Rochester Center For Rehabilitation And 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 deficiency involves the facility’s failure to provide enteral nutrition and hydration according to physician orders and professional standards of practice for three residents with feeding tubes. Facility policy required that enteral feedings be administered per physician orders, evidence-based practices, resident rights, and federal regulations. For each of the three residents, the comprehensive care plans documented a need for tube feeding related to dysphagia, with interventions to administer tube feeding and water flushes per dietician recommendations and physician orders. However, review of physician orders, Medication Administration Records (MARs), and clinical documentation showed that ordered enteral nutrition and water flushes were not consistently administered or documented, and there was no evidence of physician orders to hold or adjust feedings, clinical justification, or resident refusals. One resident had diagnoses including aspiration pneumonia, gastrostomy, and hemiplegia/hemiparesis following a cerebral infarction, and was documented as cognitively intact. Physician orders required nothing by mouth and continuous enteral nutrition at a specified rate and total daily volume, with water flushes before and after feeding and every four hours. The March MAR showed no documented administration of enteral nutrition on three consecutive days, with the amount recorded as zero and additional blank entries for both feeding and water flushes. A nursing note later documented that the resident did not receive enteral nutrition per order on one of those days. That evening, an LPN obtained an order to initiate enteral nutrition, but the resident expressed distress and requested transfer to the hospital. Hospital records documented that the resident was sent for missed enteral nutrition and concern for dehydration and was found to have dehydration, hypotension, tachycardia, and new onset atrial fibrillation with rapid ventricular response requiring IV fluid resuscitation and ICU admission. A PA confirmed the resident had not been receiving enteral nutrition at appropriate times. A second resident, cognitively intact with diagnoses including dysphagia, cerebral palsy, hyperosmolality and hypernatremia, and spastic quadriplegia, had orders for nothing by mouth, enteral nutrition at a specified rate starting in the late afternoon with a defined total daily volume, and scheduled water flushes three times daily plus water before and after feedings. Review of the MARs showed that, based on the ordered start time and rate, the expected volume by late evening would be approximately a certain amount, but documented volumes at that time varied widely and ranged from less than expected to the full daily volume. There were multiple blank entries with no documentation of volume infused or nurse signatures, and several scheduled water flushes were not documented as given. There was no documentation of orders to hold or adjust feedings, no clinical justification for the inconsistent volumes, and no resident refusals. During observation, this resident’s feeding was not running, the feeding bag was empty and dated the previous day, and the feeding was still not running nearly an hour later; an LPN eventually initiated the feeding and stated that the second nurse assigned to the unit was not coming in. A third resident with severely impaired cognition and diagnoses including dysphagia, gastrostomy status, and convulsions had orders for nothing by mouth, continuous enteral nutrition at a specified rate and total daily volume starting in the early evening, and water via automatic flushes plus additional scheduled water flushes six times a day. Orders required verification of infusion each shift and documentation of total volume infused. Review of MARs over three months showed that, based on the orders, the expected volume of enteral nutrition and water flushes by early morning should approximate specific amounts, but documented enteral nutrition volumes at that time ranged from far below expected to the full daily volume, and documented water flush volumes varied widely. There were multiple blank entries across all shifts. There was no documentation of orders to hold or adjust feedings or hydration, no clinical justification for the inconsistencies, and no resident refusals. In interviews, the DON stated that documentation contained blank entries and they could not confirm whether the three residents received enteral nutrition and hydration as ordered, acknowledging staffing and system issues. A nurse practitioner and the medical director both described significant communication gaps, missed medications and enteral feedings, lack of notification when care was not provided as ordered, and insufficient staffing to ensure safe 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 ensure sufficient nursing staff were available each day to meet resident needs and to provide timely nursing services, including medication administration and treatments. The facility assessment identified a minimum staffing plan totaling 10 nurses per 24 hours across three floors, with staffing to be adjusted based on resident acuity for a census of approximately 120–122 residents. However, review of time punch records on 17 days with high numbers of missed medications showed multiple evening and night shifts with only three or fewer nurses working for the entire facility. There were also 13 days when nursing staff punched in more than one hour late and four days when staff punched out more than one hour early, reducing coverage for significant portions of scheduled shifts. The DON later stated that each unit was expected to have two nurses on day and evening shifts and one nurse on nights for units of 40–42 residents, but acknowledged there were occasions when only one nurse was assigned per unit during day and evening shifts. Medication administration audits from February through mid-April 2026 showed repeated missed and delayed medication administration affecting many residents. On 17 days, 20 or more residents had missed medication administrations. Individual residents experienced large numbers of medications given more than one hour late, including one resident with 282 late medications in February, 327 in March, and 117 in the first half of April; another with 188 late medications in February, 170 in March, and 43 in early April; and a third with 83 late medications in February, 249 in March, and 75 in early April. Multiple LPNs reported being the only nurse on a unit of about 42 residents during evening shifts, sometimes with only one CNA, and stated they were unable to complete required care tasks, including wound care and ordered treatments, because the entire shift was consumed by medication administration and some residents did not receive medications. One LPN reported nurses sometimes punched in, left the facility for several hours, and returned before the end of the shift. A PA reported being aware of instances where entire units did not receive medications, and the Medical Director stated that one nurse assigned to 40–42 residents was not safe. The Scheduling Coordinator, responsible for staffing, reported being unaware of staffing concerns, while the Administrator acknowledged awareness of residents not receiving medications and that nurses were not always able to administer medications or complete care within expected timeframes.

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 deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, timeframes, and documentation requirements for multiple residents, including those receiving high‑risk medications. Facility policies required medications to be given safely, timely, and as ordered, with immediate documentation and recorded reasons for any omitted doses. However, record review, MARs, narcotic count sheets, and EHR medication administration audits showed repeated omissions, late administrations, duplicate dosing, and missing documentation, without evidence that medical providers were notified when medications were not given or were given outside ordered timeframes. One cognitively intact resident with heart disease, diabetes, and a left lower leg amputation had two active oxycodone orders at the same time and received doses from both, resulting in excess administration of a controlled substance, including additional doses given as close as three hours apart. This resident also had numerous missed oxycodone doses, frequent late or missed blood glucose checks and lispro insulin administrations, and two dates where evening medications, including duloxetine, propranolol, blood glucose monitoring with lispro insulin, Lantus, acetaminophen, gabapentin, Symbicort, tamsulosin, melatonin, and ipratropium‑albuterol, were not documented as given. EHR audits showed over 400 instances of medications given more than one hour late, and narcotic count sheets had multiple missing entries over several months. The resident reported that medications were frequently not administered as scheduled and that morning medications were sometimes received after mid‑afternoon. Other residents experienced similar failures. One cognitively intact resident with diabetes, heart failure, and respiratory failure had multiple blank MAR entries indicating missed evening and morning medications, including blood glucose monitoring with insulin aspart, insulin glargine, Lovenox, duloxetine, metoprolol, torsemide, melatonin, and trazodone, and had over 700 occurrences of medications administered more than one hour late; this resident reported inconsistent medication administration and delays, including morning medications received after early afternoon and blood glucose checks and insulin not completed before meals. A resident with a seizure disorder, recent seizures, diabetes, and prior CVA had numerous missed morning and evening doses of anti‑seizure and anticoagulant medications, along with over 300 late administrations. Another cognitively intact resident with osteomyelitis, toe amputation, and hypertension had multiple missed evening doses of an ordered antibiotic, missed doses of hydralazine, and a date where evening doses of carvedilol, torsemide, and gabapentin were not documented as given. The nurse practitioner, PA, medical director, and administrator all acknowledged that medications must be administered as ordered, that residents had reported not receiving medications as prescribed, that providers were not consistently notified of omissions or late administrations, and that nurses were not always able to administer medications within expected timeframes. Across these residents, facility records consistently lacked documentation that medical providers were notified when medications were omitted or administered outside ordered timeframes. Medication administration audits from the EHR showed hundreds of late administrations for several residents, and MARs contained numerous blank entries indicating omitted doses of critical medications such as insulin, anticoagulants, anti‑seizure drugs, cardiac medications, antibiotics, and controlled pain medications. The medical director stated that if residents do not receive prescribed medications they could die and that the facility was potentially causing harm. The administrator confirmed awareness of residents not receiving medications based on reports from residents, families, staff, internal audits, and corporate oversight, and acknowledged that residents should receive medications as prescribed and that nurses should notify supervisors and providers when medications are omitted or given outside ordered timeframes.

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 administer the facility in a manner that enabled effective and efficient use of resources to attain or maintain each resident’s highest practicable well-being. Facility policies required a functioning Quality Assurance and Performance Improvement (QAPI) program with regular committee meetings, continuous evaluation of systems, and corrective plans, as well as safe and timely medication administration and staffing adjusted to resident acuity. Despite being licensed for 124 beds with a census of about 120–122 residents who required medication administration, enteral nutrition, wound care, and assistance with activities of daily living, the facility did not maintain adequate administrative systems, including staffing oversight, medication administration monitoring, and QAPI processes. Record review showed systemic failures in care delivery. Under F725, the facility did not consistently meet its own minimum staffing levels and did not implement sufficient contingency staffing measures, which resulted in missed and delayed medication administrations and an inability to complete ordered treatments. Time punch records showed multiple shifts with three or fewer nurses for approximately 120 residents, and medication administration audits over several months identified 17 days on which 20 or more residents had missed medications. Under F760, clinically significant medication errors were identified for all 11 residents reviewed, including omissions, medications given outside ordered timeframes, and duplicate dosing of a controlled medication, with no documented provider notification. Hundreds of instances of medications being administered more than one hour late were identified in audits. Additional deficiencies were identified in enteral nutrition management and QAPI implementation. Under F693, the facility failed to administer prescribed enteral nutrition, with a lack of documentation that residents received ordered feeding volumes and one resident requiring hospital transfer and treatment for dehydration. Under F868, the QAPI committee did not meet at least quarterly, with about a five-month lapse between meetings and no medical provider participation. Interviews with a PA and the Medical Director confirmed awareness of units not receiving medications and that assigning one nurse to 40–42 residents was not safe. The Administrator, in the role since early February 2026, acknowledged awareness of staffing concerns, missed and late medications, reliance on agency staffing, vacant nursing leadership positions, and that missed medications were often identified through resident and family complaints or external communication rather than consistent internal monitoring.

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 its Quality Assessment and Assurance (QAA) committee met at least quarterly as required by regulation. The facility’s Quality Assurance and Performance Improvement (QAPI) Program, reviewed on 04/28/2025, outlined a purpose focused on continuous evaluation of facility systems, ensuring care delivery systems function consistently and accurately, preventing deviations from care processes, identifying issues and opportunities for improvement, and developing and implementing plans to correct identified areas. The facility’s QAPI Committee policy, last reviewed in December 2022, specified that the committee would meet monthly at an appointed time, with special meetings called as needed. Review of QAPI meeting minutes and sign-in sheets showed meetings held on 05/29/2025, 09/26/2025, 10/31/2025, and 03/24/2026, revealing an approximate five-month lapse between the 10/31/2025 and 03/24/2026 meetings, and an approximate four-month interval between the 05/29/2025 and 09/26/2025 meetings. Further review of attendance records showed that no medical provider attended the 03/24/2026 meeting. During an interview on 04/22/2026, the Administrator, who had been in the role since February 2026, confirmed that a QAPI meeting was held at the end of March 2026 and did not identify any additional meetings between October 2025 and March 2026. These findings demonstrate that the QAA committee did not meet at least quarterly and lacked required membership at one meeting, in violation of Title 10 NYCRR 415.27(c)(1).

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 conducted from January 6 to January 14, 2025, it was found that the facility failed to adequately address and document concerns raised by residents during Resident Council meetings. Six residents reported various issues, including the use of inappropriate silverware, lack of linens, restrictions on going outside, undignified treatment by staff, and delayed response to call lights. These concerns were voiced during a special Resident Council meeting on January 7, 2025, and had been recurring over the previous six months. However, the facility did not provide any follow-up, resolution, or rationale for the lack of resolution to these concerns in the meeting minutes. Interviews with the Director of Recreation and the Administrator revealed that while there was a protocol for addressing resident concerns, it was not being followed. The Director of Recreation admitted that complaints were addressed but not documented, and there was no manual or electronic record of resident concerns or follow-ups. The Administrator confirmed that directors present at the meetings should document concerns and follow-ups, but acknowledged that the follow-up process was not documented. This lack of documentation and follow-up on resident concerns constitutes a deficiency in honoring residents' rights to organize and participate in resident/family groups and have their concerns addressed.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. The social worker will meet with each resident to document each of their concerns on a grievance form. Each concern will be investigated and a resolution put in place to address the individual concern. The social worker will then address each resident with the findings and resolution to their concerns, as applicable. 2. All residents have the potential to be affected. The facility will review 12 months of Resident Council minutes to ensure that each concern brought up at the meeting was properly reviewed and addressed. 3. The recreation staff, the social worker, and the administrator were educated on the requirement to ensure that every concern or grievance brought by a resident during Resident Council Meeting must be documented and followed up with a response and provide a rationale for the response. Every resident council will be audited 2 weeks after the meeting to ensure that every concern is responded to as required. 4. The facility will audit the monthly resident council minutes for 4 months. Results of the audits will be brought to the QAPI meeting for review. The Director of Activities is the responsible party.

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 a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed during the recertification survey. On the third floor, the exhaust ventilation was non-functional in several areas, including the staff bathroom, resident bathrooms, and the soiled utility room, resulting in significant foul odors. The Maintenance Director acknowledged the issue, citing difficulties in securing an electrician for repairs. Additionally, a resident room had a damaged wall and a missing drawer, while two sit-to-stand lifts were found heavily soiled with brown residue and debris. Further observations revealed that three chairs in the second-floor dining room were in disrepair, with chipped and cracked surfaces and damaged cushions and armrests. The microwave oven in the second-floor clean utility room was heavily soiled with food splatter. The first-floor south exit stairwell was cluttered with spiderwebs and dead bugs, and the exit discharge door had a significant gap, compromising its fit. In another resident room, duct tape and heat tape around the windows were peeling, allowing cold air to enter, and a section of the wall was cracked and peeling.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. All identified issues have been addressed, specifically: 1. The exhaust ventilation on the third floor was fixed. 2. The damaged wall behind the resident bed in room [ROOM NUMBER] was repaired. 3. Two sit-to-stand lifts outside resident rooms #201 and #219 were cleaned. 4. Five new chairs were ordered to replace the three chairs that were chipped, cracked, and had damaged cushions and armrests. 5. The microwave oven in the second-floor clean utility room with heavily soiled interior was replaced. 6. The spiderwebs and dead bugs on the first floor south exit stairwell were removed. 7. The gap below and around the lower edge of the exit discharge door from the first floor leading to the back parking lot was repaired. 8. The windows in resident room [ROOM NUMBER] were re-taped around the edges of the window to prevent cold air coming through. Also, the damaged wall behind the bed closet was repaired. 2. All residents have the potential to be affected. The facility will conduct a full building audit to ensure all exhaust ventilations are functioning correctly, any damaged walls in resident rooms are repaired, all chairs used by residents are not chipped or damaged, all microwave ovens in clean utility rooms are clean, all stairwells are free of spiderwebs or dead bugs, all exit doors have tight fitting, and resident windows are appropriately heat taped. The maintenance department and the administrator were educated on the importance of maintaining a homelike environment, to continuously round the facility to identify deficient areas, and to immediately address identified areas. An audit tool will be utilized to randomly audit 3 rooms for homelike environment to ensure compliance. 3. The facility will randomly audit 3 rooms for homelike environment weekly x 4 weeks then monthly x 3 months. Identified issues will be immediately addressed. Results of the audits will be brought to the QAPI meeting for review. The Director of Maintenance is the responsible party.

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 an effective Infection Control Program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff when providing care to residents on Enhanced Barrier Precautions. Resident #34, who had multiple wounds and was at risk for infection, was observed receiving wound care from an LPN who wore gloves but no gown, despite the requirement for full PPE. Similarly, Resident #45, who had a pressure ulcer and an indwelling urinary catheter, was not properly managed under Enhanced Barrier Precautions, as staff entered the room and provided care without wearing gowns, even though the Director of Nursing acknowledged the need for full PPE. Resident #99, who had a feeding tube and a colonized multi drug-resistant organism, was also not managed according to Enhanced Barrier Precautions. An LPN entered the resident's room without performing hand hygiene and wore gloves but no gown while administering care. There was no signage indicating Enhanced Barrier Precautions, and PPE was not readily accessible outside the resident's room. The Director of Nursing admitted that the resident should have been on Enhanced Barrier Precautions, and there was confusion among staff about responsibilities for signage and PPE placement. Additionally, the facility did not enforce its policy regarding influenza vaccination declination. Staff who declined the influenza vaccine were observed not wearing face masks in resident care areas during the influenza season. Despite being aware of the policy, staff members, including a CNA and an LPN, were found without masks, indicating a lack of adherence to infection control measures. The Regional Director of Clinical Services confirmed that staff are trained on these policies, but the implementation was not consistent, as evidenced by the observations during the survey.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. Resident #34, #45, and #99 were assessed for any adverse effects without the usage of PPE with no visible signs of infection. LPNs will be re-educated on Enhanced Barrier Precautions. DON will be re-educated on Enhanced Barrier Precautions. RNs will be re-educated on Enhanced Barrier Precautions. CNAs will be re-educated on Enhanced Barrier Precautions. All staff will be re-educated on influenza season and proper mask wearing. 2. An infection control audit will be conducted. This audit will ensure that EBP are implemented for indicated residents. All residents who meet the criteria were placed on EBP. 3. The facility educator/designee will educate facility staff on infection control, proper face mask wearing, and EBP. The following policies were reviewed without changes: Enhanced Barrier Precautions and Influenza Vaccine. The facility infection preventionist/designee will conduct frequent infection control rounding, including during wound rounds, and any identified opportunities will be addressed upon discovery. The infection preventionist, director of nursing, and other facility leadership will conduct rounds throughout the facility to ensure that staff members are exercising appropriate use of personal protective equipment. Ad hoc education will be provided to persons who are not correctly adhering to infection prevention/control practices. Licensed Nurses (staff/agency) will be reeducated on infection control practices during wound care (EBP). Employees (staff/agency) will be reeducated on infection control practices. Employees (staff/agency) will be reeducated upon hire, annually, and as necessary. 4. The Infection Preventionist/designee will audit the infection control practices during 5 wound treatments weekly x 12 weeks or until substantial compliance is achieved. The Infection Preventionist/designee will conduct infection control rounds for proper mask-wearing on 20 employees weekly x 12 weeks or until substantial compliance is achieved. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee. Responsible Party: Infection Preventionist/DON

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 Survey conducted from January 6 to January 14, 2025, it was observed that the facility, which consists of three resident sleeping floors and a basement, did not meet the required building construction type as per the 2012 edition of the National Fire Protection Association (NFPA) Life Safety Code. Specifically, the structural support members, such as the red bar joists supporting the concrete floor decks, were not protected by fire-rated material. This deficiency was noted in several locations, including near the elevators on the third and second floors, and near specific rooms on the first floor. A review of the facility's Fire Safety Evaluation System (FSES) dated March 5, 2024, indicated that the minimum compliant building construction type for the facility should be Type II (111), based on its three-story height. However, the FSES classified the building as Type II (000) due to the unprotected structural members, which do not meet the requirements for Type II (111). To comply, the structural support members must be protected from fire by a rated material or a fire-rated ceiling grid system with a fire resistance rating of at least one hour.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 It was determined that for three (first, second, and third floors) of three resident sleeping floors the facility did not meet an acceptable building construction type. Specifically, structural support members were not protected by fire rated material and the ceiling assembly was not fire rated. The facility intends to use NFPA 101A-2013 as a Guide on Alternative Approaches to Life Safety, Fire Safety Evaluation System (FSES) as an equivalency in order to comply with the cited deficiency. All other LSC deficiencies found during the survey and FSES will be corrected to ensure a passing score. The facility will be conducting a new FSES by 2/19/2025 to be performed in accordance with CMS survey and certification memo 17-15-LSC, and using the mandatory values in NFPA 101A, 2001 edition, to meet the fire safety requirements for recertification based on previous use of the FSES in conjunction with this deficiency. Results of the FSES will be shared with the regional office for review. All residents had the potential to be affected. No other life safety functions were affected. The facility will in-service the maintenance director on fire safety maintenance such as identification of any potential fire safety concerns or potential for unsafe or hazardous conditions. The Maintenance Director will be educated on the results of the FSES and on the requirement to ensure the facility is in compliance with NFPA standards. The facility also intends to maintain compliance by utilizing an FSES for equivalency as necessary for future recertifications as applicable. Audits will be conducted monthly on fire safety x4. The results of the FSES, the requirement for a passing FSES and the results of the audits will be discussed at QAPI. The Administrator/Designee is responsible for this plan.

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 facility failed to ensure residents were treated with respect and dignity, as meals were consistently served using disposable cutlery and dishware. This practice was not aligned with the facility's policy on Quality of Life/Dignity, which emphasizes care that promotes dignity and individuality. Three residents, among others, were affected by this practice. Resident #9, who is cognitively intact and requires setup assistance with eating, expressed difficulty in eating with plastic utensils, which caused their food to fall off and get cold quickly. Resident #96, also cognitively intact and requiring moderate assistance with eating, felt dehumanized by the use of paper and plastic dishware, likening it to being in jail. Resident #47, who has dementia and requires substantial assistance with eating, was observed eating a pureed meal with plastic utensils, despite their care plan not indicating a need for disposable dishware. Interviews with staff revealed that the use of disposable items was due to a shortage of metal utensils, with some staff suggesting that utensils were being hoarded or thrown out. The Food Service Director mentioned that only a few residents required disposable products due to specific dietary needs, yet the practice was widespread. The Director of Nursing and the Administrator were unaware of the extent of the issue, indicating a lack of communication and oversight within the facility.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. Registered Dietitian/Designee interviewed identified residents. Resident #9 remains in the facility with no adverse effects. Resident #47 remains in the facility with no adverse effects. Resident #96 remains in the facility with no adverse effects. All three Residents’ meal service preferences reviewed and updated. An inventory of all silverware and dishware was conducted. The identified areas for F550 were identified and corrected. 2. All residents have the potential to be affected by this deficient practice. Food Service director/Designee will review meal services, practices, and preferences at the next scheduled Resident Food Council Meeting. 3. All food service personnel will receive education on dining with dignity and the use of non-disposable versus disposable meal serve ware. A weekly audit of silverware and dishware will be completed by the food service director or designee to maintain appropriate PAR levels. Service ware/silverware will be ordered as needed to maintain adequate PAR levels. 4. A Food Service Department silverware audit will be completed weekly x 4 weeks then monthly x 3 months until substantial compliance is maintained. The Administrator or Designee will review the audits weekly x 3 monthly to assure compliance. The audits will be submitted to the QAPI committee at the monthly QAPI meeting for review. The Food Service Director is the responsible party.

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 completion of comprehensive assessments for residents as required by regulatory timeframes. Specifically, the assessments for four residents were not completed within the mandated 14 calendar days after admission or the assessment reference date. Resident #53's admission assessment was completed 21 days after admission, Resident #220's was completed 18 days after admission, and Resident #99's annual assessment was completed 20 days after the assessment reference date. These delays were contrary to the facility's policy and the Centers for Medicare and Medicaid Services' requirements. Interviews with the facility's Minimum Data Set (MDS) Coordinators revealed a lack of clarity and communication regarding the timely completion and submission of assessments. MDS Coordinator #1 acknowledged the delays but could not provide reasons for them. The Director of Nursing was unaware of the assessment timelines, and the Administrator was not informed of any issues related to the timeliness of the assessments. The MDS Coordinators indicated that the corporate staff were responsible for initiating and submitting the assessments, which contributed to the delays.

Plan Of Correction

Plan of Correction: Approved February 11, 2025 1. The MDS and assessments of the 4 affected residents will be reviewed to ensure they are complete and accurate. The residents will be reassessed by an RN and the Medical Record will be reviewed as well to ensure there are no adverse effects to the resident as a result of the late assessment. The late assessments were already completed and the associated MDS submitted so no corrective action is possible regarding the past time frame. 2. All resident assessments and MDS have the potential to be affected. The facility will audit all MDS submitted for new admission in the last quarter to identify any other late assessments. 3. The nurses working in the MDS department as well as nursing administration and unit managers will be educated on the requirement to complete all comprehensive assessments within the regulatory timeframes as noted in the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument (RAI). An audit will be conducted on 3 new admissions per audit to ensure compliance with timely assessment. 4. The New Admission Assessment Audit will be conducted weekly x 4 and then monthly x 3 on three randomly selected new admissions and then three randomly selected residents on an ongoing basis quarterly. The auditor will review their MDS and related assessments to ensure they were completed within the required time frame. Results of the audits will be brought to the QAPI meeting for review. The Director of Nursing is the responsible party.

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) Resident Assessments accurately reflected the residents' status for four out of seven residents reviewed during the recertification survey. Specifically, inaccuracies were found in Section I - Active Diagnoses and Section N - Medications. For one resident, the MDS inaccurately coded a psychotic disorder without documented evidence of psychosis-related behaviors during the look-back period. Another resident was incorrectly coded as receiving anticoagulant medications when only aspirin, an antiplatelet, was administered. Additionally, a resident was marked as receiving both antidepressant and antianxiety medications, although only an antidepressant was ordered and administered. Interviews with the MDS Coordinators revealed discrepancies in how they gathered and verified information for the MDS assessments. One coordinator relied on electronic records and internet searches to classify medications, leading to misclassification. The Director of Nursing was not informed of these issues, and the Administrator was unaware of any inaccuracies in the MDS assessments. The facility's policy required that the MDS accurately reflect the resident's status, but this was not adhered to, resulting in the identified deficiencies.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The MDS assessments for the 4 affected residents will be corrected and resubmitted. 2. All resident MDS assessments have the potential to be affected. The facility will audit all MDS assessments that were submitted last quarter to identify any other incorrect MDS coding. The nurses working in the MDS department will be educated on the requirement to ensure that all MDS assessments are accurately coded including [DIAGNOSES REDACTED]. 3. The medications are to be coded according to the medication's therapeutic category and/or pharmacological classification, not on how they are used. An audit tool will be utilized to audit the medication and [DIAGNOSES REDACTED]. 4. The Accurate Assessment Audit will be conducted weekly x 4 and then monthly x 3 on three randomly selected completed MDS. The auditor will review the medication and [DIAGNOSES REDACTED]. Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) 2024. Results of the audits will be brought to the QAPI meeting for review. The Director of Nursing is the responsible party.

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 three residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #53, diagnosed with post-traumatic stress disorder (PTSD), did not have goals or interventions related to their PTSD in their care plan. Despite the resident's moderate cognitive impairment and expressed need for mental health services, the care plan lacked specific behavioral symptoms to monitor or interventions to manage the PTSD. Interviews with staff revealed a lack of awareness and documentation regarding the resident's PTSD, which resulted in inadequate care planning. Resident #220, who required care for a nephrostomy tube due to acute kidney failure and other conditions, did not have any related goals or interventions in their care plan. The resident reported not receiving any teaching about nephrostomy tube care, and documentation showed inconsistent flushing of the tube as ordered by the physician. Staff interviews confirmed that the care plan should have included nephrostomy tube care, but it was not addressed, indicating a gap in the resident's care planning. Resident #104, with a history of stroke and hemiparesis, had a physician's order for compression wraps to manage swelling in the left arm. However, observations revealed that the compression wraps were not applied as documented, and the care plan did not include this intervention. Interviews with nursing staff highlighted discrepancies in treatment documentation and a failure to communicate and apply the necessary treatment, resulting in unmet care needs for the resident.

Plan Of Correction

Plan of Correction: Approved February 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #53’s care plan was updated to include goals and interventions related to the resident’s post-traumatic stress disorder diagnosis. Resident #220’s care plan was updated to include goals and interventions related to care of the resident’s nephrostomy tube. Resident #104 had their ACE wraps applied. Nurses on those shifts will be counseled. 2. A full house audit of the comprehensive care plans was completed, and care plans were updated with specific focus related to their [DIAGNOSES REDACTED]. 3. Policy named Care Plan-Comprehensive was reviewed and no changes were made. IDT and licensed nursing staff will be educated by the Regional consultant on care plan development, revision, review, and conducting of care plan meetings. The interdisciplinary clinical team will review changes in resident’s condition and revise care plan upon admission, readmission, and changes in resident’s condition, quarterly and annually. Care plan development or revision will occur in clinical meetings by the Interdisciplinary Team. Changes in resident’s care plan will be updated by the unit manager or responsible discipline. 4. The Unit manager or designee will audit all new admissions for completeness of the comprehensive care plan weekly for a duration of 3 months. A random audit of 5 resident comprehensive care plans per week x 12 weeks will be conducted by IDT Team and then 5 random resident comprehensive care plans on an ongoing basis per quarter. DON will provide onsite oversight of the IDT care plan meetings and provide feedback to the Regional Director on the effectiveness of the interventions. The Director of Nursing will report audit findings to the QAPI committee for review and recommendation on continuance of monitoring.

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 necessary assistance with activities of daily living for Resident #21, who was unable to perform these tasks independently due to medical conditions including a stroke and hemiplegia. Despite being cognitively intact and having an assessed need for assistance with personal hygiene, Resident #21 did not receive the requested help with shaving and fingernail care. Observations revealed that the resident had long, broken, and jagged fingernails and several days of beard growth, despite having asked the nursing staff for assistance. Interviews with facility staff, including Certified Nursing Assistants and Licensed Practical Nurses, indicated that grooming tasks such as shaving and fingernail care were expected to be completed on shower days and as needed. However, these tasks were not performed for Resident #21, as evidenced by the resident's unshaved facial hair and untrimmed fingernails during multiple observations. The facility's policy required that such care be provided in accordance with the resident's assessed needs and personal preferences, but this was not adhered to, resulting in the deficiency.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. Resident #21 was provided shaving and fingernail care on 1/14/2025 as per care plan. Resident #21 remains in the facility in stable condition. There were no adverse effects including alteration of skin integrity to resident #21 noted from the lack of timely ADL care. CNAs were counseled and educated by the DON/designee regarding appropriate ADL care and subsequent documentation including refusals of care if indicated. Nurse Managers and LPN/RNs will be educated by the DON or designee regarding frequent rounding to ensure that residents are provided ADL care as per the care plan and facility policy. 2. All residents have the potential to be affected by the deficient practice. Random reviews of residents will be conducted by the Unit Managers/ designees. This review will ensure that all residents have appropriate shaving and fingernail care as per the care plan. Any issues addressed will be immediately addressed. 3. Policy for Activities of Daily Living (ADL) care and support was reviewed by the Regional RN with no revisions required. Nursing staff and facility leadership will be educated by the Regional RN/ designee regarding ADL care for residents and subsequent documentation. The unit managers will conduct random daily ADL care rounds to ensure that ADL care is completed; this daily rounding will include ensuring shaving and fingernail care as per the care plan. Any issues identified will be immediately addressed. An ADL Committee will be established; this Committee will consist of IDT team members, Nursing Administrative staff, and a CNA representative. This Committee will meet bi-weekly x 3 months and review ADL audits and barriers to provision of timely ADL care- i.e. resident refusals, CNA compliance, residents with agitation during care, and other factors as indicated. The ADL Committee will address any issues identified. 4. A comprehensive weekly audit will be conducted by the Nursing Administrative staff. Five residents from each unit will be audited for a period of 12 weeks. The audit will include a review of shaving and fingernail care and frequency of care provided. The Regional RN will review these audits weekly and provide input as needed. The results of the audits will also be reviewed with the QAPI and ADL Committees for input. The QAPI and ADL Committees will then determine if further audits are needed. The Director of Nursing is the responsible party.

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 necessary care and treatment for a resident, identified as Resident #45, who was readmitted with a pressure ulcer. Upon re-admission, the facility did not conduct a thorough wound assessment as required by their policy. The resident had a documented stage two pressure ulcer on the left trochanter, but the assessment lacked details such as size, depth, and appearance. Furthermore, there were no documented wound care treatments provided for several days, and the resident's care plan was not updated to reflect the pressure ulcer following re-admission. Observations and interviews revealed that the resident had an unlabeled and undated adhesive dressing on the left trochanter, which was not recognized or addressed by the nursing staff. A Licensed Practical Nurse was unaware of the dressing's contents and whether there were any treatment orders for the resident's condition. Certified Nursing Assistants and Licensed Practical Nurses were not adequately communicating or documenting the presence of new skin impairments, and there was a lack of follow-up to ensure proper wound care orders were in place. The Director of Nursing and Registered Nurse #2 acknowledged the oversight in reviewing the hospital's After Visit Summary and the failure to enter necessary wound care orders into the electronic medical record. The facility's policy required a complete body examination and documentation of any skin impairments upon re-admission, which was not fully executed. This lack of adherence to professional standards of practice resulted in the resident not receiving appropriate care to promote healing and prevent the worsening of the pressure ulcer.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 45 was seen by the provider on 1/10/25 with no adverse effects noted from deficient practice. Treatment orders were placed. 2. All new admissions and all residents with wound treatments have the potential to be affected. Treatment orders will be reviewed for pressure ulcers to validate treatments were provided as ordered by the physician. All other residents with wound treatments ordered will be reviewed by Wound Provider. 3. Policy “Skin and Pressure Injury Prevention and Wound Identification and Wound Rounds” was reviewed with no revisions. The DON/designee will educate licensed nurses currently working at the facility and will be reeducated on wound care management/aseptic dressing changes to ensure proper technique and documentation. All new admissions will be audited for accurate skin assessment and treatments for any and all wounds. Any issues noted will be addressed at the time of identification, including applicable reeducation. All licensed nurses will complete a treatment competency to be evaluated for correct technique, following the treatment orders as prescribed, and infection control practices on hire, yearly, and as necessary. The unit manager will conduct daily routine rounding and review of Treatment record looking at consistent documentation of resident's pressure ulcers, complete and accurate treatment orders, following the treatment orders as prescribed, and [DEVICE] functionality. Any issues discovered will be corrected at the time of discovery. 4. Wound nurse/designee will audit all residents with wounds for presence of correct wound supplies and completion of the treatments as ordered weekly x 12. All findings will be brought to the QAPI committee for review and comment. The DON will provide onsite oversight of the IDT care plan meetings and provide feedback to the Regional Director on the effectiveness of the interventions. Audit results will be forwarded to the QAPI Committee for review and input. Responsible party: The 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 a resident, who required total nutrition and hydration via a gastrostomy tube, received adequate nutritional and hydration care consistent with their comprehensive assessment. The resident, who had severe cognitive impairment, dysphagia, malnutrition, and diabetes, was supposed to receive specific amounts of enteral feeding and water flushes as per physician orders. However, the Medication Administration Record (MAR) showed multiple instances of missing documentation and discrepancies between the documented and ordered amounts of nutrition and hydration. The facility's policies on enteral feedings and intake and output monitoring were not adhered to, as evidenced by the incomplete and inconsistent documentation in the MAR. The records showed that the resident did not consistently receive the prescribed amounts of Glucerna 1.5 and water flushes, with several instances of blanks or incorrect amounts recorded. This lack of accurate documentation could lead to adverse effects such as electrolyte imbalances, dehydration, and diarrhea, as noted by the Registered Nurse Manager. Interviews with facility staff, including the Director of Nursing and the Registered Dietitian, revealed a lack of clarity and responsibility regarding the monitoring of fluid intake records. The Registered Dietitian, who worked remotely, did not notice the discrepancies in the MAR until they were pointed out during the survey. The facility administrator was also unaware of the documentation issues, indicating a breakdown in communication and oversight within the facility's nutritional care processes.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. Flush order was clarified with RD. All nursing staff will be educated about following orders and calculating correct math. 2. All residents with tube feed can potentially be affected. House-wide audit done on all tube feed orders. Any discrepancies were corrected. 3. Policy Enteral tube-flushing and Med admin-Enteral tube were reviewed and no changes made. IDT and licensed staff will be educated on the above policies specifically related to calculation of tube feeding administered and water flushes. 4. Weekly audits of tube feeding administered and water flushes x 4, bi-weekly audits x 2 and monthly audits until corrected to be done by nursing administration. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee.

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 proper storage of drugs and biologicals in accordance with State and Federal Laws, as observed during the Recertification Survey. Specifically, multiple medication carts contained insulin pens that were labeled by the pharmacy to be refrigerated until opened, yet they were found unopened and stored in the medication carts. Additionally, a vial of insulin was stored in a medication cart without being opened. These observations were made on Unit Three medication carts North and South, and Unit Two medication cart North. Licensed Practical Nurses acknowledged the improper storage and labeling of these medications during interviews. Further deficiencies were noted with the discovery of two used nicotine patches stuck to the shower room wall, dated from previous months. An opened vial of insulin with a needle attached was also found on a resident's bedside stand, which the resident attributed to a nurse's oversight. Licensed Practical Nurse Manager stated that medications requiring refrigeration should be stored accordingly and dated once opened, and that used patches should be discarded in sharps containers. The manager also indicated that cart audits should include checks for proper storage and labeling, and that staff should seek managerial advice for any improperly stored medications.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. Insulin pen was removed from resident #70 room. All unopened insulin pens were removed from all med carts and placed in the refrigerator. Used nicotine patches were removed from the shower walls. Nurses will be educated by the unit managers regarding appropriate medication storage in medication rooms & carts. 2. All residents have the potential to be affected. The unit managers will spot audit medication rooms and carts on a daily basis to ensure appropriate medication storage. Any issues noted will be addressed. Unit managers will also spot audit shower rooms to ensure appropriate discard of the patches. 3. DON/Nursing administration will educate nursing staff on proper discard of nicotine patches. Education of LPN and RN nursing staff regarding C-MED-3 Medication Storage with expected completion on or before 3/3/25. 4. Weekly cart audit x4 weeks by DON/Nursing Administration to ensure drugs/biologicals used are labeled following currently accepted professional principles and the expiration date when applicable. Monthly audit x2 months or until the deficient practice is no longer identified; continue with random audits as needed to ensure continued compliance. Weekly shower room audits x 4, bi-weekly x 2 then monthly until the deficient practice is no longer identified. All findings will be reported to the QAPI Committee for review and comment. The DON will be responsible for the correction and monitoring.

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 received the influenza or pneumococcal immunizations as required, specifically for two residents out of five reviewed. The facility's policy, dated 11/24/2024, mandates that all residents or their representatives be offered and provided with these vaccines, with documentation of any refusal and education provided. However, for Resident #8, who had severe cognitive impairment and a Health Care Proxy, there was no documentation that educational material was provided to the proxy or that a declination was completed. Similarly, for Resident #74, who was cognitively intact, there was no evidence that educational material was offered or that a declination was documented. Interviews with facility staff revealed a lack of clarity and responsibility regarding the vaccination process. The Licensed Practical Nurse Manager was not involved in the vaccination initiative and was unsure about the management of vaccine declinations. The Regional Director of Clinical Services, acting as the Infection Preventionist, stated that an automated call was made to inform Health Care Proxies about the vaccine offerings, but it was the Unit Managers' responsibility to obtain consent or declination. This lack of coordination and documentation led to the deficiency identified during the survey.

Plan Of Correction

Plan of Correction: Approved February 18, 2025 1. Resident #8 and #74 will be offered the influenza and pneumococcal vaccination. Declinations and/or consents will be obtained. 2. All residents could potentially be affected. A review of the pneumococcal and influenza immunization status of all in-house residents was conducted to determine if any other residents did not have an up-to-date pneumococcal and/or influenza immunization record. For those residents identified, the Infection Control Nurse / Clinical Care Coordinators provided influenza and pneumococcal vaccine education to the resident/responsible party to obtain consent or declination of the vaccine if not medically contraindicated. Any resident consenting to the vaccine, an MD order will be obtained and the vaccine will be administered and documented as such in the resident’s medical record. 3. The following policy and procedure were reviewed and not revised: Influenza Vaccine and Pneumococcal Vaccination-Residents. Education will be provided to all licensed Nursing Staff. Re-education to include providing influenza and pneumococcal education to the resident/responsible party, obtaining consent/declination, obtaining an MD order if not medically contraindicated, ordering of the vaccine and administration of the vaccine and documentation of administration. Administration, Nursing Administration and the Infection Control Nurse reviewed the process of obtaining the pneumococcal vaccine. 4. Weekly audits x 4, bi-weekly x 2 and monthly until corrected. Random audit of 3 residents to be done every quarter. All new admissions will be offered the vaccinations. Consents or declinations will be obtained. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee.

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 Survey conducted from January 6 to January 14, 2025, a deficiency was identified in the facility's handling of soiled linen and trash receptacles. Specifically, on January 7, 2025, a large blue receptacle filled with bags of dirty laundry was observed stored in the basement egress corridor outside the laundry room. This receptacle measured approximately 3.5 feet long by 2.5 feet wide by 2.5 feet deep, equating to 163 gallons, which exceeds the 32-gallon limit for storage in an unprotected area. The Maintenance Director acknowledged the issue and stated he would instruct staff to move it inside the laundry room. On January 8, 2025, the same large blue receptacle, along with a similar receptacle containing bags of trash, was again observed in the same location. A laundry staff member explained that the laundry bin is stored in the hall until it is full and ready to wash. This practice violates the regulations requiring such receptacles to be stored in a protected hazardous area, as outlined in 10 NYCRR 415.29(a)(2), 711.2(a)(1), and 2012 NFPA 101: 19.7.5.7.1(3), 19.3.2.1.5.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. The facility removed the 163-gallon dirty laundry receptacle and bags of soiled laundry and a similar sized receptacle containing trash from the basement egress corridor outside the laundry room. 2. All areas of the facility have the potential to be affected. The facility will conduct a full building audit to determine if there were any other dirty laundry or trash receptacles larger than 32 gallons not stored in a protected hazardous area. 3. The maintenance department, the housekeeping department, and the administrator will be educated on the requirement to not store soiled linen or trash in a receptacle larger than 32 gallons in capacity unless located in a room protected as a hazardous area when not attended. An audit tool will be utilized to audit the basement and facility hallways to ensure that soiled linen and trash containers are stored in compliance with NFPA 101. 4. The facility will utilize the soiled linen and trash containers audit weekly x 4 and then monthly x 3. Results of the audits will be brought to the QAPI meeting for review. The Director of Housekeeping/Designee is the responsible party.

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 daily nurse staffing information was posted and updated as required during a Recertification Survey. Observations on multiple occasions revealed that the daily nurse staffing information was not posted at the beginning of each shift. Additionally, the information was not updated to reflect staffing changes throughout the day, and the facility did not maintain records of the daily nurse staffing data for the required minimum of 18 months. Interviews with the Director of Human Resources and the Director of Nursing confirmed these deficiencies. The Director of Human Resources admitted that the staffing information was completed in the morning but not updated during the day or over the weekend. Furthermore, the facility was unable to provide any past daily nurse staffing information sheets when requested. The Director of Nursing acknowledged that the staffing information should be posted in an accessible area, updated for accuracy, and retained for record-keeping purposes.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. BIPA was immediately corrected. BIPAs will be placed with accurate information and saved in a binder. 2. All residents have the potential to be affected. BIPA will be placed with accurate information and saved in a binder. 3. Education was provided to the Administrator, Director of Nursing, nursing administration, and nursing staff on how to calculate the BIPA correctly. The facility will conduct weekly audit of BIPA to make sure it has correct information x 4 then monthly x 2 until corrected. The staffing coordinator or designee is responsible for the correction and monitoring.