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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews during the recertification and abbreviated survey (Case # NY 835), the facility did not ensure maintenance of acceptable parameters of nutritional status for 1 (Resident #97) of 3 residents reviewed for nutrition. Specifically, Resident #97 did not have weekly weights measured for monitoring of significant weight loss as ordered by the dietician for the weeks of 11/25/2024 and 12/09/ 2024. This is evidenced by: Cross-referenced to F804: Nutritive Value/Appearance, Palatable/Prefer Temp A facility policy titled, Weight Management, with a current revision dated of 3/01/2024, documented that the resident's weight shall be obtained within twenty-four hours of admission, weekly for four weeks, then monthly thereafter and more frequently as clinically indicated for the residents, and documented in the clinical record. It further documented that the registered dietician will review the resident weights monthly, with a significant unplanned weight change and as needed. Parameters for evaluating the significance of unplanned and undesired weight is as follows: 1 month - 5 percent weight change is significant, greater than 5 percent is severe. 3 months - 7. 5 percent weight change is significant, greater than 7. 5 percent is severe. 6 months - 10 percent weight change is significant, greater than 10 percent is severe. Resident # 97 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 8/09/2024, documented that the resident had intact cognitive ability, could be understood, and understood others. Review of Resident #97 ' s Care Plan revealed a focus of nutritional problem or potential nutritional problem related to malnutrition diagnosis, low weight for age; variable intakes since admission; dementia diagnosis; dislike of facility food with declining alterative options; and unintentional weight loss (initiated 8/19/2024). There was a goal of receiving adequate nutrition and hydration without unplanned significant weight changes (initiated 8/19/2024) and maintain stable weight with minimal change of 3 percent by next review (initiated 11/07/2024). Interventions/tasks documented were follow weights as ordered weekly weights until stable (initiated 8/19/2024), identify and honor food preferences, and monitor meal and fluid consumption records. Resident #97 ' s (MONTH) 2024 Medication Administration Record [REDACTED]. Monitor Weight (Must customize weekly weight to shift and day specified for your facility and remove these directions) Monthly Weights must be obtained by the 7th of each month -Start Date- 10/01/2024 0700. Record review of active orders showed no order for weekly weights. Record review revealed that on 08/14/2024, the resident weighed 119 lbs. On 12/04/2024, the resident weighed 107 pounds, which was a - 10. 08 percent Loss. During an interview on 12/11/2024 at 1:42 PM, Resident #97 stated the food was cold at times and could be better. A Dietary Weight Change Progress note dated 11/07/2024 at 8:03 AM documented a weight warning, with the resident ' s weight on 11/05/2024 being 107. 8 pounds which was 6. 9 percent over 30 days and was significant weight loss. Resident stated the food was unappealing to them; dietician added supplement shake to increase intake. In addition, the Dietician documented the plan of care included monitor weights weekly for four weeks. A Dietary Weight Change Progress note dated 11/13/2024 at 9:53 AM documented the resident ' s weight was 107. 6 pounds on 11/11/2024; the plan of care documented weekly weights were ordered due to significant weight loss over 30 days and to continue weekly weighs and supplement. A Provider Progress note on 11/18/2024 documented that Family Nurse Practitioner #1 saw Resident #97 due to a chief complaint of periodic dizziness; blood work was ordered, extra fluids were ordered every shift, blood pressure and pulse reviewed were taken 10/03/ 2024. Weight loss was not addressed according to the provider note. A provider progress note dated 12/05/2024 by Family Nurse Practitioner #1 documented, resident has had some gradual weight loss over the past 30 days. The resident saw a dietician. They stated that they do not like the food, so they do not have much of an appetite. That is likely where the weight loss is stemming from. Please order nutritional shakes and see a dietician for fortified foods to add to their diet. A Dietary Weight Change Note dated 12/05/2024 at 9:27 AM documented a weight warning and showed the resident ' s weight on 12/04/2024 was 107. 4 pounds; the resident was consuming on average 50-75 percent of meals; the resident told the dietician the sandwiches provided had stale bread so the resident could not eat them and the resident did not like the taste of many items on the menu. The Dietician noted to continue weekly weights. A Rehabilitation Referral Progress note dated 12/17/2024 at 9:49 AM documented that Resident #97 was unable to get in and out of bed and the resident felt they were requiring more assistance; the most recent weight was documented as 107. 4 pounds on 12/04/ 2024. Record review of weights revealed the following weights for Resident #97: 8/06/2024 - 114. 64 pounds 8/14/2024 - 119. 0 pounds 8/19/2024 - 119. 0 pounds 8/28/2024 - 118. 2 pounds 9/01/2024 - 116. 2 pounds 10/02/2024 - 115. 6 pounds 11/04/2024 - 107. 8 - struck out by Dietician and comment re-weighed on 11/8/2024 11/08/2024 - 112 pounds 11/11/2024 - 107. 6 pounds 11/19/2024 - 108. 6 pounds 12/01/2024 - 105. 4 - struck out and comment re-weighed on 12/02/2024 12/02/2024 - 105. 0 - struck out and comment re-weighed by Dietician 12/05/2024 12/04/2024 - 107. 4 pounds No weights were found for the week of 11/25/2024, 12/09/24, 12/16/24 During an interview on 12/17/2024 at 10:54 AM, Registered Nurse #3 stated that the Dietician would send an email every Monday that listed which residents required weekly weights, when the dietician was not out on leave. Registered Nurse #3 checked their emails and did not find an email dated 12/09/24 and could not find weights for resident for 11/25/24 nor 12/09/ 24. 10 New York Code Rules and Regulations 415. 12(c)(2) | Plan of Correction: ApprovedJanuary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action taken the weekly weight order was obtained and entered for resident # 97. The residents weight was obtained and the facility provider notified. The Registered Dietitian met with resident #97 regarding food preferences and dietary supplements. 2. All residents have the potential to be affected by the deficient practice. Plan to prevent reoccurrence: Registered Dietitian completed a full house of those residents who were recommended to have weekly weights. Those residents found to have weight omissions will have weights obtained and evaluated by the Registered Dietitian and nursing. 3. The facility systemic changes: The policy titled Weight Management was reviewed with no revisions necessary. The Director of Nursing re-educate Registered Dietician on 1/13/2025 on facility policy titled Weight Management with the focus on ensuring the recommended weight order is in place. 4. The Registered Dietitian will conduct an audit on all residents with weekly weights to ensure physician order [REDACTED]. Results of the reviews will be reviewed by the DON and Registered Dietitian weekly. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible party: Registered Dietitian |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification and abbreviated survey (Case # NY 835), the facility did not ensure that food and drink were palatable and attractive for 4 (Resident #s 97, 75, 8, and 107) of 7 residents reviewed for palatable and attractive food and drink. Specifically, Residents #97, #75, #8 and #107 complained of food being cold, unattractive, and not palatable. Additionally, Resident # 97 and #75 lunch ticket did not match what the resident received during their lunch service on 12/17/ 2024. This is evidenced by: A facility policy titled Food and Nutrition Services dated 1/2024 documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Resident # 107 Resident # 107 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 9/25/2024, documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 1:05 PM, Resident #107 stated that the food is always cold and not very appealing or appetizing. Resident #107 stated that the trays for meals never arrive on the unit at a consistent time. Resident #107 was asked if the food was cold would staff reheat it for them and they stated that they do not bother as it would take a long time to get it back. During a follow-up interview on 12/17/2024 at 10:45 AM, Resident #107 was asked if the surveyor was allowed to take their lunch tray to be temperature and taste tested since they made a concern about the food temperature and taste. The resident was assured that they would receive a replacement tray immediately after theirs was taken. Resident #107 agreed to surrender their lunch tray for testing purposes. During an observation on 12/17/2024 at 12:08 PM the cart with lunch trays arrived on the C-unit by the front nurse's station desk. The lunch tray cart arrived at the resident's hall at 12:17 PM. Resident #107 lunch tray was obtained from Certified Nurse Aide at 12:24 PM and a new tray was obtained by Certified Nurse Aide and delivered at 12:28 PM. During an observation of Resident #107 lunch ticket, they were to receive 8 ounces of Beef Stroganoff, a half cup of Pasta Noodles, a side lettuce salad with dressing, half cup of Mixed Fruit Cobbler, 8 fluid ounces of 2% milk, 6 fluid ounces of Hot Tea, 8 fluid ounces of Water, 1 salt packet, 1 pepper packet, 2 sugar packets, and one half and half creamer. In a comparison of the lunch ticket and meal tray, the resident did not receive their Mixed Fruit Cobbler, milk, or water. During a test tray on 12/17/2024, temperature and taste were performed on Resident #107 ' s lunch. Pasta noodles were temped at 116. 2 degrees Fahrenheit and tasted overcooked and sticky. The beef was temped at 114. 4 degrees Fahrenheit and tasted as expected, beef was easily chewed and broken down. During a follow-up interview on 12/17/2024, Resident #107 was asked how their lunch was. They stated that it was just fine, and they ate it. When asked about the temperature of their lunch they stated that it was very warm stating that it just came from the kitchen and did not spend a long time on the delivery carts. During an interview on 12/17/2024 at 01:04 PM,?é?áDietician #1 stated that they identify resident's preferences and place them into the facility system. They stated that the resident's meal tickets should be verified by the Certified Nurse Aides as they serve the tray to the resident. They stated that the individuals who are preparing the resident's trays in the kitchen should be verifying the tickets as well and checking again before the tray leaves the kitchen. Dietician #1 stated that they have a system for menus and they meet quarterly with residents to determine preferences. Resident # 97 Resident # 97 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/11/2024 at 1:42 PM, Resident #97 stated the food was cold at times and could be better. A progress note dated 11/7/2024 at 8:03 AM documented that Resident #97 stated the food was visually unappealing to them; the Dietician discussed with Resident #97 that they had 6. 9% weight loss in 30 days, which was significant. A provider progress note by Family Nurse Practitioner #1 dated 12/5/2024 documented the resident had some gradual weight loss over the past 30 days. They saw a dietician. They stated that they did not like the food, so they did not have much of an appetite. That's likely where the weight loss is stemming from. Please order nutritional shakes and see a dietician for fortified foods to add to their diet. Resident # 75 Resident # 75 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 11:33 AM, Resident #75 stated that no snacks were provided at night, the coffee and food was cold and did not taste good and the resident wanted more fresh fruit. Request to perform night observation to verify night snack availability denied by state agency management. During a follow-up interview on 12/17/2024 at 11:45 AM, Resident #75 was asked if the surveyor was allowed to take their lunch tray to be temperature and taste tested since they made a concern about the food temperature and taste. The resident was assured that they would receive a replacement tray immediately after theirs was taken. Resident #75 agreed to surrender their lunch tray for testing purposes. During an observation on 12/17/2024 at 12:08 PM, the cart with lunch trays arrived on the C-unit by the front nurse's station desk. Resident #75 ' s lunch tray was obtained from a Certified Nurse Aide at 12:15 PM and a new tray was requested, but the Certified Nurse Aide stated they were the only one on the hall and the request would cause other residents ' trays to be cold and delayed; surveyor requested replacement tray from the Administrator on the surveyor ' s way to the kitchen to request a replacement tray. During an observation of Resident #75 ' s lunch ticket, they were to receive 4 ounces of Beef Stroganoff, 2 ounces of beef gravy, a half cup of Pasta Noodles, a half cup of wax beans, half cup of Mixed Fruit Cobbler, 4 ounces of apple juice, two 6 fluid ounces of coffee, 8 fluid ounces of Water, 1 salt packet, 1 pepper packet. In a comparison of the lunch ticket and meal tray, the resident did not receive the second cup of coffee. During a test tray on 12/17/2024, temperature and taste were performed on Resident #75 ' s lunch. The beef stroganoff mixed with noodles was temped at 119. 1 degrees Fahrenheit and the texture was acceptable but the beef lacked flavor and were warm but not hot and the noodles were without issues; the fruit cobbler was temped at 88. 2 degrees Fahrenheit and was unpalatable; the wax beans were 112. 0 degrees Fahrenheit and not tasted; the apple juice was 63. 7 degrees Fahrenheit; and the water was temped at 58. 8 degrees Fahrenheit. During a follow-up interview on 12/17/2024 at 12:53 PM, Resident #75 stated that the replacement tray arrived, but the food did not look appealing to the resident; staff entered to collect the tray and asked if Resident #75 would like | Plan of Correction: ApprovedJanuary 13, 2025 1. The Registered Dietician and Food Service Director met with residents #97, 75, 8 and 107 to review meal preferences and dislikes. Revisions were updated in the menu software program. Resident #75 was provided a new lunch tray and a night snack has been scheduled per resident preference. The facility hired a new Food Service Director on 1/2/ 2025. 