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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 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 initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that irregularities reported by the Pharmacist to the attending Physician, the facility's Medical Director, and the Director of Nursing were acted upon for each resident. This was identified for one (Resident #59) of five residents reviewed for Unnecessary Medications. Specifically, the attending Physician for Resident #59 agreed to the recommendations to consider evaluating sliding scale insulin coverage and decreasing finger sticks to twice a day to obtain blood glucose readings made by the Pharmacist; however, the recommendations were not implemented. The finding is: The facility's policy titled Medication Regimen Reviews dated 10/2018 documented the consultant Pharmacist performs a comprehensive review of each resident's Medication Regimen Review upon admission/readmission and at least monthly. The Medication Regimen Review includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning, prevents or minimizes adverse consequences related to medication therapy, and is free of unnecessary medications. Findings and recommendations are reported to the Director of Nursing, the attending Physician, the Medical Director, and/or the Administrator. Recommendations are acted upon and documented in the medical record/Medication Regimen form by the facility staff and/or the prescriber. The documentation must reflect that the irregularity has been reviewed and what, if any action has been taken to address it. If there is no change to the medication, the attending Physician should document their rationale. Resident #59 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident received insulin injections during the last 7 days. A Comprehensive Care Plan titled The Resident has altered Endocrine/Metabolic Status dated 12/8/2023 and last revised 9/28/2024 documented interventions including fingerstick for blood glucose monitoring as ordered, administer medications as ordered, monitor, document, and report signs and symptoms of [MEDICAL CONDITION] (high blood sugar levels) and [DIAGNOSES REDACTED] (low blood sugar levels) to the Physician. A Medication Regimen Review form dated 1/6/2025 for Resident #59 documented the Pharmacist's recommendations including discontinuing sliding scale insulin coverage and taper fingerstick order to two times a week in the morning and the evening and notifying the Physician if results are below 70 milligrams per deciliter or greater than 250 milligrams per deciliter. The attending Physician agreed with the Pharmacist's recommendations on 2/6/2025 and documented on the Medication Regimen Review form to change the fingerstick blood glucose monitoring to two times a week and to call the Physician for blood glucose readings over 201 milligrams per deciliter, or blood glucose readings below 70 milligrams per deciliter. A Medication Regimen Review form dated 2/5/2025 for Resident #59 documented the Pharmacist's recommendations including evaluating the current need for sliding scale insulin coverage without a standing physician's orders [REDACTED]. The undated response by the attending Physician on the Medication Regimen Review form documented the attending Physician agreed with the recommendations and further documented adding [MEDICATION NAME] (an oral diabetic medication) 100 milligrams twice a day for Diabetes. The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The order included parameters of glucose readings with the corresponding insulin dosage. During an interview on 3/20/2025 at 10:04 AM, Registered Nurse #1, the Registered Nurse Supervisor, stated the nursing supervisors were responsible for initially reviewing the Medication Regimen Review forms and contacting the attending Physician regarding the recommendations made by the consultant Pharmacist and obtaining physician's orders [REDACTED].#1 could not recall reviewing the recommendations made by the consultant Pharmacist on 1/6/2025 and 2/5/2025 regarding Resident #59's blood glucose monitoring and sliding scale insulin coverage. Registered Nurse #1 further stated they did not know why the recommendations were not put in place for Resident # 59. During an interview on 3/21/2025 at 8:54 AM, Physician #1, the attending Physician, stated the Physicians were responsible for reviewing the Medication Regimen Review form and any Pharmacist recommendations. The Physicians are responsible for documenting their responses to the Pharmacist's recommendations and a rationale if they disagree with the Pharmacist's recommendations. Physician #1 stated they had initially agreed with the Pharmacist's recommendations that were made on 1/6/2025 and 2/5/ 2025. Physician #1 stated they reviewed the resident's records later and did not feel comfortable changing the orders for blood glucose monitoring and the sliding scale insulin overage for Resident #59 for clinical reasons including the resident's history of episodes of [MEDICAL CONDITION], recently starting an oral diabetic medication, and recent removal of enteral tube feeding. Physician #1 further stated they should have documented their rationale in the resident's medical record. During an interview on 3/21/2025 at 12:03 PM, the Medical Director stated all attending Physicians should review and document a response to the Pharmacist's recommendations on the Medication Regimen Review form. The Physician must document whether they agree or disagree with the recommendations with a rationale and any alternative treatments if they were in disagreement with the recommendations. During an interview on 3/21/2025 at 12:27 PM, the Director of Nursing Services stated Physician #1 should have implemented the recommendations made by the Pharmacist or provided documentation of a rationale why the recommendations were not implemented for Resident # 59. 10 NYCRR 415. 18(c)(2) | Plan of Correction: ApprovedApril 14, 2025 I. Immediate Corrective Action The attending physician has reviewed the pharmacists Medication Regimen Review (MRR) recommendations dated 1/6/2025 and 2/5/2025 and provided retrospective clinical rationale for not implementing certain recommendations. II. Identification of other residents A facility-wide audit of all residents with pharmacist Medication Regimen Reviews completed within the past 90 days was initiated and completed on 3/30/ 2025. No negative findings resulted from this review. III. Systemic Changes The facility policy titled Medication Regimen Reviews was reviewed and found to be in compliance with the regulations. All providers will be educated on the requirement to follow through on agreed to pharmacist recommendations documented in the monthly Medication Regimen Review. The Director of Nursing (DON) or designee will verify that pharmacist recommendations are routed to the attending physician and that responses are tracked through a MRR Response Tracking Log. Attending physicians were provided written notification and guidelines reminding them of the regulatory requirement to act on pharmacist recommendations and document rationale if no change is made. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled Medication Regimen Reviews. Audits will be conducted monthly by the Medical Director for three months. The audit include: Verification that the attending physician reviewed and responded to each pharmacist recommendation. Confirmation that any agreed-upon recommendations were implemented and documented in the residents medical record. Identification of any discrepancies or lack of documentation of physician rationale. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Medical Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews conducted during the Recertification survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not follow proper sanitation practices to prevent the outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, 1) during the kitchen observation on 3/17/2025, the final rinse temperature of the high-temperature dishmachine was observed to be below 180 degrees Fahrenheit. The manufacturer's temperature recommendation for the rinse cycle was 180 degrees Fahrenheit and above and the dietary staff did not know how to operate and monitor the chemical sanitization process for the dishmachine 2) Multiple observations of washed cooking equipment and washed wet trays, plates, and domes were stored away without drying. 