NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident in 1 (Resident #358) of 38 total sampled residents. Specifically, Resident #358's Minimum Data Set assessment did not accurately reflect their discharge status. The findings are: The facility policy titled Minimum Data Set 3.0 with a reviewed date of 10/2024 documented the facility is to ensure accurate and timely completion of Minimum Data Set assessments for all residents. Resident #358 had [DIAGNOSES REDACTED]. The discharge Minimum Data Set assessment dated [DATE] documented Resident #358 was discharged to an acute hospital. A nursing note dated 03/03/2025 documented Resident #358 was discharged home in stable condition and that Resident #358 left the unit accompanied by their family at 10:35 AM. A social services note dated 03/04/2025 documented Resident #358 was discharged home on[DATE]. On 03/31/2025 at 10:46 AM, Registered Nurse #2 was interviewed and stated Resident #358 was a resident on their unit. Registered Nurse #2 also stated Resident #358 was discharged home on[DATE]. On 03/31/2025 at 11:31 AM, the Minimum Data Set Coordinator was interviewed and stated they completed the discharge Minimum (MDS) data set [DATE] for Resident #358. They stated Resident #358 was discharged home and it was an error when they coded Resident #358 as discharged to an acute hospital. 10 NYCRR 415.11(b) | Plan of Correction: ApprovedApril 24, 2025 The facility recognizes the importance of accurate and timely completion of all Minimum Data Set (MDS) assessments, as per regulatory standards and our internal policy titled Minimum Data Set 3.0 (last reviewed 10/2024). Upon review of the discrepancy regarding Resident #358?ÇÖs discharge status, the following corrective and preventive measures have been implemented: 1. Immediate Correction: The MDS for Resident #358 has been corrected on 3/31/2025 to reflect the accurate discharge destination to home on 03/03/2025. 2. Staff Re-education: The MDS Coordinator received immediate re-education regarding proper discharge coding procedures and the importance of cross-referencing interdisciplinary documentation. 3. Ongoing Compliance: As part of our Quality Assurance and Performance Improvement (QAPI) program, the Director of MDS will audit five (5) discharge assessments every 4 weeks for 6 months to ensure accurate coding of discharge location and identify any additional training needs. The facility remains committed to maintaining compliance with all applicable federal and state regulations and ensuring accurate resident assessments to support appropriate care planning and transitions. Please consider this letter as our formal acknowledgment and assurance that corrective actions have been taken to address the cited concern. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/24/2025 to 03/31/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs. This was evident in 2 of 2 residents reviewed out of 35 total sampled residents. Specifically, 1.) Resident #27, who was on palliative care and had been receiving pain medications, had no care plan developed to address pain management and palliative care. 2.) Resident #123, who had a [DIAGNOSES REDACTED]. The findings are : The facility policy titled Comprehensive Care Plan with a revision date of 12/2023 documented it is the policy of the facility that all residents will have a comprehensive care plan completed in accordance with Federal and State requirements. The comprehensive care plan include measurable objectives and timetable to meet the resident's medical, nursing, and psychosocial needs that are identified from the comprehensive assessment, it will be started immediately upon admission and completed within seven days after the completion of the comprehensive assessment. Care plan will be reviewed and revised as needed by a team of qualified persons and minimally after each assessment or reassessment. 1. Resident #27 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #27 had severely impaired cognition, unable to walk, and was completely dependent on staff for dressing, transfer, bed mobility, and was spoon fed by staff during meals. During an observation on 03/25/2025 at 12:05 PM, Resident #27 stated they have pain. The physician's orders [REDACTED].#27 was on Palliative Care, on Tylenol 325 milligram 2 tablets every 6 hours as needed for low back pain and to apply [MEDICATION NAME] 1% gel twice a day and as needed for low back pain. A medical note dated 03/05/2025 documented that Resident #27 was seen for monthly assessment and physical examination, resident was on Tylenol and [MEDICATION NAME] gel for pain to both knee. A palliative care visit note dated 03/31/2025 documented Resident #27 was seen on 03/21/2025 with no complaint of pain or discomfort, consumed lunch with a fair appetite. Will visit the resident again on the next palliative care visit. A review of Resident #27's comprehensive care plans had no documented evidence that care plans for palliative care and pain management was developed. 2. Resident #123 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #123 had intact cognition and required maximal assistance in dressing, eating, transfer, and toileting. A physician's orders [REDACTED]. A review of Resident #123's comprehensive care plans had no documented evidence that a care plan to address Resident #123's [DIAGNOSES REDACTED]. On 03/31/2025, Registered Nurse #4 was interviewed and stated it is the nurse supervisors' responsibility to initiate the care plans on admission. They stated it is the Registered Nurses' responsibility to update the care plans. On 03/28/2025 at 12:30 PM, Registered Nurse #5, who was the nursing supervisor, was interviewed and stated they checked the medical record and found no care plans developed for Resident #27 on pain management and palliative care. Registered Nurse #5 stated Resident #123 had no care plan developed for diabetes. They stated care plans are initiated by the admitting Registered Nurse and that it is every nurse's responsibility to initiate and complete the care plans. 10 NYCRR 415.11(c)(1) | Plan of Correction: ApprovedJune 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F656 I. Immediate Corrective Action: Resident # 27 1) On 3/31/25 the IDT Team developed a CCP for Palliative care and pain management. 2) On 4/2/2025 the resident was reassessed by Nurse Practitioner and the total plan of care including pain management and palliative care was reviewed 3) On 4/17/2025 the SW and RNS met with the resident?ÇÖs family to review the current plan of care for pain management and palliative care and the resident?ÇÖs family verbalized satisfaction with the plan. 4) On 4/1/2025 the DON provided the SW responsible for initiating the palliative care CCP with education and counseling. Resident # 123 1) On 3/28/2025 the IDT Team developed a CCP for Diabetes. 2) On 3/28/25 the resident was reassessed by Nurse Practitioner and the total plan of care including diabetic management was reviewed. 3) On 3/31/2025 the DON issued an educational counseling to the Admitting RN for not initiating the diabetic management CCP. II. Identification of Others: 1) The facility respectfully states that all residents could potentially be affected. 2) A report will be generated from the EMR- Sigma care to determine which residents have orders for Palliative care. This list will be utilized by the SW in conjunction with the RNS to ensure all residents with palliative care have an individualized care plan. Any issues will be immediately corrected. 3) A report will be generated from the EMR-Sigma care to determine which residents have pain management medication orders. This list will be utilized by the RNS to ensure all residents have an individualized pain management care plan. Any issues will be immediately corrected 4) A report will be generated from the EMR-Sigma care for all residents with diabetes. This list will be utilized by the RNS to ensure all residents with diabetes have an individualized care plan. Any issues will be immediately corrected. III. Systemic Changes: 1) The DNS and members of the IDT reviewed the P/P on Comprehensive Care Planning and found same to be compliant. 2) All RNs, MDS Coordinators, and IDT Team members will be inserviced by the In-service Coordinator. Highlights of the lesson plan include: ?Çó The responsibility to develop and implement a care plan that describes all of the following with emphasis on palliative care, pain management and diabetes; a. Resident goals and desired outcomes; b. The care/services that will be furnished so that the resident can attain or maintain his/her highest practicable physical, mental, and psychosocial well-being; c. Resident's medical, nursing, physical, mental, and psychosocial needs, and preferences, and how the facility will assist in meeting these needs and preferences. ?Çó The specific CCP?ÇÖs that each member of the IDT is responsible for initiating. ?Çó The responsibility of all members of the IDT to initiate or update CCP?ÇÖs for changes in the residents?ÇÖ care plan that are addressed at the morning QA Meeting. ?Çó The responsibility of the IDT to review each resident?ÇÖs physician orders [REDACTED]. IV. Quality Assurance: 1) The DON developed an audit tool to ensure that all care plans are developed, implemented, and reviewed, including goals and interventions after each care plan meeting. 2) The DON/Designee will review 8 randomly selected residents weekly x 4weeks followed by 8 residents each month including new admission x 6 months. 3) Any findings regarding CCP implementation will be reviewed at the monthly QA meeting for follow-up. 4) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
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 from 03/24/2025 to 03/31/2025, the facility did not ensure that the medication error rate was not less than 5 percent. This was evident for 2 of 28 medications given during the Medication Administration task. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication [MEDICATION NAME] 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record [REDACTED]#318 to Resident #320 instead of [MEDICATION NAME] Silver 0.4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician which resulted in a medication error rate of 7.14%. The findings are: The facility policy titled Medication Administration, dated 01/2019 documented the following that it is the policy of the facility to ensure that nurses administer medications correctly and on a timely manner. The policy also documented that medication administered shall be charted immediately after administration. The policy further documented that the medication supplied for one resident shall not be administered to another resident. Borrowing one resident's medication for another resident is not permitted. Resident #320 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #320 had intact cognition and required supervision when performing Activities of Daily Living. The Physician order [REDACTED]. On 03/26/2025 at 10:05 AM, during the Medication Administration task, Licensed Practical Nurse #3 administered [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by mouth and [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600mcg-300 mcg 1 tablet by mouth to Resident #320. The Medication Administration Record [REDACTED]. Review of the Physician orders [REDACTED].#320 was prescribed [MEDICATION NAME] Silver 0.4 mg-300 mcg 250 mcg tablet,1 tablet by oral route once daily at 10:00 AM but received [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600-mcg-300 mcg 1 tablet by mouth instead. This resulted in an error rate of 7.14%. On 03/26/2025 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they signed for [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by oral route for Resident #320 when they started work this morning around 7:00 AM but they did not administer it at that time. Licensed Practical Nurse #3 also stated that they sometimes sign off medications early and hope to administer them later as many residents receive their medication at 10:00 AM and prefer to receive them all at the same time. Licensed Practical Nurse #3 further stated that they wanted to give Resident #320 all their medications together. During a follow-up interview on 03/26/2025 at 10:30 AM, Licensed Practical Nurse #3 stated that, during the Medication Administration, they did not see [MEDICATION NAME] Silver 0.4 mg-300 mcg-250 mcg dispensed for Resident #320, so they went to look for it among the extra medications located at the bottom of the medication cart. Licensed Practical Nurse #3 also stated that they just selected another [MEDICATION NAME] medication, but they did not realize that the [MEDICATION NAME] blister pack they picked belonged to another resident (Resident #318). On 03/31/25 10:10 AM, an interview was conducted with Registered Nurse #5, a unit supervisor who stated that all medication nurses are taught the five rights of medication administration. Registered Nurse #5 also stated that the [MEDICATION NAME] for Resident #320 was in the medication cabinet but is listed under another name which Licensed Practical Nurse #3 was not familiar with. Registered Nurse #5 further stated that signing for a medication that had not yet been administered to the resident is not acceptable practice On 03/31/25 at 11:00 AM, an interview was conducted with the Medical Director who stated that the [MEDICATION NAME] could be administered at any time during the morning. The Medical Director also stated that they believed the [MEDICATION NAME] being entered for administration at 8:00 AM was an error because the medication would not have any interaction with other medications if administered at 10:00 AM. The Medical Director concluded that the nursing staff should not sign off medication they have not administered. On 03/31/25 at 11:30 AM, a further interview was conducted with the Medical Director who stated that the facility has a standard [MEDICATION NAME] preparation that they use for residents. The Medical Director also stated that sometimes residents come from the hospital with a different order, or their respective provider required a different dosage of [MEDICATION NAME], so an individual order would be written, and the pharmacy would supply them individually because of the different strengths. On 03/31/25 at 12:00 PM, an interview was conducted with the Director of Nursing who stated that all nursing staff were in-serviced annually and as needed for medication administration competency. The Director of Nursing stated that the Licensed Practical Nurse #3 had received medication administration competency training, and there were no concerns with their performance at that time. 10 NYCRR 415.12(m)(1) | Plan of Correction: ApprovedJune 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F759 I. Immediate Corrective Action: 1) On 3/26/25 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 3/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN #3. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The DON conducted a meeting with the Medical Director and Pharmacy consultant to review any medication errors in the past 3 months to assess Facility medication error rate. No medication errors were reported. III. Systemic Changes: The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be inserviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: ?Çó Standard for safe medication practices: The Rights of Medication Administration that include: ?Çó Right patient, ?Çó Right drug, ?Çó Right dose, ?Çó Right route, ?Çó Right time, ?Çó Right reason, ?Çó Right Monitoring (including vital signs and observation for side effects), ?Çó Right documentation, ?Çó Right patient education, ?Çó Right evaluation and ?Çó Right to refuse. ?Çó Types of Medication Errors ?Çó Medication Documentation and communication. IV. Quality Assurance 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator /Designee 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 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 and Abbreviated Survey (NY 691) conducted from 03/24/2025 to 03/31/2025, the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made to the New York State Department of Health. This was evident in 1 (Resident #230) of 3 residents reviewed for Abuse. Specifically, Resident #230 had an unwitnessed incident on 05/17/2024 at approximately 4:00 AM, when the resident was observed sitting on the floor gym mat on the left side of their bed. Hospital x-ray report showed right pelvic fracture. Resident #230 was unable to explain the occurrence. This incident was not reported to the New York State Department of Health. The findings are: The facility policy titled Abuse Prevention with a revised date of 09/26/2024 documented the facility will report any incident and/or violation where abuse, neglect, or mistreatment is suspected to the New York State Department of Health according to all federal and state regulations. Resident #230 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #230 had severe cognitive impairment. A nurse progress note dated 05/17/2024 at 12:59 PM by Registered Nurse #1 documented late entry note, on 05/17/2024 at 4:00 AM, Registered Nurse #1 was called by the charge nurse to assess Resident #230 who was sitting on a gym mat next to their bed. Body check revealed no injuries were noted. A nurse progress note dated 05/17/2024 at 10:33 AM documented Resident #230 complained of pain to the right hip. The resident was noted with mild swelling and bluish discoloration on the right hip. The physician was notified and ordered hospital transfer. Resident #230 left the facility at 8:45 AM. The Nurse's Investigation Statement form dated 05/17/2024 completed by Licensed Practical Nurse #2 documented on 05/17/2024 at 4:00 AM, Resident #230 was observed in their room, sitting in a gym mat on the left side of their bed. The form documented Resident #230 had dementia, confused, and forgetful. There was no documented resident statement of occurrence. A review of the employee written statements revealed no one had witnessed the incident. During an interview with Certified Nurse Aide #3 on 03/27/2025 at 10:04 AM, they stated they were on duty on 05/17/2024 from 11:00 PM to 7:00 AM. They stated they found Resident #230 sitting on the floor gym mat, and they called for help and the nurse came. During an interview on 03/27/2025 at 9:46 AM, Registered Nurse #1, who was the Nursing Supervisor, stated they were on duty on 05/17/2025 from 11:00 AM to 7:30 AM. They stated they cannot recall when they received a call in the early morning about Resident #230 being found on the floor sitting on the gym mat. Registered Nurse #1 stated they assessed Resident #230, and the resident seemed alright. Registered Nurse #1 stated they did not consider the incident as a fall because Resident #230 was sitting on the gym mat. During an interview on 03/28/2025 at 7:55 AM, the Director of Nursing stated this incident was not reported to the New York State Department of Health because Resident #230 was observed on the gym mat and that was the basis of Resident #230's injury. They stated there was no unknown factor and that they concluded in their investigation that abuse was not determined. The Director of Nursing stated , because the fall was unwitnessed, the incident should have been reported to the New York State Department of Health. 10 NYCRR 415.4(b)(2) | Plan of Correction: ApprovedApril 25, 2025 P(NAME): F609 I. Immediate Corrective Actions: Resident # 230 1) On readmission 05/21/2024 the resident was reassessed by the physician and total plan of care was reviewed. 2) On 6/11/24 the IDT Team reviewed and revised the resident plan of care including Falls risk and interventions, family agreeable with plan of care. 3) The RNS reviewed and updated the CNAAR to include any new interventions. II. Identification of Others: 1) The facility states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days were reviewed to ensure that any incidents involving injuries of unknown origin, alleged, or actual abuse were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the Director of Nursing (DON) and Medical Director and is in compliance. 2) Inservice education will be provided by the Inservice Coordinator for all Direct Care staff including Licensed nurses, CNAs, Social Workers, and IDT Team members on the reporting requirements related to reporting violations involving injuries of unknown origin and actual or alleged abuse to the NYSDOH. 3) Highlights of the Lesson Plan include: ?Çó The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/ DON. ?Çó Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH ?Çó As per CMS 42CRF 483.12(c) the reporting definition ?Ç£immediately is defined as: 1. 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours if the alleged violation does not involve abuse and does not result in serious injury. ?Çó As per Federal regulation 483.12(b)(5) all reasonable suspicions of crimes and/or suspicious Incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. ?Çó Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. ?Çó The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/ designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facility?ÇÖs compliance with ensuring that all incidents and accidents are investigated, and any injuries of unknown origin or abuse are reported timely as per NYS DOH and Federal reporting guidelines. 2) All Accident and Incidents will be audited by DON weekly x 6 months. Any identified issues will be immediately addressed and shared at morning report 3) Findings will be reviewed at Monthly QA Meeting to monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 03/24/2025 to 03/31/2025, the facility did not ensure that services provided meet professional standards of quality. This was evident for 1 (Resident #320) of 3 residents observed during Medication Administration. Specifically, 1) Licensed Practical Nurse #3 was observed administering the medication [MEDICATION NAME] 50 mg-500 mg 1 tablet by mouth at 10:05 AM, however, review of the Medication Administration Record [REDACTED]#318 to Resident #320 instead of [MEDICATION NAME] Silver 0.4 mg-300 mcg 250 mcg 1 tablet by mouth as ordered by the physician. The findings are: Resident #320 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #320 had intact cognition and required supervision when performing Activities of Daily Living. The Physician order [REDACTED]. On 03/26/2025 at 10:05 AM, during the Medication Administration task, Licensed Practical Nurse #3 administered [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by mouth and [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600mcg-300 mcg 1 tablet by mouth to Resident #320. The Medication Administration Record [REDACTED]. Review of the Physician orders [REDACTED].#320 was prescribed [MEDICATION NAME] Silver 0.4 mg-300 mcg 250 mcg tablet,1 tablet by oral route once daily at 10:00 AM but received [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600-mcg-300 mcg 1 tablet by mouth instead. On 03/26/2025 at 10:15 AM, an interview was conducted with Licensed Practical Nurse #3 who stated that they signed for [MEDICATION NAME] 50 mg-500 mg tablet 1 tablet by oral route for Resident #320 when they started work this morning around 7:00 AM but they did not administer it at that time. Licensed Practical Nurse #3 also stated that they sometimes sign off medications early and hope to administer them later as many residents receive their medication at 10:00 AM and prefer to receive them all at the same time. Licensed Practical Nurse #3 further stated that they wanted to give Resident #320 all their medications together. During a follow-up interview on 03/26/2025 at 10:30 AM, Licensed Practical Nurse #3 stated that, during the Medication Administration, they did not see the medication [MEDICATION NAME] Silver 0.4 mg-300 mcg-250 mcg dispensed for Resident #320, so they went to look for it among the extra medications located at the bottom of the medication cart. Licensed Practical Nurse #3 also stated that they just selected another [MEDICATION NAME] medication, but they did not realize that the [MEDICATION NAME] blister pack they picked belonged to another resident (Resident #318). On 03/31/25 10:10 AM, an interview was conducted with Registered Nurse #5, a unit supervisor who stated that all medication nurses are taught the five rights of medication administration. Registered Nurse #5 also stated that the [MEDICATION NAME] for Resident #320 was in the medication cabinet but is listed under another name which Licensed Practical Nurse #3 was not familiar with. Registered Nurse #5 further stated that signing for a medication that had not yet been administered to the resident is not acceptable practice On 03/31/25 at 11:00 AM, an interview was conducted with the Medical Director who stated that the [MEDICATION NAME] could be administered at any time during the morning. The Medical Director also stated that they believed the [MEDICATION NAME] being entered for administration at 8:00 AM was an error because the medication would not have any interaction with other medications if administered at 10:00 AM. The Medical Director concluded that the nursing staff should not sign off medication they have not administered. On 03/31/25 at 11:30 AM, a further interview was conducted with the Medical Director who stated that the facility has a standard [MEDICATION NAME] preparation that they use for residents. The Medical Director also stated that sometimes residents come from the hospital with a different order, or their respective provider required a different dosage of [MEDICATION NAME], so an individual order would be written, and the pharmacy would supply them individually because of the different strengths. On 03/31/25 at 12:00 PM, an interview was conducted with the Director of Nursing who stated that all nursing staff were in-serviced annually and as needed for medication administration competency. The Director of Nursing stated that the Licensed Practical Nurse #3 had received medication administration competency training, and there were no concerns with their performance at that time. 10 NYCRR 415.11(c)(3)(i) | Plan of Correction: ApprovedJune 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F658 I. Immediate Corrective Action: 1) On 3/26/2025 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 03/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN #3. II. Identification of Others: 1) The DON obtained a printout from the EMR for all residents scheduled to receive medications prior to the daily standard 10 am medication time. This list will be utilized by Unit RNS?ÇÖ and DON to conduct unit rounds to determine if residents are receiving medication timely and accurately. Any issues will be immediately corrected 2) The DON obtained a list of all residents receiving [MEDICATION NAME]. This list will be utilized by the DON and Medical Director to ensure appropriately prescribed [MEDICATION NAME] vitamin doses are ordered and received. Any issues will be immediately corrected. III. Systemic Changes: 1) The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be in serviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: ?Çó Standard for safe medication practices: The Rights of Medication Administration that include: ?Çó Right patient, ?Çó Right drug, ?Çó Right dose, ?Çó Right route, ?Çó Right time, ?Çó Right reason, ?Çó Right Monitoring (including vital signs and observation for side effects), ?Çó Right documentation, ?Çó Right patient education, ?Çó Right evaluation and ?Çó Right to refuse. Types of Medication Errors Medication Documentation and communication. IV. Quality Assurance: 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator /Designee 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101:9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70:400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart mounted, provided that all of the following conditions are met: (1) The receptacles are permanently attached to the equipment assembly. (2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. (3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. (4)*The electrical and mechanical integrity of the assembly is regularly verified and documented. (5)*Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. 10.2.4 Adapters and Extension Cords. 10.2.4.1 Three-prong to two-prong adapters shall not be permitted. 10.2.4.2 Adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. 10.2.4.2.1 All adapters shall be listed for the purpose. 10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose. 10.2.4.2.3 The cabling shall comply with 10.2.3. 10.3 Testing Requirements - Fixed and Portable. 10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. Based on observation and staff interviews, during the Life Safety Recertification survey on (MONTH) 26, 2025, through (MONTH) 27, 2025, the facility did not ensure that extension cords and power strips were used in accordance with NFPA 70. Specifically, power strips and an extension cord were observed in use. The findings include, but are not limited to: On a tour of the 1st Floor revealed 1) Two unmounted power strips were in use in each the Computer Room and the Office of the Director of Nursing, 2) The Admitting office had an extension cord powering computer equipment. 3) In the Owner's Office, it was observed that the two power strips were daisy-chained and powering computer equipment. At the time of the findings, the Director of Maintenance stated that the extension cord would be removed, and the power strips would be mounted or removed. The Director of Maintenance further stated that an audit of the facility would be done, and staff would be in-serviced. 2012 NFPA 101: 9.1.2 2011 NFPA 70: 400.8 10 NYCRR 711.2(a) | Plan of Correction: ApprovedApril 26, 2025 I. Immediate Corrections: 1) On 04/25/2025 the facility engineering staff mounted and secured the two outlet strips installed for the following areas: The Director of Nursing office. The computer room. 2) The admitting office extension was removed, and additional outlets were installed. 3) The Daisy chained relocatable power taps were removed from the owner?ÇÖs office. II. Identification of Other Residents: 1. The facility electrician will review all other areas for non-compliant electrical connections and corrective measures will be taken immediately. III. Systemic Changes 1) The facility has reviewed and revised the policies for use of extension cords and Relocatable power strips to comply with guidance set forth in NFPA 99. 2) All staff will be inserviced on the use and care of extension cords and relocatable power strips. 3) A copy of the lesson plan and attendance will be filed for reference and validation. 4) The facility has developed a criterion to maintain a log for the use of relocatable power strips and extension cords to ensure timely removal and proper utilization. 5) All engineering staff and EVS staff will be educated on how to maintain the log and the requirements for compliance with the use of extension cords and power taps IV. QA Monitoring 1) The Director of Engineering has developed an audit tool to track the use of extension cords in the building for safety and compliance. 2) Audits will be done by engineering weekly x1 month then monthly thereafter to ensure safety and compliance 3) Audits with negative findings will have onsite corrective actions by the auditor and review with the Administrator for awareness 4) Audit findings will be presented to the QA Committee quarterly for evaluation and continuance as needed V. Responsible Person: Director of Engineering/designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99: 6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. 2011 NFPA 70:700.10 Wiring, Emergency System. (A) Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as components of an emergency circuit or system. (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy. Based on observation and staff interviews, the facility did not ensure that all electrical panels were provided with identification in accordance with 2012 NFPA 101. The findings include, but are not limited to: During the life safety code recertification survey on (MONTH) 26, 2025, through (MONTH) 27, 2025, between 9:00 am and 3:00 pm, 1) on a tour of the 11th Floor, in the Electric Room, it was observed that three of four electrical panels were missing identification. 2) A tour of the 9th Floor revealed the Electric Room had 3 panels without identification. 3) A tour of the Loading Dock Area revealed a junction box with an outlet powering the bug zapper, was missing the protective cover. At the time of these findings, the Director of Maintenance stated that the panels would be identified, and the junction box would be covered. 2012 NFPA 99 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedApril 27, 2025 I. Immediate Corrective Action: The following areas as identified were corrected by our facility engineering staff: 1) On 04/25/2025, the 11th Floor, in the Electric Room, three of four electrical panels had missing identification, labels applied. 2) On 04/25/2025, the 9th Floor Electric Room had 3 missing identifications, labels applied. 3) On 04/21/2025, the Loading Dock Area junction box with an outlet powering the bug zapper, the missing protective cover was installed II. Identification of Other Areas: 1) The Facility respectfully states that no residents were involved in this deficient practice 2) The Facility electrician and Director of Engineering will conduct an environment review of all other areas to ensure labeling was installed in accordance with NFPA 70. 3) Any panel found to be missing identification or any exposed junction boxes will be immediately corrected. 4) Audit findings will be documented in the facility?ÇÖs maintenance records. III. Systemic Changes: 1) All engineering staff will receive in-service training on NFPA 70 panel labeling and electrical safety standards. IV. Quality Assurance: 1) The Director of Engineering/designee will conduct monthly audits of lighting and electrical enclosure to ensure compliance with NFPA 70 2) Audits identified with quality issues, the engineering department with contact the facility Electrician for corrective actions as needed 3) These inspections will be reported quarterly to QA committee for oversight and continuous improvement. V. Responsible Person: Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99: 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA 99: 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Based on observation and staff interviews, the facility did not ensure that Oxygen cylinders were stored in accordance with NFPA 99. Specifically, oxygen cylinders were observed to be co-mingled. The findings are: On (MONTH) 26, 2025, at 4:30 PM, during the Life Safety recertification survey, a tour of the Loading Dock area was conducted, and the Oxygen storage room was noted to have oxygen tanks that were co-mingled. There were three empty e-size tanks in the same rack as full tanks. There were no signs in the Oxygen Storage Room indicating where to place the empty and full cylinders. In an interview at the time of the finding, the Director of Maintenance stated that signs would be posted. 2012 NFPA 99: 11.3.2*, 11.3.2.1, 11.6.2.3, 11.6.5.2, 11.6.5.3, 11.6.5.4 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedApril 26, 2025 I. Immediate Corrective actions taken: 1. The sign designating storage of empty and full oxygen tanks to proper areas was immediately securely reinstalled. 2. The empty tanks were relocated to the appropriate location. II. Identify other residents The facility conducted a review of all areas where oxygen is stored and determined no other areas out of compliance. Residents were at minimal risk due to this deficiency III. Systemic changes 1) The facility reviewed and updated the oxygen storage and use policy and procedure to comply with the requirements set forth in NFPA 99. All staff will be in-serviced on the requirements set forth in NFPA 99 for the storage and use of oxygen and the updates to the facility policy and procedure. 2) The Director of Security has added the inspection of oxygen storage area to the daily log. 3) Any items found out of compliance shall be corrected at the time of discovery. IV. Q/A Monitoring 1) The Director of Security will conduct weekly QAPI audits over X 3 months to determine if compliance is ongoing and report to administration for future facility improvement. 2) Audits of negative findings will have immediate corrective actions implemented. 3) Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow-up. V. Responsible Person: Director of Engineering/Director of Security |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NYCRR Title 10 - 415.29: Physical environment. The nursing home shall be designed, constructed, equipped, and maintained to provide a safe, healthy, functional, sanitary, and comfortable environment for residents, personnel and the public. Based on observation and staff interviews during the recertification survey, the facility did not maintain a functional and comfortable environment for residents. Reference is made to the free-standing closets in resident rooms. The findings include, but are not limited to: During the Life Safety Recertification Survey on (MONTH) 26, 2025, and (MONTH) 27, 2025, it was noted that freestanding closets in resident rooms [ROOM NUMBERS] were not secured to the wall and risk tipping over. In an interview on 3/26/2025 at 2:15 pm, the Director of Maintenance stated that some closets had just arrived in the days before the survey, and some closets had been moved to clean, staff were still working on them. The Director of Maintenance further stated that all freestanding closets would be checked to ensure they are all connected. NYCRR Title 10 - 415.29 | Plan of Correction: ApprovedApril 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I310 I. Immediate Corrective Action 1) On 4/21/25, freestanding closets in resident rooms [ROOM NUMBERS] were secured to the wall to reduce the risk of tipping over. II. Identification of Other Residents: 1) The facility has reviewed all other closets to ensure that they were securely fastened. No other resident was noted to be involved. III. Systemic Changes: 1) The facility reviewed the policy on replacement of room furnishings and found no required changes. 2) All engineering and EVS staff responsible for replacing furniture were inserviced on the policy. 3) Before furniture is replaced staff will be reviewed on the policy. IV.Q/A Monitoring 1) The Director of Environmental Services will conduct 10 randomly selected resident rooms per month for QAPI audits over the next quarter to determine if compliance is ongoing and report to administration for future facility improvement. 2) Audits of negative findings will have immediate corrective actions implemented. 3) Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow-up. V. Responsible Person: Director of Maintenance/Director of Environmental services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101:9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 2010 NFPA 13: 8.3.1.3* Upright sprinklers shall be installed with the frame arms parallel to the branch line, unless specifically listed for other orientation. 8.9.4.2.1 Deflectors of sprinklers shall be aligned parallel to ceilings or roofs. 8.9.4.2.2 Sidewall sprinklers, where installed under a sloped ceiling with a slope exceeding 2 in 12, shall be located at the high point of the slope and positioned to discharge downward along the slope. Based on observation and staff interviews, the facility did not ensure that all components of the building's extinguishing system were installed in accordance with NFPA 101. Specifically, a sidewall sprinkler was not installed with the deflector parallel to the ceiling. The findings include but are not limited to: During the Life Safety Code Recertification survey on (MONTH) 26, 2025, and (MONTH) 27, 2025, 1) in the A/C No. 10 room, a sidewall sprinkler was installed facing downwards, parallel to the wall. 2) On the 1st Floor corridor by the Conference Room was a concealed sprinkler that was missing its cap. 3) In the Loading Dock area, there was no sprinkler coverage from the door to the 5 steps. 4) In the small conference room, on the 1st Floor, it was observed that a sprinkler head was with missing an escutcheon and a 2 ft by 2 ft ceiling tile. Missing escutcheons and broken ceiling tiles were observed throughout the facility. 2012 NFPA 101 2011 NFPA 13 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedApril 26, 2025 I. Immediate Corrective Action 1) The Director of Engineering contacted the fire sprinkler company upon discovery to correct the following: a) Reinstall in the correct position a sidewall sprinkler in the A/C No. 10 room b) On 04/25/2025 the 1st Floor corridor by the Conference Room, a concealed sprinkler that had the missing cap was replaced c) fire sprinkler company contacted to install the loading dock area sprinkler coverage from the door to the 5 steps d) On 4/25/2025, in the small conference room, on the 1st Floor, the observed sprinkler head that was missing an escutcheon and ceiling tile was installed. 2) The facility engineer in conjunction with the sprinkler company reviewed all sprinklers for proper escutcheon plates and replaced any that were found to be missing. 3) The facility engineer replaced all damaged ceiling tiles to ensure proper fitting. II. Identification of Other Residents 1) The facility respectfully states that no residents were involved in this deficiency, however all residents were indirectly affected. 2) The Director of Engineering reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1) The Administrator, in conjunction with the Director of Engineering, reviewed and revised the facility sprinkler inspection policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies. 2) Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. 3) All Maintenance staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as an overview of requirements for sprinkler coverage as per K351. 4) The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required with all associated hardware. 5) A copy of the attendance will be maintained for reference and validation. IV. QA Monitoring 1) The Administrator, in conjunction with the Director of Maintenance, will conduct monthly reviews and inspections of sprinkler reports for the next 3 months, then upon completion of work thereafter. Documentation will be maintained in a logbook for reference and validation. 2) The Director of Maintenance will review the findings and report to the QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Responsible Person: Director of Engineering/Administrator/designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25 5.2* Inspection. 5.2.1 Sprinklers. 5.2.1.1* Sprinklers shall be inspected from the floor level annually. 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (6) Painting unless painted by the sprinkler manufacturer. 2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25 5.2* Inspection. .2011 NFPA 25: Table 6.1.1.2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 Based on observation, document review, and staff interviews, the facility did not ensure that all components of the building's extinguishing system were tested and maintained in accordance with NFPA 101. Specifically, the fire hoses were not maintained. The findings are: During the life safety code recertification survey on (MONTH) 26, 2025, and (MONTH) 27, 2025, between 9:00 am and 3:00 pm, it was noted that the fire hoses installed in Stairwells A and B on the 1st Floor and throughout the facility were stamped with a date of 9/2017. There was no documentation of the hoses having been tested or replaced within the five years before the survey. At the time of the findings, the Director of Maintenance stated that the fire hoses would be tested or replaced. 2012 NFPA 101 2011 NFPA 25 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedApril 27, 2025 I. Immediate Corrective Action 1) The Director of Engineering engaged our Service Company to replace the identified standpipe fire hoses with new hoses in all locations more than five years old. 2) The Director of Engineering engaged our Service Company to inspect the building?ÇÖs standpipe system to determine those testing years and complete NFPA required testing if necessary. II. Identification of other areas potentially affected. 1) All Residents have the potential to be affected by this practice. 2) The Director of Engineering will have the Service company inspect facility-wide standpipe and fire hose systems for similar issues. III. Systemic Changes 1) The policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2) The existing rounds inspection form has added the monthly standpipe audit tool. 3) This has been added to the facility preventive Engineering program. 4) Staff involved in the review, Engineering and/or repair of the sprinkler system were educated by the Director of Engineering that any issues with standpipe system identified during rounds will be corrected immediately and interim safety measures put in place as needed until repairs are complete. IV. Quality Assurance Monitoring 1) The Director of Engineering created an audit tool to monitor compliance with required inspections of sprinkler systems.-This audit includes inspection of fire hose racks. Any identified issues will be corrected as soon as possible. 2) The Director of Engineering will audit the whole facility monthly for the first 3 months and then quarterly for 9 months. Audit results will be submitted to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. 3) The frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. - V. Responsible Person: Director of Engineering |