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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, cleaning chemicals were not stored properly, equipment was not in good repair or installed safely, equipment and floors were not clean, and the proper testing equipment was not available for checking the concentration of sanitizing solution. This is evidenced by: During observations on 01/13/2025 at 12:29 PM, the following was noted: ?? Glass cleaner was stored above food processor. ?? The warewashing area spay hose nozzle was hanging below the sink flood rim in water. ?? The facility did not have correct test papers to check the sanitizing solution; the test papers presented did not show a 150 parts per million of quaternary ammonium compound graduation and a graduation above 400 parts per million of quaternary ammonium compound; and the sanitizer concentrate label stated the efficacy range was between 150 and 400 parts per million of quaternary ammonium compound. ?? The deli station reach-down refrigerator door gasket was split and uncleanable. ?? The underside of floor mixer, floor under bakers worktable, and floor under bakers sink were soiled with food particles or dirt. During an interview on 01/15/2025 at 1:18 PM, Administrator #1 stated that they would speak with the Dietary Department regarding the issues identified including the glass cleaner storage, the sanitizer test papers, the spray hose and potential back-siphonage, and the cleaning items. 10 New York Codes, Rules, and Regulations 415.14(h) | Plan of Correction: ApprovedFebruary 24, 2025 F812 (483.60) Spray hose and potential back siphonage issue with hose being too long and resting in standing pot water in pot room. 1.Work order placed by supervisor on duty 1/13/25 asking for shorter spray hose to be installed. Work order (# 5) completed on 1/19, issue permanently fixed. 2.All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the spray hose length is appropriate to prevent potential back siphonage. 3.Nutrition Services and Facilities team made aware that hose must be short and not rest in water. 4.Scheduled kitchen mock surveys in place to document compliance with spray hose length. If non-compliance is discovered a separate work order will be generated and issued to Facilities. 5.Target date for corrective action was 1/19/25. Director Nutrition Services is the responsible party F812 (483.60) Deli Cooler Gasket was split and uncleanable. 1.Work order submitted on 1/13/25 requesting gasket replacement. Work order (# 1) completed on 1/18/25. 2.All residents have potential to be affected by this alleged deficient practice. 3.Cooler gasket checks have been added to routine cooler preventive maintenance schedule. Deli cleaning and closing checklist revised to add gasket cleaning. Deli staff will be educated on this revised cleaning list, understanding and awareness will be confirmed via employee sign off on this education. 4.Scheduled kitchen mock surveys in place to document compliance with gaskets in main kitchen, deli and SNF kitchen. If non-compliant gaskets are discovered a separate work order will be generated and issued to Facilities. 5.Target date for corrective action was 1/18/25. Director Nutrition Services is the responsible party F812 (483.60) Incorrect sanitizer test strips used in ware washing sanitizer sink. 1.Ecolab rep called immediately and delivered a supply of QT-40 test strips in less than one hour. All Qt-10 Test strips on site were immediately discarded. 2.All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the QT-40 test strips are the only strips available and in use for testing PPM of sanitizing solution. 3.Electronic order guide updated to remove QT-10 and replace with appropriate Qt-40 test strip to help prevent the inappropriate test strip from being ordered. Education developed to include manufacturer recommendations for type of test strip to be used to test sanitizer ppm as well as target ppm range. This education will be provided bi-annually. 4.Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5.Target date for corrective action was 1/13/25 when all QT-10 were discarded and steps implemented as per above. Director Nutrition Services is the responsible party. F812 (483.60) Chemicals not stored properly. Spray bottle of glass cleaner left on windowsill in food prep area near equipment. 1.Spray bottle in question immediately removed form food prep area and stored properly. Inspection of other areas of kitchen revealed no other non-compliant chem storage issues. Staff working in impacted area made aware of non-compliance and reminded of proper storage. 2.All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor the department for compliance with proper chemical storage. 3.Nutrition Service leadership with provide initial and then bi-annual training on proper storage of chemicals. 4.Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5.Target date for corrective actions is 90 days from survey. Director Nutrition Services is responsible party. Audits and surveys will be shared with SNF QAPI monthly. F812 (483.60) Underside of the floor mixer, floor under the baker?ÇÖs worktable and bakers sink were soiled. 1.Area under baker?ÇÖs worktable and pots sink was swept/cleaned immediately by staff members. Work order # 3 submitted requesting removal of the mixer assembly on the underside of the floor mixer for proper cleaning. 2.All residents have the potential to be impacted by this alleged deficient practice. 3.Daily cleaning and closing checklist to be signed off on daily by staff/leader to ensure floors are appropriately cleaned along with other equipment in this area. Mixing assembly removed at underside of floor mixer and sent for cleaning, sanding, repainting. 4.Any non-compliance found daily during cleaning sign off will be addressed in real time. Trends in non-compliance with specific staff will be reviewed weekly when cleaning lists are reviewed prior to scanning into e-file. Non-compliance will be addressed with retraining and job performance disciplines as warranted. Scheduled kitchen mock surveys in place to document compliance with workstation and mixer cleanliness. 5.Target date for corrective action is 90 days from survey. Director Nutrition Services is the responsible party. Daily cleaning sign off and surveys will be shared with SNF Quality Assurance Performance Improvement monthly meeting. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated survey (Case #s NY 121, NY 317, and NY 618), the facility did not ensure the resident's right to be free from abuse and neglect for 3 (Resident #s 1, 14, and 23) of 4 residents reviewed for abuse and neglect. Specifically, (a.) for Resident #1, a staff member grabbed their forearm and removed their call light on 6/23/2024; (b.) for Resident #14, a bed bolster was not in place when one staff member assisted in the resident's care when the resident required two staff, resulting in a fall on 12/22/2024; (c.) for Resident #23, a staff member grabbed their hand resulting in a skin tear. This is evidenced by: A policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Resident #1 Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 4/05/2024 documented the resident was able to be understood, to understand others, and was cognitively intact. The comprehensive care plan titled, Behavioral Symptoms, documented the following interventions when the resident became verbally abusive to staff: ?? Temporarily interrupt care ?? Be sure the resident had call bell in reach The Nursing Home Investigative Report dated 7/2/2024 documented Resident #1 had reported to Registered Nurse #3 that Registered Nurse #2 had twisted their wrist and taken their call light away. Resident #1 had a reddened area to their wrist. In a witness statement dated 6/23/2024, Registered Nurse #3 documented Resident #1 had accused Registered Nurse #2 of twisting their wrist while taking the call light away. Registered Nurse #3 noted in their statement that the resident had 'some' redness to the wrist. Registered Nurse #3 notified. In a witness statement dated 6/24/2024, Licensed Practical Nurse #2 stated they did not witness the event but Resident #1 had asked not to have Registered Nurse #2 care for them because they had twisted Resident #1's wrist on their last interaction. In a progress note dated 6/24/2024, Nurse Practitioner #1 documented Resident #1 had bruising to their right wrist. Radiography was ordered and showed no fracture or dislocation. In a progress note dated 6/27/2024, Social Worker #1 met with Resident #1 who reiterated the incident to Social Worker #1. Resident #1 affirmed they felt safe at the facility. During an interview on 1/16/2025 at 1:16 PM, Director of Nursing #1 stated Resident #1 was prone to behaviors including verbal abuse of staff and making accusatory statements. The facility had developed a care plan to address these behaviors to keep both the resident and staff safe, including giving the resident space and removing themselves from the situation. They stated Registered Nurse #2 did not follow the care plan. During an interview on 1/15/2025 at 11:35 AM, Director of Nursing #1 stated Registered Nurse #2 had been a new hire and was still on probation and had chosen to resign. They stated that this incident had been reported to the Office of Professions to follow up. Resident #14 Resident #14 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Fall Risk, reviewed 1/10/2025, documented the following intervention: staff would place posey rolls (bed bolsters) while resident was in bed. The comprehensive care plan titled, Activities of Daily Living, reviewed 1/10/2025, documented the following intervention: Bed mobility was total dependence with 2-person physical assist. The Accident/Incident report dated 12/22/2024, documented Resident #14 had a witnessed fall out of bed while personal care was being completed by a Certified Nurse Aide. The report documented Certified Nurse Aide #3 was performing personal care alone when the resident was a 2-person assist. Additionally, the bed bolster was not in place. In a written statement dated 12/22/2024, Certified Nurse Aide #3 documented they had provided care without an additional assist of another staff member. During an interview on 1/15/2025 at 11:35 AM, Director of Nursing #1 stated Certified Nurse Aide #3 had received education regarding the requirement to follow the care plan to prevent accidents and injuries. They stated Resident #14 had no injuries resulting from this incident. Resident #23 Resident #23 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Behavioral Symptoms: Resists Care, effective 7/05/2023, documented the following interventions: Allow time to de-escalate and re-approach if agitated. 2 staff assist as needed for care when behavioral An Accident Report dated 12/25/2024 at 2:00 AM, documented the resident had a skin tear on the right hand caused by Certified Nurse Aide #3's failure to follow the Comprehensive Care Plan to have 2 staff present when resident was having behaviors. In a witness statement dated 12/27/2024, Registered Nurse #4 documented they observed Certified Nurse Aide #3 grab Resident #23's hands and hold them down. When told to let go, they did, and the resident's right hand was bleeding. An investigation report dated 12/26/2024 documented, upon review of the accident report on 12/25/2024 at 1:00 PM it was discovered an incident occurred on 12/25/2024 at 2:00 AM. The conclusion of the investigation was the aid failed to follow the care plan regarding the resident being resistive to care, not using the bed alarm, or treating the resident with respect. Administrator #1 notified at 2:30 PM, the Certified Nurse Aide was removed from work, and reportable incident completed. During an interview on 1/17/2025, Director of Nursing #1 stated they completed the investigation and found Certified Nurse Aide #3 to be responsible for the resident's injury and their employment was terminated. 10 New York Code, Rules, and Regulations 415.4(b)(1)(i) | Plan of Correction: ApprovedFebruary 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #1 had a skin check completed by registered nurse. Skin check revealed reddened area to wrist on 6/23/2024 Director of Nursing was notified on 6/23/2024 Administrator was notified per policy on 6/23/2024 Registered Nurse #2 was immediately placed on administrative leave and removed from facility pending investigation on 6/23/2024 Department of Health notified on 6/23//24. Provider ordered diagnostic studies on 6/24/24 which revealed no fractures. Registered Nurse #2 was terminated from employment on 6/26/24 and Office of Professions notified of incident. B. Resident #14 had a recorded witnessed fall on 12/22/24 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024 Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024 Resident #14 sent to emergency roiagnom on [DATE] and returned on 12/22/2024 with no findings Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investiation Certified Nurse Assistant was provided care plan educated on 12/23/2024. The education was provided by Nurse Educator 12/23/2024. C. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024 Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024 Registered Nurse #4 was educated reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024 Certified Nurse Assistant was placed on administrative leave on 12/25/2024 Certified Nurse Assistant was terminated on 12/27/2024 2.Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency A review of all residents with behavior care plans was completed on 02/21/2025 One additional resident was identified as requiring 2 assist with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18 2025 Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually The abuse Reporting and investigation policy was reviewed on 2/10/2025 with no changes. C. There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4.All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee ?á |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification and abbreviated survey (Case #NY 618), the facility did not ensure adequate supervision and assistive devices were provided to prevent accidents for 1 (Resident #14) of 3 residents reviewed for accident hazards. Specifically, Resident #14, who required 2 caregivers for care was assisted with 1 caregiver and a bed bolster was not in place resulting in the resident rolling out of bed. Resident #14 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The comprehensive care plan titled, Fall Risk, reviewed 1/10/2025, documented the following intervention: staff would place posey rolls (bed bolsters) while resident is in bed. The comprehensive care plan titled, Activities of Daily Living, reviewed 1/10/2025, documented the following intervention: Bed mobility total dependence with 2 person physical assist. The Accident/Incident report dated 12/22/2024, documented Resident #14 had a witnessed fall out of bed while personal care was being completed by Certified Nurse Aide #3. The report documented Certified Nurse Aide #3 performed personal care alone when the resident required a 2 person assist and the bed bolster was not in place. In a written statement dated 12/22/2024, Certified Nurse Aide #3 documented they had provided care without additional assistance from another staff member. During an interview on 1/15/2025 at 11:35 AM, Director of Nursing #1 stated Certified Nurse Aide #3 had received education on following the care plan to prevent accidents and injuries. They stated Resident #14 had no injuries resulting from this incident. 10 New York Codes, Rules, and Regulations 483.25 (d)(1)(2) | Plan of Correction: ApprovedFebruary 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #14 had a recorded witnessed fall on 12/22/24 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024 Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024 Resident #14 sent to emergency roiagnom on [DATE] and returned on 12/22/2024 with no findings Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation Certified Nurse Assistant was provided care plan educated on 12/23/2024. The education was provided by Nurse Educator 12/23/2024 2.All residents who have Activity of Dailey Living care plans for bed mobility requiring 2-person assistance have the potential to be affected by this alleged deficient practice. B.A review of all current resident's, Activity of Daily Living care plan was reviewed to identify all residents requiring two-person assistance with bed mobility on 2/21/2025. C. Twelve additional residents were identified as being care planned for 2 person assist for bed mobility D A review of all incident and accident reports since 12/22/2024 was completed on 2/21/2025 to with no other incidents/ accidents attributed to bed mobility care plan violations. 3. The incident and accident policy was reviewed by the Director of Nursing with no revisions made. B. Certified Nurse Assistant was provided care plan educated on 12/23/2024. The education was provided by Nurse Educator 12/23/2024 C. All current Registered Nurses, Licensed Practical Nurses physical, certified nurse assistants and therapy staff will be educated on Activity of Daily living Care plans to include bed mobility requiring 2 assist. D. All new Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants and Physical Therapy staff will be educated at new employee orientation 4. A random weekly visual audit of 10% (4) residents of the in-house census will be completed to ensure that staff are following compliance with the level of assistance identified in the care plan. B. Audit will be completed weekly by the Director of Nursing or designee and will include day, evening and night shifts. B. Audit results will be reported to the monthly Quality Committee until 100% compliance is maintained for 3 consecutive months and then at the recommendation of the committee. 5. Responsible Party: Director of Nursing/ Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated survey (Case #NY 317), the facility did not ensure the resident's right to be free from further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for 1 (Resident #23) of 4 residents reviewed for abuse and neglect. Specifically, Certified Nurse Aide #3 was not removed immediately from resident's care when there was an allegation of physical abuse to prevent further abuse from occurring. Certified Nurse Aide #3 was allowed to work until the end of their shift. This is evidenced by: The facility policy and procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, documented the facility would actively protect the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. When an incident of alleged abuse occurs, the Administrator or designee would be responsible for assuring the resident's security, protection, and confidentiality would be maintained during the investigation. Resident #23 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 12/29/2024 documented the resident was rarely understood, could sometimes understand, and had severely impaired cognitive skills. An Accident Report dated 12/25/2024 at 2:00 AM documented Resident #23 had a skin tear on their right hand caused by Certified Nurse Aide #3's failure to follow the Comprehensive Care Plan to have 2 staff members present when the resident was having behaviors. In a witness statement dated 12/27/2024, Registered Nurse #4 documented they observed Certified Nurse Aide #3 grab Resident #23's hands and held them down. When told to let go, they did, and the resident's right hand was bleeding. An investigation report dated 12/26/2024, documented, upon review of the accident report on 12/25/2024 at 1:00 PM it was discovered an incident had occurred on 12/25/2024 at 2:00 AM. The conclusion of the investigation was the aide failed to follow the care plan regarding the resident being resistive to care, not using the bed alarm, or treating the resident with respect. Administrator #1 was notified at 2:30 PM, Certified Nurse Aide #3 was suspended, and an incident report was made to the New York State Department of Health. During an interview on 01/17/2025 at 10:34 AM, Director of Nursing #1 stated the accused staff was not removed from resident care by the Nursing Supervisor as they should have been, and the incident was not reported to the Administrator #1 or Director of Nursing #1. It was discovered upon daily review of the incident reports. The accused staff completed their shift. The abuse allegation was substantiated by the facility investigation and the accused staff was terminated. Education was provided to the Nursing Supervisor regarding abuse reporting and investigation procedures. During an interview on 01/17/2025 at 10:34 AM, Administrator #1 stated they were not made aware of the incident right away and when they were made aware of it, they reported it. They took immediate action and took the accused staff off the schedule. The staff should have been sent home at the time the incident was discovered, but was not. 10 New York Codes, Rules, and Regulations 483.12(c)(3) | Plan of Correction: ApprovedFebruary 21, 2025 Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024 Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024 Registered Nurse #4 was educated reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024 Certified Nurse Assistant was placed on administrative leave on 12/25/2024 Certified Nurse Assistant was terminated on 12/27/2024 2.Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency A review of all residents with behavior care plans was completed on 02/21/2025 One additional resident was identified as requiring 2 assist with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18 2025 Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually The abuse Reporting and investigation policy was reviewed on 2/10/2025 with no changes. C Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4.All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification and abbreviated survey (Case #NY 317), the facility did not ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the Administrator of the facility and to the State Survey Agency for 1 (Resident #23) of 4 residents reviewed. Specifically, an allegation of physical abuse observed by staff on 12/25/2024 at 2:00 AM was not reported to the New York State Department of Health within 2 hours after the allegation was made. The allegation was reported to the New York State Department of Health on 12/26/2024 at 3:19 PM. This is evidenced by: The Policy and Procedure titled, Abuse Prevention, Investigation, and Reporting, revised 8/19/2024, stated incidents that resulted in bodily injury must be reported within 2 hours. Resident #23 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 12/29/2024 documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. An Accident Report dated 12/25/2024 at 2:00 AM, documented the resident had a skin tear on their right hand caused by Certified Nurse Aide #3's failure to follow the Comprehensive Care Plan to have 2 staff members present when the resident was having behaviors. In a witness statement dated 12/27/2024, Registered Nurse #4 documented they observed Certified Nurse Aide #3 grab Resident #23's hands and held them down. When told to let go, they did, and the resident's right hand was bleeding. An investigation report dated 12/26/2024, documented, upon review of the accident report on 12/25/2024 at 1:00 PM, it was discovered that an incident had occurred on 12/25/2024 at 2:00 AM. Administrator #1 was notified at 2:30 PM, Certified Nurse Aide #3 was suspended, and an incident report was made to the New York State Department of Health. During an interview on 01/17/2025 at 10:34 AM, Administrator #1 stated they should have been made aware sooner and this incident should have been reported within 2 hours. 10 New York Codes, Rules, and Regulations 415.4 (b)(3) | Plan of Correction: ApprovedFebruary 6, 2025 1.Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand. Registered Nurse #4 applied steri strips to skin tear on right hand. Registered Nurse #4 was reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024 2.Other residents do have the potential to be affected by alleged deficiency 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff will be educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education will include a posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually C. The Abuse Prevention, Reporting and Investigation Policy was reviewed There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4.All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee |
Scope: N/A
Severity: N/A
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the recertification survey, the facility did not sign the required documents before submitting requests for criminal history information on 5 of 5 new employees reviewed. Specifically, a facility Authorized Person did not sign the required forms Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information prior to requesting criminal history record checks, as required by 10 New York Codes, Rules and Regulations section 402.5(c). This is evidenced by: There was no documented evidence that a facility Authorized Person signed the required form Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information for Certified Nurse Aide #2, Nutrition Service Worker #1, Nutrition Service Worker #2, and Nutrition Service Worker #3. During an interview on 01/14/2025 at 10:22 AM, Director of Employee Relations #1 stated that they would ensure in the future that the facility authorized person signed all consent forms. 10 New York Codes, Rules, and Regulations 402.5(c) | Plan of Correction: ApprovedFebruary 18, 2025 1. No resident was affected by alleged deficient practice 2. Other residents have the potential to be affected by alleged deficient practice. 3. All prior Criminal History Record Check forms have been audited for signature. Those without signature are being reviewed with signatory for correction. B. Workflow and Human Resource system configuration has been updated to require written signature. C. Policy updated to highlight signature requirement. Authorized Human Resource employee who completed task has been reeducated by Human Resource Director. Two additional Human Resource employees have been set up with access through Criminal History Record Check and trained by Human Resource Director to support this work. D. A check system has been put in place, completed by a second person, to ensure all forms are verified for accuracy. 4. Human Resource Director will audit 100% of completed forms for past three months and for new hires. B. The results of all audits will be presented at the monthly Skilled Nursing Facility Quality Assurance Performance Improvement for further recommendations 5. Human Resource Director is responsible the accuracy of the process. HR Position Coordinators are responsible for completing the task. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #28) of 2 residents reviewed for communication. Specifically, Resident #28, who had impaired vision was not assisted in obtaining optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #28 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/10/2024, documented the resident was understood, able to understand others, and was cognitively intact. The Minimum Data Set documented the resident had impaired vision and used corrective lenses. Review of the medical record showed no optometry consults were documented for the resident, nor was a comprehensive care plan developed for the resident regarding their vision. During an interview on 1/13/2025 at 12:55 PM, Resident #28 stated they had not seen an eye doctor and felt they needed a new prescription. During an interview on 1/16/2025 at 1:20 PM, Registered Nurse #1 stated the resident had not seen an eye doctor since their admission to the facility. Registered Nurse #1 stated they had requested the resident be placed on the optometry list to be seen. 10 New York Codes, Rules, and Regulations 415.12(2)(b) | Plan of Correction: ApprovedFebruary 21, 2025 1. Resident #28 A. An eye examination is scheduled for (MONTH) 14,2025 2. Other residents with visual deficits have the potential to be affected by this alleged deficient practice. A full house audit of all residents was completed on 2/18/2025 by, the Intake Manager, to identify residents with visual impairment. Each current resident identified as having visual impairment was offered an eye examination on 2/21/2025. The resident representative was contacted for all residents identified with visual impairment, who cannot make their own decisions on 2/21/2025. There were 15 additional residents identified with visual impairment whose last eye exam was over 1 year. 5 of the 15 residents and the other 10 declined. 3. The policy Vision and Hearing was created by the Director of Nursing on 2/18/2025. The Vision and Hearing Policy will include required consult documentation and comprehensive care plan development for Vision and hearing. B. All Nursing staff and the administrator will be educated on the Vision and Hearing Policy. Staff will complete a written post test to ensure comprehension of the policy. Education will be completed prior to 3/4/2025 C. All current resident's Minimum Data Set Assessments will be reviewed to identify vision and or hearing needs. Residents identified as having vision or hearing needs will have consultations scheduled and upon admission for new residents then as needed. 4. A monthly audit will be completed for all residents to ensure vision appointments have been offered per policy All Audit results will be reported to the monthly Quality Committee until three consecutive months of compliance is achieved then at the direction of the committee 5. Director of Nursing / Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the emergency plan did not provide documentation about the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the facility emergency prepared plan dated 03/31/2024, addressed the following: ?? Identification of the resident population served and their unique needs, ?? Strategies the facility had put in place to address the needs of the population, ?? Description of the types of services the facility could provide in the event of an emergency, and ?? How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. During an interview on 01/15/2025 at 12:33 PM, Director of Emergency Management and Life Safety #1 stated that the emergency preparedness plan would be updated to include documentation about the resident populations that would be at risk during an emergency and the type of services the facility would put in place to address their unique vulnerabilities. 42 Code of Federal Regulations: 483.73(a)(3) | Plan of Correction: ApprovedMarch 11, 2025 1.Champlain Valley Physicians Hospital will revise that the Emergency Operations Plan includes all Skilled Nursing Unit residents and addresses the unique needs of the population. B. Strategies the facility had put in place to address the needs of the population, C. Description of the types of services the facility could provide in the event of an emergency, and D. How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. Review will be conducted by (MONTH) 15, 2025. 