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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #95) of 4 residents reviewed for care planning out of 37 total sampled residents. Specifically, Resident #95 had no comprehensive care plan developed to address comfort/palliative care. The findings are: The facility's policy titled Comprehensive Care Plan with a revision date of 01/2023 documented it is the policy of the facility that residents will have a Comprehensive Care Plan completed in accordance with the federal and state requirements which includes measurable goals and time frames. Resident #95 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] identified Resident #95 had severe impairment in cognition. Resident #95 was totally dependent on staff for activities of daily living and was spoon fed by staff in all meals. On 03/03/2025 at 10:36 AM, Resident #95 was observed in their room, alert but non- responsive to verbal command. Resident #95 had intravenous infusing on the right anticubital area and had oxygen via nasal cannula at 2 liters per minute connected to an oxygen concentrator. The physician's orders [REDACTED]. A nurse practitioner notes dated 03/03/2025 at 8:11 AM documented Resident #95 was on comfort/palliative care. A review of the Comprehensive Care Plan revealed no documented evidence that a care plan for comfort/palliative care was developed for Resident # 95. On 03/05/2025 at 3:16 PM , Registered Nurse #1 was interviewed and stated it is the Social Worker's responsibility to develope and initiate Resident #95's care plan for comfort/palliative care. On 03/05/2025 at 3:24 PM, the Director of Social Services was interviewed and stated they were not aware they have to develop a care plan for comfort/palliative care. They stated they thought they are done once they completed the necessary documentation. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedApril 2, 2025 I. Immediate Action a. Resident 95 comprehensive care plan updated to reflect comfort care. II. Identification a. Audit of all residents with advanced directives done immediately on 3/5/25 to ensure appropriate care plans were in place. No negative findings. III. Systemic Changes a. Administrator and DON reviewed Comprehensive Care Plan Policy on 3/5/25 and found it to be compliant. b. Administrator in-serviced Social Work Director and Social Worker on responsibility of implementing care plans for comfort care measures. IV. Monitoring a. DON developed an audit tool to ensure all residents on comfort care have appropriate care plans. Any resident with Advanced Directives triggering comfort care measures will be sampled for audit. b. Audit will be conducted monthly x 12 months. c. Audits with negative findings will have immediate corrective action and reported to the Administrator for review and follow up. d. Audit findings will be presented to the QA committee quarterly by the Director of Nursing / designee. V. Responsibility a. The Director of Nursing will be responsible to ensure correction of this deficiency. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Recertification Survey from 03/02/2025 to 03/07/2025,the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 10 out of 37 total sampled residents. Specifically, Residents #72, #161, #119, #97, #66, #60, #21, #6, #15, and #151's Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings are: The facility's policy titled Minimum Data Set with a reviewed date of 01/2025 documented the facility will complete at a minimum and at regular intervals, a comprehensive, standardized assessment of each resdient's functional capacity and needs. The policy did not indicate submission timeline for Minimum Data Sets. A review of submission/validation reports revealed the following: 1. ) The Quarterly Minimum Data Set assessment for Resident #72 with a reference target date of 01/06/2025 was completed on 01/20/ 2025. The scheduled submission date was 02/03/2025, actual submission date was on 02/27/ 2025. The validation report documented a warning message stating record was submitted late, more than 14 days after the assessment reference date. 2. ) The Quarterly Minimum Data Set assessment for Resident #161 with a reference target date of 12/23/2024 was completed on 01/06/ 2025. The scheduled submission date was 01/20/2025, actual submission date was 02/27/ 2025. The validation report documented a warning message stating record was submitted late, more than 14 days after the assessment reference date. 3. ) The Quarterly Minimum Data Set assessment for Resident #119 with a reference target date of 01/09/2025 was completed on 01/23/ 2025. The scheduled submission date was 02/06/2025, actual submission date was 02/27/ 2025. The validation report documented a warning message stating record was submitted late, more than 14 days after the assessment reference date. 4. ) The Quarterly Minimum Data Set assessment for Resident #97 with a reference target date of 01/09/2025 was completed on 01/23/ 2025. The scheduled submission date was 02/06/25, actual submission date was on 02/27/ 2025. The validation report documented a warning message stating record was submitted late, more than 14 days after the assessment reference date. 5. ) The Quarterly Minimum Data Set assessment for Resident #66 with a reference target date of 01/09/2025 was completed on 01/23/ 2025. The scheduled submission date was 02/06/2025, actual submission date was on 02/27/ 2025. The validation report documented a warning message stating record was submitted late, more than 14 days after the assessment reference date. 6. ) Resident #60's Quarterly Minimum Data Set assessment's reference target date was 01/03/ 2025. The scheduled submission date was on 01/31/2025 but the assessment was submitted on 02/27/ 2025. 7. ) Resident #21's Quarterly Minimum Data Set assessment's reference target date was 01/06/ 2025. The scheduled submission date was on 02/03/2025 but the assessment was submitted on 02/27/ 2025. 8. ) Resident #6's Quarterly Minimum Data Set assessment's reference target date was 01/01/ 2025. The scheduled submission date was on 01/29/2025 but the assessment was submitted on 02/27/ 2025. 9. ) Resident #15's Annual Minimum Data Set assessment's reference target date was 12/26/ 2024. The scheduled submission date was on 01/30/2025 but the assessment was submitted on 02/27/ 2025. 10. ) Resident #151's Quarterly Minimum Data Set assessment's reference target date was 12/25/ 2024. The scheduled submission date was on 01/22/2025 but the assessment was submitted on 02/27/ 2025. The Minimum Data Set final validation reports for Resdients #60, #21, #6, #15, and #151documented a warning message stating record was submitted late, more than 14 days after the assessment reference date. On 03/04/2025 at 11:09 AM, the Minimum Data Set Coordinator was interviewed and stated that the admission assessments are to be completed within 14 days of admission and submitted within 14 days of completion. The quarterly assessments should be completed within 92 days of the previous assessment, and submitted within 14 days of completion. They stated they have 14 more days to review the assessments before the required date of submission. They stated they recognized last year that Minimum Data Set submissions were late and it has been discussed during the Quality Assurance meeting and they are in the process of hiring new assessors. On 03/06/2025 at 8:46 AM, the Administrator was interviewed and stated they had ongoing discussions concerning the late submissions of Minimum Data Sets some months ago and are determining how to change the assessor's per diem schedule. They stated they are reaching out to recruiters to hire assessors. 10 NYCRR 415. 11 | Plan of Correction: ApprovedApril 2, 2025 I. Immediate Action a. DON in-serviced MDS Coordinator regarding timely submission of MDS. II. Identification a. DON and MDS Coordinator reviewed all MDS submissions from start of 2025. b. The facility respectfully states that all identified issues have been corrected. III. Systemic Changes a. DON and MDS Coordinator reviewed and updated MDS Policy on 3/11/25 to indicate submission timeline for MDS submission. b. Administrator in-serviced all staff who complete portions of MDS on timely submission beginning on 3/7/25 and as new hires came on board. c. 2 per diem MDS assistants hired and given new schedules on 3/11/ 25. d. MDS case load divided by floor to ensure timely submission IV. Monitoring a. DNS and MDS Coordinator developed an audit tool to ensure due MDS assessments are submitted in a timely manner. Audit tool will review all due MDS Assessments. b. Audit will be done monthly x 3 months, then Quarterly x 3. c. All negative findings will be immediately addressed and reported to DNS. d. All audit findings will be presented to the QA committee quarterly by the MDS Coordinator / designee. V. Responsibility a. The MDS Coordinator will be responsible to ensure correction of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure appropriate services, care, and equipment are provided to assure that residents with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. This was evident in 3 of 3 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, 1. ) Resident #22 was observed without an abductor wedge as per physician's orders [REDACTED]. 2. ) Resident #92 was observed with no bilateral heel protectors and [MEDICATION NAME] Lumbo Sacral Orthosis as per physician's orders [REDACTED]. The findings are: The facility's policy for Adaptive/Assistive Devices/Positioning Devices dated 01/2025 documented that residents will be supplied with adaptive/assistive/positioning devices that will enhance their quality of life and increase their ability to be independent in Activities of Daily Living. 1. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #22 had severe impairment in cognition and required substantial/maximal assistance and partial/moderate assistance of staff for most activities of daily living. A Comprehensive Care Plan for alteration in bone integrity due to acute Fracture was initiated on 12/20/ 2024. The care plan documented Resident #22 had [MEDICAL CONDITION] hip status [REDACTED]. A physician's orders [REDACTED]. It also included orders for abductor wedge in both lower extremities when in bed and while sitting on wheelchair. The Certified Nursing Assistant Accountability Records and Treatment Administration Records reviewed from the month of (MONTH) 2024 until (MONTH) 2025 showed no documented evidence that the abductor wedge was being applied for Resident # 22. On 03/03/2025 at 11:37 AM, Resident #22 was observed sitting on the wheelchair with no abductor wedge. On 03/04/25 at 9:18 AM, Resident #22 was observed participating in rehabilitative therapy. There was no abductor wedge in use. On 03/05/2025 at 7:58 AM, Resident #22 was observed sitting in the dining room with no abductor wedge in place. On 03/05/2025 at 12:01 PM, Resident #22 was observed in the day room with no abductor wedge in place. On 03/06/2025 at 8:54 AM, Resident #22 was observed at Rehabilitative Therapy with no abductor wedge noted. On 03/06/2025 at 8:55 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #22 is in their assignment and that they were not aware that Resident #22 has an abductor wedge that need to be applied in between resident's legs. They stated they had never seen the abductor wedge for Resident # 22. On 03/06/2025 at 9:27 AM, Registered Nurse #3 was interviewed and stated that Resident #22 had physician's orders [REDACTED]. They stated that either the nurse or aides may apply the abductor wedge. Registered Nurse #3 stated there was no documentation in the Certified Nursing Assistant Accountability Record or in the Treatment Administration Record for the abduction wedge and they were not able to tell when the abductor wedge was last applied. On 03/06/2025 at 9:52 AM, the Director of Rehabilitative Therapy was interviewed and stated that the abductor wedge was recommended by the orthopedic surgery after Resident #22's hip replacement procedure to be worn in bed and when sitting on wheelchair to prevent abduction and crossing of leg when the Resident is not walking. They stated the abductor wedge is not placed on the Resident during therapy exercise and they normally place it when resident is in bed or when sitting on the chair. 2. Resident #92 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented Resident #92 had intact cognition and was dependent on staff for transfers, bed mobility, dressing, and eating . A physician's orders [REDACTED]. A Comprehensive Care Plan on Range of Motion which was last updated on 11/14/2024 documented Resident #92 was on nursing rehabilitation with passive range of motion to bilateral lower extremities, apply bilateral heel protectors at all times, and [MEDICATION NAME] Lumbar Sacral Orthosis brace when out of bed. On 03/04/2025 at 3:29 PM, Resident #92 was observed in the unit seated on their wheelchair with no heel protectors and no [MEDICATION NAME] Lumbar Sacral Orthosis brace. On 03/05/2025 at 12:18 PM, Resident #92 was observed in their room seated in their wheelchair, with no heel protectors and no [MEDICATION NAME] Lumbar Sacral Orthosis brace. On 03/05/2025 at 12:18 PM, Certified Nursing Assistant #2 was interviewed and stated they did not apply the heel protectors and the [MEDICATION NAME] Lumbar Sacral Orthosis brace and that it was the Resident who applies the devices. On 03/05/2025 at 12:40 PM, Licensed Practical Nurse #4 stated they were not aware Resident #22 has not been using the heel protectors and the [MEDICATION NAME] Lumbar Sacral Orthosis brace. On 03/06/2025 at 10:45 AM, the Director of Nursing was interviewed and stated adaptive devices are ordered by the physician and is documented in the Certified Nursing Assistant Accountability Record or the Treatment Administration Record. They stated they are surprised that the nurses and nursing supervisors have not noticed this noticed this error to ensure that necessary interventions are carried out for the residents. 10 NYCRR 415. 12 (e)(1) | Plan of Correction: ApprovedApril 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Action a. Resident #22 was evaluated by Director of Rehabilitation. b. Director of Rehabilitation In-serviced CNAs on unit about the need to use abductor wedge. c. Director of Rehabilitation confirmed with Ortho to discontinue the abductor wedge. Care plan updated to reflect. d. DON reviewed Resident #92 care plan and confirmed physician orders [REDACTED]. e. Resident #92 counseled about the importance of wearing TLSO brace and heel protectors. II. Identification a. All residents with assistive devices audited to ensure accuracy with physician orders [REDACTED]. No negative findings. III. Systemic Changes a. Administrator, DON, Director of Rehabilitation reviewed Adaptive/Assistive Devices Policy on 3/7/35 and found it to be compliant. b. Director of Rehabilitation in-serviced all Rehab, nursing and CNA staff members on use of devices for resident safety. IV. Monitoring a. Director of Rehabilitation developed an audit tool to ensure devices ordered for residents are being used. b. Director of Rehabilitation/designee will observe 5 residents with devices at random weekly to ensure proper device compliance. c. Audit will be conducted Weekly x 4, Monthly x 3, Quarterly x 2 d. Any negative audit findings will be presented to Administrator and immediately corrected. All audit findings will be presented to the QA committee quarterly by the Director of Rehabilitation. V. Responsibility a. The Director of Rehabilitation will be responsible to ensure correction of this deficiency. |
Scope: N/A
Severity: N/A
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that all medications and biologicals were stored properly. This was evident in 1 (Unit 2) of 4 units observed during Medication Administration Task. Specifically, medications were pre-poured and left unattended on the medication cart, and the medication cart was left unattended and unlocked. The findings are: The facility's policy titled Medication Administration dated (MONTH) 2025 documented that it is the policy of the facility to handle, store, and administer medications in accordance with best practice standards, including but not limited to not leaving medications unattended on the medication cart and carts will be locked when not within view of the nurse. On 03/02/2025 at 9:31 AM, during medication pass observation on Unit 2, Licensed Practical Nurse #1 crushed and pre-poured the following medications for Resident #115: [MEDICATION NAME] 100 milligram 2 tab, Calcium 600 milligram + D 600 milligram 1 tablet, [MEDICATION NAME] 10 milligram, [MEDICATION NAME] 50 milligram, Eliquis 5 milligram, [MEDICATION NAME] 1,000 milligram, [MEDICATION NAME] 10 milligrams, and 15 milliliter of liquid solution Levetiracetam 100 milligram/milliliter. Licensed Practical Nurse #1 entered Resident #115's room to obtain the Resident's blood pressure. Licensed Practical Nurse #1 left all of the above medications on top of the medication cart unattended. The medication cart was not locked. Licensed Practical Nurse #1 was interviewed on 03/02/2025 at 10:30 AM and stated the medication cart and medications need to be secured because they have wanderers and they could take the medications left on top of the cart. On 03/02/2025 at 11:21 AM, Registered Nurse #1 was interviewed and stated the cart must be locked at all times. On 03/05/2025 at 8:49 AM, the Director of Nursing was interviewed and stated medications are not to be left unattended on top of the medication cart and the cart must be kept locked at all times when left unattended no matter for how long or short a time. 10 NYCRR 415. 18(e)(1-4) | Plan of Correction: ApprovedApril 2, 2025 I. Immediate Action a. DON gave 1:1 counseling to LPN 1 regarding following the facilities protocol and procedure of medication administration, including procedure when leaving med cart unattended. b. DON issued disciplinary action to LPN 1. II. Identification a. DON and ADON observed all LPN's doing medication pass. b. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator and DON reviewed Medication Administration Policy on 3/3/25 and found it to be compliant. b. DON and ADON in-serviced all RN and LPN on 3/2/25 staff on proper handling of medication, proper use and storage of medication cart when stepping away from the cart. c. RN and LPN's will receive performance review every 6 months, and quarterly medication pass review for all LPNs and RNs. IV. Monitoring a. DNS and ADON developed an audit tool to ensure nursing staff compliance with proper medication administration. All LPNs will be selected at random and rotated as part of the audit to ensure compliance. b. Audit will be done monthly x 3 months, then Quarterly x 3. c. All negative findings will be immediately addressed and reported to DNS. d. All audit findings will be presented to the QA committee quarterly by the MDS Coordinator / designee. V. Responsibility a. The ADON will be responsible to ensure correction of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the Recertification Survey from 03/02/2025 to 03/07/2025, the facility did not ensure residents' right to personal privacy and confidentiality of medical records were maintained. This was evident in 2 (Units 2 and 3) of 4 units observed. Specifically, licensed nurses left computer screens unlocked and unattended exposing private medical information during medication administration. The findings are: The undated facility policy titled Privacy Policy and Personal Health Information Pledge of Confidentiality documented the facility was committed to maintaining the highest level of confidentiality for resident information and Personal Health Information in accordance with the Healthcare Insurance Portability and Accountability Act. The policy stated it is every employee's responsibility to protect the confidentiality, privacy, and integrity of confidential resident information and Personal Health Information as required by law and professional ethics. 1. During medication pass observation in Unit 2 on 03/02/2025 at 9:31 AM, Licensed Practical Nurse #1 walked away from the medication cart and entered Resident #115's room to take the Resident's blood pressure. Licensed Practical Nurse #1 left the computer in the medication cart unlocked, with the computer screen open exposing residents' health information. Licensed Practical Nurse #1 was interviewed on 03/02/2025 at 10:30 AM. They stated they should have minimized the computer screen to maintain confidentiality of residents' information. On 03/02/2025 at 11:31 AM, Registered Nurse #1 was interviewed and stated confidentiality of residents' information must be maintained. They stated they make random rounds during medication administration to ensure nurses' lock the computer when they leave the medication cart. 2. ) During medication pass observation on 03/02/2025 at 10:52 AM, Licensed Practical Nurse #2 walked away from the medication cart and entered Resident #325's room to administer medications. Licensed Practical Nurse #2 left the computer in the medication cart unlocked, with the computer screen open exposing residents' health information. On 03/02/2025, Licensed Practical Nurse #2 was interviewed immediately after and stated it is important to keep residents' health information private and confidential because of mandated privacy laws of health information. On 03/05/2025 at 8:49 AM, the Director of Nursing was interviewed and stated there is a Health Insurance Portability and Accountability Act that the facility must maintain to ensure residents' information is kept private and confidential. 10 NYCRR 415. 3(e)(1) | Plan of Correction: ApprovedApril 1, 2025 I. Immediate Action LPN #1 and LPN #2 were given 1:1 education on HIPAA and protecting residents information. II. Identification a. DON and ADON observed all LPNs give med pass on each unit. b. DON and ADON issued competencies to identify and potential issues. c. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator and DON reviewed Privacy Policy and Personal Health Information Pledge of Confidentiality on 3/3/25 and found it to be compliant. b. DON in-serviced all nursing staff on HIPAA and procedure when walking away from medication cart or electronic medical record kiosk. IV. Monitoring a. DON developed audit tool to ensure nursing personnel are properly following HIPAA protocols in the facility. Specifically audit will focus on HIPAA and procedure when walking away from medication cart and or electronic medical record kiosk. b. DON/Designee will observe 5 nursing staff members at random weekly to ensure HIPAA protocol compliance. c. Audit will be conducted Weekly x 4, Monthly x 3, Quarterly x 2 V. Responsibility The ADON will be responsible to ensure correction of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification and Complaint Survey (NY 559) conducted from 03/02/2025 to 03/07/2025, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #116) of 1 resident reviewed for Abuse out of 37 total sampled residents. Specifically, on 01/29/2025 at 05:55 AM, the Administrator was made aware that on 01/29/2025 at approximately 05:30 AM, Resident #7 was accused of hitting Resident #116 in the face with a nebulizer machine. The facility reported the abuse allegation to the New York State Department of Health on 01/29/2025 at 02:28 PM. The findings are: The facility policy titled Abuse Prohibition last reviewed in (MONTH) 2025 documented that abuse is defined as the infliction of injury, unreasonable confinement, intimidation, punishment or exploitation with resulting physical harm, pain, or mental anguish. Any case in which abuse cannot be ruled out will be reported promptly to the New York State Department of Health for further investigation. If the crime involves serious bodily injury, it must be reported immediately, but no later than 2 hours after forming the suspicion that a crime has occurred against a resident. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented that Resident #7 was cognitively intact and had no behavioral symptoms directed towards others. Resident #116 was admitted to the facility with [DIAGNOSES REDACTED].#116 had severe cognitive impairments and had no behavioral symptoms directed towards others. The Summary of Investigation dated 01/31/2025 documented that on 01/29/2025 at around 05:30 AM, Licensed Practical Nurse #3 heard shouting from Resident #7 and Resident #116's shared room. Licensed Practical Nurse #3 entered the room and observed Resident #7 holding a nebulizer machine while arguing with Resident # 116. Resident #116 was observed to have redness and swelling to the left eye and a small superficial cut on the left side of the nose bridge with minimal bleeding. The residents were separated and 911 was called. Resident #7 and Resident #116 refused to speak with responding officers. Resident #116 was transferred to the hospital and returned on 01/29/2025 around 05:00 PM with the [DIAGNOSES REDACTED]. The Submission Report documents that the altercation between Resident #7 and Resident #116 occurred on 01/29/2025 at approximately 05:30 AM. The Administrator became aware of the altercation on 01/29/2025 at around 05:55 AM. The Administrator reported the altercation to the New York State Department of Health on 01/29/2025 at 02:28 PM. On 03/06/2025 at 10:38 AM, The Administrator was interviewed and stated they became aware of the physical altercation between Resident #7 and Resident #116 on 01/29/2025 at 05:55 AM and that they reported it to the New York State Department of Health on 01/29/2025 at 02:28 PM. The Administrator stated that Resident #7 was believed to have hit Resident #116 in the face with a nebulizer machine. The Administrator further stated that this altercation was a peer-to-peer incident, and that they did not believe it met the criteria for abuse, so they believed they had 24 hours to report the incident to the New York State Department of Health. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedApril 1, 2025 I. Immediate Action a. Administrator was re-educated regarding reporting guidelines and timeliness of reporting abuse by facilitys regional administrator. II. Identification a. Administrator reviewed reporting guidelines. b. The facility respectfully states that identified issue has been corrected. III. Systemic Changes a. Administrator and DON Reviewed Abuse Prohibition policy on 3/7/25 and found it to be compliant. IV. Monitoring a. Administrator developed an audit tool to ensure any alleged violations involving abuse, neglect, exploitation or mistreatment are reported in a timely manner. b. Audit will be conducted monthly x 12 months. c. All negative findings will be immediately addressed to DOH. All audit findings will be presented to the QA committee quarterly by the Administrator. V. Responsibility a. Administrator is responsible to ensure correction of deficiency. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility failed to maintain each resident's right to a safe, clean, comfortable, and homelike environment. This was evident in 3 (Units 2, 3, and 4) of 4 units observed. Specifically, resident's room, bathroom, and medical equipment were observed with dirt and rust, wheelchairs were soiled, peeled paints, and window treatments were not in good condition. The findings include but are not limited to: The facility policy titled Safe,Clean, Comfortable, and Homelike Environment dated 11/2024 documented it is the policy of the facility to provide a safe, clean, comfortable, and homelike environment in such a manner to acknowledge and respect resident rights to the extent possible.The policy documented housekeeping staff will ensure the rooms and common areas are kept clean and sanitary. 1. During multiple observations from 03/02/2025 to 03/07/2025, the following were observed in Unit 2: a. The sphygmomanometer stand was layered with dirt and dust. b. room [ROOM NUMBER]'s oxygen concentrator had accumulated dust and dirt. c. The oxygen stand at the nurse station had rust and wheels had dust. d. The mechanical lift had rust and dusty base. e. The nurse station was dusty. f. The dining room fans were layered with dust. g. The suction machine table in the dining room had rust stains and dust accumulation. h. The window shades in the dining room were missing, and some were torn and dirty. i. The chairs in the dining room had missing back cushions. j. The hand rail across room [ROOM NUMBER] had missing end caps. k. There was a soiled wheelchair in room [ROOM NUMBER]b. l. room [ROOM NUMBER]a had torn and dirty floor mats. m. The clothes bin in room [ROOM NUMBER] was embedded with black substance and debris. n. room [ROOM NUMBER]d had torn window shades and soiled wheelchair. o. room [ROOM NUMBER]b had dusty and rusty bed frame. A signed construction contract dated 02/11/2025 documented the target date for remodeling of 2nd floor unit will be in April/May 2025 pending availability of material and supplies. On 03/07/2025 at 9:23 AM, Housekeeper #1 was interviewed and stated they are responsible for maintaining a clean place for the residents. They stated their responsibility includes dusting and mopping the rooms and corridors, and cleaning the dining room after breakfast and lunch. They stated it is challenging to keep the unit clean because some residents have behaviors. They stated wheelchairs are cleaned weekly by the housekeeper on a different shift. On 03/07/2025 at 9:47 AM, the Director of Environmental Services was interviewed and stated wheelchairs are cleaned weekly and that they only clean the wheelchairs that were placed outside the rooms. They stated housekeeping staff are required to clean the blood pressure stands and intravenous poles. On 03/07/2025 at 10:20 AM, the Director of Maintenance was interviewed and stated there is a plan to remodel the 2nd floor. 2. During observations on 03/05/2025 at 11:05 AM and on 03/06/2025 at 12:57 PM, the following were observed in Unit 3: a. The chairs in the nurses' station were peeling and the medical charts are fading. b. In room [ROOM NUMBER], part of the floor linoleum was missing. c. In room [ROOM NUMBER], radiator had crusty brown substance. d. In room [ROOM NUMBER], the linoleum on the window base was peeling off. e. In room [ROOM NUMBER], radiator had crusty brown substance. f. In room [ROOM NUMBER], the door frame had peeling paint and the radiator and window frames had crusty brown substance. g. In room [ROOM NUMBER], the window shade was broken, the closet had black marks, the room entrance door base was peeling, and the bathroom entrance had a peeling frame on the floor. h. In room [ROOM NUMBER], the wall was dirty. i. In room [ROOM NUMBER], the radiator had crusty black substance. j. In room [ROOM NUMBER], the window shade and window base had a lot of dirt. k. In room [ROOM NUMBER], the wall base near the sink was broken, and the door frame had cursy brown substance. On 03/06/2025 at 3:33 PM, the Maintenance Director was interviewed and stated they have no painter in the facility and there are only 2 maintenance staff includin the Director. They stated they are looking to hire another maintenance staff. 3. During observations on 03/02/2025 at 11:19 AM and on 03/03/2025 at 12:21 PM, the following were observed in Unit 4: a. The residents' common bathroom was observed with multiple holes in the wall between the toilet and sink, peeling paint, chipped tiles around the bathtub, missing tiles on the wall beside the toilet, large gaps and brown stains on the ceiling tiles. b. room [ROOM NUMBER]a had peeling paint and multiple brown marks on the wall. On 03/02/2025 at 11:19 AM, Resident #225 was interviewed and stated they would like their room to be repainted. On 03/07/2025 at 09:54 AM, Porter #1 was interviewed and stated their job responsibilities include cleaning toilets, sweeping and mopping floors, and cleaning windows. They stated that they are not responsible for repairing things such as peeling paint or chipped tiles, but that they are responsible for reporting it to the Maintenance through the unit's Maintenance Repair Book. Porter #1 acknowledged the concerns that were observed in Unit 4 and stated that they were unsure if they had reported it to the Maintenance Department. Porter #1 further stated that they were not aware of the peeling paint and dirty wall in Resident #225's room but did state that they enter the resident's room daily to mop the floors. On 03/04/2025 at 8:10 AM, the Administrator was interviewed and stated that the building is old and needs a lot of work. They stated the first floor was newly renovated and is planning to do the same on the rest of the units. They stated they had signed a contract to begin renovation on the second floor with the start date of (MONTH) / May 2025. The Administrator stated they currently do not have remodelling proposals for Units 3 and 4, but it is in the plan. The Administrator stated they made rounds and had observed that the facility need a lot of work. They stated they have a Maintenance Director and housekeepers assigned in each unit. They stated housekeeping is challenging because some residents pull the shades and smear feces. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedApril 1, 2025 I. Immediate Action a. Director of Environmental Services and Housekeeping Director did environmental rounds on 2nd, 3rd and 4th floor. b. All high touch surfaces, including nursing stations, closets, window sills, hand rails, fans, stands, lifts, suction machines checked and cleaned. Radiators, door frames cleaned and painted. c. Housekeeping Director checked all wheel chairs on the 2nd floor and scheduled cleaning. d. Director of Environmental Services made facility rounds noting which rooms need to be repainted. e. Director of Environmental Services made rounds of all window shades on 2nd and 3rd floor and replaced missing, torn, broken shades. f. Director of Environmental Services checked all chairs at nursing stations. All peeling and torn chairs, removed off unit, Administrator purchased new chairs. g. DON checked the condition of all binders. Old binders replaced with new ones. h. Director of Environmental Services repaired resident common bathroom including new tiles, paint and repaired holes. II. Identification a.Director of Environmental Services, Director of Housekeeping and Administrator made building wide facility rounds to identify areas of improvement. b.Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator, Director of Housekeeping and Director of Environmental Services reviewed Safe and Homelike Environment Policy and found it to be compliant. b. Housekeeping Director in-serviced all housekeeping staff regarding the use of the Maintenance communication books at the nurses station when they see issues on the unit and in resident rooms. c. Director of Housekeeping and Director of Environmental Services to conduct weekly rounds on each unit. d. Full time maintenance employee hired e. Full time housekeeper hired. Part time maid to be hired. IV. Monitoring a. Director of Environmental Services developed an audit tool for routine maintenance rounds to include window blinds, bathroom tiles, ceiling tiles, paint on radiators / ac units, walls, closets, windows, sinks. b. Administrator and Housekeeping Director developed an audit tool for cleanliness of units including nursing station, furniture, radiators, windows and more. c. Audit will be done weekly for 1 month, monthly for 3 months. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services and Housekeeping Director / designee. V. Responsibility: a. Director of Environmental Services and the Housekeeping Director will be responsible to ensure correction of this deficiency. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details 2012 NFPA . 3. 6. 3* Corridor Doors. 19. 3. 6. 3. 1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13?4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes. Based on observation and staff interview, the facility did not ensure that all corridors were protected from the passage of smoke. This occurred on all floors of the facility, including the basement. The findings include: During the life safety survey on 3/3/25, between 9:30 am and 1:00 pm, it was noted that alcoves used to store combustible items, i.e. linens, on each floor were open to the corridor. This could allow the passage of smoke into the corridor in the event of a fire. These findings were confirmed by the Director of Maintenance. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 19, 2025 K636 P(NAME) I. Immediate Corrections: a. Director of Environmental Services checked all alcoves where linens are stored on resident floors and noted half door partitions. b. Director of Environmental Services took measurements and will be installing full doors to to ensure all corridors were protected from passage of smoke. II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed Fire Safety Policy. No Updates Necessary. b. Director of Environmental Services in-serviced all maintenance staff on protecting corridor from smoke in case of fire. IV. Monitoring: a. Director of Environmental Services developed an audit tool for alcoves to ensure proper closure and from passage of smoke. b. Audits will be done quarterly for one year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details Based on Document review and staff interview, the facility did not conduct any drills to test emergency preparedness. The findings include: During document review on 3/4/25, between 10: 00 am and 12:00 pm, the facility's emergency preparedness policy and procedures did not include documentation of emergency drills conducted within the last 12 months. The Director of Maintenance stated that no drills were conducted during this time. | Plan of Correction: ApprovedMarch 19, 2025 I. Immediate Corrections: a. Director of Environmental Services reviewed Emergency Preparedness Plan and found there to be inadequate safety measures, specifically documentation and execution of necessary emergency drills within the last 12 months. b. Administrator registered facility for NYC Health Long Term Care Exercise Program to ensure compliance moving forward. c. Administrator registered facility for tabletop exercise on (MONTH) 22 and (MONTH) 23rd via NYC LTC Associates / NYC DOHMH II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed Emergency Preparedness Plan. b. Administrator in-serviced all maintenance staff on Emergency Preparedness requirements including the mandatory drills done in last 12 months. IV. Monitoring: a. Director of Environmental Services developed an Disaster Drill audit to maintain compliance over required 12 month period. b. Audits will be done quarterly for 1 year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19. 3. 5. 4* The sprinkler system required by 19. 3. 5. 1 or 19. 3. 5. 3 shall be installed in accordance with 9. 7. 1. 1(1). 9. 7. 1 Automatic Sprinklers. 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 (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13 8. 6 Standard Pendent and Upright Spray Sprinklers. 8. 6. 1 General. All requirements of Section 8. 5 shall apply to standard pendent and upright spray sprinklers except as modified in Section 8. 6. 8. 6. 3. 3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. Based on observation and interview, the facility did not ensure that all sprinklers were installed in accordance with 2012 NFPA 101 and 2010 NFPA 13. This occurred on two of four resident floors and in the basement. The findings include: During the life safety survey on 3/3/25 between 9:30 am and 1:00 pm, the following were noted: 1) On the fourth floor, an alcove off of the corridor was found to be lacking a sprinkler head. 2) On the second floor the, sprinkler head noted above the smoke barrier doors near room [ROOM NUMBER] was less than the required 4 from the adjacent wall. 3) In the basement laundry chute room, the sprinkler head was less than 4 from the adjacent wall. At the time of these findings, the Director of Maintenance stated that this would be corrected. 2012 NFPA 101 2010 NFPA 13 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrections: a. Director of Environmental Services checked all sprinklers in the facility across all four floors and basement. No negative findings b. Administrator called Fire Safety Sprinkler Corp regarding the need to replace sprinkler heads on the second and fourth floor as well as the basement that are in question. c. Fire Safety Sprinkler Corp replaced 2 upright sprinkler heads next to the wall with vertical sidewall sprinkler heads near room [ROOM NUMBER] and in basement laundry chute room. d. Fire Safety Sprinkler Corp installed a new sprinkler head in the 4th floor alcove off corridor. II. Identification: a. The facility respectfully acknowledges this deficiency affects all residents. III. Systemic Changes: a. Administrator and Director of Environmental Services reviewed policy for Sprinkler System and found it to be compliant. b. Administrator in-serviced all maintenance staff on sprinkler coverage and need for sprinklers to be at least 4 inches from the wall. IV. Monitoring: a. Director of Environmental Services developed a sprinkler inspection audit to ensure all areas are sufficiently covered by sprinklers. b. Audits will be done weekly for quarterly for one year. c. All negative findings will be immediately addressed. d. All audit findings will be presented to the QA committee quarterly by the Director of Environmental Services / designee. V. Responsibility: a. The Director of Environmental Services will be responsible to ensure correction of this deficiency. |