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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2024
Corrected date: January 31, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review conducted during an abbreviated (NY 070) survey, the facility did not report incidents of staff to resident abuse to local law enforcement. This was evident for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2, and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1, and those incidents were not reported to local law enforcement. As evidenced by: The facility Policy for abuse has no date, as well as no indication of ever having any updates or reviews it is also noted to not be on any official letterhead. The Policy is written as follows, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. The Policy defines abuse and lists various types of abuse, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. There is also a definition for mistreatment the inappropriate treatment or exploitation of a resident. The Policy also documents The Elder Justice Act, which requires reporting of any reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act, (~6703 (b)(3). This requires certain individuals in long-term care facilities to report a reasonable suspicion of a crime committed against a resident. For New York State, these reports must be made to the NYSDOH and at least one local law enforcement agency of jurisdiction. Resident #1 was re-admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 had severe impaired cognition and was dependent for all cares. The quarterly minimum data set, an assessment tool, dated 9/8/24 documented that Resident #1 had short term and long-term memory problems, and was severely impaired in cognitive skills for decision making. Resident #1 was assessed to have no behaviors. Resident # 1 had impairment on both upper & lower extremities and was dependent on staff for eating, and dependent for all activities of daily living. Resident #1 was indicated to be a high-risk victim of abuse per the care plan titled Potential Victim of abuse, dated 9/10/ 24. The care plan has a goal listed that Resident #1 will be protected from being a victim of abuse thru the next review period. On 11/19/24 at 2:46pm The Potential to be victim of abuse care plan was updated and indicated that Resident #1 was a score level 10, indicating high risk. The risk factors that are marked off are: lacks basic self-protection skills, is unable to communicate needs effectively, is vulnerable due to cognitive disabilities, is vulnerable due to physical disabilities. In an interview on 11/26/24 at 11:16am with the Director of Nursing they stated that on 11/19/24 it was brought to their attention by Certified Nursing Assistant #1, that Resident Assistant #2, Resident Assistant # 3 and Certified Nursing Assistant #4 had abused Resident # 1. Director of Nursing stated that the evidence provided was videos that the family had from a camera they had placed in Resident #1's room. Director of Nursing stated the family showed the videos to them which they watched on 11/19/ 24. Immediately after viewing the videos the Director of Nursing suspended the staff pending investigation, and when they determined that abuse had occurred, they terminated the four staff identified in the videos. The Director of Nursing stated that on the day of the incident they made it clear to the family that it was their right to call 911. The Director of Nursing stated that they needed to report the incident to Department of Health. The Director of Nursing stated that the facility did not call law enforcement as they thought it was a family thing to do. The Director of Nursing stated they left the decision to call law enforcement up to the family. The facility's internal investigative report documents that the facility contacted the Department of Health on 11/19/24 at 2:31pm and that the facility did not contact any other agency. The report does indicate that the NYS Attorney General's office contacted the facility on 11/20/24 at 3:15pm. During an interview on 11/26/24 at 12:07pm with the Administrator they stated that they did not call the police or anyone else because the family was adamant that no one else be notified. On 11/25/24 Surveyors reviewed the footage of videos provided by the facility and observed the following: Video #1 dated 10/31/24 at time stamp 8:03:04 : Certified Nursing Assistant #1 and Resident Assistant #3 are seen on video in Resident #1's room to provide care. Certified Nursing Assistant #1 is seen removing Resident #1's gown forcefully. Certified Nursing Assistant #1 is seen wiping Resident #1's face in a rough manner. Video #2 has no date and no time stamp. Certified Nursing Assistant #1 and Certified Nursing Assistant #4 are in Resident #1's room. Resident #1 is seen lying in bed fully dressed. Certified Nursing Assistant #1 wearing no personal protective gown, is seen attempting to reposition Resident #1 in the bed. Certified Nursing Assistant #1 is seen pulling and tugging on Resident #1's upper body/head in a forceful manner to adjust Resident #1 in the bed. Video # 3 dated 11/04/24 at time stamp 08:07:58 : Certified Nursing Assistant #1 and Resident Assistant #2 are seen in Resident #1's room. Resident #1 is seen lying in bed wearing only incontinent brief. Resident Assistant #2 uses their right hand and pushes/smooshes Resident #1 on the left side of their face, then smacks Resident #1's left forearm and then flicks Resident #1's forehead, Certified Nursing Assistant #1 is not seen on the video during this time. 10NYCRR 415. 4 | Plan of Correction: ApprovedJanuary 21, 2025 1. Resident #1 potential victim of abuse care plan was updated as a victim of abuse, which addresses ways to ensure that he does not become a victim of abuse including but not limited to redirecting him away from persons of concern, observing whereabouts of resident and intervening as needed and monitoring socialization. The three staff members have been terminated based on the findings of the investigation. The facility policy for Abuse reviewed/revised date was added along with the facility official letterhead. 2. The Director of Nursing or designee will audit by 1/31/25 to ensure all residents at risk to be a victim of abuse have care plans in place, updated, and accurate reflecting their potential to be a victim. Any findings of noncompliance will be corrected immediately. 3. The Director of Nursing or designee will educate by 1/31/25 all licensed nursing staff on the Care Plan policy. All facility staff will be educated on the Abuse Policy and Procedure by the Director of Nursing or Designee. The facility policy will change the Abuse education from upon hire and annually, to upon hire and quarterly going forward. 4. The Director of Nursing or designee will audit all potential to be a victim care plans monthly for 3 months to ensure that all residents have appropriate and up-to-date care plans in place, with any findings of noncompliance corrected immediately. The Administrator and Director of Nursing will review the Abuse policy and procedure quarterly. The Director of Nursing or Designee will audit staff Abuse education compliance weekly for 3 months then monthly thereafter. Any findings of noncompliance will be reported to QAPI quarterly. Responsibility: Director of Nursing or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2024
Corrected date: January 31, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the abbreviated survey (NY 285), the facility did not ensure a required fire watch was conducted until such time that the fire department and New York State Department of Health were notified that the sprinkler system was restored for 2 of 3 occupied resident floors within the 918 building (2nd and 3rd floors), as requested by the fire department. Specifically, the local fire department implemented fire watch was not conducted at the required frequency or duration and proper notification was not given to cease the fire watch. Findings included: The facility's Fire Watch policy last revised 2/2020 documented: - to notify the fire department and State Regulatory/Licensure Agency that the fire alarm system was not working correctly and that fire watch procedures were in place until the system was restored. - The fire watch tours were initiated throughout the facility, at one-hour intervals, 24 hours a day. - Do not terminate the Fire Watch until all fire protection equipment was restored to normal operating condition and upon the authority of the Administrator/Incident Commander, or designee. The Fire Department's Life Safety System Emergency Impairment Form dated 12/31/2023 was signed by the Director of Nursing. The form documented the Director of Nursing was provided a copy of the Fire Department's Fire Watch Requirements, and they were instructed on the duties, frequency, record keeping and cancellation of the fire watch. The Detail Impairment section of the form documented, System will not reset after broken sprinkler head was replaced, and a qualified service company should be contacted immediately to evaluate this system, and ensure it met the standards of the New York State Uniform Fire Prevention and Building Code. The addendum, to the Fire Department's impairment form title d Fire Watch Requirements, documented periodic patrols must be conducted of the entire facility. Patrols must occur every 15 minutes if the facility has people sleeping, is an institutional facility or an occupied assembly facility. The fire watch must be maintained until the system impairment had been corrected and the Chief of Fire had determined the fire watch is no longer required. The property owner shall keep a log of fire watch related activities and the completed log shall be faxed to the Fire Department. During an observation on 1/3/2024 at 9:47 AM, there was a sprinkler head installed in the finished ceiling of resident room [ROOM NUMBER] that had a frangible bulb with green fluid inside it. The area around the sprinkler head was water damaged from a leak with two missing sections of finished ceiling. The other sprinkler heads within the ceiling of resident room [ROOM NUMBER] had a frangible bulb with red fluid inside them. During an interview on 1/5/2024 at 9:55 AM, the Director of Nursing stated they arrived on site at the facility on 12/31/2023 at approximately 10:30 PM. At that time, no vendors were on site and they did not know anything about a sprinkler head being replaced in the facility. They met with the fire department as they were entering the facility and asked them what was going on and what they needed. The fire department told them they were on site because of the water leak incident and the fire alarm panel needed to be reset. They were told by the fire department that a fire watch needed to be done until the fire alarm panel could be reset. They conducted a fire watch per the facility fire watch policy at approximately 11:00 PM. They continued the fire watch for the hour as their policy stated until they came across the Director of Maintenance in the basement who stated they were able to reset the panel and the Director of Nursing stopped the fire watch at that time. They did not see any instructions on the fire department form they signed and just went by what they were told by the fire department personnel. During an interview on 1/5/2024 at 2:21 PM, the Administrator stated they were able to talk with one of the fire fighters that were on site on 12/31/2023 and the fire fighter did not tell them what room a sprinkler head was replaced in only that a sprinkler head was replaced. The Administrator stated they did not know the fire watch was supposed to be done until the fire department was notified, and a sprinkler vendor had been out to the facility to check the replaced sprinkler head. During an interview on 1/5/2024 at 3:23 PM, Fire Department's Deputy Chief #12 stated the fire department was called to the facility on [DATE] by a mobile 911 call at 9:19 PM and responded to a water issue. They stated the fire department was in the building and observed a leak from a hot water line on the 3rd floor in room [ROOM NUMBER]. At 9:27 PM, the fire alarm was activated from a leaking sprinkler head in room [ROOM NUMBER]. The fire department had both the sprinkler system and water system shut down. The fire department changed the sprinkler head with a spare from the facility's supply and put in place a fire watch. They stated they were unable to reset the system due to the water leak and informed the Director on Nursing that they must continue the fire watch for the affected portion of the facility, which was the flooded-out rooms on the second and third floors, until the alarm could be reset, and sprinkler vendor could assess the sprinkler system. The requirements for the fire watch were communicated to the Director of Nursing as they left the facility, and a signed copy was left on site. During an interview on 1/9/2024 at 8:52 AM, the Administrator stated that they had not had a sprinkler vendor on-site to inspect the changed sprinkler head or evaluate the affected portion of the system that was identified by the local fire department. They stated their vendor was scheduled to come out on 1/15/2024 to address issues cited during a previous survey and they would have them evaluate the system at that time. During an interview on 1/9/2024 at 11:12 AM, the Administrator stated they did not have any documentation from the fire department regarding the lifting of the fire watch. They stated they spoke to someone at the fire department last week and reported what they did, when they reset the alarm panel, and when they lifted the fire watch. During an interview on 1/16/2024 at 2:22 PM, the Administrator stated the sprinkler vendor that was scheduled to come out yesterday had an emergency at another facility and they hoped to send someone this week. The facility's Fire Watch Rounding Sheet documented the Director of Nursing initialed that they completed the fire watch for the basement, 2 north, 2 south, 3 north, 3 south, 4 north, and 4 south in the 11:00 PM hour. The form had the date range of 12/31/2023 to 1/4/2024 at the top and did not specify which date the watch occurred. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 6. 1 2011 NFPA 25: 15. 6. 1, 15. 6. 3, 15. 7 | Plan of Correction: ApprovedDecember 23, 2024 The three staff members have been terminated based on the findings of the investigation. Licensed Practical Nurse #9, Certified Nursing Assistant $6, #7, #8 and Resident Assistant #15 were re-educated on Enhanced Barrier Precautions PPE requirements. The DON or designee will audit all residents who are currently EBP to ensure staff are following policy and procedure. Education has been provided to all facility staff on enhanced barrier precautions. The facility policy will change this education from upon hire and annually, to upon hire and quarterly going forward. The Director of Nursing or Designee will audit all residents who are currently EBP to ensure staff are following policy and procedure weekly for 3 months. Any noncompliance will be immediately corrected and reported to QAPI. The Director of Nursing or designee will audit staff education to ensure compliance weekly for 3 months then monthly thereafter. Any findings will be reported to QAPI. Responsibility: Director of Nursing and Infection Control Preventionist (ICP) or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2024
Corrected date: January 31, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during an abbreviated (NY 353, NY 070) survey the facility did not ensure infection control practices to prevent the development and transmission of communicable disease and infection were maintained for 2(Resident #1, Resident #6) of 3 residents reviewed. Specifically,1) Resident #1 was on enhanced precautions, Certified Nursing Assistant #7 and Licensed Practical Nurse #9 were not wearing gowns when they transferred Resident #1 from the bed-chair via Hoyer-lift and Licensed Practical Nurse #9 was not wearing a gown when they stopped Resident #1's [DEVICE] feeding, clamped the tubing and closed the feeding tube cap. Additionally, during a review of videos Certified Nursing Assistant #1 and #4 and Resident Assistant #2 and #3 were not wearing a gown while assisting Resident # 1 with a bed bath, changing clothes and emptying Resident #1's Foley catheter. 2) for Resident # 6 on enhanced barrier precautions Certified Nursing Assistant #6 and #8 and Resident Assistant # 15 were observed not wearing a gown while transferring Resident # 6 via Hoyer-lift. The Findings are: The undated Infection Prevention and Control Policy documented provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections to the extent possible. The policy documented the use of (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-Drug resistant Organisms to staff hands and clothing. 1)Resident #1 was readmitted with [DIAGNOSES REDACTED]. The 3/1/24 Physician order [REDACTED]. The 8/27/24 Care Plan titled Enhanced Precaution due to Tube Feeding documented continue with enhanced precautions. The 9/8/24 Quarterly Minimum Data Set, (an assessment tool) documented Resident # 1 had severely impaired cognition, was dependent on staff for all activities of daily living, had a Foley catheter, a stage IV wound on their sacrum and had a feeding tube. During observation on 11/25/24 at 9:25am and 9:30am Certified Nursing Assistant #7 and Licensed Practical Nurse #9 were not wearing gowns while using a Hoyer lift to transfer Resident #1 from their bed to the chair. During observation on 11/25/24 at 12:35pm Licensed Practical Nurse #9 was not wearing a gown when they stopped Resident #1's [DEVICE] feeding, clamped the tubing and closed the feeding tube cap. During interview on 11/27/24 at 10:21am Licensed Practical Nurse #9 stated a gown was not needed when transferring Resident #1 from the bed to chair via Hoyer-lift. Licensed Practical Nurse #9 stated when reading the precaution sign on the resident door, they made a mistake by not wearing a gown when transferring Resident # 1. Review of 11/25/24 video review provided by the facility revealed the following: Video #1 dated 10/31/24 time stamped 8:03:04 Certified Nursing Assistant #1 removed Resident #1's gown and provided a bed bath. Certified Nursing Assistant #1 wiped Resident #1's face, Certified Nursing Assistant #1 was not wearing a gown while providing cares which included leaning over the resident. Video #2 was undated/timed, Certified Nursing Assistant #1 pulled up Resident #1 in the bed and their clothing and arms touched Resident #1's body. Certified Nursing Assistant #1 pulled Resident #1's upper body/head to adjust the resident in the bed. Certified Nursing Assistant #1 was not wearing a gown. Video # 3 dated 11/04/24 08:07:58 Certified Nursing Assistant #1 and Resident Assistant #2 were in Resident #1's room. Resident#1 was lying in bed wearing an incontinent brief and both staff were working together to dress Resident # 1. Certified Nursing Assistant #1 emptied Resident #1's Foley catheter. Certified Nursing Assistant #1 and Resident Assistant #2 were not wearing gowns. Staff clothing touched the resident on multiple occasions. Unable to contact Certified Nursing Assistant #1/Resident Assistant # 2 despite repeated attempts. During interview on 11/27/24 at 2:37pm Certified Nursing Assistant # 7 stated they had a gown on when they were washing Resident # 1 but had taken the gown off because they were not aware they needed a gown when transferring a resident via Hoyer-lift. 2) Resident #6 was admitted with [DIAGNOSES REDACTED]. The 10/30/24 Comprehensive Minimum Data Set Assessment documented Resident #6 was cognitively intact and had a urinary catheter. The 1/2/24 Physician order [REDACTED]. During observation on 11/25/24 at 12:44pm Resident #6's door had an enhanced barrier precautions sign. Resident Assistant #15, Certified Nursing Assistant #6 and #8 transferred Resident #6 from the bed to chair. None of the staff were wearing a gown. 10 NYCRR # 415. 19 | Plan of Correction: ApprovedDecember 23, 2024 The three staff members have been terminated based on the findings of the investigation. The facility will audit all current CNAs 12 hours of education and annual performance evaluations. Any CNAs not in compliance with the 12 hours of education or annual performance evaluation will be corrected. Education will be provided to the Director of Human Resources and all CNA staff that 12-hour education is required each year as well as annual performance evaluations. The facility will audit all CNAs 12 hours of education and annual performance evaluations weekly for 3 months, then monthly thereafter to ensure all 12 hours of education and annual performance reviews are in compliance. Any findings of noncompliance will be reported to QAPI. Responsibility: Director of Nursing and Director of Human Resources or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 2, 2024
Corrected date: January 31, 2025
Citation Details Based on staff interviews and review of facility documentation conducted during an abbreviated (NY 070, NY 353) survey, it was determined that the facility did not ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide, based on the outcome of the performance reviews, received no less than twelve hours of in-service education per year. This was evident for 2 of 2 Certified Nursing Assistants (nurse aides) reviewed for completion of performance review and in-service education. Specifically, the facility did not ensure that Certified Nursing Assistant #1 & Certified Nursing Assistant #4 had a performance review at least once every 12 months and based on their individual performance review receive no less than twelve hours of in-service education per year. Findings Surveyor requested the facility administrator to provide the 2 Certified Nursing Assistant files including their performance reviews and their in-service education. Review of the documents revealed the following: Certified Nursing Assistant #1 had an orientation checklist dated 10/8/ 2014. Certified Nursing Assistant #1 had a record indicating that there was a history of verbal counseling's that occurred in the year 2024, one dated (MONTH) 7th, 2024, for failure to document, one dated (MONTH) 3rd for improper break time and one dated (MONTH) 7th for failure to document PO intake for 7 days. In Certified Nursing Assistant #1's employment file there are 2 performance evaluations, the last one is dated (MONTH) 4th, 2021. There are 9 in-services listed as having been attended by Certified Nursing Assistant #1 and no indication that these in-services would be equal to the required 12 hours of in-service education that is required. Certified Nursing Assistant #4 had a hire date of (MONTH) 29th (YEAR). There is no orientation checklist. There are 3 warning notices in their file, 2 that occurred in (YEAR), it does not indicate that they were verbal. One was for a failure to keep bed linen clean, and the other was for a failure to notify a nurse of a resident need situation. In (YEAR) Certified Nursing Assistant #4 has a warning notice dated (MONTH) 18th, that stated leave resident unattended in a bathroom, resident found sitting on the floor. The only performance review on file is dated (MONTH) 6th (YEAR), and there are only 3 in-services shown in the file one is on abuse dated (MONTH) 14th (YEAR), another one is (MONTH) 2024 for change in condition and one in (MONTH) 2014 for fall prevention. 10NYCRR 415. 26 | Plan of Correction: ApprovedDecember 23, 2024 The facility policy for Abuse reviewed/revised date was added along with the facility official letterhead. The Administrator reported the abuse on Resident #1 to the local police on 11/26/24 during the abbreviated survey. The facility Director of Nursing and Administrator have been re-educated during the abbreviated survey as well as by Regional Administrator on reporting regulations of the Elder Justice Act that requires reports to be made to at least one local law enforcement agency of jurisdiction. The facility Administrator and Director of Nursing will be re-educated by the Regional Administrator on the reporting requirements quarterly. All facility staff will be educated on the Abuse Policy and Procedure by the Director of Nursing or Designee. The facility policy will change this education from upon hire and annually, to upon hire and quarterly going forward. The Administrator will report education compliance to QAPI for 6 months. The Director of Nursing or Designee will audit staff Abuse education, which includes reporting requirements, compliance weekly for 3 months then monthly thereafter. Any findings of noncompliance will be reported to QAPI quarterly. Responsibility: Director of Nursing, Administrator or Designee |