2. All residents have the potential to be affected by the deficient practice. The facility did an audit of 10 consecutive meals on the units to ensure residents food was warm, palatable, and presentable. This audit also included checking that meal tickets were accurate and the preferences were served. 3. The Policy titled ?ôFood Service?Ø has been reviewed with no revisions necessary. The Registered Dietician or the staff educator will provide re-education to dietary staff on the policy titled ?ôFood Service?Ø. The emphasis is on meal production to include tray accuracy as well as residents personal food preferences and meal temperatures. The Food Service Director or Supervisor will facilitate a meal production meeting daily with dietary staff and report to the registered dietician should any deviations to the menu be needed. Facility nursing staff will be re-educated on the Food Service policy with emphasis on tray accuracy, residents personal food preferences and food temperatures. 4. The Registered Dietitian or Food Service Director will conduct reviews on 15 trays for accuracy, temperatures and resident preferences weekly x 4 weeks and monthly x 3 months. The Food Service Director or Registered Dietician will conduct a review on 15 trays per week on tray accuracy, appearance and palpability weekly x 4 weeks, then monthly x 3 months. The Food service Director or Registered Dietician will review food temperature logs daily for 30 days, then weekly thereafter to ensure safe food temperatures is maintained. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. 5. Responsible party: Food Service Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a recertification survey, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences for 1 (Resident #112) of 1 residents reviewed for pain management. Specifically, the facility failed to administer Resident #112 ' s pain medication in a manner that managed the resident ' s pain and which resulted in the resident expressing their pain was 10 out of 10, and Family Member #2 calling 911 to have Resident #112 sent to the hospital for care. This is evidenced by: A facility policy titled Medication Administration ?óÔé¼ÔÇ£ Documentation, last revised 1/2019, documented that when administering medications, documentation must include, as a minimum, a. Name and strength of the drug; b. Dosage; c. Method of administration; d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused; and f. Signature and title of the person administering the medication. A facility policy titled, Pain Management last revised 3/2020, documented that the facility would determine appropriate intervention to manage pain and side effects, review interdisciplinary assessments and documentation, include the resident and family in determining the resident ' s pain goal and acceptable level of pain, identify the potential cause(s) for resident pain, evaluate alleviating and/or exacerbating factors. Appropriate interventions may include pharmacologic as well as non-pharmacologic interventions. Document pain management interventions. Evaluate effectiveness of pain management intervention(s) within 30-60 minutes. Notify physician if interventions are not effective in achieving resident comfort and/or functional goals and re-assess resident status as indicated including, but not limited to level of pain, side effect management, effectiveness of interventions and need for increasing/decreasing amount of medication due to tolerance or side effects. Resident #112 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was not at the facility long enough to have a Minimum Data Set (a resident assessment) completed. The discharge summary from the hospital, dated 09/19/2024, documented that Resident #112 suffered a compression fracture to the lumbar vertebra #1 (lower back fracture) which required intravenous narcotics, thenan increase in the resident ' s oral narcotics until the pain was controlled. The hospital discharge summary documented Resident #112 should continue to take ropinirole 0. 25 milligram (medication for restless leg syndrome which causes uncontrollable spasms of the legs) tab oral daily at bedtime. Additionally, the hospital summary documented that Resident #112 use a [MEDICATION NAME] 1. 3 percent patch every 12 hours, [MEDICATION NAME] (Tylenol extra strength) 500 milligram tab, take 1000 milligrams oral 3 times per day, and [MEDICATION NAME] 5 milligram tab every 4 hours as needed for pain not to exceed 40 milligrams per day. Specifically, the hospital summary documented the following parameters for [MEDICATION NAME] administration: 5-10 milligrams: give 5 milligrams (1 tab) for pain level 3-5 and 10 milligrams for pain level 6- 10. Resident #112 ' s Comprehensive Care Plan for alteration in comfort due [MEDICAL CONDITION] and fracture, documented a goal of Resident was able to verbalize pain and request pain medications as needed. Interventions/tasks documented included: ?é?À to administer medications as ordered ?é?À Notify physician is interventions were unsuccessful or is current complaint was a significant change from residents past experience of pain ?é?À Report to Nurse resident complaints of pain or requests for pain treatment ?é?À Resident was able to verbalize pain and request pain medications as needed. Resident #112 ' s Comprehensive Care Plan for Fracture/Joint Replacement: Alteration in physical function related to fracture dated 09/19/2024 documented a goal of resident will be free of complications from fracture. The documented Interventions/Tasks included giving medications as ordered and monitor for increased signs or symptoms of pain ad notify provider of any change. A Physician order [REDACTED]. Resident #112 ' s Order Summary Report for (MONTH) 2024 documented orders as follows: ?é?À [MEDICATION NAME] extra strength oral tablet 500 milligrams, give 2 tablets by mouth three times a day for pain, ordered 9/19/ 2024. ?é?À [MEDICATION NAME] tablet 325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain (not to exceed 3 grams in 24 hours), ordered 9/19/ 2024. ?é?À [MEDICATION NAME] 5 milligrams, give 1 tablet by mouth every 4 hours as needed for pain, ordered 9/19/ 2024. ?é?À [MEDICATION NAME] 5 milligrams, give 2 tablets by mouth every 4 hours as needed for pain, ordered 9/19/ 2024. ?é?À [MEDICATION NAME] 5 milligrams, give 2 tablets by mouth one time only for pain for 1 day, ordered 9/19/ 2024. ?é?À Ropinirole .25 milligrams, give 1 tablet by mouth at bedtime for restless legs, ordered 9/19/ 2024. No order for [MEDICATION NAME] 1. 3 percent patch every 12 hours was found on the order summary for Resident # 112. During an interview on 12/16/2024 at 10:45 AM, Family Member #2 stated that Resident #112 was initially admitted to the facility from the hospital because this facility was the only one with a bed open and Resident #112 needed some rehab before they could return home; the resident was transported in the afternoon of 09/19/ 2024. Around 9:00 AM on 09/20/2024, Resident #112 called Family Member #2 and was in great distress. The resident stated to them they had laid in their bed without medication for pain, had soiled clothing, and did not have food. Family Member #2 stated that when they heard this, they called 911 so the resident could be transported back to the hospital. A nursing note dated 09/20/2024 at 10:00 AM, documented that Family Member #2 came to speak with the staff regarding the resident ' s condition. Family Member #2 stated they had called 911 and informed the dispatch that Resident #112 needed to be transferred back to the hospital. When asked what was going on Family Member #2 stated Resident #112 was in pain. Staff educated Family Member #2 on the resident ' s current meds including meds that had been administered. Offered to call the provider to review pain and alternate pain relief. Family Member #2 declined and continued to state, I think its better the resident goes back to the hospital. Provider made aware. During an interview on 12/16/2024 at 1:01 PM, Emergency Medical Technician #1 stated the family met the ambulance outside when they arrived at the facility; the family requested transport for Resident #112 back to the hospital. Emergency Medical Technician #1 stated it was a while ago and from what they recalled, the resident had increased pain, and the facility gave the resident pain medication right before or when the ambulance arrived on 09/20/ 2024. Resident #112 ' s Medication Administration Record [REDACTED] ?é?À 09/19/2024 4:00 PM, [MEDICATION NAME] 1000 milligrams. ?é?À 09/19/2024 5:51 PM, [MEDICATION NAME] 5 milligrams, 2 tablets given. ?é?À 09/19/2024 8:00 PM, [MEDICATION NAME] 1000 milligrams. ?é?À 09/20/2024 8:00 AM, [MEDICATION NAME] 1000 milligrams. ?é?À 09/19/2024 10:36 PM, [MEDICATION NAME] 650 milligrams for 10 out of 10 pain. ?é?À 09/20/2024 5:07 AM, [MEDICATION NAME] 650 milligrams for 5 out of 10 pain. Total of 4300 milligrams of [MEDICATION NAME] in 13 hours and 7 minutes, order was not to exceed 3000 milligrams in 24 hours. The narcotic log for Resident #112 documented the following: ?é?À 09/19/2024 5:46 PM [MEDICATION NAME] 5 milligrams, 2 tablets were administered. ?é?À 9/20/2024 10:41 AM [MEDICATION NAME] 5 milligrams, 2 tablets were administered (t | Plan of Correction: ApprovedJanuary 17, 2025 1. Resident #112 no longer resides in facility. Registered Nurse # 4 no longer employed at facility 2. All residents have the potential to be affected by the deficient practice. Nursing managers conducted a 90 day look back audit from 10/13/2024 - 1/13/2025 of all residents pain scales to determine other residents who have triggered for pain and received appropriate pain relief. 3. The Facility systemic changes: The policy titled Pain Management was reviewed by administration with no revisions necessary. The Facility educator will re-educate licensed staff on policy titled ?ôPain Management?Ø. Re-education will focus on provider notification with any resident reports of increased pain that is not being relieved with current interventions for further directive. 4. The Nurse Managers will conduct reviews of those residents who have triggered for pain to ensure appropriate intervention and provider notification. Pain medication reviews will be completed weekly x 4 weeks then monthly x 3months. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification and abbreviated survey (Case # NY 208), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s choices for 10 (Resident #s 365, 368, 112, 56, 29, 73, 109, 75, 18, and 89) of 10 residents reviewed for quality of care, which included residents in every unit of the facility. Specifically, the facility failed to place and read the purified protein derivative test for [MEDICAL CONDITION] (an infectious disease) for Resident #365 and Resident #368; the facility failed to notify a provider when Resident #365 ' s blood sugar was 61; the facility failed to monitor the vital signs of Resident #368 when the resident was newly admitted to the facility. The facility failed to ensure that Resident #112 received treatment and care to prevent hospitalization , the facility administered 4300 milligrams of Tylenol in a 13-hour period, and the facility documented vital signs for Resident #112 after the resident discharged from the facility. The facility failed to obtain and document monthly vital signs according to provider orders for Residents #29, 89, and 73. This is evidenced by: Cross-referenced to F697: Pain Management The facility policy titled, Vital Signs and last revised 12/2020, documented that the facility would ensure vital signs were being monitored according to physician orders [REDACTED]. document findings in the resident ' s medical record . alert the medical doctor of any findings outside of the resident ' s baseline. The facility policy titled, [MEDICAL CONDITION] - Residents and last revised 8/22/2024, documented that the facility shall conduct a baseline screen of residents for [MEDICAL CONDITION] infection on admission including a [MEDICAL CONDITION] skin test, also referred to as a purified protein derivative test. The results of the [MEDICATION NAME] Skin Test must be read by a qualified nurse or healthcare practitioner (i.e., Registered Nurse) forty-eight (48) to seventy-two (72) hours after administration. Residents were not allowed to read or interpret their own [MEDICATION NAME] Skin Test results. A. If the reaction to the first [MEDICATION NAME] Skin Test is negative, administer a second [MEDICATION NAME] Skin Test 1 to 3 weeks after the first test. 1. If the test reading/interpretation was not completed within 72 hours, the [MEDICATION NAME] Skin Test must be repeated. Resident #365 Resident #365 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/14/2024 documented that the resident was cognitively intact, could understand others and could be understood by others. The physician's order [REDACTED]. Resident #368 Resident #368 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that the resident had intact cognitive ability, could be understood and understood others. The Medication Administration Record [REDACTED] 2024. During an interview on 12/12/2024 at 12:13 PM, Director of Nursing #1 agreed it was not appropriate to read the test on 12/12/2024 and stated they would update the scheduled reading of the test and re-educate the staff. The physician's order [REDACTED]. The (MONTH) 2024 Medication Administration Record/Treatment Administration Record documented the following duplicate vital signs: ?é?À 12/07/2024 11 PM shift: not done ?é?À 12/10/2024 3PM shift: blood pressure 123/73, temperature 97. 2, pulse 84, respiration 18, oxygen saturation 98 percent ?é?À 12/10/2024 11PM shift: blood pressure 123/73, temperature 97. 2, pulse 84, respiration 18, oxygen saturation 98 percent Resident #112 Resident #112 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was not at the facility long enough to have a Minimum Data Set (a resident assessment) completed. Resident #112 ' s Order Summary Report for (MONTH) 2024 documented orders as follows: ?é?À Begin Medication Regime When Available, ordered 9/19/ 2024. ?é?À [MEDICATION NAME] extra strength oral tablet 500 milligram, give 2 tablets by mouth three times a day for pain, ordered 9/19/ 2024. ?é?À [MEDICATION NAME] tablet 325 milligram, give 2 tablets by mouth every 6 hours as needed for pain (not to exceed 3 grams in 24 hours), ordered 9/19/ 2024. Resident #112 ' s Medication Administration Record [REDACTED] ?é?À 9/19/2024 4:00 PM, [MEDICATION NAME] 1000 milligrams ?é?À 9/19/2024 5:51 PM, [MEDICATION NAME] 5 milligrams, 2 tablets given ?é?À 9/19/2024 8:00 PM, [MEDICATION NAME] 1000 milligrams ?é?À 9/20/2024 8:00 AM, [MEDICATION NAME] 1000 milligrams The facility administered a total of 4300 milligrams of [MEDICATION NAME] in 13 hours and 7 minutes, but the order was not to exceed 3000 milligrams in 24 hours. During an interview on 12/16/2024 at 10:45 AM, Family #2stated that Resident #112 was transported to the facility in the afternoon of 9/19/ 2024. Around 9:00 AM on 9/20/2024, Resident #112 called Family #2 and was in great distress. The resident stated they laid there without medication for pain, soiled clothing, and without food. Family #2 called 911 for transport back to the hospital. Resident #112 was in a great amount of pain and had been all night. Review of Resident #112 ' s vital signs revealed on 9/21/2024 at 2:33 AM a blood pressure of 139/79 was performed in the lying position on the right arm, the pulse was 83 beats per minute, 19 breaths per minute, and a temperature of 97. 9; all of these vital signs were taken after the resident left the faciity on [DATE] around 11:00 AM and did not return to the facility. Resident #29 Resident #29 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The physician's order [REDACTED]. The (MONTH) 2024 Medication Administration Record [REDACTED] ?é?À 9/4/2024: Blood Pressure 122/78, Temperature 97. 4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent ?é?À 9/5/2024: Blood Pressure 122/78, Temperature 97. 4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent ?é?À 9/6/2024: Blood Pressure 122/78, Temperature 97. 4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent The (MONTH) 2024 Medication Adminis | Plan of Correction: ApprovedFebruary 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action resident #365 no longer resides in facility. Resident #368 has reached compliance upon return from hospital with two step Purified protein derivative plant and read per facility policy and completed on 1/9/ 2025. Provider notified on 1/9/2025 of incident with no new orders recommended. The Medical provider was notified on 1/9/2025 of residents #638, 29,89,73 that facility failed to monitor vital signs per provider order with no new order recommended. Licensed staff responsible for failure to notify medical provider of resident blood sugar outside parameters was counseled and reeducation completed on 1/10/2025 by the Assistant Director of Nursing. 2. All residents have the potential to be affected by the deficient practice. The facilities plan to prevent reoccurrence: Nurse management conducted a 90 day look back from 10/9/24 through 1/9/25 for residents with active orders for blood sugar monitoring. As a result of the audit no issues noted. All residents have the potential to be affected by the deficient practice. The facilities plan to prevent reoccurrence, the previous 30 days of admissions were reviewed for compliance with purified protein derivative placement and results documented per policy. Audit completed on 1/10/ 2025. A total of 30 residents were reviewed. Out of the 30, 8 residents were discharged , 2 were complaint and 20 were identified to be out of compliance. A [MEDICATION NAME] screen was completed for those residents per policy. The Results of [MEDICATION NAME] screen was reported to medical provider for further review. No further directives given. Nursing management conducted a full house review 1/17/2025 on residents with active orders containing Tylenol to determine the potential for the resident to exceed the recommended limit. Results of the review concluded one resident was identified at risk to potentially exceed the daily recommended limit. Those resident identified were submitted to the medical provider for review with one resident with new orders. A full house review was conducted on 1/16/2025 on residents vital signs per the provider order. The results of those residents with orders for monthly vital signs concluded all residents to be out of compliance. Results submitted to medical provider with new order for one resident. Results of resident review for new admission vital sign orders concluded 23 residents review. Review of audit concluded 14/23 residents were identified to be out of compliance. Any residents identified as having vital sign omissions received updated vitals and results reviewed with medical provider. 3. The systemic changes: The facility reviewed the policies titled Vital Signs, Diabetes Mellitus Guidelines and [MEDICAL CONDITION]. They were reviewed by medical with no revisions necessary. The facility educator re-educated licensed staff on vital signs, diabetes mellitus guidelines and [MEDICAL CONDITION] policies with emphasis on notifying provider with results of blood sugar outside parameters, administration and timely result documentation per MD order of Purified protein derivative, daily recommended Tylenol consumption not to exceed recommended limit and obtaining and monitoring of resident specific vital sign order for frequency. This education was accompanied with a posttest to ensure retention. All results of blood sugar, results of the [MEDICATION NAME] skin test and results of vital signs will be documented in the medication administration record. Facility supervisor will complete a 24 hr look back of all new Tylenol orders will be reviewed to ensure there is no potential to exceed the recommended daily limit. Facility supervisor will complete 24 hr look back on residents blood sugars to ensure residents identified with blood sugars outside parameters were reviewed and submitted to the medical provider. Facility supervisor will complete a 48 hr look back on residents who received a [MEDICATION NAME] skin test to follow up and document [MEDICATION NAME] skin test read. Facility supervisor will complete a 24 hr look back of those residents with active vital sign orders to determine vital signs obtained per provider order. Any result out of compliance, the supervisor will notify the medical provider for further directives and will document the outcome in the medical record. 4. Quality assurance: The Unit managers will audit all new admissions Purified protein derivative status to ensure compliance is meet This will be audited weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Assistant Director if Nursing will submit weekly immunization documentation tracker form weekly. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit residents blood sugars. This audit will look for any documented value outside parameters to ensure medical provider was notified this will be conducted weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit compliance with vital signs completion weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. Unit managers will Audit all active Tylenol orders to ensure resident does not exceed daily limit. This audit will be done weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improving for review and determine recommendations of frequency of reviews required. The Director of Nursing will oversee all audits. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey, the facility did not ensure that it provided or obtained emergency dental services to meet the needs of each resident for 1 (Resident #75) of 1 resident reviewed for Dental Services. Specifically, Resident #75 had broken a front tooth the week of 12/02/2024 and had not been seen by the dentist. This is evidenced by: The facility policy titled, Dental Services, last revision date 9/2019, documented both routine and emergency dental services were available to meet the oral needs of each resident. Resident #75 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 8/14/2024 documented Resident #75 was able to be understood by others and could understand others, had mild cognitive impairment, and had no mouth or facial pain, or difficulty chewing. Resident had obvious cavities and broken natural teeth. On 12/12/2024 at 11:33 AM, Resident #75 was observed in their room and their top front teeth were broken. During an interview 12/12/2024 at 11:33 AM, Resident #75 stated they had broken their teeth 2 weeks ago and they had not seen the dentist yet and continued to have slight pain. During an interview on 12/18/2024 at 10:55 AM, Licensed Practical Nurse #1 stated they would give the information to the Finance Director #1, who was responsible for setting up dental appointments. During an interview on 12/18/2024 at 10:55 AM, Finance Director #1 stated that Resident #75 had seen the dentist on 6/20/2024, but that they would add Resident #75 to the list to see the dentist on their next visit. 