper hand hygiene 2. Resident # 8 had no ill effects from the CNA who did not conduct proper hand hygiene 3. Resident # 26 had no ill effects from the CNA who did not conduct proper hand hygiene 4. Resident # 31 had no ill effects from the CNA who did not conduct proper hand hygiene 5. Resident # 39 had no ill effects from the CNA who did not conduct proper hand hygiene 6. Resident # 44 had no ill effects from the CNA who did not conduct proper hand hygiene 7. Resident # 54 had no ill effects from the CNA who did not conduct proper hand hygiene 8. Resident # 82 had no ill effects from the CNA who did not conduct proper hand hygiene 9. Resident # 102 had no ill effects from the CNA who did not conduct proper hand hygiene 10. Resident # 145 had no ill effects from the CNA who did not conduct proper hand hygiene 11. Resident # 157 had no ill effects from the CNA who did not conduct proper hand hygiene 12. CNA # 7 was given Educational Counseling and 1:1 Inservice on Handwashing and Hygiene with emphasis on cleaning her hands in between residents while assisting multiple residents with hand hygiene before meal service. II. Identification of Others: 1. The facility respectfully acknowledges that all residents have the potential to be affected by these deficient practices. 2. The RN supervisors conducted a meal observation on each unit for lunch on 2/6/2025 to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. No further issues were identified III. System Changes: 1. The Administrator, Medical Director and DNS reviewed the policy on ?ôHandwashing and Hygiene?Ø and found it to be compliant 2. The Administrator, Medical Director and DNS reviewed and revised the policy on ?ôDining Meal Service?Ø to include the CNA performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. RN, LPN and CNA will be inserviced on the ?ôHandwashing and Hygiene?Ø policy and the policy on ?ôDining Rooms Meal Service?Ø with emphasis on performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 4. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The DNS / ADNS developed an audit tool to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 2. Audits will be done by the RN Supervisor / Designee on 10 meals weekly x 4 weeks, 10 meals monthly x 3 months and 10 meals quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS is responsible for overseeing this plan of correction by 4/7/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 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 conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident in 1 (Resident #101) of 35 total sampled residents. Specifically, during 2 observations conducted on 02/05/2025, medications were observed unattended in Resident #101's bedside. Licensed Practical Nurse #4 failed to ensure Resident #101 had taken the medications before leaving the room and documenting in the Medication Administration Record. The findings are: The facility policy titled Medication Administration and Documentation- General with a last revision date of 05/2024 stated that the Licensed Nurse administers full dose of medication to resident via correct route, offers resident a drink and observes resident to insure medication consumption . Licensed Nurse documents all held or refused medications on the electronic Medication Administration Record, [REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #101 was cognitively intact. Resident #101 had [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. [MEDICATION NAME] 325 milligram (65 mg iron) tablet, 1 tablet by oral route once daily for [MEDICAL CONDITIONS] Eliquis 5 milligram, 1 tablet orally two times a day for [MEDICAL CONDITION] Embolism Aspirin 81 milligram, 1 tablet once daily for [MEDICAL CONDITIONS] [MEDICATION NAME] 40 milligram/5 milliliter (8 milligram/milliliter) oral suspension, give 2. 5 milliliters (20 milligram) by oral route once daily for [MEDICAL CONDITION] Reflux Disease [MEDICATION NAME] (Vitamin B2) 100 milligram tablet, give 2 tablets by oral route 2 times per day for [DIAGNOSES REDACTED] The electronic Medication Administration Record [REDACTED]. On 02/05/2025 at 10:06 AM, Resident #101 was observed sleeping in bed with medications in a pill cup at bedside table. The pill cup contained 2 yellow pills, 1 oval pill, one round pink pill, and one red pill. There was also a liquid medication sitting in another pill cup. On 02/05/2025 at 10:48 AM, Resident #101 observed sleeping in bed with same medications still at the bedside table. The State Surveyor brought these medications to the attention of Licensed Practical Nurse #4 who stated the medications were liquid Iron, Eliquis, Chewable Aspirin, [MEDICATION NAME], and Vitamin B 2. Licensed Practical Nurse #4 stated they thought Resident #101 already took them. On 02/05/2025 at 10:52 AM, Licensed Practical Nurse #4 was interviewed and stated that Resident #101 was eating when they went to administer medication in the morning. Licensed Practical Nurse #4 stated they placed the medication in Resident #101's hand who stated they would take the medications. Licensed Practical Nurse #4 stated they stepped out to talk to another resident in the same room and didn't realize Resident #101 did not take the medications. Licensed Practical Nurse #4 stated they are aware they should be watching the residents take the medication and should be with them until it is taken. On 02/11/2025 at 12:10 PM, the Registered Nurse #6 , who was the Registered Nurse Supervisor was interviewed and stated that the Licensed Practical Nurse #4 should have made sure Resident #101 had taken the medications before signing off on the electronic Medication Administration Record. Registered Nurse #6 stated licensed nurses are discouraged to leave the medications at resident's bedside even if a resident requested because of the risk that other residents may come and take those medications. Registered Nurse #6 stated residents need to be assessed for medication self-administration before they are allowed to take their own medication. They stated Resident #101 was not assessed for self-administration of medication. On 02/12/2025 at 10:45 AM, Director of Nursing #1 was interviewed and stated that medications should never be left at resident's bedside. Director of Nursing #1 stated it is a resident safety issue and must be certain that the resident takes the medications. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMarch 5, 2025 I. Immediate Corrective Action 1. Resident # 101 was immediately given the morning medications with no adverse reactions. 2. The DNP assessed the resident since his medication was left at his bedside. There were no ill effects noted. 3. LPN # 4 was given educational counseling, a 1:1 in-service, and written warning on medication administration with proper medication administration techniques and not leaving medication unattended. 4. A medication administration observation was completed with LPN # 4 by the DNS II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. On 2/5/2025, the RN Supervisor checked all residents rooms on unit 2 AB and no other medications were left unattended at the bedside. 3. On 2/25/2025, the RN Supervisor checked all residents MAR indicated [REDACTED] 4. No other issues were identified III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the Medication Administration?Ø policy and found it to be compliant. 2. All RNs and LPNs will be in-serviced by the DNS/Designee on the above policy with emphasis on administering a full dose of medication to the resident via correct route, offers the resident a drink and observes the resident to insure medication consumption. Medication should never be left unattended. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that medication was being administered to the resident and not left at the bedside. 2. Audits will be done by the RN Supervisor / Designee on 10 random residents room / bedside for medication weekly x 4 weeks, 10 random residents room / bedside for medication monthly x 3 months and 10 random residents room / bedside for medication quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 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 and Complaint Survey (NY 525) conducted from 02/05/2025 to 02/12/2025, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #97) of 2 residents out of 39 total sampled residents reviewed for Abuse. Specifically, on 01/12/2024 at approximately 8:08 AM, Resident #97 alleged that a staff slapped them in the face. The facility reported the abuse allegation to the New York State Department of Health on 01/12/2024 at 7:03 PM. The findings are: The facility policy titled Abuse Prevention with a last reviewed date of 08/2024 documented that physical abuse includes hitting, slapping, pinching, and kicking. The abuse policy also documented all alleged abuse violations must be reported immediately but not later than 2 hours if the alleged violation involves abuse. Resident #97 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident # 97 had severe impairment in cognition and had no behavior symptoms directed towards others. The facility investigation report documented Resident #97 reported at approximate 09:15 AM on 01/12/2024 that they were slapped on left face by a staff earlier in the morning. The Accident/Incident Report by Licensed Practical Nurse #1 documented Resident #97 reported to them at about 9:15 AM that a certified nursing assistant slapped their face 3 times. The New York State Department of Health Aspen Complaint Tracking System intake documented the incident happened on Friday 01/12/2024 at 08: 08. The intake also documented the Administrator was first made aware of the incident on Friday 01/12/2024 at 18: 00. The auto reply email from New York State Department of Health to Director of Nursing documented the facility submitted the report to Department of Health on Friday 01/12/2024 at 19: 03. On 02/10/2025 at 09:36 AM, Certified Nursing Assistant #2 was interviewed and stated they were assigned to Resident #97 during the day shift from 7:00 AM to 3:00 PM on 01/12/ 2024. Certified Nursing Assistant #2 stated they made round to their assigned residents between 7:15 AM to 7:30 AM when Resident #97 told them that someone slapped their left face earlier at the night time. Certified Nursing Assistant #2 stated they reported the incident to Licensed Practical Nurse #1 immediately. On 02/10/2025 at 11:38 AM, Licensed Practical Nurse #1 was interviewed and stated Certified Nursing Assistant #2 reported between 7:00 AM and 8:00 AM on 1/12/2024 that Resident #97 made an allegation that someone slapped their left side of the face 3 times. Licensed Practical Nurse #1 stated they reported the allegation to Registered Nurse #1 at about 8:00 AM on 1/12/ 2024. 02/10/2025 at 11:51 AM, Registered Nurse #1 was interviewed and stated Licensed Practical Nurse #1 reported the allegation made by Resident # 97 upon their arrival to the unit at around 8:00 AM on 1/12/ 2024. Registered Nurse #1 stated they reported the incident to Director of Nursing immediately as it was an allegation of abuse. On 02/10/2025 at 12:14 PM, Director of Nursing was interviewed and stated they were responsible to report allegations of abuse to the New York State Department of Health. The Director of Nursing stated they had to report allegation of abuse within 2 hours to Department of Health. They stated Registered Nurse #1 reported the allegation in the morning on 1/12/ 2024. The Director of Nursing stated they did not report the allegation to the New York State of Department of Health because they do not believe the allegation occurred becasue there was no injury and numerous inconsistencies in Resident #97's account. The Director of Nursing stated they decided to report the allegation after Resident #97 accused a Certified Nursing Assistant #1 as the person that slapped them. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedMarch 5, 2025 I. Immediate Corrective Action 1. Resident # 97 was assessed by the DNP on 1/12/2025 and there were no visible signs of injury. There were no complaints of pain. 2. Resident # 97 was assessed by the RN Supervisor on 1/12/2025 and there were no visible signs of injury. There were no complaints of pain. 3. The Administrator received an Educational Counseling by the Medical Director with emphasis on ensuring that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency and Law Enforcement. 4. The Director of Nursing received an Educational Counseling by the Medical Director with emphasis on ensuring that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency and Law Enforcement. II. Identification of Others 1. The facility respectfully acknowledges that all residents who have accidents/incidents have the potential to be affected by this deficiency. 2. The DNS / designee reviewed Accident/Incident reports for the past 30 days to ensure that any residents with alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property, were reported no later than 2 hours if the event results in bodily injury or no later than 24 hours if the events that cause the allegation do not involve serious bodily injury. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the policy related to residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This policy was found to be compliant. This policy includes: Abuse Prevention with emphasis on ensuring residents remain free from abuse and neglect, and the immediate removal from the facility of any individual alleged to have been involved in the abuse / neglect until completion of the investigation. All alleged abuse or serious bodily injury must be reported to the Department of Health and law enforcement within 2 hours. It also emphasizes reporting guidelines to submit the outcome of investigations within 5 days. 2. All staff will be in-serviced by the DNS/Designee on the above policy with emphasis on the importance of ensuring all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency and law enforcement. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. An audit tool was developed by the Administrator and DNS to ensure that any residents with alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property, were reported no later than 2 hours if the event results in bodily injury or no later than 24 hours if the events that cause the allegation do not involve serious bodily injury. 2. Audits will be done by the DNS / Designee on 10 accident / incident reports weekly x 4 weeks, 10 accident / incident reports monthly x 3 months and 10 accident / incident quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA committee quarterly by the DNS / designee for monitoring of performance and recommendations and follow-up. V. The Director of Nursing will be responsible to ensure correction of this deficiency by 4/7/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 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 conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. This was evident in 1 (Resident #36) of 4 residents reviewed for Care Planning. Specifically, Resident #36's representative has been unable to attend care plan meetings. The facility failed to ensure that the care plan meeting invitations were mailed and received by Resident #36's representative. The findings are: The facility policy titled Comprehensive Care Plan with a reviewed date of 06/2024 documented that the facility will have a Comprehensive Care Plan completed in accordance with Federal and State requirements. The development of the Comprehensive Care Plan is prepared with an interdisciplinary team approach. The team members include the resident and the resident's family or their legal representative. Resident #36 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented that Resident #36 was severely impaired in cognition. The Minimum Data Set assessment also documented Resident # 36 and their representative participated in the assessment. On 02/06/2025 at 10:22 AM, Resident #36 was interviewed and stated they did not recall having care plan meeting with the interdisciplinary team and was not sure if their representative participated in the care plan meeting for them. On 02/07/2025 at 10:11 AM, the State Surveyor called the primary representative on Resident #36's face sheet. The message from the phone service carrier saying the phone number was not in service. On 02/10/2025 at 10:13 AM, the State Surveyor called Resident #36's primary representative again after the facility updated their phone number in the Resident's medical record. The representative stated the Director of Social Services called their family member and got their phone number on 2/7/ 2025. The representative stated they lived in the state of New Jersey and did not receive any invitation letter or call from the facility to participate in the care plan meetings for Resident # 36. The representative also stated they would like to participate in the care plan meeting for Resident #36 if they were invited to the meetings. The representative further stated the address listed at Resident #36's medical record for them was Resident #36's address in Brooklyn of New York City before their admission to the facility. The 2024 care plan schedule documented Resident #36 had care plan meetings scheduled on 1/2/2024, 2/13/2024, 4/16/2024, 7/9/2024, 10/1/2024, and 12/31/ 2024. The Social Services note dated 1/2/2024, 2/14/2024, 4/16/2024, 7/9/2024, 10/1/2024, and 12/30/2024 documented Resident #36 was unable to meaningfully participate in the care plan meeting. The Social Services notes also documented letters were mailed to representative for invitation to care plan meeting. The Social Services notes further documented the representative did not call back to participate in the care plan meetings. The care plan meeting reports dated 1/2/2024, 2/13/2024, 4/16/2024, 7/9/2024, 10/1/2024, and 12/31/2024 documented family was invited to and did not attend the care plan meetings. The envelopes for care plan meeting invitation to Resident #36's representative had Resident #36's address in Brooklyn of New York City before their admission to the facility. The Social Services note dated 2/7/2025 documented the social worker called Resident #36's representative to discuss plan of care and the phone was not working. The Social Services note dated 2/7/2025 documented the social worker finally spoke to the representative and updated the contact information of the representative in Resident #36's medical record. There was no documented evidence in Resident #36's medical records that the care plan meeting invitations were mailed to the designated representative, that the facility had confirmed the representative's correct contact information, and any follow up to confirm invitations to care plan meeting were received by the representative. On 02/10/2025 at 11:20 AM, the Social Services Director was interviewed and stated they mailed the invitation of the care plan meeting to the representative after receiving the care plan meeting schedule from the Minimum Data Set Department about 1 month ahead of the care plan meetings. Social Services Director also stated the invitation of care plan meeting was mailed by regular mail. Social Services Director further stated they assumed the invitation of care plan meeting was delivered to the representative if it was not returned to the facility. Social Services Director stated they did not call the representative to follow up if they received the invitation and did not call them on the day the care plan meeting was held. Social Services Director also stated they just used the address in the medical record to mail the invitation and did not confirm if the address was updated or correct. Social Services Director further stated they had no proof that the invitation of care plan meeting was mailed to the representative. 10 NYCRR 415. 3(f)(1)(v) | Plan of Correction: ApprovedMarch 5, 2025 I. Immediately Corrective Action 1. Resident #36 representative was contacted and new information was obtained in order to ensure that the care plan meeting invitations were mailed and received by Resident # 36s representative by the Director of Social Service. 2. The Director of Social Service received a 1:1 inservice on the importance of ensuring that the resident and/or the residents representative participated in the development, review, and revision of the person - centered comprehensive care plan. This includes ensuring that the address the letter is mailed to is the most current contact information. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service and the MDS Coordinator compiled a list of residents in the last 30 days who have had a comprehensive care plan meeting to ensure a care plan meeting invitation was mailed and received by the residents representative. 3. No other issues were identified III. Systematic Changes 1. The Administrator, Medical Director, DNS and Director of Social Service reviewed and revised the policy & procedure for the Comprehensive Care Plan. 2. All Social Workers will be in-serviced by the Administrator / Designee on the revised policy and procedure. The lesson plan will focus on the Care Plan Meeting Invitation to the resident and the residents representative, the response to the letter and accurate documentation. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that Care Plan Meeting Invitation are mailed to the residents representative, a response is received or follow up is initiated and documented accordingly. 2. Audits will be done by the Director of Social Service/Designee on 10 random Care Plan Meeting Invitations for follow-up weekly x 4 weeks, 10 Care Plan Meeting Invitations monthly x 3 months and 10 Care Plan Meeting Invitations quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible for overseeing this corrective action plan by 4/7/ 2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Recertification survey from 02/05/2025 through 02/12/2025, the facility did not ensure that a resident has a right to make choices about aspects of their life in the facility that are significant to the resident. This was evident for 1 (Resident #7) of 1 resident reviewed for Choices. Specifically, Resident #7 was not consistently showered twice a week or according to their preference. The findings are: The facility Policy and Procedure titled Activities of Daily Living dated 3/12/2018 and reviewed 6/2024 stated that all residents will be showered at least twice a week. All showers will be done on the 7AM -3PM or 3PM -11 PM shift. The policy also stated that refusals are documented on the Certified Nursing Assistant accountability record and the nurse must be informed. Resident #7 was admitted to facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #7 had intact cognition and required dependent assistance with showering and bathing. The Admission Minimum Data Set assessment also documented that it was very important for Resident #7 to choose between a tub bath, shower, bed bath, or sponge bath. On 02/05/25 at 02:34 PM, Resident #7 was observed sitting on their wheelchair, neatly dressed and groomed. During an interview Resident #7 stated that they could not recall when last they had received a shower, and that while they would like to shower every day, they could go along with whatever the facility can offer. Resident #7 also stated that they could not recall if showers were discussed with them on admission, however they have hardly had shower since they were admitted and have received regular bed baths. The Resident Nursing Instructions stated that effective 12/11/2024 Resident was to be showered every week on Tuesday at Saturday 3:00 pm-11:00 pm. The Resident CNA (Certified Nursing Assistant) Documentation History Detail dated 11/1/2024 to 2/10/2025 documented that Resident #7 received showers on the following days: 12/17/2024 at 4:36pm, 12/24/2024 at 5:03pm, 01/03/2025 at 5:20pm, 01/13/2025 at 4:45pm, 01/21/2025 at 9:49pm and 02/08/2025 at 9:03pm for a total of six showers since admission on 11/13/ 2024. On 02/10/25 at 03:12 PM, Certified Nursing Assistant #11 stated during interview that they float throughout the building, but they are familiar with Resident #7 and is assigned to assist with them with care on occasion. Certified Nursing Assistant #11 also stated that they start their day by checking the shower book and computer to know when a resident is scheduled for a shower, and if the resident refused, they would inform the nurse and document the event. Certified Nursing Assistant #11 also stated that they had never provided a shower to Resident #7, as sometimes they check the computer after Resident #7 had already been placed back in bed and then they realized that Resident #7 was supposed to have been showered on that date. Certified Nursing Assistant #11 further stated that the Resident #7 had never refused care from them. On 02/10/25 at 03:27 PM, Licensed Practical Nurse #3 was interviewed and stated that their responsibility is to ensure that residents are properly taken care of and that they are safe. Licensed Practical Nurse #3 also stated that residents are usually showered two times a week. Licensed Practical Nurse #3 further stated that skin checks are done for the resident on shower days. Licensed Practical Nurse #1 stated that they work on the unit two or three times per week and their duties also include checking the Certified Nursing Assistant's accountability report every shift. Licensed Practical Nurse #3 stated that some residents do refuse shower on cold days, but they did not recall that Resident #7 had not refused a shower. On 02/10/25 at 04:36 PM, Registered Nurse #3 was interviewed and stated that they cover all units on the 2nd Floor, and supervise 4 Licensed Practical Nurses, 8 Certified Nursing Assistants and do admissions. Registered Nurse #3 also stated that the schedule for showers is twice a week, and residents can take a shower every day if they want, but they need to let the facility know. Registered Nurse #3 further stated that there is no one that would check the accountability daily, and that the Certified Nursing Assistants would report to the nurse if the resident refused care. Registered Nurse #3 stated that Resident #7 has not complained about not getting showers and it was not brought to their attention, and it is the duty of Licensed Practical Nurse to inform the Certified Nursing Assistants to check the shower schedule. On 02/10/25 at 04:58 PM, the Director of Nursing was interviewed and stated that scheduled showers are mandatory at least twice a week, and residents can get a shower as often as they want if they request it. The Director of Nursing also stated that if residents do not want to shower on the designated shift, the facility can accommodate them. The Director of Nursing further that shower days are assigned to residents on admission. Residents should be asked their preference, and they would like to believe this is being asked, but it is not documented on the actual admission assessment. The Director of Nursing stated that on the shower day the Licensed Practical Nurse goes with the Certified Nursing Assistant to do a skin check. The sign off should be that a shower was given, and that the skin check done. If a resident is refusing the shower, it should be documented. If we are seeing a pattern (three or more) that the resident is not receiving showers, and that only bed baths are documented, then the nurses and supervisor should be discussing with the resident. The Director of Nursing also stated that supervisors should be checking accountability sheets at the end of the shift to make sure all tasks are done. On 02/11/25 at 11:33 AM, a telephone interview was conducted with Certified Nursing Assistant #5 who stated that Resident #7 can be difficult sometimes and tries to be independent. Certified Nursing Assistant #5 also stated that they give showers to Resident #7 and assist them with clean them up after they use bathroom. Certified Nursing Assistant #5 further stated that there is a book that they check to know a resident's shower days. Certified Nursing Assistant #5 stated that sometimes Resident #7 would refuse showers, and they would then just provide a bed bath which they would inform the nurse of sometimes. Certified Nursing Assistant #5 also stated that they offered Resident #7 a shower on their designated days, and they did not document that Resident #7 was refusing showers. 10 NYCRR 415. 5 (b)(1-3) | Plan of Correction: ApprovedMarch 5, 2025 I. Immediate Corrective Action 1. Resident # 7 was spoken to by the RN Supervisor regarding her shower schedule which is twice a week and as requested. Resident # 7 was also asked for her preference, but is agreeable to the shower schedule that is already in place. 2. The CNAAR for Resident # 7 was reviewed to ensure that the shower schedule was correctly documented and activated in the residents EMR. 3. CNA # 11 was given a 1:1 inservice on ADL care. This inservice included the importance of the resident receiving a shower twice a week and more often if requested. If the resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. 4. CNA # 5 was given a 1:1 inservice on residents refusing showers. If the resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The DNS / ADNS developed an audit tool to ensure that the residents CNAAR reflects residents preference for shower schedules with proper documentation. The DNS / designee developed a list of 10 random residents on each unit in order to audit the showering schedule and documentation on each resident. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the policy & procedure for the Activities of Daily Living and found the policy to be compliant. 2. RN, LPN and CNA will be in-serviced by the DNS/Designee on this policy with emphasis on the importance of the resident receiving showers twice a week as to their preference. If a resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that the residents CNAAR is accurate for the showering schedule with proper documentation. 2. Audits will be done by the DNS/Designee on 10 random residents weekly x 4 weeks, 10 random residents monthly x 3 months and 10 random residents quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/ 2025. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the weekend staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing dated 10/2024 stated it is the policy of the facility to provide enough nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 to 09/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment Tool last updated on 06/2024 documented a facility capacity of 188 residents with a staffing plan by shift as follows: Day shift: 13 Licensed Nurses providing direct care and 24 Certified Nursing Assistants Evening shift: 9 Licensed Nurses providing direct care and 19 Certified Nursing Assistants Night shift: 6 Licensed Nurses providing direct care and 10 Certified Nursing Assistants Total staffing for 24-hour period: 28 Licensed Nurses providing direct care and 54-Certified Nursing Assistants The undated document titled Certified Nursing Assistant Staffing Par Levels and Nurses Par Levels documented a staffing plan by shift and unit as follows: Day shift by units: Unit 2AB: 3 Nurses and 5 Certified Nursing Assistants Unit 2 CD: 3 Nurses and 5 Certified Nursing Assistants Unit 3 AB: 2 Nurses and 5 Certified Nursing Assistants Unit 3 CD: 3 Nurses and 5 Certified Nursing Assistants Unit 4 CD: 2 Nurses and 4 Certified Nursing Assistants Day shift total: 13 Nurses and 24 Certified Nursing Assistants Evening shift by units: 2 RN supervisors on shift for all units Unit 2AB: 2 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 2 CD: 2 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 3 AB: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 3 CD: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 4 CD: 1 Licensed Practical Nurse and 3 Certified Nursing Assistants Day shift total: 9 Nurses and 19 Certified Nursing Assistants Night shift by units: 1 RN supervisors on shift for all units Unit 2AB: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 2 CD: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 3 AB: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 3 CD: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 4 CD: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Day shift total: 6 Nurses and 10 Certified Nursing Assistants Total staffing for 24-hour period: 28 Nurses and 54 Certified Nursing Assistants Review of the actual weekend facility staffing schedule from 07/01/2024 to 09/30/2024 documented the following: On 07/06/2024 on the 7 AM-3 PM shift, there was a shortage of: 1 Nurse on 2 CD. On 07/07/2024 on the 7AM-3 PM shift, there was a shortage of: 1 Nurse on 3 CD. On 07/07/2024 on the 3-11 PM shift, there was a shortage of: 1 Nurse on 2 AB. On 07/13/2024 on the 3-11 PM shift, there was a shortage of: 1 Nurse on 2 AB, 1 CNA on 2 CD. On 07/21/2024 on the 7AM-3 PM shift, there was a shortage of: 1 Nurse and 1 Certified Nursing Assistance on 2 AB. On 07/28/2024 on the 7AM-3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2AB, 1 Nurse on 2CD and 1 Certified Nursing Assistant on 3 CD. On 07/28/2024 on the 3PM-11 PM shift, there was a shortage of : 1 Nurse on 2AB, 1 Certified Nursing Assistant on 2 CD and 3 AB. On 08/03/2024 on the 3PM-11 PM shift, there was a shortage of : 1 Nurse on 2AB, 1 Certified Nursing Assistant on 3 AB. On 08/04/2024 on the 3PM-11 PM shift, there was a shortage of : 1 Nurse on 2AB, 1 Certified Nursing Assistant on 3 AB. On 08/10/2024 on the 7AM-3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2CD and 3 CD. On 08/10/2024 on the 3AM-11PM shift, there was a shortage of : 1 Certified Nursing Assistant on 3 CD. On 08/11/2024 on the 7AM-3PM shift, there was a shortage of : 1 Nurse on 3 CD. On 08/17/2024 on the 7AM-3PM shift, there was a shortage of : 1 Nurse on 2 AB , 3 CD. On 08/18/2024 on the 7AM-3PM shift, there was a shortage of : 1 Nurse on 2 CD. On 08/25/2024 on the 3PM-11PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2 CD and 3 AB. ON 08/31/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2 AB. ON 08/31/2024, on the 3PM- 11 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 4CD. On 09/01/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Nurse and 1 Certified Nursing Assistant on 2 AB, 1 Nurse on 2CD, On 09/07/2024, on the 3PM-11PM shift, there was a shortage of: 1 Certified Nursing Assistant on 2AB. On 09/08/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Nurse on 2 AB and 2CD. On 09/08/2024, on the 3PM-11PM shift, there was a shortage of: 1 Nurse on 2CD. On 09/14/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 3 AB and 3 CD. On 09/15/2024, on the 3PM-11PM shift, there was a shortage of: 1 Nurse on 2CD. On 09/21/2024, on the 3PM-11PM shift, there was a shortage of: 1 Certified Nursing Assistant on 2CD. On 09/22/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Nurse on 2CD. On 09/28/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 4CD. On 09/28/2024, on the 3PM- 11PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2AB and 3 CD. A review of the facility weekend staffing As part of the Staffing facility task, staffing sheets were also reviewed for the weekend of 02/08/2025 - 02/09/ 2025. On Saturday, 02/08/2025, on the 7AM- 3 PM shift there was a shortage of 1 Nurse on 3 CD. On Saturday, 02/08/2025, on the 3PM-11PM shift there was a shortage of: 1 Certified Nursing Assistant on 3 AB. On Sunday, 02/09/2025, on the 7AM-3PM shift there was a shortage of : 1 Nurse on 3 CD and 1 Certified Nursing Assistant on 4 CD. On Sunday, 02/09/2025, on the 3PM-11PM shift there was a shortage of : 1 Certified Nursing Assistant on 3 AB and 3 CD. On 02/12/2025 at 11:19 AM, Resident #77 was interviewed and stated they are short staffed and there are days when Certified Nursing Assistants have 14-15 residents assigned to each aides particularly on the weekends. On 02/05/2025 at 04:50 PM, Resident #116's next of kin was interviewed and stated the facility had issues with staffing and the Resident was smelly when they came to visit this past Saturday. On 02/05/2025 at 10:16 AM, Resident #34 was interviewed and stated the facility is short staffed most weekends. On 02/11/2025 at 03:35 PM, Certified Nursing Assistant #10 was interviewed and stated they work every other weekends and there are days when they have 13 residents on their assignment instead of 10. They stated they had to rush when providing care and difficult for them to take a break. On 02/11/2025 at 03:41 PM, Certified Nursing Assistant #16 was interviewed and stated they work on weekends and there will be days when they 13 to 14 residents on their assignment. They stated it is too much for them, they do not take breaks, and will be rushing to provide care. They stated residents complain about not getting changed on time due to not having enough staff. On 02/11/2025 at 11:55 AM, Registered Nurse Supervisor #6 was interviewed and stated there is usually 1 Registered Nurse Supervisor during the weekends and there are a lot of staff call outs. When a nurse calls out, other nurses will be transferred to a different floor with less coverage and the Registered Nurse Supervisor will come in to he | Plan of Correction: ApprovedMarch 5, 2025 I. Immediate Corrective Action 1. The monthly staffing patterns as of (MONTH) 2025 will be reviewed by the DNS, ADNS and the Staffing Coordinator to ensure that there is sufficient nursing staff provided to meet the needs of the residents on all shifts. 2. Facility will actively continue to enhance staffing by contacting more agencies, advertise for hiring more staff, pay overtime when needed, offer incentives to work extra shifts, increase orientation classes with sign-on bonuses and offer opportunities to join the union when appropriate 3. Resident # 34 met with the DNS, ADNS and Social Worker who reinforced the facilitys commitment to staffing and the importance of their safety as well as maintaining their highest physical, mental and psychosocial well being as determined by their assessments and person-centered plan of care. II. Identification of others:. 1. The facility is aware that they must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 2. The DNS/ADNS/RNS will review all staffing patterns prior to the schedule being posted to ensure that sufficient nursing staff is consistently provided to meet the needs of residents on all shifts 3. An audit tool was developed by the DNS to review staffing to ensure that there is sufficient nursing staff provided to meet the needs of the residents on all shifts. This audit will be done for one week from 3/16/2025 to 3/22/2025 by the DNS / designee. All issues identified will be immediately corrected. III. System changes: 1. The Administrator and DNS reviewed and revised the policy on ?ôStaffing?Ø. 2. ADNS, Staffing Coordinator, Licensed Nurses and Certified Nursing Assistants will be re-educated by the staff educator / designee on the above policy with emphasis on ensuring resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and person - center care plans. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance: 1. The DNS developed an audit tool to ensure that there is sufficient staffing every day on all three shifts. 2. Audits will be done by the ADNS / designee daily x 4 weeks, 3 days a week monthly for 3 months, 3 days a week quarterly thereafter. 3. Any issues identified will have immediate corrective action taken by the DNS & reported to the Administrator. 4. The outcome of this audit will be quantified & reported to the QA committee by the DNS. V. The Director of Nursing will be responsible to ensure correction of this deficiency by 4/7/2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 19. 3. 6. 3. 1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13?4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes. 19. 3. 6. 4 Transfer Grilles. 19. 3. 6. 4. 1 Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors. Based on observation and staff interview, the facility did not ensure that all corridor doors were maintained to resist the passage of smoke. This occurred on floors 1- 4. The findings include: During the life safety survey of 2/10/25, between 9:30 am and 1:00 pm, the following were noted: Transfer grilles were found on corridor doors in the following locations: 1) On the doors to the janitor's closets near rooms 4C25 and 4 DO8 on the 4th floor. 2) On the 3rd floor janitor's closets near rooms 3A08, 3D08 and 3B 25. 3) On the 2nd floor near rooms C25 and D08 4) On the 1st floor on the utility room near the activities room. 2012 NFPA 101 2011 NFPA 25 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 24, 2025 I. Immediate Corrective Action The transfer grilles which were found on corridor doors in the following locations were closed off with metal plates: 1) On the doors to the janitor's closets near rooms 4C25 and 4 DO8 on the 4th floor. 2) On the 3rd floor janitor's closets near rooms 3A08, 3D08 and 3B 25. 3) On the 2nd floor near rooms 2C25 and 2D08 4) On the 1st floor on the utility room near the activities room. II. Identification of Other Residents a. An audit has been conducted of all corridor doors throughout the facility to make sure all doors close and latch as required with proper sealing to prevent the transfer of smoke. b. no additional doors were found noncompliant. c. No residents' additional residents were found to be affected upon completion of this review. III. Systemic Changes 1. The facility has reviewed the Preventive Maintenance Plan and door inspection policy and revised the same to include directives for ventilation grilles, as well as inspection observations 2. All Maintenance staff will be educated by the maintenance director on the Preventive Maintenance Plan and requirement for appropriate Door operation 3. The Lesson Plan will concentrate on the following: > Overview of requirements for K363 > Preventive Maintenance plan for performing observational inspections of the doors > Responsibility for providing appropriate door closures. 4. A copy of the Lesson Plan and attendance will be filed for reference and validation a. The facility reviewed and revised its policy regarding corridor doors. b. All maintenance staff were in service on the updated corridor door policies. IV. QA monitoring a. An audit tool was created to monitor the facilitys corridor doors. b. Monitoring of the facilitys doors shall be performed monthly for the first 3 months and then quarterly thereafter for 9 months. c. Any negative findings from inspections shall be reported to the administrator for further evaluation and will be addressed. d. All reports shall be brought to the Quality Assurance meeting to review with the team to ensure that repairs are being performed in a timely manner for 12 months. V. Title Responsible Director of maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA . 5. 2 Heating, Ventilating, and Air-Conditioning. 19. 5. 2. 1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9. 2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19. 5. 2. 2. 9. 2 Heating, Ventilating, and Air-Conditioning. 9. 2. 1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 90A 4. 3. 11 Plenums. 4. 3. 11. 1 Storage. 4. 3. 11. 1. 1 Plenums shall not be used for occupancy or storage. 4. 3. 11. 1. 2 Accessible abandoned material shall be deemed to be in storage and shall be removed. Where cables are identified for future use with a tag, the tag shall be of sufficient durability to withstand the environment involved. 4. 3. 11. 2 Ceiling Cavity Plenum. The space between the top of the finished ceiling and the underside of the floor or roof above shall be permitted to be used to supply air to the occupied area or to return or exhaust air from the occupied area, provided that the conditions in 4. 3. 11. 2. 1 through 4. 3. 11. 2. 7 are met. 4. 3. 11. 2. 1 The integrity of the fire and smoke stopping for penetrations shall be maintained. 4. 3. 11. 2. 2 Light diffusers, other than those made of metal or glass, used in air-handling light fixtures shall be listed and marked Fixture Light Diffusers for Air-Handling Fixtures. 