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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: January 14, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification, the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels of Certified Nursing Aides and Licensed Practical Nurses were not met every day on multiple shifts and multiple units, from 12/01/2024 - 12/05/ 2024. In addition, record review indicated resident grievances related to staffing shortages, there were observations of delayed call light responses times, and resident complaints of low staffing. This is evidenced by: Based on the facility assessment, dated 8/28/2024, the following was the current staffing plan, presented as the number of Full Time Employees by position by shift. 6 AM-2 PM (days) 2 PM-10 PM(evenings) 10 PM-6 AM (nights) Registered Nurse 11 2 1 Licensed Practical Nurse 10 10 5 Certified Nursing Assistant 23 20 10 Review of the facility daily staffing guidelines dated 12/01/2024, the following were missing from the evening shift: A-wing was missing 1. 375 Certified Nurse Aides, 1 Licensed Practical Nurse B-wing was missing 1 Certified Nurse Aide, 1 Licensed Practical Nurses D-wing was missing 1. 5 Certified Nurse Aides, 1. 5 Licensed Practical Nurse G-wing was missing 0. 5 Certified Nurse Aide, 1 Licensed Practical Nurses S-wing (secure) was missing 2. 125 Certified Nurse Aides, 1 Licensed Practical Nurse Review of the facility daily staffing guidelines dated 12/01/2024, the following were missing from the night shift: B-wing was missing 1 Certified Nurse Aide D-wing was missing 1 Certified Nurse Aide, 0. 5 Licensed Practical Nurse Review of the facility daily staffing guidelines dated 12/02/2024, the following were missing from the day shift: A-wing was missing 1 Certified Nurse Aide B-wing was missing 1 Licensed Practical Nurses D-wing was missing 2 Certified Nurse Aides G-wing was missing 1 Certified Nurse Aides, 1 Licensed Practical Nurses S-wing (secure wing) was missing 2. 5 Certified Nurse Aides Review of the facility daily staffing guidelines dated 12/02/2024, the following were missing from staff from the evening shifts: A-wing was missing 2 Licensed Practical Nurses B-wing was missing 1 Certified Nurse Aide, 2 Licensed Practical Nurses D-wing was missing 2. 25 Certified Nurse Aides, 2 Licensed Practical Nurses G-wing was missing 1. 5 Certified Nurse Aides, 1 Licensed Practical Nurse S-wing was missing 3 Certified Nurse Aides, 1 Licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/02/2024, documented the following were missing from the night shifts: B-wing was missing 0. 5 Certified Nurse Aides D-wing was missing 0. 1876 Certified Nurse Aides, 1 Licensed Practical Nurse G-wing was missing 0. 5 Certified Nurse Aide S-wing was missing 1. 5 Certified Nurse Aides From 10:00 PM - 11:00 PM there was not a Registered Nurse working at the facility. Review of the facility daily staffing guidelines, dated 12/03/2024, documented the following were missing from the day shifts: A-wing was missing 2 Certified Nurse Aides B-wing was missing 1. 5 Certified Nurse Aides, 1 Licensed Practical Nurse D-wing was missing 2. 5 Certified Nurse Aides G-wing was missing 2 Certified Nurse Aides S-wing was missing 1. 5 certified Nurse Aides Review of the facility daily staffing guidelines, dated 12/03/2024, documented the following were missing from the evening shifts: A-wing was missing 0. 5 certified nurse aides, 1. 5 Licensed Practical Nurses B-wing was missing 1 Certified Nurse Aide, 1 Licensed Practical Nurse D-wing was missing 2 Certified Nurse Aides, 1. 5 Licensed Practical Nurses G-wing was missing 2 Certified Nurse Aides, 1 Licensed Practical Nurse S-wing was missing 1. 5 certified nurse aides, 0. 5 licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/03/2024, documented the following were missing from the night shifts: A-wing was missing 1 Certified Nurse Aide B-wing was missing 0. 5 Certified Nurse Aide D-wing was missing 0. 5 Certified Nurse Aides Review of the facility daily staffing guidelines, dated 12/04/2024, documented the following were missing from the day shifts: A-wing was missing 2. 5 Certified Nurse Aides B-wing was missing 1 Certified Nurse Aide D-wing was missing 1. 5 Certified Nurse Aides G-wing was missing 1 Certified Nurse Aide, 1 Licensed Practical Nurse S-wing was missing 3 certified nurse aides, 0. 5 Licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/04/2024, documented the following were missing from the evening shifts: A-wing was missing 0. 5 Certified Nurse Aide, 1. 5 Licensed Practical Nurses B-wing was missing 1. 5 Certified Nurse Aide, 2 Licensed Practical Nurses D-wing was missing 2 Certified Nurse Aides G-wing was missing 0. 5 Certified Nurse Aide, 1 Licensed Practical Nurse S-wing was missing 1. 5 certified nurse aides, 2 Licensed Practical Nurses Review of the facility daily staffing guidelines, dated 12/04/2024, documented the following were missing from the night shifts: A-wing was missing 1 Certified Nurse Aide B-wing was missing 1 Certified Nurse Aide D-wing was missing 0. 5 Certified Nurse Aide G-wing was missing 0. 5 Certified Nurse Aide S-wing was missing 1 Certified Nurse Aide Review of the facility daily staffing guidelines, dated 12/05/2024, documented the following were missing from the day shifts: A-wing was missing 2. 5 Certified Nurse Aides, 1. 5 Licensed Practical Nurses, 1 Registered Nurse B-wing was missing 1. 5 Certified Nurse Aides D-wing was missing 0. 5 Certified Nurse Aides G-wing was missing 2. 5 Certified Nurse Aides, 1. 5 Licensed Practical Nurses S-wing was missing 2. 5 certified nurse aides, 1 Registered Nurse Review of the facility daily staffing guidelines, dated 12/05/2024, documented the following were missing from the evening shifts: A-wing was missing 1. 5 certified nurse aides, 2 Licensed Practical Nurses B-wing was missing 2 Licensed Practical Nurses D-wing was missing 2. 5 Certified Nurse Aides, 1 Licensed Practical Nurse G-wing was missing 2. 5 Certified Nurse Aides, 2 Licensed Practical Nurses S-wing was missing 1. 5 certified nurse aides, 1 Licensed Practical Nurse Review of the facility daily staffing guidelines, dated 12/05/2024, documented the following were missing from the night shifts: A-wing was missing 0. 5 Licensed Practical Nurses G-wing was missing 1 Certified Nurse Aides Review of the facility grievance sheets documented 10 grievances related to staffing levels between 02/2024 - 09/ 2024. A grievance dated 2/05/2024 regarded poor care from a Certified Nurse Aide with the facility response of, there was only 1 Certified Nurse Aide on the unit between 2 PM - 4 PM.A grievance dated 2/14/2024 regarded toileting with the facility response of, staffing was minimal. A grievance dated 2/12/2024 - 02/13/2024 regarded long wait for assistance with the facility response of, .is waiting a long time for BR (bathroom), as is every other resident. A grievance dated 2/13/2024 regarded a 2. 5- hour call light wait by a resident that led to incontinence with the facility response of, 2 Certified Nursing Assistants and 1 Licensed Practical Nurse, looking at adding 2 agency Certified Nursing Assistants. A grievance dated 6/25/2024 regarded a resident asking to use the restroom and staff saying no with the facility response of, because that means not helping others that are needing help at that time. A grievance dated 8/11/2024 regarded a resident who waited over 30 minutes and had an accident with the facility response of, this was right after supper. A grievance dated 8/26/2024 regarded a resident being left by the nursing station without staff interaction with the facility response of social worker decided to have resident out in the lobby watching TV with other residents to promote social interaction. A grievance dated 9/19/2024 regarded a resident not being toileted and the facility response of the family member attempted to assist the resident with toileting at 1:00 PM and 2:00 PM. A grievance dated 9/25/2024 regarded a resident that wished to go back to bed after care at 5:00 - 6:00 AM and a Certified Nurse Aide told the resident they had to stay up because there were 22 other residents who needed assistance. A grievance dated 10/06/2024 regarded a resident engaging a call light without a timely response to the point that the resident used the waste bin to urinate with a facility response of, only 1 Certified Nursing Assistant and 1 Licensed Practical Nurse from 2200 (10:00 PM) - 0600 (6:00 AM). During an observation in the G wing on 12/02/2024 at 12:01 PM, a call light was active in room [ROOM NUMBER] and was answered at 12:23 PM for a response time of 22 minutes. During an observation on the G wing on 12/02/2024 at 1:01 PM a call light was on in room [ROOM NUMBER] and was answered at 1:23 PM for a response time of 22 minutes. During an observation on the G wing on 12/03/2024 at 11:38 AM, a call light was on in room [ROOM NUMBER] and was answered at 11:52 AM for a response time of 14 minutes. During an observation on the G wing on 12/04/2024 at 7:30 AM, a call light was on in room [ROOM NUMBER] and was answered at 8:23 AM for a response time of 53 minutes. During an observation in the D wing on 12/05/2024 at 6:05 AM, a foul odor was noted by room [ROOM NUMBER] and a separate foul odor beyond room [ROOM NUMBER]. During an observation on the D wing on 12/05/2024 at 6:32 AM, a strong urine smell was still noted when first entered the unit by room [ROOM NUMBER], and a separate urine smell by room [ROOM NUMBER] was still present. During an observation on the D wing on 12/05/2024 at 6:55 AM the foul odor by room [ROOM NUMBER] and separate odor on other side of 24 were still present. During an observation on 12/05/2024 at 6:13 AM, the call light G wing room [ROOM NUMBER] was engaged and it was still on at 6:53 AM for a 40- minute call light time. During an observation on 12/05/2024 at 6:16 AM, there was an odor of urine outside of room G- 18. During an observation on 12/05/2024 at 6:27 AM on the S Wing, there were 3 residents in recliners in the television room with no staff around, and at 6:48 AM 2 of the same residents were in the same place in the television room. At 6:46 AM, 2 residents were in recliners in the living room area with the lights off and no staff present. During an observation on 12/05/2024 at 7:00 AM on A Wing, the call light was engaged in room [ROOM NUMBER] and remained on until 7:46 AM for a 46- minute call light response time. During an observation on 12/05/2024 at 7:00 AM on A Wing, 6 residents in geri chairs were lined up in the hall by lower numbered rooms with 1 resident calling for help from the chair, and 3 residents in geri chairs were across the nurses' station area in the hall; 1 resident had an electronic device, and the rest had no music, television, or staff interaction in the hall. At 7:30 AM the same residents were in the same positions in the hallway around the nurses' station. During an interview on 12/02/2024 at 12:01 PM, Resident #35 stated the facility needed more help and the roommate had waited over 30 minutes for help after engaging the call light. During an interview on 12/02/2024 at 12:08 PM, Resident #334 stated they screamed until their throat hurt after their call light wait was on too long and the resident wet themselves and then staff tell the resident to stop shouting. On 12/03/2024 at 11:30 AM during a resident council meeting, several residents stated that multiple times residents had waited for a long period of time for staff to answer the call lights. In addition, it was stated that sometimes staff were too busy to help residents eat. Everyone stated that there was not enough staff to help and take care of daily needs. During an interview on 12/03/2024 at 12:35 PM, Resident #21 stated the facility was short on staff and sometimes the resident had to wait for a long time to get help, easily over an hour on average. The wait time was the most around mealtimes because staff were with other residents. During an interview on 12/05/2024 at 6:13 AM, Licensed Practical Nurse #5 stated there was only one Certified Nurse Aide for the second half of the night shift. During an interview on 12/06/2024 at 11:48 AM, Registered Nurse #3 stated that it was difficult when all shifts were not filled; they stated that staff from other units would sometimes cover but those filler staff did not know the residents as well, so it took longer to provide care when it was not the staff assigned to the unit. During an interview on 12/06/2024 at 12:00 PM, Licensed Practical Nurse #6 stated that they had experienced understaffing on several units, and it tended to slow down care of the residents when the staff were stretched too thin. During an interview on 12/06/2024 at 1:12 PM, Assistant Director of Nursing #1 stated that call lights were answered as quick as possible, and it was unrealistic to expect a light to be answered in a specific time frame. They stated that 36 of 40 residents on Unit A required a mechanical lift to get out of bed and that was why residents were lined up along the nurse's station, there was nowhere else to put the residents first thing in the morning. They also stated it was acceptable for a call light to be engaged for over 50 minutes on this unit in the morning and at different times on different units call light times of over 30 minutes was expected. 10 New York Code Rules and Regulations 415. 13(a)(1)(i-iii) | Plan of Correction: ApprovedJanuary 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #334 care plan was updated to include resident's use of oxygen and a nebulizer. 2. All current resident medication administration records will be reviewed for orders for oxygen and/or nebulizer treatments and their care plans were reviewed to ensure comprehensive care plans are in place. New admissions with oxygen orders will have their care plan reviewed as described in #4 below. 3. All Registered Nurses will be re-educated on the requirement and associated time frames to develop care plans for oxygen and/or nebulizer treatments. No changes to the relevant policies were indicated. 4. All new physician orders [REDACTED]. 100% review of new orders for 3 months; no less than 75% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results (actual threshold of compliance will influence the decision to continue audits beyond 6 months). Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: January 17, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that each resident received accommodated resident choices, intolerances, and preferences. This was identified for one (Resident #82) of 35 residents reviewed. Specifically, Resident #82 had a dietician recommendation, signed by the physician, to discontinue a collagen supplement. For 35 days after the recommendation, the collagen was still ordered. This is evidenced by: The Policy titled Pressure Injury (PI)/ and Wound Care dated 11/15/2024 documented the facility was to ensure that the residents would receive wound care consistent with resident needs, goals, and recognized standards of practice. The procedure was that the nurse manager or designated registered nurse, dietician, physical therapist, and other interdisciplinary team members as needed would evaluate resident's clinical condition and pressure ulcer risk factors. The interdisciplinary team would define and implement interventions as appropriate. The facility would maintain a system to assure that the procedure for monitoring and documentation were implemented consistently throughout the facility. Resident #82 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/04/2024 documented Resident #82 could understand others and be understood by others, and was cognitively intact. The Comprehensive Care Plan titled, Eating initiated on 10/30/2024, documented Resident #82 received a collagen supplement, revised on 11/04/2024, documented the resident had the collagen supplement discontinued. A physician's orders [REDACTED]. The progress note dated 11/04/2024 documented Resident #82 would like to discontinue the collagen supplement, the provider was agreeable, and Registered Nurse unit manager #2 was notified and the care plan was updated. The progress note dated 12/04/2024 documented requested discontinue collagen supplement at last follow up. The order was still in place, Registered Nurse unit manager #2 was notified. On 12/05/2024 a 7:33 AM, Resident #82 was observed in their room on precautions and in no apparent distress. During an interview on 12/05/2024 at 8:08 AM, Registered Nurse unit manager #2 stated that new orders were processed by them and put in the electronic medical record, then placed in the paper medical record. They confirmed that the order was in the paper record and not processed in the electronic record for the administration record. Registered nurse unit manager #2 stated that they missed this one and would take care of it right away. During an interview on 12/05/2024 at 10:07 AM, Director of Nursing #1 stated they would expect the signed dietary recommendation signed by the provider to be followed and discontinued as ordered. 10 New York Codes, Rules, and Regulations 415. 14(d)(4) | Plan of Correction: ApprovedJanuary 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents #59 and #86 Medication Administration Orders were corrected to ensure 14 day limits were included as required for their as-needed (PRN) [MEDICAL CONDITION] medication orders. 2. All current resident medication administration orders were reviewed for as needed [MEDICAL CONDITION] medications to ensure 14 day stop dates are in place. 3. All medical providers re-educated on requirement that [MEDICAL CONDITION] medications given on an as needed basis must have an end date specified in the order not to exceed 14 days, along with other policy requirements. All nurses who have the potential to enter orders (Registered Nurses, Licensed Practical Nurses) will be re-educated on the requirements in [MEDICAL CONDITION] medication order entry. 4. All new orders for as needed??ÿ [MEDICAL CONDITION] will be audited weekly from medical provider order summary, in addition to the pharmacist's drug regimen review process (on admission and monthly) which will identify any non-conforming order. Any pharmacist finding and recommendation pertaining to as needed [MEDICAL CONDITION] medications will be brought to the direct attention of the Director of Nursing or her designee. Results of the reviews will be reported to the Quality Assurance & Performance Improvement Committee; 100% of new as needed [MEDICAL CONDITION] orders will be reviewed for compliance with policy for 6 months; frequency of audit to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results. Responsible Party: Director of Nursing |
Scope: N/A
Severity: N/A
Citation date: December 6, 2024
Corrected date: January 6, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: January 17, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices that were accurately documented and completed for 3 (Residents #21, 144. and #171) of 35 residents reviewed. Specifically, (a.) for Resident #21, the facility incontinence care provided was not documented; (b.) for Residents #144 and #171 the care provided by Certified Nurse Aides were not consistently documented, including the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. This is evidenced by: A review of policy titled Documentation for Certified Nursing Assistants dated 11/22/2010 documented all documentation of care delivered to a resident by a Certified Nursing Assistant would be done using the Point Click Care (PCC) kiosks. The policy stated care should be entered as close as possible after the care had been rendered and staff was to enter information at the kiosk at various times during their tour of duty, not waiting until the end of a shift. The policy also documented all documentation was to be completed accurately prior to the completion of the Certified Nursing Aide's tour of duty. Resident #21 Resident #21 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/18/2024, documented the resident was able to make themself understood and had the ability to understand others. Resident #21 had a moderate cognitive impairment for activities of daily living. A review of Resident #21's Minimum (MDS) data set [DATE] indicated for Resident #21, a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had been attempted and was currently being used to manage the resident's urinary continence. Resident #21 was listed as being frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) for urinary continence. A review of Resident #21's care plan initiated 08/17/23 with focus, Resident #21 has bladder incontinence related to impaired mobility listed an intervention as, Check me every 2-4 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN and after incontinence episodes. A review of task log for Resident #21 listed task as, Individualized toileting schedule: toilet before meals, then walk to D-wing dining room. Must wake up and take to toilet during the overnight shift even if already incontinent. This task log indicated Resident #21 was checked to see if they voided on the following dates at the following times: 11/08/2024: Documented care was performed at 1:04 AM; 10:18 AM, 1:41 PM, 8:54 PM, 8:54 PM (8:54 PM was listed twice). 11/09/2024: Documented care was performed at 2:15 AM, 4:56 AM, and 10:00 AM. 11/10/2024: Documented care was performed at 7:00 AM and 8:00 PM. 11/11/2024: Documented care was performed at 9:06 PM and 9:06 PM (9:06 PM was listed twice). 11/12/2024: Documented care was performed at 1:24 AM, 7:24 PM and 7:24 PM (7:24 PM was listed twice). 11/13/2024: Documented care was performed at 1:34 PM. 11/14/2024: Documented care was performed at 12:00 PM. 11/15/2024: Documented care was performed at 8:00 AM, 12:00 PM, 9:45 PM, 9:45 PM (9:45 PM was listed twice). 11/16/2024: Documented care was performed at 10:42 AM, 1:49 PM, 7:32 PM, 7:32 PM (7:32 PM was listed twice). 11/17/2024: Documented care was performed at 10:43 AM, 1:46 PM, 7:13 PM, 7:13 PM (7:13 PM was listed twice). 11/18/2024: Documented care was performed at 11:23 PM. 11/19/2024: Documented care was performed at 5:54 AM. 11/20/2024: Documented care was performed at 4:12 AM. 11/21/2024: Documented care was performed at 3:42 PM. 11/22/2024: Documented care was performed at 9:02 PM. 11/23/2024: Documented care was performed at 1:32 AM, 11:01 AM, 12:00 PM. 8:43 PM, and 8:44 PM. 11/24/2024: Did not document care was performed. 11/25/2024: Documented care was performed at 3:22 AM, 4:08 PM, 7:01 PM. 11/26/2024 through 11/29/2024: Resident #21 was unavailable for voiding review due to being hospitalized and out of the facility. 11/30/2024: Documented care was performed at 5:00 PM and 8:00 PM. 12/01/2024 Documented care was performed at 1:49 AM, 9:38 PM and 9:38 PM (9:38 PM was listed twice). 12/02/2024: Documented care was performed at 1:28 AM, 8:00 AM, 12:00 PM, 8:05 PM, and 8:05 PM (8:05 PM was listed twice). 12/03/2024: Documented no care was performed. 12/04/2024: Documented care was performed at 10:56 AM, 1:49 PM, 9:42 PM, and 9:42 PM (9:42 PM was listed twice). 12/05/2024: Documented care was provided 7:47 PM and 7:47 PM (7:47 PM was listed twice). During an interview on 12/05/24 at 1:32 PM, Certified Nurse Aide #1 stated they used a peri wash, wipe the resident from front to back, and clean Resident #21 every time they go to the bathroom. Certified Nurse Aide #1 stated they documented the toileting of Resident #21 on the kiosk. Certified Nurse Aide #1 stated they tried to document services provided when they occurred, but t was not always possible, and they may document the services provided at the end of their shift. During an interview on 12/05/24 at 11:57 AM, Licensed Practical Nurse #1 stated that after the Certified Nurse Aides provided care relating to toileting/continence for Resident #21, they should document they provided care. Licensed Practical Nurse #1 stated they would expect to see a check on the report every 4 hours for Resident # 21. During an interview on 12/05/24 at 2:40 PM, Registered Nurse #1 stated they did not know if there was a place for Certified Nurse Aides to document they had provided care for a resident. When Registered Nurse #1 was shown the task log mentioned above, they stated they never saw it before and would have to look into it further. During an interview on 12/06/24 at 10:02 AM, Assistant Director of Nursing #1stated if a resident was care planned to be checked and changed for toileting, there should be a task for it to allow Certified Nurse Aides to document the care provided. The Certified Nurse Aides documented tasks on the kiosk when care was performed, but they may wait to document that care was performed because they may not have a chance to document when they performed the actual care. If a resident was to be checked/changed every 4 hours, it should be documented that it occurred every 4 hours. When the Assistant Director of Nursing was shown the above referenced task log, they stated, There is a documentation issue. Resident #144 Resident #144 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/11/2024 documented the resident was understood, was able to be understood, and severely cognitively impaired. Resident #144's comprehensive care plan documented the resident was at nutritional risk. The documented interventions included: offer a bedtime snack nightly and provide health shakes three times a day. The Point of Care Response History for Supplement consumed - health shake three times a day? (11/5/2024-12/5/2024) documented incomplete or missing documentation for the following dates: 11/7/2024: two health shakes documented at 8:30 AM and 12:00 PM 11/8/2024: no health shakes documented. 11/11/2024: one health shake documented at 8:48 PM 11/12/2024: no health shakes documented. 11/14/2024L two health shakes documented at 8:30 AM and 12:00 PM 11/15/2024: one health shake documented at 9:04 PM 11/18/2024: one health shake documented at 8:30 AM and 12:00 PM 11/19/2024: no health shakes documented. 11/20/2024: two health shakes documented at 11:05 AM and 7:30 PM 11/21/2024: one health shakes documented at 6:32 PM 11/22/2024: one health shake documented at 8:48 PM 11/23/2024: two health shakes documented, both at 1:53 PM 11/24/2024: two health shakes documented at 12:00 PM and 9:39 PM 11/25/2024: one health shakes documented at 8:37 PM 11/26/2024: two health shakes documented at 1:45 PM and 8:25 PM 11/27/2024: one health shake documented at 9:42 PM 11/28/2024: no health shake documented. 11/29/2024: one health shake documented at 9:33 PM 12/1/2024: one health shake documented at 8:29 PM 12/3/2024: one health shake documented at 9:29 PM 12/4/2024: one health shakes documented at 9:31 PM 12/5/2024: two health shakes documented at 1:31 PM and 1:32 PM The Point of Care Response History for what percentage of the meal was eaten? (11/5/2024-12/5/2024) documented incomplete or missing documentation for the following dates: 11/8/2024: no meals documented. 11/11/2024: one meal documented at 6:21 PM 11/12/2024: no meal documented. 11/14/2024: two meals documented at 8:30 AM and 12:00 PM 11/15/2024: one meal documented at 9:04 PM 11/18/2024: two meals documented at 8:30 AM and 12:00 PM 11/19/2024: no meals documented. 11/20/2024: two meals documented at 11:05 AM and 7:30 PM 11/21/2024: one meal documented at 6:32 PM 11/23/2024: one meal documented at 1:53 PM 11/24/2024: two meals documented at 12:00 PM and 9:19 PM 11/25/2024: no meals documented. 11/26/2024: one meal documented at 8:24 PM 11/27/2024: one meal documented at 9:42 PM 11/28/2024: no meals documented. 11/29/2024: one meal documented at 9:33 PM 12/1/2024: one meal documented at 8:29 PM 12/3/2024: one meal documented at 9:29 PM 12/4/2024: one meal documented at 9:24 PM Point of Care Response History for offer nourishing snack: task completed (11/5/2024-12/5/2024) documented missing documentation for the following dates: 11/14/2024 11/18/2024 11/19/2024 11/20/2024 11/23/2024 11/28/2024 12/02/2024 12/05/2024 During an interview on 12/5/2024 at 12:16 PM, Licensed Practical Nurse #4 stated the registered nurses checked for documentation completion. During an interview on 12/5/2024 at 12:23 PM, Registered Nurse #3 stated the licensed practical nurses were to check the electronic medical record dashboard for the completion of certified nurse aide tasks before the certified nurse aides leave at the end of the shift. Resident #171 Resident #171 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 9/26/2024 documented the resident was able to be understood and could understand others; the resident was severely cognitively impaired. It further documented that the resident was totally dependent on assistance to eat, toilet, and lower body dressing. On 06/26/2024, the resident weighed 151. 4 pounds. On 12/02/2024, the resident weighed 130. 8 pounds which is a - 13. 61 % Loss in 6 months. Resident #171's care plan documented that the resident had a potential for weight loss, initiated 9/13/2024, and the intervention was to monitor and record food intake at each meal if applicable (also initiated 9/13/2024). Resident #171's amount of food eaten from 11/4/2024 - 12/2/2024, printed 12/3/2024, was missing meal documentation as follows: 11/4/2024 - 1 meal documented at 5:00 PM 11/5/2024 - 1 meal documented at 5:00 PM 11/6/2024 - 1 meal documented at 6:18 PM 11/7/2024 - 1 meal documented at 7:36 PM 11/8/2024 - all 3 meals documented. 11/9/2024 - 1 meal documented at 5:00 PM 11/10/2024 - all 3 meals documented. 11/11/2024 - all 3 meals documented. 11/12/2024 - 2 meals documented at 10:39 AM and 1:45 PM 11/13/2024 - 1 meal documented at 5:00 PM 11/14/2024 - 1 meal documented at 7:03 PM 11/15/2024 - 2 meals documented at 8:30 AM and 12:00 PM 11/16/2024 - all 3 meals documented. 11/17/2024 - 1 meal documented at 8:33 PM 11/18/2024 - all 3 meals documented 11/19/2024 - 1 meal documented at 9:53 PM 11/20/2024 - 1 meal documented at 9:37 PM 11/21/2024 - 1 meal documented at 9:38 PM 11/22/2024 - 2 meals documented at 8:30 AM and 12:00 PM 11/23/2024 - 1 meal documented at 9:45 PM 11/24/2024 - 1 meal documented at 5:00 PM 11/25/2024 - 1 meal documented at 9:08 PM 11/26/2024 - all 3 meals documented. 11/27/2024 - 1 meal documented at 5:00 PM 11/28/2024 - 1 meal documented at 9:16 AM 11/29/2024 - 1 meal documented at 9:27 PM 11/30/2024 - 1 meal documented at 9:41 PM 12/1/2024 - all 3 meals documented. 12/2/2024 - all 3 meals documented. During an interview on 12/5/2024 at 12:25 PM, Certified Nurse Aide #2 stated all care was to be documented after it was given. This included meals, supplements, and snack consumptions. They stated if the task read for a supplement to be given three times a day, it should be documented that it was given three times a day. During an interview on 12/6/2024 at 10:00 AM, Assistant Director of Nursing #1 stated that documentation should be completed as ordered. They stated the amount of meals consumed should be documented with each meal. The licensed practical nurses were able to access the dashboard in the electronic medical record to check if documentation was completed with the expectation that it was completed. 10 New York Codes, Rules, and Regulations 483. 70 (h)(2)(ii) | Plan of Correction: ApprovedJanuary 16, 2025 1. Resident #82 Medication Administration Record [REDACTED] 24. A corresponding medication error sheet was also completed per facility policy on 12/5/ 24. Responsible Registered Nurse self-identified that when she had followed up with the resident, the resident had clarified they didn't ask for a discontinuation of the Collagen order, but rather a change in administration time and this Registered Nurse followed through on the residents request, but failed to update the medical provider of this resident's request, nor get a refreshed order based on the residents request, as defined in policy. 2. All resident records on the unit (B wing) where the Registered Nurse was entering medical orders and made the above error to be reviewed to ensure any written recommendations made by an ancillary service during the prior three months (including Registered Dietician, therapy, psychiatry, or specialist consultants--Orthopedics, Cardiology, Neurology) to ensure there is a corresponding medical order that is properly executed. 3. All licensed nurses responsible for transferring recommendations to medical orders will be provided with a policy overview of the procedure for transferring clinical recommendations to properly executed medical orders. There is no policy change indicated as this deficiency is directly related to a single order that was not completed by one employee, who self-identified the error. 4. On a daily basis (defined as every day), the night shift licensed nurse will conduct a 100% audit (visual review) of all new orders obtained during the prior 24 hours, to include written recommendations which are to be transferred to a written medical order. The results will be provided to the Director of Nursing (or designee) daily (which means daily; or the next day after a weekend). Errors, if identified, are raised to the attention of the Registered Nurse Supervisor who is in communication with the Director of Nursing or her designee and will be addressed immediately, or at the most appropriate time based on the nature of the error found (i.e. prior to the advent of additional error). A summary of the audit results will be provided to Quality Assurance & Performance Improvement monthly, with frequency to be re-evaluated after six months. As the nightly audit is being reviewed by the Director of Nursing or her designee (the assistant director of nursing) on a daily, or near daily basis, monthly reporting to Quality Assurance and Performance Improvement Committee is appropriate. In the event the Director of Nursing identifies trends or clusters of errors, correction actions will be implemented immediately. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: January 31, 2025
Citation Details None | Plan of Correction: ApprovedJanuary 16, 2025 1. Residents #21, #144, and #171 documentation will be reviewed by the Registered Nurse Manager, with a summary assessment documented on their toileting or nutritional intake (based on nature of identified missing documentation). Missed documentation of this type cannot be accurately recreated in a retrospective manner, and a summary of the resident's status based on the Registered Nurse assessment is appropriate to substitute in this manner. 2. All residents on a specific toileting program or identified as high risk nutritionally requiring meal intake monitoring will be reviewed to assure their plan is appropriate and the documentation is substantially complete. If found to be insufficient, a summary assessment will be conducted and documented on their toileting or nutritional status by the Registered Nurse. See further explanation under #1 above. 3. The following corrective measures will be implemented: a. Toileting documentation ?ö?ç?ú Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements of clinical task documentation. Within the last hour of each scheduled shift, the Licensed Practical Nurse (charge nurse) will review all task documentation that is outstanding via electronic reporting and communicate findings to assigned CNAs. Information will be provided to Registered Nurse Manager, who will provide ongoing counseling and education as necessary on the units. b. Intake Recording ?ö?ç?ú Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements for intake monitoring and documentation. Hand-held devices (tablets) will be deployed in the dining areas for documentation at each meal. Charge Nurse will maintain a list of residents on intake monitoring, validating documentation completeness and accuracy during and after each meal. No documentation policy changes were indicated. In the event the charge nurse is unable to perform the audits at the end of their shift, they will first do a verbal check in with the aides; and second, if necessary, will report to their Nurse Manager or Supervisor they were unable to complete this task. #4 below will be the final review of all documentation review procedures. 4. Registered Nurse Unit Managers will audit (visually review of documentation in electronic health record) compliance for no less than 4 days per week (using a 24 hour report) for 3 months, and 2 days per week for 3 months to determine compliance, with results reported monthly to Quality Assurance & Performance Improvement. In the event any particular unit(s) find continuing compliance issues, the findings will be reviewed with the Director of Nursing (or designee) to determine if increasing frequency of review is indicated (vs. isolated performance issue). Frequency of audits will be reevaluated after 6 months by Quality Assurance & Performance Improvement committee. Frequency of auditing may be increased at any point by the quality assurance and performance improvement committee based on audit results. Responsible Party: Assistant Director of Nursing for Quality and Education |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: January 15, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (Residents #334) of 35 residents reviewed. Specifically, Resident #334 received oxygen that was not noted in the care plan. This is evidenced by: The Policy titled Care Planning dated 09/21/2017, documented the purpose of the policy was to have a written plan for staff to follow to provide care to a resident of the facility. Upon admission the 48-hour care plan would be developed and reviewed with the resident and/or the health care proxy within 48 hours. The care plan would be completed by the first care plan meeting within 14 days of admission. The care plan will be added to as new issues arise and when recognized plans have been resolved. Resident #334 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/28/2024 documented the resident could understand and be understood by others; resident was cognitively intact. Resident #334 used oxygen at 2 liters per minute continuously at the facility. The Comprehensive Care Plan dated 11/21/2024, did not have documented evidence of Resident #334's use of oxygen and nebulizer. The electronic health record documented an order on 11/25/2024 for oxygen at 2 liters per minute continuously, [MEDICATION NAME]-[MEDICATION NAME] inhalation solution via nebulizer four times a day and every 6 hours as needed. The progress note dated 11/21/2024 documented Resident #334 arrived at the facility with oxygen in place at 2 liters per minute via nasal cannula. On 12/04/2024 at 8:39 AM, Resident #334 was observed with oxygen in place at 2 liters per minute. During an interview on 12/06/2024 at 9:24 AM, Licensed Practical Nurse #3 stated the registered nurse unit managers would update the care plans. They would receive some orders and process them into the electronic health record and call to pharmacy when needed but the registered nurse would update the care plan. During an interview on 12/06/2024 at 9:59 AM, Assistant Director of Nursing #1 confirmed there was no care plan for oxygen for Resident #334, stated they would expect the oxygen to be on the care plan. 10 New York Codes, Rules, and Regulations 415. 11(c)(2) (i-iii) | Plan of Correction: ApprovedJanuary 16, 2025 1. Residents #35 and #168 were assessed for safety in self-administering associated medication (inhaler and oxygen respectively) with medical orders provided if indicated and care planned accordingly. #35 medication is no longer left at bedside. #168 is not allowed to self-regulate oxygen or change tank per facility policy. 2. All resident medication administration records will be reviewed to identify orders which allow medication(s) to be left at bedside, and corresponding self-administration assessments. No other residents were identified which had medications at bedside without corresponding assessments and medical orders. All residents on oxygen reviewed to identify any resident that was independently changing supply or adjusting flow rates independently ?ö?ç?ú no other residents identified. 3. All medical providers and Registered Nurses (RNs) will be re-educated on facility policy regarding self-administration of medication for residents, including assessment, medical orders and care planning requirements. No policy changes were indicated following review. 4. All new medication orders stating self-administration??ÿ identified during the pharmacist's monthly medication regimen review process will be reviewed to assure appropriate protocols (including assessment, medical order and care plan) are followed. Review to consist of 100% new orders for 3 months; and no less than 50% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance and Performance Improvement Committee based on overall compliance with policy. Responsible Party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: January 31, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 2 (Residents #59 and #86) of 6 residents reviewed for unnecessary medications. Specifically, for Residents #59 and #86, as-needed [MEDICAL CONDITION] medication orders did not include stop dates. This is evidenced by: The policy and procedure titled [MEDICAL CONDITION] Medication Use, dated 6/2024, stated as needed orders for [MEDICAL CONDITION] medications would be time limited. Resident #59 Resident #59 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was usually able to be understood and could usually understand others; the resident was severely cognitively impaired. Resident #59 had an order for [REDACTED].#59's Medication Administration Record [REDACTED]#86 Resident #86 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/04/2024 documented the resident was able to be understood, could understand others, and was severely cognitively impaired. Resident #86 had an order for [REDACTED]. The order start date was documented as 12/04/ 2024. There was no end date documented; the end date was documented as indefinite. A Medication Regimen Review was completed on 12/03/ 2024. The pharmacy consultant recommended an end date be applied to the [MEDICATION NAME] order. Nurse Practitioner #1 documented disagreement with the recommendation and no end date was added to the order. During an interview on 12/06/2024 at 12:49 PM, Nurse Practitioner #1 stated there was a fear that if the medication had an end date, it might not be renewed. They understood that it was a Centers for Medicare and Medicaid requirement that [MEDICAL CONDITION] medications given on an as needed basis had an end date in the order. 10 New York Codes, Rules, and Regulations 415. 18 (c)(2) | Plan of Correction: ApprovedJanuary 16, 2025 1. In the absence of resident-specific corrections to be made, the Administrator and/or Director of Nursing will meet with the Resident Council to review this Plan of Correction and request feedback. 2. All Customer grievances related to call bell response times over the last 12 months will be reviewed for trend identification to determine if there are root cause issues or common time/shifts/units, etc. If identified, focused action plans will be implemented. 3(a). The following strategies focused on staff recruitment and retention will continue to be implemented and continually adjusted based on response to address overall staffing levels. a. Aggressive recruitment campaign, including sign on bonus, referral bonus, tuition reimbursement, etc., with addition on 1/1/25 of new social media contract service. NOTE - agency nursing, including travel nurse resources are extremely scarce in rural areas. Several contracts are in place but unable to provide actual supplemental staff. Staffing requests remain pending and unfilled. Facility will review, screen and onboard agency staff that contracted agency finds. Current staff will continue to be offered significant shift bonuses (Up to $25 per hour differentials) for hard to fill shifts. b. Continued implementation of Nurse Aide training program, including evening classes (grant funded) c. Continued mentorship programs for newly hired Certified Nursing Assistants and Licensed Practical Nurses. d. Continued tuition reimbursement program (currently sponsoring 3 Licensed Practical Nursing students' full tuition plus stipend for living expenses while in school). e. Incentive programs for longevity, attendance and other positive promotion strategies. 3(b). The following strategies will focus specifically on call light response times: a. Educational awareness program to be implemented for all clinical and support staff emphasizing the importance of call light response promptness. b. Review and revision of morning care routines for residents identified as consistently requesting assistance at predictable times with care plan adjustments as determined appropriate. c. Incorporate all staff, including ancillary department employees, with the responsibility to respond to call bells to address those issues and request within their scope of abilities, and communicate to nursing specific needs that may exist. d. No specific policy changes are indicated as this portion of the Plan of Correction focuses on staff awareness and education, combined with objective assessment of care delivery routines. 3(c). The Facility Assessment will be reviewed and updated to more clearly assess and articulate: a. Optimal staffing levels vs. minimally appropriate levels based on acuity and related variables required for appropriate resident care b. Appropriate staffing adjustments based on census (as current Assessment and basis for deficiency is based on 100% occupancy but facility is not operating at that level) c. Recognition of support staff, reassigned staff, and other resources routinely accessed but not evident on daily staffing sheets 4. Overall staffing levels by unit will be summarized daily and compared to the Facility Assessment optimal and minimally appropriate levels ?ö?ç?ú Summarized and reported to Quality Assurance & Performance Improvement Committee monthly for six months. Total number of new hires and terminations for Certified Nursing Assistants and Licensed Practical Nurses, and overall turnover rates to be summarized monthly and reported to Quality Assurance & Performance Improvement for six months. No fewer than 5 visual observation audits (call bell response time) on different units and/or different times of day will be conducted weekly to measure call light response time. Audits will occur weekly for 3 months, followed by 10 audits per month for three months. Audit results to be reviewed by Quality Assurance & Performance Improvement Committee, which may extend or increase frequency based on results. Responsible Party: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: February 3, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: February 14, 2025
Citation Details None | Plan of Correction: ApprovedFebruary 18, 2025 1. All outstanding repairs for the G Wing 1 Elevator and Service Elevator completed by contractor on 2/11/ 25. Department of Health state sanitarian had been emailed 1/31/25, prior to the facility's original date certain that the elevator contractor would not be in by facility's date certain but would email the confirmation of work completed as soon as facility was in receipt of it. Facility was able to send forth work completion documents 2/14/25 confirming work was completed as of 2/11/ 25. 2. No other elevators exist in the building with outstanding service work recommended in inspection. 3. Director of Plant Operations re-educated on elevator/inspection testing requirements and the requirement to have documentation attesting indicated work has been completed available for the Authority Having Jurisdiction at the time of request. 4. Inspection, testing and repair information will be provided to the Quality Assurance and Performance Improvement (QAPI)Committee on a quarterly basis for one year to ensure any indicated work identified upon 6 month inspection is closed out, with frequency to be reassessed after one year based on overall compliance with frequency and repair follow up. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: February 3, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: February 3, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: February 3, 2025
Citation Details Based on record review and interview conducted during a Life Safety Code Post-Survey Review survey, the facility did not provide evidence that the facility (1) conducted required testing and repairs to the elevators and (2) ensure that the Electronic Plan of Correction was implemented relative to Building # 1. Specifically, the facility did not repair the G Wing 1 elevator emergency phone and conducted a rupture test on the service elevator. This is evidenced by: The facility-supplied Electronic Plan of Correction stated in part, (a) proposal for all outstanding repairs (was) accepted on 12/10/24 and is scheduled to be completed by (the plan of correction) completion date of 2/3/ 25. Inspection, testing and repair information will be provided to the Quality Assurance/Performance Improvement Committee. There was no documented evidence that the G Wing 1 elevator emergency phone was repaired and a rupture test was conducted on the service elevator. During a telephone interview on 02/12/2025 at 12:39 PM, Administrator #1 stated that they would consult with the maintenance department regarding the elevator testing and repair reports that might be missing. Electronic correspondence from the facility administrator dated 02/12/2025 documented that a vendor had completed the elevator repairs and testing on 02/11/ 2025. The facility-signed Electronic Plan of Correction for this citation documented a Credible Allegation Date of 02/03/ 2025. The facility did not ensure the Electronic Plan of Correction was fully implemented by the Credible Allegation Date. The facility was cited for the following during the recertification survey: **** Based on observation and interviews during the recertification survey, the facility did not inspect and test the elevator in accordance with the adopted regulations relative to Building # 1. Specifically, the elevator was not tested at 12-month and 5-year intervals as required by American Society of Mechanical Engineers booklet A17-1 Safety Code for Elevators and Escalators 2004 Edition Section 8. 11. 1. 3 and Table N- 1. This is evidenced by: There was no documented evidence for the following: ??®??Ç G Wing 1 elevator was inspected and tested during 2022 and 2024 and that the emergency phone was repaired, the lighting circuit that disables door power was repaired, the unsealed valve was repaired, and a pit 120 vac was installed as documented on the 05/25/2023 and 11/21/2023 inspection reports. ??®??Ç G Wing 2 elevator was inspected and tested during 2022 and 2024 and that the lighting circuit disables door power was repaired as documented on the 11/21/2023 inspection report. ??®??Ç The service elevator was inspected and tested during 2022 and 2024, an inspection was conducted during 05/ 2023. The 11/21/2023 reports that a rupture test is due during 2024. ??®??Ç The dumbwaiter was inspected and tested during 2022 and 2024 and tested during 11/ 2023. During an interview on 12/06/2024 at 1:47 PM, Administrator #1 stated that they believe that the elevators had been tested and inspected as required, but that they were unable to find the documentation at present. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101: 9. 4 2008 American Society of Mechanical Engineers booklet A 17. 3 1. 5 2004 American Society of Mechanical Engineers booklet A 17. 1 8. 6, Table N-1 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a) | Plan of Correction: N/A Plan of correction not approved or not required |