10 New York Code Rules and Regulations 415. 17(b)(1)(2) | Plan of Correction: ApprovedJanuary 17, 2025 1. Immediate corrective action taken Resident #75 was immediately referred to dentist on 12/18/2024 and evaluated on 12/19/ 2024. 2. Plan to prevent reoccurrence: All residents have the potential to be affected by the deficient practice. Nursing conducted a full house audit on 1/16/2025 to ensure no other residents had any broken teeth or emergency dental care needs. None were noted. 3. The facility systemic changes :The policy titled Dental Services was reviewed by administration with no revisions. The Facility educator will re-educate licensed staff on policy titled ?ôDental Services.?Ø The education will focus on actions needed when someone needs emergency dental care. 4. The Unit Managers will conduct a review of oral inspection for broken teeth and any emergent dental care not previously noted. This audit will be conducted weekly x 4 weeks then monthly x 3 months. Results will be submitted at QAPI for review and determination recommendation of frequency reviews required. Responsible party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification and abbreviated (NY 208 and NY 484) survey, the facility did not ensure the 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, 1) an analysis of the actual staffing schedule showed that on multiple occasions from 12/01/2024 to 12/18/2024, the facility was below the minimum levels required. 2) several nursing staff members reported a lack of sufficient staffing, and 3) multiple residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and residents not getting out of bed in time for appointments and therapy. This is evidenced by: Upon entrance to the facility on [DATE] there were 115 residents residing in 3 units. The Facility Assessment, which was conducted on 2/27/2024 and updated on 10/03/2024, documented the facility's staffing plan for direct residential care. The assessment documented that they were to have a certain minimum number of Certified Nurse Aides for the day, evening, and night shifts. The facility was to maintain daily average staffing hours equal to 3. 5 hours of care per resident per day by a Certified Nurse Aide, Registered Professional Nurse, Licensed Practical Nurse, or Nurse Aide. Out of such 3. 5 hours, no less than 2. 2 hours of care per resident per day shall be provided by a Certified Nurse Aide. A review of staffing sheets provided by the facility from 12/01/2024 through 12/18/2024 documented the following: -12/01/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 111 residents, the amount of direct care should have been 244. 2 hours. -12/02/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248. 6 hours. -12/03/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/04/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/05/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/06/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257. 4 hours. -12/07/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257. 4 hours. -12/08/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257. 4 hours. -12/09/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250. 8 hours. -12/10/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/11/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/12/2024: The facility had 25 Certified Nurse Aides scheduled for a total of 200 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248. 6 hours. -12/13/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248. 6 hours. -12/14/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250. 8 hours. -12/15/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248. 6 hours. -12/16/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250. 8 hours. -12/17/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248. 6 hours. -12/18/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250. 8 hours. During an interview on 12/11/2024 at 1:47 PM, Resident #105 stated the facility was short on staff and sometimes the resident had to wait for a long time to get help. They stated that they could easily wait for over an hour on average depending on which staff person is working. During an interview on 12/12/2024 at 12:00 PM Resident #89 stated when they rang their call bell, they had to wait for 2 hours to be taken to the bathroom, and on several occasions, the staff did not attend to their bathroom needs, and would only come to assist them when they were doing their cares. Resident #89 also stated that they were late for their therapy session on several occasions because the staff got them out of bed late resulting in decreased time in therapy. During an interview on 12/12/2024 at 12:22 PM, Resident #80 stated that they always have to wait on staff to get care as they do not have enough people at times. They stated they could wait anywhere from 45 minutes to an hour at times for staff to come in to help. During an observation on 12/17/2024 at 1:35 PM, there were 3 rooms with call lights activated on the C unit. There were no staff members present in the unit. A family member came out to the main desk area to see if there were any staff present and voiced their displeasure that there was no one available. During an interview on 12/17/2024 at 2:22 PM Certified Nurse Aide #1 stated they needed to have more staff to perform all their duties. They stated that they feel very stressed and overworked due to the lack of staffing. Certified Nurse Aide #1 stated that they do multiple double shifts for the facility at least three times per week. They stated that there have been numerous times when they were unable to get the resident's afternoon care completed and had to either stay late to finish or turn the care over to the staff coming in during the evening. During an interview on 12/17/2024 at 2:48 PM Certified Nurse Aide #2 stated there were times it was impossible to get all the residents out of bed when the facility was short-staffed. They stated that they prioritized the residents who had therapy first when they were short-staffed. They stated they did double shifts for the facility two to three times per week. During an interview on 12/17/2024 at 3:22 PM Licensed Practical Nurse #2 stated that usually they feel there is enough staff, and everyone works together to provide the care for the residents. They stated that residents do wait an extended period for care during the evening (3 PM ?óÔé¼ÔÇ£ 11 PM) shift because of staffing issues, especially between 6 PM ?óÔé¼ÔÇ£ 9 PM. During a follow-up interview on 12/18/2024 at 9:45 AM Certified Nurse Aide #1 stated that they had only 2 aides for the day, and they were going to be very busy. They stated that they do not know the reason why they are extremely short-staffed for the day. During an interview on 12/18/2024 at 10:19 AM Registered Nurse #3 s | Plan of Correction: ApprovedJanuary 17, 2025 1. Immediate corrective action the facility currently has ads posted online and is offering a sign-on bonus to attract new certified nursing assistants to Granville Center. Due to a lack of certified nursing assistants in the local area, the facility recruits out-of-state certified nursing assistants and houses them nearby. 2. All residents and staff have the ability to be affected by this deficient practice. Plan to prevent reoccurrence: The facility currently has ads posted online and is offering a sign-on bonus to attract new certified nursing assistants to Granville Center. Due to a lack of certified nursing assistants in the local area, the facility recruits out-of-state certified nursing assistants and houses them nearby 3. The facility systemic changes: Increased their certified nursing assistant pay rates on 12/22/24 in an effort to attract more staff. The facility has recruited additional certified nursing assistants from out-of-state who will begin between (MONTH) and February. Should the certified nursing assistant staffing levels fall below the minimum established levels, the Administrator or Director of Nursing will implement the emergency staffing plan. The Administrator, Director of Nursing and Scheduler will meet 3 times per week to review upcoming certified nursing assistant schedules. The Administrator will organize a recruitment and retention committee to come up with new ideas to recruit and retain certified nursing assistants. 4. The facility emergency staffing plan and ideas from the recruitment and retention committee will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations. Responsible Parties: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #70) of 2 residents reviewed for communication. Specifically, for Resident #70, the facility did not ensure the resident, who had impaired vision, was provided with an optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #70: Resident #70 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/21/2024, documented the resident was understood, able to understand others, and was cognitively intact. The Minimum Data Set documented the resident had impaired vision and used corrective lenses. The Policy and Procedure titled, Physician ?óÔé¼ÔÇ£ Consultations, dated 8/2019, stated it was the policy of the organization to ensure all residents receive medical care in a timely manner. The Consult Form dated 3/07/2023 documented the resident had been examined by an optometrist. The form documented the next follow up should be scheduled for 3/ 2024. Review of the medical record showed no further optometry consults were documented for the resident or a comprehensive care plan developed for the resident regarding their vision. During an interview on 12/11/2024 at 1:03 PM, Resident #70 stated they would like to see the eye doctor. During an interview on 12/17/2024 at 11:12 AM, Registered Nurse #1 stated the resident should see the optometrist every 6-12 months. They stated they would forward any recommendations to Medical Records #1 to schedule follow-up appointments. During an interview on 12/18/2024 at 10:04 AM, Medical Records #1 stated they receive an email from the nurse managers to schedule appointments. They stated they keep a list of the doctors that come to the facility (dental, optometry, podiatry) and give that list of residents to be seen to the doctors. 10 New York Codes, Rules, and Regulations 415. 12(2)(b) | Plan of Correction: ApprovedJanuary 17, 2025 1. Immediate corrective action resident # 70 was seen by optometry on 3/25/2024 with recommendations to follow up in 1 year. Medical records clerk was re-educated on scanning consults into residents chart timely on 1/13/ 2025. 2. Plan to prevent reoccurrence: Medical records completed a full house review of facility residents optometry consults from the previous 12 months to identify any additional missed scanned consults. This audit was completed on 1/17/ 2025. Results of the audit will be provided to medical provider for review. 3. The facility systemic changes: Education was given to medical records on 1/13/2025 by the Director of Nursing to ensure they are following the consultation policy. Medical records will document and monitor vison consults utilizing a consultation tracker form to ensure completed consults are scanned into resident chart. 4. Medical records coordinator will conduct a review of residents vision consults weekly x 4 weeks then monthly x 3 months. Results will be submitted to the Director of Nursing for final review. The Results of the reviews will be brought to QAPI for review and determination of frequency reviews and additional any recommendations. Responsible Party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
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) installed an all-weather surface on the exit discharge from the B-Wing west exit and (2) ensured that the Electronic Plan of Correction was implemented. Specifically, the facility did not provide an approved time limited waiver from the Centers for Medicare & Medicaid Services. This is evidenced by: The facility-supplied Electronic Plan of Correction stated in part, 'The facility has requested a waiver for this because the winter weather conditions will prevent completion at this time. The all-weather surface will be installed on the exit discharge from the B-Wing west exit.' During an interview on 01/24/2025 at 1:14 PM, Administrator #1 stated that they would review their Plan of Correction for K-271 and resubmit with a more detailed time-limited waiver request. The facility-signed Electronic Plan of Correction for this citation documented a Credible Allegation Date of 01/29/ 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 interview during the recertification, the facility did not maintain exits in accordance with adopted regulations for 3 of 3 resident units. Specifically, exit discharges were not all-weather surfaces and were not marked to make clear the direction of egress travel from the exit discharge to a public way in accordance with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19. 2. 7 and 7. 7. This is evidenced by: During observations on 12/13/2024 at 3:41 PM, the exit discharge from the B-Wing west exit was grass and not an all-weather surface. During observations on 12/13/2024 at 3:44 PM the following exit discharges were not marked to make clear the direction of egress travel from the exit discharge to a public way: ?é?À A-Wing west exit ?é?À B-Wing West exit ?é?À C-Wing north exit ?é?À C-Wing south exit During an interview on 12/17/2024 at 11:49 AM, Administrator #1 stated they would install an all-weather surface for the B-Wing west exit discharge and mark the exit discharges to show the direction to the public way. 42 Code of Federal Regulations 483. 70(a)(1) 2012 NFPA 101 19. 2. 7, 7. 7 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 18, 2025 What corrective action will be accomplished for those residents found to have a been affected by the deficient practice. 