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Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that Minimum Data Set assessments accurately reflected the resident's cognitive status. This was evident in 1 (Resident #57) of 23 total sampled residents. Specifically, the Minimum Data Set assessment for Resident #57 did not accurately reflect the Resident's cognition. The findings are: The facility's policy titled Minimum Data Set Completion with a last revised date of 05/2024 documented that federal regulations require that the assessment accurately reflects the resident's status and that an accurate assessment requires collecting information from multiple sources. Resident #57 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #57's cognition as independent-decisions consistent/reasonable, resident unable to respond, and no behaviors. A Comprehensive Care Plan on cognition, cognitive loss, dementia was inititiated for Resident #57 on 03/24/ 2020. The care plan documented that Brief Interview for Mental Status was attempted but could not be completed. Resident was unable to make needs known and require cues. A physician's note dated 12/24/2024 documented Resident #57 had a history of [REDACTED]. A social worker's resident interview assessment dated [DATE] documented Resident #57's cognition as severely impaired. On 03/06/2025 at 9:15 AM, Certified Nursing Assistant#1 was interviewed and stated Resident #57 does not follow commands, would sometimes pick up some of their food, but sometimes need to be fed. On 03/06/2025 at 10:50 AM, the Social Worker Director was interviewed and stated that the Resident #57 is nonverbal and has impaired cognition. They stated that the Minimum Data Set should have reflected that Resident #57 has poor memory and is impaired. On 03/07/2025 at 12:08 PM, the Director of Nursing, who was also the Minimum Data Set Coordinator, was interviewed and stated they sign off on the completion of the Minimum Data Sets, and that the disciplines who completed each sections attest to their own accuracy. 10 NYCRR 415. 11 (b) | Plan of Correction: ApprovedMarch 28, 2025 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 5 (Residents #6, #41, #48, #88, #92) of 5 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings are: The facility's policy titled Minimum Data Set 3. 0 Completion with a revised date of 05/2024 documented that submissions should be done according to the Resident Assessment Instrument manual and federal and state guidance. The Quarterly Minimum Data Set Assessment for Resident #6 was completed on 02/09/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/ 2025. The Quarterly Minimum Data Set Assessment for Resident #41 was completed on 02/06/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/ 2025. The Quarterly Minimum Data Set Assessment for Resident #48 was completed on 02/06/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/ 2025. The Quarterly Minimum Data Set Assessment for Resident #88 was completed on 02/06/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/ 2025. The Quarterly Minimum Data Set Assessment for Resident #92 was completed on 02/06/25 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/ 2025. The facility's validation report dated 3/5/2025 documented that all 5 submissions were transmitted late. On 03/07/2025 at 12:14 PM the Director of Nursing was interviewed and stated they are currently the Minimum Data Set Coordinator and is responsible for submitting the Minimum Data Set assessments to the Centers for Medicare and Medicaid Services Data System. The Director of Nursing stated they are aware that the submissions were late, and that it was an oversight. 10 NYCRR 415. 11 | Plan of Correction: ApprovedMarch 31, 2025 F 640 Element #1 The MDS compliance consultant will educate the MDS coordinator on timely submissions. Element #2 The facility will review the last months submissions to ensure they were submitted timely. Element #3 The policy and procedure for MDS completion will be updated to include timely submissions. The MDS consultant will in-service the MDS coordinator on the revised policy upon the completion of the update to the policy. Element #4 An audit tool will be developed by the Director of Nursing to monitor monthly for timely MDS submissions. Audits will be done for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of nursing will present findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Director of Nursing 5/1/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during Recertification Survey conducted from [DATE] to [DATE] the facility did not ensure safe food storage was practiced. This was evident during Kitchen Observation. Specifically, outdated food items were observed in the kitchen refrigerator. The findings are: The facility's policy titled Storage and Holding Timeframe for Food Items with a last reviewed date ,[DATE] documented to ensure safe food consumption, food items will be dated, placed in a container and if not consumed will be discarded. During the initial tour of the kitchen on [DATE] from 10:00 AM to 10:30 AM, the following expired items were observed stored in the kitchen refrigerator: 1. Dietary prepared snack of 20 plastic cups of 4 ounces cottage cheese with a labeled date of ,[DATE]/ 2025. 2. 8 plastic cups of 4 ounces skim milk with a labeled date of ,[DATE]/ 2025. 3. 4 plastic cups of 4 ounces cut pears with a labeled date of ,[DATE]/ 2025. 4. 20 plastic cups of 4 ounces cranberry juice with a labeled date of ,[DATE]/ 2025. On [DATE] at 11:08 AM, Dietary Aide #1 was interviewed and stated that outdated food items were overlooked and should have been discarded. On [DATE] at 12:13 PM, the Dietary Supervisor was interviewed and stated they had not worked for 2 days and had not realized they have outdated or expired residents' snacks in the refrigerator. They stated expired food are health hazard and should not be consumed. 10 NYCRR 415. 14 (h) | Plan of Correction: ApprovedMarch 31, 2025 Element #1 All foods that were out of date were discarded immediately. Element #2 A thorough inspection of the kitchen area will be completed by the food service Director to identify similar defective practices and any deficient practices will be addressed immediately. 2. Counseling will be issued to all employees for noncompliance. Element #3 Dietary consultant will provide an in-service on when foods should be discarded. The policy for food storage will be reviewed by the food service director to ensure it states when food should be discarded. All kitchen staff will be in-serviced with the updated policy. Element #4 An audit tool will be developed by the Dietary consultant to ensure compliance with out of date food. The dietary service supervisor or designee will conduct weekly inspections of the kitchen area to verify the consistent to specific standards. Should the inspections find any issues necessitating corrective actions, the Food service Director will address them immediately. The Food service Director will submit a status report to the administrator on a weekly basis. The Food service Director will present the findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident in 1 (Resident #41) of 2 residents reviewed for positioning / mobility out of 21 total sampled residents. Specifically, Resident #41 was observed multiple times without a left-hand roll in place as per physician's orders [REDACTED]. The findings are: The facility's policy titled Adaptive Devices with a last reviewed date of 10/2023 stated it was the policy of the facility to provide adaptive devices to its residents. All adaptive devices with current orders with physician and nursing staff will be picked up by nursing staff and entered to the Certified Nursing Assistant Accountability with correct don/on/off devices with appropriate wearing schedule. Resident #41 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented that Resident #41 had moderately impaired cognition and was dependent in all areas of activities of daily living. The assessment also documented that Resident #41 had and an impairment on one side of the upper extremity. A care plan with focus on restorative nursing rehabilitation was initiated for Resident #41 on 04/24/2024 and was last reviewed on 3/02/ 2025. The facility interventions included left hand roll to be worn at all times except for skin check and hygiene. A physician's orders [REDACTED]. During multiple observations on 03/03/2025 at 1:09 PM, on 03/03/2025 at 3:00 PM, on 03/04/2025 at 12:03 PM, and on 03/04/2025 at 1:45 PM, Resident #41 was observed without a left-hand roll in place. On 03/04/2025 at 1:46 PM, an interview was conducted with Certified Nursing Assistant #8 who was assigned to Resident # 41. Certified Nursing Assistant #8 stated they started working with Resident #41 about one month ago and that Resident #41 is totally dependent for care. Certified Nursing Assistant #8 stated they did not apply the left-hand roll and does not know where it was. On 03/04/2025 at 1:54 PM, Registered Nurse #1 was interviewed and stated Resident #41 is fully dependent on activities of daily living and requires extensive assistance. Registered Nurse #1 stated Resident #41 was prescribed a left hand roll due to left hand stiffness. They stated staff are to document and sign off when they place the device on the hand of the Resident. On 03/04/2025 at 2:40 PM, the Director for Rehabilitation was interviewed and stated that Resident #41 had tightness in their left hand and was prescribed a hand roll. They stated they observed Resident #41 earlier in the day without a left-hand roll applied, and they placed a new hand roll on the left hand. They further stated Certified Nursing Assistants are responsible for putting the hand roll on. On 03/07/2025 at 11:09 AM, the Director of Nursing was interviewed and stated if the left-hand roll is not in place for Resident #41, Resident #41 may develop contractures which can worsen over time. The Certified Nursing Assistants are responsible for applying the left-hand roll. The Registered Nurses and Licensed Practical Nurses on the unit are responsible for ensuring that the Certified Nursing Assistants are applying the device. 10 NYCRR 415. 12 (e)(2) | Plan of Correction: ApprovedMarch 28, 2025 Element #1 Resident #41 was immediately given a new hand roll. The CNA whom had resident # 41 was disciplined for not providing the residents hand roll. Element #2 The Director of rehabilitation reviewed all residents with assistive devices to ensure assistive devices are present and in use. Element #3 The nursing staff will be educated to use assistive devices that are ordered by the physician. The policy was reviewed and no revisions were made. Element #4 An audit tool will be developed by the Director of Rehabilitation to monitor the use of assistive devices. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of Rehabilitation will present findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Director of Rehabilitation 5/01/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a therapeutic diet was provided when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident in 1 (Resident #3) of 2 residents reviewed for Activities of Daily Living out of 23 total sampled residents. Specifically, Resident #3, who had a physician's orders [REDACTED]. The findings are: The facility's policy titled Thicken Up with a last revised date of 12/2024 documented that there are Thicken Up Instant Food Thickener on the trays based on Physician's, Dietician's, Nursing, and Speech Therapist evaluations of swallowing ability related to fluids. Thicken Up is ordered for those with swallowing issues for fluids. The facility's policy titled Activities of Daily Living with a last revised date of 11/2024, documented that nursing staff are in serviced upon new hire and as needed on following the plan of care. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #3's cognition as intact, required moderate assistance for eating, and complained of difficulty or pain with swallowing. A Speech Therapist's progress note dated 01/28/2025 documented Resident #3 presented with anterior spillage when eating / drinking and coughing episodes with thin liquids. Recommended puree, honey thick liquids, skilled speech therapy services for dysphagia, and consistency modification. A Comprehensive Care Plan for dysphagia (impaired swallowing) was initiated for Resident #3 on 01/30/ 2025. The facility interventions include ongoing dysphagia assessment and treatment, and diet as ordered by the physician. A care plan notes dated 01/30/2025 by Registered Dietitian #1 documented Resident #3's diet was downgraded to pureed with moderately thick liquids as resident having difficulty time coordinating respiration and swallowing function. A physician's orders [REDACTED]. During dining observation on 03/02/2025 at 11:40PM, Resident#3's meal tray ticket documented nectar thick liquids, regular-puree. A packet of thickener and 3 cups of juice were observed on the tray. There was no staff observed putting thickener on Resident #3's juice. Resident #3 was observed on 2 occasions drinking juice without a thickener and started coughing. On 03/07/2025 at 12:53 PM, the Speech Language Pathologist was interviewed and stated that Resident #3 had orders for nectar thick liquid because Resident has dysphagia and is high risk for aspiration. On 03/07/2025 at 2:38 PM, Certified Nursing Assistant #2 was interviewed and stated it is the nurses' responsibility to put thickener on residents' drink. They stated thickener packets would usually be on the residents' tray, and they would notify the nurse who would put it in the residents' drinks. On 03/07/2025 at 2:45 PM, Licensed Practical Nurse #1 was interviewed and stated that nurses are responsible for thickening the liquids for residents on thickened liquids. On 03/07/2025 at 11:54 AM, the Director of Nursing was interviewed and stated that Certified Nursing Assistants are responsible for adding the thickener on the residents' drink when they serve the resident's meal tray. They stated all Certified Nursing Assistants received an in-service education and were trained that if there was a thickener on the tray, then it was supposed to be given. 10 NYCRR 415. 12(i)(2) | Plan of Correction: ApprovedMarch 31, 2025 Element #1 The resident was immediately assessed by the RN supervisor and found to have no ill effects from the lack of thickener. Element #2 The facility purchased pre-thickened fluids to provide to residents that have orders for thickened liquid diet. The Director of Nursing will review of all residents with thickened fluids orders to ensure residents are receiving pre-thickened fluids. Element #3 The nursing staff will be educated on the use of thickened fluids. The policy and procedure on thickened fluids will be updated to include the use of pre-thickened fluids and the responsibility of the LPN and CNA to ensure the resident receives thickened fluids. Element #4 An audit tool will be developed by the Director of Nursing to monitor the use of thickened fluids. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of nursing will present findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Director of Nursing 05/01/25 |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the daily nurse staffing information included all the required information. This was evident during review of the Staffing Task. Specifically, the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. The findings are: The facility policy titled Staffing Guidelines with a last reviewed date of 09/2024 documented that the facility will post the nursing staff information including the census on a daily basis at the beginning of each shift. During multiple observations from 03/02/2025 through 03/03/2025, the nurse staffing information was posted on a door in the front lobby near the security desk. The information