Hillside Manor Rehab & Extended Care Center

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's Do Not Resuscitate (DNR) advance directive was followed. The resident, who had a signed Medical Order for Life Sustaining Treatment indicating DNR status, was found unresponsive and without vital signs. Despite the presence of a yellow wristband indicating DNR and documentation in the electronic medical record, nursing staff initiated cardiopulmonary resuscitation (CPR) efforts. The initial responding nurse did not check the resident's wristband or properly verify the code status in the electronic medical record, and incorrectly informed the supervising nurse that the resident was a full code. As a result, CPR was started and continued until staff became aware of the resident's DNR status. Multiple staff members, including the Registered Nurse Supervisor and a Certified Nursing Assistant, participated in resuscitation efforts. The Registered Nurse Supervisor also failed to verify the resident's code status before continuing CPR and only discovered the DNR order after checking the electronic medical record during the event. Emergency Medical Services were called and continued involvement until they were informed of the DNR order, at which point resuscitation efforts ceased. Interviews with staff revealed that the initial nurse was unfamiliar with code procedures and did not follow facility protocol for verifying advance directives. The resident involved had a history of hypertension, diabetes mellitus, and atherosclerotic heart disease, and was documented as having moderately impaired cognition. The facility's policy required staff to check for a DNR wristband and verify advance directives in the electronic medical record before initiating resuscitation. However, these procedures were not followed, resulting in the administration of unwanted life-sustaining treatment contrary to the resident's documented wishes.

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 develop and implement comprehensive person-centered care plans for two residents, which is a requirement under Federal and State regulations. Resident #27, who was on palliative care and receiving pain medications, did not have a care plan addressing pain management and palliative care. Observations noted that the resident expressed experiencing pain, and physician orders included Tylenol and a topical gel for pain management. Despite these needs, there was no documented evidence of a care plan for pain management or palliative care in the resident's records. Similarly, Resident #123, who had a diagnosis of diabetes mellitus, did not have a care plan addressing their diabetic condition. The resident required maximal assistance with daily activities and had physician orders for insulin administration. However, a review of the resident's comprehensive care plans showed no documentation of a care plan for diabetes management. Interviews with nursing staff revealed that it was the responsibility of nurse supervisors and registered nurses to initiate and update care plans, but this was not done for these residents.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F656 I. Immediate Corrective Action: Resident # 27 1) On 3/31/25 the IDT Team developed a CCP for Palliative care and pain management. 2) On 4/2/2025 the resident was reassessed by Nurse Practitioner and the total plan of care including pain management and palliative care was reviewed. 3) On 4/17/2025 the SW and RNS met with the resident’s family to review the current plan of care for pain management and palliative care and the resident’s family verbalized satisfaction with the plan. 4) On 4/1/2025 the DON provided the SW responsible for initiating the palliative care CCP with education and counseling. Resident # 123 1) On 3/28/2025 the IDT Team developed a CCP for Diabetes. 2) On 3/28/25 the resident was reassessed by Nurse Practitioner and the total plan of care including diabetic management was reviewed. 3) On 3/31/2025 the DON issued an educational counseling to the Admitting RN for not initiating the diabetic management CCP. II. Identification of Others: 1) The facility respectfully states that all residents could potentially be affected. 2) A report will be generated from the EMR- Sigma care to determine which residents have orders for Palliative care. This list will be utilized by the SW in conjunction with the RNS to ensure all residents with palliative care have an individualized care plan. Any issues will be immediately corrected. 3) A report will be generated from the EMR-Sigma care to determine which residents have pain management medication orders. This list will be utilized by the RNS to ensure all residents have an individualized pain management care plan. Any issues will be immediately corrected. 4) A report will be generated from the EMR-Sigma care for all residents with diabetes. This list will be utilized by the RNS to ensure all residents with diabetes have an individualized care plan. Any issues will be immediately corrected. III. Systemic Changes: 1) The DNS and members of the IDT reviewed the P/P on Comprehensive Care Planning and found same to be compliant. 2) All RNs, MDS Coordinators, and IDT Team members will be inserviced by the In-service Coordinator. Highlights of the lesson plan include: - The responsibility to develop and implement a care plan that describes all of the following with emphasis on palliative care, pain management and diabetes; a. Resident goals and desired outcomes; b. The care/services that will be furnished so that the resident can attain or maintain his/her highest practicable physical, mental, and psychosocial well-being; c. Resident's medical, nursing, physical, mental, and psychosocial needs, and preferences, and how the facility will assist in meeting these needs and preferences. - The specific CCP’s that each member of the IDT is responsible for initiating. - The responsibility of all members of the IDT to initiate or update CCP’s for changes in the residents’ care plan that are addressed at the morning QA Meeting. - The responsibility of the IDT to review each resident’s physician orders [REDACTED]. IV. Quality Assurance: 1) The DON developed an audit tool to ensure that all care plans are developed, implemented, and reviewed, including goals and interventions after each care plan meeting. 2) The DON/Designee will review 8 randomly selected residents weekly x 4 weeks followed by 8 residents each month including new admission x 6 months. 3) Any findings regarding CCP implementation will be reviewed at the monthly QA meeting for follow-up. 4) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025-Director of Nursing

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 cited for a medication administration error resulting in a medication error rate of 7.14%, exceeding the acceptable threshold of less than 5%. During the recertification survey, it was observed that an LPN administered the wrong medication to a resident. Specifically, the LPN gave [MEDICATION NAME] Silver Ultra Men's 300 mcg-60 mcg-600 mcg-300 mcg instead of the prescribed [MEDICATION NAME] Silver 0.4 mg-300 mcg 250 mcg. The error occurred because the LPN did not find the correct medication in the medication cart and mistakenly selected a medication intended for another resident. The LPN admitted to signing off on medications before administering them, intending to give all medications at the same time for convenience. This practice was against the facility's policy, which requires medications to be charted immediately after administration. The LPN also acknowledged not recognizing the correct medication due to unfamiliarity with its listing under another name. Interviews with the unit supervisor and the Medical Director confirmed that the medication was available but not correctly identified by the LPN. The facility's policy prohibits borrowing medications from one resident for another, and the error highlighted a lapse in adherence to the five rights of medication administration.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F759** I. Immediate Corrective Action: 1) On 3/26/25 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 3/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director. 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN #3. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The DON conducted a meeting with the Medical Director and Pharmacy consultant to review any medication errors in the past 3 months to assess Facility medication error rate. No medication errors were reported. III. Systemic Changes: The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be inserviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: - Standard for safe medication practices: The Rights of Medication Administration that include: - Right patient - Right drug - Right dose - Right route - Right time - Right reason - Right Monitoring (including vital signs and observation for side effects) - Right documentation - Right patient education - Right evaluation - Right to refuse. - Types of Medication Errors - Medication Documentation and communication. IV. Quality Assurance 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator /Designee. 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025 - Director of Nursing

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 report an alleged violation involving a resident's unwitnessed incident to the New York State Department of Health within the required timeframe. Resident #230, who had severe cognitive impairment and a diagnosis of dementia, was found sitting on a gym mat next to their bed at approximately 4:00 AM. Despite the resident's inability to explain the occurrence and the subsequent discovery of a right pelvic fracture, the incident was not reported as required by the facility's policy and state regulations. Interviews and record reviews revealed that the nursing staff did not consider the incident a fall because the resident was found sitting on a gym mat. The Director of Nursing acknowledged that the incident should have been reported due to its unwitnessed nature, but it was not reported because they concluded there was no unknown factor or abuse involved. This oversight led to a deficiency in the facility's compliance with reporting requirements for incidents involving potential abuse, neglect, or mistreatment.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 P(NAME): F609 I. Immediate Corrective Actions: Resident # 230 1) On readmission 05/21/2024 the resident was reassessed by the physician and total plan of care was reviewed. 2) On 6/11/24 the IDT Team reviewed and revised the resident plan of care including Falls risk and interventions, family agreeable with plan of care. 3) The RNS reviewed and updated the CNAAR to include any new interventions. II. Identification of Others: 1) The facility states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days were reviewed to ensure that any incidents involving injuries of unknown origin, alleged, or actual abuse were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the Director of Nursing (DON) and Medical Director and is in compliance. 2) Inservice education will be provided by the Inservice Coordinator for all Direct Care staff including Licensed nurses, CNAs, Social Workers, and IDT Team members on the reporting requirements related to reporting violations involving injuries of unknown origin and actual or alleged abuse to the NYSDOH. 3) Highlights of the Lesson Plan include: - The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/ DON. - Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH. - As per CMS 42CRF 483.12(c) the reporting definition “immediately” is defined as: 1. 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours if the alleged violation does not involve abuse and does not result in serious injury. - As per Federal regulation 483.12(b)(5) all reasonable suspicions of crimes and/or suspicious incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. - Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. - The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/ designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facility’s compliance with ensuring that all incidents and accidents are investigated, and any injuries of unknown origin or abuse are reported timely as per NYS DOH and Federal reporting guidelines. 2) All Accident and Incidents will be audited by DON weekly x 6 months. Any identified issues will be immediately addressed and shared at morning report. 3) Findings will be reviewed at Monthly QA Meeting to monitor sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025 - Administrator

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 services provided met professional standards of quality during a recertification survey. This deficiency was identified when a Licensed Practical Nurse (LPN) administered incorrect medications to a resident. Specifically, the LPN gave a resident a [MEDICATION NAME] 50 mg-500 mg tablet and a [MEDICATION NAME] Silver Ultra Men's tablet instead of the prescribed [MEDICATION NAME] Silver 0.4 mg-300 mcg-250 mcg tablet. The error occurred because the LPN did not find the correct medication in the medication cart and mistakenly selected a medication intended for another resident. The LPN admitted to signing off on medications before administering them, intending to give all medications at the same time due to the preference of multiple residents. The LPN was unaware that the correct medication was listed under a different name in the medication cabinet. The Registered Nurse and Medical Director confirmed that signing off on medications before administration is not acceptable practice. The Director of Nursing stated that the LPN had received medication administration competency training and there were no prior concerns with their performance.

Plan Of Correction

Plan of Correction: Approved April 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F658** I. Immediate Corrective Action: 1) On 3/26/2025 Resident # 320 was assessed by the MD/NP and no adverse effects of receiving late administration of [MEDICATION NAME] and the administration of a different type of [MEDICATION NAME] were noted. 2) On 03/26/25 a medication error report was developed by the DON for this incident and shared with Pharmacy Consultant and Medical Director. 3) On 4/1/25 the DON issued a disciplinary action for LPN# 3 responsible for the medication error. 4) On 4/1/25 a Medication competency was conducted by the RNS for LPN #3. II. Identification of Others: 1) The DON obtained a printout from the EMR for all residents scheduled to receive medications prior to the daily standard 10 am medication time. This list will be utilized by Unit RNS and DON to conduct unit rounds to determine if residents are receiving medication timely and accurately. Any issues will be immediately corrected. 2) The DON obtained a list of all residents receiving [MEDICATION NAME]. This list will be utilized by the DON and Medical Director to ensure appropriately prescribed [MEDICATION NAME] vitamin doses are ordered and received. Any issues will be immediately corrected. III. Systemic Changes: 1) The DON, Medical Director and Administrator in conjunction with the Pharmacy Consultant reviewed the Facility policies/procedures for medication administration and found same to be compliant. The P/P will be in serviced to all Licensed Medication nurses by the Inservice Coordinator. The Lesson plan will focus on: - Standard for safe medication practices: The Rights of Medication Administration that include: - Right patient - Right drug - Right dose - Right route - Right time - Right reason - Right Monitoring (including vital signs and observation for side effects) - Right documentation - Right patient education - Right evaluation - Right to refuse. - Types of Medication Errors - Medication Documentation and communication. IV. Quality Assurance: 1) The DON will develop an audit tool to monitor compliance with ensuring compliance with standards of practice for Medication Administration. 2) The audit will be done by the DON/Designee on 4 randomly selected medication nurses on random shifts weekly x 4 weeks, followed by 4 randomly selected medication nurses monthly x 6 months. 3) All Nurses will continue to have a Medication Competency upon hire and annually completed by the Inservice Coordinator/Designee. 4) Results from the audit will be brought to the Quarterly QA Meeting to monitor compliance and track sustainability. V. Date of Correction and Person Responsible for this F Tag: 05/29/2025 - Director of Nursing

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 the Minimum Data Set (MDS) assessment accurately reflected a resident's discharge status. This deficiency was identified during a recertification survey conducted from March 24, 2025, to March 31, 2025. Specifically, the MDS assessment for a resident with unspecified diagnoses inaccurately documented the resident as being discharged to an acute hospital, whereas nursing and social services notes indicated that the resident was discharged home in stable condition, accompanied by family. Interviews with a registered nurse and the MDS Coordinator confirmed that the resident was indeed discharged home, and the error in coding was acknowledged by the MDS Coordinator.

Plan Of Correction

Plan of Correction: Approved April 24, 2025 The facility recognizes the importance of accurate and timely completion of all Minimum Data Set (MDS) assessments, as per regulatory standards and our internal policy titled Minimum Data Set 3.0 (last reviewed 10/2024). Upon review of the discrepancy regarding Resident #358’s discharge status, the following corrective and preventive measures have been implemented: 1. Immediate Correction: The MDS for Resident #358 has been corrected on 3/31/2025 to reflect the accurate discharge destination to home on 03/03/2025. 2. Staff Re-education: The MDS Coordinator received immediate re-education regarding proper discharge coding procedures and the importance of cross-referencing interdisciplinary documentation. 3. Ongoing Compliance: As part of our Quality Assurance and Performance Improvement (QAPI) program, the Director of MDS will audit five (5) discharge assessments every 4 weeks for 6 months to ensure accurate coding of discharge location and identify any additional training needs. The facility remains committed to maintaining compliance with all applicable federal and state regulations and ensuring accurate resident assessments to support appropriate care planning and transitions. Please consider this letter as our formal acknowledgment and assurance that corrective actions have been taken to address the cited concern.

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 life safety code recertification survey conducted over two days, it was observed that the facility failed to ensure proper identification of electrical panels in accordance with the 2012 NFPA 101 standards. Specifically, on the 11th Floor, three out of four electrical panels in the Electric Room were missing identification. Similarly, on the 9th Floor, the Electric Room contained three panels without identification. Additionally, in the Loading Dock Area, a junction box with an outlet powering a bug zapper was found to be missing its protective cover. These deficiencies were noted during the survey, and the Director of Maintenance acknowledged the issues at the time of the findings.

Plan Of Correction

Plan of Correction: Approved April 27, 2025 I. Immediate Corrective Action: The following areas as identified were corrected by our facility engineering staff: 1) On 04/25/2025, the 11th Floor, in the Electric Room, three of four electrical panels had missing identification, labels applied. 2) On 04/25/2025, the 9th Floor Electric Room had 3 missing identifications, labels applied. 3) On 04/21/2025, the Loading Dock Area junction box with an outlet powering the bug zapper, the missing protective cover was installed. II. Identification of Other Areas: 1) The Facility respectfully states that no residents were involved in this deficient practice. 2) The Facility electrician and Director of Engineering will conduct an environment review of all other areas to ensure labeling was installed in accordance with NFPA 70. 3) Any panel found to be missing identification or any exposed junction boxes will be immediately corrected. 4) Audit findings will be documented in the facility’s maintenance records. III. Systemic Changes: 1) All engineering staff will receive in-service training on NFPA 70 panel labeling and electrical safety standards. IV. Quality Assurance: 1) The Director of Engineering/designee will conduct monthly audits of lighting and electrical enclosure to ensure compliance with NFPA 70. 2) Audits identified with quality issues, the engineering department will contact the facility Electrician for corrective actions as needed. 3) These inspections will be reported quarterly to QA committee for oversight and continuous improvement. V. Responsible Person: Director of Engineering

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 Life Safety recertification survey, it was observed that the facility did not comply with NFPA 99 standards for the storage of oxygen cylinders. Specifically, in the Oxygen storage room located at the Loading Dock area, oxygen tanks were found to be co-mingled, with three empty e-size tanks stored in the same rack as full tanks. Additionally, there were no signs present in the Oxygen Storage Room to indicate where empty and full cylinders should be placed. This deficiency was confirmed through observation and an interview with the Director of Maintenance, who acknowledged the lack of signage and stated that signs would be posted.

Plan Of Correction

Plan of Correction: Approved April 26, 2025 I. Immediate Corrective actions taken: 1. The sign designating storage of empty and full oxygen tanks to proper areas was immediately securely reinstalled. 2. The empty tanks were relocated to the appropriate location. II. Identify other residents The facility conducted a review of all areas where oxygen is stored and determined no other areas out of compliance. Residents were at minimal risk due to this deficiency. III. Systemic changes 1) The facility reviewed and updated the oxygen storage and use policy and procedure to comply with the requirements set forth in NFPA 99. All staff will be in-serviced on the requirements set forth in NFPA 99 for the storage and use of oxygen and the updates to the facility policy and procedure. 2) The Director of Security has added the inspection of oxygen storage area to the daily log. 3) Any items found out of compliance shall be corrected at the time of discovery. IV. Q/A Monitoring 1) The Director of Security will conduct weekly QAPI audits over X 3 months to determine if compliance is ongoing and report to administration for future facility improvement. 2) Audits of negative findings will have immediate corrective actions implemented. 3) Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow-up. V. Responsible Person: Director of Engineering/Director of Security

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 Life Safety Recertification Survey, it was observed that the facility did not maintain a functional and comfortable environment for residents due to unsecured freestanding closets in certain resident rooms. These closets were not attached to the walls, posing a risk of tipping over. The Director of Maintenance explained that some closets had recently arrived and others had been moved for cleaning, and staff were still in the process of securing them. This situation was identified during observations and staff interviews conducted on the survey dates.

Plan Of Correction

Plan of Correction: Approved April 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action 1) On 4/21/25, freestanding closets in resident rooms [ROOM NUMBERS] were secured to the wall to reduce the risk of tipping over. II. Identification of Other Residents: 1) The facility has reviewed all other closets to ensure that they were securely fastened. No other resident was noted to be involved. III. Systemic Changes: 1) The facility reviewed the policy on replacement of room furnishings and found no required changes. 2) All engineering and EVS staff responsible for replacing furniture were inserviced on the policy. 3) Before furniture is replaced staff will be reviewed on the policy. IV. Q/A Monitoring 1) The Director of Environmental Services will conduct 10 randomly selected resident rooms per month for QAPI audits over the next quarter to determine if compliance is ongoing and report to administration for future facility improvement. 2) Audits of negative findings will have immediate corrective actions implemented. 3) Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow-up. V. Responsible Person: Director of Maintenance/Director of Environmental Services

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 all components of the building's extinguishing system were installed in accordance with NFPA 101 standards. During the Life Safety Code Recertification survey, several deficiencies were observed. In the A/C No. 10 room, a sidewall sprinkler was improperly installed facing downwards, parallel to the wall instead of having the deflector parallel to the ceiling. Additionally, a concealed sprinkler in the 1st Floor corridor by the Conference Room was missing its cap. The Loading Dock area lacked sprinkler coverage from the door to the 5 steps. Furthermore, in the small conference room on the 1st Floor, a sprinkler head was missing an escutcheon and a 2 ft by 2 ft ceiling tile. Missing escutcheons and broken ceiling tiles were observed throughout the facility, indicating a widespread issue with the maintenance of the sprinkler system.

Plan Of Correction

Plan of Correction: Approved April 26, 2025 I. Immediate Corrective Action 1) The Director of Engineering contacted the fire sprinkler company upon discovery to correct the following: a) Reinstall in the correct position a sidewall sprinkler in the A/C No. 10 room b) On 04/25/2025 the 1st Floor corridor by the Conference Room, a concealed sprinkler that had the missing cap was replaced c) Fire sprinkler company contacted to install the loading dock area sprinkler coverage from the door to the 5 steps d) On 4/25/2025, in the small conference room, on the 1st Floor, the observed sprinkler head that was missing an escutcheon and ceiling tile was installed. 2) The facility engineer in conjunction with the sprinkler company reviewed all sprinklers for proper escutcheon plates and replaced any that were found to be missing. 3) The facility engineer replaced all damaged ceiling tiles to ensure proper fitting. II. Identification of Other Residents 1) The facility respectfully states that no residents were involved in this deficiency, however all residents were indirectly affected. 2) The Director of Engineering reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1) The Administrator, in conjunction with the Director of Engineering, reviewed and revised the facility sprinkler inspection policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies. 2) Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. 3) All Maintenance staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as an overview of requirements for sprinkler coverage as per K351. 4) The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required with all associated hardware. 5) A copy of the attendance will be maintained for reference and validation. IV. QA Monitoring 1) The Administrator, in conjunction with the Director of Maintenance, will conduct monthly reviews and inspections of sprinkler reports for the next 3 months, then upon completion of work thereafter. Documentation will be maintained in a logbook for reference and validation. 2) The Director of Maintenance will review the findings and report to the QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Responsible Person: Director of Engineering/Administrator/designee

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 life safety code recertification survey conducted on two consecutive days in 2025, it was observed that the facility failed to maintain its fire extinguishing system in accordance with NFPA 101 and NFPA 25 standards. Specifically, the fire hoses located in Stairwells A and B on the 1st Floor, as well as throughout the facility, were found to be stamped with a date of 9/2017. This indicates that the hoses had not been tested or replaced within the required five-year period prior to the survey. The deficiency was identified through a combination of observation, document review, and staff interviews. The lack of documentation confirming the testing or replacement of the fire hoses within the stipulated timeframe was noted. At the time of the survey, the Director of Maintenance acknowledged the oversight and stated that the fire hoses would be tested or replaced, although this action is not part of the deficiency itself.

Plan Of Correction

Plan of Correction: Approved April 27, 2025 I. Immediate Corrective Action 1) The Director of Engineering engaged our Service Company to replace the identified standpipe fire hoses with new hoses in all locations more than five years old. 2) The Director of Engineering engaged our Service Company to inspect the building’s standpipe system to determine those testing years and complete NFPA required testing if necessary. II. Identification of other areas potentially affected. 1) All Residents have the potential to be affected by this practice. 2) The Director of Engineering will have the Service company inspect facility-wide standpipe and fire hose systems for similar issues. III. Systemic Changes 1) The policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2) The existing rounds inspection form has added the monthly standpipe audit tool. 3) This has been added to the facility preventive Engineering program. 4) Staff involved in the review, Engineering and/or repair of the sprinkler system were educated by the Director of Engineering that any issues with standpipe system identified during rounds will be corrected immediately and interim safety measures put in place as needed until repairs are complete. IV. Quality Assurance Monitoring 1) The Director of Engineering created an audit tool to monitor compliance with required inspections of sprinkler systems. This audit includes inspection of fire hose racks. Any identified issues will be corrected as soon as possible. 2) The Director of Engineering will audit the whole facility monthly for the first 3 months and then quarterly for 9 months. Audit results will be submitted to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. 3) The frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. V. Responsible Person: Director of Engineering

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 Life Safety Recertification survey, the facility was found to be non-compliant with NFPA 70 standards regarding the use of extension cords and power strips. Specifically, surveyors observed that two unmounted power strips were in use in both the Computer Room and the Office of the Director of Nursing. Additionally, an extension cord was found powering computer equipment in the Admitting office. Furthermore, in the Owner's Office, two power strips were daisy-chained to power computer equipment, which is a violation of the electrical safety standards. These observations indicate that the facility did not ensure that electrical systems were used in accordance with the National Electrical Code, as required by NFPA 101 and NFPA 70. The improper use of power strips and extension cords, such as daisy-chaining and using unmounted power strips, poses potential safety hazards and does not comply with the established guidelines for electrical safety in healthcare facilities.

Plan Of Correction

Plan of Correction: Approved April 26, 2025 I. Immediate Corrections: 1) On 04/25/2025 the facility engineering staff mounted and secured the two outlet strips installed for the following areas: The Director of Nursing office and the computer room. 2) The admitting office extension was removed, and additional outlets were installed. 3) The Daisy chained relocatable power taps were removed from the owner’s office. II. Identification of Other Residents: 1. The facility electrician will review all other areas for non-compliant electrical connections and corrective measures will be taken immediately. III. Systemic Changes 1) The facility has reviewed and revised the policies for use of extension cords and relocatable power strips to comply with guidance set forth in NFPA 99. 2) All staff will be inserviced on the use and care of extension cords and relocatable power strips. 3) A copy of the lesson plan and attendance will be filed for reference and validation. 4) The facility has developed a criterion to maintain a log for the use of relocatable power strips and extension cords to ensure timely removal and proper utilization. 5) All engineering staff and EVS staff will be educated on how to maintain the log and the requirements for compliance with the use of extension cords and power taps. IV. QA Monitoring 1) The Director of Engineering has developed an audit tool to track the use of extension cords in the building for safety and compliance. 2) Audits will be done by engineering weekly x1 month then monthly thereafter to ensure safety and compliance. 3) Audits with negative findings will have onsite corrective actions by the auditor and review with the Administrator for awareness. 4) Audit findings will be presented to the QA Committee quarterly for evaluation and continuance as needed. V. Responsible Person: Director of Engineering/designee

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the New York State Department of Health. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and chronic kidney disease, was found sitting on a gym mat next to their bed in the early morning hours. The resident was unable to explain the occurrence, and no staff witnessed the incident. Initial assessment by nursing staff did not reveal injuries, but later that morning, the resident complained of right hip pain, and further examination revealed swelling and discoloration, leading to a hospital transfer where a right pelvic fracture was diagnosed. Despite the unwitnessed nature of the incident and the resident's inability to provide an account, the event was not reported to the Department of Health as required by facility policy and state regulations. Staff interviews indicated that the incident was not considered a fall or a reportable event at the time, as the resident was found on a gym mat. The Director of Nursing later acknowledged that, due to the unwitnessed nature of the incident, it should have been reported, but this was not done. The failure to report the incident constituted noncompliance with regulatory requirements for timely reporting of suspected abuse, neglect, or injuries of unknown source.

Penalty

Inspection fine: $34,947

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 protect a resident from physical abuse, as evidenced by multiple incidents involving a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN). The LPN witnessed the CNA physically forcing the resident to sit in a chair and later in a wheelchair, despite the resident's resistance. The LPN did not intervene or report the abuse immediately, allowing the CNA to continue providing care to the resident. The situation escalated when the LPN observed the CNA hitting the resident multiple times on the thigh with a closed fist. The resident involved had a history of osteoarthritis, osteoporosis, and metabolic encephalopathy, with moderately impaired cognition. The resident's care plan included interventions for behavior and victimization, such as separating the resident from others as needed and using a calm approach. Despite these interventions, the resident was subjected to rough handling and physical abuse by the CNA, which was witnessed by the LPN and another CNA. The abuse resulted in physical harm to the resident, including bruising and pain, and was reported as an assault to the police. The facility's policy on abuse prevention was not followed, as the LPN failed to intervene or report the abuse in a timely manner. The LPN admitted to being in shock and not knowing what to do, which contributed to the delay in addressing the situation. The Director of Nursing and the Administrator were notified of the incident later in the evening, and the police were called. The facility concluded that abuse had occurred based on the LPN's report and the resident's account of the events.

Removal Plan

• Certified Nursing Assistant #1 was removed from the unit, relieved of duty, and was terminated.
• 911 Police were called.
• A Quality Assurance Performance Improvement meeting was held. The abuse incident and actions to be taken were discussed.
• All 12 residents on Certified Nursing Assistant #1's assignment were assessed for bruising by a Registered Nurse #1. There were no negative findings.
• Licensed Practical Nurse #1 was counseled on abuse prevention and reporting immediately. Licensed Practical Nurse #1 was suspended post counseling.
• Certified Nursing Assistant #2 was counseled on abuse prevention and reporting immediately and was suspended.
• A Psychiatrist evaluated Resident #1 and documented Resident #1 did not sustain any psychosocial harm.
• A Psychologist evaluated Resident #1, and recommendations were made for individual Psychotherapy to reduce emotional symptoms.
• The facility revised its policy on abuse prevention to include a Registered Nurse/supervisor complete a full body assessment of the resident to determine injuries. The facility will monitor trends and/or patterns of occurrence via the Quality Assurance Committee to identify any potential incidents of abuse.
• The facility conducted all house in-service (classroom and via phone) on Abuse for F600 and F610 with 98% active staff in-serviced. Staff members who are furloughed will be in-serviced before returning to their shift.
• Interviews were done with several staff members: nurses, Certified Nursing Assistants, housekeeping/environmental staff, security staff, recreation staff, physical/occupational therapist, social workers, dietary staff, and administrative staff, and all were knowledgeable on the abuse prevention protocol, what to do if they observe abuse, when to report, and who they should report to.

Penalty

Inspection fine: $34,947

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 remove a Certified Nursing Assistant (CNA) from resident care after an incident of witnessed abuse, which was evident for one resident. On the evening of the incident, a Licensed Practical Nurse (LPN) observed the CNA physically forcing a resident to sit in a chair in the hallway. Later, the same LPN and another CNA witnessed the CNA grab and push the resident into a wheelchair and wheel them into their room. The LPN did not intervene or remove the CNA from providing care to the resident or other residents. The situation escalated when the LPN heard noises from the resident's room and entered to find the CNA hitting the resident multiple times on their right thigh with a closed fist. Despite witnessing this abuse, the LPN did not take immediate action to separate the CNA from the resident or report the incident promptly. The resident, who had a history of osteoarthritis, osteoporosis, and metabolic encephalopathy, was found with bruising and redness on their right arm, a bluish discoloration on the right hip, and an ecchymosis at the left temple. The facility's policy on abuse prevention, which mandates the removal of staff from direct care during an abuse investigation, was not followed. The LPN's failure to intervene or report the initial encounter contributed to the continuation of the abuse, resulting in actual harm to the resident and placing other residents at risk. The incident was eventually reported to the Registered Nurse Supervisor, but not until after the abuse had occurred multiple times.

Removal Plan

• Certified Nursing Assistant #1 was removed from the unit, relieved of duty, and was terminated.
• 911 Police were called.
• A Quality Assurance Performance Improvement meeting was held. The abuse incident and actions to be taken were discussed.
• All 12 residents on Certified Nursing Assistant #1's assignment were assessed for bruising by a Registered Nurse #1. There were no negative findings.
• Licensed Practical Nurse #1 was counseled on abuse prevention and reporting immediately. Licensed Practical Nurse #1 was suspended post counseling.
• Certified Nursing Assistant #2 was counseled on abuse prevention and reporting immediately and was suspended.
• A Psychiatrist evaluated Resident #1 and documented Resident #1 did not sustain any psychosocial harm.
• A Psychologist evaluated Resident #1, and recommendations were made for individual Psychotherapy to reduce emotional symptoms.
• The facility revised its policy on abuse prevention to include a Registered Nurse/supervisor complete a full body assessment of the resident to determine injuries. The facility will monitor trends and/or patterns of occurrence via the Quality Assurance Committee to identify any potential incidents of abuse.
• The facility conducted all house in-service (classroom and via phone) on Abuse for F600 and F610 with 98% active staff in-serviced. Staff members who are furloughed will be in-serviced before returning to their shift.
• Interviews were done with several staff members: nurses, Certified Nursing Assistants, housekeeping/environmental staff, security staff, recreation staff, physical/occupational therapist, social workers, dietary staff, and administrative staff, and all were knowledgeable on the abuse prevention protocol, what to do if they observe abuse, when to report, and who they should report to.

Penalty

Inspection fine: $34,947

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's administration failed to operate in a manner that effectively and efficiently used its resources to ensure the highest practicable well-being of each resident. This deficiency was evident in the case of a resident who was subjected to abuse by a Certified Nursing Assistant (CNA). The facility's policy on abuse prevention, revised in November 2022, mandates protection from abuse, neglect, and mistreatment. However, the in-service lesson plan on managing aggressive behavior did not provide guidance on how staff should respond to witnessed abuse. On the date of the incident, a Licensed Practical Nurse (LPN) witnessed the CNA forcefully handling the resident and later observed the CNA hitting the resident on the thigh. Despite witnessing these actions, the LPN did not separate the resident from the CNA, which allowed the abuse to continue. The resident involved had a history of osteoarthritis, osteoporosis, and metabolic encephalopathy, with moderately impaired cognition as per a recent assessment. During interviews, staff, including the LPN, expressed a lack of awareness that they should have separated the victim from the abuser. The Director of Nursing and the Administrator acknowledged that the LPN should have intervened by removing the CNA from the situation. The in-service coordinator admitted that the lesson plan lacked instructions on protecting residents from abuse, indicating a gap in staff training and awareness regarding immediate protective actions in cases of suspected or witnessed abuse.