1) The facility has requested a time limited waiver for the installation of a permanent all-weather surface as winter weather conditions will prevent completion at this time. The all-weather surface will be installed from the B-Wing West exit discharge and end at the public way. The facility began the process of vendor quotes on (MONTH) 10, 2025 and will have one quote by (MONTH) 15, 2025. Several other vendors have been contacted to review the scope of work. The facility will continue to obtain quotes through the month of (MONTH) as more providers become available with a vendor decision by (MONTH) 1, 2025. Work to be completed no later than (MONTH) 18, 2025. During this period the Administrator will check-in with the Sanitarian the first of each month to update progress on the project. During walkway installation, periodic inspections of all exit discharges to ensure that they are clear at all times as well as staff education on maintaining same will be completed by the Maintenance Director and/or Administrator. Until the permanent all-weather surface can be installed a temporary walkway will be put in place from the B-Wing West exit to the public way. The facility received a quote on (MONTH) 11, 2025 for the installation of a temporary walkway which will be completed by (MONTH) 13, 2025. All staff to be in-serviced on fire safety. A copy of the resident safety plan, facility life safety floor plan will be submitted to LTCLCwaiver@heath.ny.gov by (MONTH) 29, 2025. Appropriate evacuation route/discharge signage was installed on (MONTH) 29, 2025 to mark the direction of egress travel from the four noted areas of exit discharge. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed an audit of all exit discharges to ensure all exit discharges either had direct access to a public way and were clear or were marked with signage directing to a public way and were clear and that all-weather discharge passageway surfaces were intact. No additional areas of concern were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur. 3) Education was provided to all maintenance staff on maintaining exit discharges with all-weather surfaces as well as appropriately marking exit discharges to make clear the direction of egress travel to the public way. Appropriate direction of egress signage was installed on (MONTH) 29, 2025 for the four noted exits to clearly indicate the direction of egress pathways to the public way. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction. 4) The Maintenance Director or Maintenance Assistant will audit exit passageways for appropriate signage and all-weather surface integrity weekly for two months and monthly thereafter for four months. The results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly and additional recommendations for interventions and duration of audits will be given as needed. This task has also been added to the weekly environmental rounding schedule. Responsible Party: Director of Maintenance Date of Correction (signage): (MONTH) 29, 2025 Date of Correction (temporary walkway): (MONTH) 13, 2025 Date of Correction (all weather surface): (MONTH) 18, 2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
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 resting of the emergency generator fuel reserve until the fuel reserve passes the fuel quality test and (2) ensure that the Electronic Plan of Correction was implemented. Specifically, the facility did not provide passing fuel quality test results for the emergency generator fuel reserve. This is evidenced by: The facility-supplied Electronic Plan of Correction stated in part, 'The facility will . address the high particle count in the fuel reserve and will . resolve the source of the water contamination in the fuel reserve. Should the fuel reserve fail retesting, corrective actions will be taken with additional retesting until the fuel reserve passes the fuel quality test.' During a telephone interview on 02/07/2025 at 10:07 AM, Administrator #1 stated that they did not yet have the results of emergency generator fuel reserve retesting. The facility-signed Electronic Plan of Correction for this citation documented a Credible Allegation Date of 01/29/ 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 record review and interviews during the recertification survey, the facility did not maintain the emergency generator as required by adopted regulations. Specifically, the emergency generator fuel reserve was not treated and retested after failing fuel quality testing, as required by the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition section 8. 3. This is evidenced by: There was no documented evidence that the emergency generator fuel reserve was tested in 2023. The document titled (vendor) Fuel Analysis Report and dated 06/24/2024 documented that the emergency generator fuel reserve failed analysis as follows: ?é?À The particle count results exceed acceptable limits, and the use of portable filtration or a more aggressive approach to filtration is suggested. ?é?À Water contamination exceeded specifications, and investigating the source of the water contamination is suggested. There is no documented evidence that the emergency generator fuel reserve was treated to reduce the contamination levels or that the vendor suggestions were followed. During an interview on 12/16/2024 at 11:24 AM, Maintenance and Life Safety Consultant #1 stated that they would have the emergency generator fuel reserve treated. 42 Code of Federal Regulations 483. 70(a)(1) 2010 NFPA 110 8. 3 10 New York Codes, Rules, and Regulations 415. 29, 711. 2(a) | Plan of Correction: ApprovedFebruary 14, 2025 What corrective action will be accomplished for those residents found to have a been affected by the deficient practice. 1) The facility used a more aggressive approach to address the high particle count previously found in the fuel reserve testing by completely emptying the tank and totally replacing with new fuel. The facility Maintenance Director scheduled a new generator fuel reserve test and will treat for contamination if needed as per vendor recommendations. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. 2) All residents and staff have the ability to be affected by this deficient practice. The facility audit for other emergency generator fuel reserves found that there was another emergency generator fuel reserve tank on the grounds. This tank was drained as the generator is not connected to the building in any way and will not be used. The facility will have the test results for the tank in use by (MONTH) 15, 2025. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur. 3) Facility Maintenance Director was educated by the Administrator on having the generator fuel reserve tested annually and to complete recommendations given by the vendor. The generator fuel reserve testing has been added to the preventative maintenance schedule to be completed annually. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction. 4) Findings of the annual fuel reserve testing will be reviewed by the Quality Assurance Performance Improvement Committee annually and additional recommendations for interventions will be given as needed. Responsible Party: Director of Maintenance Date of Correction: (MONTH) 15, 2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details Details not available | 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 7, 2025
Corrected date: N/A
Citation Details Details not available | 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 7, 2025
Corrected date: N/A
Citation Details Details not available | 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 7, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |