NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: May 8, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during a complaint survey (#NY 182) conducted on 8/25/2022 through 8/26/2022 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) CNA #1 did not follow transmission-based (isolation) precautions for Resident #1 upon entering their room. 2) CNA #1 and CNA #2 did not follow transmission-based precautions prior to personal care for Resident # 2. 3) CNA #1 and CNA #2, did not perform hand hygiene in between care of Resident#1 and Resident # 2. The findings are: 1) Resident #1 was admitted to the facility on [DATE] with the following medical [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) Assessment, dated 06/19/2022 documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of the facilities infection control policy titled, Infection Control: Staff Guidelines and dated 01/05/2020, documented: Nursing staff will/may initiate strict isolation measures on any resident that demonstrates potential for spreading communicable disease. Review of the facilities policy titled, Covid-19 Virus- Screening and Testing of Residents, dated 02/10/2022 documented: Signage to identify a resident for cohort: 1) blue signs are for residents under observation: Droplet, Contact Precautions, Strict Isolation. Red signs are for residents that are positive for COVID-19: Personal Protective Equipment used: N95 (respirator) mask with a surgical mask over it and eye protection. Gowns must be utilized with all direct care. All staff with proper Personal Protective Equipment may enter the resident's rooms. A Physician order, dated 08/19/2022, documented Strict Isolation, Droplet and Contact Precautions. Resident #1 was Covid Positive. The Comprehensive Care Plan (CCP), dated 08/19/2022, titled, at risk for COVID-19 due to pandemic outbreak and a Covid positive diagnosis. Interventions included: staff will wear a mask when within 6 feet from an individual. The Covid-19 test result revealed Resident #1 had a positive Covid-19 test result on 08/19/ 2022. During an observation on 08/25/2022 at 3:10 PM, CNA #1 was observed to entered Resident #1's room with two surgical masks across their (CNA#1s) face. CNA#1 was not wearing eye goggles, or a face shield as required per sign posted on Resident #1's door. The red sign documented, STOP Droplet and Contact Precautions everyone must Wear a fit tested N95 (respirator) mask, surgical mask over the N95 (respirator) mask and eye protection. Certified Nursing Assistant (CNA) #1 was interviewed on 08/25/2022 at 3:14 PM. CNA #1 stated that Resident #1's door had a sign posted for Transmission Based Precautions and they (CNA#1) were supposed to wear an N95 (respirator) mask. CNA #1 stated a red sign that is posted on a resident's door usually means a resident was positive with COVID. CNA#1 could not explain why they (CNA#1) did not follow facility policy on Transmission Based Precautions. The Director of Nursing Services (DNS) was interviewed on 08/26/22 at 1:24 PM. The DNS stated a red sign posted on the residents' door means the resident is Covid positive and on strict isolation contact and droplet precautions. The DNS stated the policy is to have a Single use of gowns, goggles, or a disposable face shield. Additionally, the DNS stated that CNA #1 should wear an N95 (respirator) mask, with a surgical mask over it or just an N95 (respirator). The DNS further stated that CNA #1 did not follow the facility policy to wear an N95 (respirator) mask and eye shield. The Administrator was interviewed on 08/26/2022 at 3:27 PM. The Administrator stated that Covid positive transmission-based precautions include gloves, gowns, N95 (respirator) with surgical mask over it and eye protection (goggles or shield). The Administrator also stated staff are required to wear a surgical mask over the N95(respirator), which CNA #1 failed to do. 2) Resident #2 was readmitted to the facility on [DATE], with the following medical [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2022, documented that Resident #2's cognitive skills for daily decision making was severely impaired. Resident #2 required extensive assistance of two persons for toilet use and extensive assistance of one person for dressing and personal hygiene. Review of the facilities policy titled, Covid-19 Virus- Screening and Testing of Residents, dated 02/10/2022 documented: Signage to identify a resident for cohort: 1) blue sign rooms are for residents under observation: Droplet, Contact Precautions, Strict Isolation. Red signs on residents doors are for residents that are positive for Covid-19: Personal Protective Equipment used: N95 (respirator) mask with a surgical mask over it and eye protection. Gowns must be utilized with all direct care. All staff with proper Personal Protective Equipment may enter the resident's rooms. The Comprehensive Care Plan (CCP) for Resident #2, dated 07/12/2022 and titled: Covid at risk for Etiology: documented that Resident #2 was at risk for Covid-19 due to a pandemic outbreak. Interventions included: All staff will wear a mask within 6 feet of the resident and follow Covid-19 protocols and procedures. The Comprehensive Care Plan (CCP) dated 07/13/2022 and titled: Infection, documented status [REDACTED]. A Physician's Progress Note, dated 07/27/2022 at 8:00 PM, documented that Resident #2 had Covid 19. Certified Nursing Assistant #2 (CNA#2) was observed on 08/25/2022 at 3:20 PM, wearing two surgical masks and eye goggles while providing care to Resident # 2. A blue quarantine sign was observed on the door of Resident #2's room that documented Quarantine, droplet and contact precautions, everyone must sanitize their hands before entering and exiting the room, wear fit tested N95 (respirator) mask, surgical mask, and eye protection. The sign also documented must change gown and gloves for each resident. Please ask resident to wear a mask during care and disinfect all re-usable medical and rehabilitation equipment. Certified Nursing Assistant #2 (CNA#2) and CNA #1 were observed on 08/25/2022 at 3:30 PM, entering Resident #2's room. CNA #2 had two surgical masks in place over their face with goggles and no gown and CNA #1 had two surgical masks on over their face, no goggles or gown. Certified Nursing Assistant #2 (CNA #2) was interviewed on 08/25/2022 at 3:30 PM. CNA #2 stated they (CNA#1 and CNA#2) entered Resident #2's room without proper N95(respirator) mask and gown. CNA #2 could not explain why they (CNA#1 & #2) did not follow facility policy on Transmission Based Precautions. Certified Nursing Assistant #2 (CNA#2) was interviewed on 08/25/2022 at 4:18 PM. CNA #2 stated they (CNA#1 & #2) went in Resident #2's room to assist CNA #1 with care of Resident #2 and did not wear gowns or N95 (respirator) masks. CNA #2 could not explain why they (CNA#1 & #2) did not follow facility policy on Transmission Based Precautions. The Director of Nursing Services (DNS) was interviewed on 08/26/2022 at 1:24 PM. The DNS stated for a blue quarantine sign the difference was full Personal Protective Equipment was required during direct care. The Administrator was interviewed on 08/26/2022 at 3:27 PM. The Administrator stated the staff communicate during the morning meeting about which residents are on isolation. Review of facility training/in-service titled, Respiratory Protection Standard, dated 05/11/2022, revealed CNA #2 had received training. 3 (A) Resident #2 was readmitted to the facility on [DATE], with the following medical [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2022, documented that Resident #2's cognitive skills for daily decision making was severely impaired. The Comprehensive Care Plan (CCP), dated 07/12/2022, titled: Covid at risk for Etiology: documented that Resident #2 was at risk for Covid-19 due to the pandemic outbreak. Interventions included: All staff will wear a mask within 6 feet of resident, follow COVID-19 protocols and procedures. The Comprehensive Care Plan (CCP), dated 07/13/2022, titled: infection, status [REDACTED]. B) Resident #3 was admitted to the facility on [DATE] with the following medical [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (MDS) Assessment, dated 08/7/2022, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the facilities infection control policy, Hand Hygiene, dated 04/2018, documented Proper hand hygiene is required for the prevention of transmission of infectious diseases. Utilizing proper handwashing technique and appropriate use of hand sanitizer is a basic skill employees must possess. Policy: All personnel working in the long-term care facility are required to wash (sanitize)their hands before and after resident contact, after touching contaminated surfaces and when coming out of a room with posted precautions. Physicians' orders, dated 08/10/2022, documented an order for [REDACTED].#2 was then observed to exit Resident #3's room without performing hand hygiene and then proceeded to push a cart, with Styrofoam cups on top. Certified Nursing Assistant #1 (CNA#1) and CNA #2 were observed on 08/25/2022 at 3:30 PM. CNA#1 and CNA#2 entered Resident #2's room and provided care to Resident #2 without performing hand hygiene prior to entrance. Certified Nursing Assistant #2 (CNA#2) was interviewed on 08/25/2022 at 3:30 PM. CNA #2 stated they went into Resident #2's room and failed to wash or sanitize their hands before and after entry into the room. CNA#2 could not explain why they (CNA#2) did not follow facility policy on hand hygiene. Licensed Practical Nurse #1 (LPN #1) was interviewed on 08/25/2022 at 3:45 PM. LPN # 1 stated handwashing or hand sanitizing is required before and after coming out of the resident's room and after resident care. Licensed Practical Nurse #2 (LPN #2) was interviewed on 08/25/2022 at 3:49 PM. LPN #2 stated the staff should wash or sanitize hands before, and upon exiting the resident's room. Director of Nursing Services (DNS) was interviewed on 08/26/2022 at 1:24 PM. The DNS stated that hand hygiene should be performed before entrance of a resident's room and after removing Personal Protective Equipment. The DNS also stated staff are to wash hands or sanitize their hands in between glove changes. The Administrator was interviewed on 08/26/22 at 3:27 PM. The Administrator stated hand hygiene should be performed before and after care and in between resident service, and before and after room entrance and exit. RN #1 (Registered Nurse) was interviewed by telephone on 09/09/2022 at 11:15 AM. RN #1 stated they (RN#1) worked with DNS to educate staff to the facilities infection control protocols. RN #1 stated that CNA #1 and CNA #2, had been trained to perform hand hygiene upon hire. RN #1 stated the process to train staff was to first have staff understand and read the facility policies. Then to follow the policy/training provided. RN#1 stated handwashing competency was reviewed with facility staff, to wash hands for 20 seconds with soap and water or (hand sanitizer) along with return demonstration and included when hand hygiene was required. ??®??? 483. 80 (a) (1-3); (3) | Plan of Correction: ApprovedMay 9, 2025 Step 1: Licensed nurses that failed to sign Narcotic shift to shift counts received written disciplinary memos. DON and Unit Managers with units less than 100% compliance for Narcotics shift to shift counts were counseled by the Director Of Clinical Operations regarding daily follow up of Narcotic ledgers and shift to shift count. No residents were affected by the lack of compliance. All narcotics were reconciled on 4/28/25 with no discrepancies noted. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to Narcotics shift to shift count. All Narcotic ledgers were reviewed for omissions and disciplinary actions issued as indicated. Step 3: Unit Narcotic ledgers will be brought to morning meeting for IDT team review x 4 weeks. Licensed nurses who failed to sign shift to shift count will receive progressive disciplinary action. All licensed nurses will be re-educated regarding Narcotic Management including necessity of shift to shift count. Education will include progressive disciplinary action for nurses failing to follow protocol. Education will include a post test to ensure understanding of information. The policy for Narcotic Management was reviewed by the Director Of Clinical Operations with no revisions required. Step 4: The DON or designee will complete Weekly Narcotics Reconciliation audit of all Unit Narcotics ledgers x 8 weeks. Audits will ensure that all shift to shift counts are completed and will include random observations to verify that shift to shift counts are being completed. Any issues identified will result in disciplinary action. The Pharmacy Consultant was made aware of the facilities plan for compliance and will review audits monthly x 3 months. The results of reviews and audits will be forwarded to the QAPI Committee for review and input. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: May 8, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews during a complaint survey (#NY 182) conducted on 8/25/2022 through 8/26/2022 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) CNA #1 did not follow transmission-based (isolation) precautions for Resident #1 upon entering their room. 2) CNA #1 and CNA #2 did not follow transmission-based precautions prior to personal care for Resident # 2. 3) CNA #1 and CNA #2, did not perform hand hygiene in between care of Resident#1 and Resident # 2. The findings are: 1) Resident #1 was admitted to the facility on [DATE] with the following medical [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) Assessment, dated 06/19/2022 documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Review of the facilities infection control policy titled, Infection Control: Staff Guidelines and dated 01/05/2020, documented: Nursing staff will/may initiate strict isolation measures on any resident that demonstrates potential for spreading communicable disease. Review of the facilities policy titled, Covid-19 Virus- Screening and Testing of Residents, dated 02/10/2022 documented: Signage to identify a resident for cohort: 1) blue signs are for residents under observation: Droplet, Contact Precautions, Strict Isolation. Red signs are for residents that are positive for COVID-19: Personal Protective Equipment used: N95 (respirator) mask with a surgical mask over it and eye protection. Gowns must be utilized with all direct care. All staff with proper Personal Protective Equipment may enter the resident's rooms. A Physician order, dated 08/19/2022, documented Strict Isolation, Droplet and Contact Precautions. Resident #1 was Covid Positive. The Comprehensive Care Plan (CCP), dated 08/19/2022, titled, at risk for COVID-19 due to pandemic outbreak and a Covid positive diagnosis. Interventions included: staff will wear a mask when within 6 feet from an individual. The Covid-19 test result revealed Resident #1 had a positive Covid-19 test result on 08/19/ 2022. During an observation on 08/25/2022 at 3:10 PM, CNA #1 was observed to entered Resident #1's room with two surgical masks across their (CNA#1s) face. CNA#1 was not wearing eye goggles, or a face shield as required per sign posted on Resident #1's door. The red sign documented, STOP Droplet and Contact Precautions everyone must Wear a fit tested N95 (respirator) mask, surgical mask over the N95 (respirator) mask and eye protection. Certified Nursing Assistant (CNA) #1 was interviewed on 08/25/2022 at 3:14 PM. CNA #1 stated that Resident #1's door had a sign posted for Transmission Based Precautions and they (CNA#1) were supposed to wear an N95 (respirator) mask. CNA #1 stated a red sign that is posted on a resident's door usually means a resident was positive with COVID. CNA#1 could not explain why they (CNA#1) did not follow facility policy on Transmission Based Precautions. The Director of Nursing Services (DNS) was interviewed on 08/26/22 at 1:24 PM. The DNS stated a red sign posted on the residents' door means the resident is Covid positive and on strict isolation contact and droplet precautions. The DNS stated the policy is to have a Single use of gowns, goggles, or a disposable face shield. Additionally, the DNS stated that CNA #1 should wear an N95 (respirator) mask, with a surgical mask over it or just an N95 (respirator). The DNS further stated that CNA #1 did not follow the facility policy to wear an N95 (respirator) mask and eye shield. The Administrator was interviewed on 08/26/2022 at 3:27 PM. The Administrator stated that Covid positive transmission-based precautions include gloves, gowns, N95 (respirator) with surgical mask over it and eye protection (goggles or shield). The Administrator also stated staff are required to wear a surgical mask over the N95(respirator), which CNA #1 failed to do. 2) Resident #2 was readmitted to the facility on [DATE], with the following medical [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2022, documented that Resident #2's cognitive skills for daily decision making was severely impaired. Resident #2 required extensive assistance of two persons for toilet use and extensive assistance of one person for dressing and personal hygiene. Review of the facilities policy titled, Covid-19 Virus- Screening and Testing of Residents, dated 02/10/2022 documented: Signage to identify a resident for cohort: 1) blue sign rooms are for residents under observation: Droplet, Contact Precautions, Strict Isolation. Red signs on residents doors are for residents that are positive for Covid-19: Personal Protective Equipment used: N95 (respirator) mask with a surgical mask over it and eye protection. Gowns must be utilized with all direct care. All staff with proper Personal Protective Equipment may enter the resident's rooms. The Comprehensive Care Plan (CCP) for Resident #2, dated 07/12/2022 and titled: Covid at risk for Etiology: documented that Resident #2 was at risk for Covid-19 due to a pandemic outbreak. Interventions included: All staff will wear a mask within 6 feet of the resident and follow Covid-19 protocols and procedures. The Comprehensive Care Plan (CCP) dated 07/13/2022 and titled: Infection, documented status [REDACTED]. A Physician's Progress Note, dated 07/27/2022 at 8:00 PM, documented that Resident #2 had Covid 19. Certified Nursing Assistant #2 (CNA#2) was observed on 08/25/2022 at 3:20 PM, wearing two surgical masks and eye goggles while providing care to Resident # 2. A blue quarantine sign was observed on the door of Resident #2's room that documented Quarantine, droplet and contact precautions, everyone must sanitize their hands before entering and exiting the room, wear fit tested N95 (respirator) mask, surgical mask, and eye protection. The sign also documented must change gown and gloves for each resident. Please ask resident to wear a mask during care and disinfect all re-usable medical and rehabilitation equipment. Certified Nursing Assistant #2 (CNA#2) and CNA #1 were observed on 08/25/2022 at 3:30 PM, entering Resident #2's room. CNA #2 had two surgical masks in place over their face with goggles and no gown and CNA #1 had two surgical masks on over their face, no goggles or gown. Certified Nursing Assistant #2 (CNA #2) was interviewed on 08/25/2022 at 3:30 PM. CNA #2 stated they (CNA#1 and CNA#2) entered Resident #2's room without proper N95(respirator) mask and gown. CNA #2 could not explain why they (CNA#1 & #2) did not follow facility policy on Transmission Based Precautions. Certified Nursing Assistant #2 (CNA#2) was interviewed on 08/25/2022 at 4:18 PM. CNA #2 stated they (CNA#1 & #2) went in Resident #2's room to assist CNA #1 with care of Resident #2 and did not wear gowns or N95 (respirator) masks. CNA #2 could not explain why they (CNA#1 & #2) did not follow facility policy on Transmission Based Precautions. The Director of Nursing Services (DNS) was interviewed on 08/26/2022 at 1:24 PM. The DNS stated for a blue quarantine sign the difference was full Personal Protective Equipment was required during direct care. The Administrator was interviewed on 08/26/2022 at 3:27 PM. The Administrator stated the staff communicate during the morning meeting about which residents are on isolation. Review of facility training/in-service titled, Respiratory Protection Standard, dated 05/11/2022, revealed CNA #2 had received training. 3 (A) Resident #2 was readmitted to the facility on [DATE], with the following medical [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS) Assessment, dated 07/15/2022, documented that Resident #2's cognitive skills for daily decision making was severely impaired. The Comprehensive Care Plan (CCP), dated 07/12/2022, titled: Covid at risk for Etiology: documented that Resident #2 was at risk for Covid-19 due to the pandemic outbreak. Interventions included: All staff will wear a mask within 6 feet of resident, follow COVID-19 protocols and procedures. The Comprehensive Care Plan (CCP), dated 07/13/2022, titled: infection, status [REDACTED]. B) Resident #3 was admitted to the facility on [DATE] with the following medical [DIAGNOSES REDACTED]. Resident #3's Minimum Data Set (MDS) Assessment, dated 08/7/2022, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the facilities infection control policy, Hand Hygiene, dated 04/2018, documented Proper hand hygiene is required for the prevention of transmission of infectious diseases. Utilizing proper handwashing technique and appropriate use of hand sanitizer is a basic skill employees must possess. Policy: All personnel working in the long-term care facility are required to wash (sanitize)their hands before and after resident contact, after touching contaminated surfaces and when coming out of a room with posted precautions. Physicians' orders, dated 08/10/2022, documented an order for [REDACTED].