3) One out of six air circulation fans in the walk-in refrigerator was dusty with black build-up around the fan guard; the dry goods storage room floor was unclean; and a condiment compartment tray was in an unsanitary and dirty condition. Additionally, non-food items including but not limited to cutlery bags and tray cover boxes were placed directly on the floor in the paper goods storage room. The findings are: 1) The facility's policy and procedure titled Dish Machine Temperature Procedure dated 5/2022 documented that food service workers, dietary managers, or supervisors will monitor wash and rinse temperature to ensure proper (dishmachine) temperature. The wash temperature should meet a minimum of 150 degrees Fahrenheit, and the final rinse temperature should meet a minimum of 180 degrees Fahrenheit. The dietary manager or supervisor should complete the temperature log every shift. Food service workers should stop using the machine and notify the dietary manager or supervisor if the machine does not meet identified temperatures. Administration, Maintenance, and the dishmachine Service Company should be contacted immediately for repair if the dishmachine is not meeting the proper temperature. The use of low-temperature sanitizing procedures should be instituted if needed. The dishmachine manufacturer's instruction dated 11/2012 documented minimum temperatures of the Wash, Rinse, and Final Rinse cycle while using high-temperature sanitizing were 150 degrees Fahrenheit, 160 degrees Fahrenheit, and 180 degrees Fahrenheit. The dishmachine was observed being operated by Dietary Aide #1 on 3/17/2025 at 9:41 AM, in the presence of the Food Service Director. Dietary Aide #2 was also present and was removing the washed dish load out of the dishmachine. A moderate amount of water was observed leaking from below the digital temperature display on the dishmachine which read 146 degrees Fahrenheit for the Wash and 122 degrees Fahrenheit for the Final Rinse cycle. The Final Rinse temperature of a second load read 121 degrees Fahrenheit. During an interview on 3/17/2025 at 9:48 AM, Dietary Aide #1 stated they were using the dishmachine to wash the dishes from the breakfast meal. Dietary Aide #1 stated the dishmachine is a high-temperature machine and the Wash cycle temperature should be at 160 degrees Fahrenheit and the Final Rinse cycle temperature should be at 180 degrees Fahrenheit. Dietary Aide #1 stated they did not notice that the Final Rinse cycle temperature was low and therefore, they did not notify anyone. Dietary Aide #1 stated they did not know the procedures regarding how and when chemical sanitization should be instituted. Dietary Aide #1 did not know how to test for the chemical concentration of the water solution during the final rinse cycle. During an interview on 3/17/2025 at 9:51 AM, Dietary Aide #2 stated that they were newly hired and were not regularly assigned to the dishwashing task. Dietary Aide #2 stated they knew the basics of how to operate the dishmachine such as turning on the machine, loading and removing dishes, and refilling the sanitizing chemicals. Dietary Aide #2 stated they did not know the operation and procedures of when to use chemical sanitization. During an interview on 3/17/2025 at 10:07 AM, the Director of Food Services stated they were not notified of the low dishmachine Wash and Rinse cycle temperatures and should have been notified. The Director of Food Services stated they would have called the Maintenance Department and the Dishmachine company for servicing. The Director of Food Services stated all kitchen staff should be familiar with the operation of the dishmachine both in high temperature and chemical sanitization mode. 2) The dishwasher instruction dated 11/2012 documented to allow dishes to drain and air-dry before removing the ware (dishes) from the rack. The facility's policy and procedure titled Dish Machine Temperature Procedure dated 5/2022 did not document the procedures to dry and store washed dishes and equipment. During an initial kitchen tour on 3/17/2025 at 9:41 AM, the dishmachine operation was observed. Dietary Aide #1 was washing and loading the dirty dishes into the dishwashing machine and Dietary Aide #2 was clearing the washed load out of the machine and putting the washed dishes away. The washed trays, plates, and domes were not completely air-dried before Dietary Aide #2 stacked the washed items on the meal truck for lunch preparation. During an observation of the meal trucks on 3/17/2025 at 11:39 AM, wet domes were observed set up on the residents' individual meal trays that were set up in preparation for the lunch meal. The Director of Food Services was immediately interviewed after the observation on 3/17/2025 and stated that washed items such as trays, dishes, utensils, pots and pans, etc. should be wiped and dried before storing. The Director of Food Services stated they did not have sufficient space and drying racks to allow items to be completely air-dried before storage. During an observation on 3/17/2025 at 11:45 AM, the pot washer was observed cleaning and sanitizing large cooking pots and pans in a 3-compartment sink. Wet stainless steel sheet pans and steam table pans were nesting on top of each other and water was dripping from the top pans onto pans stacked below. During a follow-up kitchen tour on 3/18/2025 at 2:45 PM, washed trays, plates, and domes were observed to be wet and nesting on top of each other. 3) The facility's policy and procedure titled Storeroom/Food Delivery Procedure dated 7/2022 documented that all food items will be properly rotated, dated, and stored in a clean environment. The dietary aide will clean the storeroom daily per assignment. Nothing is to be stored 18 inches or less from the ceiling. Nothing could be stored on the floor. The policy did not include the cleaning procedure of the walk-in refrigeration units. During an initial tour of the kitchen on 3/17/2025 at 11:26 AM, one out of six air circulation fans in the walk-in refrigerator was observed dusty with black build-up around the fan guard. The fan sat directly above a shelf with stored food items. The Director of Food Services was immediately interviewed and stated the dietary staff/stocker who received food delivery on Wednesdays and Fridays was responsible for cleaning the refrigerator. The Director of Food Services stated they expected the walk-in units to be cleaned at least weekly on one of the two delivery days. Dietary staff assignment and schedule were reviewed for the week of 3/9/2025 and 3/16/ 2025. There was no documented evidence that the dietary staff/stocker performed weekly cleaning of the walk-in refrigerator. The dietary staff/stocker was unavailable for the interview. During an initial tour of the kitchen on 3/17/2025 at 11:43 AM, the dry goods storage room was observed with debris, single-use jelly jam containers, salt and pepper packets, and spilled dry beans on the floor. A dirty condiment tray, with black unidentified pieces, was observed on a trolley. The Director of Food Services was immediately interviewed and stated the storage room should be kept clean. During a tour of the dry paper goods storage area | Plan of Correction: ApprovedApril 15, 2025 I. Immediate Corrective Action While no residents were identified as being harmed by the deficient practices, immediate corrective actions were taken to address observed sanitation and food safety issues: The dish machine was taken out of service immediately. Dishes were sanitized using the approved 3-compartment sink method with chemical sanitizer until the dish machine was repaired and recalibrated. All wet dishes and utensils that had been improperly stored were rewashed, properly air-dried, and stored in a sanitary manner. The dirty air circulation fan in the walk-in refrigerator was cleaned and sanitized. The dry goods storage room was cleaned, with all debris and spilled food removed. The dirty condiment tray was discarded. All items improperly stored on the floor in the paper goods storage area were relocated to appropriate shelving. Staff involved were counseled and re-educated on proper food safety protocols and dish sanitization procedures. II. Identification of other residents All noncompliant practices were corrected on the spot.Although no direct resident harm was identified, all residents who receive food prepared in the facility could have been affected by the improper sanitization of dishware and unsanitary kitchen conditions. All noncompliant practices were corrected on the spot. III. Systemic Changes The facility policies titled Dish Machine Procedure and Storeroom/Food Delivery Procedures were reviewed and found to be in compliance with the regulations. Staff were re-educated on dishmachine operation, temperature requirements, and procedures for chemical sanitization. The kitchen staff were re-educated on dishware and food storage and maintaining the cleanliness of the kitchen overall. All dietary staff were in-serviced on how to read temperature gauges and test chemical concentrations when needed. A No Wet Nesting policy was reinforced, and staff are now required to inspect items for dryness prior to storage. All dietary staff were educated on the No Wet Nesting policy. A weekly cleaning schedule was developed and assigned to staff for: Walk-in refrigerator cleaning (including fan guards). Dry goods and paper goods storage areas. Removal of expired, open, or improperly stored items. Nothing on the Floor signage was placed in all storage areas. IV. QA Monitoring An Audit Tool has been developed to track compliance with the facility policies titled Dish Machine Procedure and Storeroom/Food Delivery Proceduressuch as: Documentation of daily dishmachine temperature checks. Weekly sanitation inspections of all food preparation and storage areas Monitoring of dish storage for signs of wet nesting or improperly dried items. This audit will be conducted by the Food Service Director/Designee weekly for three months. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Food Service Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that a resident with a limited range of motion receives appropriate treatment and services. This was identified for one (Resident #42) of seven residents reviewed for Activities of Daily Living. Specifically, Resident #42 was observed on multiple occasions with a gauze roll in their left hand. The resident's Comprehensive Care Plan documented the discontinuation of the use of the gauze roll in April 2024. An interview with the Director of Rehabilitation revealed that any object in the resident's hands may stimulate involuntary tone and greater tension in the resident's hands which was more detrimental than beneficial for the resident due to the [MEDICAL CONDITION] diagnosis. Additionally, The Rehabilitation screening did not include and measure the resident's current extent of movement of their joints and the identification of limitations and opportunities for improvement. The finding is: The facility's policy titled Contracture Management Program, effective (MONTH) 2022 documented that residents at risk or present with contractures will be assessed to determine appropriate interventions, including the use of orthotic devices and range of motion (ROM) exercises. Use of orthotic devices will be prescribed by the Occupational Therapist or Physical Therapist as part of the resident's care plan. The schedule of orthotic device use will be documented and followed by the Nursing staff. Nursing staff will receive instructions on the proper application, removal, and monitoring of the orthotic devices as well as performing a range of motion exercise as per the care plan. Nursing and Therapy staff will collaborate in care plan meetings to adjust interventions as necessary. The facility's policy titled Activities of Daily Living, effective (MONTH) (YEAR) documented to provide necessary care and services based on comprehensive resident assessment to prevent decline unless it is unavoidable. Passive range of motion shall be encouraged or performed during daily Activities of Daily Living care. Documentation of Activities of Daily Living shall be recorded in the (Electronic Medical Record). The facility's policy titled Restorative Nursing and Unit Activity Program, effective (MONTH) 2021 documented Certified Nursing Assistants should review instructions on Kardex and deliver care to residents who are ordered on the Unit Activity Program. Certified Nursing Assistant then should document information in (the resident's) plan of care. Resident #42 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status was not conducted because the resident rarely understands and was rarely understood. Resident #42 had functional limitations in the range of motion on both sides of the upper and lower extremities. Resident #42 is dependent on all activities of daily living and mobility. The Minimum Data Set did not indicate the use of a splint or brace. The Rehabilitation Therapy Screening dated 7/18/2024 documented Resident #42 had fixed contractures and significant flexor tone in bilateral upper and lower extremities. Resident #42 did not have any orthotics. Resident #42 was on a unit activity program to receive a passive range of motion. There was no documentation that the assessment evaluated the degrees of severity of the existing fixed contractures to determine if current management and interventions were effective. The Rehabilitation Therapy Screening dated 10/16/2024 documented Resident #42 had fixed contractures and significant flexor tone in bilateral upper and lower extremities. Resident #42 did not have any orthotics. Resident #42 was on a unit activity program to receive a passive range of motion. There was no documentation that the assessment evaluated the degrees of severity of the existing fixed contractures to determine if current management and interventions were effective. The Rehabilitation Therapy Screening dated 1/14/2025 documented Resident #42 had fixed contractures and significant flexor tone in bilateral upper and lower extremities. Resident #42 did not have any orthotics. Resident #42 was on a unit activity program to receive a passive range of motion. There was no documentation that the assessment evaluated the degrees of severity of the existing fixed contractures to determine if current management and interventions were effective. The Comprehensive Care Plan titled Potential for Further Skin Breakdown last revised 12/20/2024 did not include the use of gauze handroll for preventative skin care. The Comprehensive Care Plan titled Impaired Mobility and Activities of Daily Living Self-Care Performance Deficit last revised on 3/19/2025 documented resident has impaired ability due to [MEDICAL CONDITION] with contracture and a history of [MEDICAL CONDITION]. The interventions included passive range of motion during morning and evening care. The interventions did not include the use of a gauze handroll. The Nursing Aide Task Instruction (Kardex-resident care instruction provided to Certified Nursing Assistants) dated 3/19/2025 documented to keep skin clean and dry. Resident #42 is to receive a Passive Range of Motion to the bilateral upper and lower extremities during morning and evening care. The instructions did not include the use of a gauze handroll. There was no physician's order for the use of [REDACTED] During an observation on 3/17/2025 at 12:43 PM, Resident #42 was lying in bed with both hands resting on top of their chest, in a fisted position, with a gauze roll in the left hand. Resident #42 was cognitively impaired and therefore was unable to provide information about the gauze roll. During an observation on 3/19/2025 at 11:48 AM, Resident #42 was lying in bed with both hands resting on top of their chest, in a fisted position, with a gauze roll in the left hand. During an observation on 3/19/2025 at 2:17 PM, Resident #42 was lying in bed with both hands resting on top of their chest, in a fisted position, with a gauze roll in the left hand. Resident #42's right hand was observed tightly closed and the fingertips appeared to be digging into the resident's palm and the resident's fingers were blanched. During an interview on 3/19/2025 at 2:42 PM, Certified Nursing Assistant #3 stated they were responsible for placing the gauze rolls in the resident's contracted hands. Certified Nursing Assistant #3 stated they did not document the use of the gauze rolls because the task was not included in the Kardex (Certified Nursing Assistant instruction). Certified Nursing Assistant #3 stated they did not place a gauze roll in the resident's right hand because they (Certified Nursing Assistant #3) could not open the resident's hand. Certified Nursing Assistant #3 stated they did not notify anyone because the resident's hands had been that way for a long time. During an observation and interview on 3/19/2025 at 3:38 PM, Resident #42's hand was observed with Licensed Practical Nurse #3 and Registered Nurse Supervisor # 7. The resident's right hand required more effort and assistance to open. The skin on both hands was intact and moist with some dry skin flakes. Licensed Practical Nurse #3 stated Resident #42 had contractures on both hands and required hand rolls to prevent skin breakdown. Licensed Practical Nurse #3 stated the handrolls were issued by the Rehabilitation department. Licensed Practical Nurse #3 pulled down the blanket and found a gauze roll on top of the resident's gown. Licensed Practical Nurse #3 stated the roll must have slipped out from Resident #42's right hand. Licensed Practical Nurse #3 stated that the nursing staff was responsible for placing and ensuring the hand rolls stayed in place at all times. Registered Nurse Supervisor #7 assessed the skin and assisted Licensed Practical Nurse #3 in placing the gauze roll back into Resident #42's right hand. During an inte | Plan of Correction: ApprovedApril 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action For Resident #42, the gauze hand roll was immediately removed upon identification and not reintroduced. The assigned staff (RN and CNA who placed the gauze) were educated regarding the resident's condition. They were educated by the Director of Rehabilitation that any object in the resident's hands may stimulate involuntary tone and greater tension in the resident's hands which was more detrimental than beneficial for the resident. The resident's care plan was updated to include the specific information. The therapy staff who conducted screening for the resident were educated regarding specifying and documenting the resident's unique condition and notifying the direct care staff. The resident was assessed on 1/14/2025 and re-assessed again on 4/8/2025 using visual observation, functional positioning analysis, palpation, and tone assessment which are also valid components of contracture evaluationÔÇØparticularly in residents with fixed, chronic, or neurologically-based tone abnormalities, such as Resident # 42. Passive Range of Motion (PROM) for bilateral upper and lower extremities were continuing to be performed twice a day. The rehab assessment on 4/8/2025 did not indicate any observed changes in the residents contracture status compared to the previous evaluation conducted on 1/14/ 2025. The residents presentation remained consistent, with fixed contractures and significant flexor tone in all four extremities, and no new functional limitations or deterioration were noted. II. Identification of other residents A facility-wide audit of all residents with limited range of motion, contractures, or passive range of motion (PROM) interventions was conducted on 3/21/ 2025. The audit included: Review of current care plans and Kardexes for accuracy and alignment with therapy evaluations. Confirmation that all orthopedic or positioning devices were prescribed, care planned, and monitored appropriately. Identification of residents using non-prescribed devices (e.g., rolled washcloths, gauze). Following this review, no negative findings were identified. III. Systemic Changes The facilitys policies titled Contracture Management Program was reviewed and found to be in compliance with the regulations. All CNAs will be educated to follow instructions on the CNAAR-KARDEX. All staff will be re-educated to follow instructions on the resident's care plan. In-service training will be provided to all licensed nurses and Certified Nursing Assistants the week of 4/13/2025 covering: Proper hand hygiene and skin integrity care for residents with contractures. Risks associated with use of non-prescribed items in contracted hands. Documentation requirements and proper execution of PROM. All rehabilitation therapists were re-inserviced regarding: Acceptable clinical methods of contracture measurement, Documentation expectations when using non-goniometric tools, Importance of clarifying when a residents condition is irreversible and further intervention is contraindicated. Therapy evaluations will include justification for the choice of assessment method (I.e. functional observation, or tone scale, etc.), particularly when goniometry is contraindicated or clinically unnecessary . Attendance and Lesson plan will be kept on file for validation. IV. QA Monitoring An audit tool has been developed and implemented by the Director of Rehabilitation in collaboration with the Director of Nursing. All residents diagnosed with [REDACTED]. The audits will include: Review of care plans, Kardexes, and therapy evaluations for alignment and accuracy. Verification that all positioning aids were prescribed by therapy and reflected in physician orders [REDACTED]. documentation. Identification and immediate correction of any non-prescribed device use (e.g., washcloths, gauze rolls). Any findings and documentation gaps will be corrected immediately. Audits will be conducted weekly for one month, then monthly for two months Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible Party: Director of Rehabilitation |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 21, 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 initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure it provided an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was identified for two (Resident #32 and Resident #3) of four residents observed during Medication Administration; one (Resident #50) of three residents reviewed for Pressure Ulcers; one (Resident #133) of two residents observed for infection control; and One (Unit 4 medication storage room) of two medication storage rooms observed during the Medication Storage Task. Specifically, 1) During the Medication Administration observation on 3/18/2025, Licensed Practical Nurse #1 handled medications with bare hands for Resident # 32. 2) Resident #133 had an incorrect isolation precaution signage posted outside their door that was not in accordance with the physician's orders [REDACTED]. Additionally, during the Medication Administration observation on 3/18/2025 Licensed Practical Nurse #2 picked up an electrical cord from the floor and did not sanitize their hands prior to preparing the medications a resident; and during the wound care observation for Resident #50, Registered Nurse #3 did not sanitize hands prior to applying the wound medication. The findings include but are not limited to: The facility's policy titled Infection Prevention Control Program, effective 2/2024 documented the primary purpose of the Infection Prevention and Control Program is to establish guidelines to follow in preventing, controlling, and eliminating the development and transmission of contagious, infectious, or communicable diseases. Nursing staff shall follow all policies and procedures related to infection prevention and control, including proper hand washing and transmission-based isolation procedures. Elements of the program include following hand hygiene procedures. 1) Resident #32 was admitted with [DIAGNOSES REDACTED]. The 3/7/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The current physician's orders [REDACTED]. 8. 6 milligrams (two tablets) for [DIAGNOSES REDACTED]. During the Medication Administration observation on 3/18/2025 at 8:17 AM, Licensed Practical Nurse #1 poured the Aspirin and Senna tablets from the respective medication bottles directly into their bare hand and then placed the medications from their bare hand into the souffle cup. Licensed Practical Nurse #1 then dispensed the Losartan tablet from the blister pack directly into the souffle cup. Licensed Practical Nurse #1 confirmed that they had handled the medications with bare hands and stated they should have not touched the medications without gloves. Licensed Practical Nurse #1 did not attempt to discard the medications and replace them. Licensed Practical Nurse #1 was then requested by the surveyor to discard and administer newly dispensed medications to the resident. During an interview on 3/19/2025 at 8:14 AM, the Director of Nursing Services, who was also the Infection Preventionist and Nurse Educator, stated Licensed Practical Nurse #1 should have dispensed the medications into the souffle cup without hand contact. The Director of Nursing Services stated that touching medications with bare hands is a significant infection control breach. 2) The facility's policy titled Contact Precautions, effective 11/2017, documented all personnel, including visitors, that have direct contact with a resident on contact precautions shall be required to follow all procedures as outlined within this policy in addition to standard precautions and general isolation precaution guidelines. Contact precautions are intended to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and require the use of appropriate Personal Protective Equipment, including a gown and gloves upon entering (i.e., before making contact with the resident or resident's environment) the room or cubicle. Before leaving the resident's room or cubicle, the Personal Protective Equipment is removed, and hand hygiene is performed. The facility's policy titled Enhance Barrier Precautions, effective 11/2017, documented the facility will utilize Enhanced Barrier Precautions (EBP) which entail the use of gowns and gloves during high-contact resident care activities for residents with the following : - Infection or colonization with a Centers for Disease Control-targeted Multi-Drug Resistant Organism when Contact Precautions do not otherwise apply; or -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with Multi-Drug Resistant Organism. Enhanced Barrier Precautions protocols are to be followed when secretions or excretions cannot be adequately covered or contained. Resident #133 was admitted with [DIAGNOSES REDACTED]. The 2/22/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. A physician's orders [REDACTED]. Resident # 133's care plan for Contact Precautions for Scabies, dated 3/13/2025, documented the resident was on contact precautions for the [DIAGNOSES REDACTED]., if the resident/patient is incontinent, has diarrhea, an [MEDICAL CONDITION], a [MEDICAL CONDITION], or has wound drainage that is not contained by a dressing. Use appropriate personal protective equipment for any potential contact or exposure to blood, body fluids, mucous membranes, non-intact skin and potentially contaminated environmental surfaces or equipment. During the initial unit tour on Unit 2 East on 3/17/2025 at 11:25 AM, Enhanced Barrier Precautions signage was observed on Resident #133's private room door. The resident was alone in the room. During an interview on 3/17/2025 at 11:30 AM, Registered Nurse #6 stated the Enhanced Barrier Precautions signage at Resident #133's door was correct. Registered Nurse #6 stated staff only wear personal protective equipment when rendering care, and visitors do not have to wear personal protective equipment if they are not providing care. Registered Nurse #6 stated the Director of Nursing Services, designated as the Infection Prevention Specialist, was responsible for placing the transmission-based precautions signage. During an interview on 3/17/2025 at 11:35 AM, Licensed Practical Nurse #6 stated the resident was diagnosed with [REDACTED].#133's room. Licensed Practical Nurse #6 was unaware of the differences between the Enhanced Barrier Precautions and the contact isolation precautions. During an interview on 3/17/2025 at 11:54 AM, the Director of Nursing Services stated they were responsible for posting the transmission-based precautions signage, and Resident #133's room had the incorrect signage. The Director of Nursing Services stated the residents on contact precautions must be approached wearing personal protective equipment to include a gown, gloves, and a mask, at all times, by all individuals. During an interview on 3/20/2025 at 11:18 AM, Physician #20 stated all visitors and staff should wear full personal protective | Plan of Correction: ApprovedApril 15, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action Resident #32: Medications dispensed by hand were discarded immediately upon identification, and a new, properly handled dose was administered. Licensed Practical Nurse #1 received immediate re-education on infection control standards during medication administration. Resident #133: The Enhanced Barrier Precautions (EBP) signage was removed and replaced with the correct Contact Isolation signage per physician order [REDACTED]. Resident #50: Registered Nurse #3 was re-instructed on proper hand hygiene protocols. Residents wound site was reassessed with [REDACTED]. No harm identified. Unit 4 Medication Refrigerator: The medication refrigerator was immediately cleaned and disinfected. All outdated or damaged labels were removed, and the area was sanitized according to facility policy. RN Supervisor was counseled on proper oversight. Resident #3: Licensed Practical Nurse #2 sanitized their hands after being prompted by the surveyor. Nurse was immediately reminded of hand hygiene protocol prior to medication handling. II. Identification of other residents Any resident receiving wound care and/or medication has the potential to be affected by this deficiency. All residents on any level of Infection Control Precautions were assessed for the correct signage on their room door. All signage matched the physicians orders. All medication storage room refrigerators were assessed and found to be clean. III. Systemic Changes The facility policies titled Medication Administration Guidelines, Pressure Injury/Pressure Ulcer Assessment, Prevention and Management, Infection Prevention Control Program, Contact Precautions, Enhanced Barrier Precautions and Medication Refrigerator Cleaning were reviewed and found to be in compliance with the regulations. All licensed nurses will be educated on proper infection prevention policies and practices during medication administration and wound treatment, as well as medication storage room refrigerator cleaning procedures. The Infection Preventionist will be educated on utilizing precaution signage according to physicians orders. A copy of the attendance sheet will be filed for reference and validation. IV. QA Monitoring Existing medication pass and wound treatment competencies will be used to audit infection prevention/control practices during these service provisions. Each licensed nurse will be assessed monthly for three months. An Audit Tool has been developed to monitor the placement of appropriate infection precaution signage on resident room doors. And an Audit Tool has been developed to assess the cleanliness of medication storage room refrigerators. Five licensed nurses will be audited weekly for one month using the two audits (Medication Pass and Wound Treatment Competencies. Further audits will be conducted on 5 nurses monthly for 2 months. The placement of appropriate infection precaution signage on resident room door will be audited weekly for one month, then monthly for 2 months. The cleanliness of medication storage room refrigerator will be audited weekly for one month, then monthly for 2 months. Audit findings will be compiled, analyzed and brought to the QAPI Committee. During the quarterly QAPI Committee meeting, the audit results will be reviewed and assessed for continuance, based on compliance and incidence of negative findings. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. This was identified for two (Unit 2 East and Unit 4 West medication carts) of three medication carts reviewed during the Medication Storage Task. Specifically, 1) one opened [MEDICATION NAME] (a long-acting insulin) [MEDICATION NAME] pen and one opened bottle of [MEDICATION NAME] Ophthalmic solution (a treatment for [REDACTED]. The findings are: The facility's policy titled Storage of Medications dated 4/2019 documented that multi-dose vials that have been opened or accessed should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial. Prior to and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration date once opened on the product label itself. Any medication that has been prescribed, but is no longer in use by a resident, shall be destroyed or disposed of in accordance with the Public Health Law unless the resident's Physician requests that the medication be discontinued for a specific temporary period. 1) Resident #92 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The Minimum Data Set assessment documented the resident received insulin injections in the last 7 days. The current physician's orders [REDACTED]. Resident #98 was admitted with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status of 3, indicating the resident had severe cognitive impairment. The Minimum Data Set Assessment documented the resident had impaired vision and used corrective lenses. A review of the physician's orders [REDACTED]. 1. 4 percent ([MEDICATION NAME] Alcohol), which was discontinued on 1/30/ 2025. During an observation of the Unit 4 West medication cart on 3/20/2025 at 1:26 PM with Registered Nurse #1, one opened [MEDICATION NAME] pen for Resident #92 and one open bottle of [MEDICATION NAME] Ophthalmic Solution for Resident #98 were observed without an open date documented on the medications. During an interview on 3/20/2025 at 1:34 PM, Registered Nurse #1, the Registered Nurse Supervisor, stated insulin pens should be labeled with an open date as soon as the pen is opened. The insulin pens should be discarded within 28 days from the opening date. The insulin pen and the bottle of [MEDICATION NAME] Ophthalmic Solution should have had the open date documented on the medication. Registered Nurse #1 stated they did not know when to discard the eye drops after the eye drop bottle was opened. During an interview on 3/21/2025 at 6:59 AM, Pharmacist #1 stated [MEDICATION NAME] pens can be stored at room temperature after opening and should be discarded 28 days after opening because the medications can become less effective after 28 days when stored at room temperature. The [MEDICATION NAME] Ophthalmic solution can be stored at room temperature once opened, and it should be discarded 28 to 30 days after opening as the preservative in the medication can break down and make the medication more susceptible to contamination. During an interview on 3/21/2025 at 10:47 AM, Registered Nurse #5, the Registered Nurse Supervisor, stated if the medication order was discontinued the medication should be immediately removed from the medication cart. 2) Resident #436 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident had intact cognition. The Minimum Data Set Assessment documented the resident was taking hypoglycemic medication. A physician's orders [REDACTED]. During an observation of the Unit 2 East medication cart on 3/20/2025 at 2:03 PM with Registered Nurse #8, one opened Humalog insulin pen for Resident #436 was observed without an opened date documented on the pen. During an interview on 3/20/2025 at 2:06 PM, Registered Nurse #8, the medication nurse, stated the Humalog insulin pen should also have had an open date documented on the pen because the insulin had to be discarded 28 days after opening. Registered Nurse #8 further stated they did not know the reason why the Humalog insulin pen was stored in the medication cart without an open date. During an interview on 3/21/2025 at 6:59 AM, Pharmacist #1 stated Humalog insulin pens can be stored at room temperature after opening and should be discarded 28 days after opening because the medications can become less effective after 28 days when stored at room temperature. During an interview on 3/21/2025 at 12:41 PM, the Director of Nursing Services stated all open medications should have the open date documented on them. All nurses are responsible for ensuring proper labeling and storage of medications with an open date. The Director of Nursing Services further stated the discontinued medications should be removed from the medication cart. 10 NYCRR 415. 18(d)(e)(1-4) | Plan of Correction: ApprovedApril 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action Resident #92: The opened [MEDICATION NAME] pen was immediately removed and replaced with a properly labeled pen reflecting the current date of opening. Medication administration was not interrupted, and the resident was not harmed. Resident #98: The discontinued [MEDICATION NAME] Ophthalmic Solution was immediately discarded upon identification. Residents active medications were reviewed to ensure no expired or discontinued medications remained on hand. Resident #436: The improperly labeled Humalog insulin pen was discarded, and a new insulin pen with a documented open date was initiated per physician order. Resident continued to receive timely insulin administration without clinical consequence. II. Identification of other residents A facility-wide audit of all medication carts and medication storage areas was conducted on 3/21/2025 by the Director of Nursing (DON) and Unit Nurse Managers. The audit focused on: All multi-dose vials, insulin pens, and ophthalmic solutions in use. Verification that each item was appropriately labeled with the date opened. Removal if any expired or discontinued medications are observed. There were no negative findings from this review. III. Systemic Changes The facility policy titled Storage of Medications was reviewed and found to be in compliance with the regulations. All licensed nurses will be re-educated on the proper handling of open and/or expired medications including. All medications that require discarding within a specific time frame or shortened expiration dates once opened (e.g., 28 days after opening) must be labeled with the date opened upon first use. All discontinued medications must be removed from the cart or storage area immediately. A medication must not be used unless it is properly labeled. A copy of the attendance sheet will be kept on file for validation. The Pharmacy Consultant will reinforce labeling and storage requirements in monthly audits and report deficiencies in real time to the DON. IV. QA Monitoring The RN Supervisor will conduct weekly medication cart and medication refrigerator audits for 4 weeks, verifying: o All opened medications have a clear, legible open date. o No expired or discontinued medications are present. After 4 weeks of 100% compliance, audits will continue monthly for 3 months, then be reviewed for integration into routine quarterly pharmacy audits. Results will be reported to the QAPI Committee monthly. Any trends in noncompliance will prompt immediate re-education and performance improvement plans. Responsible Party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025 the facility did not ensure that nurse staff posting data was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. Specifically, The facility entrance lobby was observed on 3/17/2025 at 9:00 AM with the Daily Staff Posting dated 3/13/ 2025. There were no Daily Staff Postings for 3/14/2025, 3/15/2025, 3/16/2025 and 3/17/ 2025. Additionally, the Daily Staff Posting did not include the actual number of licensed and unlicensed nursing staff per shift. The finding is: During an observation on 3/17/2025 at 9:00 AM, a Daily Staff Posting dated 3/13/2025 was observed near the facility reception area. The Daily Staff Posting did not include the actual number of licensed and unlicensed staff directly responsible for resident care for each shift: 7:00 PM-7:00 AM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM. During an interview on 3/20/25 at 1:29 PM, the Staffing Coordinator stated that the 7:00 PM-7:00 AM Registered Nurse Supervisor was responsible for posting the Daily Staff Posting sheet at the front desk Reception area. The Staffing Coordinator stated that the Daily Staff Posting should include the total number of licensed and unlicensed nursing staff for each shift and should be posted at the reception area on a daily basis. During an interview on 3/21/25 at 9:10 AM, Registered Nurse #5 stated that they worked the 3/16/2025-3/17/2025 night shift and were usually responsible for posting the Daily Staff Posting. Registered Nurse #5 stated they normally remove the Daily Staff Posting sheet from the previous day before posting the current sheet. Registered Nurse #5 stated that it was a busy weekend and they must have forgotten to remove the old Daily Staff Posting dated 3/13/2025 which was still posted on 3/17/ 2025. Registered Nurse #5 further stated that the Daily Staff Posting sheet must include the actual total number of licensed and unlicensed staff for each shift. During an interview on 3/21/2025 at 11:37 AM, the Director of Nursing stated the Registered Nurse Supervisors were responsible for ensuring Daily Staff Posting which included the number of licensed and unlicensed staff was posted daily. The Director of Nursing Service stated they were unable to explain why the Daily Staff Posting from 3/13/2025 was still posted on 3/17/ 2025. 10 NYCRR 415. 13 | Plan of Correction: ApprovedApril 14, 2025 I. Immediate Corrective Action The Staffing Coordinator was actively updating the staffing information for the current day and removed the prior posting. However, due to an oversight, an outdated Daily Staff Posting dated 3/13/2025 was inadvertently left displayed in the reception area. This occurred during a routine shift update and was not intentional. The Coordinator has since been re-educated on the importance of ensuring that only the current and complete staffing information is displayed at the start of each shift. The current days Staffing Posting was posted immediately after updates were entered by the Staffing Coordinator. II. Identification of other residents A 30-day retrospective review of daily staffing postings was conducted to determine if similar lapses had occurred. No additional instances of incorrect or missing postings were identified. III. Systemic Changes The facility policy titled Posting of Nursing Staff was reviewed and found to be in compliance with the regulations. No changes was made. The Staffing Coordinator and Registered Nurse Supervisors were rein-service on 4/15/2025 regarding: Daily posting requirements. Posting at the beginning of each shift. Accurate documentation of licensed/unlicensed staff per shift. Visibility and accessibility standards per federal regulation. A copy of the attendance sheet will be kept on file for validation. IV. QA Monitoring An Audit Tool has been developed to track compliance with the facility policy titled Posting of Nursing Staff. Any non-compliant findings will be promptly addressed, with corrective actions implemented. All audits will be completed weekly for 4 weeks, then monthly for 2 months. The results of the audits will be submitted quarterly to the Quality Assurance and Performance Improvement (QAPI) committee for discussion and continuance. Responsible person: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details Based on record review and staff interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that a Criminal History Record Check (CHRC) 105 Form was submitted within the required 30-day time frame to the New York State Department of Health (NYSDOH) after an individual, who had sought employment at the facility, was never hired. This was identified for one (Employee #6) of six employee records reviewed for Criminal History Record Check. Specifically, the facility received a negative determination letter from the New York State Department of Health dated 1/14/2025 for Employee # 6. Employee #6 was not hired by the facility; however, the facility did not submit a Criminal History Record Check 105 Form to the New York State Department of Health within 30 days as required. The finding is: The policy titled, State Mandated Criminal History Record dated 3/18/2021, documented that in cases where a Criminal History Record Check results in a Final Denial Letter for a prospective employee, the individual must be immediately removed for providing direct care and an electronic termination 105 Form must be submitted. A review of Employee #6's file revealed that the facility received a Final Denial-b Letter to Provider on 1/14/2025; however, there was no documented evidence that a Criminal History Record Check 105 Form was submitted to the New York State Department of Health to terminate the employee from the Criminal History Record Check system until 2/14/ 2025. During an interview on 3/19/2025 at 11:10 AM, the Human Resources Coordinator stated they run a weekly termination report based on the facility's payroll system to identify staff that need to be terminated from the Criminal History Record Check system by submitting a 105 Form. The Human Resources Coordinator stated Employee #6 was never hired and was not in the facility's payroll system, therefore they were overlooked. The Human Resources Coordinator stated they should have terminated Employee #6 from the Criminal History Record Check system right away when a letter was received from the New York State Department of Health on 1/14/ 2025. During an interview on 3/19/2025 at 11:50 AM, the Administrator stated the Human Resources Coordinator should have sent the 105 Form within 30 days after receiving the Final Denial-b to Provider Letter on 1/14/2025 because Employee #6 was never going to be hired | Plan of Correction: ApprovedApril 14, 2025 I. Immediate Corrective Action For Employee #6, who received a Final Denial-B letter on 1/14/2025, the facility submitted the required CHRC 105 Form on 2/14/ 2025. Although delayed, the employee had no contact with residents, was not entered into the payroll system, and was never employed by the facility. The potential employee affected by the deficient practice had his Form 105E processed prior to the beginning of the recertification survey. The employee record has been updated to reflect the final CHRC action and the associated submission date to NYSDOH. The Human Resources Coordinator was counseled and received additional education regarding CHRC reporting timelines and the proper handling of applicants who are denied clearance but never hired. II. Identification of other employees CHRC records were reviewed and there were no other outstanding Final Denial Letters found. III. Systemic Changes The facility policy titled State Mandated Criminal History Record Check was reviewed and found to be in compliance with the regulations. The two facility Authorized Persons have been educated as to the requirement to take the necessary action when in receipt of a Final Denial Letter, within 30 days of receipt of the letter. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled State Mandated Criminal History Check. This audit will be conducted by either of the Authorized Persons every other week. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification Survey and Abbreviated Survey (NY 077) initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified for one (Unit 3) of three resident units review for Sufficient and Competent Nurse Staffing. Specifically, there were insufficient Certified Nursing Assistants staffed on Unit 3 on the weekends for the following dates: 9/21/2024, 9/22/2024, 9/28/2024, 9/29/2024, and 10/6/2024 for various shifts. The finding is: The facility assessment dated ,[DATE] documented on Unit 3, that there should be five Certified Nursing Assistants staffed for the day shift (7:00 AM to 3:00 PM) and the evening shift (3:00 PM to 11:00 PM). On the night shift (11:00 PM to 7:00 AM) there should be three Certified Nursing Assistants on Unit 3. The facility assessment prior to 12/2024 was not available for review. -The facility nursing staffing sheet dated 9/21/2024 documented that four Certified Nursing Assistants were assigned to Unit 3 during the 3:00 PM to 11:00 PM shift. -The facility nursing staffing sheet dated 9/22/2024 documented that four Certified Nursing Assistants were assigned to Unit 3 during the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shift. -The facility nursing staffing sheet dated 9/28/2024 documented that four Certified Nursing Assistants were assigned to Unit 3 during the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shift. -The facility nursing staffing sheet dated 9/29/2024 documented that four Certified Nursing Assistants were assigned to Unit 3 during the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shift. -The facility nursing staffing sheet dated 10/6/2024 documented that four Certified Nursing Assistants were assigned to Unit 3 during the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shift. During an interview on 3/21/2025 at 2:52 PM, the Staffing Coordinator stated they were working at the facility as a staffing coordinator from (MONTH) to October 2024. The Staffing Coordinator stated they would assist with finding coverage on the weekends if there was a call out on a weekend. The Unit 3's full capacity was 50 residents. On 9/21/2024 there were 48 residents, on 9/22/2024 there were 49 residents, on 9/28/2024 there were 50 residents, and on 10/6/2024 there were 50 residents on Unit 3. The Staffing Coordinator further stated the staffing needs remained the same in (MONTH) and (MONTH) 2024 as they are documented in the current facility assessment therefore, Unit 3 was not sufficiently staffed on the weekends during the day and evening shifts. During an interview on 3/21/2025 at 4:25 PM, the Administrator stated they updated the facility assessment and did not save the information from the previous facility assessment. The Administrator further stated they did not have the previous facility assessment with the staffing information for each unit prior to (MONTH) 2024 and did not recall the changes that were made to the current facility assessment. During an interview on 3/21/2025 at 4:35 PM, the Director of Nursing Services stated they had recently started working at the facility and did not know what the staffing needs were in (MONTH) or (MONTH) of 2024. The Director of Nursing Services stated that based on the current facility assessment dated ,[DATE], the weekend dates from 9/21/2024 to 10/6/2025, Unit 3 had an insufficient number of Certified Nursing Assistant staff during the day and evening shifts. During an interview on 3/21/2025 at 4:50 PM, the Administrator stated that based on the current facility assessment, they expected at least five Certified Nursing Assistants to be working on Unit 3 during the day shift and evening shift. 10 NYCRR 415. 13(a)(1)(i-iii) | Plan of Correction: ApprovedApril 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action The Facility Assessment was developed utilizing maximum staffing and should have reflected the minimum counts necessary to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. The Facility Assessment was reviewed and updated immediately. The facility reviewed all CNA P(NAME)s/Accountability records on the identified floor, on the indicated dates in question and found 100% completion and compliance. There were no falls on the third floor on the indicated dates and all changes in condition were noted as they occurred. Staffing was sufficient to meet the residents needs and NO residents were negatively affected by the deficient practice. II. Identification of other residents Although no specific resident harm was identified, a comprehensive review of care delivery during those weekends was conducted. The facility reviewed all CNA P(NAME)s/Accountability records on the identified floor, on the indicated dates in question and found 100% completion and compliance. A full review of A&Is and the 24 hour report from the identified weekends was reviewed and there were no falls on the third floor and all changes in condition were noted as they occurred. Staffing was sufficient to meet the residents needs and no residents were negatively affected by the deficient practice. III. Systemic Changes The facility assessment tool was reviewed and revised by the Administrator, Director of Nursing Services, Medical Director and Staffing Coordinator on 3/21/2025 to validate that staffing ratios remain appropriate for resident acuity, unit size, and shift coverage. The Facility Assessment was updated to reflect the changes. The Staffing Coordinator and RN Supervisors were educated on the revised Facility Assessment as it pertains to staffing expectations. The Facility has developed a system utilizing a tool that will be completed daily to reflect each shifts scheduled employees, call outs, coverage secured, and actual employees, which will then be compared to the par and thus creating a variance. The above will ensure minimum counts necessary to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. The Staffing Coordinator and RN Supervisors were educated on the system and tool as it pertains to staffing expectations. IV. QA Monitoring A Quarterly Facility Review will be conducted moving forward to: Confirm current staffing levels match resident acuity and needs. Adjust minimum staffing expectations as needed. The Administrator and Director of Nursing will conduct monthly meetings with the staffing team to evaluate scheduling challenges and review mitigation strategies. Quarterly results of review will be filed for validation and presented to the QAPI Committee for discussion. Responsible Party: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/17/2025, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for two (Resident #123 and Resident #50) of three residents reviewed for Pressure Ulcers. Specifically, 1) Resident #123 had a physician's orders [REDACTED]. During an observation on 3/17/2025, the resident was in bed and the air mattress weight setting was not consistent with the resident's weight, and 2) Resident #50 had a physician's orders [REDACTED]. During an observation on 3/17/2025, the air mattress was not plugged into the power outlet. The findings are: The facility's policy titled Air Mattress, effective 10/2023, documented the purpose (of an air mattress) is to prevent pressure ulcer/injury and to assist in healing pressure ulcers. Continuous monitoring of the functionality and effectiveness of an air mattress will be conducted to ensure optimal pressure redistribution and to prevent potential malfunctions. 1) Resident #123 was admitted with [DIAGNOSES REDACTED]. The 2/28/2025 Significant Change Minimum Data Set assessment documented no Brief Interview for Mental Status score due to the resident having short and long-term memory problems. The Minimum Data Set assessment documented the resident had one unstageable pressure ulcer, was at risk for developing pressure ulcers, and was dependent on staff members for bed mobility and positioning. A Braden Scale (a scale for determining pressure ulcer risk), dated 3/14/2025, documented a score of 10, indicating the resident was at high risk for pressure ulcer development. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. 95. 6 pounds as of 3/12/ 2025. A review of the undated Operation Manual for the air mattress documented: Determine the resident's weight and set the control knob to that weight setting on the control unit. On 3/17/2025 at 9:54 AM, Resident #123 was observed in bed. The weight setting on the air mattress control unit was set at 230 pounds. Licensed Practical Nurse #1 was at the resident's bedside and stated the resident was admitted to the facility with a pressure ulcer to the right elbow. During an interview on 3/19/2025 at 8:43 AM, Wound Care Registered Nurse #1 stated they are mainly responsible for checking air mattress settings, but the nurses going in and out of the room during the day are also responsible for ensuring the air mattress weight setting is correct. The proper weight setting helps heal the wound. Wound Care Registered Nurse #1 stated they did not have an explanation as to why the air mattress was not set at the appropriate weight setting on 3/17/2025 and this was a mistake. During an interview on 3/19/2025 at 12:55 PM, Wound Care Physician #1 stated the weight setting of the mattress should correspond with the resident's weight to assist in wound healing. During an interview on 3/20/2025 at 10:49 AM, the Director of Nursing Services stated the nurses have to make sure the air mattress weight setting is correct and corresponds to the resident's weight. 2) Resident #50 was admitted with [DIAGNOSES REDACTED]. The 12/19/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident was at risk for pressure ulcer development and did not have a pressure ulcer at the time of the assessment. The assessment documented that the resident required supervision/touching assistance for bed mobility and positioning. A review of the resident's record revealed the resident acquired an unstageable pressure ulcer to the left buttock in the facility, which was identified on 2/12/ 2025. A Braden Scale (a scale for determining pressure ulcer risk), dated 2/17/2025, documented a score of 11, indicating a high risk of developing pressure ulcers. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an observation on 3/17/2025 at 11:15 AM, Resident #50 was lying in bed on an air mattress. The lights on the air mattress control unit were not on, and the air mattress did not appear to be functioning. The surveyor asked Licensed Practical Nurse #1 (unit nurse) to look at the mattress. Licensed Practical Nurse #1 and Registered Nurse Wound Care Nurse # 1 came into the room and untangled the wires of the mattress revealing that the air mattress was not plugged into the power outlet. The air mattress was then plugged into the wall outlet and the mattress control unit light was turned on. During an interview on 3/19/2025 at 8:43 AM, Wound Care Registered Nurse #1 stated all nursing staff that go into the room, including Certified Nursing Assistants, have a responsibility to ensure that the mattress is plugged in and operating. During an interview on 3/20/2025 at 10:49 AM, the Director of Nursing Services stated the nurses are responsible for making sure the air mattress weight settings are set correctly and all nursing staff are responsible for checking that the mattress is turned on and working appropriately. 10 NYC RR 415. 12(c)(1) | Plan of Correction: ApprovedApril 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action Despite routine checks functionality and of the adjustment knob by nursing staff, the air mattress setting was inadvertently not aligned with the residents current weight. Resident #123: The air mattress was immediately adjusted to match the residents actual weight of 95. 6 lbs. Resident #50: The air mattress was immediately plugged into the power outlet and confirmed to be fully functional. Staff involved were re-inserviced on their responsibilities regarding equipment operation. Care plan and treatment orders were reviewed and reinforced. II. Identification of other residents A facility-wide audit of all residents with physician orders [REDACTED]. The audit included verification of: Current weight settings vs. resident weight. Functionality (power connection) of each air mattress. Staff awareness regarding equipment monitoring. III. Systemic Changes A mandatory in-service training will be conducted for all licensed nurses and CNAs on: Importance of matching air mattress settings to resident weight. Daily functionality checks (including ensuring the mattress is plugged in and operating properly). Documentation and escalation protocols if discrepancies are noted. The policy on Air Mattress was reviewed and found to be appropriate. A modification has been made whereby an Air Mattress Check q shift has been added to the Treatment Accountability Record (TAR), requiring a nurse signature. IV. QA Monitoring An audit tool was developed for all residents on air mattresses for: Correct weight settings Proper power/functionality Accuracy of related documentation Audit results will be submitted to the Director of Nursing weekly Any non-compliance identified will be addressed with immediate re-education and progressive disciplinary action if warranted. Audit frequency will be weekly for 1 month, monthly for 2 months until 100% compliance. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Person Responsible: Wound Care Coordinator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 21, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/17/2025 and completed on 3/21/2025, the facility did not ensure that each resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding (tube feeding). This was identified for one (Resident #123) of one resident reviewed for Tube Feeding. Specifically, on 3/17/2025, Resident #123 received the wrong enteral formula. The bottle for the enteral formula did not have a label indicating the resident's name, the flow rate, the time, and the date of the administration. The finding is: The facility's policy titled Administration of Gastrostomy Tube Feeding, effective 3/2025, documented tube feeding shall be administered and monitored by a licensed nurse upon the written order of a Physician/Nurse Practitioner. The licensed nurse will verify the physician's orders [REDACTED]. Attach the completed label with the details of the physician's orders [REDACTED]. Mark the bag or bottle with the resident's name, date, and time of administration. Resident #123 was admitted with [DIAGNOSES REDACTED]. The 2/28/2025 Significant Change Minimum Data Set assessment documented no Brief Interview for Mental Status score due to the resident having long and short-term memory problems. The Minimum Data Set documented the resident had a feeding tube and had a weight loss of 5% or more in the last month or 10% or more in the last 6 months. A physician's orders [REDACTED]. 1. 2, 1500 milliliter; at the rate of 75 milliliter/hour. A Dietary note dated 3/13/2025 documented a weight warning; significant weight loss, current weight 95. 6 pounds. The resident receives nothing by mouth; Glucerna 1. 5 1000 milliliters, at the rate of 50 milliliters per hour for 20 hours; recommend to change the formula to Glucerna 1. 2, 1500 milliliters at 75 milliliters per hour for 20 hours. During an observation on 3/17/2025 at 9:58 AM, Resident #123 was observed in bed. The Glucerna 1. 5 1000 milliliter bottle bottle of tube feeding formula was hanging from a pole at the bedside. There was no label on the bottle including the resident's name or the feeding start time. Licensed Practical Nurse #1, who was in the resident's room, stated the feeding was started at 4:00 PM the previous day and they had just stopped the feeding because the tube feeding was leaking. Licensed Practical Nurse #1 stated they just noticed that there was no resident label on the bottle and that the nurse who started the feeding was supposed to apply the label. A review of the (MONTH) 2025 Medication Administration Record [REDACTED] 2. During an interview on 3/18/2025 at 11:50 AM, Registered Nurse #2 stated they did not remember to add the tube feeding label including the resident's name and the feeding start time. Registered Nurse #2 stated they knew that the flow rate had changed from 50 milliliters per hour to 75 milliliters per hour; however, they did not know that the feeding solution order had also changed to Glucerna 1. 2. During an interview on 3/19/2025 at 8:08 AM, the Director of Nursing Services, who was also the Infection Preventionist and Nurse Educator, stated the tube feeding bottle should be labeled with the resident's name, flow rate, and the time the feeding was started. The Director of Nursing Services stated the nurses must check the physician's orders [REDACTED]. During an interview on 3/19/2025 at 8:19 AM, Registered Dietician #1 stated Resident #123 was noted with weight loss, and the formula was changed from Glucerna 1. 5 to Glucerna 1. 2 to provide additional calories and protein to Resident #123 for maintaining their weight. 10 NYCRR 415. 12(g)(2) | Plan of Correction: ApprovedApril 14, 2025 I. Immediate Corrective Action The incorrect tube feeding formula (Glucerna 1. 5) on Resident #123 was identified. The correct formula (Glucerna 1. 2) as per the physician's updated order dated 3/13/2025 was initiated. The licensed nurse responsible for the deficient practice was identified and received disciplinary action. The resident's weight, tolerance to feeding, and nutritional intake were reassessed by the interdisciplinary team, including the Registered Dietitian and primary care provider. II. Identification of other residents A comprehensive audit was initiated and completed for all residents receiving enteral nutrition to: Verify that the formula being administered matches the most current physician order. Ensure that all enteral feeding containers are clearly labeled with resident identifiers, prescribed formula, flow rate, and time of administration. No negative findings were identified from this review. III. Systemic Changes The Enteral Nutrition Administration policy was reviewed and revised to reinforce: The requirement that nurses must verify both the formula and flow rate against the physicians most current order before administering or hanging tube feedings. Mandatory labeling of every tube feeding bottle with the residents name, formula, flow rate, and time started. Mandatory in-service training will be conducted on for all licensed nursing staff, focusing on: o Interdisciplinary communication related to order changes (e.g., from dietary to nursing). o Proper verification of tube feeding orders and documentation procedures. o Risks of administering incorrect formulas (e.g., weight loss, aspiration, metabolic imbalance). Nursing shift-to-shift handoff documentation was revised to include a checklist for enteral nutrition administration, including verification of the formula, rate, and labeling compliance. IV. QA Monitoring A Tube Feeding Audit Tool has been developed and will be utilized by the RN Supervisor or Designee as follows: o Weekly audits for four weeks to verify accurate formula administration, proper labeling, and correct documentation. o Thereafter, audits will be conducted monthly for three months or until sustained compliance is achieved. Audit results will be reported to the Director of Nursing Staff found non-compliant will receive immediate re-education and may be subject to progressive disciplinary measures as needed. The Director of Nursing will continue to oversee adherence to the enteral nutrition protocols as part of ongoing performance improvement. Audit findings will be presented to the QAPI Committee during the quarterly meeting for review and determination of whether to continue with the audits. Responsible Party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 8, 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: September 8, 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: September 8, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |