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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for four (Residents #31, #47, #80, and #99) of seven residents reviewed, the facility did not ensure the Minimum Data Set Resident Assessment accurately reflected the residents' status. Specifically, the issues involved inaccurate coding for Section I - Active [DIAGNOSES REDACTED].#31, #80, and #99). This is evidenced by the following: Review of the current Long Term Care Facility Resident Assessment Instrument 3. 0 User's Manual, dated (MONTH) 2024, Section I included the disease conditions in the section required a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure law) in the last 60 days. Section N included medications are to be coded according to the medication's therapeutic category and/or pharmacological classification, not on how they are used. Additionally, antiplatelet medications such as aspirin, should not be coded as an anticoagulant. The facility policy Minimum Data Set (MDS) 3. 0, dated (MONTH) 2019, included the Resident Assessment Instrument (RAI) process had multiple regulatory requirements including, but not limited to, the assessment would accurately reflect the resident's status. 1. Resident #47 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 11/27/2024, included Resident #47 had moderate cognitive impairment and Section I (Active Diagnoses) was coded as having a [MEDICAL CONDITION] (other than [MEDICAL CONDITION]) within the past seven days (look back period). Review of a medical provider note, dated 11/15/2024, revealed no documented evidence that Resident #47 had [MEDICAL CONDITION]-related behaviors. 2. Resident #99 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 10/20/2024, included Resident #99 had severe cognitive impairment and Section N (Medications) was coded as receiving an anticoagulant. The Minimum Data Set Resident Assessment, dated 12/18/2024, included Resident #99 received anticoagulant and antiplatelet medications (under Section N). Review of the (MONTH) 2024 Medication Administration Record [REDACTED] 2024. There was no documented evidence that an anticoagulant medication was administered. Review of the (MONTH) 2024 Medication Administration Record [REDACTED]. 3. Resident #31 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/10/2024, included the resident was cognitively intact and Section N (Medications) was marked as receiving antidepressant and antianxiety medications. Review of physician's orders [REDACTED]. 2024. There were no medications ordered for anxiety. Review of the (MONTH) 2024 Medication Administration Record [REDACTED]. During an interview on 01/14/2025 at 9:03 AM with Minimum Data Set Coordinator #1 and Minimum Data Set Coordinator #2, Minimum Data Set Coordinator #1 stated their role consisted of gathering resident information, such as behaviors and medications, to enter and complete sections of the Minimum Data Set Resident Assessment. Minimum Data Set Coordinator #1 stated to complete Section I - Active Diagnoses, they used active [DIAGNOSES REDACTED]. Minimum Data Set Coordinator #2 stated they determined active [DIAGNOSES REDACTED]. Minimum Data Set Coordinator #2 reviewed Resident #47's Minimum Data Set Resident Assessment, dated 11/27/2024, at this time, and stated the resident had the [DIAGNOSES REDACTED]. Minimum Data Set Coordinator #1 stated when completing Section N- Medications, they reviewed resident Medication Administration Records to determine how medications were classified and had access to a list of medications or would use Google (internet-based search engine) to determine medication classifications. Minimum Data Set Coordinator #1 reviewed Resident #99's Minimum Data Set Resident Assessment, dated 10/30/2024, at this time and stated anticoagulant was selected, but the resident received aspirin and it was not an anticoagulant. Minimum Data Set Coordinator #1 reviewed Resident #31's Minimum Data Set Resident Assessment, dated 12/10/2024, at this time and stated antidepressant and antianxiety medications were selected. Resident #31 received an antidepressant medication, but not an antianxiety medication. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated the Minimum Data Set Nurse Coordinators did not report to them, Aspirin was not an anticoagulant, and Minimum Data Set Resident Assessments should include accurate information. During an interview on 01/14/2025 at 1:45 PM, Administrator #1 stated they were not aware of any issues related to Minimum Data Set Resident Assessments not being completed accurately. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedFebruary 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The MDS assessments for the 4 affected residents will be corrected and resubmitted. 2. All resident MDS assessments have the potential to be affected. The facility will audit all MDS assessments that were submitted last quarter to identify any other in correct MDS coding. The nurses working in the MDS department will be educated on the requirement to ensure that all MDS assessments are accurately coded including [DIAGNOSES REDACTED]. And the medications are to be coded according to the medication's therapeutic category and/or pharmacological classification, not on how they are used. An audit tool will be utilized to audit the medication and [DIAGNOSES REDACTED]. 4. The Accurate Assessment Audit will be conducted weekly x 4 and them monthly x 3 on three randomly selected completed MDS. The auditor will review the medication and [DIAGNOSES REDACTED]. Resident Assessment Instrument 3. 0 User's Manual, dated October 2024. Results of the audits will be brought to the QAPI meeting for review. The Director of Nursing is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025 for one (Resident #21) of nine residents reviewed, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #21 did not receive assistance with shaving and fingernail care as requested. This is evidenced by the following. The facility policy Activities of Daily Living Care and Support, revised 03/13/2024, included activities of daily living care and support will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care including grooming. Nail care should be provided as needed for the resident. Facial hair will be groomed as per resident's preference and/or assessed needs. Resident #21 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 11/06/2024, documented Resident #21 was cognitively intact and needed assistance with personal hygiene. Review of the Resident #21's Comprehensive Care Plan, revised 11/11/2024, and the current Kardex (care plan used by Certified Nursing Assistants for daily care) revealed Resident #21 had an activities of daily living self-care performance deficit and required assistance from staff for personal hygiene. Review of the resident's Treatment Administration Report in the electronic medical record revealed Resident #21 received a shower on 01/05/2025 at 2:13 PM. During an observation on 01/06/2024 at 3:35 PM, Resident #21 had long fingernails on both hands with several broken and jagged nails and several days of beard growth. During an interview at this time, Resident #21 stated they wanted to be shaved and have their fingernails cut, they had asked nursing staff for a shave and fingernails to be cut, but no one had helped them. During an observation on 01/08/2025 at 10:11 AM, Resident #21's facial hair remained unshaved and their fingernails remained uncut and dirty. During an interview on 01/08/2025 at 2:50 PM with Certified Nursing Assistant #1 and Certified Nursing Assistant #2, Certified Nursing Assistant #2 stated they should complete shaving and fingernail care on shower days and as needed. During an interview on 01/08/2025 at 3:56 PM, Licensed Practical Nurse #8 stated resident grooming was typically completed by the certified nursing assistants and grooming, including shaving and fingernail care, were reviewed for completion during skin checks which were scheduled on shower days. During an interview on 01/08/2025 at 4:10 PM, Licensed Practical Nurse Manager #2 stated activities of daily living including personal hygiene and grooming should be completed on shower day, as needed, per preference, and per request. Certified Nursing Assistants should be providing the care, and the nurses should be checking to make sure it was completed. During an observation of Resident #21 at this time, Licensed Practical Nurse Manager #2 stated Resident #21's nails were very long, should have been trimmed, and Resident #21 should have received a shave per their request or during their shower. 10 NYCRR 415. 12(a)(3) | Plan of Correction: ApprovedFebruary 7, 2025 1. Resident #21 was provided shaving and fingernail care on 1/14/2025 as per care plan. Resident # 21 remains in the facility in stable condition. There were no adverse effects including alteration of skin integrity to resident # 21 noted from the lack of timely ADL care. CNAs were counseled and educated by the DON/designee regarding appropriate ADL care and subsequent documentation including refusals of care if indicated. Nurse Managers and LPN/RNs will be educated by the DON or designee regarding frequent rounding to ensure that residents are provided ADL care as per the care plan and facility policy. 2. All residents have the potential to be affected by the deficient practice. Random reviews of residents will be conducted by the Unit Managers/ designees. This review will ensure that all residents have appropriate shaving and fingernail care as per the care plan. Any issues addressed will be immediately addressed. 3. Policy for Activities of Daily Living (ADL) care and support was reviewed by the Regional RN with no revisions required. Nursing staff and facility leadership will be educated by the Regional RN/ designee regarding ADL care for residents and subsequent documentation. The unit managers will conduct random daily ADL care rounds to ensure that ADL care is completed; this daily rounding will include ensuring shaving and fingernail care as per the care plan. Any issues identified will be immediately addressed. An ADL Committee will be established; this Committee will consist of IDT team members, Nursing Administrative staff, and a CNA representative. This Committee will meet bi-weekly x 3 months and review ADL audits and barriers to provision of timely ADL care- i.e. resident refusals, CNA compliance, residents with agitation during care, and other factors as indicated. The ADL Committee will address any issues identified. 4. A comprehensive weekly audit will be conducted by the Nursing Administrative staff. Five residents from each unit will be audited for a period of 12 weeks. The audit will include a review of shaving and fingernail care and frequency of care provided. The Regional RN will review these audits weekly and provide input as needed. The results of the audits will also be reviewed with the QAPI and ADL Committees for input. The QAPI and ADL Committees will then determine if further audits are needed. The Director of Nursing is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for four (Resident #31, #53, #99 and #220) of seven residents reviewed, the facility did not ensure that a comprehensive assessment of residents' needs, strengths, goals, life history, and preferences were conducted per the regulatory timeframes using the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument (RAI) process. Specifically, Residents #53 and #220 did not have their comprehensive admission assessments completed within 14 calendar days of admission, and Resident #99 did not have their comprehensive assessment completed within 14 calendar days of the assessment reference date. This is evidence by the following: The State Operations Manual and the Resident Assessment Instrument (Minimum Data Set Resident Assessment) Manual 3. 0 include facilities, at a minimum, are required to complete a comprehensive assessment (Minimum Data Set Resident Assessment) of each resident within 14 calendar days after admission to the facility. Additionally, the Resident Assessment Instrument Manual 3. 0 included annual comprehensive assessments are required to be completed no later than 14 days after the assessment reference date. The facility policy Minimum Data Set (MDS) Completion and Submission, dated (MONTH) 2024, included the facility would conduct and submit resident assessments in accordance with federal and state submission timeframes. An admission assessment completion date would be the admitted plus 13 calendar days. An annual assessment completion date would be the assessment reference date plus 14 calendar days. 1. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set Resident Assessment, dated 11/21/2024, was not completed until 12/05/2024 (21 calendar days after admission). 2. Resident #220 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set Resident Assessment, dated 12/27/2024, was not completed until 01/07/2025 (18 calendar days after admission). 3. Resident #99 had [DIAGNOSES REDACTED]. The annual Minimum Data Set Resident Assessment, dated 12/18/2024, was not completed until 01/07/2025 (20 calendar days after the Assessment Reference Date). During an interview on 01/14/2025 at 9:03 AM with Minimum Data Set Coordinator #1 and Minimum Data Set Coordinator #2, Minimum Data Set Coordinator #1 stated their role consisted of reading and gathering (resident information) to complete sections of the Minimum Data Set Resident Assessments. Minimum Data Set Coordinator #1 stated they had 14 days to finish an admission Minimum Data Set Resident Assessment and had 21 days (from admitted ) to submit the assessments to the Centers for Medicare and Medicaid. Minimum Data Set Coordinator #1 stated once all the sections were completed, they would email the corporate Registered Nurse Minimum Data Set Coordinator, who would review, complete, sign, and submit the assessments. During review at this time, Minimum Data Set Coordinator #1 stated Resident #53's admission Minimum Data Set Resident Assessment, dated 11/21/2024, and Resident #99's annual Minimum Data Set Resident Assessment, dated 12/18/2024, were not completed timely and did not know why. Minimum Data Set Coordinator #2 stated corporate staff were responsible for opening (initiating) and submitting all the Minimum Data Set Resident Assessments to the Centers for Medicare and Medicaid. Minimum Data Set Coordinator #1 stated the timely completion and submission of assessments had an impact on resident care because they helped to build a resident's care plan. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated the Minimum Data Set Nurse Coordinators did not report to them and they did not know when the assessments should be completed or submitted. During an interview on 01/14/2025 at 1:45 PM, Administrator #1 stated they were not aware of any issues related to Minimum Data Set Resident Assessments not being completed timely. 10 NYCRR 415. 11(a)(3)(i) | Plan of Correction: ApprovedFebruary 11, 2025 1. The MDS and assessments of the 4 affected residents will be reviewed to ensure they are complete and accurate. The residents will be reassessed by an RN and the Medical Record will be reviewed as well to ensure there are no adverse effects to the resident as a result of the late assessment. The late assessments were already competed and the associated MDS submitted so no corrective action is possible regarding the past time frame. 2. All resident assessments and MDS have the potential to be affected. The facility will audit all MDS submitted for new admission in the last quarter to identify any other late assessments. 3. The nurses working in the MDS department as well as nursing administration and unit managers will be educated on the requirement to complete all comprehensive assessment within the regulatory timeframes as noted in the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument (RAI). An audit will be conducted on 3 new admissions per audit to ensure compliance with timely assessment. 4. The New Admission Assessment Audit will be conducted weekly x 4 and them monthly x 3 on three randomly selected new admission and then three randomly selected residents on on-going basis quarterly. The auditor will review their MDS and related assessments to ensure they were completed within the required time frame. Results of the audits will be brought to the QAPI meeting for review. The Director of Nursing is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (Residents #53, #104, and #220) of 26 residents reviewed, the facility did not develop and/or implement the comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet all the resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #53's Comprehensive Care Plan did not include goals and interventions related to the resident's post-traumatic stress disorder diagnosis. Resident #220's Comprehensive Care Plan did not include goals and interventions related to care of the resident's nephrostomy tube (tube inserted into the kidney that drains urine directly into a drainage bag and bypassing the bladder). Resident #104 had a physician's orders [REDACTED]. There were multiple observations of Resident #104 not wearing the compression wraps despite documentation by staff that they were applied. This is evidenced by the following: The facility policy Care Plans - Comprehensive, dated 08/02/2024, included that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, would develop and implement a comprehensive, person-centered care plan for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. Resident #53 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 11/21/2024, included the resident had moderately impaired cognition and had a [DIAGNOSES REDACTED]. The Care Area Assessment form (area of the Minimum Data Set Resident Assessment that analyzes areas that require care planning) triggered from the 11/21/2024 Minimum Data Set Resident Assessment included that Resident #53 had a psychiatric disorder (including post-traumatic stress disorder) that should be considered for care planning. The form was not signed or dated when it was completed. Review of the resident's current Comprehensive Care Plan revealed no information related to Resident #53's post-traumatic stress disorder [DIAGNOSES REDACTED]. Review of Resident #53's Kardex (care plan used by the Certified Nursing Assistants for daily care) included to monitor/record occurrence of target behavior symptoms but did not include what target behavior symptoms to monitor for or interventions. During an interview on 01/07/2025 at 10:56 AM, Resident #53 stated they had a [DIAGNOSES REDACTED]. During an interview on 01/13/2025 at 11:57 AM, Licensed Practical Nurse #2 stated they would know if a resident had a post-traumatic stress disorder by reading (progress) notes (in the resident's electronic medical record), but would not know what triggers they had unless they talked to the resident. Licensed Practical Nurse #2 stated they did not know of any residents (currently) that had been diagnosed with [REDACTED]. Licensed Practical Nurse #2 stated Resident #53 was screaming at the top of their lungs (the other night), threatened to leave the facility, and stated they were not feeling right mentally. During an interview on 01/13/2025 at 1:08 PM, Licensed Practical Nurse Manager #2 stated the care plans should include interventions on how to care for a resident related to their diagnosis(es). Licensed Practical Nurse Manager #2 stated they believed Resident #53 had been diagnosed with [REDACTED]. Licensed Practical Nurse Manager #2 stated Resident #53's care plan did not include their post-traumatic stress disorder [DIAGNOSES REDACTED]. Licensed Practical Nurse Manager #2 stated they did not have much involvement with care plans but that it would be important for the [DIAGNOSES REDACTED].#53's care plan so staff would know how to assist the resident if they were upset or displaying certain behaviors. During an interview on 01/14/2025 at 10:49 AM, Registered Nurse #2 stated care plans were generated based on the resident's admission assessments that included auto-populated information (unsure from where) which they then reviewed/changed. Registered Nurse #2 stated the care plans should include diagnoses, goals, and related interventions. A [DIAGNOSES REDACTED]. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated a resident's care plan should include a post-traumatic stress [DIAGNOSES REDACTED]. 2. Resident #220 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/27/2024, included the resident had moderately impaired cognition and required moderate assistance for personal hygiene. The Care Area Assessment section of the Minimum Data Set Resident Assessment included Resident #220 triggered for an indwelling catheter and should be care planned for it. Review of the Comprehensive Care Plan, dated 12/23/2024, revealed no information related to Resident #220's nephrostomy tube, care of or any other interventions to assist the resident with nephrostomy tube needs. In a progress note, dated 01/08/2025, Nurse Practitioner #2 documented Resident #220 would need home care and assistance with flushing the nephrostomy tube. During an observation and interview on 01/08/2025 at 10:32AM, Resident #220 stated they had not heard about any plans for a care plan meeting and had not received any teaching about care for the nephrostomy tube which was covered with a dressing at this time. Resident #220 stated facility staff were flushing it. Review of Resident #220's (MONTH) 2025 Treatment Administration Record revealed inconsistent documentation that the nephrostomy tube was being flushed as ordered by the physician. During an interview on 01/14/2025 at 10:35 AM, Licensed Practical Nurse Manager #2 stated that a Registered Nurse or the Director of Nursing developed the Comprehensive Care Plans and Resident #220 should have had nephrostomy tube care in their care plan. During an interview on 01/14/2025 at 10:43AM, the Director of Nursing stated the Comprehensive Care Plan starts at the time of admission, can be updated at any time, and Resident #220's Comprehensive Care Plan should have included nephrostomy tube care. 3. Resident #104 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 11/27/2024, included Resident #104 had moderate cognitive impairment and an impairment in one arm and one leg. Review of Resident #104's Comprehensive Care Plan, dated 08/02/2024, revealed the resident had a fluid deficit related to [MEDICAL CONDITION] with a goal to receive adequate fluids and maintain good skin turgor. Interventions did not include compression wraps to their left arm. Physician orders, dated 12/25/2024, included for staff to place an ACE (compression dressing used to help reduce swelling) wrap on the resident's left arm in the morning and remove at bedtime for swelling. Review of Resident #104's Treatment Administration Record revealed documentation that the compression wrap had been applied daily from 01/06/2025 through 01 | Plan of Correction: ApprovedFebruary 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #53s care plan was updated to include goals and interventions related to the residents post-traumatic stress disorder diagnosis Resident # 220s care plan was updated to include goals and interventions related to care of the residents nephrostomy tube. Resident # 104 had their ACE wraps applied. Nurses on those shifts will be counseled 2. A full house audit of the comprehensive care plans was completed, and care plans were updated with specific focus related to their [DIAGNOSES REDACTED]. 3. Policy named Care Plan-Comprehensive was reviewed and no changes were made. IDT and licensed nursing staff will be educated by the Regional consultant on care plan development, revision, review and conducting of care plan meetings. The interdisciplinary clinical team will review changes in residents condition and revise care plan upon admission, readmission and changes in residents condition, quarterly and annually. Care plan development or revision will occur in clinical meetings by the Interdisciplinary Team. Changes in residents care plan will be updated by the unit manager or responsible discipline. 4. The Unit manager or designee will audit all new admissions for completeness of the comprehensive care plan weekly for a duration of 3 months. A random audit of 5 resident comprehensive care plans per week x 12 weeks will be conducted by IDT Team and then 5 random resident comprehensive care plans on on-going basis per quarter. DON will provide onsite oversight of the IDT care plan meetings and provide feedback to the Regional Director on the effectiveness of the interventions. The Director of Nursing will report audit findings to the QAPI committee for review and recommendation on continuance of monitoring |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025 the facility did not ensure they established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #34, #45, and #99) of 24 of residents reviewed. Specifically, appropriate Personal Protective Equipment (PPE) was not worn by nursing staff in residents' room that were identified by the facility as requiring Enhanced Barrier Precautions while preforming high contact care to residents. Additionally, observations of multiple facility staff who had declined the influenza vaccine were not wearing face masks while in resident care areas during the current influenza season as determined by the Department of Health. The facility policy Enhanced Barrier Precautions, dated 05/30/2024, documented Enhanced Barrier Precautions would be initiated and implemented for residents as applicable in accordance with federal and/or state regulations and/or in accordance with Centers for Disease Control guidance to reduce the risks of transmission of Multiple Drug-Resistant Organisms. Enhanced Barrier Precautions is applicable for resident with any of the following: a. Infection or colonization with a Multiple Drug-Resistant Organisms. b. Wounds (e.g. any type of wound requiring a dressing) c. Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, [MEDICAL CONDITION]/ventilator, etc.) Issue 1 1. Resident #34 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 10/02/2024, documented the resident was cognitively intact. Review of Resident #34's current Comprehensive Care Plan, created 07/12/2024, revealed the resident was at risk for infection and multi drug-resistant organisms (MDRO) and was on Enhanced Barrier Precautions due to multiple wounds to both lower extremities (calf, ankles, feet). Staff were to wear Personal Protective Equipment (gown and gloves) when providing high contact resident care including dressing, bathing/showering, transferring, linen change, providing personal hygiene, changing briefs, and wound care. During an observation on 01/08/2025 at 12:14 PM, Resident #34 had an Enhanced Barrier Precaution sign hanging at eye level at the entrance to their room. Licensed Practical Nurse #3, wearing gloves but no gown, provided wound care to Resident #34 that included wounds on both lower extremities. Wound care included removal of soiled dressings, cleansing the wounds, applying creams, and redressing wounds. 2. Resident #45 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/12/2024, documented the resident had severely impaired cognitive function and a stage 3 (full thickness tissue loss) pressure ulcer. Review of Resident #45 Comprehensive Care Plan, dated 12/05/2024, revealed the resident had an alteration in skin integrity related to an actual pressure ulcer and an indwelling urinary catheter. The Comprehensive Care Plan did not include that Resident #45 was on Enhanced Barrier Precautions. During an observation on 01/10/2025 at 10:10 AM, the Director of Nursing, Registered Nurse Supervisor #2, and Certified Nursing Assistant #5 entered Resident #45 room. An Enhanced Barrier Precaution sign was hanging at the entrance to Resident #45's room. Certified Nursing Assistant #5 and Registered Nurse #2, wearing gloves but no gowns, repositioned the resident and removed their clothing. The Director of Nursing, wearing gloves but no gown, removed the wound/ulcer dressing and measured and assessed the wound/ulcer with their gloved hands. During an interview on 01/10/2025 at 11:03 AM, the Director of Nursing stated Personal Protective Equipment including gown, gloves, and mask should be worn in residents' rooms who are on Enhanced Barrier Precautions. The Director of Nursing stated they should have worn full Personal Protective Equipment in Resident #45 room when assessing and dressing the pressure ulcer. 3. Resident #99 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/18/2024, documented the resident was severely impaired of cognitive function and had a pressure ulcer and a feeding tube (surgically inserted tube directly into the stomach via the abdomen to administer nutrition). Review of Resident #99's current Comprehensive Care Plan, dated 07/12/2024, revealed the resident was on Enhanced Barrier Precautions due to a colonized multi drug-resistant organism (MDRO) [MEDICAL CONDITION] (MRSA) and for staff to wear Personal Protective Equipment (gown and gloves) when providing high contact care to residents including dressing, bathing/showering, transferring, providing hygiene, changing briefs, device care (feeding tube), and wound care. During an observation on 01/10/2025 at 4:52 PM, Licensed Practical Nurse #3 entered Resident #99's room without performing hand hygiene and applied gloves but no gown. There was no Enhanced Barrier Precaution signage outside of Resident #99's room and no Personal Protective Equipment was easily accessible outside the resident's room. Licensed Practical Nurse #3 checked the resident's blood glucose (using a finger prick to test the resident's blood glucose level) and then administered tube feeding. During an interview on 01/13/2024 at 10:04 AM, Register Nurse Manager #2 stated residents with catheters, feeding tubes, or anything that is a possible point of entry for an infection should be placed on Enhanced Barrier Precautions. Registered Nurse Manager #1 stated with any hands-on care provided to residents, staff should wear gowns, gloves, and masks. Registered Nurse Manager #1 stated that Resident #99 was on Enhanced Barrier Precautions related to having a gastrostomy (feeding) tube. Registered Nurse Manager #2 stated they were not aware who was responsible for placing Enhanced Barrier Precaution signage or placing Personal Protective Equipment by residents' rooms. During an interview on 1/14/25 at 9:55 AM, Licensed Practical Nurse Manager #3 stated they provide wound care to residents on Enhanced Barrier Precautions and should wear Personal Protective Equipment (gown and gloves), but the gowns are so hot, they do not always wear the gowns. During an interview on 01/13/2025 at 10:49 AM, the Director of Nursing stated any resident with a wound or a feeding tube should be on Enhanced Barrier Precautions. The Director of Nursing stated the Assistant Director of Nursing who was the Infection Preventionist recently quit. The Director of Nursing stated Resident #99 should have been on Enhanced Barrier Precautions. Issue 2 The facility policy Influenza Vaccine, dated 08/22/2024, documented that staff will provide consent or declination for the influenza vaccine each year. Individuals refusing the vaccination may be required to wear a standard face mask in resident care areas throughout influenza season, as defined and required by the state Department of Health. Review of the employee influenza, pneumococcal, and covid-19 vaccination status list provided by the facility listed 10 randomly picked employees from all departments and their vaccination status. Nine of the ten employees listed included they had declined the flu vaccine. During an observation and interview on 01/13/2025 at 4:23 PM on 2nd floor residential care unit, Certified Nursing Assistant #8 was in the dining room with six residents and was not wearing a face mask. Certified Nursing Assistant #8 stated they had declined the flu vaccine this year and knew that they should wear a mask in resident care areas during influenza season, but were not aware that influenza season had start | Plan of Correction: ApprovedFebruary 7, 2025 1. Resident #34, # 45 and #99 were assessed for any adverse effects without the usage of PPE with no visible signs of infection LPNs will be re-educated on Enhanced Barrier Precautions DON will be re-educated on Enhanced Barrier Precautions RNs will be re-educated on Enhanced Barrier Precautions CNAs will be re-educated on Enhanced Barrier Precautions All staff will be re-educated on influenza season and proper mask wearing 2. An infection control audit will be conducted. This audit will ensure that EBP are implemented for indicated residents. All residents who meet the criteria were placed on EBP. 3. The facility educator/designee will educate facility staff on infection control, proper face mask wearing and EBP. The following policies were reviewed without changes: Enhanced Barrier Precautions and Influenza Vaccine The facility infection preventionist/designee will conduct frequent infection control rounding, including during wound rounds, and any identified opportunities will be addressed upon discovery The infection preventionist, director of nursing, and other facility leadership will conduct rounds throughout the facility to ensure that staff members are exercising appropriate use of personal protective equipment. Ad hoc education will be provided to persons who are not correctly adhering to infection prevention/control practices. Licensed Nurses (staff/agency) will be reeducated on infection control practices during wound care (EBP) Employees (staff / agency) will be reeducated on infection control practices. Employees (staff/agency) will be reeducated on upon hire, annually and as necessary. 4. The Infection Preventionist/designee will audit the infection control practices during 5 wound treatments weekly x 12 weeks or until substantial compliance is achieved The Infection Preventionist/designee will conduct infection control rounds for proper mask-wearing on 20 employees weekly x 12 weeks or until substantial compliance is achieved The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee. Responsible Party: Infection Preventionist/DON |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure each resident received the influenza or the pneumococcal immunizations (vaccine) for two (Resident #8 and #74) of five residents reviewed. Specifically, the facility was unable to provide any evidence the residents or their representatives had been provided educational material, been offered, or declined the immunizations. The facility policy Infection Control-Influenza Vaccine/Pneumococcal Vaccine, dated 11/24/2024, documented that all residents and/or the resident representative will be offered and provided influenza vaccine and pneumococcal vaccine. Residents have the opportunity to refuse the vaccine. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and pneumococcal vaccine and placed in the resident's medical record and will include that the resident or resident's representative was provided education regarding the benefits and potential side effects of the vaccine. 1. Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 11/06/2024, documented that Resident #8 had severely impaired cognition and listed their spouse as their Health Care Proxy. Review of Resident #8 electronic medical record revealed under immunizations the pneumococcal vaccine had been refused. The facility was unable to provide any documentation that educational material regarding the benefits and potential side effects of the vaccine had been provided to the resident's Health Care Proxy or a declination of the vaccine completed and signed or refused. 2. Resident #74 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 10/09/2024, documented Resident #74 was cognitively intact. Review of Resident #74's electronic medical record revealed under immunizations that the influenza and pneumococcal vaccines had been refused. The facility was unable to provide any documentation that educational material regarding the benefits and potential side effects of the vaccine had been offered to Resident #74 or a declination of the vaccines had been completed and signed or refused. During an interview on 1/14/2025 at 12:10 PM, Licensed Practical Nurse Manager #1 stated they did not take part in the influenza vaccination initiative this season, it was the Assistant Director of Nursing who did. Licensed Practical Nurse Manager #1 stated they were not sure how declinations of the vaccines are managed. During an interview on 1/10/2025 at 11:03 AM, the Regional Director of Clinical Services (acting Infection Preventionist) stated an automated call is made from the facility to all residents Health Care Proxy's that influenza vaccines are being offered and the Unit Managers were responsible to reach out to residents and resident's Health Care Proxys for consent or declination. 10 NYCRR 415. 19(a)(3) | Plan of Correction: ApprovedFebruary 18, 2025 1. Resident # 8 and #74 will be offered the influenza and pneumococcal vaccination. Declinations and/or consents will be obtained. 2. All residents could potentially be affected. A review of the pneumococcal and influenza immunization status of all in house residents was conducted to determine if any other residents did not have an up to date pneumococcal and/or influenza immunization record. For those residents identified, the Infection Control Nurse / Clinical Care Coordinators provided influenza and pneumococcal vaccine education to the resident/ responsible party to obtain consent or declination of the vaccine if not medically contraindicated. Any resident consenting to the vaccine, an MD order will be obtained and the vaccine will be administered and documented as such in the residents medical record. 3. The following policy and procedure were reviewed and not revised: Influenza Vaccine and Pneumococcal Vaccination-Residents. Education will be provided to all licensed Nursing Staff. Re-education to include providing influenza and pneumococcal education to the resident/responsible party, obtaining consent/declination, obtaining an MD order if not medically contraindicated, ordering of the vaccine and administration of the vaccine and documentation of administration. Administration, Nursing Administration and the Infection Control Nurse reviewed the process of obtaining the pneumococcal vaccine. 4. Weekly audits x 4, bi-weekly x 2 and monthly until corrected. Random audit of 3 residents to be done every quarter. All new admissions will be offered the vaccinations. Consents or declinations will be obtained. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for three (Unit Three medication cart North, Unit Three medication cart South, Unit Two medication cart North) of three medication carts reviewed. Specifically, multiple medication carts contained several insulin pens labeled by pharmacy to refrigerate until opened that were unopened and stored in the medication carts and a vial of insulin stored in the medication cart that was not opened. Additionally, two nicotine patches were observed stuck to the shower room wall and an opened insulin was observed at a resident's bedside. This evidenced by the following: The facility policy Medication Storage, dated (MONTH) 2019, documented that medication will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of health guidelines. During observation on 01/06/2025 at 9:20 AM, in resident room [ROOM NUMBER]b there was an opened vial of insulin (needle attached) on the resident's bedside stand. Resident #70 stated the nurse must have left it there. During an immediate interview, Licensed Practical Nurse #7 stated they had become distracted and forgot to grab the insulin pen when leaving the room. During an observation on 01/07/2025 at 10:35 AM, the Unit Three medication cart North contained four insulin pens that were unopened and unrefrigerated. All four pens had pharmacy instruction labels on them to refrigerate until opened. Three of the insulin pens had resident identifiers on them. During an interview at the time, Licensed Practical Nurse #1 stated each resident-specific medication should have a label that included resident identifiers, and insulin should be labeled with an open and expiration date or remain refrigerated until ready for use. During an observation on 01/07/2025 at 10:51 AM, the Unit Three medication cart South contained four insulin pens labeled with resident identifiers that were unopened, unrefrigerated, and labeled with orange pharmacy stickers that read refrigerate until opened. In addition, the cart contained an unopened oral solution of [MEDICATION NAME] [MEDICATION]) that was labeled with resident identifiers and an orange pharmacy sticker that read refrigerate until opened. During an immediate interview, Licensed Practical Nurse #2 stated opened insulin should be refrigerated until ready for use and it should be dated once opened. During observations on 01/07/2025 11:25 AM, the Unit Two medication cart South contained a vial of insulin that was unopened and unrefrigerated. During an interview on 01/08/2025 at approximately 2:00 PM, Licensed Practical Nurse Manager #1 stated the protocol for medication storage and labeling is to refrigerate medications that specify the requirement, and that once it is opened, it should be dated. Licensed Practical Nurse Manager #1 stated that Licensed Practical Nurses should locate a manager for advisement on unlabeled and improperly stored medications and that cart audits should include checks for this. During an observation on 01/13/2025 in the Unit Two shower room, there were two used nicotine patches, dated 12/09/2024 and 12/30/2025, stuck to the shower wall. During an immediate interview, Licensed Practical Nurse Manager #1 stated they were unaware of why anyone would leave the patches there and proceeded to pull three more used patches off the wall. Licensed Practical Nurse Manager #1 stated the patches should be discarded by whomever removed them from the resident in the sharps containers on the medication carts. Licensed Practical Nurse Manager #1 also stated it was most likely the Certified Nursing Assistants removing them during resident showers. 10 NYCRR 415. 18 (e) (1-4) | Plan of Correction: ApprovedFebruary 7, 2025 1. Insulin pen was removed from resident #70 room. All unopened insulin pens were removed from all med carts and placed in the refrigerator. Used Nicotine patches were removed from the shower walls. Nurses will be educated by the unit managers regarding appropriate medication storage in medications rooms & carts. 2. All residents have the potential to be affected. The Unit managers will spot audit medication rooms and carts on a daily basis to ensure appropriate medication storage. Any issues noted will be addressed. Unit managers will also spot audit shower rooms to ensure appropriate discard of the patches 3. DON/Nursing administration will educate nursing staff on proper discard of nicotine patches. Education of LPN and RN nursing staff regarding C-MED-3 Medication Storage with expected completion on or before 3/3/25 4. Weekly cart audit x4 weeks by DON/Nursing Administration to ensure drugs/biologicals used are labeled following currently accepted professional principles and the expiration date when applicable. Monthly audit x2 months or until the deficient practice is no longer identified; continue with random audits as needed to ensure continued compliance. Weekly shower room audits x 4, bi-weekly x 2 than monthly until the deficient practice is no longer identified. All findings will be reported to the QAPI Committee for review and comment. The DON will be responsible for the correction and monitoring. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for one (Resident #99) of one resident reviewed, the facility did not ensure a resident maintained acceptable parameters of nutritional status and was offered sufficient fluid intake to maintain proper hydration and health. Specifically, the facility could not provide documented evidence for a resident that required total nutrition and hydration via a gastrostomy tube (the delivery of nutrients through a feeding tube directly into the stomach also referred to as an enteral feeding) was provided nutritional and hydration care and services consistent with the resident's comprehensive assessment. Additionally, Resident #99's Medication Administration Record [REDACTED]. This was evidenced by the following: Review of the facility policy Enteral Feedings, dated (MONTH) 2023, included when administering enteral nutrition therapy (tube feeding), the nurse should verify the physician order and documentation was to include, but not limited to, the type and amount of the enteral feeding. Review of the facility policy Intake and Output, dated (MONTH) 2019, documented Clinical Services personnel would maintain a record of intake and output in keeping with physician orders for residents requiring monitoring. The nurse should verify the physician's order, review the resident's care plan to assess for any special needs, total the amounts of all liquids consumed, and record all fluid intake on the intake record. Resident #99 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 10/30/2024, documented the resident had severe cognitive impairment, had weight loss, and was not on a physician-prescribed weight-loss regimen, had a feeding tube, and received 51% or more of total calories and 501 cubic centimeters per day or more fluid intake per day by tube feeding. Current physician's orders included, but were not limited to: - Enteral Feed Order, initiated on 12/11/2024, Glucerna 1. 5 via enteral gastrostomy tube bolus (the administration of a limited volume of enteral formula over brief periods of time) 474 milliliters to be administered three times a day at 9 AM, 1 PM, and 5 PM. - Enteral Feed Order, initiated on 12/11/2024, Glucerna 1. 5 via enteral gastrostomy tube bolus 237 milliliters to be administered one time a day at 9 PM - Enteral Feed Order, initiated on 12/11/2024, administer 150 milliliters of water every six hours via enteral tube four times a day. - Enteral Feed Order, initiated on 12/11/2024, administer 80 (water) milliliters before and after tube feeding administration four times daily. Review of the current Comprehensive Care Plan, initiated 08/09/2024, revealed Resident #99 had a nutritional problem related to severe malnutrition, a gastrostomy tube in place, received tube feeding, and had significant weight loss times six months. Interventions included, but were not limited to, administer tube feeding and water flushes per Registered Dietitian recommendation and medical doctor orders, Glucerna 1. 5 calories via enteral tube gastrostomy tube 474 milliliters to be administered at 9 AM, 1 PM, 5 PM, and 237 milliliters at 9 PM, total tube feeding to equal 1659 milliliters, and flush with 80 (water) milliliters before and after bolus feeds (640 milliliters) and 150 milliliters every six hours (600 milliliters). Total fluids to equal 2500 milliliters. Review of Resident #99's (MONTH) 2025 Medication Administration Record [REDACTED] - On 12/13/2024 and 12/14/2024 at 6 AM, there were blanks (no documentation that it was administered) in the record for 150 milliliters of water. - On 12/17/2024 at 9 PM, there was a blank in the record for Glucerna 1. 5 administer 237 milliliters and 80 (water) milliliters before and after tube feed administration. - For the Enteral Feed Order, initiated on 12/11/2024, administer 80 milliliters before and after (total 160 milliliters) tube feeding administration four times daily; it was documented that 80 milliliters was administered at 9 AM for 17 of 20 opportunities, at 1 PM for 16 of 20 opportunities, at 5 PM for 12 of 21 opportunities, and at 9 PM for 10 of 21 opportunities. On 12/30/2024, it was documented that zero milliliters was administered. - For the Enteral Feed Order, initiated on 12/11/2024, Glucerna 1. 5 via enteral gastrostomy tube bolus 474 milliliters to be administered three times a day at 9 AM, 1 PM, and 5 PM; it was documented that 237 milliliters was administered at 9 AM for seven of 20 opportunities (on 12/16/2024 it was documented that 447 milliliters was administered), at 1 PM for eight of 19 opportunities, and at 5 PM for five of 20 opportunities. Review of Resident #99's (MONTH) 2025 Medication Administration Record [REDACTED] - For the Enteral Feed Order, initiated on 12/11/2024, administer 80 milliliters before and after (total 160 milliliters) tube feeding administration four times daily; it was documented that 80 milliliters was administered at 9 AM for five of eight opportunities, at 1 PM for four of eight opportunities, at 5 PM for three of seven opportunities, and at 9 PM for three of seven opportunities. - For the Enteral Feed Order, initiated on 12/11/2024, Glucerna 1. 5 via enteral gastrostomy tube bolus 474 milliliters to be administered three times a day at 9 AM, 1 PM, and 5 PM; it was documented that 237 milliliters was administered at 5 PM for two of seven opportunities. During an observation and interview on 01/10/2025 at 8:47 AM, Licensed Practical Nurse #1 stated (while demonstrating) the process for documenting Resident #99's fluid intake was done by entering the milliliter amount in the electronic health record for each separate enteral feeding order. Licensed Practical Nurse #1 stated all intake documentation was completed in the electronic health record. During interviews conducted on 01/13/2025 at 10:49 AM and 1:33 PM, Director of Nursing #1 stated they thought the Registered Dietitian would be responsible for monitoring fluid intake records, but needed to clarify. They stated there was no clinical nutrition support currently in the facility and a remote Registered Dietitian was being utilized. At 1:33 PM, Director of Nursing #1 stated the Registered Dietitian monitored the intake records and managed tube feeding orders. During an interview on 01/14/2025 at 10:55 AM, Registered Nurse Manager #1 stated the nurses documented the total amount administered on the electronic Medication Administration Record [REDACTED]. If the amount documented was less than or more than what was ordered, there could be adverse effects such as electrolyte imbalances, dehydration, and diarrhea. Registered Nurse Manager #1 stated they would expect the volume of tube feed and flushes be documented accurately because the documentation would assist providers with addressing a resident's medical concern. During a telephone interview on 01/13/2025 at 3:43 PM, Registered Dietitian #1 stated they only worked remotely to cover until the facility filled the Registered Dietitian position. There was no clinical nutrition support on-site and they monitored fluid intakes for residents who received tube feeds by reviewing the electronic Medication Administration Record [REDACTED]. If two, 237 milliliters cartons of enteral feeding were administered, a total of 474 milliliters should be documented. Registered Dietician #1 stated they reviewed Resident #99's tube feed intakes monthly and when the (MONTH) 2024 Medication Administration Record [REDACTED]. Duri | Plan of Correction: ApprovedFebruary 7, 2025 1. Flush order was clarified with RD. All nursing staff will be educated about following orders and calculating correct math. 2. All residents with tube feed can potentially affected. House-wide audit done on all tube feed orders. Any discrepancies were corrected. 3. Policy Enteral tube-flushing and Med admin-Enteral tube were reviewed and no changes made. IDT and licensed staff will be educated on the above policies specifically related to calculation of tube feeding administered and water flushes. 4. Weekly audits of tube feeding administered and water flushes x 4, bi-weekly audits x 2 and monthly audits until corrected to be done by nursing administration. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee. |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details Based on observations, interviews, and record reviews conducted during a Recertification Survey from 01/06/2025 to 01/14/2025, the facility did not ensure the daily nurse staffing information was posted on a daily basis. Specifically, the nursing staff information was not posted daily at the beginning of each shift during the survey, the information on the form was not updated to reveal current staffing changes, and the facility did not maintain the daily nursing staffing data for a minimum of 18 months. This is evidenced by the following: During observations on 01/06/2025 at 12:12 PM and 3:03 PM, 01/07/2025 at 11:24 AM and 4:17 PM, and 01/08/2025 at 8:29 AM, the daily nurse staffing information was not posted. During an interview on 01/08/2025 at 11:22 AM, the Director of Human Resources stated they are responsible for completing and posting the daily nurse staffing information. They stated daily nurse staffing information was completed for all shifts in the morning and posted, but was not updated to reflect any changes in staffing at any point during the day. Weekend daily nurse staffing information was printed on Fridays and was supposed to be rotated by the receptionist for Saturday and Sunday and was not updated during the weekend. The Director of Human Resources stated the daily nurse staffing sheets were not saved. They stated the daily nursing staffing information should have been posted for 01/06/2025, 01/07/2005, and 01/08/2025, but was not. The facility was unable to provide any past daily nurse staffing information sheets when requested. During an interview on 01/10/2025 at 9:41 AM, the Director of Nursing stated the daily nurse staffing information should be posted daily in an area readily accessible by residents and visitors, should be updated throughout the day to ensure accuracy, and the information sheets should be retained. They stated the daily nursing staffing information is posted to let residents and visitors know how much staff is currently working. 10 NYCRR 415. 13 | Plan of Correction: ApprovedFebruary 7, 2025 1. BIPA was immediately corrected. BIPAs will be placed with accurate information and saved in a binder. 2. All residents have the potential to be affected. BIPA will be placed with accurate information and saved in a binder. 3. Education was provided to the Administrator, Director of Nursing, nursing administration, and nursing staff on how to calculate the BIPA correctly. The facility will conduct weekly audit of BIPA to make sure it has correct information x 4 then monthly x 2 until corrected. The staffing coordinator or designee is responsible for the correction and monitoring. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NY 644 NY 465 Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (Residents #9, #47, and #96) of 15 residents reviewed, the facility did ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, all residents were observed being served meals using disposable cutlery (plastic utensils) and dishware (paper/plastic plates) and stated it was ongoing. This was evidenced by the following: Review of the facility policy, Quality of Life/Dignity, dated 05/28/2024, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. 1. Resident #9 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 10/20/2024, documented the resident was cognitively intact, had no behaviors, and required set up assistance with eating. Review of the Comprehensive Care Plan, dated 09/13/2024, revealed Resident #9 had a nutritional problem or potential nutritional problems related to being at risk for malnutrition and inadequate intake. The care plan did not include a need for disposable dishware or utensils During an observation on 01/06/2025 at 12:57 PM, Resident #9 received plastic utensils and beverages (coffee, juice, and water) were in plastic cups during the lunch meal. During an interview on 01/06/2025 at 1:07 PM, Resident #9 stated their meals were served on paper plates with plastic utensils which made eating difficult because they could not cut their food well and it fell off the utensils casusing the food to get cold faster. 2. Resident #96 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/10/2024, documented the resident was cognitively intact, had no behaviors, and required partial/moderate assistance with eating. Review of the Comprehensive Care Plan, dated 08/26/2024, Revealed resident #96 had a nutritional problem or potential nutritional problem related to being at risk for malnutrition, significant weight gain, depression, and obesity. The care plan did not include a need for disposable cutlery and/or dishware. During an observation on 01/06/25 at 1:12 PM, Resident #96's meal was served with plastic cups, utensils, and paper plates. In an immediate interview the resident stated their food usually came on a paper or plastic plate and made them feel like they were in jail which was dehumanizing. 3. Resident #47 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 11/27/2024, documented the resident was rarely/never understood, had no behaviors, and required substantial/maximal assistance with eating. Review of the current Comprehensive Care Plan, dated 04/17/2024, revealed Resident #47 had a potential for altered nutrition related to at risk for malnutrition, significant weight loss and dysphagia (difficulty swallowing). Interventions included, but were not limited to, regular diet with ground minced moist consistency and thin liquids. The care plan did not include a need for disposable cutlery and/or dishware. During an observation on 01/08/2025 at 9:54 AM, Resident #47 was eating breakfast independently in the dining room with a pureed consistency meal on a paper plate and plastic utensils on their tray. The resident's meal ticket did not include disposable cutlery or dishware. During an observation on 01/06/2025 at 8:51 AM, breakfast tray line was in progress, with service to the second and third units. Plastic utensils were being placed on resident meal trays and there were no metal utensils on the tray line. During an interview on 01/06/2025 at 8:55 AM, Dietary Aide #1 stated plastic utensils were being used because there were not enough metal utensils. During an interview on 01/06/2025 at 9:30 AM, Cook #1 stated plastic and paper products were being used because there was not enough metal utensils. They stated when metal utensils, cereal bowls, and coffee mugs were in stock, the items went out and never came back. Cook #1 stated residents may have been hoarding them or they were getting thrown out. During an interview on 01/13/2025 at 3:21 PM, Food Service Director #1 stated the facility used the paper plates and plastic utensils because they have a few residents who had something in their urine. They had a list of the residents whose diet plans included to have disposable products. At that time, Food Service Director #1 provided a list of three residents (Residents #78, #87, and #94) that required paper/plastic dishware. During an interview on 01/14/2025 at 12:36 PM, Director of Nursing #1 stated it was brought to their attention there was a large quantity of paper plates and plastic utensils used throughout the building (at mealtimes) and were only aware of one resident who was to receive paper products for a behavioral issue. They were not aware of any other reason for residents to be receiving paper or plastic. During an interview on 01/14/2025 at 1:45 PM, Administrator #1 stated they were not aware that multiple residents had received paper products and plastic utensils. 10 NYCRR 415. 5(a) | Plan of Correction: ApprovedFebruary 7, 2025 1. Registered Dietitian/Designee interviewed identified residents. Resident #9 remains in the facility with no adverse effects Resident #47 remains in the facility with no adverse effects Resident #96 remains in the facility with no adverse effects All three Residents meal service preferences reviewed and updated. An inventory of all silverware and dishware was conducted. The identified areas for F550 were identified and corrected 2. All residents have the potential to be affected by this deficient practice. Food Service director/ Designee will review meal services, practices and preferences at next scheduled Resident Food Council Meeting. 3. All food service personnel will receive education on dining with dignity and the use of none disposal versus disposal meal serve ware. A weekly audit of silverware and dishware will be completed by the food service director or designee to maintain appropriate PAR levels. Service ware/silverware will be ordered as needed to maintain adequate PAR levels. 4. A Food Service Department silverware audit will be completed weekly x 4 weeks then monthly x 3mths until substantial compliance is maintained The Administrator or Designee will review the audits weekly x 3monthly to assure compliance. The audits will be submitted to the QAPI committee at the monthly QAPI meeting for review. The Food Service Director is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details Based on interviews and record reviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for six (Residents #34, #36, #44, #70, #71, and #92) of six residents reviewed, the facility did not ensure that concerns voiced by residents during Resident Council meetings related to resident care and life in the facility were responded to and a rationale given for the response. Specifically, during a special Resident Council meeting, multiple residents voiced multiple care concerns that they felt had not been followed up on. Review of the previous six months of meeting minutes did not include any follow ups, resolution, or a rationale for lack of resolution to the resident's concerns. This is evidenced by the following: During a special Resident Council meeting on 01/07/2025 at 2:00 PM, with six residents present, it was reported that appropriate silverware was not provided to residents for meals instead utensils that were plastic, miniature in size, and often broke in half while using. Residents reported lack of linens, not being allowed to go outside without permission, roommate issues, being treated by staff in an undignified manner, and call lights not being answered timely (up to one hour). Residents reported the facility did not follow up on their concerns (when brought up in the Resident Council meetings) and they were not given an explanation as to why they had not been addressed. Review of the previous six months of meeting minutes revealed residents had voiced issues such as a shortage of linen, regular use of plastic silverware during meals, cold food temperatures, lack of permission to go outside unescorted, staff using inappropriate language (swearing), and missing clothing. The meeting minutes did not include any follow-up done by the facility related to the resident's voiced concerns. During an interview on 01/08/2025 at 10:05 AM, the Director of Recreation stated complaints were addressed, but they did not document this anywhere. The Director of Recreation also stated they did not manually or electronically maintain records of resident concerns, follow-ups, or updates, but that it was facility protocol that minutes from the previous months should be reviewed at the beginning of every meeting before opening the meeting for new concerns. Concerns that are voiced at the meeting should be followed up on and a concern/response form filled out by the designated staff representative and addressed to the corresponding department heads to provide a resolution. Additionally, residents who expressed a concern should be provided with a resident notification summary form, providing a summary of concern stated and the resolution given by the department head. The Director of Recreation was unable to provide any documented evidence that the concerns recorded in the previous six meeting minutes had been followed up on. During an interview on 01/14/2025 at 1:45 PM, the Administrator stated that when concerns are expressed during Resident Council meetings the directors present at the meetings should document the concerns and follow ups and outcomes discussed at the next meeting. The Administrator stated that the follow up process is not currently documented anywhere that they were aware of. 10 NYCRR 415. 5 (c)(6) | Plan of Correction: ApprovedFebruary 7, 2025 1. The social worker will meet with each resident to document each of their concerns on a grievance form. Each concern will be investigated and a resolution put in place to address the individual concern. The social worker will then address each resident with the findings and resolution to their concerns, as applicable. 2. All residents have the potential to be affected. The facility will review 12 months of Resident Council minutes to ensure that each concern brought up at the meeting was properly reviewed and addressed. 3. The recreation staff, the social worker, and the administrator were educated on the requirement to ensure that every concern or grievance brought by a resident during Resident Council Meeting must be documented and followed up with a response and provide a rationale for the response Every resident council will be audited 2 weeks after the meeting to ensure that every concern is responded to as required. 4. The facility will audit the monthly resident council minutes for 4 months Results of the audits will be brought to the QAPI meeting for review. The Director of Activities is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, exhaust ventilation was not functional, ready stand lifts were dirty, there was wall and window damage, chairs were in disrepair, a microwave oven was dirty, an exit stairwell was dirty, and an exit door was not tight fitting into the door frame. The findings are: Observations on 01/07/2025 from 9:05 AM to 9:33 AM included the exhaust ventilation on the third floor was not functioning in the staff bathroom, bathrooms of resident rooms #319 and #322, and the soiled utility room. Significant foul odors were noted in each of these rooms and when a piece of paper was placed against the exhaust grates, no air draw was observed. During an interview at this time, the Maintenance Director stated the exhaust on the third floor was not working and it has been hard getting an electrician to make repairs. Observations on 01/07/2025 at 9:21 AM included a large section of the wall behind the bed in resident room [ROOM NUMBER] was damaged and a drawer at the base of the wardrobe in this room was missing. Observations on 01/07/2025 at 9:45 AM included two sit-to-stand lifts (mechanical lifts used to transfer residents) in the corridor outside resident rooms #201 and #219 were heavily soiled with brown residue, crumbs, and debris on the footrests. Observations on 01/07/2025 at 9:50 AM included three chairs in the second-floor dining room were chipped, cracked, and the cushions and armrests were damaged. Observations on 01/07/2025 at 10:00 AM included the interior of the microwave oven in the second-floor clean utility room was heavily soiled with food splatter and debris. Observations on 01/07/2025 at 10:10 AM included the inside of the first floor south exit stairwell had a large amount of spiderwebs and dead bugs on the floor. Observations on 01/07/2025 at 10:50 AM included an approximately one to one and a half-inch gap below and around the lower edge of the exit discharge door from the first floor leading to the back parking lot near the medical waste storage room. Observations on 01/10/2025 at 12:47 PM included duct tape and heat tape around the windows in resident room [ROOM NUMBER] was peeling off and cold air could be felt coming through small openings around the edges of the windows. Additionally, in this room there was an approximately two-foot by one-foot section of the wall behind the bed closest to the window that was cracked, peeling, and damaged. 10 NYCRR: 415. 29, 415. 29(c), 415. 29(e)(3), 415. 29(h)(1)(2), 415. 29(i)(1), 415. 29(j)(1) | Plan of Correction: ApprovedFebruary 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. All identified issues have been addressed, specifically: 1. The exhaust ventilation on the third floor was fixed 2. The damaged wall behind the resident bed in room [ROOM NUMBER] was repaired 3. Two sit-to-stand lifts and outside resident rooms #201 and #219 were cleaned 4. Five new chairs were ordered to replace the three chairs that were chipped, cracked and had damaged cushions and armrests. 5. The microwave oven in the second-floor clean utility room with heavily soiled interior was replaced 6. The spiderwebs and dead bugs on the first floor south exit stairwell were removed 7. The gab below and around the lower edge of the exit discharge door from the first floor leading to the back parking lot was repaired 8. The windows in resident room [ROOM NUMBER] were re-taped around the edges of the window to prevent cold air coming through. Also, the damaged wall behind the bed closet was repaired. 2. All residents have the potential to be affected. The facility will conduct a full building audit to ensure all exhaust ventilations are functioning correctly, any damaged walls in resident rooms are repaired, all chairs used by residents are not chipped or damaged, all microwave ovens in clean utility rooms are clean, all stairwells are free of spiderwebs or dead bugs, all exit doors have tight fitting, and resident windows are appropriately heat taped The maintenance department and the administrator were educated on the importance of maintaining homelike environment, to continuously round the facility to identify deficient areas, and to immediately address identified areas. An audit tool will be utilized to randomly audit 3 rooms for homelike environment to ensure compliance. 4. The facility will randomly audit 3 rooms for homelike environment weekly x 4 weeks then monthly x 3 months. Identified issues will be immediately addressed Results of the audits will be brought to the QAPI meeting for review. The Director of Maintenance is the responsible party |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 01/06/2025 to 01/14/2025, for one (Resident #45) of one resident reviewed, the facility did not ensure the resident received the necessary care, treatment, and services consistent with professional standards of practice to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, Resident #45 did not receive a thorough wound assessment upon re-admission to the facility after a hospitalization with a pressure ulcer and no pressure ulcer care or treatments were documented as provided for multiple days. This is evidenced by the following: The facility policy Wound Identification and Wound Rounds, last revised 11/06/2023, included the facility will identify, assess, and manage residents with pressure injuries, skin alterations, impairments, or wounds in accordance with current standards of practice. New admissions and re-admissions will have a complete body examination to identify any pressure injuries, skin alterations, impairments, or wounds. Upon discovery of a skin impairment, the registered nurse completes a skin assessment, including documentation of size, depth, stage if applicable, and appearance of the skin impairment. The licensed nurse will notify the health care provider and obtain a treatment order utilizing the Centers Wound Care Guidelines. The wound nurse/designee, wound care provider, and registered dietician are notified of pressure ulcer or skin impairment and the resident is scheduled for weekly wound rounds. Resident #45 was recently readmitted to the facility following a hospital stay with [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment, dated 12/12/2024 (prior to recent hospitalization ), documented Resident #45 was cognitively intact, at risk for pressure ulcers, and had a pressure ulcer at that time. Review of the hospital After Visit Summary (a document that summarizes a patient's hospital stay and is given to them at time of discharge that includes medications, treatments, and recommendations from the hospital) revealed Resident #45 had a wound to the left trochanter (hip) and recommendations for wound care treatment. Review of Resident #45's Comprehensive Care Plan, effective 12/05/2024, revealed the resident had a pressure injury (ulcer) and included interventions for staff to evaluate the wound weekly and monitor the dressing daily. There was no evidence the care plan had been revised to include a pressure ulcer following Resident #45's recent re-admission from the hospital. During an interview on 01/06/2025 at 3:11 PM, Resident #45 stated they had a pressure ulcer on their left hip and were not receiving dressing changes to it. Review of physician's orders [REDACTED]. The Admission/Readmission Evaluation Part One Skin Assessment, signed on 01/03/2025 by Registered Nurse #2, documented that Resident #45 had a stage two pressure ulcer to the left trochanter (hip). The assessment did not include the size, depth, appearance or treatment of [REDACTED]. During an observation of morning care with Certified Nursing Assistant #9 on 01/08/2025 at 9:29 AM, Resident #45 had an unlabeled and undated adhesive dressing to the left trochanter. Licensed Practical Nurse #9 was notified and removed the dressing which revealed an open area approximately two inches by one inch with a moderate amount of yellow drainage. During an interview at this time, Licensed Practical Nurse #9 stated they did not know what was under the dressing on Resident #45 and did not know if the resident had any ordered treatments to the left hip. During an interview on 01/08/2025 at 2:50 PM with Certified Nursing Assistant #1 and Certified Nursing Assistant #2, Certified Nursing Assistant #2 stated certified nursing assistants should notify the nurse of any new wounds when care was provided and that they were not assigned to Resident # 45. During an interview on 01/08/2025 at 3:56 PM, Licensed Practical Nurse #8 stated certified nursing assistants should notify them of any new skin impairments and they should then notify the registered nurse. If nursing saw an undated dressing, they should check the orders for what treatment to provide and if there was no order, they should notify the nursing supervisor or manager to get an order for [REDACTED]. During an interview on 01/10/2025 at 9:09 AM, Registered Nurse #2 stated they were responsible for reviewing the hospital's After Visit Summary for residents who were admitted or readmitted from the hospital, and they should review the orders and recommendations from the hospital with the medical provider and enter new orders into the electronic medical record, including wound care recommendations and orders. Once the resident is admitted they completed the initial skin assessments and a thorough assessment of any identified skin impairments and document that information in the electronic medical record. Registered Nurse #2 stated they completed the readmission skin assessment for Resident #45, documented the pressure ulcer to the left trochanter, and did not complete a skin assessment on the wound but should have. They stated they reviewed the After Visit Summary with the medical provider, but must have overlooked the wound care recommendations, and no wound care orders had been placed at the time of re-admission. During an interview on 01/10/2025 at 9:41 AM, the Director of Nursing stated the After Visit Summary should have been reviewed and any hospital recommendations for wound care should have been entered into the electronic medical record, a thorough skin assessment should have been completed at the time of admission or re-admission, and if a skin impairment was identified, it should have been assessed and documented in the electronic medical record. If an undated and unlabeled dressing was identified by a certified nursing assistant or licensed practical nurse, it should have been reported, a new dressing placed, and if there is no order, the medical provider should have been contacted for wound care orders. 10 NYCRR 415. 12(c)(2) | Plan of Correction: ApprovedFebruary 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 45 was seen by the provider on 1/10/25 with no adverse effects noted from deficient practice. Treatment orders were placed. 2. All new admissions and all residents with wound treatments have the potential to be affected. Treatment orders will be reviewed for pressure ulcers to validate treatments were provided as ordered by the physician. All other residents with wound treatments ordered will be reviewed by Wound Provider 3. Policy ?ôSkin and Pressure Injury Prevention and Wound Identification and Wound Rounds?Ø was reviewed with no revisions DON/designee will educate Licensed nurses currently working at facility will be reeducated on wound care management/aseptic dressing changes to ensure proper technique and documentation. All new admissions will be audited for accurate skin assessment and treatments for any and all wounds. Any issues noted will be addressed at the time of identification, including applicable reeducation. All licensed nurses will complete a treatment competency to be evaluated for correct technique, following the treatment orders as prescribed, and infection control practices on hire, yearly, and as necessary. Unit manager will conduct daily routine rounding and review of Treatment record looking at consistent documentation of resident's pressure ulcers, complete and accurate treatment orders, following the treatment orders as prescribed, and [DEVICE] functionality. Any issues discovered with be corrected at time of discovery. 4. Wound nurse/ designee will audit all residents with wounds for presence of correct wound supplies and completion of the treatments as ordered weekly x 12 All findings will be brought to the QAPI committee for review and comment. The DON will provide onsite oversight of the IDT care plan meetings and provide feedback to Regional Director on the effectiveness of the interventions. Audit results will be forwarded to the QAPI Committee for review and input. Responsible party: The Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review conducted during a Life Safety Code Survey completed 01/06/2025 to 01/14/2025, for three (first, second, and third floors) of three resident sleeping floors, the facility did not meet an acceptable building construction type. Specifically, structural support members were not protected by fire rated material and the ceiling assembly was not fire rated. The findings are: On 01/10/2025, the facility was observed to be three stories with a basement. There was no documentation provided to show that the building met a compliant building construction type under the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code. Observations above the suspended ceilings on 01/10/2025 from 9:09 AM to 9:50 AM included unprotected structural steel members (red bar joists) supporting the concrete floor decks including, but not limited to, the following locations: third floor near the elevators, second floor near the elevators and by room [ROOM NUMBER], and first floor near rooms 101 and 112. Record review of the facility Fire Safety Evaluation System (FSES), dated 03/05/2024 (completed after the prior Life Safety Code Survey), revealed the minimum compliant building construction type for the facility is Type II (111), based on the height of the building (three stories). The FSES also included that the first, second, and third floors do not meet the requirements for Type II (111) due to unprotected structural members and classified the building as Type II (000) construction. In order to achieve an acceptable building construction type, structural support members for a three-story building must be protected from fire by a rated material or a fire rated ceiling grid system with a fire resistance rating of at least one hour. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1); 2012 NFPA 101: 8. 2, 8. 2. 1, 8. 2. 1. 1, 8. 2. 1. 2, 19. 1. 6. 1, 2012 NFPA 220 Standard on Types of Building Construction: 4. 1, 4. 1. 1, 5. 1, 5. 1. 2. 3 | Plan of Correction: ApprovedFebruary 7, 2025 It was determined that for three (first, second, and third floors) of three resident sleeping floors the facility did not meet an acceptable building construction type. Specifically, structural support members were not protected by fire rated material and the ceiling assembly was not fire rated The facility intends to use NFPA 101A-2013 as a Guide on Alternative Approaches to Life Safety, Fire Safety Evaluation System (FSES) as an equivalency in order to comply with the cited deficiency. All other LSC deficiencies found during the survey and FSES will be corrected to ensure a passing score. The facility will be conducting a new FSES by 2/19/2025 to be performed in accordance with CMS survey and certification memo 17-15-LSC, and using the mandatory values in NFPA 101A, 2001 edition, to meet the fire safety requirements for recertification based on previous use of the FSES in conjunction with this deficiency. Results of the FSES will be shared with the regional office for review. All residents had the potential to be affected. No other life safety functions were affected The facility will in-service the maintenance director on fire safety maintenance such as identification of any potential fire safety concerns or potential for unsafe or hazardous conditions. The Maintenance Director will be educated on the results of the FSES and on the requirement to ensure the facility is in compliance with NFPA standards. Facility also intends to maintain compliance by utilizing an FSES for equivalency as necessary for future recertification's as applicable. Audits will be conducted monthly on fire safety x 4. The results of the FSES, the requirement for a passing FSES and the results of the audits will be discussed at QAPI. The Administrator/Designee is responsible for this plan |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 14, 2025
Corrected date: N/A
Citation Details Based on observations and interviews conducted during the Life Safety Code Survey from 01/06/2025 to 01/14/2025, for one of one basement, the facility did not properly maintain soiled linen and trash receptacles. Specifically, soiled linen and trash receptacles exceeding 32 gallons were stored in a space that was not protected as a hazardous area. The findings are: Observations on 01/07/2025 at 10:58 AM included a large blue receptacle full of bags of dirty laundry stored in the basement egress corridor outside the laundry room. This receptacle measured approximately 3. 5 feet long by 2. 5 feet wide by 2. 5 feet deep (163 gallons). During an interview at this time, the Maintenance Director stated he would tell them to move it inside (the laundry room). Observations on 01/08/2025 at 2:50 PM included the same large blue receptacle containing bags of dirty laundry and a similar blue receptacle with bags of trash stored in the basement egress corridor outside the laundry room. During an interview at this time, a laundry staff member stated the laundry bin is stored in the hall until it is full and ready to wash. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7. 5. 7. 1(3), 19. 3. 2. 1. 5 | Plan of Correction: ApprovedFebruary 7, 2025 1. The facility removed the 163-gallon dirty laundry receptacle and bags of soiled laundry and a similar sized receptacle containing trash from the basement egress corridor outside the laundry room. 2. All areas of the facility have the potential to be affected. The facility will conduct a full building audit to determine if there were any other dirty laundry or trash respectable larger than 32 gallons not stored in a protected hazardous area. 3. The maintenance department, the housekeeping department and the administrator will be educated on the requirement to not store soiled linen or trash in a receptacle larger than 32 gallons in capacity unless located in a room protected as a hazardous area when not attended. An audit tool will be utilized to audit the basement and facility hallways do ensure that soiled linen and trash containers are stored in compliance with NFPA 101. 4. The facility will utilize the soiled linen and trash containers audit weekly x 4 and them monthly x 3 Results of the audits will be brought to the QAPI meeting for review. The Director of Housekeeping/Designee is the responsible party. |