#2 was then observed to exit Resident #3's room without performing hand hygiene and then proceeded to push a cart, with Styrofoam cups on top. Certified Nursing Assistant #1 (CNA#1) and CNA #2 were observed on 08/25/2022 at 3:30 PM. CNA#1 and CNA#2 entered Resident #2's room and provided care to Resident #2 without performing hand hygiene prior to entrance. Certified Nursing Assistant #2 (CNA#2) was interviewed on 08/25/2022 at 3:30 PM. CNA #2 stated they went into Resident #2's room and failed to wash or sanitize their hands before and after entry into the room. CNA#2 could not explain why they (CNA#2) did not follow facility policy on hand hygiene. Licensed Practical Nurse #1 (LPN #1) was interviewed on 08/25/2022 at 3:45 PM. LPN # 1 stated handwashing or hand sanitizing is required before and after coming out of the resident's room and after resident care. Licensed Practical Nurse #2 (LPN #2) was interviewed on 08/25/2022 at 3:49 PM. LPN #2 stated the staff should wash or sanitize hands before, and upon exiting the resident's room. Director of Nursing Services (DNS) was interviewed on 08/26/2022 at 1:24 PM. The DNS stated that hand hygiene should be performed before entrance of a resident's room and after removing Personal Protective Equipment. The DNS also stated staff are to wash hands or sanitize their hands in between glove changes. The Administrator was interviewed on 08/26/22 at 3:27 PM. The Administrator stated hand hygiene should be performed before and after care and in between resident service, and before and after room entrance and exit. RN #1 (Registered Nurse) was interviewed by telephone on 09/09/2022 at 11:15 AM. RN #1 stated they (RN#1) worked with DNS to educate staff to the facilities infection control protocols. RN #1 stated that CNA #1 and CNA #2, had been trained to perform hand hygiene upon hire. RN #1 stated the process to train staff was to first have staff understand and read the facility policies. Then to follow the policy/training provided. RN#1 stated handwashing competency was reviewed with facility staff, to wash hands for 20 seconds with soap and water or (hand sanitizer) along with return demonstration and included when hand hygiene was required. ??®??? 483. 80 (a) (1-3); (3) | Plan of Correction: ApprovedMay 9, 2025 Step 1: Licensed nurses that failed to sign Narcotic shift to shift counts received written disciplinary memos. DON and Unit Managers with units less than 100% compliance for Narcotics shift to shift counts were counseled by the Director Of Clinical Operations regarding daily follow up of Narcotic ledgers and shift to shift count. No residents were affected by the lack of compliance. All narcotics were reconciled on 4/28/25 with no discrepancies noted. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to Narcotics shift to shift count. All Narcotic ledgers were reviewed for omissions and disciplinary actions issued as indicated. Step 3: Unit Narcotic ledgers will be brought to morning meeting for IDT team review x 4 weeks. Licensed nurses who failed to sign shift to shift count will receive progressive disciplinary action. All licensed nurses will be re-educated regarding Narcotic Management including necessity of shift to shift count. Education will include progressive disciplinary action for nurses failing to follow protocol. Education will include a post test to ensure understanding of information. The policy for Narcotic Management was reviewed by the Director Of Clinical Operations with no revisions required. Step 4: The DON or designee will complete Weekly Narcotics Reconciliation audit of all Unit Narcotics ledgers x 8 weeks. Audits will ensure that all shift to shift counts are completed and will include random observations to verify that shift to shift counts are being completed. Any issues identified will result in disciplinary action. The Pharmacy Consultant was made aware of the facilities plan for compliance and will review audits monthly x 3 months. The results of reviews and audits will be forwarded to the QAPI Committee for review and input. |