that was documented on the form included the facility name, date, resident census, and actual number of hours worked by licensed and unlicensed nursing staff. There was no documentation of the total number of licensed and unlicensed nursing staff directly responsible for resident care. 03/07/2025 10:22 AM, Staffing Coordinator #1 was interviewed and stated they are aware that the staff posting should include the total number of hours worked by Licensed Practical Nurses, Certified Nursing Assistant and Registered Nurses, in addition, to the actual hours worked by staff and the resident census. However, the Staffing Coordinator #1 stated that they never paid attention to the information on the staff posting as they are not primarily responsible for it. On 03/07/2025 at 12:00 PM, Registered Nurse #2 was interviewed and stated they were not aware that the total number of Registered Nurse, Licensed Practical Nurses and Certified Nursing Assistants that worked each shift should be included in the staff posting. On 03/07/2025 at 10:57 AM, the Director of Nursing was interviewed and stated they and Registered Nurse #2 are primarily responsible for the staff posting. the Director of Nursing stated they were not aware that the total number of Certified Nursing Assistants, Registered Nurses and Licensed Practical Nurses giving direct care should also be included on the staff posting. They stated they did not realize the guidelines had been changed and the total number of staff giving direct care was required to be posted. On 03/07/2025 at 03:07 PM, the Administrator was interviewed and stated that while they were aware the total number of hours worked by nursing staff should be listed on the staff posting, they were not aware that the total number of staff giving direct care should be included. 10 NYCRR 415. 13 | Plan of Correction: ApprovedMarch 31, 2025 Element #1 The Nurse supervisors were immediately counseled on the proper requirements for the nurse staff posting. The facility immediately updated and posted the nurse staffing posting as required with the total amount of nurse staff hours, people and the census. The posting will be updated every shift. Element #2 The Director of Nursing reviewed the updated nurse staff posting to ensure it has all the required posting elements. The Director of Nursing educated all RN supervisors and the staffing coordinator of the required information needed on the daily nurse staffing posting. Element #3 The policy and procedure for the nurse staff postings will be updated to include the total amount of nurse staff hours, people and the census. The posting will be updated every shift. The Director of Nursing will educate all RN supervisors and the staffing coordinator of the of the updated policy. Element #4 An audit tool will be developed by the Director of Nursing to monitor the nurse staff posting. Audits will be done weekly for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of nursing will present findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25 |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that the Medical Director consistently participated or attended the Quality Assurance & Performance Improvement (QAPI) meetings. Specifically, the Medical Director had not participated in 2 of the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings. The findings are: The facility policy titled Quality Assurance and Performance Improvement (QAPI) and Quality Assurance (QAA)with a last revision date of 12/04/2024 stated the purpose of Quality Assurance and Performance Improvement is to study, plan, analyze and validate specific areas of improvement for positive resident care outcomes. The committee members include Members of the Governing Board, Administrator, Medical Director, Director of Nursing Services, Infection Preventionist, Director of Rehabilitation, Director of Environmental Services, Director of Food Services/Dietary, Director of Social Services and Direct Care Staff. A review of the quarterly Quality Assurance & Performance Improvement meeting attendance Sheets showed no documented evidence that the Medical Director attended the meetings held on 08/21/2024 and 01/07/ 2025. On 03/07/25 at 02:17 PM, the Director of Nursing was interviewed and stated that the Medical Director would have signed the attendance sheet if they were present at the Quality Assurance and Performance Improvement meetings. On 03/07/2025 at 03:43 PM, the Administrator was interviewed and stated they invited the Medical Director on every Quality Assurance and Performance Improvement meetings. They stated the last time the Medical Director attended the meeting was on May 2024. The Administrator stated that the Medical Director could not attend one of the quarterly meetings due to scheduled cataract surgery. 10 NYCRR 415. 15(a-c) | Plan of Correction: ApprovedMarch 28, 2025 Element #1 The Medical Director was given the updated QAPI policy to reflect that if the medical director is unable to make a QAPI meeting, he must send a designee. Element #2 The medical director reviewed the last 2 QAPI minutes and reports. Element #3 The QAPI policy will be update to reflect that if the medical director is unable to make a QAPI meeting, he will send a designee. Element #4 An audit tool will be developed by the administrator to ensure compliance of QAPI meetings. The administrator will audit the next 3 QAPI meeting to ensure the medical director attends. The administrator will present the findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Administrator 5/01/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the resident's right to be treated with respect and dignity was maintained. This was evident in 2 (Resident #32 and #40) of 23 total sampled residents. Specifically, 1. ) Resident #32's urinary drainage bag was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible) and was visible from the hallway, and 2. ) Licensed Practical Nurse #2 remained standing while feeding Resident # 40. The findings are: The facility's policy titled Promoting/Maintaining Resident Dignity with a revised date of 07/2024 documented it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. The facility's policy titled Foley Catheter Management with a last revision date of 01/2024 documented that privacy bags should be always provided. 1. Resident #32 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #32 had intact cognition and had an indwelling catheter, Resident was dependent for bed mobility. A Comprehensive Care Plan for urinary incontinence and indwelling catheter was initiated on 03/30/2022 and was last reviewed on 06/01/ 2025. The facility interventions include to observe for changes in continence status. During observation on 03/02/2025 at 1:59 PM, 03/03/2025 at 8:57AM, and on 03/04/2025 at 8:46 AM, Resident #32 was observed in bed in their room with their urinary catheter drainage bag uncovered and hanging on the bed frame. The urinary drainage bag was visible to people passing in the hallway. On 03/04/2025 at 8:46 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #32 was in their assignment. They stated they thought the urinary dignity bag is only used when resident is out of bed. On 03/04/2025 at 8:51AM, Registered Nurse #1 was interviewed and stated Resident #32 should always have the urinary drainage bag must be inside a dignity bag and that the staff are aware of this. On 03/07/2025 at 12:19 PM, the Director of Nursing was interviewed and stated that dignity bags must always be used for residents with urinary catheters, whether resident is in bed or on the chair. Surveyor: Roy, Elizabeth 2. Resident #40 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #40 had moderately impaired cognition required total assistance of one-person for eating. The physician orders [REDACTED].#40 was on comfort care and needs total assistance in eating to prevent food aspiration secondary to [DIAGNOSES REDACTED]. During observation on 03/02/2025 at 11:32 AM, Licensed Practical Nurse #2 was observed standing next to Resident #40 while spoon feeding the Resident. Resident #40 had their head raised to catch the food. On 03/06/2025 at 10:54 AM, Licensed Practical Nurse # 2 was interviewed and stated Resident #40 needs total assist with meals and is spoon fed. They stated they were standing while they spoon fed Resident #40 and knew this was inappropriate. On 03/07/2025 at 11:01 AM, the Director of Nursing was interviewed and stated staff should be seated next to the resident while spoon feeding them to ensure appropriate precaution is observed and dignity is preserved. 10 NYCRR 415. 3(a) | Plan of Correction: ApprovedMarch 28, 2025 Element #1 The CNA whom had resident # 32 was disciplined for not providing the dignity cover for the foley. The LPN whom fed resident # 40 resigned. It is the policy of the facility to ensure proper dignity to all residents. Element #2 All residents in the facility, with Foleys, were reviewed to ensure proper dignity bags are provided. All nursing staff will be in-serviced on proper use of dignity bags. All nursing staff will be in-serviced about not standing while feeding a resident. Element #3 The Director of Nursing reviewed the policy and procedure for dignity and updated accordingly to include and specify feeding a resident while standing and dignity bags for foleys. Element #4 Using a standardized audit tool, the Director of Nursing/designee will conduct an audit of: a) All residents, with foleys, will have a random check weekly for 4 weeks then monthly for 3 months to ensure dignity bags are in place. All findings will be reported to the quality assurance committee for the next two QAPI meetings. B) During meals, in the main dining room, there will be a random check weekly for 4 weeks then monthly for 3 months to ensure proper dignity while feeding a resident. All findings will be reported to the quality assurance committee for the next two QAPI meetings. Element #5 the Director of Nursing Date of completion 5/1/2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided to the residents. This was evident during environmental observation. Specifically, resident rooms were observed with mismatched paint, uneven floor, and ripped door kick plate, mattress in disrepair, and broken side tables. The findings include but are not limited to: The facility's undated policy titled Environmental Services documented it is the policy of the facility to safely and properly clean floor surfaces, the purpose of the procedure was to provide guidelines for cleaning and disinfecting resident rooms. The policy documented housekeeping surfaces, including tabletops, will be cleaned on a regular basis when spill occurs and when these surfaces are visibly soiled. During observation on 03/02/2025 between 10:00 AM and 2:00 PM and on 03/07/2025, the following were observed: 1. West Wing room [ROOM NUMBER] had a ripped door kick plate, with the first half of the panel missing. 2. West Wing room [ROOM NUMBER] had mismatched paint and stained and uneven floor. 3. Resident's Main dining room had uneven floor and floor tiles were discolored. 4. East Wing room [ROOM NUMBER] had unpainted walls, and bedside table was in disrepair. 5. East Wing room [ROOM NUMBER] had broken and worn looking bedside tables, and mattress in disrepair. 6. The baseboard in the hallway and the porter's closet were observed with dirt and grime. The Maintenance and Housekeeping logbook showed no documentation of repairs needed in West Wing room [ROOM NUMBER], #18, and in the resident's Main Dining room. On 03/07/2025 at 9:41 AM, during environmental rounds with the Surveyor, the Director of Housekeeping and Maintenance stated terminal cleaning is performed on a daily basis, cleaning 2 rooms per day in each unit. They stated they were waiting for the resident in room [ROOM NUMBER] on the East Wing to get out of bed before they paint the wall. The Director stated they swap the old bed side tables when in disrepair and that they change the mattress, if needed, during terminal cleaning. They stated they were in the process of doing a building refresh program when the State Surveyor walked in for survey. On 03/07/2025 at 11:33 AM, the Director of Housekeeping and Maintenance was interviewed and stated they were in the process of cleaning and replacing the tiles when the State Surveyors walked in. The Director stated the missing half panel of the door kick plate will be replaced and that the rooms with uneven floors and discolored tiles will be replaced with new ones to match the rest of the floor. On 03/07/2025 at 11:45 AM, the Administrator was interviewed stated repairing and fixing is a big challenge for them since the facility is an old building. They stated they will do what is right for the residents because this is the residents' home, and the environment should be taken care of properly. The Administrator stated they will make sure the concerns will be corrected. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedMarch 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1 west wing room [ROOM NUMBER] kickplate will be replaced. west wing room # 18 will be painted and the floor repaired, tiles will be replaced. Main dining room floor and tiles will be repaired and made even. East wing room # 4 will be painted and the bed side table will be replaced. East wing # 10 bedside table and mattress will be replaced. The baseboards in the hallway and porters closet will be thoroughly cleaned. Element #2 The Director of housekeeping will inspect all other areas to ensure there is no mismatched paint or tiles and no other tables and mattresses are in disrepair. The Director of housekeeping will inspect the entire premises for cleanliness. Element #3 Maintenance staff will be in-serviced on ensuring furniture, mattresses and rooms are not in disrepair. The housekeeping staff will be in-serviced on proper cleaning of baseboards and porter closets. The maintenance manual on preventative maintenance will be updated to include specifically mattresses, furniture, mismatched or broken tiles, painting and uneven floors. The policy and procedure for general cleaning was reviewed with the housekeepers and no revisions were made. Element #4 An audit tool will be developed by the housekeeping director to audit rooms, common areas and nursing stations to ensure cleanliness and preventative maintenance. Audits will be done weekly by the housekeeping director for three months and then quarterly. All findings and corrective actions if indicated will be discussed with the administrator. The Director of housekeeping will submit a status report to the administrator on a monthly basis. The Director of housekeeping will present findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Administrator 5/01/2025 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends for the quarter of July- (MONTH) 2024 which was confirmed by a review of the Weekend Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing Guidelines with a last reviewed date of 09/2024 documented that the facility will promote resident quality care and safety by ensuring adequate and competent staffing levels that are based on the facility assessment. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 to 09/30/2024) documented excessively low weekend staffing was triggered. The Facility Assessment Tool which was last updated on 01/07/2025 documented a facility capacity of 102 residents with a staffing plan by shift as follows: Day shift by units (7:00 AM - 3:00 PM) East Wing: 1 Registered Nurse, 2 Licensed Practical Nurse and 5 Certified Nursing Assistants West Wing: 1 Registered Nurse, 2 Licensed Practical Nurse and 5 Certified Nursing Assistants Evening Shift by Unit: (3:00 PM - 11:00 PM) 1 House Registered Nurse East Wing: 2 Licensed Practical Nurse and 3 Certified Nursing Assistants West Wing: 2 Licensed Practical Nurse and 3 Certified Nursing Assistants Night Shift by Unit: (11:00 PM - 7:00 PM) 1 House Registered Nurse East Wing: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants West Wing: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants The facility assessment does distinguish that on the weekends there is 1 House Registered Nurse for each shift while the number of Licensed Practical Nurses and Certified Nursing Assistants remain the same. Review of the actual weekend facility staffing schedule from 07/01/2024 to 09/30/2024 documented the following: On 07/06/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the West Wing. On 07/07/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the West Wing. On 07/13/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing. On 07/13/2024 on the 3:00 PM - 11:00 PMshift, there was a shortage of: 1 Licensed Practical Nurse on the West Wing. On 07/14/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 2 Certified Nursing Assistants on the East Wing and 1 Certified Nursing Assistant on the West Wing. On 07/14/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 2 Certified Nursing Assistants on the East Wing On 07/21/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing and 1 Certified Nursing Assistant on the West Wing On 07/27/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/3/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing and 1 Certified Nursing Assistant on the West Wing On 08/4/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the West Wing On 08/4/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/10/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the East Wing On 08/10/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the West Wing On 08/11/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse and 1 Certified Nursing Assistant on the East Wing On 08/17/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the West Wing On 08/17/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the West Wing On 08/18/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the East Wing and 1 Certified Nursing Assistant on the West Wing. On 08/18/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/25/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the West Wing On 09/01/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the West Wing On 09/01/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the West Wing On 09/21/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing. On 03/02/2025 at 10:00 AM, Resident #67 was interviewed and stated it takes too long for the staff to come when they ask for assistance. On 03/02/2025 at 2:05 PM, Resident #32 was interviewed and stated the facility does not have enough staff and they wait a long time for assistance, especially at nights. 03/05/2025 3:39 PM, Certified Nursing Assistant #4 was interviewed and stated they work from 3:00 PM to 11:00 PM on the weekends and are assigned 15 residents. They stated there are 3 aides usually assigned on their shift but when there are call outs, they get assigned more residents. On 03/06/2025 at 2:40 PM, Certified Nursing Assistant #5 was interviewed and stated they work 7:00 AM to 3:00 PM on weekends and are assigned around 11 residents regularly. Certified Nursing Assistant #5 stated there are times when there is staffing shortage in the weekends at which time they will be assigned 14 residents. On 03/06/2025 at 3:10 PM, the Staffing Coordinator was interviewed and stated they were hired in (MONTH) 2024 and at that time they were informed that there was a slight staffing shortage in the 11:00 - 7:00 PM shift for both weekdays and weekends. They stated staffing shortages occur on the weekends due to call outs. On 03/07/2025 at 10:57 AM, the Director of Nursing was interviewed and stated that they do the best they can to maintain staffing levels. They stated they were not aware of low weekend staffing between (MONTH) to (MONTH) 2024 or that the Payroll Based Journal was triggered for low weekend staffing for that quarter. Director of Nursing Services #1 further stated that the Administrator is primarily responsible for Payroll Based Journal Submission. On 03/07/2025 at 3:07 PM, the Administrator was interviewed and stated they were aware Payroll Based Journal was triggered for low staffing but is unsure as to why. Administrator #1 stated the staffing levels have not changed much and that in fact, it has improved compared to the previous years at which time the facility was not triggering this low. The Administrator further stated that since the Centers of Medicare Services updated the measures in the middle of 2024, the facility has been triggering worse even though staffing levels have not changed. They stated staffing for the weekends and weekdays is generally the same, however, there may be call outs during the weekend. 10 NYCRR 415. 13(a)(1)(i-iii) | Plan of Correction: ApprovedMarch 31, 2025 Element #1 Residents # 67, and 32 were interviewed about their concerns of short staffing on the weekends to efficiently address their concerns. Residents were updated on the plan of correction to ensure that the facility is fully staffed. Element #2 On weekends, the facility will schedule an extra CNA to each shift as padding to cover for call outs. The Staffing coordinator and the Shift RN supervisor will be educated that overtime may be used to cover call outs. Element #3 The facility will post ads to attract and hire more staff. The facility will update the policy that all weekend shifts will have padding of an extra CNA on all weekend shifts and overtime maybe used to cover available shifts. All RN supervisors and the staffing coordinator will be in serviced by the Director of nursing on the new policy. Element #4 An audit tool will be developed by the Director of Nursing and completed weekly for three months to ensure the facility has sufficient weekend staffing. The Director of nursing will submit a status report to the administrator on a weekly basis for three months. Director of Nursing will present the findings and corrective actions if indicated to the QAPI committee and there after the QAPI committee will determine the frequency of reports. Element #5 Administrator 05/01/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details 2012 NFPA . 3. 5 Extinguishment Requirements. 19. 3. 5. 1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9. 7, unless otherwise permitted by 19. 3. 5 2010 NFPA 13 8. 15. 7* Exterior Roofs, Canopies, Porte-Cocheres, Balconies, Decks, or Similar Projections. 8. 15. 7. 1 Unless the requirements of 8. 15. 7. 2, 8. 15. 7. 3, or 8. 15. 7. 4 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft ( 1. 2 m) in width. 8. 15. 7. 2* Sprinklers shall be permitted to be omitted where the canopies, roofs, porte-cocheres, balconies, decks, or similar projections are constructed with materials that are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant- Treated Wood and Fire-Retardant Coatings for Building Materials. 8. 15. 7. 3 Sprinklers shall be permitted to be omitted from below the canopies, roofs, porte-cocheres, balconies, decks, or similar projections of combustible construction, provided the exposed finish material on the roofs, canopies, or portecocheres are noncombustible, limited-combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials, and the roofs, canopies, or porte-cocheres contain only sprinklered concealed spaces or any of the following unsprinklered combustible concealed spaces: (1) Combustible concealed spaces filled entirely with noncombustible insulation. (2) Light or ordinary hazard occupancies where noncombustible or limited-combustible ceilings are directly attached to the bottom of solid wood joists so as to create enclosed joist spaces 160 ft3 ( 4. 5 m3) or less in volume, including space below insulation that is laid directly on top or within the ceiling joists in an otherwise sprinklered attic (see 11. 2. 3. 1. 4(4)(d)) (3) Concealed spaces over isolated small roofs, canopies, or porte-cocheres not exceeding 55 ft2 ( 5. 1 m2) in area 8. 15. 7. 4 Sprinklers shall be permitted to be omitted from exterior exit corridors when the exterior walls of the corridor are at least 50 percent open and when the corridor is entirely of noncombustible construction. 8. 15. 7. 5* Sprinklers shall be installed under roofs, canopies, porte-cocheres, balconies, decks, or similar projections greater than 2 ft ( 0. 6 m) wide over areas where combustibles are stored. Based on observation and staff interview, the facility did not ensure that all areas of the building were protected by the automatic sprinkler system. This occurred in the large storage structure attached to the back of the building. The findings are: During the life safety survey on 3/6/2025 at approximately 10:30 am a storage structure, approximately 20 feet by 8 feet, was noted located within 10 feet of an egress door at the rear of the building. This structure was built with combustible materials including wooden roof supports, and contained a large amount of cardboard boxes. During the exit conference on 3/6/25 at approximately 2:00 pm, the Administrator stated that this would be corrected. 2012 NFPA 101 2010 NFPA 13 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 19, 2025 I. Immediate Corrective Actions 1. The facility maintenance department made a plan to demolish the storage shed near the egress. 2. The storage identified without a sprinkler will be completely removed II Identification of Other Residents 1. All residents have the potential to be affected by the deficient practice 2. The maintenance department reviewed sprinkler coverage throughout the Facility and no additional areas were identified III. Systemic Changes: 1. All Maintenance staff were informed and educated on (MONTH) 18th regarding sprinkler heads and their locations, as well as overview of requirements for sprinkler coverage as per K351 2. The education concentrated on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required IV. QA Monitoring 1. The Maintenance staff has developed an audit tool to validate preventive maintenance and track compliance with all the sprinkler heads/locations. 2. Audits will be done weekly x4 initially by Maintenance/designee to inspect the sprinkler heads/locations, then monthly thereafter for compliance with our preventive maintenance plan 3. Any sprinkler heads/locations identified with quality issues by these audits will be corrected by the Maintenance staff or Fire Safety Company staff as needed 4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as indicated. II. Responsible person: Director of Environmental Services Date of completion 5/1/25 |