Eddy Village Green

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. Specifically, in two medication carts and all eight medication rooms reviewed, opened medications lacked open and expiration dates, and one active medication was found to be expired. Additionally, medication rooms were left open and unattended, and unlicensed staff had access to these rooms. Observations revealed that medication room doors were left open, allowing unauthorized access by staff such as Certified Nurse Aides and dietary personnel, who were not certified to administer medications. This access was granted because some patient care supplies were stored in the medication rooms. Further observations showed that several medications, including insulin pens, ear drops, and inhalers, were stored without proper labeling of open and expiration dates. The medication rooms also contained stock medications and supplies accessible to unauthorized staff. Alcoholic beverages were found in the medication room refrigerator and on top of a filing cabinet, with no tracking of their usage. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that unauthorized access to medication rooms was a common practice, and there was a lack of adherence to the facility's policies regarding medication storage and access control.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be non-compliant with the requirement to post nurse staffing information in an area accessible to all residents and visitors. During the recertification survey, it was observed that the daily nurse staffing levels were only posted on one resident unit and not accessible to residents and visitors on the other units. The postings were located on the wall by the reception desk in the administration building, which was not readily visible or accessible to all residents and visitors. The Director of Nursing confirmed that the nurse staffing postings were not displayed in the residential houses and expected residents and visitors to go to the administration building to view them.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the ongoing provision of activity programs tailored to meet the interests and support the physical, mental, and psychosocial well-being of three residents. Resident #22, who had severe cognitive impairments, was observed multiple times in the common area dozing off with no documented activities on several dates. The resident's care plan indicated they should participate in activities of their choice to maintain the highest quality of life, yet there was no evidence of such activities being provided. Resident #25, also with severe cognitive impairments, was observed alone in their room on multiple occasions without any activities or interaction. Although personal craft supplies were available, they were not within reach, indicating a lack of engagement in planned activities. Similarly, Resident #16, with moderate cognitive impairment, was observed without staff interaction or activities, despite their care plan indicating participation in group activities of choice. Interviews with staff revealed inconsistencies in the implementation of the activity calendar, with some staff not following it. The Recreational Therapy Manager noted that activities were dependent on the availability of staff, and there were limited outside trips due to a lack of drivers. The facility's policy required a written plan for activities based on individual needs, but the observations and interviews indicated a failure to consistently implement these plans, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that assessments were coordinated with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid for eight residents. Specifically, residents were admitted with or received new diagnoses that potentially indicated mental illness or intellectual disability, yet the necessary Level II evaluations were not conducted. The facility's policy required a Level I screening prior to admission to determine if a resident had a mental illness or intellectual disability, and if indicated, a Level II evaluation should be completed by a qualified mental health professional. However, for several residents, the Level I screenings did not identify serious mental illness, and subsequent psychiatric consultations revealed diagnoses that should have prompted a Level II evaluation. Interviews with facility staff revealed a lack of coordination and follow-up regarding the PASARR process. Social workers and the admissions coordinator acknowledged that Level II screens should be requested for certain conditions, but this was not consistently done. For instance, one social worker stated that a developmental disability, serious mental illness, or intellectual disability would warrant a Level II screen, yet residents with such conditions did not receive the necessary evaluations. This oversight in the screening process led to a deficiency in ensuring appropriate assessments and care planning for residents with potential mental health needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure food was stored in accordance with professional standards for food service safety in four of its 16 resident central kitchens. Specifically, bulk food items were not labeled for their contents, and both bulk and outside items were not date-labeled after opening or labeled with an expiration date. Additionally, appliances were found to be unclean, with dirt, grime, and unknown substances present. An instance of improper food handling was observed where uncooked chicken was being thawed incorrectly in a kitchen sink. During observations, numerous items in the freezers of Houses #10, 12, 14, and 16 were found without labels describing their contents. Items such as frozen French fries, scones, cookies, sausage patties, fish fillets, peas, dinner rolls, and broccoli were among those not labeled. Furthermore, several items lacked labels indicating when they were opened, including bags of chips, packages of cookies, and wheat bread. The appliances in these kitchens were also noted to have seals covered with dirt and grime, old labels dating back to previous years, and unknown substances within ovens and microwaves. Interviews with staff revealed a lack of diligence in labeling and tracking item dates. Certified Nurse Aides (Shahbaz) and Registered Nurses acknowledged the responsibility of maintaining cleanliness and ensuring food safety. It was noted that labels often did not stick in the freezer, leading to their falling off. The Director of Nursing stated that while the Food Service Director oversaw food management, it was a joint effort among staff to check food items regularly for expiration dates, with a daily cleanliness checklist in place for the Shahbaz to follow.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from neglect, as evidenced by the lack of toileting care provided to four residents during the evening and night shift on 10/27/2024. These residents were left in the same clothes from the previous day, with their incontinence garments, clothes, and bedding saturated with urine. Surveillance footage confirmed that no staff entered the rooms of these residents to provide care until the arrival of the day shift on 10/28/2024. The residents involved required varying levels of assistance for toileting and transfers, as documented in their care cards, which were not adhered to by the staff. Interviews and written statements from the staff revealed that the neglect occurred due to the failure of the Certified Nurse Aides (Shahbaz #11 and #12) to follow the residents' care cards. Shahbaz #11 admitted to not changing or toileting the residents during the overnight shift, while Shahbaz #12 acknowledged placing extra incontinence pads on a resident against the care card instructions. The Director of Nursing confirmed that it was mandatory for staff to read and follow the care cards, and the involved staff members were terminated for neglect following the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that each resident's medication regimen was managed and monitored to promote or maintain their highest practicable well-being. Specifically, for five residents, as-needed medication orders for anti-psychotic and anti-anxiety medications did not include end dates, contrary to the facility's policy. The policy required that as-needed orders for such medications be limited to 14 days unless the attending physician or prescribing practitioner evaluated the resident and documented the rationale for extending the order. However, the orders for these residents were documented with indefinite end dates. The residents involved had various diagnoses, including conditions affecting the nervous system and cognitive impairments. Despite the facility's policy, the orders for as-needed medications for these residents were not appropriately time-limited. Interviews with the Medical Director and Director of Nursing revealed an awareness of the regulation but indicated a belief that medical providers should have discretion in applying end dates. This oversight in medication management was identified during a recertification survey, highlighting a deficiency in adhering to established medication management protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and functioning assistance devices for Resident #146, who was at risk for elopement due to severe cognitive impairment and a history of wandering. The resident's electronic monitoring device, intended to alert staff if the resident approached an exit, was found to be non-functional during an observation. The device, attached to the resident's walker, failed to trigger alarms at the facility's doors, and there was no documentation of daily checks for its placement and function, as required by the facility's policy. The device's battery was discovered to be dead, indicating a lapse in the weekly checks that were supposed to ensure its proper functioning. Additionally, the facility did not maintain a safe environment free of accident hazards, as evidenced by the presence of unattended alcoholic beverages in accessible areas of Houses #10, #16, and #21. In House #16, a box of beer was found in a pantry accessible to residents, staff, and visitors, with some bottles unlabeled. In House #10, an unlocked medication room contained bottles of wine and hard liquor. Similarly, in House #21, the medication room door was left open, with wine bottles inside, and staff were observed entering and leaving the room without securing it. The facility lacked a system to track the distribution and consumption of alcohol, and there was no assessment of the risk posed by accessible alcoholic beverages. The facility's failure to identify and mitigate these risks, including the lack of documentation and monitoring of the electronic monitoring device and the unsecured access to alcohol, contributed to the deficiencies noted in the survey. The absence of proper checks and balances, as well as the failure to adhere to established policies, resulted in an environment that was not adequately safeguarded against potential accidents or unintended consumption of alcohol by residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were treated with dignity and respect, as evidenced by three specific incidents involving different residents. Resident #110, who was mildly cognitively impaired, was administered medication in a common area without their permission, while other residents were present. The Licensed Practical Nurse involved did not seek the resident's consent, assuming it was acceptable since the resident always took their medication in the living room. This action was contrary to the facility's policy on resident rights, which emphasizes the importance of personal privacy during care and treatment. Resident #136, who had severe cognitive impairment, was assisted with their meal by a Certified Nursing Aide who stood over them instead of sitting down. The aide cited the lack of available chairs as the reason for standing, although it was acknowledged that sitting next to residents during meals is important for their dignity and comfort. Additionally, Resident #145, who was severely cognitively impaired, was served meals with plastic utensils without this being documented in their comprehensive care plan. The use of plastic utensils for safety reasons should have been included in the care plan, as per facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient nursing staff to maintain the safety and well-being of its residents. An analysis of the staffing schedule revealed that from late January to early April 2025, the facility frequently operated below its assessed minimum staffing levels. Specifically, the day shift often had fewer Shahbaz (Certified Nurse Aides) than required, with some houses having as few as 1 or 1.5 Shahbaz instead of the planned 2.5 per house. This staffing shortfall was corroborated by staff and resident interviews, where both groups reported insufficient staffing levels. Residents expressed concerns about the impact of inadequate staffing on their care. They reported long wait times for assistance, with some residents waiting up to an hour for help with bathroom needs. The call bell system was described as unreliable, with staff sometimes ignoring or turning off call lights without returning to provide the requested care. Residents also noted delays in receiving meals, particularly breakfast, due to the shortage of staff available to assist during mealtimes. Staff interviews further highlighted the staffing issues, with Shahbaz and Registered Nurses acknowledging the frequent short-staffing and its impact on their ability to provide timely care. The facility's scheduler admitted to difficulties in filling shifts, particularly the 8:00 AM to 1:00 PM shift, and often had to operate at minimum staffing levels. The use of agency personnel was noted as a recent necessity due to ongoing staffing challenges. Despite the facility's assessment indicating a need for three Shahbaz per house, the scheduler and nurse educator were unaware of this requirement, suggesting a disconnect between the facility's staffing plan and its implementation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure prompt resolution of a grievance filed by Resident #28's family member regarding missing hearing aids. The grievance was initially filed on 2/19/2025, but the facility did not follow up until 4/01/2025. The facility's policy required a response within 21 days, but this was not adhered to. The grievance involved the loss of two hearing aids, with only one being found. The family member reported the issue to a nurse and filed a grievance with the Social Worker, but no resolution was provided in a timely manner. Interviews with staff revealed a lack of communication and follow-up regarding the missing hearing aids. Shahbaz #8, a Certified Nurse Aide, and Licensed Practical Nurse #5 were unaware of the missing hearing aids, and Registered Nurse #4 only learned of the issue after speaking with the family member on 4/01/2025. Social Worker #2 acknowledged a disconnect in follow-up, and Administrator #1 stated that grievances should be resolved within 21 days, although missing items might take longer. The facility's failure to promptly address and resolve the grievance led to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a written notice of the bed-hold policy to a resident, identified as Resident #130, who was transferred to the hospital in an emergency situation. The facility's policy requires that the Bed Hold Policy Summary form be given to the resident or their representative at the time of transfer, or within 24 hours in cases of emergency transfer. However, there was no documented evidence that this notice was provided to Resident #130 or their representative following the transfer to the hospital after the resident was found on the floor and diagnosed with a medical condition requiring hospitalization. Interviews with facility staff revealed that the social worker responsible for sending the Bed Hold/Transfer Notice did not follow the established policy, citing that the transfer occurred over a weekend and was overlooked. The social worker typically mails the notice to the family and notifies the Ombudsman, but this procedure was not followed in this instance. The Admission's Coordinator confirmed that the Bed Hold policy is reviewed with residents upon admission, but subsequent transfers are managed by social work, indicating a lapse in the process for this particular case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident. Specifically, the deficiency involved Resident #54, who was admitted with various diagnoses and had intact cognition for daily living decisions. During an observation, it was noted that the kitchen pantry contained a box of beer labeled with the resident's name, and additional bottles were found in the pantry refrigerator without labels. The resident's care plan indicated that they enjoyed a beer on occasion, and staff were instructed to offer this during Happy Hour. However, the physician's orders allowed the resident to have a beer nightly at dinner and daily, but there was no documented process for staff to record when the resident was given an alcoholic beverage. Further investigation revealed that there was no documented evidence of policies regarding resident consumption of alcoholic beverages. During an interview, a registered nurse stated that nurses were to provide the alcoholic beverage upon the resident's request but were unsure where to document this in the medical records. The nurse acknowledged that there should be a system in the electronic records to track and record when the resident received the beverage. This lack of documentation and policy adherence led to the deficiency cited under the New York Code of Rules and Regulations 483.70 (h)(2)(ii).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as Resident #84, was properly assessed for the ability to self-administer medications. During a recertification survey, it was observed that Resident #84 was independently taking medications from a plastic cup while eating breakfast in the dining area. There was no documented evidence in the resident's medical record indicating that an assessment for self-administration had been conducted or that a physician's order was obtained to allow the resident to self-administer medications. The facility's policy required an interdisciplinary team assessment and a physician's order for residents wishing to self-administer medications, which was not followed in this case. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), revealed that the staff were unaware that Resident #84 had not been formally assessed for self-administration of medications. The LPN admitted to leaving the medications for the resident to take independently, while the RN confirmed that an assessment should have been completed. The Director of Nursing (DON) also acknowledged that an assessment was necessary and confirmed that Resident #84 did not have the required evaluation, indicating a lapse in adherence to the facility's medication administration policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents requiring respiratory care received it in accordance with professional standards. Specifically, Resident #28, who had a diagnosis of [MEDICAL CONDITION] and moderate cognitive impairments, was not administered continuous oxygen as ordered. During an observation, it was noted that the resident was wearing a nasal cannula connected to an oxygen concentrator that was turned off, meaning the resident was not receiving the prescribed oxygen. Family members and staff interviews confirmed that the concentrator was not turned on when the resident was returned to their room after breakfast, despite the order for continuous oxygen. Similarly, Resident #89, who was cognitively intact and had a history of cardiac issues, was not consistently receiving the prescribed 2 liters of oxygen. Observations showed that the oxygen concentrator was set at different flow rates than ordered, with one instance at 5 liters per minute and another at 3 liters per minute, contrary to the physician's order for 2 liters. Interviews with the Director of Nursing and other staff highlighted a lack of adherence to the prescribed oxygen orders, indicating a failure to ensure residents received the necessary respiratory care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain medical records in accordance with accepted professional standards for one resident. Specifically, a resident with diagnoses including Friedreich Ataxia, gastro-esophageal reflux disease, and essential hypertension had a physician's order to receive a beer nightly at dinner and daily. The resident's care plan also indicated that staff should offer the resident a beer during Happy Hour. During observation, beer labeled with the resident's name was found in the kitchen pantry, and additional bottles without a label were found in the pantry refrigerator. Upon review of the resident's Medication Administration Record and Treatment Administration Record for the relevant month, there was no documentation of when the resident was given an alcoholic beverage. There was also no documented process for staff to record the administration of alcoholic beverages in the medical record, nor any policy regarding resident consumption of alcohol. During an interview, a registered nurse confirmed that there was an order for the resident to receive beer but stated there was no way to document its administration in the electronic system.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that criminal history record checks were performed as required by regulations for an employee. Specifically, an Environmental Aide was observed working in the facility without documented evidence of a Criminal History Background Check. The aide was initially employed at a sister facility and was brought in to assist with environmental tasks. During an interview, the facility's administrator acknowledged that a background check should have been conducted but was not.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with the requirement to notify the New York State Criminal History Record Checks Legal Review Unit within 30 calendar days after rescinding an offer of employment. Specifically, there was no documented evidence that the Legal Review Unit was informed within the required timeframe when the offer of employment for a Certified Nursing Aide Trainee was rescinded. This deficiency was identified during a recertification survey through record review and an interview with a Colleague Relations Partner, who acknowledged that the Department of Health should have been notified within the 30-day period.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 Element 1: Certified Nursing Aide was terminated from Employment. Element 2: Human Resources will review staff whose job offers are rescinded as a result of a background check. Element 3: Policy for Criminal History Record Check has been updated to reflect the need for any staff that has had a job rescinded needs to notify the New York State Criminal History Record Checks Review Unit within 30 days from when the offer of employment is rescinded. Human Resources will be in-serviced on the requirement to notify the New York State Criminal History Record Checks Legal Review Unit within 30 days from when the offer of employment is rescinded due to the results of the Criminal History Background Check. Element 4: Audits will be conducted monthly to ensure that any employee that had an offer of employment rescinded that the New York State Criminal History Record Checks Legal Review Unit is notified within 30 days. The Quality Assurance Performance Improvement Committee will be responsible for recommending ongoing need and frequency of audits and if plan needs to be amended based on findings of audits and compliance with plan. Human Resources Authorized Person is responsible for on-going compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain emergency generator testing records in compliance with the National Fire Protection Association (NFPA) standards and federal regulations. Specifically, the emergency generator monthly test records did not document the load percentage of the nameplate under which the tests were conducted, nor did they record the generator transfer times. Additionally, the 4-hour load test records lacked documentation of engine performance during each hour of the test, including transfer time, percent of load, amperage, oil pressure, and water pressure. This deficiency was identified across multiple buildings within the facility, including Buildings #2, #3, #4, #5, #6, #7, #8, #10, #12, #14, #16, #19, #21, #22, #24, and #31 (House #1). The lack of proper documentation was consistent throughout these buildings, indicating a systemic issue in maintaining accurate and complete records for emergency generator testing. The absence of detailed records as required by NFPA 99 and NFPA 110 standards suggests a failure in the facility's processes for ensuring compliance with life safety code requirements. During the survey, the Facilities Manager acknowledged the deficiencies in the generator testing records and indicated plans to update the records to include the necessary information. However, the report focuses on the existing deficiencies and the lack of compliance with the required standards, without detailing any corrective actions or plans for future compliance.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 Element 1: Generator vendor was contacted to complete the 4-hour load test by (MONTH) 13, 2025, including engine performance during each hour of the test, including transfer time, percent of load, amperage, oil pressure, and water pressure. Generator testing records were amended to the load and generator testing times. Element 2: All residents have potential to be impacted. Element 3: Maintenance staff will be educated by facilities manager on the updated generator test log to ensure staff are aware of the required elements of generator testing. Education will be completed by (MONTH) 13, 2025. Element 4: Generator Test logs will be reviewed by facility manager or designee after all any generator testing to ensure all required elements were documented. Completed log will be brought to the monthly Quality Assurance committee to ensure compliance. Audits will be an ongoing part of the monthly Quality Assurance Committee. Committee will make recommendations for changes in plan as appropriate based on audit results. Facility Manager responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Standard Life Safety Code Survey, it was found that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan and Training Program lacked instruction and a demonstration of knowledge, such as a quiz, on the most likely hazards identified by the risk assessment. These hazards included tropical storms, blizzards, floods, thunderstorms, snow, and communication failures. There was no documented evidence that the Emergency Preparedness Plan included training and a demonstration of knowledge for these hazards. During an interview, a Nurse Senior Educator acknowledged the omission and stated that they would update the Emergency Preparedness Plan to include the necessary training and demonstration of knowledge.

Plan Of Correction

Plan of Correction: Approved May 3, 2025 Element 1 The Emergency Plan was updated to include training on the hazards rated most likely. The plan was updated to more correctly reflect the hazards the facility is most at risk to experience. The updated plan includes training for the following: Blizzard, Thunderstorm, Snow, Communication Failure. Element 2 All residents have potential to be impacted. Element 3 The Emergency preparedness education plan was updated to include training on the hazards most likely based on the facility hazard vulnerability assessment. The nurse educator will provide education to staff regarding the high-risk areas. Annually, as part of the facility assessment review, the All hazards assessment will be reviewed. Any changes in identified risks will be added to the education plan. Element 4 Results of the education will be presented to the Facility Quality Assurance Committee at the monthly meeting. The committee will make recommendations for ongoing frequency and any need for change in plan, education, or policy based on results of review. The Executive Director is responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a recertification survey, it was observed that the exits in Building #4, Building #12, Building #16, and Building #24 were not maintained in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. Specifically, the exit doors were not kept free of obstructions or impediments for full instant use. This was evidenced by the presence of stop signs placed on the smoke barrier doors, which could potentially hinder the immediate use of these exits in an emergency situation. The observations were made on March 27, 2025, at 12:51 PM, when surveyors noted the placement of stop signs on the smoke barrier doors across multiple buildings. This placement of signs is a direct violation of the NFPA 101 Life Safety Code, which mandates that exits must be maintained free of any obstructions to ensure they are readily accessible in case of an emergency. During an interview conducted on the same day at 1:33 PM, the Facilities Manager acknowledged the presence of the stop signs and indicated that they would be removed. However, the report does not provide any further details on corrective actions or the timeline for the removal of these signs. The deficiency highlights a lapse in maintaining the safety standards required for emergency preparedness in the facility.

