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NYS Health Profiles
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Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the assessment accurately reflected each resident's status. This was evident in 4 (Residents #1, #36, #42, and #54) of 20 total sampled residents. Specifically, 1. ) Resident #1, #36, and #42's [MEDICAL CONDITION] medication use was inaccurately documented in the Minimum Data Set assessment, and 2. ) Resident #54's assessment inaccurately documented that the Resident had [DIAGNOSES REDACTED]. The findings are: The facility policy Minimum Data Set Functional Coding with a revision date of 02/11/2024 documented that the policy ensures that all Minimum Data Set assessments are completed accurately, on time, and in compliance with the Centers for Medicare and Medicaid Services guidelines. Coding will be based on direct observation, medical records documentation, staff interviews, and resident input. 1. Resident #1 was admitted with diagnoses of [MEDICAL CONDITION], Hypertension, and Opioid Dependence. A physician's orders [REDACTED]. The Minimum Data Set assessment dated [DATE] and 10/19/2024 documented that Resident #1 received antibiotics. A review of Resident #1's physician orders [REDACTED].#1 received antibiotics. 2. Resident #36 was admitted with diagnoses of Calculus of Gall Bladder, [MEDICAL CONDITION], and Chronic [MEDICAL CONDITIONS]. A physician's orders [REDACTED]. The Minimum Data Set assessment dated [DATE] and 11/13/2024 documented that Resident #36 received antibiotics. A review of Resident #36's physician's orders [REDACTED].#36 received antibiotics. 3. Resident #42 had diagnoses of [MEDICAL CONDITION] disorder, Unspecified Dementia, and [MEDICAL CONDITION]. A physician's orders [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] and 11/16/2024 documented that Resident #42 received antibiotics. A review of Resident #42's physician's orders [REDACTED].#42 received antibiotics. On 12/04/2024 at 11:29 AM, Registered Nurse #1, who was the Nurse Unit Manager, was interviewed and stated that [MEDICAL CONDITION] medications are considered antibiotics. Registered Nurse #1 stated their electronic medical record system classifies [MEDICAL CONDITION] as antibiotics. On 12/04/2024 at 9:51 AM, the Minimum Data Set Coordinator was interviewed and stated that it is the Nurse Manager's responsibility to complete the medication section of the Minimum Data Set assessment. The Coordinator stated that [MEDICAL CONDITION] were coded as antibiotics. The Minimum Data Set Coordinator stated that anti-[MEDICAL CONDITION] medications are automatically triggered as antibiotics in the electronic medical record system. On 12/05/2024 at 11:08 AM, during a subsequent interview with The Minimum Data Set Coordinator, they stated that the Resident Assessment Instrument manual does not classify [MEDICAL CONDITION] as antibiotics, it was the electronic medical record system that triggers the [MEDICAL CONDITION] as antibiotics. On 12/09/2024 at 11:04 AM, the Director of Nursing was interviewed and stated that [MEDICAL CONDITION] medicates fall under antibiotics in the Centers for Medicare and Medicaid Services guidelines. On 12/09/2024 at 11:59 AM, the Administrator was interviewed and stated that the Minimum Data Set Coordinator is responsible for the accuracy of each resident's Minimum Data Set assessments. 4. Resident #54 was admitted with diagnoses of [MEDICAL CONDITION] Disorder and Diabetes Mellitus. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #54 has Non-Alzheimer's Dementia. A review of Resident #54's diagnoses sheet and physician assessments had no documentation that Resident #54 had Non-Alzheimer's Dementia. On 12/06/2024 at 10:44 AM, Registered Nurse #1, who was the Nurse Unit Manager, was interviewed and stated that Non-Alzheimer's Dementia was checked off in the Minimum Data Set assessment because Resident #54 has mild cognitive impairment. On 12/06/2024 at 9:47 AM, Physician Assistant #1 was interviewed and stated that Resident #54 although cognitively impaired, is alert and oriented to person, time, and place. Physician Assistant #1 stated Resident #54 has no [DIAGNOSES REDACTED]. On 12/09/2024 at 11:04 AM, the Director of Nursing was interviewed and stated that they did not see in the medical records that Resident #54 had [DIAGNOSES REDACTED]. On 12/09/2024 at 11:59 AM, the Administrator was interviewed and stated that the Minimum Data Set Coordinator is responsible for the accuracy of each resident's Minimum Data Set assessments. 10 NYCRR 415. 11 (b) | Plan of Correction: ApprovedJanuary 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -The MDS coordinator on 12/06/2024 corrected immediately the deficiencies identified to accurately reflect the residents clinical diagnoses. The antibiotic checkbox was unticked for Resident #1, Resident #36 and Resident #42, and the corrected MDS was re-submitted to CMS. The MDS for the affected resident #54 was also immediately reviewed, corrected to remove the non-Alzheimers dementia diagnosis, and re- submitted to CMS. The error did not affect the residents quality of care at the facility. -The DON on 12/06/2024 held an IDT team huddle with the facilitys physician, physician assistant #1, unit RN managers and individually informed the affect residents of the coding error and the corrective actions taken. -The IDT team from 12/06/2024 to 12/11/2024 performed due diligence in assuring that no care plan changes or interventions were affected by the incorrect coding, and no adverse impact occurred. No additional residents were inaccurately documented during the prior MDS submissions from 08/2024 to 11/ 2024. -The Compliance team on 12/12/2024 reviewed the facilitys Minimum Data Set Functional Coding Policy. No amendments were needed. Identification of Others Potentially Affected: -facility respectfully submits all residents were potentially affected by this practice, after reviewing MDS records. System Changes to Prevent Recurrence: -The MDS coordinator was re-in-serviced on proper Section N (Medications) coding procedures, emphasizing accuracy and review processes. Training included the importance of cross-referencing the MAR indicated [REDACTED] facilitated by the compliance officer. In addition, training was also provided for proper coding for Section I (Active Diagnoses), including verifying [DIAGNOSES REDACTED]. residents medical record before coding. -Subsequent to a root cause analysis, the Administrator contacted the MDS software vendor on 12/10/2024 to address the automated logic or interface issues causing incorrect antibiotic selection. Thus, implementing software updates or adjustments to prevent related errors. -The DON on 12/10/2024 instituted a secondary review process for all MDS submissions: A designated staff member (Senior RN Manager or ADON) will verify accuracy before all submission. Quality Assurance Monitoring: -The DON will Conduct weekly audits of 10% of MDS submissions for the next 90 days to ensure accuracy in functional coding, with special focus on Section I and Section N. Findings will be reviewed during monthly QA meetings, and adjustments to processes will be made as necessary. -The Performance Metrics is set at a goal of 100% compliance with accurate MDS coding. Any errors identified during audits will be addressed immediately. -Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Complaint (NY 130, NY 122) Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that each resident's comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect a change in resident's status. This was evident in 4 (Residents #42, #51, #50, #61) of 20 total sampled residents. Specifically, the comprehensive care plans for Residents #42, #51, #50, and #61 were not reviewed and revised following their involvement in a resident to resident altercation. The findings are: The facility titled Comprehensive Care Plan with a reviewed date of 09/2023 documented that the care plan is reviewed monthly and revised after each assessment, at least quarterly, annually, and as changes in the resident's condition dictates. The facility Investigation Summary dated 09/27/2024 documented that on 09/21/2024 at 6:30 PM, Resident #51 approached Resident #42 and accused them of sending texts with a threatening message. Staff intervened and directed Resident #51 to their room. The facility concluded that the allegations were verified. The text messages sent by Resident #42 were transphobic and referenced physical harm to Resident # 51. Resident #42 was remorseful and apologetic for actions taken in anger. Mediation with both residents was made by the Director of Social Services. 1. Resident #42 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #42 had intact cognition. A nurse's progress note dated 09/21/2024 at 9:53 PM documented that around 6:45 PM, Resident #42 was going up and down, screaming, cursing, calling names, was very agitated, and had a verbal altercation with another resident. There was no documented evidence that Resident #42's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident verbal altercation on 09/21/ 2024. 2. Resident #51 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #51 had intact cognition. A nurse's progress note dated 09/21/2024 at 9:47 PM documented that at 6:45 PM, loud voices were coming from the front lounge. Resident #51 was observed standing very close to Resident #42, while Resident #42 remained seated. Resident #51 stated the disagreement resulted from a text message received from Resident # 42. A comprehensive care plan related to behavior symptoms, potential for abuse and neglect was initiated for Resident #51 on 05/14/ 2024. There was no documented evidence that Resident #51's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident verbal altercation on 09/21/ 2024. On 12/09/2024 at 9:30 AM, the Director of Social Service was interviewed and stated that there was a misunderstanding between Residents #42 and # 51. They stated that they were not on duty when the incident occurred and was made aware after the fact. The Director of Social Service stated they are responsible for updating Resident #42 and #51's care plan on behavior. On 12/09/2024 at 10:52 AM, the Director of Nursing was interviewed and stated that they were aware that Resident #42 and #51's care plan was not updated after the incident on 09/21/ 2024. The Director of Nursing stated it is the Social Services department's responsibility to update the care plan on resident's behavior and that the interdisciplinary team must ensure that all department heads update the care plans. The facility Investigation Summary dated 09/27/2024 documented that on 09/21/2024 at 6:00 PM, Resident #61 threw water into Resident #50's face without seeming cause. Both residents were sent to their room after the Licensed Practical Nurse intervened. 3. Resident #50 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #50 had severe impairment in cognition. A nurse's progress note dated 09/21/2024 at 11:59 PM documented that at 6:00 PM, Resident #50 was in the hallway talking to Resident #61, when all of a sudden, Resident #61 threw their drinking water to Resident #50's face. Residents were asked to stay away from each other. There was no documented evidence that Resident #50's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident physical altercation on 09/21/ 2024. 4. Resident #61 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #61 had intact cognition. A nurse's progress note dated 09/21/2024 at 8:17 PM documented that Resident #61 was in the hallway talking to Resident #50 when all of a sudden Resident #61 threw water onto Resident #50's place. A care plan for potential for abuse and neglect was initiated for Resident #61 on 07/05/ 2024. There was no documented evidence that the care plan was reviewed and revised following the 09/21/2024 incident. There was no documented evidence that Resident #61's comprehensive care plan was reviewed and revised with new interventions following the occurrence of resident-to-resident physical altercation on 09/21/ 2024. On 12/09/2024 at 9:44 AM, the Director of Social Services was interviewed and stated that if a resident has aggressive behaviors prior to admission, the Social Services must document and initiate the care plan on behavior. The Director of Social Services stated if a resident displayed an abusive behavior or if there is any abuse concern after the resident has already been admitted to the nursing home, either the Social Services or Nursing can initiate the care plan as a multidisciplinary approach. The Director of Social Services stated they were not aware that Resident #50's comprehensive care plan was not reviewed and care plan for behavior not initiated after their altercation with Resident # 61. On 12/09/2024 at 8:53 AM, the Director of Nursing was interviewed and stated that Social Services is responsible for reviewing the comprehensive care plan after the altercation and initiating the behavioral and abuse care plan. The Director of Nursing stated nurses can also initiate and update the care plan if there is any episodic behavior or abuse incident. The Director of Nursing further stated they are not aware that Resident #50's comprehensive care plan was not reviewed after the incident and that care plan for potential for abuse was not initiated after the incident on 09/21/ 2024. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedJanuary 3, 2025 Immediate Corrective Action: -The Director of Social Services on 12/09/2024 and 12/10/2024 conducted care plan reviews and revision to assess Resident #42, Resident #50, Resident #51 and Resident #61 for physical, emotional, and behavioral changes post-altercation. DSS updated findings in the medical records and ensured appropriate interventions were implemented. The updated care plans include specific behavioral interventions, safety measures, and triggers identified during the assessment. -The Director of Social Services conducted an urgent IDT huddle on 12/10/2024 to review and revise care plans for all residents involved in the incident. The IDT team was informed of the care plan updates and instructed on implementing the new interventions. Identification of Others Potentially Affected: The facility respectfully submits all residents were reviewed and was not affected by this practice. System Changes to Prevent Recurrence: -The Compliance team on 12/12/2024 reviewed the facilitys care plan policies. No amendments were needed. The Compliance officer re-in-serviced the DSS and social workers to mandate immediate IDT care plan reviews and updates following significant resident incidents, such as altercations, falls, or changes in condition. -The Social Services team and senior nursing team received mandatory training on 12/12/2024 by the compliance officer on Identifying triggers for care plan updates, Proper documentation of incidents and interventions, Collaboration during care plan reviews and implementing a communication system to ensure direct care staff promptly report significant resident incidents to the IDT for review. -The Compliance team on 12. 13. 2024 instilled protocol for monitoring and documenting behavior changes following incidents, and responsibilities for ensuring care plan alignment. IDT and all direct care staff as of 12/31/2024 were in-serviced. Quality Assurance Monitoring: -The DSS will Perform weekly audits of resident incident reports to verify care plan updates were completed for all significant changes. The DSS will also review a random sample of 10% of care plans weekly for three months to ensure they reflect the residents current status and needs. -The audit results will be discussed at monthly Quality Assurance (QA) meetings to adjust training or policies based on findings from the ongoing audits. -The Performance Metrics is set at a compliance target of 100% for care plan updates following significant resident-to-resident incidences. -Audit Tool created. Responsible Party: Director of Social Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. This was evident during the Kitchen Task. Specifically, there were multiple cans of expired beef stew in the emergency food storage and expired frozen omelets stored past the expiration date in the kitchen freezer. The findings are: The undated facility policy titled Food Storage documented sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. Old stock is always used first, First in - First out method. Food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high-risk foods. An initial tour of the kitchen was conducted on [DATE] from 9:42 AM to 10:01 AM with the Assistant Food Manager. The following was observed: 14 cans of 6. 63 pound cans of beef stew with a best by date of ,[DATE]/ 2024. In the freezer, the following was observed: 2 boxes of frozen omelets with a use by date of [DATE], 15. 75-pound box of frozen folded plain omelet with a use by date [DATE], a box of frozen egg patty with a use by date of [DATE], and cooked eggs dated [DATE] in the refrigerator. During an interview on [DATE] at 02:52 PM, the Assistant Food Manager stated the expired food was an oversight and that they did not look at the date when they did rounds. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedJanuary 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -All expired food was immediately removed and discarded. -Assistant Food Manager and Food Manager doubled check all emergency food storage for expired food. -Assistant Food Manager and Food Manager was re-educated on the food storage safety policy. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: -The Compliance Officer reviewed the food storage safety policy on [DATE] and no modifications were made. The policy and procedure align with the standardized state and regulatory requirements. -The Compliance Officer in-serviced all kitchen staff on [DATE] on the food storage safety policy. -In order improve our current intake monitoring system, we are implementing a check and valances rotation checkup form. Which will consist of cataloging our inventory with the dates in which everything was received, contrasted with the expiration date on said products. Quality Assurance Monitoring: -Food Manager and/Assistant Food Manager will audit the emergency food storage biweekly for 3 months, thereafter monthly. -All findings and/or deficient will be highlighted during the QAPI monthly meetings. -Audit tool was created and implemented for ongoing monitoring Responsible Party: Food Manager/ Assistant Food Manager |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the Infection Preventionist had completed specialized infection prevention and control training. This was evident during the review of the Infection Control Task. Specifically, the facility's designated Infection Preventionist did not have documented evidence of completing specialized infection prevention and control training. The findings are: The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality Safety by Oversight Group (QSO-19-10-NH), dated 03/11/2019, documented that effective 11/28/2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's infection prevention and control program. The facility's Infection Preventionist Job Description documented that the Infection Preventionist, under the direction of the Director of Nursing Services, is responsible for developing, directing, implementing, managing, and operating infection prevention in the long-term care facility. The candidate must have completed specialized training in infection prevention. The facility submitted the Infection Preventionist certificate in Infection Control and Barrier Precautions with four contact hours dated 02/28/ 2023. There was no documented evidence that the Infection Preventionist had completed a specialized training in infection control. On 12/05/24 at 2:32 PM, the Infection Preventionist was interviewed and stated they had been the Infection Preventionist since early 2023. The Infection Preventionist stated they were unaware of the specialized training requirement before assuming the infection preventionist role. On 12/09/2024 at 10:31 AM, the Director of Nursing was interviewed and stated the Infection Preventionist assumed the role since 2023. The Director of Nursing stated they were not aware that Infection Preventionists require a specialized training. On 12/09/2024 at 11:27 AM, the Administrator was interviewed and stated that the Infection Preventionist assumed the role in September 2023. The Administrator stated they were not aware that Infection Preventionist require specialized training before assuming the position. 10 NYCRR 415. 19 | Plan of Correction: ApprovedJanuary 7, 2025 Immediate Corrective Action: -Assistant DON (Infection Preventionist) successfully completed the specialized training in infection prevention on 12/03/ 24. -In addition, we will continue the support of The Infection Control Preventionist from our Nurse Practitioner who provides additional onsite support. -DON and Assistant DON was re-educated on the Infection Preventionist policy and procedure. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: -Compliance Officer reviewed and revised the Infection Preventionist job description and policy and procedure on 12/05/ 24. -DON, ADON and NP were in-serviced on the revised job description and policy and procedure on 12/10/ 24. -ADON and Nurse Practitioner will actively participate in IPRO QIN QIO that offers free access to AHCA/NCALs Infection Preventionist Specialized Training (IPCO). -Audit tool has been created and put into place for ongoing compliance monitoring. Quality Assurance Monitoring: -Infection Preventionist is a member of the facilitys QAA Committee. The Infection Preventionist routinely report to the QAA Committee on the facilitys IPCP. -Audit tool has been created and put into place for ongoing compliance monitoring. - The Director of Nursing will conduct auditing and monitoring to ensure surveillance and monitoring of active infections in the facility is being implemented, and the ADON (Infection Preventionist) is receiving specialized education and training. After 4 weeks of weekly monitoring and demonstrating that expectations are being met, monitoring will reduce to twice monthly for one month. Monthly monitoring will continue at a minimum for 2 months. Responsible Party: -Assistant DON and Nurse Practitioner |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident in 2 (3rd and 4th Floor) of 3 units. Specifically, 1. ) Expired [MEDICATION NAME] lock flush syringes were stored in the medication room. 2. ) Food items were stored together with the intravenous bags in the medication room. The findings are: The facility policy on Medication Storage and Handling with a last revision date of ,[DATE] documented that medications, biologicals, and intravenous sections having an expiration date are removed from storage and usage and properly disposed of after such date. On [DATE] at 11:05 AM, an observation of the 4th Floor Medication Room was conducted with Registered Nurse # 2. Nineteen (19) [MEDICATION NAME] lock flush syringes with expiration dates of [DATE] and [DATE] were observed in the Medication Room drawer. Registered Nurse #2 was immediately interviewed after the observation and stated that medications should be used by the expiration date, or it might not be effective. On [DATE] at 11:24 AM, an observation of the 3rd Floor Medication Room was conducted. Food items (plastic containers of coffee and containers of coffee creamer) were observed stored next to the intravenous fluid bags inside the cabinet. On [DATE] at 3:21 PM, Registered Nurse #3 was interviewed and stated there should be no food stored in the Medication Room. On [DATE] at 1:25 PM, the Director of Nursing was interviewed and stated that there should be no food kept in the Medication Storage areas. 10 NYCRR 415. 18(e)(,[DATE]) | Plan of Correction: ApprovedJanuary 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -All expired medication (19 [MEDICATION NAME] lock flush syringes) were removed and discarded from Unit 3 (4th floor) medication room. -All food items were removed from Unit 2 (3rd floor) medication room. -RN #3 and RN #4 were re-educated on the Medication Labeling / Storage policy and procedure. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: -All Unit RN Managers will do daily rounds to ensure all medications rooms, drawers and cabinets are free from expired Medication and food. -Review of the Medication Storage and Handling Policy was done on 12/13/ 24. The policies align with the current standards and professional practice and regulatory guidelines. No modifications made. -All Nurses will be re-educated on the policy. -The Pharmacy Consultant will audit unit medication carts when onsite monthly for expired medications. Quality Assurance Monitoring: -The Director of Nursing developed a tool to audit all medication rooms and medication carts. -Audits will be performed by the Director of Nursing/designee. -Audits will be performed on all Medication Carts and Medication Rooms, bi-weekly for 3 months, then monthly thereafter, until 95% accuracy is achieved. -The Director of Nursing will maintain a list of negative findings and any corrective actions taken including but not limited to immediate reporting to the Administrator/designee, re-education of involved staff and progressive disciplinary actions. -Audit findings will be reviewed and presented to the QAPI Committee at least quarterly for needed revisions in the action plan, and improvement of our delivery and resident outcomes. -The lesson plan for this plan of correction will be included in the facilitys orientation and annual training of all Nurses. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 12/04/2024 to 12/09/2024, the facility did not ensure appropriate liability and appeal notices to Medicare beneficiaries were provided. This was evident for 2 (Residents #24 and #36) of 3 residents reviewed for Beneficiary Protection Notification Rights, out of 20 total sampled residents. Specifically, the facility did not provide residents with Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- form CMS- ) at the termination of their Medicare Part A benefits. The residents remained in the facility. The findings are: The Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF-ABN) Form CMS - (2024) documented that Medicare requires Skilled Nursing Facilities to issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage to Original Medicare, also called fee-for-service, patients prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage is a Centers for Medicare and Medicaid Services-approved model notice and should be replicated as closely as possible when used as a mandatory notice. Failure to use this notice or significant alterations of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage could result in the notice being invalidated and/or the skilled nursing facility being held liable for the care in question. The Skilled Nursing Facility must give the applicable Medicare coverage guideline(s) and a brief explanation of why the resident's medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the patient to understand why Medicare may deny payment. The facility's policy and procedure titled Advanced Beneficiary Notice with a review date of 11/2024 documented that the Advanced Beneficiary Notice is issued by the facility to original Medicare beneficiaries in situations where Medicare payment is expected to be denied. The facility's policy included a procedure of when to issue the Advanced Beneficiary Notice and a copy of the form CMS- that must be used. Resident #24 was admitted to the facility on [DATE] and started Medicare Part A Skilled Services on 10/08/ 2024. Resident #24's last covered day for Medicare Part A Skilled Services was on 11/06/2024 with 69 days remaining. Resident #24 remained in the facility. There was no documented evidence that form CMS- was given to the resident, informing them of their potential liability for payment. Resident #36 was admitted to the facility on [DATE] and started Medicare Part A Skilled Services on 10/15/ 2024. Resident #36's last covered day for Medicare Part A Skilled Services was on 11/13/2024 with 70 days remaining. Resident #36 remained in the facility. There was no documented evidence that form CMS- was given to the resident, informing them of their potential liability for payment. On 12/05/2024 at 10:08 AM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for informing residents of their Medicare coverage, when it takes effect and when it ends. The Minimum Data Set Coordinator stated Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage has not been issued to Residents #24 and #36 because they were not aware of this requirement. On 12/09/2024 at 11:37 AM, the Director of Nursing Services was interviewed and stated that they are not involved in the beneficiary notification process and that it is handled by the Minimum Data Set Coordinator. 10 NYCRR 415. 3(h)(2)(i) | Plan of Correction: ApprovedJanuary 3, 2025 Immediate Corrective Action: -The Facility Administrator on 12/09/2024 issued the Minimum Data Set Coordinator a memorandum regarding Medicaid/Medicare Coverage/Liability Notice and updated protocols for ensuring residents are aware of their rights. -An Adhoc meeting was held by the DON on 12/09/2024 with the MDS coordinator and Compliance Officer to review and discuss the notification process and policy. No amendments were made to the policy. Resident #24 and Resident #36 were individually notified at the conclusion of the meeting regarding the ineffective notification and the facilitys commitment to minimizing these deficiencies. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice. A list of other residents that remained in the facility and were discharged from a MCR Part A stay were reviewed and will be given the SNFABN as appropriate. Systemic Changes to Prevent Recurrence: -The Compliance officer and DON formulated; and reinstated the protocol and procedure for Medicaid/Medicare Coverage/Liability Notification on 12. 10. 2024. -The MDS coordinator and RN Managers were re-in-serviced on 12. 12. 2024 by DON for the protocols and procedures regarding NOTIFYING RESIDENTS OF MEDICAID/MEDICARE COVERAGE OR LIABILITY. Quality Assurance Monitoring: -The Minimum Data Set Coordinator will perform weekly audits for residents for the next 2 months, then monthly thereafter to maintain compliance. Any discrepancies identified during the audit will be reported and documented to the DON. The qualitative summary and analytics will be presented quarterly at the QAPI team meetings. -Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 12/04/2024 to 12/09/2024, the facility did not ensure residents received necessary respiratory care consistent with professional standards of practice. This was evident for 1 (Resident #36) of 4 residents reviewed for Respiratory Care out of 20 total sampled residents. Specifically, Resident #36 received oxygen at a flow rate that was not consistent with physician's orders [REDACTED]. The findings are: The facility's policy and procedure titled Oxygen Therapy dated 01/2021 documented that oxygen therapy must be ordered by a Medical Provider to provide resident with a concentration of oxygen that is higher than room air and to supply oxygen to body tissues that are receiving insufficient amounts from the circulating blood. The resident receiving oxygen therapy will be checked at regular intervals by the licensed nursing staff. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #36 had intact cognition and was receiving continuous oxygen therapy. On 12/04/2024 at 11:56 AM, Resident #36 was observed in bed with nasal cannula attached to the oxygen concentrator at bedside. Resident #36 was receiving 5 liters per minute of oxygen. There was no date noted on the oxygen tube indicating when it was last changed. On 12/05/2024 at 12:29 PM and on 12/06/2024 at 10:31 AM, Resident #36 was observed resting in bed and was receiving oxygen at 5 liters per minute. There was no date noted on the oxygen tube indicating when it was last changed. A Comprehensive Care Plan for impaired respiratory status with a last revised date of 09/19/2024 documented Resident #36 was receiving continuous oxygen via nasal cannula and had acute [MEDICATION NAME] spasm. The facility interventions include to provide treatments per physician's orders [REDACTED]. The physician's orders [REDACTED]. The Treatment Administration Record for 11/01/2024 to 12/06/2024 documented Resident #36 received nasal oxygen at 3 to 4 liters per minute every shift. Review of the electronic medical record contained no documented evidence that the physician ordered to increase oxygen flow rate to 5 liters per minute. Furthermore, there was no documented evidence of when oxygen tubing was last changed for Resident # 36. On 12/06/2024 at 10:21 AM, Licensed Practical Nurse #4 stated Resident #36's oxygen concentrator is checked every shift to ensure water tank is filled and working properly. They stated the oxygen is set as per physician's orders [REDACTED].#4 had not changed the setting. Licensed Practical Nurse #4 stated they were not aware that the oxygen flow rate was increased to 5 liters per minute and was not able to tell when the tube was last changed. On 12/06/2024 at 10:26 AM, Licensed Practical Nurse #1 stated Resident #36 had an order to receive oxygen 3 to 4 liters per minute and was not able to explain why Resident #36's oxygen was set at 5 liters per minute. On 12/09/2024 at 11:12 AM, Registered Nurse #1 stated the unit nurse is responsible to ensure residents receive oxygen according to the physician's orders [REDACTED].#36's oxygen flow should have not been adjusted without proper assessments and without physician's orders [REDACTED].#1 stated nurses change the oxygen tubing weekly and it must be dated. Registered Nurse #1 was not able to explain when Resident #36's tubing was last changed since they have not been documenting the tube change in the medical record. On 12/09/2024 at 11:37 AM, the Director of Nursing Service stated residents are provided with oxygen as per physician's treatment order and it must be checked daily by the unit nurse. The tubing is also changed weekly and dated by the nurse to indicate staff initials and the date it was changed. 10 NYCRR 415. 12 (k)(6) | Plan of Correction: ApprovedJanuary 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -The DON and ADON on 12/04/2024 and 12/05/2024 immediately assessed and informed resident #36 and all other applicable residents to ensure they were receiving oxygen at the correct flow rate or replace any oxygen tubing as outlined in the physicians order. The IDT team simultaneously reviewed resident #36 care plans and checked for any adverse effects due to the incorrect flow rate. -The Physician Assistant performed a general evaluation on 12. 05. 2024 to identify any symptomatic or chief complaints as a result of the error. No adverse effects were identified as of 01/02/ 2024. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: -The Facilitys Policy and Procedure titled Oxygen therapy was reviewed by the IDT team on 12/12/ 2024. No amendments were made. -The compliance team and DON created and enforced the respiratory care policies dated 12/12/2024 to include verification of oxygen flow rates against physician orders [REDACTED]. scheduled changes of oxygen tubing with proper documentation and labeling. -As of 01/02/2024, 100% direct nursing care staff (RNs and LPNs) were in-serviced on the respiratory care policy, ensuring oxygen flow rates align with physician orders [REDACTED]. -Audit tool created. Quality Assurance Monitoring: -The ADON will perform weekly audits for the first month, then monthly thereafter. Audit results will be reviewed in monthly QAPI meetings to assess compliance and determine if further action is necessary. Responsible Party: Assistant Director of Nursing Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that it promoted and facilitated a resident's right to self-determination through support of resident's choice. This was evident for 1 (Resident #43) of 2 residents reviewed for choices out of 20 total sampled residents. Specifically, Resident #43's choice to refuse care was not respected. The findings are: The facility's policy titled Resident's Bill of Rights dated 10/2022 documented that the facility assures that all residents are guaranteed the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care while at the facility. Resident #43 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #43 had intact cognition and was dependent on staff for personal hygiene, lower body dressing, shower, and toileting/hygiene. The assessment documented that Resident #43 had no behavioral symptoms and had not rejected care. On 12/04/2024 at 10:21 AM, Resident #43 was observed in their room. Resident #43 was interviewed and stated that some months ago, Certified Nursing Assistant #2 came in to provide care and Resident #43 told the aide they did not want to be changed at that time. Certified Nursing Assistant #2 insisted to give the care; went ahead to forcefully removed their cover and was got thrown over to the side of the bed. Resident #43 stated they reported the incident to the Administration. A comprehensive care plan for activities of daily living function, self-care deficit, was initiated on 04/12/ 2024. The care plan documented Resident #43 required extensive care in some areas of activities of daily living. Resident #43 required total assist for dressing, hygiene, toileting, and bathing. The facility interventions include to encourage resident to make choices associated with activities of daily living where possible. A Grievance/Complaint Report form dated 01/09/2024 documented that Resident #43 made a complaint about Certified Nursing Assistant # 2. The grievance documented that on the night of 01/08/2024, Certified Nursing Assistant #2 came to Resident #43's room. Resident #43 told Certified Nursing Assistant #2 they do not want to be changed but the aide proceeded anyway. Certified Nursing Assistant #2 ripped the covers off the Resident, put them on their side and held them down, ripped their incontinence briefs off and aggressively wiped their private area with a wet cloth. Resident #43 stated they yelled at Certified Nursing Assistant #2 to stop and asked the nurse to have another aide take care of them. On 12/05/2024 at 10:50 AM, Certified Nursing Assistant #2 was interviewed and stated that they worked a double shift, from 8:00AM to 12:00 AM, on the day of the incident. They stated, on the day of the incident, Resident #43 refused care all day and would not allow any staff to do the care. Certified Nursing Assistant #2 stated Resident #43 refused care during the 8:00 AM - 4:00 PM shift and still refused care on the following shift. Certified Nursing Assistant #2 stated Resident #43 was then forced to be changed because they were concerned about the Resident's skin breaking down. Certified Nursing Assistant #2 stated they had not reported Resident #43's care refusal to the nurse. On 12/05/2024 at 11:06 AM, Licensed Practical Nurse #2 was interviewed and stated that Resident #43 will sometimes refuse care. They stated they will usually leave the resident and come back later to encourage and re-offer care. Licensed Practical Nurse #2 stated they were not on duty when Resident #43 was forced to change by a Certified Nursing Assistant, otherwise they would have not allowed it. They stated they would speak with the Resident and if they still refuse, they will report the behavior to the nursing supervisor. On 12/05/2024 at 11:13 AM, Registered Nurse #2 stated they were not on duty when the incident occurred. Registered Nurse #2 stated the Certified Nursing Assistant should have reported Resident #43's refusal for care instead of forcing the resident. On 12/06/2024 at 11:09 AM, the Director of Nursing stated Resident #43 filed a grievance against Certified Nursing Assistant #2 being rough with care. The stated they investigated the incident and Certified Nursing Assistant #2 stated they insisted on changing Resident #43 because they were worried that Resident #43's skin might breakdown if not changed for so long. On 12/06/2024 at 11:18 AM, the Administrator was interviewed and stated that Resident #43 reported that a staff was rough when they were being changed. The Administrator stated Resident #43 had history of refusing care, and they explained to the staff that residents have the right to refuse. 10 NYCRR 415. 5(b) (1-3) | Plan of Correction: ApprovedJanuary 3, 2025 Immediate Corrective Action: -The Administrator held an audio conference with the Director of Nursing, Assistant Director of Nursing and Compliance Officer on 12/06/2024 to review the current facility's policy titled Resident's Bill of Rights dated 10/2022; and strategize on maintaining fidelity during residents refusal of care to assure that all residents are guaranteed the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care while at the facility. The policy remains intact. -The Facility Administrator and Director of Nursing issued a memorandum on 12/06/2024 to resident #43, and all other residents and care unit representatives to reassure their bill of rights while at the facility in accordance with CFR(s): 483. 10(f)(1)- (3)(8). Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: -Resident #43 was interviewed on 12/09/2024 by the Director of Social Services to identify/address any additional grievances. Resident #43 did not have any additional grievances and requested to remain at the facility. -RN #2, LPN #2, CNA #2 and all other direct resident care nursing staff including Interdisciplinary team were re-in-serviced on Resident Bill of Rights and Refusal of Care & Non-Adherence to Care Plan from 12/09/2024 to 12/12/2024 by the ADON. -From 12/09/2024 to 12/21/2024, the DON and RN Managers reviewed the nursing notes in Sigma care for all residents during the period of 08. 2024 ÔÇ£ 12. 2024 to identify any refusal of care and reconciliation outline. No additional defective practice was identified. RN Managers and DON will observe ADLs (change of linens, grooming, etc.) for residents 2x per week over the next eight weeks. Quality Assurance Monitoring: -Audit tool has been created and implemented for ongoing monitoring. -The Director of Nursing Services will perform weekly audits for randomized resident(s) for the next 4 months, then quarterly thereafter to sustain 100% compliance. Defective Practices will be reported to the compliance team and findings presented to the quarterly QAPI team meetings. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details Based on observation and interview it was determined that the facility did not ensure that approved UL listed power strips were used. This was observed on 1 out of 4 units. The Finding(s) are: On 12/3/24 and 12/4/24 between the hours of 9:30 a.m and 2:30 p.m, during the life safety code survey, the following observation(s) made: - On 12/3/24 at approximately 11:00 am, observation in the lounge area on 3rd floor revealed a christmas tree plugged in to an unapproved power strip. In an interview with the maintenance director at approximately 11:05 am, stated the appliance will be removed and they will ensure compliance with this code. 10. 2. 3. 6 (NFPA 99), 10. 2. 4 (NFPA 99), 400-8 (NFPA 70), 590. 3(D) (NFPA 70), TIA 12-5 | Plan of Correction: ApprovedDecember 19, 2024 Immediate Corrective Action: The Maintenance Director and Facility Supervisor on 12. 03. 2024 removed the unapproved power strip on the third floor of the facility. A Christmas tree was plugged into the extension cord and as such, required a direct outlet. The Maintenance team rectified this deficiency as of 12. 04. 2024. The Senior Administrator and Quality Improvement team issued a memorandum on 12. 03. 2024 to the Maintenance Director and facility team regarding power strips in accordance to CMS K-Tag 920. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance team are now mandated to have biannual Life Safety Code checklist in-services. The maintenance and facilities supervisor will conduct daily (M-F) maintenance walk-through ensuring existing UL power strips are installed as outlined in K-Tag- 920. Quality Assurance Monitoring: The Facility supervisor will audit the daily test logs, monthly test reports and complete the quarterly internal tracker -K category to ensure compliance with the required Life Safety Code lists. Any deficiency identified for K-Tag 920 will be rectified immediately and subjected to quarterly internal audit by the quality assurance unit until substantial measures are enacted. Responsible Party: Facility Supervisor |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details Based on observation and interview it was determined that the facility did not ensure lighting in path of egress was fully functional. References are made to tube lights in a stairwell egress to Anthony Avenue. This was observed on 1 out of 4 units. The Findings are: On 12/3/24 and 12/4/24 between the hours of 9:30 a.m and 2:30 p.m, during the life safety code survey, the following observation(s) made: - On 12/3/24 at approximately 11:15 am, egress path in stairwell to Anthony Avenue was noted to have two (2) lighting tubes partially illuminated. In an interview with the Maintenance Director, immediately after the finding, they advised staff to correct this concern. 2012 NFPA 101: 7. 8. 1. 1, 7. 8. 1. 2, 7. 8. 1. 3*, 7. 9. 1. 2, 7. 9. 2 10 NYCRR 711. 2 (a)(1) | Plan of Correction: ApprovedDecember 19, 2024 Immediate Corrective Action: The Maintenance Director and Facilities Supervisor on 12. 04. 2024 effectively replaced the two identified lightbulbs/ lighting tubes that were partially illuminated ÔÇ£ in stairwell egress to(NAME)Avenue - in accordance with NFPA 101 section 7. 9 Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance Director and facility team were re-in-serviced on 12. 09. 2024 for state requirements regarding Means of Egress and TAG K-291: Emergency Lighting specificities by the compliance officer. The Maintenance Director will continue to perform Monthly emergency Lights test ÔÇ£ 30 seconds per month hold button; and annual checks of 90 minutes unplugged. In addition, the maintenance team are now required to observe, record and ensure the path of egress is functionally illuminated during daily environmental rounds. Quality Assurance Monitoring: The Maintenance Director will complete the updated daily compliance facilities testing tracker and immediately provide replacement or work order(s) for TAG K291 on the tracker in the event illumination is affected. The Internal Record of Inspection and Testing reports are then reviewed by the facilities Manager and the compliance team. Any deficient practice/findings will be reported for reconciliation during the QA monthly meetings. Responsible Party: Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details Based on observation and staff interview, it was determined that the facility did not ensure that a hazardous area (soiled utility room) door located on floor four (4) latched completely in its frame. This was observed on 1 out of 4 units. The Finding is: On 12/3/24 and 12/4/24 between the hours of 09:30 am - 02:30 pm, during the life safety surveythe following observation was made: - On 12/3/24 at approximately 10:43 am, the soiled utility room (425) door failed to latch properly in its frame when tested . In an interview with the maintenance director, they stated this concern will be corrected immediately. 711. 2(a)(1) 2012 NFPA 101 19. 3. 2. 1 | Plan of Correction: ApprovedDecember 19, 2024 Immediate Corrective Action: The Maintenance Director and facility team on 12. 03. 2024 adjusted the hinges on the door for the Soiled Utility Room (RM-425) that failed to latch in its frame. The facility team on 12. 04. 2024 successfully completed and tested the requested work order from the Senior Administrator to ensure the Hazardous Area ÔÇ£ (RM-425) designated as the Soiled Utility Room was equipped with a door that properly latched. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Compliance Officer has updated the daily compliance facilities testing tracker to identify hazardous areas that are artificially propped open or inoperable to latch in its frame. The facility supervisor will observe and test the latches within Hazardous areas during the daily (M-F) maintenance rounds. Any discrepancies will be logged and immediate work order(s) submitted for approval by the executive team. Quality Assurance Monitoring: The Maintenance Director will conduct weekly review/reconciliation on the test logs, monthly test reports and vendor reports to ensure complete compliance with the required Life Safety Code testing lists. Any maintenance/testing that is required will be documented and subjected to quarterly internal audit by the quality assurance unit. Responsible Party: Maintenance Director |