St Johnland Nursing Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kings Park, New York.
- Location
- 395 Sunken Meadow Road, Kings Park, New York 11754
- CMS Provider Number
- 335487
- Inspections on file
- 20
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at St Johnland Nursing Center Inc during CMS and state inspections, most recent first.
A resident with a history of stroke, hemiparesis, UTI, and moderate cognitive impairment was initially assessed as not at risk for elopement, but later told a provider they wanted to leave and was observed walking unassisted, looking toward an emergency exit, and showing increased suspiciousness and disorientation. Although nursing was aware of these mental status changes, there was no documented elopement risk reassessment or enhanced supervision that day, and the resident subsequently exited an exterior door unaccompanied and undetected, remaining outside until staff found and returned them to the unit.
A resident with multiple comorbidities and intact cognition had an assessed need for two-person assistance with transfers, documented in the care plan and kiosk instructions. A CNA, relying on the resident’s prior status and not checking the kiosk, attempted a one-person transfer from wheelchair to bed. During the transfer, the resident’s legs became weak, and the CNA lowered the resident to the floor, causing an open knee wound that required first-aid treatment. An RN later observed the resident on the floor with the knee injury, and the DON confirmed the expectation that staff check current transfer status before care, consistent with the facility’s neglect policy.
A resident with a history of sexually inappropriate behavior was inadequately supervised, leading to multiple incidents of sexual abuse involving other residents. Despite being on 30-minute checks, the resident was able to inappropriately touch others in the dining room and a private room, resulting in actual harm and immediate jeopardy. The facility's failure to implement effective supervision and separation measures contributed to these incidents.
During a Life Safety Code survey, a facility was cited for deficiencies in elevator maintenance. The elevator machine room contained unnecessary items, and two elevators had non-functioning emergency communication systems. Despite attempts to address these issues, the facility failed to provide evidence of successful repairs.
The facility failed to provide sufficient nursing staff, resulting in unmet resident needs across multiple units. On the Head Injury Rehabilitation Unit, only one CNA was available for 15 residents, leading to delayed care. In the Inn Unit, a resident missed scheduled showers due to understaffing, with only two CNAs for 38 residents. The [NAME] Hall Unit had one CNA for 46 residents during a night shift, causing incomplete care. The facility's staffing policy was not followed, and the absence of agency staff worsened the situation.
The facility failed to monitor cold food temperatures during meal service, with items like sandwiches and potato salad exceeding safe temperature limits. The Executive Chef and Registered Dietitian acknowledged the risk of foodborne illness due to improper temperature control, as cold foods were not routinely checked and exceeded the required 41 degrees Fahrenheit limit.
The facility failed to maintain resident dignity during meal times on a dementia unit due to delayed meal transport racks from the kitchen. Some residents received their meals while others at the same table did not, leading to a dignity issue. Staff interviews confirmed the ongoing problem, and the need for better coordination between nursing, kitchen, and dietary staff was acknowledged.
A resident with Alzheimer's Disease was observed multiple times without the required leg rests on their wheelchair, despite a physician's order. Staff interviews revealed a lack of communication and responsibility in addressing the missing leg rests, which were necessary for the resident's safety and mobility. The facility's policy on wheelchair safety was not followed, leading to a deficiency in the resident's care plan.
A facility failed to involve a resident and their representative in the care planning process, as required by policy. The facility did not conduct interdisciplinary care plan meetings or invite the resident or their representative for quarterly assessments. Staff interviews revealed that meetings were only held for admissions, annuals, and significant changes, not quarterly reviews. The resident, with moderate cognitive impairment, wanted to participate but was not invited.
A resident with Alzheimer's and severe cognitive impairment required two-person assistance for transfers. However, a CNA independently used a mechanical lift, resulting in the resident sustaining a forehead injury. The facility's policy and care plan mandated two-person assistance, which was not followed, leading to the incident.
A CNA failed to follow the two-person transfer protocol for a resident with severe cognitive impairment and functional limitations, resulting in a forehead bruise. Despite the care plan and facility policy requiring two-person assistance for mechanical lift transfers, the CNA performed the transfer alone, without seeking available staff assistance.
A resident with Diabetes Mellitus and Peripheral Vascular Disease was found with two unlabeled tubes of Voltaren cream on their nightstand, without a physician's order or staff awareness. Facility staff confirmed that residents are not allowed to self-medicate without proper assessment and orders, highlighting a lapse in medication management protocols.
A resident with multiple health conditions expressed dissatisfaction with the meals served, noting they were not assessed for food preferences and were served items they do not eat. The resident did not receive a menu to choose meals, and dietary assessments lacked documentation of preferences. Staff interviews revealed a lack of initial documentation and assessment of the resident's food preferences, leading to the deficiency.
A deficiency was identified when a nurse handled medications with bare hands during administration to a resident, contrary to infection control policies. The medications were placed on an unsanitized table without a barrier, and the nurse touched them while explaining to the resident. Facility staff confirmed this practice was unacceptable.
A resident with significant mobility and communication impairments was found with a call bell out of reach on multiple occasions, despite facility procedures requiring it to be placed on their knee or lap. Staff interviews revealed inconsistencies in call bell placement, and the Chief Nursing Officer confirmed the importance of keeping it accessible.
The facility failed to maintain sanitary conditions in its food service areas, with surveyors observing a buildup of substances around ice dispensers and dust on sprinkler heads. The Dietary Department is responsible for cleaning the ice machines weekly, and the Senior Director of Operations acknowledged the need to clean the dusted sprinkler heads.
During a survey, improper exit signage was found in two resident units and the basement. Exit signs in the (NAME) unit pointed towards a wall, and in the Kipp unit, non-delayed egress doors were marked with delayed egress signage. The basement lacked proper exit signage for the Dental/exam room. The Engineering Manager and Senior Director of Operations acknowledged the issues.
During a survey, deficiencies were found in the maintenance and inspection of fire doors in the facility. In the Muhlenberg unit, double fire doors did not adjust properly, and in the Sunset Hall unit, doors got stuck on the frame. The facility's checklist did not verify all required inspection items, indicating non-compliance with NFPA standards.
The facility did not conduct fire drills at unexpected times as required by NFPA 101 standards. A review of fire drill logs showed that drills were consistently held at similar times across all shifts. The Senior Director of Operations acknowledged the issue, and the Engineering Manager noted the timing was chosen to avoid waking residents during evening and night shifts.
Failure to Reassess Elopement Risk and Provide Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and timely elopement risk assessment for a resident who expressed a desire to leave the facility. The resident was admitted with diagnoses including stroke, hemiparesis, and urinary tract infection, and had a BIMS score of 11, indicating moderate cognitive impairment. A Wandering/Elopement Evaluation completed in early December documented that the resident was not at risk for elopement at that time. Facility policy on Elopement Prevention required that upon a significant change in condition, each resident be reassessed for elopement risk using the Elopement Risk Tool and that appropriate interventions be implemented as indicated. On a later date, a neuropsychology note documented that the resident was observed walking unassisted into the dayroom, looking toward an emergency exit door, and attempting to convince staff to allow them to leave. The note also documented increased suspiciousness and disorientation, including the resident stating an incorrect date, and indicated that nursing was aware of the mental status change and the need for continued observation. However, there was no documented evidence that an elopement risk reassessment was completed after this change or that enhanced supervision or elopement interventions were implemented that day. Video surveillance later showed the resident exiting an exterior door unaccompanied and undetected and being brought back into the building by staff approximately 35 minutes later. A nursing progress note recorded that the resident was found outside the building sitting on the curb with no apparent distress and was safely returned to the unit.
Failure to Follow Two-Person Transfer Care Plan Resulting in Resident Injury
Penalty
Summary
The deficiency involves a failure to protect a resident from neglect by not following the comprehensive care plan and current transfer instructions. The resident had diagnoses including UTI, atrial fibrillation, hypertension, and COPD, and an MDS assessment documented intact cognition and a need for assistance of two or more helpers for transfers from chair to bed and toilet. The comprehensive care plan and kiosk nursing instructions, updated in mid-October, specified that the resident required two-plus person physical assistance for transfers. Despite this, on the evening in question, a CNA attempted to transfer the resident from a wheelchair to a bed using only a one-person assist, contrary to the documented plan of care and kiosk instructions. During the transfer, the resident’s legs became weak and the CNA lowered the resident to the floor, resulting in removal of a scab and an open area on the left knee measuring 3 cm by 3 cm by 0 cm, which required cleansing with normal saline, application of Neosporin, and a dry protective dressing. The CNA later stated they did not check the kiosk nursing instructions for the resident’s current transfer status prior to the transfer and acknowledged they usually do not check if they are familiar with the residents, relying instead on the resident’s prior status before readmission. An RN found the resident on the floor lying on the left side, with the left knee injury but no reported pain, discomfort, or head injury. The DON stated the expectation that the CNA should have checked the kiosk for the resident’s current transfer status at the beginning of the shift before providing care, consistent with the facility’s abuse and neglect policy, which defines neglect to include failure to follow the care plan.
Inadequate Supervision Leads to Sexual Abuse Among Residents
Penalty
Summary
The facility failed to ensure adequate supervision to prevent sexual abuse among residents, resulting in actual harm to three residents. On one occasion, a Licensed Practical Nurse (LPN) responded to a call for help in the dining room and found a resident touching another resident's genital area. The LPN removed the victim but left the aggressor unsupervised, who then proceeded to touch another resident inappropriately. The facility's investigation confirmed probable evidence of abuse, neglect, or mistreatment. Another incident involved the same aggressor entering a resident's room and touching them inappropriately. A Registered Nurse (RN) responded to the victim's cries for help and found the aggressor at the bedside with the victim's pants and sheets pulled down. The facility's investigation again concluded there was probable evidence of abuse, neglect, or mistreatment. Interviews with staff revealed that the aggressor had a history of sexually inappropriate behavior and was on 30-minute checks, but this supervision was insufficient to prevent further incidents. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving the same aggressor. The aggressor had a documented history of sexually inappropriate behavior and cognitive impairment, yet the interventions in place, such as periodic checks and redirection, failed to prevent further abuse. The facility's failure to adequately supervise and separate the aggressor from other residents led to multiple instances of sexual abuse, resulting in immediate jeopardy to the health and safety of the residents involved.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-600 I. The following actions were accomplished for the residents identified in the sample: **Resident #1** Resident #1 was hospitalized on [DATE] and remains in the hospital. If the resident is discharged back to the facility, the IDCPT will develop a care plan that addresses the resident’s risk of abusing other residents and to be abused with resident-specific care plan interventions. The facility has determined that the resident may require one-to-one supervision when he returns to the facility, but a determination will be made on his return. **Resident #2** The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/24/2024 following the resident-to-resident sexual abuse incident and no complaints were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the resident’s risk to be abused. On 3/26/2025 the IDCP Team completed an additional review of the resident’s risk to be abused care plan and updated it to include person-centered interventions based on the resident’s involvement with family and interest in recreational activities including: - Provide the resident with a cup of coffee and home magazines to flip through - Weekly rosary program - Utilize catholic prayers (Hail (NAME) and Our Father to calm the resident) - Music programs with emphasis on show tunes (favorite music) - Resident was removed from the early get up list, by preference (hx of combative behavior during caregiving) The resident has not been involved in any negative peer-to-peer interaction since 12/16/24. **Resident #3** The resident was seen by the social worker on 12/16/2024 and had no recollection of the incident from earlier in the day. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 12/17/2024 following the resident-to-resident sexual abuse incident and no issues were identified. The resident continues to be free of any psychological symptoms of distress. The IDCP Team updated the plan of care on 12/16/2024 to address the resident’s risk to be abused. On 03/26/2025 the IDCP Team completed an additional review of the resident’s potential for abuse care plan and added additional person-centered interventions including: - Provide opportunities to watch old movies with her peers - Play music of preference i.e. Sinatra, Dean Martin, Perry Como - Participation in Busy Bees table to engage in diversional activity- ensure game is provided to the resident first, as per preference and history of grabbing items from others The resident has not been involved in any negative peer-to-peer interactions since 12/16/25. **Resident #4** The resident was seen by the social worker on 2/24/2025 and had no recollection of the incident that occurred on 2/22/2025. The resident showed no evidence of psychological trauma. The resident was assessed by the medical provider on 02/24/2025 following the resident-to-resident sexual abuse incident and no distress was identified at that time. The resident had been followed by psychiatry and psychology since readmission on 5/14/2024 related to her behaviors/ [DIAGNOSES REDACTED]. depression. She continues to be followed by both services and is closely monitored related to ongoing behaviors i.e. refusals of care, wandering, flirtatious comments, verbal outbursts. The resident is currently on 30-minute checks related to her behaviors. [MEDICAL CONDITION] medications inclusive of [MEDICATION NAME] sprinkles, duloxetine, [MEDICATION NAME] and trazodone continue to be part of the resident’s treatment plan. The IDCP Team updated the plan of care on 02/24/2024 to address the resident’s risk of being abused. On 03/26/2025 the IDCP Team completed an additional review of the resident’s risk of being abused. The care plan was updated to include: - If resident is upset and/or agitated call nephew or cousin to allow resident to speak with them - Offer activities of specific resident interest i.e. Good Housekeeping magazines, cards, casino games - Utilize soda and sweet snacks to divert from undesirable comments/behaviors (resident preference) - If resident refuses care, provide time and space and reapproach The resident has not been involved in any negative peer-to-peer interactions since 02/22/2025. On 03/05/2025, the facility developed and implemented a plan for Abuse Prevention education related to the immediate jeopardy situation to ensure all staff received this education prior to the start of their next assigned shift. 89% of staff on duty completed the education by 03/07/2025. This education continued through 03/25/2025. 100% compliance was met by all departments, other than nursing, which has a compliance rate of 96%. Directed In-service is scheduled to be initiated on 04/01/2025. II. The facility was notified of the immediate jeopardy situation on 03/05/2025 and implemented the following: The facility convened a QAPI meeting on 03/06/2025 to discuss the root cause of the abuse situation. Administration initiated staff training on the following topics on 03/06/2025: - Reporting process - How to report Abuse, Neglect and Mistreatment - Unit Behavior Management meeting - 1:1 observation and 30-minute monitoring - Role of the RN Supervisor regarding reporting abuse, neglect and mistreatment - Safeguarding residents with cognitive impairments against sexual and/or inappropriate behaviors III. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Please refer to corrective actions outlined at Sections II, III and IV of this DP(NAME). The CNO reviewed all Incident Reports for the period of 01/5 to 03/25/2025 and no additional events of abuse have occurred. The DNS/designee will continue to review all new Incident Reports daily to ensure prompt follow-up is completed for any type of abuse report. The facility’s QAPI Committee and outside consultant participated in a DP(NAME) QAPI meeting on 03/25/2025, to discuss the issues identified at F-600 and conducted a Root Cause Analysis. During this meeting, the outside consultant provided education to the Committee members on Abuse Prevention principles and how non-adherence to abuse prevention practices, including management of resident sexual behaviors, can result in deficient practices such as those cited in the SOD. Education also addresses use of a Root Cause Analysis when compliance issues are identified. All resident care plans related to abuse risk, at risk to be a victim or to victimize, requiring behavior management or other interventions to prevent are being reviewed by the IDCPT and updated, as necessary, to address the resident’s current needs and problems and to ensure preventative measures are in place. If a care plan indicating potential risk to be a victim or to victimize has not been developed, one will be initiated for all identified at-risk residents. Nurse Managers will review the plan of care with the unit staff responsible and update the care plan and Kiosk as indicated. Effective 04/01/2025 through 04/03/2025, education will be provided by the outside consultant to all facility staff on the facility’s Abuse Prohibition protocols including behavior management principles for residents at risk to abuse and those at risk of being abused. The education will include types of abuse; need for identification and monitoring of resident behaviors that may result in a potential abuse situation for another resident and staff response to behavioral symptoms with appropriate interventions to prevent abuse from reoccurring. This education will continue to be provided until all facility staff receive this mandatory education. IV. The following system changes will be implemented to ensure continuing compliance with regulations: The CEO/Administrator, Medical Director and CNO and outside consultant reviewed and revised, as needed, the facility’s policy on Abuse Prohibition Protocols to ensure that it addressed monitoring of resident behaviors that may provoke a reaction by staff, residents or others or create potential situations of abuse and protocols to manage such behaviors. The policy was revised to include the utilization of unit-based behavioral management meetings to utilize in the identification and management of challenging and/or inappropriate behaviors. On 03/25/2025, the CEO/Administrator, Medical Director, CNO and outside consultant reviewed and revised, as needed, the facility’s policy on Resident Supervision Protocols. The policy was revised to include the use of 1:1 supervision and 30-minute checks to closely monitor a resident to ensure their safety and well-being, often due to behavioral, medical or cognitive concerns. On 03/25/2025 CEO/Administrator, Medical Director, CNO and outside consultant reviewed and revised the facility protocols for behavior management interventions related to managing a resident’s risk factors to abuse others or to be abused. This protocol includes identifying resident-specific risk factors to abuse or be abused and interventions to implement to prevent resident-to-resident abuse, including sexual abuse. Abuse Prevention education will continue to be provided by the Staff Educator/designee during orientation, annually and on an as-needed basis, including following any resident-reported abuse events. The Director of Social Work will follow up on all complaints voiced by a resident and/or family member regarding any allegation of abuse. The Director of Nursing and RN Supervisors will monitor for compliance during random and routine monitoring rounds and observations on the Nursing Units and medical record review. Immediate corrective actions, such as re-education or reevaluation of a resident’s plan of care regarding the potential to abuse or be abused, will be implemented as indicated. V. The facility’s compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a QAPI Committee meeting co-chaired by an outside consultant was convened on 03/25/2025 to examine this deficiency. The facility will develop an audit tool to monitor and evaluate staff knowledge and understanding of the facility Abuse Prohibition Protocol and responsibilities in monitoring of resident behaviors that may result in a potential situation of abuse if appropriate preventative actions are not implemented. The Staff Educator will audit twenty-five staff members for staff knowledge and understanding of Prevention of Abuse, Neglect and Mistreatment and Reporting Protocols monthly for the next six months and then on a quarterly basis for the next two quarters. The sample will include staff from all disciplines. Corrective actions such as reeducation will be implemented when indicated. The compliance for staff knowledge threshold will be 95%. If the compliance threshold is not met at the end of the first 6-month period, monthly auditing will continue as well as additional staff education provided. Monthly auditing will continue until a compliance threshold of 95% is reached. Audit findings will be reported to the QAPI Committee monthly for the next six months and then quarterly for evaluation and follow-up. The facility will develop an audit tool to monitor compliance with Abuse Prevention protocols to ensure documentation addressed resident-specific risk factors and interventions. DNS/designee will audit twenty-five resident care plans related to Abuse Risk and Behavior Management monthly for the next six months and then quarterly for the next two quarters. Residents who exhibit sexual behaviors will be included in the survey sample. Corrective actions such as reeducation and/or updating of the plan of care will be implemented when indicated. The compliance threshold will be 95%. If the compliance threshold is not met at the end of the first 6-month period, monthly auditing of at-risk for abuse or to be abused care plans will continue monthly with additional staff education provided. Monthly auditing will continue until a compliance threshold of 95% is reached. All Abuse Risk and Behavior Management audit findings will be reported to the QAPI Committee monthly for the next six months and then quarterly for evaluation and follow-up. The CNO/designee will continue to report all Abuse, Neglect and Mistreatment allegations and investigation findings to the QAPI Committee on an ongoing basis for evaluation, discussion and implementation of system changes to assist with the Prevention of Abuse, Neglect and Mistreatment. The CNO/designee will continue to review all reported allegations of abuse and make a report to the NYSDOH as per requirements. Responsibility: Chief Nursing Officer Completion Date: 4/17/2025
Elevator Maintenance and Safety Deficiencies
Penalty
Summary
The facility was found to have deficiencies related to the maintenance and operation of its elevators during a Life Safety Code recertification survey. Specifically, it was observed that the elevator machine room in the basement contained four TV screens, which are not necessary for the maintenance or operation of the elevator. This is a violation of the 2007 ASME A 17.1 Safety Code, which stipulates that only machinery and equipment used directly in connection with the elevator should be stored in such spaces. Further document review revealed that two out of three elevators serving the facility were not maintained in accordance with the NFPA 101: Life Safety Code and ASME A17.1/CSA B44: Safety Code for Elevators and Escalators. Inspection records indicated that the emergency communication systems in these elevators were not functioning properly. Specifically, the car emergency signals for two elevators were marked as 'no good' due to the absence of a dial tone on the phones, indicating a failure in the emergency communication system. The facility's failure to maintain the elevator communication systems was further evidenced by repair time tickets and vendor communications. These documents showed ongoing issues with the elevator phones, including inactive phone lines and the need for new phone installations. Despite efforts to address these issues, the facility had not submitted evidence of successful repairs by the time of the offsite Life Safety Code Post Survey, indicating a continued deficiency in maintaining the required safety standards for elevator operations.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 Plan of Correction for affected areas: The maintenance staff immediately removed the identified storage items from the Elevator machine room. The Director of Maintenance secured independent telephone lines for each elevator and engaged our Elevator vendor to install, test and maintain the emergency telephones in each elevator. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. All Elevator machine rooms were checked for storage not directly related to the elevator use. Any items found were immediately removed. Plan of Correction for system measures to prevent reoccurrence: A “Storage is Prohibited” sign was permanently installed on the Elevator Machine Room Door. All maintenance staff will receive additional education, and all participants will understand the life safety issues with Elevators in accordance with the requirements of 2012 NFPA 101:19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4 and ASME A17.3, Safety Code for Existing Elevators and Escalators. The In-Service Coordinator/designee has been assigned the responsibility for the education of staff. This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all Elevator machine rooms for improper storage and test the Emergency telephones in each elevator monthly. The Director of Maintenance will utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, as observed during a recertification survey. On the Head Injury Rehabilitation Unit, 13 out of 15 residents remained in bed late into the morning due to insufficient staffing, with only one Certified Nursing Assistant (CNA) available to care for all residents, despite the requirement for two-person assistance. This CNA was unable to provide scheduled showers and had to perform tasks alone that required assistance, compromising resident care. In the Inn Unit, a resident did not receive scheduled showers on two occasions due to understaffing. The unit was consistently short-staffed, with only two CNAs available for 38 residents, many of whom required two-person assistance. This led to delays in care, including missed showers and late transfers back to bed, as CNAs struggled to manage high resident-to-staff ratios. The [NAME] Hall Unit also experienced staffing shortages, with only one CNA assigned to 46 residents during a night shift. This resulted in incomplete care for many residents, as the CNA could only attend to their assigned residents. The facility's staffing policy was not adhered to, and the lack of agency staff exacerbated the issue, leading to significant gaps in resident care and unmet needs.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #38 The Nurse Manager for Resident #38 met with the resident to discuss his/her concerns. Resident #38 was provided with a shower. The Nurse Manager provided additional education to unit staff regarding their responsibility for following the resident’s plan of care, including his/her shower schedule. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. Between 11/29/24 and 12/10/2024 the Nurse Manager/designee for the Lawrence Hall Unit met with each resident and/or representative to discuss their preferences for related to their out of bed schedule. The Nurse Manager updated the care plan to reflect the resident’s preference for getting out of bed, updated the CNA’s assignment and reviewed the care plan revisions with the unit staff. A comprehensive review of ADL documentation from the last quarter will be conducted by the Nurse Managers/supervisors to identify any potential concerns related to provision of care, including adherence to shower schedules and out of bed preferences. Consideration will be given to redistribution of routine tasks to different shifts, if possible, to assist with staff efficiency and completion of required duties. Effective 12/10/2024, the Unit Managers for all units, including the Muhlenberg unit, were directed by the Chief Nursing Officer to conduct additional observational rounds to ensure each resident’s plan of care is being carried out consistently as it relates to showers, out of bed and other needs. Any concerns identified will be immediately addressed, such as re-educating staff about the plan of care and ensuring the resident’s need is met, such as being assisted out of bed at that time or a shower provided. The Nurse Manager/designee will include assessing completion of shower associated documentation as part of the observation rounds. The Unit Managers will review the list of resident shower schedules, out of bed preferences/schedules and other scheduled ADL assistance with responsible staff to ensure the plan of care is consistently carried out. CNAs who cannot complete all assigned duties during a shift will report this concern to the Unit Manager/Nurse Supervisor for timely follow-up. The Social Worker for each unit will meet with a random sample of five different interview-able residents monthly to conduct an interview regarding satisfaction and their perception of care and staffing, including as it relates to receiving showers and being assisted out of bed in accordance with their preferences. The results of these structured interviews will be provided to the Director of Social Work for reporting to the Administrator and Chief Nursing Officer. This information will be utilized as appropriate to inform staffing needs for all units and shifts. The Staff Educator/designee will provide additional education to all Nursing staff regarding their responsibility to ensure that the plan of care is followed for all residents, including adhering to shower schedules, assisting residents with getting out of bed, and other care directives. Licensed staff were re-educated regarding their responsibility to assist CNAs, as needed, including for residents who require two-person assistance. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Chief Nursing Officer reviewed the facility’s staffing policy and procedure and Facility Assessment to determine if any revisions were necessary to staffing levels to meet resident care needs. The Chief Nursing Officer/designee will educate the Staffing Coordinator, Assistant Director of Nursing and Nursing Supervisors regarding the need to ensure that actual unit-based staffing is based on the staffing levels included in the Facility Assessment. The Chief Nursing Officer/designee will continue to direct responsible staff to immediately attempt to fill any staffing need due to call-ins and document attempts to obtain additional staff, whether it is through advising existing staff of additional shift opportunities or contacting agencies to supplement facility staffing needs. The Administrator and the Chief Nursing Officer will convene routine staffing assessment meetings to review actual staffing levels, call outs, double shifts, retention and use of agency staff and to determine if any staffing level changes are necessary based on the current census. The facility will continue to advertise and actively promote all open roles at the facility through online job postings, on-site job fairs and explore additional opportunities for recruitment and retention, including contacting local nursing schools to identify additional prospective staff. The facility will create an incentivize sign on bonus program for new employees to help with recruitment/retention. The Administrator and Chief Nursing Officer will continue to employ all available tactics to attract and retain staff, including exploring additional staffing agencies to contract with. Attempts to hire additional agency staff are continuously underway. The Administrator and Chief Nursing Officer will continue to explore opportunities to increase staff retention, which is an identified concern. The facility will explore an incentivize Mentorship program by pairing experienced staff with new hires to foster guidance, support and connection. The facility is exploring additional options for weekend shift incentives to increase retention. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor the facility’s compliance with meeting sufficient staffing requirements, as determined by the Facility Assessment’s staffing plan. The Chief Nursing Officer/designee will audit the facility’s actual staffing daily against the facility’s master staffing plan and report to the QAPI Committee on an ongoing, monthly basis regarding staffing status changes. The facility’s recruitment and retention efforts will be reviewed quarterly during QAPI Committee meetings on an ongoing basis. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer
Deficiency in Cold Food Temperature Monitoring
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a kitchen observation, it was noted that the facility did not monitor the temperature of cold food items such as sandwiches, potato salad, and pudding at the time of meal service. The facility's policy requires that cold foods be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. However, there was no documented evidence that cold food temperatures were taken during the meal service. Interviews with the Executive Chef and Registered Dietitian revealed that cold food temperatures were not routinely obtained because the food was held in the refrigerator, and the refrigerator temperature was used as a proxy. However, when tested, the temperatures of several food items not stored in the refrigerator were found to be above the required range, with a tuna sandwich at 50 degrees Fahrenheit, a ham sandwich at 48 degrees Fahrenheit, potato salad at 48 degrees Fahrenheit, and pudding at 50 degrees Fahrenheit. The Executive Chef acknowledged that these temperatures posed an increased risk of foodborne illness. The General Manager of the vendor company providing dietetic services confirmed that cold food should not exceed 41 degrees Fahrenheit and should be held on a bed of ice if not refrigerated, indicating a potential for harm if these standards are not met.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 I. The following actions were accomplished for the residents identified in the sample: No residents were identified in the Statement of Deficiencies. On 12/4/24, any cold food items that were above 41F degrees were removed from trayline and replaced with new product. The Food Service Director and RDO toured the kitchen to identify any other food item temperature concerns. No other items were identified. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Effective 12/4/24, in-service education was provided to Dietary Staff and RDs related to cold food holding procedure on trayline and monitoring of cold food temperatures at every meal. This education included monitoring cold food temperatures on the trayline at each meal, and procedures for holding cold food that is not being held in a refrigerated unit, including holding food on ice or using ice blankets. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Food Service reviewed and revised, as needed, the Food Service policies and procedures related to monitoring of cold food temperatures at mealtimes and holding of cold foods on trayline. Effective 12/4/24, the Director of Food Service/Designee will implement a system of holding all cold food items on tray line in refrigerator unit, or on other cold source including ice or ice blankets, and monitoring of cold food temperatures at every meal on a temperature log sheet to ensure cold food temperatures are being held appropriately and remain 41F degrees and below daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/Designee will provide additional education to all dietary staff whenever issues related to holding, monitoring and recording of cold food temperatures are identified. The Director of Food Service will review findings with the Administrator monthly for three months then quarterly. Effective 12/4/24, the Food Service Director/Designee will monitor cold food holding and monitoring and recording of cold food temperatures daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/Designee will provide additional education to all food service workers whenever issues related to cold food holding and monitoring and recording of cold food temperatures are identified. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with cold food holding on cold source and monitoring and recording of cold food trayline temperatures on temperature log during meal service. The Director of Food Service/Designee will conduct monitoring of cold food holding and monitoring and recording of cold food temperatures monthly for three months then quarterly for the next three quarters. The Director of Food Service/Designee will conduct competency evaluations of all Food Service workers to ensure they are following established protocols and have a clear understanding of the protocols. On-site education will be provided as necessary to ensure staff compliance. Competency evaluations will be conducted on all new Food Service Workers upon completion of orientation and twice yearly thereafter. The Food Service Supervisor/Designee will report cold food holding and monitoring and recording cold food temperatures audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the QAPI Committee. Completion Date: 01/31/2025 Responsibility: Director of Food Service
Dignity Issue Due to Delayed Meal Delivery
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal times, as observed during a recertification survey. On the [NAME] Unit, a secure dementia unit, residents were seated at tables waiting for their lunch trays, but due to delays in the delivery of meal transport racks from the kitchen, some residents received their meals while others at the same table did not. This resulted in a situation where some residents were eating while others were left waiting, which was identified as a dignity issue. The facility's policy on resident rights emphasizes the importance of dignity and respect, yet the meal delivery system did not align with these principles. Interviews with staff, including LPNs and CNAs, revealed that the late arrival of meal transport racks was a known issue, and the kitchen staff was aware of the problem. The General Manager for kitchen and dining operations acknowledged the need for better coordination between nursing, kitchen, and dietary staff to ensure that all residents at a table are served simultaneously. The Director of Nursing Services also emphasized that even though residents on the dementia unit may be confused, they should still be able to eat together rather than watching others eat, highlighting the importance of maintaining dignity during meal times.
Plan Of Correction
Plan of Correction: Approved January 6, 2025 I. The following actions were accomplished for the residents identified in the sample: No specific residents were identified in the Statement of Deficiencies. On 12/30/24, a seating chart was developed by the Nurse Manager for the Kipp unit and provided to the Dietary Department, so that truck order of trays is consistent with seating chart and all residents at the same table receive their meal at the same time. On 12/4/24 the Staff Educator/designee provided Inservice training to the Kipp unit Nursing staff on meal service, including serving all residents seated at the same table their meal tray at the same time. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by same practice. Effective 12/30/24, education was provided to Nursing and Dietary staff related to the facility policy and procedure for the development of seating chart for all units for mealtimes, and dietary developing a system to arrange food trucks in table order so that all meal trays for residents at the same table arrive on the units at the same time by Food Supervisor. This education included staff discussion regarding importance of resident respect, dignity and quality of life as it relates to mealtimes, including concerns for residents at the same table receiving trays at the same time. This education also included the need to review and update seating charts on a routine basis and Nursing’s responsibility for alerting the Dietary Department of any changes needed to the truck tray order. Nurse Managers and Dietitians will conduct meal observations on a random basis for all meals and shifts weekly to identify any concerns related to meals not being served in table order. Issues identified with the food carts not being loaded in table order for distribution will be addressed by the Food Service Director for all reported concerns. Issues related to a resident being seated at a table that is inconsistent with the seating chart will be addressed by the Unit Nurse Manager. The Manager will update the seating chart, if indicated, or provide staff education regarding their responsibility to adhere to the seating chart during all meals. If a resident must be moved to another table for meals, the Manager will promptly update the seating chart. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Food Service reviewed and revised, as needed, the Food Service policies and procedures related to preparation of meal trucks, including providing trucks in order of residents seating to ensure that all residents receive their meal at the same time at each table. The Chief Nursing Officer reviewed and revised, as needed, policies and procedures related to resident dining and meal service related to resident rights and quality of life and directed the development of resident seating charts for each unit, which will be updated, as needed, and be provided to dietary when updated. Effective 12/10/24, the Director of Food Service/Designee and Chief Nursing Officer/Nurse Managers/designee will monitor meals to ensure all residents at same table are provided with meals at same time daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including Nursing of Food Service staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/designee will provide additional education to all Nursing and Dietary staff whenever issues related to residents receiving meals at same time when seated at the same table are identified. The Director of Food Service will review meal service findings with the Administrator monthly for three months then quarterly. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with Resident Rights related to meal service including residents at same table receiving meals at same time, accuracy of seating charts and accuracy of meal tray order on trucks to ensure meal service promotes resident dignity and respect and quality of life. The Director of Food Service/Designee will conduct monitoring of residents at same table receiving meals at same time monthly for three months then quarterly for the next nine months. The Director of Food Service/Designee will conduct competency evaluations of all Food Service workers to assure they are following established protocols and have a clear understanding of the protocols for proper truck order. On-site education will be provided, as necessary, to ensure staff compliance. Competency evaluations will be conducted of all new Food Service Workers upon completion of orientation and twice yearly thereafter. Chief Nursing Officer/designee will conduct meal service observations of nursing staff job performance during meal service to ensure resident respect and dignity and quality of life concerns are addressed when identified. Observation will include assessing the development and currency of seating charts, communication of updates to the Dietary Department, and residents being in their designated seating area for meals. The Food Service Supervisor/designee will report residents’ meal service audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. The Chief Nursing Officer will report meal service observation audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. Completion Date: 01/31/2025 Responsibility: Director of Food Service
Failure to Implement Comprehensive Care Plan for Resident's Wheelchair Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Alzheimer's Disease, who had a physician's order for a wheelchair with bilateral leg rests. Despite the order, the resident was repeatedly observed sitting in a wheelchair without the required leg rests, with their feet resting on the floor. This was noted during multiple observations over several days, and staff interviews revealed that the leg rests were not available in the resident's room or the spare supply area. The facility's policy mandates that residents must not be transported without foot pedals, yet this was not adhered to in the case of the resident. Staff interviews indicated a lack of communication and responsibility regarding the missing leg rests. A Certified Nursing Assistant, not regularly assigned to the resident's unit, attempted to locate the leg rests but was unsuccessful. The Rehabilitation Department Director confirmed the necessity of leg rests for the resident, and a Licensed Practical Nurse acknowledged the oversight and stated a work order was placed with the maintenance department to address the issue. The Director of Nursing Services later stated that the staff should have contacted the Maintenance and Rehabilitation department immediately upon noticing the absence of leg rests, rather than directing a CNA to search for spare parts.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #152 On 12/5/24 Rehabilitation staff checked the resident’s wheelchair to ensure that the leg rests placed by the maintenance staff were appropriate for the resident and were consistent with the resident’s care plan for use of elevating leg rests as per physician order [REDACTED]. The IDCP Team reviewed the overall CCP to ensure that it was person-centered, and no issues were identified. The Nurse Manager reviewed the plan of care with the unit staff to ensure that staff understood the importance of adhering to the facility policy for Wheelchair Safety, physician orders [REDACTED]. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require the use of a wheelchair with leg rests have been identified as potentially being affected by the same practice. The Nurse Managers and Rehabilitation staff will identify all residents who require a wheelchair with leg rests. The IDCP Team will review the plan of care for all identified residents to ensure that an order for [REDACTED]. The IDT will continue to review and revise each resident’s CCP on a quarterly and as needed basis to ensure that the CCP is person-centered for the individual resident. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer and MDS Coordinator reviewed the policy and procedure for Comprehensive Care Plans, including protocols related to person-centered care plans and staff following the plan of care for individual resident needs, such as providing leg rests to residents who require the use of a wheelchair and leg rests, and determined that the policy is consistent with the facility’s practices. The Staff Educator/designee will provide education to the IDCP Team regarding care planning protocols and the facility’s policy. Education will address the importance of adhering to the plan of care related to person-centered interventions, such as providing a wheelchair with leg rests as ordered. This education will be incorporated into the orientation of new IDCP Team members and will be reviewed on an as needed basis. The Nurse Managers/designee will monitor compliance with the comprehensive care plan policy during review of the comprehensive care plan at care plan meeting discussions and during audits of staff following the person-centered care plan interventions. Immediate corrective actions, such as revision/updating of an individual resident’s care plan or staff re-education regarding following the person-centered interventions, will be implemented, as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Chief Nursing Officer and MDS Coordinator will develop an audit tool to monitor compliance with the requirements of F-656 including person-centered care plan interventions and staff adherence to following the plan of care. The MDS Coordinator/designee will audit 20% of resident CCPs monthly for the next three months and then quarterly for an additional two quarters. Residents requiring a wheelchair with leg rests will be included in the audit sample. All care plan audit findings will be reported to the Administrator and CNO. Corrective action, such as staff re-education regarding following the plan of care or revision/updating of a resident’s CCP, will be implemented as indicated. The MDS Coordinator will report all comprehensive care plan audit findings to the QAPI Committee monthly for three months and then quarterly for an additional two quarters for evaluation and discussion. The accepted level of compliance is 95%. At the end of the 3rd quarter a decision will be made by the QAPI Committee regarding the need for ongoing monitoring specific to comprehensive care planning and at what frequency. Completion Date: 01/31/2025 Responsibility: MDS Coordinator
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to ensure the participation of a resident and their representative in the development of the resident's care plan, as required by their policy and federal and state regulations. This deficiency was identified during a recertification survey, where it was found that the facility did not conduct interdisciplinary care plan meetings or provide notice of invitation to the resident or their representative for quarterly assessments. The facility's policy, revised in October 2024, mandates the creation of a comprehensive, individualized care plan for each resident, with active involvement from the resident and/or their legal representatives. However, the medical record for the resident in question lacked documented evidence of such invitations. Interviews with facility staff revealed a lack of clarity and adherence to the policy regarding care plan meetings. The Director of Social Work and other staff members confirmed that the facility only held care plan meetings for admissions, annuals, and significant change assessments, not for quarterly reviews. The Chief Nursing Officer was unaware that the interdisciplinary care plan team was not holding meetings for quarterly assessments. The resident involved, who had moderate cognitive impairment, expressed a desire to participate in the care planning process, but there was no evidence that they or their family were invited to do so.
Plan Of Correction
Plan of Correction: Approved January 8, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #66 On 12/30/24, the IDCP Team held a meeting with the resident to review his/her plan of care and address any questions or concerns that the resident had. The resident indicated that he/she agreed with the current plan of care. The resident’s preference to be invited to and attend all care plan meetings was reviewed and documented in the resident’s record. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents could be potentially affected by the same practice. Effective 12/19/24, the IDCP Team will hold quarterly care plan reviews that includes the resident and/or representative. Residents and/or their representatives will continue to be invited to the other meetings. The IDT will meet with each resident who has had a Quarterly MDS Assessment in the past 3 months to provide an update on their plan of care. For residents who are unable to participate, the resident’s representative will be provided with an update to the plan of care. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer, and Director of Social Work reviewed the facility policy, “Care Planning,” and revised it to reflect the need to hold quarterly care plan meetings with the IDCP Team and ensure that the resident and/or representative are invited to participate. The IDCP Team was provided with education by the Director of Social Work regarding the revisions to the policy and changes to the facility’s care plan meeting protocol. All Social Workers were educated regarding the care planning process and their responsibility to ensure that residents have the right to participate in planning their care, including attending all care plan meetings. The Social Worker will ensure that all cognitively intact residents, including those who have been evaluated by Psychiatry and have can make their own decisions, and their representatives, as appropriate, are invited to all care plan meetings, including quarterly meetings. If the resident’s preference is to have a representative attend or be updated on the plan of care, this preference will be documented in the resident record and honored. The Social Worker will ensure that the representatives of residents who cannot or do not wish to participate in planning their care are invited to all meetings. Any resident who declines to participate will be provided with an update on the plan of care after the meeting if this is his/her preference. Members of the IDCP Team will follow up on concerns or questions as needed. The Social Workers were educated to document all care plan invitations and attendance, including for quarterlies, in the resident record. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: An audit tool will be developed to monitor compliance with the facility’s policy to ensure residents and/or their representatives are invited to participate in all care plan meetings, including quarterlies. Director of Social Work and/or Designee will conduct a 100% review of all care plan meeting attendance records to ensure that the resident and/or representative were invited to all care plan meetings, including quarterly meetings monthly for 3 months and then quarterly for an additional two quarters. The Director of Social Work will report all care plan meeting attendance findings to the Administrator. The audit findings will be reported monthly to the QAPI Committee for 3 months and then quarterly for 2 quarters for discussion, evaluation and follow-up action. The QAPI Committee will evaluate the need for continued monitoring at the end of the reporting period. The acceptable level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Director of Social Work
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident #73, who required two-person assistance for bed mobility and mechanical lift transfers. On November 18, 2024, Certified Nursing Assistant #14 independently transferred Resident #73 using a mechanical lift, contrary to the facility's policy and the resident's care plan, which mandated two-person assistance. This action led to an incident where the resident sustained a bruise on the forehead, which was discovered after the transfer. Resident #73, who has Alzheimer's Disease, Cerebral Infarction, and Type 2 Diabetes Mellitus, was admitted with severely impaired cognition and functional limitations in both upper and lower extremities. The resident's care plan and physician's orders clearly documented the need for two-person assistance for transfers due to the resident's increased risk for falls and injuries. Despite this, CNA #14 proceeded with the transfer alone, resulting in the resident's head coming into contact with the mechanical lift bar, causing a lump and a small cut on the forehead. Interviews with various staff members, including CNAs, LPNs, and RNs, confirmed that CNA #14 did not request assistance for the transfer, even though the unit was not short-staffed. The Director of Nursing Services acknowledged that CNA #14 did not adhere to the care plan, which required two-person assistance for mechanical lift transfers, and stated that it was unacceptable for the transfer to be conducted without a second staff member.
Plan Of Correction
Plan of Correction: Approved January 9, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #73 On 11/18/24, the IDCP Team reviewed the resident’s plan of care related to risk for accidents and determined that the resident continues to require two-person assistance with bed mobility and two-person assistance with a mechanical lift for transfer in and out of bed. The Nurse Manager reviewed that plan of care for two-person assist for bed mobility and mechanical lift transfers with unit staff. CNA #14, who completed the mechanical lift transfer without assistance causing the resident to sustain a head injury that required a CT scan was terminated. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Nurse Managers and IDCP Team will identify all residents who are at risk for an accident through a review of accident risk associated assessments, need for supervision and assistance with ADL care, including all residents who require two-person assist with transfer and a mechanical lift, and have impaired cognitive status. The IDCP Team will review the care plan and CNA Care Instructions for all identified residents to ensure that the care plan and CNA Care Instructions are current and include resident-specific interventions for supervision and assistance, including two-person transfers with a mechanical lift, necessary to prevent an accident. The responsible Nurse Manager/designee will review any changes to the plan of care with the responsible unit staff. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director, Chief Nursing Officer and Risk Manager will review the facility’s policies and procedures for Accident Prevention, including protocols related to residents who require the use of a mechanical lift with two-person assist for transfers. The Staff Educator/designee will provide general reeducation to all staff regarding Accident Prevention and resident safety. Education for the Nursing staff will also include following the plan of care for residents who require a mechanical lift for transfer with two-person assist. All CNAs will be reeducated on the requirement to review the ADL/Care instructions prior to providing care or transferring a resident. Accident Prevention education will be included in the orientation of all staff and be reviewed annually and as needed. Nursing-specific education on Accident Prevention will be provided during orientation, annually and on an as needed basis. The RN Supervisors and Nurse Managers will continue to monitor for compliance with accident prevention protocols during routine and random rounds and observations of care being provided/transfers being completed to ensure the plan of care is being followed to prevent accidents. Residents who require two-person assistance with a mechanical lift for transfer will be monitored for staff compliance with two-person transfer assist as outlined in the plan of care. The Unit Manager/shift charge nurse will conduct random checks of staff following the plan of care related to two-person assist with a mechanical lift. Immediate corrective actions, such as staff reeducation regarding a two-person transfer/use of a mechanical lift and responsibility to follow the plan of care or updating of the plan of care to prevent an accident when a resident requires a different level of ADL/transfer assistance, will be implemented as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with adhering to the Accident Prevention Policy, including protocols for following the resident’s individual ADL/transfer plan of care for assistance to be provided to prevent accidents. The Nurse Manager/designee will complete 5 random unannounced observation audits to assess compliance with safe provision of care consistent with the ADL/transfer assist instructions weekly x 4 weeks then monthly x 3 months inclusive of all 3 shifts. The ADL/transfer assist instructions will be audited at the same time for accuracy. Residents who require a two-person transfer assist with a mechanical lift will be included in the audit sample. The Risk Manager/designee will audit 15% of all Occurrence Reports on a quarterly basis to determine compliance with Accident Prevention protocols. All findings will be reported to the Administrator. The Risk Manager/Designee will continue to report accident prevention and supervision audit findings to the QAPI Committee, minimally, on a quarterly basis for discussion, evaluation, and follow-up corrective action. The accepted level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer
Failure to Follow Two-Person Transfer Protocol
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills necessary to care for resident needs, specifically for a resident requiring two-person assistance with bed mobility and mechanical lift transfers. On one occasion, a Certified Nursing Assistant (CNA) independently turned and positioned the resident and used a mechanical lift for transfer without assistance, contrary to the facility's policy and the resident's care plan. The resident involved had severe cognitive impairment and functional limitations due to Alzheimer's Disease, Cerebral Infarction, and Type 2 Diabetes Mellitus. The care plan and physician's orders specified the need for two-person assistance for transfers, which was not followed by the CNA. This resulted in the resident sustaining a bruise on the forehead, indicating a failure to adhere to the established care plan. Interviews revealed that the CNA did not seek assistance for the transfer, despite the availability of staff, and had a history of similar incidents. The CNA admitted to transferring the resident alone, believing a nurse was nearby, but no assistance was provided. The Director of Nursing confirmed the CNA's actions were against the facility's policy and unsafe for the resident.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 I. The following actions were accomplished for the residents identified in the sample: Resident #73 On 11/18/24, the IDCP Team reviewed the resident’s plan of care related to risk for accidents and determined that the resident continues to require two-person assistance with bed mobility and two-person assistance with a mechanical lift for transfer in and out of bed. CNA #14, who repositioned the resident and completed the mechanical lift transfer without a second staff member providing assistance to complete these tasks was terminated. On 12/30/24, the Chief Nursing Officer met with the Staff Educator to review her responsibility to monitor and ensure that all required CNA annual competencies, including two-person assisting with turning and positioning in bed and mechanical lift transfers are completed by each CNA. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require two-person assistance with turning and positioning and/or require the use of a mechanical lift for transfers have been identified as potentially being affected by the same practice. The Staff Educator will identify all CNAs who have not completed competencies related to two-person assistance for turning and positioning in bed and completing a mechanical lift for transfer during 2024. All identified CNAs will have these competencies completed by 01/31/2025. III. The following system changes will be implemented to assure continuing compliance with regulations: The Chief Nursing Officer and Staff Educator will review the facility’s list of annual CNAs competencies and will revise the competency list as needed. Annual competencies will continue to include two-person assistance with turning and positioning/bed mobility and two-person assist mechanical lift transfers. The Staff Educator/designee will schedule and complete annual competency training for all CNAs during 2025 to ensure that all CNAs are able to demonstrate that they are competent to provide care and services as outlined in each resident’s person-centered plan of care. The RN Supervisors and Nurse Managers will continue to monitor for compliance with the Nursing staff following the plan of care during routine and random rounds and observations of care being provided, staff assistance with bed positioning, and transfers being completed with a mechanical lift and two-person assist to ensure the plan of care is being followed and staff demonstrate care practices consistent with facility policy. Immediate corrective actions, such as staff reeducation on bed mobility assistance, transfer/use of a mechanical lift and responsibility to follow the plan of or revision of the plan of care to meet a resident’s care needs based on a change in status. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with all CNAs completing the required CNA competency training annually. The Nurse Manager/designee will complete 5 random unannounced competency observation audits to assess compliance with safe provision of care consistent with the ADL/transfer assist instructions weekly x 4 weeks then monthly x 3 months inclusive of all 3 shifts. Residents requiring two-person assistance with bed mobility and/or two-person assist with a mechanical lift transfer will be included in the audit sample. Auditing will begin early 01/2025. The Staff Educator/designee will review and summarize all observation audits on a weekly then monthly basis as outlined above and will report all findings to the Chief Nursing Officer and Administrator. Corrective actions will be implemented based on summary information. The Staff Educator will report competency audit findings to the QAPI Committee monthly during the 4-month monitoring period for discussion, evaluation, and follow-up corrective action. At the end of the 4-months a decision will be made regarding the need for ongoing auditing and at what frequency. Completion Date: 01/31/2025 Responsibility: Staff Educator
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored and labeled according to accepted pharmaceutical principles. This deficiency was identified during a recertification survey for a resident who had two unlabeled tubes of Voltaren analgesic cream on their nightstand. The resident, who had a diagnosis of Diabetes Mellitus and Peripheral Vascular Disease, was observed with these tubes in their room without any staff present. The resident stated they applied the cream to their hands, but there was no physician's order for the Voltaren cream, and it was not included in the resident's comprehensive care plan. Interviews with facility staff revealed that residents are not permitted to self-medicate without an assessment and physician's orders, and medications should not be stored in resident rooms. The Licensed Practical Nurse/Patient Care Coordinator and the Director of Nursing Services were unaware of the presence of the Voltaren cream in the resident's room, indicating a lapse in the facility's medication management and storage protocols.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Resident #19 On 12/5/24, the Nurse Manager met with the resident to discuss the tubes of [MEDICATION NAME] observed in his room and removed the tubes following discussion with the resident and the need for a physician order [REDACTED]. The medicated hand cream was delivered by the provider pharmacy with a label that included the resident’s name and directions for use. The resident was evaluated for self-administration and a determination was made to keep the medication on the medication cart and allow the resident to self-administer. The Licensed Practical Nurse/Patient Care Coordinator #1 was reeducated by the Chief Nursing Officer on her responsibility to ensure that all medications/ointment/creams are properly labeled and stored for individual resident use. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practices. The Chief Nursing Officer directed the unit Nurse Managers to check each resident’s room for unlabeled medications including medicated creams/ointments that were not ordered by the Physician. Discussions will be held with any resident who has a medication in their room that was not ordered by the Physician, is not appropriately labeled with the resident’s name and directions for and without an order for [REDACTED]. The Chief Nursing Officer has arranged for all medication storage areas and med carts to be inspected to ensure that there are no outdated or opened items that should be discarded, all medications for discharged residents have been discarded, all medications are properly labeled, and that items that require light sensitive storage are properly stored. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Consultant Pharmacist and Chief Nursing Officer reviewed the facility’s policy and procedure for labeling and storage of drugs and biologicals, including protocols related to parameters for a resident keeping medications in their room and determined that the policies did not require revision. Re-education will be provided by the Staff Educator/designee to all Nurses regarding the appropriate storage of drugs and biologicals and will include the identified survey issue in this education. This education will be included during orientation of licensed nurses and be reviewed on an as needed basis. Weekly monitoring of the medication carts, medication storage areas and refrigerators will be conducted by the Unit Manager/Shift Supervisors to ensure appropriate storage. The nurses responsible for medication administration will be responsible for completing a visual check of the resident’s room for medications that have not been ordered. Immediate corrective action, such as staff re-education related to proper labeling and storage, or removal of an inappropriately stored item will be implemented as needed. Each nurse will continue to be responsible for the proper storage of medications on their cart and upon receipt of medications from pharmacy deliveries. Pharmacy consultant will continue to reinforce proper storage of drugs and biologicals during routine monthly inspection visit. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with storage of drugs and biologicals, including protocols related to a resident not keeping medication in their room unless there is a Physician order [REDACTED]. The Nurse Manager/designee will audit storage areas and resident rooms on a monthly basis for 3 months and then quarterly for an additional 2 quarters. Storage of drugs and biologicals audit findings will be reported to the Administrator and Chief Nursing Officer monthly for 3 months and quarterly for 2 quarters. Corrective actions, such as removal of improperly stored items or staff re-education, will be implemented as needed. The Chief Nursing Officer will report storage of drugs and biological audit findings to the QAPI Committee monthly for 3 months and then quarterly for an additional 2 quarters for evaluation and follow-up discussion. The accepted level of compliance is 95%. At the end of the third quarter the Committee will decide on the need for additional auditing or a change in the frequency of auditing. Completion Date: 01/31/2025 Responsible Person: Chief Nursing Officer
Failure to Assess and Document Resident's Food Preferences
Penalty
Summary
The facility failed to ensure that Resident #79 was provided with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, as well as their personal preferences. The resident, who had diagnoses including Cushing's syndrome, Type 2 Diabetes Mellitus, and Chronic Kidney Disease, expressed dissatisfaction with the food served, specifically noting that they were not assessed for food preferences and were served pork and beef, which they do not eat. The resident also reported not receiving a menu to choose their meals. A review of the resident's dietary assessments revealed no documentation of an assessment for food preferences, and the comprehensive care plan initially did not reflect the resident's dietary restrictions. Interviews with facility staff, including a dietician and a Licensed Practical Nurse (LPN), revealed that the resident's food preferences were not documented or assessed upon admission. The dietician stated that the resident did not want to endorse their food preferences initially, which led to the lack of documentation. The LPN noted that the resident would refuse meals and express dissatisfaction afterward, and the resident did not receive a menu. The General Manager from the dietary services contract company confirmed that food preferences should be documented in the resident's medical record and that a menu should be provided to alert and oriented residents. The Director of Nursing Services acknowledged that if a resident chooses not to endorse food preferences, this should be documented in the medical record and reflected in the comprehensive care plan.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #79 On 12/09/24, the Dietitian met with Resident #79 to discuss his/her food preferences and updated his/her food preferences in the meal tracker. On 12/9/24, a full house preference check was completed with information entered into meal tracker and scanned copies of preference sheets kept in binder in RD office. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practice. Effective 12/11/24, in-service education was provided to RDs related to obtaining residents’ food preferences upon admission, and at least quarterly, and appropriate documentation of same by Regional Dietitian. Food preference sheets will be maintained in the RD office in the binder. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Clinical Nutrition reviewed and revised, as needed, the Clinical Nutrition policies and procedures related to completing a comprehensive nutrition assessment, including obtaining residents' food preferences and entering same into meal tracker, plus procedure for providing menu to residents. The Chief Nursing Officer reviewed and revised, as needed, policies and procedures related to nursing staff reporting any changes to food preferences identified during meals to RD and food service staff. Effective 12/30/24, the Director of Clinical Nutrition/Designee will implement chart auditing specifically to monitor for obtaining and honoring food preferences as part of clinical nutrition assessment upon admission, at least quarterly, and as preference changes arise, and that this information is up to date and accurate in food preference binder kept in RD office and meal tracker. Dietitians will make meal rounds regularly to obtain feedback from residents at meal time, and this will be monitored by Director of Clinical Nutrition/Designee. The Director of Clinical Nutrition/Designee will also audit to ensure that all residents who meet the criteria to receive menu receive same, and review criteria to ensure it captures all eligible residents. Effective 12/30/24, the Director of Clinical Nutrition will monitor obtaining and provision of food preferences during sample chart reviews and resident interviews on a Monday through Friday basis for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including staff re-education, updating of the CCP or documenting a nutritional progress note, will be implemented as necessary. Residents from all units will be included in the sample. The Staff Educator/Director of Clinical Nutrition/designee will provide additional education to all nursing and dietary staff whenever issues related to residents’ food preferences are identified. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with obtaining, providing, and updating residents’ food preferences. The Director of Clinical Nutrition/Designee will monitor that residents’ food preferences are obtained and provided monthly for three months then quarterly for the next three quarters. The Director of Clinical Nutrition/Designee will conduct competency evaluations of all RDs to ensure they are following established protocols and have a clear understanding of the protocols related to food preferences. On-site education will be provided as necessary to ensure staff compliance. Competency evaluations will be conducted on all new RDs upon completion of orientation and twice yearly thereafter. The Director of Clinical Nutrition will review findings with the Administrator monthly for three months then quarterly. The Director of Clinical Nutrition/designee will report food preference audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the QAPI Committee. Completion Date: 01/31/2025 Responsibility: Director of Clinical Nutrition
Infection Control Breach During Medication Administration
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's infection prevention and control program. Specifically, a registered nurse was observed handling oral medication tablets with bare hands during medication administration for a resident. The nurse placed the medications on an unsanitized overbed table without a barrier, touched each medication with bare hands while explaining them to the resident, and then administered the medications. This action was contrary to the facility's policy, which requires following infection control protocols and not touching medications with bare hands. The resident involved was cognitively intact and had diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Depression. The facility's policies on medication administration and infection control were not adhered to, as confirmed by interviews with the Registered Nurse Inservice Coordinator, the Director of Nursing Services, and the Registered Nurse Infection Preventionist. All agreed that handling medications with bare hands was unacceptable and that there are alternative methods to explain medications to residents without direct contact.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 I. The following actions were accomplished for those residents found to have been affected by the deficient practice: Resident #48 On 12/11/24, the resident was evaluated by the Physician who determined that the resident exhibited no signs or symptoms of an infection following consuming medications that the nurse had handled with her bare hands. RN #1 On 12/5/24, the Staff Educator provided education to RN #1 related to general principles of infection control related to medication administration include not touching a resident’s medication with the nurse’s bare hands. II. The following corrective actions will be implemented to identify other residents having the potential to be affected by the same deficient practice: All residents have been identified as potentially being affected by the same practice. Effective 12/5/24, all licensed nurses, who are responsible for medication administration, will have a medication administration competency, including an assessment of the staff member’s infection control practices and management of a resident’s medication without touching the medication with their bare hands during administration, completed by the Staff Educator/designee. III. The following system changes will be implemented to ensure that the deficient practice does not recur: On 12/18/24, the Administrator, Medical Director, Chief Nursing Officer and Infection Preventionist reviewed the policy and procedure for medication administration and associated infection control practices related to medication management and not handling a resident’s medication during the administration process. The Staff Educator will conduct additional medication administration competency skill evaluations, that includes a review of acceptable infection controls that the nurse must adhere to when administering medication for any licensed nurse who did not successfully pass the initial medication competency completed for all nurses responsible for medication administration as outlined above in Section II. Medication administration competencies will continue to be included in the licensed nurses’ orientation and will be reviewed on an as needed basis. Inservice education on general infection control practice will continue to be provided annually. Licensed nurses’ infection control education will include standards of practice associated with medication administration. The Infection Preventionist and Nursing Supervisors will monitor for compliance with general infection control practices including protocols related to medication administration during routine and random rounds on the resident units. Findings will be documented on the Infection Control Rounding audit tool. Immediate corrective actions, such as counselling or reeducating staff, will be implemented as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Staff Educator/designee will audit 5 licensed nurses during medication administration for compliance with hand hygiene and infection control practices weekly for one month then 10 licensed nurses monthly for the next two months and then on a quarterly basis for the next two quarters. Licensed nurses from all shifts will be included in the audit sample. All audit findings will be reported to the Administrator and Chief Nursing Officer. Additional corrective action, such as staff reeducation or competency retesting, will be implemented as indicated. The Infection Preventionist will continue to conduct routine weekly Infection Control Rounds and will report findings from rounds, infection control rates and other pertinent infection control data to the QAPI Committee, minimally, on a quarterly basis for discussion, evaluation and follow-up corrective actions. Completion Date: 01/31/2025 Responsibility: Infection Preventionist
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for each resident at their bedside, specifically for a resident who required assistance with transfer and locomotion. This resident, who had a history of traumatic brain injury, anoxic brain injury, and myocardial infarction, was observed on multiple occasions with the tap call bell out of reach. The resident was non-verbal and dependent on staff for mobility, necessitating the call bell to be placed on their knee when out of bed. However, during observations, the call bell was found hanging on the wall or placed on the bed, both out of the resident's reach. Interviews with staff revealed inconsistencies in the placement of the call bell. A nurse manager confirmed that the call bell should be on the resident's knee, while a CNA stated they placed it on the resident's lap or chest, depending on whether the resident was in a wheelchair or bed. Despite these procedures, the call bell was not consistently within reach, as confirmed by the Chief Nursing Officer, who emphasized the importance of ensuring accessibility. The deficiency was identified during a recertification and abbreviated survey, highlighting a lapse in the facility's adherence to ensuring resident safety and communication needs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #39 Resident #39’s tap bell was immediately placed on his knee per the plan of care; no further corrective action was required. The IDCP Team determined that the resident continues to benefit from the use of the tap bell and ensured that this is in the CCP. The Nurse Manager re-educated all unit staff regarding their responsibility to ensure that call bells, including tap bells or other adaptive call bell devices, are within reach of the resident. Licensed staff responsible for administering medications were provided with additional education regarding their responsibility to check if the call bell is within reach when completing medication administration. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who are unable to utilize the facility’s standard call system may be affected by the same practice. The Nurse Managers and Rehabilitation staff will identify any resident who cannot manipulate a standard call bell to determine if the resident would benefit from an adaptive call bell or tap bell. The Nurse Manager will update the plan of care as needed and review the plan of care with the unit staff. The Nurse Manager, licensed nurses and CNAs continue to make rounds and resident observation at various times every shift to monitor residents including their access to their call bell. If a resident is noted not to have their call bell in reach, the situation is corrected by the staff member who identified that the call bell was not accessible. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator and Chief Nursing Officer reviewed the facility’s policy for Call (NAME) Use, and determined no revisions were necessary. Nurse Managers on all units will re-educate staff regarding their responsibility to ensure that tap bells and other call devices are within reach of the resident while in their rooms. Nurse Managers/Nurse Supervisors/Charge Nurses will conduct routine observations each shift during rounds to ensure residents requiring a tap call bell or adaptive call bell have them in place. Any call bell which is identified to be out of reach will be immediately addressed and responsible staff re-educated as necessary. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with ensuring all call bells including alternative call bells, such as tap bells, are within reach of residents when they are in their rooms. The Nurse Manager/designee will audit a sample of 10 call bells per shift per unit monthly for three months and then quarterly for two quarters, for accessibility and placement as per the plan of care. The sample audit will include residents requiring a tap bell or other adaptive call bell. The Chief Nursing Officer/ designee will report call bell related audit findings monthly to the QAPI Committee for three months and then quarterly for two quarters. The accepted level of compliance is 95%. At the end of the reporting period, the QAPI Committee will determine the need for further auditing and at what frequency. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer
Sanitary Deficiencies in Food Service Areas
Penalty
Summary
The facility was found to have deficiencies in maintaining sanitary conditions in its food service areas, as required by the State Sanitary Code. During a Life Safety Code recertification survey, surveyors observed a buildup of a white and/or brown colored substance around the ice dispensers in several locations, including the kitchenette in the Hiru unit, the nurse station in the Inn unit, the kitchenette in the Sunset Hall unit, and the employee cafeteria. The Engineering Manager confirmed that the Dietary Department is responsible for cleaning the ice machines, which are supposed to be cleaned weekly. Additionally, the surveyors noted that pendent sprinkler heads were heavily dusted in the kitchenette of the unnamed unit and by the three-compartment sink area in the kitchen. The Senior Director of Operations acknowledged the presence of dust on the sprinkler heads and stated that they would be cleaned. These observations indicate a failure to maintain food contact surfaces and sprinkler system components in a clean condition, as required by the sanitary code.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Plan of Correction for affected areas: No residents were identified. Action taken: All ice machines in the community were cleaned by dining staff. On (MONTH) 18, 2024, the maintenance staff cleaned the identified sprinkler pendants in the kitchenette in the (NAME) unit and by the three-compartment sink in the main kitchen. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The maintenance staff checked all sprinkler pendants throughout the building for dust or foreign material. Any pendants with dust or foreign material were cleaned. On 12/31/24, the FSD, RDO, and RD’s were educated on how to properly clean the outside/chute of the ice machines, avoiding the internal areas of ice production to avoid contamination of chemicals with ice. Plan of Correction for system measures to prevent reoccurrence: As a systemic change, the FSD or designee will round in the kitchenettes/café weekly to ensure compliance with ice machine cleaning. Dining staff will be responsible for cleaning the ice machines weekly. Cleaning compliance will be documented and audited by the FSD and/or designee weekly. All maintenance staff will receive additional education, and all participants will understand the life safety issues with sprinkler pendants that must be installed and maintained free of dust and foreign material. The In-Service Coordinator has been assigned the responsibility for the education of staff. This education will also be provided to all new maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect the sprinkler pendants monthly for dust and foreign material and utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The FSD or designee audits will be compiled with findings reported to the QAPI committee for review for 6 months. The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as the correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025
Improper Exit Signage in Facility
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: Life Safety Code during a recertification survey. Specifically, the surveyors observed that exit signs did not properly indicate the direction of egress in two of the seven resident units and in the basement. In the (NAME) unit, an exit sign near the Oxygen storage and soiled utility room had directional arrows pointing towards a wall instead of an egress route. In the Kipp unit, two non-delayed egress emergency exit doors were incorrectly marked with delayed egress signage, and an emergency door between two sets of entrance doors lacked a directional sign pointing to the emergency exit. Additionally, in the basement, one of the required means of egress from the Dental/exam room lacked exit signage to indicate the path of egress. The Engineering Manager acknowledged the findings, noting that the dental exam room is used for residents' dental services once a week, and residents are always accompanied when visiting the room. The Senior Director of Operations, present during the observations in the (NAME) and Kipp units, confirmed that there are no delayed egress doors in the facility and committed to removing the incorrect signage and fixing the other exit signs. These deficiencies indicate a failure to ensure that exit signs were displayed in accordance with the NFPA 101: Life Safety Code, potentially impacting the safety and evacuation procedures within the facility.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 Plan of Correction for affected areas: On (MONTH) 9, 2024 the maintenance staff permanently repositioned the Emergency exit light on the (NAME) unit by the Oxygen storage and soiled utility room, so the directional arrows pointed to the egress route. On (MONTH) 9, 2024 the maintenance staff permanently removed the delayed egress signs on the identified exit doors on the Kipp unit corridor along the Adult Day Care Center. The maintenance staff will permanently install Emergency Exit signage with directional arrows in the Kipp unit at the emergency door located between the two set of entrance doors to the unit showing the egress route. The maintenance staff will permanently install Emergency Exit signage with directional arrows to indicate the path of egress for the second required means of egress from the Dental/exam room in the basement. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiency. No other deficiencies were found. Plan of Correction for system measures to prevent reoccurrence: All maintenance staff will receive additional education, and all participants will understand the life safety issues with Exit signage in accordance with the requirements of NFPA 101, 2012 Edition section 7.10.1.5.1. The In-Service Coordinator/designee has been assigned the responsibility for the education of staff. This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all areas for Exit signs and directional arrows showing egress routes monthly and utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025
Deficiencies in Fire Door Maintenance and Inspection
Penalty
Summary
During a Life Safety Code recertification survey conducted from early to mid-month in 2024, several deficiencies were observed in the maintenance and inspection of fire doors used as means of egress in the facility. Specifically, in the Muhlenberg unit, the double fire door by a certain room did not adjust properly when tested, and another set of double doors left a gap of approximately 1/3 inch between the door meeting edges at the bottom. Additionally, in the Sunset Hall unit, the double doors by another room got stuck on the frame and did not close properly. These observations indicate that the doors were not maintained in accordance with NFPA 101: Life Safety Code and NFPA 80: Standard for Fire Doors and Other Opening Protectives. Further document review revealed that the facility's Fire and Exit Door Checklist, dated late October 2024, included a column for checking each door, but did not verify the 11 specific inspection items required by NFPA 80:5.2.4.2. This lack of detailed inspection documentation suggests that the facility did not ensure comprehensive compliance with the necessary standards for fire door maintenance and inspection. The Engineering Manager acknowledged the issue and mentioned that a vendor had been called to replace one of the problematic doors, while the Senior Director of Operations stated that the checklist would be updated to include the required inspection items.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Plan of Correction for affected areas** The facility engaged a certified fire door vendor to repair or replace the double fire doors by room [ROOM NUMBER] and the double fire doors by room [ROOM NUMBER] in the Muhlenberg unit. On (MONTH) 10, 2024 the maintenance staff adjusted the double fire doors by room [ROOM NUMBER] in Sunset Hall. The double doors self-close in the frame and are smoke tight. The maintenance staff will complete an annual 11-point inspection of all smoke barriers and fire-rated doors in the building. All doors with deficiencies will be corrected on the spot or scheduled for replacement. **Plan of Correction to identify other areas potentially affected** The facility acknowledges that all residents have the potential to be affected by this practice. Maintenance staff will complete an 11-point inspection of all smoke barriers and fire-rated doors in the building. All doors with deficiencies will be corrected on the spot or scheduled for replacement. **Plan of Correction for system measures to prevent reoccurrence** The Director of Maintenance updated the Policy and Procedure for the annual inspection and testing of Fire Doors. The Policy and Procedure now includes the annual inspection and testing of Fire Doors utilizing a new audit tool including the 11-point inspection criteria required by NFPA 80, 2010 Edition. All maintenance staff will receive additional education by the in-service coordinator/designee and all participants will understand the life safety issues with Inspection and testing of fire doors in accordance with the requirements. The In-Service Coordinator/designee has been assigned responsibility for the education of staff. This education will also be provided to all new maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all fire doors monthly and utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. **Plan of Correction for monitoring corrective actions** The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of all the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. **Responsibility:** Director of Operations **Compliance Date:** January 27, 2025
Fire Drills Not Conducted at Unexpected Times
Penalty
Summary
The facility failed to conduct fire drills at unexpected times as required by the 2012 NFPA 101 standards. During a Life Safety Code Survey, a review of the facility's fire drill logs for the past 12 months revealed that the drills were consistently held at similar times across all shifts. Specifically, for the morning shift (7:30 AM - 3:30 PM), three out of four drills were conducted between 10:14 AM and 11:00 AM. For the evening shift (3:30 PM - 11:30 PM), three out of four drills occurred between 5:20 PM and 5:40 PM. Similarly, for the night shift (11:30 PM - 7:30 AM), three out of four drills were conducted between 6:15 AM and 6:25 AM. The Senior Director of Operations acknowledged the issue and mentioned the intention to spread the drills more evenly throughout each shift. The Engineering Manager noted that the timing was chosen to avoid waking residents during evening and night shifts.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 Plan of Correction for affected areas: The Director of Maintenance will complete the fire drills at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. All fire drills will be a minimum of 1 hour apart on each shift and not duplicated in the same 12-month period. Fire drills conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. All Fire Drills are conducted by the Director of Maintenance. Plan of Correction for system measures to prevent reoccurrence: The Director of Maintenance developed a Fire Drill spreadsheet to document varied times and conditions of each drill monthly to maintain compliance. The Senior Director of Operations will review the spreadsheet monthly for compliance and will utilize an audit tool to document the findings and report the audit findings to the Quality Assurance/Quality Improvement Committee monthly for a period of six (6) months. Plan of Correction for monitoring corrective actions: The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Senior Director of Operations or Designee will report the result of the audits to the Quality Assurance/Quality Improvement Committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Operations Compliance Date: January 27, 2025
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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