Plan Of Correction

Plan of Correction: Approved May 3, 2025 Element 1: The STOP sign has been removed from all smoke barrier doors. Element 2: All residents can be impacted by this practice. All exit doors were checked to ensure they were free of obstructions. No issues identified. Element 3: The facility manager or designee will provide education to the facility management staff regarding the requirement for exit doors to be free of obstructions or impediments per National Fire Protection Association (NFPA). Environmental rounds will be made daily by nursing supervisor or designee to ensure exit doors remain accessible and unencumbered. Any issues identified will be corrected immediately and education provided. Element 4: Facilities staff will complete weekly audits of all exit doors to ensure they meet the National Fire Protection Association (NFPA) requirements. Results of the audits will be presented to the Facility Quality Assurance Committee at monthly meetings. The committee will make recommendations for ongoing frequency and any need for change in plan, education, or policy based on results of review. Audits will continue until facility achieves 100 percent compliance. Facility Manager responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with emergency preparedness requirements during a recertification survey. Specifically, the facility's Emergency Management Plan and Communications Plan lacked documented contact information for resident physicians and other health care facilities with which they have agreements. This deficiency was identified through record review and an interview with the Facilities Manager, who acknowledged the omission of the necessary contact information.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 Element 1 The Emergency plan, communications was updated to include the contact information for the attending physicians, medical director, facilities included in our emergency preparedness plan. Element 2 The Emergency Plan, communications were reviewed to ensure all required elements included in the plan. No changes required. Element 3 Nursing educator will provide education to Leadership Team (i.e., Director of Nursing, social work, Rehabilitation manager, facilities manager, Assistant Director of Nursing, Dietary manager, Nurse managers) on the addition of the contact information in the plan. Education will include but not be limited to the following: The information in the communications plan and how to use information in the communications plan. Element 4 The Safety Committee will review the Emergency Preparedness plan monthly to ensure that the plan is up to date and includes all required elements per regulation. Review will be reported monthly at the facility quality assurance committee for review and recommendations. This review will continue as a standard agenda item for the monthly quality assurance meeting. Facility manager responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the facility failed to include strategies for addressing each emergency event identified by their risk assessment. There was no documented evidence of emergency policies and procedures for the loss of the sprinkler system, cyber-attacks, and the use of portable generators. This deficiency could potentially affect all residents at the facility. During an interview, the Facilities Manager acknowledged the absence of these policies and procedures and indicated an intention to update the Emergency Plan.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 Element 1 The Emergency Plan was updated to include policy and procedures for: - Loss of sprinkler - Cyber-attack - Use of portable generators Element 2 All required elements for Emergency Preparedness reviewed to ensure facility plan includes all required elements. No additional changes required. Element 3 Nursing Education will provide education to all staff regarding the above named areas. The education includes but not limited to the following: - Interruption of the fire system/sprinkler system - Cyber-attack - Portable generators This education will be included in the annual education and new hire education programs. Element 4 Emergency Preparedness Plan will be reviewed monthly as part of the safety meeting agenda. Results of the Review will be reported to Quality Committee monthly. This will continue to be a standing item of the Quality Committee and Safety committee. Executive Director responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain patient care-related electrical equipment in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 10.3. During a recertification survey, it was observed that Nebulizer ASP 59, located in a specific room, was plugged in and not in use. The manufacturer's user manual for the nebulizer specified that to reduce the risk of electrocution, the nebulizer should be unplugged after use. This requirement was not followed, as evidenced by the observation of the plugged-in nebulizer. During interviews, a registered nurse acknowledged that the nebulizer should have been unplugged, and the Director of Nursing confirmed awareness of the issue. The deficiency was identified as a failure to adhere to the prescribed maintenance procedures outlined in the nebulizer's user manual, which is a requirement under the relevant NFPA standards and federal regulations.

Plan Of Correction

Plan of Correction: Approved May 5, 2025 ELEMENT 1 Nebulizer was unplugged at time of identification by surveyor during the facility New York State Department of Health annual recertification survey. Nursing staff assigned to that house was re-educated to need to unplug the nebulizer after use at the time the nebulizer was identified as being plugged in. ELEMENT 2 All nebulizers have been checked to ensure that they have been unplugged and comply with manufacturer requirements. No issues identified. ELEMENT 3 Education will be provided to staff regarding PCREE including but not limited to the following: - Testing and inspection prior to use - Availability of owner's manual for all Patient Care Electrical Equipment to determine appropriate use and safety measures specific to the equipment - Risks associated with the use of Patient Care Electrical Equipment During weekly environmental rounds, checking of Patient Care Electrical Equipment will be added to items reviewed to ensure compliance with safe use of this equipment. ELEMENT 4 Audits on 25% of Patient Care Electrical Equipment will be completed monthly to ensure that the Patient Care Equipment is being used per owner's manual. Results will be recorded on the Equipment audit tool. These audits with results and trends will be reported to the monthly Quality Assurance Committee. Any equipment noted to be out of compliance will be corrected at time of audit with education in real time to clinical staff. Audits will continue until the facility achieves 100% compliance. Quality Assurance Committee will make recommendations as to ongoing need for frequency and duration of audits. Maintenance Director responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. During the recertification survey, it was observed that smoke detectors were installed within 3 feet of ventilation ducts in the nurse office across multiple buildings, specifically Buildings #10, #14, #21, and #22. This placement does not comply with the required standards for smoke detector installation relative to ventilation system supply and return ductwork. The observations were made on March 27, 2025, between 11:00 AM and 1:30 PM. The surveyors noted that the smoke detectors' proximity to the ventilation ducts could potentially affect their functionality and effectiveness in detecting smoke. This deficiency was consistent across several buildings within the facility, indicating a systemic issue with the installation of smoke detectors. During an interview conducted at 1:30 PM on the same day, the Facilities Manager acknowledged the incorrect placement of the smoke detectors and stated that they would be relocated. However, the report does not provide details on any corrective actions taken or planned by the facility to address this deficiency. The focus remains on the improper installation of the smoke detectors and the facility's acknowledgment of the issue.

Plan Of Correction

Plan of Correction: Approved May 5, 2025 Element 1: The smoke detector will be removed and relocated to be in compliance with the National Fire Protection Association 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1 by (MONTH) 13, 2025. Element 2: All residents have the potential to be impacted by this practice. All smoke detectors will be checked to ensure compliance with National Fire Protection Association as it relates to location of detector and distance from ventilation ducts. Any alarms identified as needing to be moved to meet these requirements will be moved by (MONTH) 13, 2025. Element 3: Smoke detectors will be added to the monthly facility preventive maintenance rounds to ensure that all smoke detectors are in a location that meets National Fire Protection Association regulations. Any new installation of smoke detectors will be checked by the facility Fire Alarm Protection vendor to ensure they meet National Fire Protection Association guidelines. Element 4: Installation of new or replacement of existing smoke detectors will be added to the monthly Facility Quality Assurance Committee meeting to ensure that the new equipment was approved by the Fire Alarm Detection system vendor. This will be a standing item for this meeting. Facility Manager responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be deficient in providing emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This deficiency was observed during a recertification survey conducted on March 28, 2025. The surveyors noted that the facility did not have emergency lighting or lighting that would operate automatically without manual intervention along the means of egress to the public way in Building #2. This lack of compliance with the required safety standards was evident during observations made at 12:00 PM in the den area. During the survey, it was further revealed through an interview with Facilities Manager #1 that the facility had not installed the necessary emergency lighting in the dens. The manager acknowledged the absence of such lighting and indicated plans to address the issue. However, at the time of the survey, the deficiency remained uncorrected, posing a potential risk to the safety of residents and staff in the event of an emergency requiring evacuation. The deficiency was not isolated to Building #2, as similar issues were identified in multiple other buildings within the facility, including Buildings #3, #4, #5, #6, #7, #8, #10, #12, #14, #16, #19, #21, #22, #24, and #31 (House #1). In each case, the facility failed to provide emergency lighting that would function automatically without manual intervention, as required by the NFPA 101 Life Safety Code. This widespread non-compliance highlights a systemic issue within the facility's emergency preparedness measures.

Plan Of Correction

Plan of Correction: Approved May 3, 2025 Element 1: Vendor has been contacted to install required emergency lighting in the den in accordance with National Fire Protection Association 101 safety code to illuminate means of egress. Work to be completed by (MONTH) 13, 2025. Element 2: All residents have potential to be impacted by this practice. Element 3: Facilities manager will educate maintenance staff on the emergency lighting installed and addition of lights to the Preventative maintenance schedule. Element 4: Emergency lighting audits will be completed monthly. Audits will be checking the functionality of the emergency lights to ensure they are in good working order. Results of audits will be provided monthly to the Quality Assurance Committee. Results will be reported for three months with the Quality Committee making recommendations as to ongoing frequency. Facilities Manager responsible for compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a recertification survey, it was found that the facility failed to maintain fire-rated doors in accordance with the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition. The deficiency was identified in multiple buildings, specifically Buildings #2, #5, #6, #16, #19, #21, and #24. The issue was related to the lack of application of lubricant to the steel doors, as documented in the Coiling Steel Door Inspection and Drop Test Report dated 01/08/2025. This report indicated that lubrication was required, but there was no documented evidence that this maintenance task was completed. The deficiency was further substantiated through interviews conducted during the survey. Facilities Manager #1 confirmed during an interview on 03/26/2025 that there was no documentation available to verify that the lubrication had been applied to the doors. This lack of documentation suggests that the necessary maintenance was not performed, which could interfere with the proper operation of the fire-rated doors. The failure to maintain the fire-rated doors as required by the NFPA standards and the absence of documentation indicating that the necessary lubrication was applied represent a significant oversight in the facility's maintenance procedures. This deficiency was noted across several buildings within the facility, indicating a systemic issue in adhering to the required fire safety standards.

Plan Of Correction

Plan of Correction: Approved May 5, 2025 Element 1: Lubricant was applied to the steel door per Inspection report. Element 2: All doors in the facility were reviewed for compliance with NFPA. No issues identified. Re: Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Element 3: Facilities manager will provide education to the facility staff on following through on all inspection recommendations and documentation of work completed. Element 4: All inspection reports will be reviewed by Facility Manager to ensure any identified work needed is scheduled and completed. The report will be rolled up to the monthly quality assurance committee to review work recommended and date completed. This will be a standing agenda item for the monthly quality meeting. Facility manager responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The automatic sprinkler system in Building #31 (House #1) was not maintained according to the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition. Specifically, the top of storage was found to be less than 18 inches from the sprinkler deflectors, which is a violation of sections 4.1.6.1 and 5.3.1.1.1.6 of the NFPA 25 standard. This deficiency was observed during a recertification survey on March 28, 2025, at 2:24 PM, in both the storeroom and walk-in freezer. During an interview conducted shortly after the observation, the Facilities Manager acknowledged the issue and indicated plans to address the storage placement and communicate with the dietary department regarding the storage requirements.

Plan Of Correction

Plan of Correction: Approved May 5, 2025 Element 1: Storeroom and walk-in freezer was moved to ensure storage is not within 18 inches of the sprinkler. Element 2: All kitchen storage areas will be checked to ensure storage meets requirements with sprinkler clearance. Any inconsistency in storage will be corrected at time of identification and education provided. Element 3: The nurse educator or designee will provide education to food service staff regarding storage clearance requirements. This education will be part of onboarding of new staff and annual education. Element 4: Weekly audits of the storage room and walk-in freezer will be completed to ensure that storage is not within 18 inches of sprinkler. Audits will continue for 3 months. Results of audits will be reviewed at the monthly Quality Assurance Committee meeting. Audits will continue for 3 months; at that time, the Quality Assurance Committee will make recommendations regarding ongoing audits, frequency, or change in plan. Facility manager responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure the environment was free from accident hazards for a resident with Alzheimer's Disease, peripheral vascular disease, and a psychotic disorder. The resident's care plan specified that the bed should be positioned against the wall on the left side near the window. However, the bed was not kept away from the heating unit, resulting in the resident lying in bed with their left arm and shoulder in contact with the heater. This led to first and second degree burns on the resident's left arm, as documented by both nursing staff and a hospital discharge summary. Staff interviews revealed that aides were instructed after the incident to keep beds away from heaters, and that the resident was known to move around in bed frequently. Maintenance staff later discovered a faulty valve in the heating unit, which contributed to the incident. At the time of the incident, the resident was found with burn marks and the affected area was hot to the touch. The deficiency was identified through record review, staff interviews, and direct observation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the residents' right to be free from abuse and neglect, affecting four residents. One resident was physically abused by a Certified Nurse Aide (CNA) who pushed them to the floor, resulting in a broken hip. The incident was not immediately reported or investigated, and the resident was moved without a proper assessment by a Registered Nurse (RN). Another resident was left unattended in the bathroom for over an hour, leading to a fall and injury. The staff member responsible provided a false account of the incident, which was later contradicted by video evidence. A third resident experienced verbal abuse when a CNA yelled profanities at them. This incident was reported days later, and the staff member involved continued to work during the investigation. The facility's response to the verbal abuse was delayed, and the investigation was not promptly initiated. Additionally, a fourth resident reported being physically abused by a CNA who pushed them down on the bed. This incident was not reported to the administration until days later, and the investigation revealed that the CNA had neglected their duties by not providing care to multiple residents during their shift. The facility's policies on abuse prevention and investigation were not followed, as incidents were not reported or investigated in a timely manner. Staff members involved in the incidents were not immediately suspended or removed from resident care, and there was a lack of communication and action from the facility's leadership. The deficiencies in handling these incidents resulted in Immediate Jeopardy and substandard quality of care, affecting the health and safety of all residents in the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure all allegations of abuse were thoroughly investigated for three residents. In the first incident, video surveillance footage revealed that a Certified Nurse Aide (CNA) pushed a resident to the floor, resulting in a fractured hip. Despite the incident being captured on video, there was no documented evidence that the facility initiated an investigation on the day of the incident. The CNA was allowed to continue assisting the resident after the fall, and the facility did not take immediate measures to prevent further potential abuse. In the second incident, a resident was left unattended in the bathroom by another CNA for one hour and twenty minutes, leading to a fall and injury. The facility did not review the surveillance footage until three days later, and there was no documented evidence of measures taken to prevent further potential abuse by the CNA. Additionally, the facility did not submit a 5-day Investigation Report to the New York State Department of Health. The third incident involved verbal abuse, where a CNA yelled at a resident to sit down. The facility was first made aware of the incident two days later, and there was no documented evidence of measures taken to prevent further abuse by the CNA. The facility's investigation deemed the allegation likely, but there was no documented evidence of corrective action for other staff members involved in the incident.

Plan Of Correction

Plan of Correction: Approved March 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction. **Element 1** Resident 1 was provided with medical intervention at the time of the incident. Resident is being monitored for any psychosocial stressors related to this event. The resident's medical record was reviewed to determine if any changes to routine patterns were documented; none identified. Law enforcement was notified of the event. Resident 2 was discharged on [DATE]. Staff involved are no longer at the facility. A full investigation was completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25. Resident 3 is being monitored for any psychosocial stressors related to this event. The resident's medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented; none identified. A full investigation was completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25. **Element 2** All residents have the potential to be affected by the stated deficiency. All residents that reside in the facility will be interviewed by social work to determine if they feel safe in the facility. Any concerns will be investigated and reported as required. Nursing and social work will monitor the identified residents for potential adverse effects related to allegations (e.g., mood/behavioral changes, changes in daily routine, etc.). The past 30 days of Incident Reports were reviewed by the Director of Nursing to determine the thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrence. Review will be completed by 3/27/25. No follow-up action required. All staff were in-serviced by the nursing educators on 2/12/25 - 2/13/25 on the investigation of allegations of abuse, neglect, and mistreatment. **Element 3** Measures taken to ensure the problem does not recur: The Abuse Reporting/Investigation policy and procedure were reviewed by the Administrator, Director of Nursing, and Nursing Administration. The abuse reporting/investigation policy changed to reflect the need to report immediately but not more than two hours for all allegations of abuse, neglect, and mistreatment. Supervisors have been educated on the process to report and given standard work instructions outlining the process. This includes the following: - Notify Administrator - Notify Director of Nursing - Submit report to Department of Health - Notify Law Enforcement Social work, nursing supervisor, nurse manager, assistant director of nursing, director of nursing, and administrator were educated on completing the Investigation Checklist for Allegation of Resident Abuse, Neglect, or Mistreatment contained in the Abuse Reporting Policy. By completing all elements of the checklist, it will provide a thorough review of the incident and the ability for staff to make appropriate corrective actions to prevent reoccurrence of the event. The review of the Investigation Checklist includes, but is not limited to, the following: - Notification of Administrator and Director of Nursing - Accused removed from assignment/suspended until investigation complete - Incident Report/Resident Statement - Statement of accused/witness statements - Face sheet/[DIAGNOSES REDACTED] - Residents' most recent History and Physical - Current physician's orders [REDACTED] - Progress notes - Care plan related to incident/Kardex reviewed or revised - Brief interview for mental status assessment - Most recent Minimum Data Set - X-ray reports - Staffing assignments - Copy of acknowledgment of submission to Department of Health - A record of interviews - An explanation of evidence reviewed - Police report if appropriate per Elder Justice Act - The conclusion reached based on above elements and data points collected during the investigation. The conclusion is drawn following a thorough and complete investigation where critical thinking is used to review the investigation and determine actions that need to be taken to prevent reoccurrence of the incident. The above education will be repeated yearly and is part of onboarding for previously identified staff. All open investigations will have a shift-to-shift handoff to the next senior leader (supervisor, director of nursing, administrator, or designee) to continue the investigation until all elements are complete to ensure the investigation is completed and closed. Any step in the process missed by staff involved in the investigation will receive immediate re-education by the administrator or designee. **Element 4** The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: The Administrator or designee will update and maintain the Investigation Log at the time of each event to ensure that the facility appropriately responds to and investigates allegations of potential misconduct per policy. The log will document elements including, but not limited to, the following: 1. Date incident reported 2. Resident demographics 3. Type of event 4. If reportable, reported within time frame 5. Investigation checklist completed 6. Conclusion 7. If any deficient practice identified, remediation/education provided The log will be audited by the Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and re-education provided. Audits will continue weekly for three months. The log will be brought to the Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. The Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy, or education based on results of audits. The committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely reporting of alleged abuse, neglect, and mistreatment incidents involving four residents. The incidents included physical abuse resulting in serious injuries, such as a broken leg and shoulder, and verbal abuse. The facility's policy mandates immediate reporting of such incidents to the New York State Department of Health and other relevant authorities, but this was not adhered to. For instance, an incident involving a resident who sustained a broken hip was not reported until the following day, and another incident involving a broken shoulder was reported four days later. The facility's staff, including the Assistant Director of Nursing and other nursing staff, did not follow established procedures for investigating and reporting these incidents. In one case, a resident was left unattended on a toilet for over an hour, resulting in a fall and injury, but the incident was not reviewed or reported promptly. Video surveillance footage, which could have provided immediate evidence, was not reviewed until days after the incidents occurred. This delay in action and reporting compromised the facility's ability to provide a safe environment for its residents. Interviews with staff revealed a lack of immediate response and investigation into the allegations. Staff members reported incidents to their superiors, but there was a delay in initiating investigations and notifying the facility's administration. The facility's failure to report these incidents in a timely manner is a violation of regulations and policies governing resident abuse, which require immediate action to protect residents and ensure their safety.

Plan Of Correction

Plan of Correction: Approved March 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction. **Element 1** Resident 1 was provided with medical intervention at the time of the incident. Resident is being monitored for any psychosocial stressors related to this event. The resident's medical record was reviewed on (MONTH) 21, 2025, to determine if any changes to routine patterns were documented; none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact (i.e., withdrawal, decrease appetite, change in sleep patterns) due to this event. Resident 2 was discharged on [DATE]. Resident 3 is being monitored for any psychosocial stressors related to this event. The resident's medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented; none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact (i.e., withdrawal, decrease appetite, change in sleep patterns) due to this event. Resident 4 was interviewed on 3/20/25 to determine if they feel safe in the facility. Resident stated she does. Resident will be monitored and observed for any signs of psychosocial stressors related to this incident. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact (i.e., withdrawal, decrease appetite, change in sleep patterns) due to this event. Staff cited in deficiency are no longer employed by the facility and appropriate referrals made to law enforcement and/or Office of Professional Discipline. **Element 2** All residents have the potential to be affected by the stated deficiency. All residents that reside in the facility will be interviewed by social work or designee to determine if they feel safe in the facility. Any concerns will be investigated and reported as required under New York State Department of Health reporting requirements. Interviews will be completed by (MONTH) 26, 2025. For any resident who is unable to be interviewed, the responsible party will be contacted to determine any concerns. These contacts will be completed by (MONTH) 26, 2025. Nursing and social work will monitor the identified residents for potential adverse effects related to the stated deficient practice. The past 30 days of incident reports will be reviewed by the Director of Nursing or designee to determine the thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrences. Review will be completed by (MONTH) 26, 2025. If any areas are identified as being inconsistent with policy, further investigation will be completed at the time of review and, if required, incidents reported to the regulatory body per regulation and policy. All staff were educated on 2/12/25 - 2/13/25 on abuse reporting requirements and abuse reporting policy. **Element 3** Measures taken to ensure the practice does not reoccur: The abuse reporting/investigation policy was reviewed by the administrator, Director of Nursing, and nursing administration. The policy was revised. Policy updated to state all staff have the responsibility to immediately report any abuse/allegation of neglect, mistreatment, or misappropriation. Policy also updated to clarify the need to report all allegations within 2 hours to New York State Department of Health and, as appropriate, other regulatory entities. Education provided to social work, nursing supervisor, nurse managers, and administrator and all staff by a third-party consultant as part of a directed in-service plan. Education included but is not limited to the following: definitions of abuse, neglect, and mistreatment; reporting timeline; reporting obligations; investigation. The above education will be repeated yearly and is part of onboarding. All investigations will have a shift-to-shift handoff to the next senior leader (Supervisor, Director of Nursing, administrator, designee) to continue the investigation until all elements are complete to ensure the investigation is completed and closed. Any steps in the process missed by staff completing the investigation will receive immediate re-education by the administrator or designee. Review of the Centers for Medicare and Medicaid (CMS) Critical Element Pathway with the Registered Nurse Supervisory staff to ensure full understanding of the reporting requirements. Standard work instruction developed for use by the supervisor to ensure he/she has the tools needed to report all allegations/suspected/actual incidents of abuse per policy (immediately but no later than 2 hours) and to assist in the thorough investigation of all incidents. **Element 4** The facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Audits will be completed on 5 elders and 5 staff per week. Elders will be asked if they feel safe and if they have any concerns regarding staff or care. Audits will be completed by social work or designee. Staff will be audited on his/her knowledge of abuse reporting requirements. Staff audits will be done by Nurse Manager or designee on varying shifts. Any areas identified that require follow-up or education will be done immediately. Audits will be completed weekly for the first three months. Audits will be brought to the Quality Assurance Committee monthly. The committee will make recommendations based on audit results. The administrator or designee will update and maintain the Investigation Log at the time of each event to ensure that the facility appropriately responds and reports allegations of abuse, neglect, or mistreatment. The log will document elements including but not limited to the following: 1. Date incident reported 2. Resident demographics 3. Type of event 4. If reportable, reported within time frame 5. Conclusion 6. If any deficient practice identified, remediation/education provided. The log will be audited by the Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and re-education provided. Audits will continue weekly for three months. The log will be brought to the Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. The Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy, or education based on results of audits. The committee will make recommendations for continued monitoring and frequency of audits. The administrator will be responsible for ongoing compliance.