2. All skilled nursing facility residents have the potential to be affected by alleged deficient practice. 3. The Skilled Nursing Facility staff will be educated on the revised Emergency Operations Plan annually and as needed 4.The Director of Emergency Management will conduct one policy audit per quarter , and as needed, to confirm Identification of the resident population served and their unique needs, ?? Strategies the facility had put in place to address the needs of the population, ?? Description of the types of services the facility could provide in the event of an emergency, and ?? How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency All Revisions to the Emergency Operations Plan will be reviewed at Skilled Nursing Facility Quality Assurance Committee for recommendations and approval 5. Director of Life Safety & Emergency Management |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not ensure that 18 of 63 staff received annual training in emergency preparedness policies and procedures. This could affect all residents. This is evidenced by: There was no documented evidence that 18 of the 63 staff working in the skilled nursing facility received annual training in the emergency plan. During an interview on 01/15/2025 at 1:05 PM, Registered Nurse #1 stated that they would consult with the Organizational Development Coordinator to ensure all staff that work on the skilled nursing facility received the required training. 42 Code of Federal Regulations 483.73(d)(1)(ii) | Plan of Correction: ApprovedMarch 3, 2025 1. There were eighteen (18) staff identified as not having completed annual Emergency Preparedness Education. B. Any staff member who was identified as incomplete will complete the annual Emergency Preparedness Training prior to 3/04/2025. Any staff who did not complete the Emergency Preparedness Training by 03/04/2025 will be removed from the schedule and unable to work on Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. B. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Organizational Development Coordinator will run completion reports. An Educational report for completion status of the Emergency Preparedness Training will be reviewed monthly to ensure all staff are compliant with Emergency Preparedness Training 4. Completion report of the Emergency Preparedness Training will be reviewed at the monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did protect pressurized oxygen cylinders in accordance with adopted regulations. Specifically, empty cylinders were not marked as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition Section 11.6.2.2 This is evidenced by: During observations on 01/14/2025 at 12:31 PM, 4 empty oxygen cylinders in the Clean Supply room (room [ROOM NUMBER]B) were not marked. During an interview on 01/14/2025 at 12:44 PM, Licensed Practical Nurse #1 stated that 3 oxygen tanks in the unmarked rack were empty. During an interview on 01/14/2025 at 1:06 PM, Administrator #1 stated that signs would be installed to mark empty oxygen cylinders. 42 Code of Federal Regulations 483.70 (a) (1) 2012 NFPA 99 11.6.2, 11.6.5 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(26) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were four (4) oxygen cylinders identified in the alleged deficient practice. B. The oxygen tank racks were inspected, and empty cylinders were moved to the empty cylinder rack at the time of the survey. C. Signage on the racks was updated to reflect the clean and empty racks and signs were secured to racks. 2. All residents with Oxygen Orders have the potential to be affected by this alleged deficient practice. B All Current Skilled Nursing Facility staff will be educated on Compressed Gas. The Compressed Gas Training includes proper storage and placement of Oxygen Cylinders. C All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Day shift Charge Nurse will complete daily inspection of compressed gas racks on the Skilled Nursing Unit to ensure signage is in place and cylinders are suitably stored. The inspection will be documented on the Environment of Care log. 4.Scheduled [MEDICATION NAME] and Environment of Care rounds are in place to document compliance with compressed gas storage B. Results of daily Compressed Gas Storage and monthly Enviromental Rounds will be reviewed at the monthly Quality Assurance Performance Improvement Committee for further recommendations. 5. Associate Vice President of Facilities. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not manage pressurized oxygen cylinders in accordance with adopted regulations. Specifically, 19 of 63 employees that handle oxygen cylinders did not receive education on the risks associated with their handling and use as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1. This is evidenced by: There was no documented evidence that 19 of 63 employees working in the skilled nursing facility including the physical therapy department and [MEDICAL TREATMENT] section received periodic training on the risks and proper handling of oxygen cylinders. During an interview on 01/15/2025 at 9:14 AM, Registered Nurse #1 stated that staff working in the physical therapy department and [MEDICAL TREATMENT] section did not receive training on the risks and proper handling of oxygen cylinders. During an interview on 01/15/2025 at 1:02 PM, Registered Nurse #1 stated that they would consult with the Organizational Development Coordinator to ensure all staff that work in the skilled nursing facility received the required training on handling oxygen cylinders. 42 Code of Federal Regulations 483.70 (a) (1) 2012 NFPA 99 11.5.2.1 | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were nineteen (19) staff identified as not having completed annual Compressed Gas Education. B. Any staff member who was identified as incomplete including staff in [MEDICAL TREATMENT] and physical Therapy will complete the annual Compressed Gas Training prior to 3/04/2025. C. Any staff who did not complete the Compressed Gas Training by 03/04/2025 will be removed from the schedule and unable to work on Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. 3.The Organizational Development Coordinator will provide an Education report for completion status of the Compressed Gas Training will be reviewed monthly to ensure all staff of the Skilled Nursing Facility are compliant with Compressed Gas Training Education will be documented in the facility electronic education soft wear or on education sign in sheet. Staff who are not compliant will be removed from the schedule until verification of completion all other staff working in the skilled nursing facility will be reviewed for the required training and those that have not, will receive the training. 4. Completion Report of the Compressed Gas will be audited monthly with audit results reviewed at the Monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations in 2 resident areas. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 01/15/2025 at 8:44 AM, the activities room and dining room did not have emergency lighting. During an interview on 01/15/2025 at 9:32 AM, Associate Vice President of Patient Care Operations #1 stated that emergency lighting would be installed in the activities room and dining room on the skilled nursing unit. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedMarch 6, 2025 1.Lighting controls within the Dining and Activity rooms will be changed to maintain constant illumination within the Dining and Activity Room per NFPA 101: 7.8. Specific fixtures identified will be connected to emergency power circuits. 2 Facilities will verify the lights operate continuously and cannot be turned off with a wall switch. Facilities will survey all other areas of the Skilled Nursing Unit and the adjacent, 5 Main East wing to verify that the emergency lighting system conditions are in compliance with NFPA 101: 7.8. This survey will be completed by (MONTH) 10, 2025. 3.The Environment of Care Checklist will be modified to include evaluation of emergency lighting to ensure conformance with NFPA 101:7.8. This will be completed by (MONTH) 10, 2025. 4.The Facility currently conducts checks of all emergency lighting on the Skilled Nursing Unit on a monthly frequency. Documentation is maintained by Facilities. 5.Associated Vice President of Facilities |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include strategies for addressing each emergency event identified by the facility risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the facility emergency preparedness plan developed plans for loss of call bell, loss of emergency generator, and cyber-attack. During an interview on 01/15/2025 at 12:53 PM, Director of Emergency Management and Life Safety #1 stated that the emergency preparedness plan would be updated to include plans for loss of call bell, loss of emergency generator, and cyber-attack. 42 Code of Federal Regulations 483.73(a)(1) | Plan of Correction: ApprovedMarch 12, 2025 1.The Emergency Preparedness Plan will be reviewed and revised B. The Emergency Preparedness plan will be revised to include response actions that address loss of generator, loss of nurse call, cyber -attack and missing residents specific to the Skilled Nursing Facility. Review of the Emergency Preparedness Plan will be complete by (MONTH) 15, 2025. 2.The skilled nursing facility will review and revise the Emergency Operations Plan to include ensure compliance with all emergency preparedness requirements 3. The Skilled Nursing Facility staff will be educated on the policies for loss of generator, loss of nurse call, cyber -attack and missing residents in an annual basis and with any changes to the Emergency Preparedness plan 4.The Director of Life Safety and Emergency Preparedness Plan will review the Emergency plan annually at a minimum and as needed to ensure to ensure all emergency events in the facility risk assessment are addressed. B. The Emergency Preparedness plan will be presented quarterly at the skilled nursing facility Quality Assurance and Performance Improvement committee and as needed for approval. 5.The Director of Life Safety & Emergency Management |