4. 3. 11. 2. 3 The temperature of air delivered to these plenums shall not exceed 121?é??C (250?é??F). 4. 3. 11. 2. 4 Materials used in the construction of a ceiling plenum shall be noncombustible or shall be limited combustible having a maximum smoke developed index of 50, except as permitted in 4. 3. 11. 2. 4. 1 through 4. 3. 11. 2. 4. 3, and shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the plenum. 4. 3. 11. 2. 4. 1 Materials used in the construction of a plenum space between the ceiling and roof (or floor) of other than the fire-resistive assemblies covered in 5. 3. 3 shall be permitted as specified in 4. 3. 11. 2. 4. 2 and 4. 3. 11. 2. 4. 3. 4. 3. 11. 2. 4. 2 The ceiling material shall have a flame spread index of not more than 25 and a smoke developed index not greater than 50. All surfaces, including those that would be exposed by cutting through the material in any way, shall meet these requirements. 4. 3. 11. 2. 4. 3 The ceiling materials shall be supported by noncombustible material. 4. 3. 11. 2. 5 Where the plenum is a part of a floor-ceiling or roof-ceiling assembly that has been tested or investigated and assigned a fire resistance rating of 1 hour or more, the assembly shall meet the requirements of 5. 3. 3. 4. 3. 11. 2. 6 Materials within a ceiling cavity plenum exposed to the airflow shall be noncombustible or comply with 4. 3. 11. 2. 6. 1 through 4. 3. 11. 2. 6. 10, as applicable. 4. 3. 11. 2. 6. 1* Electrical wires and cables and optical fiber cables shall be listed as having a maximum peak optical density of 0. 50 or less, an average optical density of 0. 15 or less, and a maximum flame spread distance of 1. 5 m (5 ft) or less when tested in accordance with NFPA 262, Standard Method of Test for Flame Travel and Smoke of Wires and Cables for Use in Air- Handling Spaces, or shall be installed in metal raceways without an overall nonmetallic covering, metal sheathed cable without an overall nonmetallic covering, or totally enclosed nonventilated metallic busway without an overall nonmetallic covering. 4. 3. 11. 2. 6. 2 Pneumatic tubing for control systems shall be listed as having a maximum peak optical density of 0. 5 or less, an average optical density of 0. 15 or less, and a maximum flame spread distance of 1. 5 m (5 ft) or less when tested in accordance with ANSI/UL 1820, Standard for Safety Fire Test of Pneumatic Tubing for Flame and Smoke Characteristics. 4. 3. 11. 2. 6. 3 Nonmetallic fire sprinkler piping shall be listed as having a maximum peak optical density of 0. 5 or less, an average optical density of 0. 15 or less, and a maximum flame spread distance of 1. 5 m (5 ft) or less when tested in accordance with ANSI/UL 1887, Standard for Safety Fire Test of Plastic Sprinkler Pipe for Visible Flame and Smoke Characteristics. 4. 3. 11. 2. 6. 4 Optical fiber communications and signaling raceways shall be listed as having a maximum peak optical density of 0. 50 or less, an average optical density of 0. 15 or less, and a maximum flame spread distance of 1. 5 m (5 ft) or less when tested in accordance with ANSI/UL 2024, Standard for Optical Fiber and Communication Cable Raceway. 4. 3. 11. 2. 6. 5* Loudspeakers, recessed lighting fixtures, and other electrical equipment with combustible enclosures, including their assemblies and accessories, cable ties, and other discrete products, shall be permitted in the ceiling cavity plenum where listed as having a maximum peak optical density of 0. 5 or less, an average optical density of 0. 15 or less, and a peak heat release rate of 100 kW or less when tested in accordance with ANSI/UL 2043, Standard for Safety Fire Test for Heat and Visible Smoke Release for Discrete Products and Their Accessories Installed in Air-Handling Spaces. 4. 3. 11. 2. 6. 6 Plastic piping and tubing used in plumbing systems shall be permitted to be used within a ceiling cavity plenum if it exhibits a flame spread index of 25 or less and a smoke developed index of 50 or less when tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials, or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials, at full width of the tunnel and with no water or any other liquid in the pipe during the test. 4. 3. 11. 2. 6. 7 Supplementary materials for air distribution systems shall be permitted provided they comply with the provisions of 4. 3. 3. 4. 3. 11. 2. 6. 8 Smoke detectors shall not be required to meet the provisions of Section 4. 3. 3. 11. 2. 6. 9 Air ducts complying with 4. 3. 1. 2 and air connectors complying with 4. 3. 2 shall be permitted. 4. 3. 11. 2. 6. 10 Materials that, in the form in which they are used, shall have a potential heat value not exceeding 8141 kJ/kg (3500 Btu/lb), when tested in accordance with NFPA 259, Standard Test Method for Potential Heat of Building Materials, and include either of the following: (1) Materials having a structural base of noncombustible material, with a surfacing not exceeding a thickness of 3. 2 mm (1?8 in.) that has a flame spread index not greater than 50 (2) Materials, in the form and thickness used, having neither a flame spread index greater than 25 nor evidence of continued progressive combustion, and of such composition that surfaces that would be exposed by cutting through the material on any plane would have neither a flame spread index greater than 25 nor evidence of continued progressive combustion, when tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials, or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials. 4. 3. 11. 2. 7 The accessible portion of abandoned materials exposed to airflow shall be removed. Based on observation and staff interview, the facility did not ensure that all components of the heating and ventilation system were in compliance with 2012 NFPA 101 and 2012 NFPA 90A. This occurred on the second floor of the extension building. The findings include: During the Life Safety Code portion of the recertification survey on 2/10//25 at approximately 11:30 am, an unducted air return was being used as a ceiling plenum on the lobby level in the office suite. Areas above the ceiling were observed to have multiple penetrations between the lobby, which is a means of egress, and the adjacent offices. This arrangement would allow smoke to enter the lobby and impede egress in the event of a fire in these adjacent spaces. At | Plan of Correction: ApprovedFebruary 24, 2025 I. Immediate Corrections:?é-?é-?é- 1. The facility conducted a review of the lobby and office area plenum for compliance with NFPA 90A 4. 3. 11. 2. 1 through 4. 3. 11. 2. 7 The integrity of the fire and smoke stopping for penetrations shall be maintained. 2. The facility maintenance department has sealed with appropriate material all openings that were found throughout the above ceiling to adjoining rooms to prevent the transfer of smoke. ?é-?é- ?é-?é-?é- II Identification of Other residents:?é-?é-?é- 1. The Facility respectfully states that?é-all residents were potentially affected but?é-no residents were involved in this deficiency.?é-?é- 2. There were no?é-additional?é-issues identified from this environment review, as all egress doors functioned appropriately?é-?é-?é- ?é-?é-?é- III. Systemic Changes:?é-?é-?é- 1. The Director of Maintenance has reviewed and implemented a Preventive Maintenance Program Whereby the above ceilings are checked?é-in accordance with 2012 NFPA 90A: 4. 3. 11. 2. 1 through 4. 3. 11. 2. 7 and documented on the inspection log with any corrective actions required or completed.?é- 2. If repairs cannot be completed in house, then the items shall be logged on master work Log and appropriate service company called with completion noted on master work log.?é-?é- 3. Staff performing the required inspections shall in-serviced on the requirements set forth above. ?é-?é-?é- ?é-?é-?é- IV. QA?é-Monitoring ?é-?é-?é- 1. The?é-Director of Maintenance will audit the completed inspection and testing log for completeness and completed repairs. 2. The audit will be completed weekly?é-by the Maintenance staff /designee as assigned and reviewed by the Director of Maintenance.?é-?é-?é- 3. Any quality issues identified will be communicated to the Administrator and repaired for compliance?é-as identified?é-?é-?é- 4. Audit findings from the monthly tool will be presented to the Quarterly QA Committee by the Director of?é-Maintenance for evaluation and follow-up as indicated.?é- The review will continue for 6 months and then semiannual if there are no deficiencies found.?é- responsible Person:?é-?é-?é- V. Title Responsible Director of maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 3. 5 Extinguishment Requirements. 19. 3. 5. 1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9. 7, unless otherwise permitted by 19. 3. 5. 5. 2010 NFPA 13 8. 6. 5. 1 Performance Objective. 8. 6. 5. 1. 1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8. 6. 5. 2 and 8. 6. 5. 3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard Reaching the Hazard. 8. 6. 5. 3. 1 Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8. 6. 5. 3. Based on observation and interview, the facility did not ensure that all areas of the building were protected by the automatic sprinkler system. This occurred on the 1st and 2nd floors. The findings include: During the life safety survey on 2/10/25 between 9:30 am and 1:00 pm, the following were noted: 1) In the 2nd floor air handling room on the A unit, there was one sprinkler head on the door side of the room. There was no sprinkler head under the wide ductwork that is suspended from the ceiling. 2) In the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station and the 1st floor utility closet by the activities room, a light fixture was located directly under the upright sprinkler heads. This may affect the spray pattern of the sprinkler heads. At the time of these findings, the Director of Maintenance stated these fondings would be corrected. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 24, 2025 I. Immediate Corrective Action 1. The facility Director of Maintenance contacted the Fire Sprinkle Company upon Discovery to install the required missing fire sprinklers in the 2nd floor air handling room on the A unit, there was under the wide ductwork that is suspended from the ceiling. 2. In the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station and the 1st floor utility closet by the activities room, The light fixture which was located directly under the upright sprinkler heads has been relocated to provide proper clearance to not affect the spray pattern of the sprinkler heads and was provided with Appropriate coverage. II. Identification of Other Residents The Facility respectfully states that no residents were involved in this deficiency, however all residents were directly affected. The Director of Maintenance reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1. The Administrator, in conjunction with the Director of Maintenance, reviewed and revised the facility construction/renovation policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies for any Renovation Plan. 2. Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. IV. QA Monitoring 1. The Administrator, in conjunction with the Director of Maintenance, will conduct monthly reviews and inspections of sprinkler reports for the next 3 months, then upon completion of work thereafter. Documentation will be maintained in logbook for reference and validation. 2. The Director of Maintenance will review the findings and report to QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Title Responsible Director of maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25 5. 2* Inspection. .2011 NFPA 25: Table 6. 1. 1. 2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 5. 3. 2* Gauges. 2011 NFPA 25 5. 3. 2. 1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 5. 3. 2. 2 Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. 5. 3. 3 Waterflow Based on observation and staff interview, the facility did not ensure that all fire hoses were inspected, tested and maintained in accordance with 2011 NFPA 25. This occurred on all landings of the E stairwell. The findings include: During the life safety survey on 2/11/25, between 9:30 am and 1:00 pm, it was noted that the fire hoses in stair E on landings 1-4, were marked with a date of 3-18 (March (YEAR)). There was no documentation that the hoses had been inspected or replaced within the last five years. At the time of this finding, the Director of Maintenance stated that the vendor would be contacted to correct this. 2012 NFPA 101 2011 NFPA 25 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 24, 2025 I. Immediate Corrective Action 1. The Director of Maintenance engaged our Service Company to replace the identified standpipe hoses with new hoses in all locations more than five years old. 2. The Director of Maintenance engaged our Service Company to inspect the buildings standpipe system to determine hose testing years and complete NFPA required testing if necessary. II. Identification of Other Residents All Residents have the potential to be affected by this practice. The Director of Maintenance had the company check all hose stations and for similar issues. No other deficiencies were found. No other standpipe, hose or water-based fire prevention issues were found. III. Systemic Changes 1. The Administrator policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2. The existing rounds inspection form has added the monthly standpipe audit tool. 3. All environment of care staff were educated on the revision of this policy by the Director of Maintenance. Non-compliant hose systems shall be Replaced with appropriate type and reported to the Administrator and Director of Maintenance for scheduled correction. 4. This has been added to the facility preventive Engineering program. 5. Staff involved in the of the sprinkler system were educated by the Director of Maintenance that any issues with standpipe system identified during rounds will be corrected asap and interim safety measures put in place as needed until repairs are complete IV. QA Monitoring An audit tool was created by the Director of Maintenance to monitor compliance with required inspections of sprinkler systems.?é-This audit includes inspection of Hose racks. Any identified issues will be scheduled for correction asap. All of the facilities plenum will be audited monthly by the Director of Maintenance for the first 3 months and then quarterly for 9 months. Audit results shall be reported to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. Frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. ?é- V. Title Responsible Director of maintenance |