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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during the Recertification survey from 2/20/25 through 2/27/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #27) reviewed for activities of daily living. Specifically, Resident #27 required staff assistance with personal hygiene was observed on 3 occasions with long and dirty fingernails. Findings include: The policy and procedure titled Clinical, Activities of Daily Living Protocol, Policy and Procedure last revised 11/2022 documented the facility will implement measures to assess the resident's ability to perform Activities of Daily Living and based on the assessment, will implement treatment and services, based on the resident's needs and choices, to maintain/improve and prevent decline due to reversible causes whenever possible. The facility provides services for the following Activities of Daily Living, which included but not limited to hygiene - bathing, dressing, grooming and oral care. The Resident #27 was admitted with [DIAGNOSES REDACTED]. The 1/31/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented the Resident #27 had intact cognition, had impairment on both sides of upper and lower extremities and was dependent with self-care abilities. The 10/3/24 care plan titled Activities of Daily Living documented the resident was dependend ton staff for eating, hygiene, dressing, and bathing. The resident did none of the effort and staff did all the effort. The certified nurse aide was responsible for activities of daily living. The 2/20/25, 2/21/25 and 2/24/25 Certified Nurse Assistant Activity of Daily Living Tasks documented Resident #27 was dependent on staff for ability to maintain personal hygiene. During observation on 2/20/25 at 11:44 AM, Resident #27 was in bed. The resident had finger deformities on their both hands. Some fingers were twisted in an outward direction revealing long fingernails with dark brown matter underneath, other fingers in the middle joint bended inward, toward the palm. The resident stated that they would like to take care of their long fingernails, but they could not, and the staff told them that they were busy. During observations on 2/21/25 at 2:16 PM and 2/24/25 at 10:58 AM, Resident #27 was in bed, revealing long fingernails with dark brown matter underneath. During an interview on 2/26/25 3:58 PM, Certified Nurse Aide #19 stated that shaving and clipping fingernails were included under the personal hygiene care. They said that they documented performance of personal hygiene for residents, but there was no specific task for shaving or fingernail clipping to document. Certified Nurse Aide #19 stated that by observation or asking the resident's preferences the Certified Nurse Aide could perform these tasks. They stated these were Certified Nurse Aide responsibilities. The surveyor went to the resident's room accompanied by Certified Nurse Aide and observed the resident's short fingernails. The resident stated that the nurse clipped their nails yesterday. The Certified Nurse Aide #19 stated when they provided assistance with personal hygiene they did not remember if the nails were long, and did not remember when they were clipped last time. During an interview on 2/26/25 at 4:11 PM Licensed Practical Nurse #18 stated clipping of fingernails and shaving tasks were included under personal hygiene care. They said that they clipped the resident's fingernails on 2/25/25 and noticed how long they were. They stated they did not know when the resident's nails were last clipped and they sometimes clipped them when the certified nurse aides were busy. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMarch 21, 2025 F 677 ADL Care Provided for Dependent Residents I. The Following Actions were accomplished for the residents identified in the Sample: ?é?ÀResident #27 was assessed by Licensed Unit Manager on 2/25/2025 and the designated C.N.A provided nail care, including trimming, and documented accordingly. ?é?ÀThe C.N.A assigned to Resident #27 and the Licensed Practical Nurse #18 received in-service education on the importance of providing nail care for all residents. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have been identified as potentially affected by the same practices. ?é?ÀAll Unit Manager will conduct direct care observations of all residents in their assigned units to ensure that fingernails are properly trimmed, cleaned and filed. ?é?ÀAny identified residents will be provided with nail care and will be documented accordingly. III. The following systemic changes will be implemented to ensure the deficient practice will not recur: ?é?ÀThe Policy and Procedure titled Clinical, Activities of Daily Living Protocol and Policy was reviewed by the Administrator and Director of Nursing. No further revisions were necessary. ?é?ÀNursing staff will be provided with an in-serviced education by the Licensed Staff Educator or ADON on providing nail care and documented accordingly. IV. The facilitys corrective action will be monitored to ensure the deficient practice does not recur utilizing the following Quality Assurance practice: ?é?ÀThe Director of Nursing/designee will develop an audit tool entitled ?ôNail Care ÔÇ£ Personal Hygiene.?Ø The Audit tool will be utilized to monitor ten (10) residents per week for each unit and all new admissions to ensure that nail care is provided and documented accordingly. ?é?ÀThe audits will be conducted weekly for 3 months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing/Designee. Responsible: Director of Nursing is responsible for ensuring all above is completed |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 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 initiated on 2/20/2025 and completed on 2/27/2025 the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for one (Resident #112) of one resident reviewed for bowel and bladder. Specifically, Resident #112 was not assessed and care planned to improve and restore continence to the extent possible. Findings include: The facility Policy and Procedure, dated 11/1/2026, titled Clinical Bladder Management, documented it is the policy of the facility to assess each resident's bladder continence status on a defined schedule. This assessment will enable the staff to implement a resident-specific re-training, toileting program that addresses the individual's bladder function needs. Resident #112 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (an assessment tool) dated 2/5/25 documented the resident's cognition was intact, they required supervision with eating, and substantial to maximal assist with all other activities of daily living. The resident's bowel and bladder status was documented as frequently incontinent. The Nurse Admission assessment dated [DATE], documented the resident was occasionally incontinent. The Activities of Daily Living documentation revealed the resident was incontinent of bladder on 2/1/25,2/5/25, 2/7/25, 2/9/25, 2/10/25, 2/11/25, 2/13/25, 2/16/25, 2/21/25, and 2/25/ 25. The Activities of Daily Living Care Plan dated 1/30/25, documented the resident required extensive assistance for toilet hygiene and toilet transfers. The care plan did not include a voiding diary or a toileting program. During an interview on 02/21/25 at 11:39 AM, Resident #112 stated the facility had them wear a pullup, and they did not like to wear a pullup. They stated before they came to the facility, they were able to use the bathroom and had no accidents. They stated they would like to be able to use the bathroom and not wear a pull up. They did not recall being on a toileting schedule or being encouraged to use the bathroom every 2 hours. During an interview on 02/25/25 at 1:25 PM, Registered Nurse #2 stated if a resident had a new onset of incontinence, they would expect to complete an assessment and complete an incontinence care plan. They were unsure why the resident did not have a care plan for incontinence. During an interview on 02/25/25 at 04:45 PM, the Assistant Director of Nursing stated they were unsure why the incontinence care plan or a toileting program was not created for Resident # 112. During an interview on 02/26/25 at 1:54 PM, Certified Nurse Aide #33 stated they usually toileted all residents every 2 hours on rounds. Resident #112 knew when they needed to go to the bathroom and rang the bell for assistance. They stated Resident #112 was put on a toileting program yesterday. 10NYCRR- 415. 12(d)(2) | Plan of Correction: ApprovedMarch 21, 2025 F 690 Bowel/Bladder Incontinence, Catheter, UTI I: The Following Actions were accomplished for the residents identified in the Sample: ?é?ÀResident # 112 is now on a toileting program. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have the potential to be affected by this deficient practice. ?é?ÀAll new admissions will be reviewed for the past three months to ensure appropriate interventions are in place. ?é?ÀAny identified resident who has a decline in continence of bladder will be placed on toileting program. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ?é?ÀThe Administrator and Director of Nursing reviewed the facility policy titled Clinical Bladder Management. ?é?ÀThere were no revisions necessary. ?é?ÀAll nursing staff will receive an in-service education focused on identifying residents who have recently become incontinent with bladder, as well as newly admitted residents who are incontinent with bladder. This in-service education will emphasize the importance of initiating a toileting program aimed at restoring continence to the extent possible. IV: The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ?é?ÀThe Director of Nursing/Designee will develop an audit tool entitled ?ôIncontinent of Bladder ÔÇ£ Toileting Program.?Ø This tool will identify residents who are admitted as being incontinent with bladder, as well as resident who have recently become incontinent with bladder. It will assess whether they were promptly placed in a toileting program immediately, with the aim of restoring the residents continence to the extent possible. ?é?ÀThis audit will be conducted weekly for three (3) months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing/Designee. Responsible Person: The Director of Nursing is responsible for ensuring all above is completed. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details Based on observation and interview conducted during the recertification survey from 2/20/25 to 2/27/25, the facility did not ensure specific food items were maintained in accordance with professional standards for food safety and infection control prevention. Specifically, opened and not dated potentially hazardous foods were observed in one of the refrigerators and the dry pantry, and 3 of 4 dietary aides were observed wearing disposable gloves for meal service and did not change gloves after touching other non-meal service objects. The findings are: The facility policy last revised on 1/2025, 'Production, Purchasing, Storage: Food and Supply Storage' included documentation procedure to cover, label and date unused portions and open packages, using Medvantage/Freshdate labeling system. The facility policy last revised on 1/2024 'Sanitation and Infection Prevention/Control: Disposable Glove Use' included documentation procedure disposable gloves must be changed, and hands washed when moving from one task to another. The initial tour of the kitchen was conducted on 2/20/25 at 10:31 AM. The following items were observed: An opened, undated container of thickened milk in the refrigerator. An opened, undated bag of powdered sugar, wrapped with plastic wrap in dry storage. The Food Service Director was interviewed at that time of observation and stated they were unaware the two items were not dated after opening according to facility policy. On 2/21/25 at 11:45 AM Dietary Aide #26 on unit 5A was observed taking temperatures of food on tray line wearing disposable gloves. They held the ink pen and clipboard to write the temperatures while wearing the gloves, placed gloved hand on the wall while waiting for thermometer to register the temperature, and lifted the garbage lid to dispose of paper while wearing disposable gloves. Dietary Aide #26 continued to wear the disposable gloves to begin meal service. On 2/24/25 at 11:43 AM Dietary Aide #27 on unit 3A was observed taking temperatures of food on tray line wearing disposable gloves. They held the ink pen and clipboard to write the temperatures while wearing the gloves, touched door handle to leave the serving area, and then opened the refrigerator door to obtain bread while wearing disposable gloves and then returned to begin meal tray preparation. On 2/25/25 at 12:15 PM during dining observation on unit 5A, Dietary Aide #28 stop plating food for meal service, answered the phone, holding the telephone receiver wearing disposable gloves, and then continued to serve the meal without changing gloves. On 2/27/25 at 1:54 PM during an interview, the Food Service Director stated all dietary staff had been in-serviced on disposable glove use. Staff should have known to change gloves whenever moving from one task to another and when serving food on the resident units per policy on disposable glove use. 10 NYCRR 415. 15(h) | Plan of Correction: ApprovedMarch 21, 2025 F 812 Food Procurement I: Immediate Corrections ?é?ÀThe opened undated container of thickened milk and undated bag of powdered sugar were all discarded on 2/20/ 25. ?é?ÀThe Dining Service staff that were identified during observations were immediately provided with an in-service education on proper disposable glove usage on (MONTH) 14 through (MONTH) 16, 2025. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll freezers, refrigerators, and dry storage areas were inspected for any additional items that may be unlabeled or past their expiration date and holding. ?é?ÀAll Dining Service Staff were provided in-service education on (MONTH) 25, 2025, on proper food storage procedures including importance of labelling all opened items and monitoring food expiration dates, including all dates identified as ?ôsell-by?Ø, best-by?Ø, ?ôenjoy-by?Ø, or use-by?Ø. ?é?ÀAll Dining Service Staff were provided in-service education on (MONTH) 14 ÔÇ£ (MONTH) 16, 2025, on proper disposable glove usage. III: The following system changes will be implemented to ensure continuing compliance with regulations: ?é?ÀThe Administrator and Director of Food Services reviewed the policy titled, Production, Purchasing, Storage: Food and Supply Storage. There were no revisions necessary. ?é?ÀThe Administrator and Director of Food Services reviewed the policy titled, Sanitation and Infection Control: Disposable Glove Use Policy. There were no revisions necessary. ?é?ÀAll Dining Services Staff were provided with in-service education on the facilitys policy titled Production, Purchasing, Storage: Food and Supply Storage by the Director of Food Services. ?é?ÀAll Dining Services Staff were provided in-service education on the facilitys policy titled, Sanitation and Infection Control: Disposable Glove Use Policy by the Director of Food Services. IV: The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ?é?ÀDirector of Food Services will develop an audit tool entitled, ?ôLabeling of Food Products.?Ø This tool will be utilized by the Dining Service Managers and will conduct daily inspection of all refrigerators, freezers, and dry storage areas to ensure all items are properly labelled, dated, and within appropriate date ranges. The audit will be conducted weekly for 3 months. ?é?ÀDirector of Food Services will develop an audit tool entitled. ?ôDisposable Glove Use.?Ø This audit tool will be utilized to monitor compliance of five (5) Dining Service Staff members on Sanitation and Infection Control with Disposable Glove Use. The audit will be conducted weekly for 3 months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement committee by the Food Service Director. Responsible Person: The Dining Director is the person responsible for ensuring all the above actions are completed. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 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 2/20/25 through 2/27/25, the facility did not ensure each resident received adequate supervision to prevent accidents and/or the residents' environment remained as free of accident hazards as possible for 2 of 10 residents (Residents #183 and #242) reviewed for accidents. Specifically, 1. Resident #183 was at risk for elopement related to wandering in and out other resident's rooms, roaming, trying to open exit doors and get in the elevator without staff supervision and 2. Resident #242 sustained falls on 11/15/24, 11/27/24, 1/10/25, 1/19/25 and 1/25/ 25. The findings are: Resident #183 was admitted with [DIAGNOSES REDACTED]. The 12/6/24 Care Plan titled Risk for Victimization documented encourage resident to attend specific task/activity of interest, separate from others as needed and engage in task/activity of interest, visual checks as indicated per protocol and plan of care, and keep resident at a safe distance from aggravating factors. The 12/16/24 Care Plan titled Dementia/Cognitive loss documented establish a consistent daily routine. The 1/31/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #183 had severely impaired cognition, was independent with mobility, and required partial assistance with toileting and personal hygiene. During observation on 2/20/25 at 11:48 AM, without staff supervision Resident #183 ambulated with a walker in the unit hallway and entered Resident #27's room (dependent with self-care abilities) Resident #183 stood in front of the closet located to the left of the room door looking over at Resident # 27. Resident #27 screamed get out, get out, get out Resident #183 continued to stand in Resident #27's room, then exited the room and ambulated with a walker down the hallway. At 11:51 AM Resident #183 ambulated with a walker back down the hall and reentered Resident #27's room. Resident #27 yelled get out, get out, please get out. Certified Nurse Aide #19 entered Resident #27's room and redirected Resident #183 to exit Resident #27's room. At 12:03 PM Resident #183 ambulated with the walker down the hallway, without supervision entered Resident #27's room, left Resident #27's room and then proceeded to ambulate unsupervised into aother resident room. During observation on 2/20/25 at 2:30 PM, without staff supervision and without a walker Resident #183 was holding onto Resident #47's wheelchair while pushing Resident #47 who was sitting in the wheelchair down the unit hallway. During observation on 2/20/25 at 2:41 PM, without supervision Resident #183 ambulated with a walker, opened and entered Resident #151's room. During observation on 2/21/25 at 11:34 AM, without supervision Resident #183 ambulated in the hallway with a walker, stopped and attempted to open the stair 2 fire exit door. During an interview on 2/26/25 at 3:43 PM, Certified Nurse Aide #19 stated they always tried to stop and redirect Resident #18 from wandering into other residents' rooms. Certified Nurse Aide #19 stated Resident #183 thought they once worked at the facility. Certified Nurse Aide #19 stated Resident #19 refused to participate in morning activities most of the time. During an interview on 02/27/25 at 10:31 AM, the Recreation and Activities Director stated Resident #183 preferred to participate in afternoon activities. They stated Resident #183 liked social activities, coloring, watching TV, and received a lot of pastoral care. They stated unfortunately Resident #183 had a short attention span and would often leave the room in the middle of activities. During an interview on 02/27/25 at 10:37 AM, Licensed Practical Nurse #183 stated staff kept an eye on Resident #183 as much as they could and tried to engage them in activities. Licensed Practical Nurse #18 stated they were aware Resident #183 entered other resident rooms. They stated it was hard to prevent the resident's wandering due to advanced dementia. They stated if they had more staff, better supervision would be provided. 2. Resident #242 was admitted with the [DIAGNOSES REDACTED]. The Comprehensive Care Plan titled Risk for Falls initiated on 10/28/24 documented gait balance problems/neurological disease. Stationary chair removed from room for safety, provide obstacle free environment, refer to rehabilitation as needed, provide assistance when walking to the room after meals. The Annual Minimum Data Set (a resident assessment tool) dated 11/6/24, documented Resident #242 had moderate cognitive impairment, used a walker for ambulation with moderate assistance and required moderate assistance with transfers. The Physician order [REDACTED]. During observation on 2/21/25 at 12:25 PM Resident #242 with an unsteady gait ambulated with a walker, unassisted out of the dining room and into the hallway. During observation on 2/24/25 at 12:54 PM Resident #242 with an unsteady gait ambulated with a walker, and unassisted in the hall to their room after lunch. During interview on 2/25/25 at 12:58 PM Licensed Practical Nurse #10 stated Resident #242 no longer required assistance with ambulation. During interview on 2/26/25 at 5:35 PM the Assistant Director of Nursing stated there was no documentation in the care plan to indicate assistance when walking to the room after meals had been discontinued. The 2/26/25 Progress Note documented Resident #242 had a fall due to an abrupt turn, and loss of balance. During interview on 2/27/25 at 4:35 PM the Director of Nursing stated there should be a note correlating the removal of any intervention from the care plan. During interview on 2/27/25 at 10:19 AM Unit Manager #11 stated Resident #242 was not oriented to the unit at the time of admission and that was why the care plan interventions included staff assistance. Unit Manager #11 stated Resident #242 wandered less now to find their room and the intervention was no longer needed. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMarch 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 689 Free of Accident Hazards/Supervision/Devices I: The Following Actions were accomplished for the residents identified in the Sample: ?é?ÀResident #27 and Resident #151 were provided with a mesh stop sign on the door to prevent Resident #183 from wandering in the rooms on (MONTH) 18, 2025. ?é?ÀResident #183 background interest and past occupation were reviewed by IDT and revised care plan intervention to simulate her past profession as a housekeeper. ?é?ÀResident # 242 was re-evaluated on (MONTH) 18, 2025, by rehab and continues to demonstrate the ability to safely perform independent bed mobility, functional transfers, and ambulation to desired locations within the unit with chorea movements. This gait pattern is consistent with long-term effects of [MEDICAL CONDITION]. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have the potential to be affected by this deficient practice. ?é?ÀAll Unit Managers/Designee will review facilitys wanderguard list to identify residents who exhibit intrusive wandering behavior in their assigned unit(s) and will update residents care plan for appropriate interventions. ?é?ÀAll residents diagnosed with [REDACTED]. This assessment will focus on any fluctuations in their gait beyond their baseline chorea movements. Based on the findings, their care plans will be updated to implement appropriate interventions. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ?é?ÀAll licensed nurses in the facility will be re-inserviceD on the facilitys Elopement Risk Assessment and Procedure Policy as it relates to the assessment of Elopement risk and initiation of Resident specific interventions such as monitoring of residents for their safety. ?é?ÀThe Staff Development Nurse will be responsible for re-inservicing all other Licensed Nurses on the facilitys Elopement Risk Assessment and Procedure Policy. ?é?ÀThe Staff Development Nurse will provide an inservice education to all licensed nurses, highlighting the importance of promptly notifying the rehabilitation department about any residents diagnosed with [REDACTED]. This in-service education aims to ensure early identification of ambulation fluctuation and prompt implementation of intervention. ?é?ÀThe Director of Nursing and Administrator reviewed the facilitys Elopement Risk Assessment and Procedure Policy and the Wander Alert System Operation. No revision is necessary. IV: The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: ?é?ÀThe Director of Nursing/Designee will develop an audit tool entitled, ?ôIdentification of Intrusive Wandering Behavior.?Ø The audit tool will be utilized to identify residents exhibiting intrusive wandering behavior. It will also assess the immediate interventions implemented by staff and ensure that the plan of care is updated accordingly to address these behaviors effectively. The audits will be conducted weekly for 3 months. ?é?ÀThe Director of Rehab/Designee will develop an audit tool entitled ?ô[MEDICAL CONDITION] ÔÇ£ Ambulation Fluctuations.?Ø This audit tool will be utilized to identify residents who experience falls during ambulation in the HD unit, specifically focusing on fluctuations in their gait that are not attributable to their baseline chorea movements. This approach will effectively recognize and implement appropriate interventions tailored to enhance safety and mobility. The audits will be done weekly for 3 months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing and Director of Rehab. Responsible Person: The Administrator is responsible for ensuring all the above is completed. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, during the Recertification Survey from 2/20/25 to 2/27/25 the facility did not ensure that needed services, care and equipment were provided to assure that resident with limited range of motion and mobility to maintain or improve function based on the residents' clinical condition for 1 of 4 residents reviewed for position mobility. Specifically, a resident #36 had limited range of motion in their lower extremities was observed to have right or left foot dangling off the foot pedal of their wheelchair, not appropriately positioned on the foot pedal. The findings are: Resident #36 was admitted to the facility, with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident was independent in cognition. The MDS further documented the resident had limited range of motion in bilateral lower extremities. The 2/7/25 Comprehensive Care Plan (CCP) titled Need for restorative Occupational Therapy documented inability to self function as evidenced by decreased muscle strength. There was no documentation occupational therapy evaluated resident's wheelchair for proper positioning. The 2/7/25 physician's orders [REDACTED]. The 2/7/25 Occupational Therapy evaluation and treatment notes documented Resident #36 was evaluated for wheelchair mobility to increase strength for self-propelling wheelchair. There was no documentation of resident #36 being assessed for proper positioning in wheelchair. There was no documentation of wheelchair being assessed for repairs. On 2/21/25 at 12:18 PM, Observed resident #36 in their wheelchair at dining room table. The resident's right foot was dangling behind foot pedal. Resident was struggling to place it back on the foot pedal started to move foot but never placed it on the foot pedal of the wheelchair. On 2/21/25 at 12:38 PM, Observed resident #36 with right foot hanging off foot pedal of wheelchair. On 2/26/25 at 12:31 PM, Observed resident #36 observed with left foot hanging foot pedal and dangling while sitting in their wheelchair while in the dining room. On 2/26/25 at 4:50 PM, Occupational Therapist #13 stated the resident was asking about a new chair and stated they would be more comfortable in a bariatric broad wheelchair. Occupational Therapist #13 stated instead of downgrading the chair that would make them more dependent they put the resident on program to help get the resident to increase their mobility in the wheelchair and better propel themselves. Observed wheelchair with Occupational Therapist #13 left foot pedal has foot box to prevent foot from dropping because resident #36 had a left foot ankle inversion. The right foot has no inversion, so it didn't have a foot box. Occupational Therapist #13 stated the phalange is not set up the same on both sides and is not working correctly something needs to be fixed. Occupational Therapist #13 stated the phalange will not clip fully allowing foot pedal to swing out to the side and why resident would have trouble keeping foot in place. The left foot box on foot pedal was out of position and needed to be fixed. On 2/27/25 at 12:50 PM, Certified Nurse Aide #14 stated resident #36 never complained they were uncomfortable in the wheelchair. Certified Nurse Aide #14 stated they noticed the residents left foot pedal was swinging out yesterday and not locking. Certified Nurse Aide #14 stated they did not report it to anybody. On 2/27/25 at 1:05 PM Occupational Therapist #13 stated nursing staff usually would verbally report when a wheelchair is in need of repair, but did not receive any report from nursing. Occupational Therapist #13 stated they have no official rounding schedule for assessing wheelchairs and no documented audits. 483. 25(c)(2) | Plan of Correction: ApprovedMarch 21, 2025 F 688 Increase/Prevent Decrease in ROM/Mobility I. The Following Actions were accomplished for the residents identified in the Sample: ?é?ÀThe wheelchair for Resident #36 was repaired first thing in the morning on (MONTH) 27, 2025. ?é?ÀCertified Nurse Aide #14 received an education on the importance of promptly reporting broken wheelchair to their immediate supervisor to ensure that repairs are initiated without delay. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have the potential to be affected by this deficient practice. ?é?ÀThe Director of Rehab/Designee will identify all residents utilizing bariatric wheelchairs. This will specifically focus on foot pedals that show signs of increased wear and tear resulting from the weight of the foot pedal support. ?é?ÀAny identified deviations will be promptly reported to the Support Services for immediate repair and provide appropriate intervention or change existing intervention. III. The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ?é?ÀAll Nursing Staff will be provided with an in-service education for promptly reporting any broken wheelchair to their immediate supervisor. This ensures that necessary repairs are initiated without delay, thereby maintaining residents functional status. ?é?ÀThe Occupational Therapist will continue to monitor the foot pedals of residents using bariatric wheelchairs, as these experience increased wear and tear due to the extent of weight put on them. During quarterly screenings, the Occupational therapist will document assessment findings to ensure proper positioning in wheelchair and address necessary adjustments or interventions. IV. The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: ?é?ÀThe Director of Rehab/Designee will develop an audit tool entitled ?ôBariatric Resident - Wheelchair Positioning.?Ø This audit tool will be utilized to monitor resident who use bariatric wheelchair focusing on foot pedals that exhibit wear and tear. It will help identify those requiring repairs or additional devices to maintain their functional mobility. Additionally, the tool will ensure that all necessary documentation regarding residents wheelchair positioning is reflected in the residents chair. The audit will be conducted weekly for three (3) months. ?é?ÀThe Support Services Director/Designee will develop an audit tool entitled ?ôWheelchair Reporting and Repair.?Ø This tool will be utilized to assess whether the staff have properly followed the facilitys procedure for reporting broken wheelchairs and to verify that repairs were completed in a timely manner. Responsible Person: The Administrator is responsible for ensuring all above is completed. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the recertification and abbreviated surveys (NY 358) from 2/19/25-2/27/25 it was determined that for one (Resident #400) of two residents reviewed for notification of change, the facility did not notify the resident's representative timely when there was a change in their plan of care. Specifically, Resident #400's [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (antidepressive medication) were discontinued after a gradual dose reduction, and their representative was not notified of the change in the plan of care. The findings are: The facility policy titled Psychoactive Drugs dated 9/2017, documented the attending physician will monitor and modify the medication regimen in conjunction with the resident and/or representative and other members of the Interdisciplinary Team including psychiatry. A resident or resident representative has the right to be informed about the resident's condition, treatment options, relative risks and benefits of treatment, required monitoring, expected outcomes of the treatment and has the right to refuse care and treatment. Resident #400 was admitted to the facility with [DIAGNOSES REDACTED]. The 8/15/24 Minimum Data Set Assessment documented the resident's cognition was severely impaired. The resident ate meals with tray set up and walked independently in hallways with a cane. The physician order [REDACTED].#400 was prescribed [MEDICATION NAME] 50 milligrams one tablet at bedtime by Attending Physician # 1. Psychiatric Nurse Practitioner #3's note dated 3/19/24, documented a recommendation to reduce [MEDICATION NAME] to 25 milligrams at bedtime. The physician order [REDACTED].#400 was prescribed [MEDICATION NAME] 50 milligrams 1/2 tablet (25 milligrams) at bedtime by Attending Physician # 1. Psychiatric Nurse Practitioner #3's note dated 4/16/24, documented a recommendation to reduce [MEDICATION NAME] to 12. 5 milligrams at bedtime. (There was no corresponding order or documentation as to a reason this was not done.) The physician orders [REDACTED]. The physician order [REDACTED].#400 was prescribed [MEDICATION NAME] 12. 5 milligrams daily for depression by Attending Physician # 2. The order was discontinued on 8/16/ 24. There was no documentation in the progress notes reviewed from 3/19/24 -5/9/24 that the resident's representative was notified about the gradual dose reduction for [MEDICATION NAME] on 3/19/24 or when it was discontinued. There was also no documented evidence the resident's representative was notified of the initiation of [MEDICATION NAME] on 5/10/24 and discontinuation on 8/16/ 24. During an interview with the Assistant Director of Nursing on 2/25/25 at 10:00 AM they stated the resident was admitted to the facility already on [MEDICATION NAME] and was tapered then discontinued. They stated when a resident was on [MEDICAL CONDITION] medications the family should be notified by the physician and they were not sure what happened in this case. They stated Attending Physician #1 was not good at contacting families and was no longer employed by the facility. During an interview with Attending Physician #2 on 2/25/25 at 12:08 PM, they stated when a report from the Psychiatric Nurse Practitioner comes in, they will go over the report with the Unit Manager and track Psychiatry notes and gradual dose reductions. They will call family or Unit Manager will call to inform the family the gradual dose reduction has been initiated. In this case, they did not recall if they spoke to the family because there was a changeover of attending physicians. Attending Physician #2 could not recall if they notified the resident's representative about the medication changes. During an interview with the Psychiatric Nurse Practitioner #3 on 2/25/25 at 12:28 PM, they stated they saw residents for medication review, loss or deterioration in cognition, and made recommendations. They did not notify families of gradual dose reductions. They stated they were only a consultant and did not know what happened in this case. 10 NYCRR 415. 3(e)(1)(a) | Plan of Correction: ApprovedMarch 21, 2025 F 580 Notification of Changes I: The Following Actions were accomplished for the residents identified in the Sample: ?é?ÀResident #400 expired on (MONTH) 13, 2024. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have the potential to be affected by the same practice. ?é?ÀThe Director of Nursing/Designee will complete chart reviews of other residents with psychoactive medication changes from (MONTH) 2024 till present to ensure all residents family or representative were notified of any changes on psychoactive medications. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ?é?ÀThe Administrator and Director of Nursing reviewed the policy entitled ?ôPsychoactive Drugs?Ø on (MONTH) 17, 2024, and no revision is needed. ?é?ÀThe Licensed Nurse Educator/Designee will provide education to all licensed nurse on the existing policy for Psychoactive Drugs. ?é?ÀThe Attending Physician #2 was also provided one to one education by the Licensed Nurse Educator/ADON of the responsibility to notify the Residents family or representative of any psychoactive medication changes. ?é?ÀThe Medical Director will also complete the educational in-service to all medical providers. ?é?ÀThe Staff Educator/Designee will create a lesson plan regarding Psychoactive Medication changes. The lesson plan will be discussed with all licensed nurses to ensure compliance with the policy for Psychoactive Medication. IV: The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ?é?ÀDirector of Nursing/Designee will develop an audit tool entitled ?ôPsychoactive Medication Notification of Changes.?Ø The audit tool will be utilized to monitor compliance with family or representative notification for any psychoactive medication changes. The audits will be conducted weekly for 3 months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. Responsible: Director of Nursing is responsible for ensuring all above is completed |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey from 2/20-2/27/2025, the facility did not ensure that 1 of 3 residents (Resident # 93) reviewed for nutrition were monitored within acceptable parameters for nutritional status. Specifically, Resident #93's weight loss a 7. 5% in three months, and a 13% weight in four months was not addressed. Additionally, the resident's weight was not recorded for the last 2 months. The findings include: Resident #93 had [DIAGNOSES REDACTED]. Resident MOLST dated 1/27/2018 documented no limitation on medical interventions and long-term feeding tube if needed. Annual Minimum (MDS) data set [DATE] documented severely impaired cognition, dependent on assistance for activities of daily living, no swallowing disorder, no significant weight loss, height 65 inches, 134 pounds. The registered dietician's note dated 8/30/24 documented the resident weighed 134. 4 pounds, remained within their usual weight range, and was the same as 6 months prior. They were fed by staff, on a puree diet and received Hi Cal and Ensure Plus. The plan was to continue the current plan of care to support weight maintenance. Comprehensive Care Plan for Nutrition updated 8/30/2024 documented the goal for Resident #93 was to maintain weight of 135 +/- 3% Quarterly Minimum (MDS) data set [DATE] documented severely impaired cognition, dependent on assistance for activities of daily living, no swallowing disorder, no significant weight loss, height 65 inches, 123 pounds. (The MDS did not document the 7. 5% weight loss since the Annual MDS on 8/28/24). Review of the resident's record revealed no notes by the Registered Dietician after 8/30/24 and no evidence the weight loss was addressed. Weights for Resident #93 documented a 13. 1% loss in 4 months from (MONTH) to (MONTH) 2024 and included the following: 8/06/24 134. 4 pounds, 9/6/24 128 pounds, 10/4/24 122. 8 pounds, 11/6/24 123. 6 pounds, and 12/6/24 116. 8 pounds. There was no documented evidence of weights for Resident #93 in (MONTH) or February 2025. Meal Acceptance History for Resident #93 from (MONTH) 2024 until (MONTH) 2025 documented intake 0%-100% for meals with the majority documented as 100%. During an observation on 02/21/25 at 8:58 AM, Resident #93 observed in dining room, assisted by staff eating breakfast. Resident #93 needed to be roused to eat and had very poor intake. During an interview on 02/26/25 at 1:54 PM, Registered Nurse Unit Manager #11 reviewed Resident #93's electronic medical record and stated that Resident #93 had a weight loss from (MONTH) to December 2024. The stated the dietician tracked the weights and was unaware the resident had no recorded weights for the last two months. During an interview on 02/27/25 at 11:36 AM, Registered Dietician #20 confirmed the last weight recorded for Resident #93 was on 12/6/ 24. No weights were recorded in the electronic medical record for (MONTH) or February 2025. They stated nursing obtained the weights and they reviewed them and requested reweights as needed. They stated they requested that Resident #93 be reweighed in (MONTH) and February, but it was not done. They stated they had not documented nutritional notes or put additional interventions in place because they were still waiting for the reweights. 10NYCRR 415. 12(i)(1) | Plan of Correction: ApprovedMarch 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 692 Nutrition/Hydration Status Maintenance I: The Following Actions were accomplished for the residents identified in the Sample: ?é?ÀResident #93 had their most current weight obtained on 2/27/ 25. This was reported to the Registered Dietitian and recommendations were made and carried out. ?é?ÀAn IDCP team meeting was held on 3/21/25 with Resident #93 family to discuss the anticipated progression of the residents [MEDICAL CONDITION], which is impacting the residents appetite and contributing to ongoing weight loss. Residents family has decided to place her on Palliative Care due to progression of [MEDICAL CONDITION]. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have the potential to be affected by this deficient practice. ?é?ÀAll residents weight from (MONTH) 2024 to present will be reviewed to ensure that the most recent and accurate weights will be obtained and will be reported to the Dietician. Any recommendations will be implemented promptly. ?é?ÀAll residents identified as experiencing weight loss over the past four months will be reviewed to ensure that appropriate documentation and care plan interventions are in placed to address their weight loss. Concurrently, the medical provider will be notified to incorporate any recommendations into the residents care plan, ensuring that proper documentation and interventions are implemented effectively. ?é?ÀAll residents identified as experiencing weight loss will also be reviewed weekly by the IDCP team during weekly weight management meetings to ensure ongoing monitoring and support for residents nutritional needs are maintained. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ?é?ÀThe Director of Nursing and Dietitian will conduct a review of the facilitys current process for obtaining and recording residents weights and re-weights. This review will be communicated to all Nursing Staff as an education in-service to ensure that weight is recorded or reported promptly and accurately. ?é?ÀThe Administrator will provide in-service education to the Dietitian to ensure that weight loss is addressed promptly and effectively. This includes ensuring all relevant documentation is accurately recorded in the residents charts and that interventions to manage weight loss are implemented without delay. IV: The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ?é?ÀThe Dietician or Designee will develop an audit tool entitled, ?ôTimely Recording of Weights/Re-Weights.?Ø This audit tool will be used to monitor the weight of twenty (20) residents on a weekly basis for a duration of three (3) months. This process aims to ensure that weights and reweights are recorded and reported in timely manner. ?é?ÀThe Director of Nursing or Designee will develop an audit tool entitled ?ôAddressing Weight Loss Timely.?Ø This audit tool will be utilized to review the weights of five (5) residents identified as experiencing weight loss during the weekly IDCP team weight management meetings. The audit tool will monitor whether dietary notes or medical provider recommendations regarding weight loss have been properly documented and addressed. This audit will be conducted weekly for three (3) months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Registered Dietitian. Responsible Person: The Administrator is the person responsible for ensuring all the above actions have been completed. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey from 2/20/25-2/27/25, the facility did not ensure that 1 of 4 residents (Resident #122) reviewed for positioning and limited range of motion, received treatment and care in accordance with professional standards of practice. Specifically, Resident #122 had a history of [REDACTED]. The finding are: The undated facility policy titled Resident Positioning Policy for Therapy and Nursing Staff documented that the purpose of the policy is to establish standardized guidelines for proper positioning to ensure optimal comfort, prevent complications, and promote the overall health and safety of residents. Assistive devices should be used whenever necessary to minimize risk and injury to residents and staff. Resident #122 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented Resident #122 had severely impaired cognition and was dependent on staff for all activities of daily living and mobility. The Comprehensive Care Plan for Activities of Daily Living dated 11/18/24 documented the resident was dependent on staff for eating. There were no interventions regarding positioning while eating. A Speech Therapy evaluation note dated 11/14/24 documented Resident #122 was noted with increased coughing and gagging during meals. The diet was downgraded to pureed consistency with honey thickened liquids and assistance with feeding was recommended. During an observation on 2/21/25 at 12:28 PM, Resident # 122 was eating lunch with assistance from staff. They were sliding down and positioned very low in their chair and coughed intermittently. During an observation on 2/25/25 at 12:42 PM, Resident #122 was low in their chair while a staff member was assisting the resident with feeding. Resident #122 was observed sliding lower in their chair while eating and was not repositioned by staff. During an observation on 2/26/25 at 12:32 PM, Resident #122 was very low in their chair prior to starting lunch. Staff did reposition resident to a more upright position in chair prior to feeding. During an interview with the Registered Nurse Unit Manager #11 on 2/26/25 at 1:32 PM, they stated that staff attempted to feed Resident #122 the best they could, but it could be difficult at times and their intake fluctuated. They stated Resident #122 was on a pureed diet with honey thickened liquids and had not been evaluated by occupational or physical therapy for chair positioning during feeding. They stated Resident #122 should have been sitting upright in their chair and not reclined or sliding down while eating. During an interview with Occupational Therapist #13 on 2/27/25 at 10:18 AM, they stated a recent screen was requested by family and completed for Resident #122 for dexterity. They stated a screen for positioning in their chair while eating had not been requested. They stated they completed regular quarterly screens for residents, and nursing could request a screen if there was a concern. They stated there were devices that could be used to prevent the resident from sliding down in the chair and the resident should have been upright while eating. During a follow-up interview on 2/27/25 at 3:23 PM, Occupational Therapist #13 stated they evaluated Resident #122 during lunch and added a device to help prevent them from sliding down in the chair. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMarch 21, 2025 F684 Quality of Care I. Immediate Corrections ?é?À The Director of Rehab conducted a complete and thorough investigation into the residents plan of care regarding their positioning in the wheelchair during mealtimes. The Occupational Therapist assessed the resident during lunch on 2/27/2025 and added positioning wedge under front end of the cushion to help prevent them from sliding down in the wheelchair. ?é?À The CNA was educated regarding positioning wedge and how to ensure the resident was properly positioned in the wheelchair. The nurse and RN supervisor were also provided with an Inservice on the use of the device. II. Plan of Correction to identify other areas potentially affected ?é?À The Director of Rehab reviewed all residents in the facility positioning during mealtimes to ensure all were safely and appropriately positioned and all positioning devices (have orders and) were included in the comprehensive care plans. ?é?ÀInservice was also provided to all CNA assigned to each resident. Respectfully, no other residents were identified to have been affected at this time. III. Systemic Changes ?é?À The policy for positioning was reviewed and found to be compliant with the regulations. The licensed nurses, CNAs and licensed therapists were educated on the updated policy and the need to ensure all devices are in place in the care plans to reflect the condition of the residents. A copy of the lesson plan and attendance sheets will be kept on file for validation. IV. Quality Assurance Monitoring ?é?À The Director of Rehab/designee will perform monthly audits for the positioning of residents during mealtimes on all units x 3 months, then quarterly thereafter to ensure residents are properly positioned, any positioning devices are in place, and care plans are accurate and reflect the services required by the residents. Any outstanding issues will be corrected on site by the auditor. ?é?À All audit findings will be reported to the Administrator and QA committee. Responsible Party: Director of Rehab/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details Based on observations and interviews during the recertification and abbreviated (NY 899) surveys from 2/20/25-2/27/25, the facility did not ensure that the environment was maintained in a safe, clean, comfortable and homelike manner. Specifically, 1. ) the shower room on the 3A unit had black stains on the shower curtain, the tiles at the base of the toilet had brown discoloration, and the tile grout in the shower stall was discolored with black and orange stains. Furthermore, there was an air conditioner in the window next to the shower stall that caused a cold draft in the room. 2). Dirty linens were observed on the floor next to Resident #27's bed. 3) A broken handrail with a sharp edge was found on the right side of the entrance to the 3A dining room. The findings are: 1) During an interview on 2/20/25 at 11:39 AM, Resident #18 stated that the shower room on 3A was cold and had mildew. During observations of the shower room on the 3A unit on 2/20/25 at 11:59 AM and 2/25/25 at 10:23 AM, shower tiles along the base of the shower stall had black and orange discoloration. Black stains were on the bottom of the shower curtain. The white tiles around the toilet base were discolored brown. There was a cold draft coming from the window next to the shower stall where a window air conditioner unit was in place. During an interview on 2/25/25 at 10:46 AM, the Director of Housekeeping stated housekeeping was responsible for cleaning the shower rooms daily. If shower curtains were soiled, staff should have contacted them for washing or replacement. They stated housekeeping cleaned the tiles, but if the tiles could not be cleaned, maintenance would be contacted for regrouting or repair. They stated they had not received any reports from staff about conditions observed in the shower room on the 3A unit. They stated the tiles needed to be cleaned and the shower curtain should have been replaced. During an interview on 2/25/25 at 4:12 PM, the Director of Maintenance stated they were not aware of any issues in the 3A shower room and acknowledged that the grout in the shower stall was discolored and should be addressed. They stated the air conditioner could be the reason for drafts. 2) During observation of the Resident #27's room on 2/20/25 at 11:44 AM, linens soiled with feces were observed on the floor next to the resident's bed. During an interview on 2/20/25 at 12:02 PM, Certified Nurse Aide #19 picked up the soiled linen from the floor and placed it in a plastic bag. They stated that soiled linens should always be bagged and kept in linen hamper and not on the floor. 3) During an observation on 2/26/25 at 11:52 AM, the handrail on the right side of the dining room entrance was broken and had a sharp edge. When interviewed on 2/26/25 at 11:58 AM, the Maintenance Worker #31 stated they were not aware of the railing being broken in dining room. When interviewed on 2/27/25 at 3:28 PM, the Director of Maintenance stated they added handrails as an item on the to look at when doing rounds. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedMarch 21, 2025 F 584 Safe/ Clean/ Comfortable Homelike Environment I. Immediate Corrections: ?é?ÀThe Housekeeping staff cleaned the Shower room on unit 3A. The black and orange dis-coloration along the base of the shower stall was removed. Completed 2/26/ 2025. ?é?ÀThe Housekeeping staff cleaned shower curtains. Black stains on the bottom of curtain were removed. Completed 2/25/ 2025. ?é?ÀThe Housekeeping staff cleaned the toilet. Discolored brown stains on tiles around the base of toilet were removed. Completed 2/26/ 2025. ?é?ÀThe window air conditioner unit that was allowing cold draft to enter the shower stall was removed by the maintenance staff. Completed 2/26/2025 ?é?ÀThe Certified Nursing Assistant picked up the soiled linen with feces that was next to the bed in Resident # 27 room. The Linen was bagged and placed in hamper. Completed 2/20/2025 ?é?ÀThe broken handrail on the right side of the dining room entrance was repaired by the maintenance staff. Completed 2/26/2025 II Plan of Correction to identify other areas potentially affected ?é?ÀThe facility acknowledges that all residents have the potential to be affected by this practice. ?é?ÀThe Director of Plant Operations will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be scheduled for correction. Completed 2/28/2025 III Systemic Changes ?é?ÀAll maintenance staff, housekeeping and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483. 10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff. ?é?ÀThe Policy & Procedures were reviewed, and it was determined that no changes to the policy were necessary. IV Quality Assurance Monitoring ?é?ÀThe Director of Plant Operations/Housekeeping will conduct audits on all rooms to ensure a homelike environment is maintained weekly x 4 weeks and then monthly for 3 months unless any significant trends are identified. Any concerns during audits will be addressed immediately to ensure compliance with standards of care or practice. ?é?ÀThe Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. Responsibility: Director of Plant Operations |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification and abbreviated (NY 899) surveys from 2/20/25 to 2/27/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1) on sixty-nine (69) of ninety-six (96) shifts the facility did not provide the minimum number of staff documented in the facility Minimum Staffing Standard Matrix, and on nine (9) of thirty-two (32) night shifts the facility did not provide the minimum number of staff documented in the general staffing plan in the Facility Assessment, and several staff stated resident's care and resident's meals were delayed when they were short staffed, 2) observations were made of unsupervised residents on the dementia unit and 3) lunch was served late on the 3rd floor. Findings include: The facility Minimum Staffing Standard Matrix levels documented the facility staffing should include 3 certified nurse aides on all units on day shift and evening shifts, and 2 certified nurse aides on all units on night shift. On Sixty-nine (69) of ninety-six (96) shifts reviewed, from 1/19/25 to 2/20/25, the facility did not provide the minimum number of staff documented in the facility Minimum Staffing Standard Matrix. The general staffing plan in the 1/14/2025 Facility Assessment documented the staffing was based on acuity and census. It documented 3-4 certified nurse aides to 66 residents on the [MEDICAL CONDITION] unit on the night shift. On nine (9) of thirty-two (32) night shifts reviewed, from 1/19/25 to 2/20/25, the facility did not provide the minimum number of staff documented in the general staffing plan in the Facility Assessment. On 02/24/25 at 10:50 AM during an interview and review of the facility minimum staffing levels and 30 days of facility staffing from 1/19/25 to 2/20/25 with the Staffing Manager, they stated 2 Certified Nurse Aides should be working on each unit on night shift, and 3 Certified Nurse Aides should be working on each unit on day & evening shift. On 02/24/25 at 4:12 PM during an interview with the facility Administrator, they stated they used the general staffing plan in their 1/14/2025 Facility Assessment for their staffing minimums, which was based on acuity and census. The facility Administrator stated it was not ideal for any unit to drop below 2 Certified Nurse Aides on the night shift. During a review of the actual staffing from 1/19/25 to 2/20/25 with the facility Administrator, nine (9) night shifts were identified when there was only 1 Certified Nurse Aide working on a unit, which included 2/20, 2/18, 2/15, 2/14, 2/9, 2/8, 2/4, 2/3, and 2/2/ 25. On 02/25/25 at 1:01 PM during an interview, Licensed Practical Nurse #1 stated they worked the night shift. They stated they often were mandated to stay for the day shift against their will. They stated they were not a day person and when they were mandated, they were tired, and it was difficult for them to complete their work. They stated on night shift, at least 4 times per month, they work with only one Certified Nurse Aide although there should be 2 Certified Nurse Aides on the night shift. They stated that working with only one Certified Nurse Aide had a negative impact on the residents. Residents had to wait for assistance, and there were safety concerns depending on the acuity and behaviors of particular residents. They stated they were only able to assist the Certified Nurse Aide sometimes, as it depended on the residents' health and behaviors. They further stated the nursing supervisors did not come up to assist unless they were called for a concern. On 02/25/25 at 6:07 PM during an interview, Certified Nurse Aide #5 stated they work all 3 shifts. They stated they had worked short often lately, they worked alone on the night shift sometimes, and lately worked with only one other Certified Nurse Aide on the evening shift. They stated that short staffing affected the residents on night shift as the staff did not get any residents out of bed when they were working without another Certified Nurse Aide. They stated that more than 10 residents on Unit 2B were dependent on staff for assistance. On 02/25/25 at 6:16 PM during an interview, Certified Nurse Aide #6 stated they work nights. They stated they have been the only Certified Nurse Aide working on the night shift with one nurse a few times in the past month. They stated short staffing affects the residents on night shift because they do not get any residents out of bed when they are the only Certified Nurse Aide working that shift. They stated residents are not assisted with toileting timely when they are the only Certified Nurse Aide working that shift. On 02/25/25 at 06:22 PM during an interview, Certified Nurse Aide #7 stated they worked fulltime evening shift. They stated they had worked with only one other Certified Nurse Aide and one nurse on the evening shift. They stated having only 2 Certified Nurse Aides affected the residents because the residents were not provided assistance with toilet use timely, dinner was delayed, and transferring residents to bed was also delayed. They stated the nurse helped with the dining room but did not assist with resident care. They stated that approximately 14 residents required 2 staff assistance with transfers with mechanical lifts. On 02/25/25 at 06:27 PM during an interview, Certified Nurse Aide #8 stated they were the only Certified Nurse Aide working with one nurse on night shift and the residents were not assisted with toilet use timely and no residents were assisted out of bed. On 02/27/25 at 09:35 during a follow-up interview, the Staffing Manager stated they utilized the Minimum Staffing Standard Matrix for staffing and strived to have 2 Certified Nurse Aides on night shifts. 2) On 02/26/25 from 01:12 PM until 01:32 PM an observation was conducted on Unit 2B (the Dementia Unit). No staff was observed in the day room supervising 20 residents. Residents were observed appearing confused and unable to find seats. On 02/26/25 at 10:05 AM during an interview, Licensed Practical Nurse Unit Manager #9 stated sometimes they only have 2 Certified Nurse Aides on the dementia unit on day shift, and they always needed 3 Certified Nurse Aides. 3) During a lunch observation on 02/25/25 the following was observed: - at 12:46 PM, dietary staff was prepping meal trays for resident rooms on unit 3A and the last lunch tray was observed being delivered to a resident in the 3A dining room. - at 12:49 PM all trays were delivered in the 3B dining room. - at 12:57 PM, Resident #91 was standing in hallway by their room and stated they were hungry. - at 1:17 PM, Certified Nurse Aide #25 delivered a lunch tray to Resident # 91. When interviewed on 02/25/25 at 1:21 PM Certified Nurse Aide #25 stated they were unaware Resident #34 took their own tray from the cart and said staff should be delivering the trays. On 02/26/25 at 11:53 AM during an interview, Dietary Aide #22 stated they usually arrived to unit around 11:45 AM to prep the food and put it on the steam table. Nursing staff brought the residents into the dining room and delivered the trays. They stated meals were delayed when nursing was short staffed. On 02/26/25 at 11:56 AM during an interview, Certified Nurse Aide #23 stated meals were delayed when nursing was short staffed or when they had to wait for the nurse to finish giving medications. Certified Nurse Aide #23 stated the Unit Manager was on leave and there was no organization on the unit with the Unit Manager out. 10NYCRR 415. 13 (A)(1)(i-iii) | Plan of Correction: ApprovedMarch 21, 2025 F 725 Sufficient Nursing Staff I The Following Actions were accomplished to ensure minimum staffing levels for certified nurse aides are met on all shifts: ?é?ÀA review of the facility-wide assessment was conducted on 3/17/25 based on the revised Medicaid CMI to re-evaluate the allocation of resources needed to care for the residents. The facility-wide assessment will provide information regarding direct care staff needs and capabilities to provide services to the residents. II The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ?é?ÀAll residents have the potential to be affected by the deficient practices. ?é?ÀThe facility-wide assessment conducted will re-evaluate the allocation of resources and staffing on all shifts. Corrective action will include following the minimum determined staffing levels for certified nurse aides on all shifts. III The following systemic changes will be implemented to ensure minimum staffing levels for certified nurse aides are met on all shifts: ?é?ÀThe Administrator and Director of Nursing will provide education to the Staffing Coordinators on the importance of meeting minimum staffing requirements for all shifts. ?é?ÀThe Facility Assessment will be conducted on a routine basis by the Administrator and the Director of Nursing to review the staffing levels based on current Case Mix Index information and ADL and care needs of the residents. ?é?ÀAny changes to the staffing levels in all shifts based on the facility assessment will be communicated to the staffing coordinator to ensure that staffing levels are maintained. When staffing levels are not at the designated levels after all resources available to the staffing coordinator will notify the Administrator and the Director of Nursing to determine additional actions needed to meet the needs of the residents levels determined by the facility assessment. ?é?ÀThe Administrator, along with the Director of Nursing, continuously works on hiring more C.N.A. staff for all shifts. The facility staffing levels improved over the last three months by successfully hiring more staff for all shifts. These new staff members assisted our residents needs by picking up shifts each week. Agency staff are also utilized to meet the needs if all employed staff solutions are exhausted. The facility has a plan to meet staffing requirements through an in-house recruiter who was recently hired and has helped tremendously with staff recruitment. Also, the facility has offered referral bonuses, sign-on bonuses and retention bonuses. An in-house childcare center will be opening soon and will be offered to all staff to help with recruitment and retention. IV The facilitys corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: ?é?ÀThe daily staffing is reviewed by the facilities Staffing Coordinator, Director of Nursing and Administrator to assure that the staffing levels meet the residents needs. These levels are reported weekly for 3 months. ?é?ÀA quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing. Responsible Person: The Director of Nursing is the person responsible to ensure all of the above actions have been completed. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details Based on observation, documentation review and staff interview, the facility did not ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110. Specifically, documentation for the current fuel quality test was missing and not provided at time of survey. The findings are: During the Life Safety recertification survey on 2/24/25, at approximately 11:10 AM, documentation review of the facility generator logs revealed that the current fuel quality test was missing and not provided at time of survey. Documentation revealed that the last fuel quality test was performed in 2023. In an interview with Corporate Regional on 2/25/26 at approximately 1:15 PM, Corporate Regional stated that the vendor will be contacted. 2012 NFPA 101: 9. 1. 3, 9. 1. 3. 1 2010 NFPA 110: 8. 3. 8 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 14, 2025 K918 ÔÇ£ Essential Electrical Testing and maintenance I. Immediate Corrections The facility engaged the Emergency Generator service provider to perform fuel quality testing. Testing completed (MONTH) 7, 2025. II. Plan of Correction to identify other areas potentially affected. It was determined that all residents have the potential to be affected by the facility not ensuring that the required emergency generator fuel quality test is completed. The Director of Plant Operations will review all record and log reports to ensure required systems testing and inspection are completed as per the required code and regulations. Work completed: (MONTH) 12, 2025 III. Systemic Changes The facility maintenance record and log policy were reviewed, it was determined that no changes were needed to the policy. The Director of Plant Operations will review all required records and logs to ensure periodic testing, inspections and services are completed as per schedule. All maintenance staff will receive in-service education, and all participants will understand the life safety issues identified, with a focus on the annual fuel testing requirements for the Emergency Generators. The Director of Plant Operation has been assigned responsibility for the education of staff. Work completed: (MONTH) 13, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that required generator annual fuel test are completed in accordance NFPA101 and NFPA 110. 1. Audits will be completed by the Director of Plant Operations quarterly x 2 quarters, then complete annually thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee Quarterly x 2 Quarters then annually thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the means of egress was clearly marked to indicate the direction of travel to the nearest exit. Specifically, the exit sign with directional arrows indicated a path of travel through a separate occupied space (daycare). This was noted on 1 of 4 resident floors. The findings are: On 2/25/25 at 1:55 PM, the directional arrows on the exit sign installed between the elevator and the recreation room on the B wing indicated the path of travel through the daycare. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the exit sign will be changed. 2012 NFPA 101: 19. 2. 10, 19. 2. 10. 1, 7. 10. 2, 7. 10. 2. 1* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 17, 2025 K293 ÔÇ£ Exit Signage I. Immediate Corrections The facility removed directional arrow on the exit sign installed between the elevator and recreation room on the B wing indicating the path of travel through the Daycare Center. Work completed (MONTH) 12, 2025 II. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for the same deficiency. None were identified. Work completed: (MONTH) 14,2025 III. Systematic Changes The facility maintenance and repairs were reviewed, it was determined that no changes were needed to the policy. The Director of Plant Operations will provide in-service education to all maintenance staff, all participants will understand the safety issues with NFPA Life Safety Code 2012 7. 10. 2. with focus on exit signs, maintenance and inspections. Work completed: (MONTH) 14, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that exit and directional signs are displayed in accordance with NFPA Life Safety Code 2012 7. 10. 2. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the illumination in the means of egress was continuous in accordance with NFPA 101. Specifically, the wall mounted light switches in the resident dining room turned off all the lights in the room leading to the emergency stairwell exit in the room. This was noted on 1 of 3 resident floors. The findings are: During the Life Safety recertification survey conducted on 2/24/23 at 12:50 PM, a tour of the fifth floor dining room revealed that the wall mounted light switches in the room, when turned to the off position, turned off all the lights in the room and an emergency stairwell exit was located in the room. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the lights in the rooms will be continuous. 2012 NFPA 101: 7. 8, 7. 8. 1, 7. 8. 1. 1, 7. 8. 1. 2, 7. 8. 1. 3*, 7. 9. 2. 3* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 14, 2025 K281 ÔÇ£ NFPA 101 Illumination of Means of Egress I. Immediate Corrections: The manual operated wall mounted light switches in fifth floor dining room were removed, allowing all lights in the room to be on continuously. Work completed (MONTH) 4, 2025. II. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Plant Operations inspected all areas throughout the facility for the same deficiencies. No additional instances of non-compliant were found. Work completed (MONTH) 6, 2025 III. Systemic Changes The Policy relating to Illumination of Means of Egress was reviewed and it was determined that no changes were needed to the policy. All maintenance staff will be provided with in-service education by the Director of Plant Operations on the policy relating to Illumination of Means of Egress with a focus on the importance of ensuring that Illumination of the Means of Egress were installed and maintained in accordance with 7. 8. Work completed: (MONTH) 6, 2025 IV. QA Monitoring The Director of Plant Operations will develop an audit tool to verify that Means of Egress were installed and maintained in accordance with 7. 8. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee |