Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waterview Nursing Care Center during CMS and state inspections, most recent first.
Failure to Timely Report Alleged Abuse-Related Incidents: The facility did not report three abuse-related allegations to DOH within the required timeframe. A resident with severe cognitive impairment alleged sexual abuse, but the event was investigated and deemed unfounded without immediate state reporting. Another resident with dementia had an unwitnessed fall and later a facial fracture, and the report was not made until the injury was known. A third resident with Lewy Body dementia was found with unexplained bruising, but staff treated it as behavior-related and did not report it as an injury of unknown origin.
Care plans were not reviewed and revised by the IDT after assessments for multiple residents. One resident with aphasia, CP, seizure disorder, severe vision impairment, skin breakdown risk, and behavioral symptoms had vision, pressure ulcer risk, and behavioral care plans left unchanged after assessment. Another resident with Alzheimer’s dementia and schizophrenia had cognition and falls care plans not updated after assessment, and a third resident with glaucoma, cataract, and a fall history had a vision care plan that was not updated after each assessment. RN supervisors and the DON stated care plans were due based on MDS assessment dates, but these plans were not updated.
The facility experienced significant staffing shortages on weekends, failing to meet the required levels of RNs, LPNs, and CNAs as outlined in their staffing plan. Staff interviews revealed that CNAs and LPNs were often overwhelmed, having to prioritize essential tasks and rush through their duties due to frequent call-outs and difficulty in finding replacements. Despite efforts to hire more staff, the facility struggled with retention, and the staffing levels listed in the Facility Assessment did not match the actual staffing on the units.
The facility failed to maintain a safe, sanitary, and comfortable environment, with deficiencies noted in multiple units, including mismatched paint, discolored blinds, worn window treatments, and damaged furniture. Maintenance and housekeeping staff reported delays in repairs and cleaning, contributing to the ongoing issues.
The facility was found to have several environmental deficiencies during a recertification survey, including damaged walls, dusty and dirty areas, and broken furniture in the Lobby, hallways, and nursing stations. The administrator acknowledged these issues but had not yet documented or implemented corrective actions.
The facility failed to report allegations of abuse and injuries of unknown origin in a timely manner. A resident's allegation of sexual abuse was not reported within the required two-hour timeframe. Another resident's elbow fracture was not reported when first observed, and a fall resulting in a hand fracture was not reported to the Department of Health. These incidents highlight deficiencies in the facility's adherence to reporting protocols.
The facility failed to involve two residents in their care plan meetings, violating their rights to participate in their person-centered care plans. One resident, who is cognitively intact, was not invited to any meetings since admission, and another resident with moderately impaired cognition was not documented as being invited or participating. The facility's policy requires invitations to these meetings, but this was not followed, as confirmed by staff interviews.
The facility failed to accurately document wandering behavior in the MDS assessments for two residents with dementia. Despite care plans and staff observations indicating wandering and elopement risks, the MDS assessments did not reflect these behaviors. The MDS Coordinator's approach of not documenting unobserved behaviors during the assessment period contributed to this deficiency.
A resident with dementia and depression was prescribed Seroquel and Valproic Acid without attempts at gradual dose reduction, despite no documented psychotic behaviors. The psychiatrist recommended dose reduction, but the resident's son refused, preventing its implementation. This led to a deficiency in managing psychotropic medications.
A facility failed to create and implement a comprehensive care plan for a resident with Prurigo Nodularis, despite ongoing skin issues and a dermatology diagnosis. The resident reported itchy skin since admission, and a dermatology consult confirmed the condition, but no care plan was developed. Interviews revealed a lack of coordination among staff, with the Medical Doctor not renewing Cortisone cream due to concerns about skin thinning and intermittent complaints, and the DON indicating that care plan responsibilities were not fulfilled.
A facility failed to review and revise a resident's oral/dental care plan quarterly, as required by policy. The resident, with conditions including Anxiety Disorder and Type 2 Diabetes Mellitus, had a care plan created in August 2023, but it was not updated following quarterly assessments. The DON acknowledged the oversight, attributing responsibility to the MDS Coordinator and RN supervisors.
The facility did not maintain the kitchen's automatic extinguishing system as required by 2009 NFPA 17A standards. The last inspection was overdue, and a report indicated issues with the cheese melter's protection. The Facilities Director stated that the equipment was replaced and a new vendor was contracted, but it was unclear if the new system was certified by the local fire department.
The facility was found deficient in providing continuous illumination for egress paths, as required by NFPA 101 standards. During a survey, it was noted that lights at the first-floor exit discharge and adjacent dining room exit were controlled by a timer, which did not comply with the requirement for continuous lighting. The Facilities Director acknowledged the issue.
A facility failed to report an alleged incident of sexual abuse involving a resident and a maintenance employee to law enforcement, as required by policy and federal regulations. The resident, with intact cognition, reported inappropriate touching by the employee. Despite the facility's policy mandating reporting to law enforcement, the facility did not proceed after the resident refused to contact law enforcement.
A medication error occurred when an LPN administered tube feeding to a resident without a medical order for it. The LPN failed to verify the resident's identity, leading to the administration of feeding formula through the Gastrostomy tube of a resident with a history of cerebral infarction and cognitive impairment. The error was discovered when the resident's spouse intervened, and no adverse effects were noted.
A resident with severe cognitive impairment eloped from the facility undetected due to inadequate supervision. Despite being last seen in their room, staff failed to verify the resident's whereabouts, leading to a delay in realizing the resident was missing. The resident was later found by police at a family member's house.
Failure to Timely Report Alleged Abuse-Related Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the New York State Department of Health within 2 hours of the allegation. This deficiency involved three residents reviewed for abuse-related concerns: one resident with an allegation of sexual abuse, one resident with an unwitnessed fall that later involved a facial fracture, and one resident with bruising of unknown origin that was treated as behavioral rather than reported as a possible abuse-related event. One resident with bipolar disorder, schizoaffective disorder, major depressive disorder, multiple sclerosis, and severely impaired cognition stated that a male person came into the room and laid on top of the resident. The facility investigated by obtaining staff statements and reviewing video footage, concluded there was no perpetrator and no abuse, neglect, or mistreatment, and did not report the allegation to the state agency at that time. The DON stated the facility believed there was no need to report because the allegation was unfounded, while the Administrator later stated the regional consultant determined the incident should have been reported and that the report to the Department of Health was not made until months later. Another resident with repeated falls, dementia, and a history of chronic subdural hemorrhage was found on the floor next to the bed after an unwitnessed fall. The resident initially had no visible injury or change in mental status, but later developed a nosebleed and was transferred to the hospital, where a closed fracture of the right zygomatic bone was identified. The facility incident report was submitted to the Department of Health only after the facial fracture was known. The DON and Administrator stated the event should have been reported within 2 hours because it involved an unwitnessed fall with injury and an injury of unknown origin. A third resident with coronary artery disease and Lewy Body dementia, severe cognitive impairment, wandering, and inappropriate behaviors was found with bruising and discoloration under one eye and redness on one hand. The resident could not explain what happened. The facility documented the incident as behavioral in nature and consistent with the resident’s dementia-related behaviors, and the DON stated it was not reported because staff believed the bruises were related to the resident’s known behaviors and bumping into others or objects. The incident was not reported to the state reporting system as an injury of unknown origin.
Care plans not reviewed and revised after assessments
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team periodically and after each comprehensive and quarterly assessment for four sampled residents. The deficiency involved Resident #19, Resident #11, and Resident #44, whose care plans were not updated after assessments as required by the facility’s care plan policy, which states that the comprehensive care plan should be reviewed at intervals not to exceed 92 resident days after the last assessment reference date. Resident #19 was admitted with aphasia, cerebral palsy, and a seizure disorder. The quarterly MDS documented unclear speech, rarely or never understood, severely impaired vision, and no behaviors. The resident had comprehensive care plans for vision impairment/legal blindness, pressure ulcer risk/potential for skin breakdown, and behavioral symptoms, with last evaluations dated 11/06/2025 stating the current care plans would remain in effect for the next 90 days. The behavioral care plan addressed the resident’s repeated removal of shoes, TED stockings, clothing, and socks during the shift, and staff attempts to replace them. Resident #11 was admitted with Alzheimer’s dementia and schizophrenia. The significant MDS documented severely impaired cognition, no wandering, maximal assistance with eating, dependence for bed mobility, chair-to-bed transfer, and toilet transfer, and one fall. The resident had care plans for cognitive loss/dementia and falls, but these were not reviewed and revised after each assessment. Resident #44 was admitted with open angle glaucoma, age-related cataract, and a history of falling; the quarterly MDS documented moderate cognitive impairment and impaired vision. Nursing notes stated the resident continued to receive ordered eye drops and followed up with an ophthalmologist, and the vision care plan was last updated on 01/30/2026 rather than after each assessment.
Staffing Shortages on Weekends
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, particularly on weekends. The facility's policy on staffing guidelines, which was reviewed in September 2024, emphasized the importance of adequate and competent staffing levels based on the Facility Assessment. However, the Payroll Based Journal Staffing Data Report for the third quarter of 2024 indicated excessively low staffing levels on weekends, which was confirmed by a review of the actual weekend staffing schedules from April to June 2024. The facility's staffing plan outlined specific numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) required for each shift, but these numbers were not met, leading to significant staff shortages. Interviews with staff members, including CNAs and LPNs, revealed that the facility frequently operated with insufficient staff, resulting in increased workloads and stress for the remaining staff. CNAs reported having to prioritize essential tasks such as personal care and feeding residents, often having to rush to complete their duties. LPNs expressed feeling overwhelmed due to the responsibility of administering medications to all residents on their units, despite having another nurse present. The staff shortages were attributed to frequent call-outs and the difficulty in finding replacements, particularly on weekends. The facility's administration, including the Human Resources Director and the Director of Nursing, acknowledged the staffing challenges but believed that the current staffing levels were adequate based on the facility's acuity. However, the facility was flagged for not meeting the Centers for Medicare and Medicaid Services mandate of 3.5 hours of care per patient per day. Despite efforts to hire more staff, the facility struggled to retain them, and the staffing levels listed in the Facility Assessment did not reflect the actual staffing on the units. The ongoing staffing issues raised concerns about the facility's ability to provide safe and adequate care to its residents.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction 1) On 12/30/24, The Administrator, DON and HR Director furthered Facility recruitment efforts including: 2) On 12/30/24 contacted CNA School Training program 3) On 12/30/24 contacted 1199 SEIU Hiring division 4) On 12/30/24 contacted additional Staffing agencies like Meridian and Towne. 5) Reviewed the potential to add/hire HHA Hall Monitors to assist in responding to call bells and non-clinical needs informing Charge Nurse of resident needs as indicated. 6) The facility continues to post and promote ads for recruitment for all open positions in the facility with the Apploi platform on job sites like Indeed and Zip Recruiter. 7) On 12/31/24 The Administrator, DON and Staffing Coordinator met with the Resident Council to discuss Facility plan for improving staffing numbers and ensuring care needs are met. Residents expressed satisfaction. 8) Incentives to recruit staff, including the use of sign-on bonuses, job fairs, tuition coverage, shift pickup bonuses and staffing agencies, will continuously be used to increase the facility’s staffing levels. Identification of Others 1) Resident Safety Assessment: The Administrator will conduct a comprehensive review of all residents by 12/31/2024 to identify any who may have been negatively impacted by staffing shortages. This will include checking for delays in care, unmet needs, or changes in physical, mental, or psychosocial well-being. Any identified issues will be addressed by the interdisciplinary team. Systemic Changes 1) The interdisciplinary team revised the staffing policy and Facility Assessment to accurately reflect current staffing needs based on resident acuity, census, and care plans. 2) The DNS and Administrator will review and revise the Facility Assessment to document sufficient staffing needs for each unit based on: - Acuity level and Census including special care needs of residents on individual units, and any other pertinent information about the resident needs. - An evaluation of diseases, conditions, physical, functional, or cognitive limitations of the resident population - Specific skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. - The number of Nursing staff to provide services to residents and assist and monitor aides. 3) Implementing a weekend staffing strategy that includes a dedicated pool of on-call staff, incentives for weekend shifts, and pre-scheduled backup coverage. 4) Reviewing and revising licensed nurses and CNA Assignments for each Unit to ensure any staffing adjustments needed based on resident needs and acuity. 5) Developing an audit tool to identify the number of open positions based on par levels to ensure that safe sufficient staffing would be maintained. 6) The DNS will provide RN's, LPN's and CNA's with education on measures to be taken when staffing is below par levels. Highlights of the Inservice include: - The responsibility of the RNS to check staff at the beginning of each shift. - The need to have a contact list of available staff and agencies to be called in as needed. - The responsibility of the Charge Nurse on each unit to complete an assignment sheet and update as needed for any staffing changes. - The responsibility of all Nursing Staff to report to Charge Nurse/RNS when any care or services cannot be provided to residents during the shift. - The responsibility of the RNS is to ensure resident medications, treatments and care are provided in accordance with resident plan of care. - The need for ancillary staff to assist with responding to call bells and informing direct caregivers of resident needs/requests. - The responsibility of the DON/Designee to contact the NYSDOH Surge and Flex if the facility implements crisis staffing plan. Quality Assurance 1) The QAPI committee will conduct weekly audits of staffing patterns and compliance with the updated Facility Assessment. 2) Initiate resident and family satisfaction survey audit tools to identify concerns related to staffing or care delivery. 3) Review all incidents and complaints quarterly to identify any trends or correlations with staffing levels. 4) Include staffing as a standing agenda item during quarterly QAPI meetings to ensure continuous monitoring and improvement. 5) Audits will be completed by the Director of Human Resources weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 6) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as observed during a recertification survey. Multiple deficiencies were noted across several units, including mismatched paint patches, discolored blinds, worn window treatments, torn wallpaper, damaged furniture, and dirty, dusty areas. These issues were evident in four out of five units, indicating a widespread problem with the facility's maintenance and housekeeping practices. On Unit 1 North, the baseboard and door corners in the shower room were in disrepair, and several rooms had large unpainted areas near the radiator. Unit 1 East had unpainted patches on hallway walls and ceilings, dirty windows, cracked plaster, missing privacy curtain hooks, and damaged walls. The 2nd Floor had mismatched paint, peeling paint, unpainted patches, tattered window treatments, and loose air conditioner units. Unit 1 West had stained and worn furniture, broken window blinds, dusty and dirty window sills, and broken plaster. Interviews with maintenance and housekeeping staff revealed that repairs and cleaning were not being completed in a timely manner. Maintenance workers acknowledged delays in painting and repairing damaged areas due to other priority assignments. Housekeepers reported challenges in cleaning certain areas due to resident presence and the inability to clean certain items effectively. The Director of Housekeeping and Maintenance and the Administrator acknowledged the issues and stated that efforts were being made to address them, but the deficiencies remained uncorrected at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Immediate Correction:** 1) As of 12/31/24, The Maintenance Department will prioritize the immediate repair of all areas identified in the survey, including the unpainted walls, mismatched paint patches, cracks, and damaged areas in Rooms 40, 38, 37 (Unit 1 North), Rooms 25, 28, 18, 16/17 (Unit 1 East), Rooms 206, 210, 203, 211, 215, 217 (2nd Floor), and Rooms W49, W65, W47b, W52 (Unit 1 West). 2) As of 12/31/24, All areas observed with visible dirt, dust, or staining (e.g., air conditioner units, windowsills, walls, and bathroom tiles) were thoroughly cleaned and sanitized by the Maintenance/Housekeeping team. 3) As of 12/31/24, the windows in room [ROOM NUMBER], the air conditioners in multiple rooms (e.g., W49b, W65), and the bathrooms with stained tiles were cleaned by the Maintenance/Housekeeping team. 4) As of 12/31/24, The Housekeeping staff performed a detailed cleaning of the affected areas and provided documentation of completion. 5) As of 12/31/24, In Room W49b, the stained and worn mattress, broken bed frame, and broken closet were repaired. 6) As of 12/31/24, The missing door handle in Room W49b was replaced by the Maintenance team. **Identification of Others:** 1) Units 1 North, 1 East, 2nd Floor, and 1 West will have their rooms assessed for cleanliness and safety, and corrective actions will be taken as needed. All affected rooms will be given priority for repairs and cleaning. 2) The Director of Housekeeping and Maintenance will oversee that the rooms are returned to a safe, clean, and comfortable environment. 3) A facility-wide audit will be conducted to identify any additional rooms or common areas that may require repair, cleaning, or redecoration. This includes assessing all floors, any unpainted walls, damaged window treatments, and necessary repairs to ensure that all areas meet the facility’s safety and comfort standards. **Systemic Changes:** 1) The facility’s Safe, Clean, Comfortable and Homelike Environment policy will be revised to include clearer guidelines on maintaining rooms, common areas, and the timely reporting of repairs or maintenance concerns. 2) The updated policy will also specify the roles and responsibilities of the Housekeeping and Maintenance departments in ensuring a safe and homelike environment. 3) The Director of Maintenance and Maintenance and housekeeping workers will undergo additional training to understand the updated standards and expectations for maintaining a safe, clean, and homelike environment. 4) A clear protocol will be implemented for housekeeping staff to immediately report issues to the Maintenance Director, including a system for tracking repairs and ensuring all issues are addressed in a timely manner. 5) The facility will implement daily environmental rounds with the Administrator, Assistant Administrator, Director of Housekeeping, and Maintenance Director to assess the cleanliness, safety, and comfort of resident rooms and common areas. 6) A formal audit checklist will be developed to ensure the environment meets the facility's standards for cleanliness, maintenance, and homelike qualities. 7) Any issues identified during the rounds will be documented, and corrective actions will be taken immediately. Any issues that cannot be resolved during the rounds will be logged and addressed within a defined timeframe (e.g., 24-72 hours). 8) A Maintenance Log will be implemented, where maintenance and housekeeping staff will be required to record and report any issues they notice during cleaning. This log will be reviewed daily by the Maintenance Director to ensure timely action is taken. 9) The facility will ensure all maintenance issues reported in the log are tracked through completion, with clear timelines for resolution and documentation. 10) Staff will be instructed to immediately report any areas of concern in resident rooms or common areas, ensuring that all repairs and cleanliness issues are promptly addressed. **Quality Assurance:** 1) The Director of Maintenance/Housekeeping will conduct weekly audits for the next 3 months to ensure that all repairs, cleaning, and updates have been completed as per the standards outlined in this plan. The audits will also assess whether the facility is maintaining a safe, clean, comfortable, and homelike environment for residents. 2) The facility administration will establish a feedback mechanism for residents and their families to provide input on the condition of the environment. A survey or comment box will be placed in common areas to allow for anonymous feedback on cleanliness, safety, and comfort. 3) Feedback will be reviewed by the Administrator and the QAPI team, and corrective actions will be taken based on the feedback received. 4) Weekly audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. **Person Responsible for this Ftag:** 1) The Administrator.
Environmental Deficiencies in Facility's Common Areas
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and the public, as observed during a recertification survey. Several deficiencies were noted in various areas of the facility, including the Lobby area, hallways, and nursing stations. Specifically, the bathroom near the Main Dining Room had holes in the wall, a rusty call bell panel, and broken molding. Additionally, cable wires at one nurse station were covered in dirt and dust, while the second-floor nurse station had torn vinyl armrests on chairs and a desk with broken Formica paneling. Further observations revealed that the third-floor nurse station had peeling wallpaper, a desk with rough edges, and a malfunctioning bottom drawer. The staff bathroom in this area also had a leaking faucet. The 1 North Nursing station was noted to have dusty areas and unpainted ceiling patches. The facility's policy emphasizes providing a clean, comfortable, and homelike environment, but the administrator acknowledged the environmental concerns and stated that corrective actions were not yet documented or implemented.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) As of 12/31/24, the facility repaired the holes in the wall of the bathroom near the Main Dining Room, repainted as needed and replaced the rusty call bell panel and broken molding. 2) As of 12/31/24, the West unit nurse station was thoroughly cleaned specifically all cable wires to remove accumulated dirt and dust. 3) As of 12/31/24, On the 2nd Floor nursing station, Maintenance/Housekeeping department replaced the two black swivel chairs with torn vinyl armrests and repaired the desk with broken and rough-edged Formica paneling. 4) As of 12/31/24, On the 3rd floor nursing station, Maintenance/Housekeeping department replaced the peeling and torn wallpaper underneath the desk area, repaired the desk with rough bottom edges and broken Formica panels, repaired the bottom desk drawer to ensure proper closure and fixed the leaking and loose faucet in the staff bathroom. 5) As of 12/31/24, On the North unit nursing station, the Maintenance/Housekeeping department cleaned the dusty areas thoroughly and patch/painted the unpainted ceiling areas. 6) The above Immediate repairs and replacements were documented in the maintenance log and overseen by the Maintenance Director to ensure timely completion. Identification of Others 1) The Director of Maintenance and Housekeeping will conduct a facility-wide environmental audit to identify other areas that may not meet the standards of a safe, functional, sanitary, and comfortable environment. 2) Include all common areas, resident rooms, nursing stations, and staff areas in the audit. 3) Document all findings and create a prioritized corrective action plan for each identified issue. Systemic Changes 1) Review and revision of the facility's Environmental Policy to include: - Detailed cleaning schedules for all areas, including nursing stations and common spaces. - Timelines for routine inspections of furniture, fixtures, and equipment to ensure functionality and safety. - Clear procedures for promptly addressing and documenting maintenance requests. 2) Provide in-service training to Housekeepers, Maintenance Workers, RN's, LPN's and CNA's on the importance of maintaining a safe, clean, and homelike environment. 3) Emphasize protocols for reporting environmental concerns promptly to the Maintenance Director through in servicing and education. 4) Establish an annual budget and timeline for replacing worn or damaged furniture and equipment. 5) Maintain a vendor proposal log and receipts to ensure accountability for all purchases and replacements. Quality Assurance 1) The Maintenance Director or designee will develop and conduct a weekly environmental rounds audit tool focusing on areas cited in the deficiency and other high-traffic locations. 2) Conduct monthly audit of common areas, resident rooms, and nursing stations to ensure ongoing compliance. 3) Solicit feedback from residents, families, and staff through surveys and suggestion boxes to identify additional environmental concerns or improvements. 4) Audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin in a timely manner, as required by their policy and state regulations. Specifically, an allegation of sexual abuse involving a resident was not reported to the New York State Department of Health within the mandated two-hour timeframe. The incident occurred when a resident reported being inappropriately touched by another resident. The Registered Nurse on duty did not believe the allegation and delayed notifying the Director of Nursing, resulting in a late report to the authorities. Another deficiency involved a resident with a cognitive impairment who was found with a bluish discoloration and swelling on their elbow, which was later diagnosed as a fracture. The initial signs of injury were observed by a Certified Nursing Assistant, but the incident was not reported to the Department of Health when first noticed. The Director of Nursing was not informed until two days later, and the injury was only reported after the fracture was confirmed by an x-ray. Additionally, a resident experienced a fall resulting in a fracture of the right hand. The incident was unwitnessed, and although the resident was assessed and found to have no immediate visible injuries, an x-ray the following day revealed the fracture. The facility did not report this injury to the Department of Health, as the Assistant Director of Nursing believed it did not affect the resident's health condition or care. These failures to report incidents as required highlight deficiencies in the facility's adherence to reporting protocols.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction: 1) On 12/31/24, the facility implemented a 24-hour shift check to ensure that all staff are familiar with and adhere to reporting guidelines for abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. 2) On 12/31/24, training was provided to all staff on the importance of timely reporting of any alleged violations, specifically the 2-hour reporting requirement for abuse or serious bodily injury and the 24-hour reporting requirement for non-serious events that don’t result in major injury. 3) There were no adverse effects to Resident #139 as a result of reporting the incident late to the DOH. 4) There were no adverse effects to Resident #103 as a result of reporting the incident late to the DOH. 5) There were no adverse effects to Resident #71 as a result of not reporting the incident to the DOH. Identification of Others: 1) Conduct a facility-wide audit of all incidents reported over the past 6 months to identify if any other incidents were not timely reported. This will include any allegations of abuse, neglect, injuries of unknown origin, or accidents requiring reporting to the DOH. 2) The audit will be conducted by the Director of Nursing, Assistant Director of Nursing, and Administrator. Systemic Changes: 1) The facility’s Abuse Prevention Program and Incident Reporting policies will be reviewed and revised to: - Clarify the specific timeframes for reporting to the Department of Health and other relevant authorities. - Emphasize the need for immediate notification of the Administrator, Director of Nursing, and Department of Health within 2 hours of any abuse allegations or incidents involving serious bodily injury. - Include a clear statement that all incidents which don’t result in serious bodily injury must be reported to the Department of Health within 24 hours. 2) The reviewed policies will be distributed to all staff and reviewed in staff meetings. 3) Ensure that all nurses, nursing assistants, and supervisory staff are trained on the timely reporting of incidents, particularly those related to abuse, neglect, and injury of unknown origin. Training will emphasize: - Definition and identification of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. - The 2-hour and 24-hour reporting timeframes, as well as appropriate escalation procedures. - Use of the facility’s reporting forms, including how to promptly notify the Administrator, Director of Nursing, and Department of Health. 4) The facility will implement a tracking system audit tool for all reported incidents. This will allow for better tracking of timely reporting, including automated reminders and alerts for the 2-hour and 24-hour reporting requirements. 5) A daily log audit tool of incidents will be maintained, with a designated team to review and ensure compliance with reporting timeframes. 6) The Director of Nursing and Assistant Director of Nursing will implement a daily audit tool review of all reported incidents to ensure they are reported timely and accurately to the Department of Health. Any discrepancies in reporting will be addressed with immediate corrective action. Quality Assurance: 1) The Quality Assurance (QA) Committee will meet weekly to review the status of incident reporting and ensure that all allegations of abuse, neglect, and injury are reported in a timely manner. 2) The Director of Nursing (DON) and Assistant Director of Nursing (ADON) will review all current/future incidents and ensure all required reporting to the Department of Health (DOH) and State Survey Agency are submitted immediately where necessary. 3) A monthly audit of all incident reports will be conducted by the QA Committee to ensure that no incidents are missed and that all reporting requirements are followed. 4) The monthly audit will be completed by the Director of Nursing, Assistant Director of Nursing, and Administrator, weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents' rights to participate in the development and implementation of their person-centered care plans. This deficiency was identified during a recertification survey, where it was found that two residents were not invited to attend their scheduled Comprehensive Care Plan and quarterly meetings. Resident #111, who is cognitively intact, reported not being invited to any care plan meetings since admission a year ago, and there was no documented evidence of their participation or invitation. The facility's policy requires that residents receive written or verbal invitations to these meetings, but this was not adhered to, as confirmed by interviews with the Director of Social Work and Social Worker #1. Similarly, Resident #13, who has moderately impaired cognition, was not documented as being invited to or participating in care plan meetings. Although the resident's family was involved, there was no evidence that the resident was asked to participate or that their refusal was documented. The Director of Social Work acknowledged the lack of documentation regarding Resident #13's refusal to participate. The facility's failure to document invitations and participation in care plan meetings for these residents constitutes a violation of their rights under 10 NYCRR 415.3(f)(1)(v).
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction: 1) On 12/30/24, Immediate written and/or verbal invitations were sent to Resident #111 for all upcoming care plan meetings, including quarterly, significant change, and annual care plan meetings. 2) On 12/30/24, The Social Worker visited Resident #111 to explain the right to participate and assist in identifying a preferred time and manner for involvement in care planning meetings. 3) On 12/30/24, Documentation was completed by the Director of Social Services in the care plan and progress notes to indicate Resident #111's participation or refusal to attend each meeting. 4) On 12/30/24, Resident #13 was provided with written and/or verbal invitations for all upcoming care plan meetings, including quarterly, significant change, and annual meetings. 5) On 12/30/24, The Social Worker visited Resident #13 to assess their preference for participation and offer the option of attending the next care plan meeting. 6) If Resident #13 continues to refuse participation, the refusal will be documented in the progress notes, and the family will be invited to participate, with proper documentation of their involvement. Identification of Others: 1) The facility will review all other residents who have been cognitively assessed as capable of participating in care planning to ensure that all eligible residents and resident representatives have been appropriately invited and given the opportunity to engage in their care plan development. 2) A full audit by the DSW of residents who are cognitively intact and those with partial or full impairments will be conducted to ensure that invitations for care plan meetings are consistently extended, and participation is documented. Systemic Changes: 1) The facility's policy on Comprehensive Care Planning, revised 09/24, will be reviewed to clearly specify that residents must be invited to all care plan meetings, including quarterly, annual, and significant change meetings. Invitations must be extended in writing and/or verbally to all residents deemed cognitively intact. 2) The policy will include instructions for the Social Worker and interdisciplinary team on the documentation requirements, including invitations, attendance, refusals, and family involvement, to be included in the progress notes and sign-in sheets. 3) The Social Work department will receive additional training on the facility's policy regarding resident participation in the care planning process, including the requirement for documented invitations, participation, and refusals. 4) The Social Workers will be in serviced and training will focus on the importance of inviting all residents who are cognitively intact and resident representatives accurately documenting attendance, and ensuring all communications with residents and family members are clear and complete. 5) The care planning meeting schedule and process will be revised to include a checklist that confirms each resident's participation, the invitation status, and any family involvement. This checklist will be reviewed by the Director of Social Services before each meeting to ensure compliance. 6) The Director of Social Worker will ensure documentation is accurately recorded for future meetings, including whether the resident was invited and/or participated by documented efforts in progress notes and having the resident sign the care plan meeting sheets. Quality Assurance: 1) The Director of Social Services will implement a monthly audit of care plan meeting invitations, participation, and refusal documentation for the next three months to ensure compliance with the facility policy. 2) The facility administration will establish a process for residents and families to provide feedback regarding the care planning process and whether they felt adequately invited or involved by surveying residents and families on an ongoing basis. 3) The Care Plan Meeting Invitation Audits will be completed by the Director of Social Services weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Social Services.
Inaccurate MDS Assessments for Wandering Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status, specifically regarding wandering behavior. This deficiency was identified during a recertification survey for two residents. Resident #37, diagnosed with Non-Alzheimer's Dementia, Anxiety Disorder, and Mood Disorder, was documented in the MDS assessments as not exhibiting wandering behavior, despite evidence to the contrary. The resident's care plan included interventions for wandering, and observations noted the resident at the facility's entrance, indicating a risk for elopement. Interviews with staff confirmed that the resident occasionally attempted to leave the facility, contradicting the MDS assessment. Similarly, Resident #130, with diagnoses of Non-Alzheimer's Dementia, Malnutrition, and Depression, was also inaccurately documented in the MDS assessment as not exhibiting wandering behavior. The resident's care plan and evaluation notes indicated a history of wandering and the need for constant redirection. Observations during the survey showed the resident wandering off the unit and requiring staff intervention. Staff interviews corroborated these observations, highlighting the resident's frequent wandering and need for engagement in activities to prevent such behavior. The MDS Coordinator, responsible for completing the assessments, stated that wandering behavior was not documented if it was not observed during the assessment period. This approach led to inaccuracies in the MDS documentation for both residents, as their wandering behaviors were evident through care plans, staff observations, and interviews. The facility's policy on comprehensive assessments did not specifically address the accuracy of the assessments, contributing to the deficiency.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction 1) On 12/30/24, The Minimum Data Set (MDS) Coordinator reviewed and updated the Quarterly MDS assessment to accurately document Resident #37’s wandering behavior. 2) On 12/30/24, The Comprehensive Care Plan for Resident #37 was reviewed and revised by the MDS Coordinator to ensure interventions accurately reflect their current wandering status, including additional monitoring and activities to reduce wandering episodes. 3) On 12/30/24, The Quarterly MDS assessment for Resident #130 was reviewed and updated to reflect their wandering behavior accurately. 4) On 12/30/24, The Comprehensive Care Plan was updated by the MDS Coordinator to ensure alignment with observed behaviors, including enhanced monitoring and interventions to address wandering tendencies. 5) On 12/30/24, Education Counseling was conducted and completed on Accuracy of Assessments for the MDS Coordinator, DON, ADON, DSW, and DOR. Identification of Others 1) An audit of the last 30 days of MDS assessments will be conducted by the MDS Coordinator to identify any inaccuracies related to wandering or other behaviors. 2) Residents identified with discrepancies will have their MDS assessments updated, and care plans revised accordingly. Systemic Changes 1) The facility policy on Minimum Data Set Comprehensive Assessments has been revised by the Administrator to include explicit guidelines emphasizing the importance of accurate documentation of residents’ behaviors, including wandering. 2) All MDS Coordinators, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) will be re-educated on: - A review of the regulatory requirement of F641. - The importance of accurate MDS documentation. - Observing, reporting, and documenting wandering and other behavioral patterns. - Utilizing interdisciplinary team input to ensure MDS accuracy. 3) A daily communication audit tool will be developed and implemented to ensure all wandering behaviors are documented and considered during MDS assessments. Quality Assurance (QA) 1) An interdisciplinary team meeting will be held bi-weekly to review residents with identified wandering behaviors and ensure care plans and interventions are appropriate and effective. 2) Monthly in-service training sessions on MDS accuracy and behavioral documentation will be conducted to ensure ongoing compliance x 6 months. 3) Audits will be completed by the MDS Coordinator weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The MDS Coordinator.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic drugs underwent gradual dose reductions unless clinically contraindicated. This deficiency was identified during a recertification survey, where it was found that a resident with a diagnosis of Non-Alzheimer's Dementia and Major Depressive Disorder was receiving Seroquel and Valproic Acid for an unspecified mood disorder. Despite the absence of documented psychotic behaviors or mood symptoms that would justify the continued use of these medications, no attempts at gradual dose reduction were made. The resident's medical records and observations during the survey period showed no evidence of psychotic behavior, yet the resident continued to receive the prescribed antipsychotic medication. The psychiatric consultation notes indicated that the psychiatrist had recommended a gradual dose reduction of Seroquel, but the resident's son consistently refused this intervention. Interviews with the psychiatric nurse practitioner and the Director of Nursing confirmed that the resident's son opposed the dose reduction, preventing its implementation. The facility's failure to attempt a gradual dose reduction, despite the absence of clinical indications for continued use of the medication, constitutes a deficiency in adhering to regulatory requirements for the management of psychotropic medications.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Correction 1) On 12/24/24, A care conference was held with Resident #153’s son, the psychiatric nurse practitioner, and the attending physician to discuss the necessity of a gradual dose reduction (GDR) and behavioral interventions. 2) On 12/14/24, The psychiatrist/psychiatric nurse practitioner documented the clinical justification for attempting the GDR. 3) On 12/24/24, All [MEDICAL CONDITION] medications and CCP were updated by the IDT team for Resident #153 to ensure compliance with requirements, and any necessary changes were documented in the clinical record. Identification of Others 1) Develop an audit tool of all residents currently prescribed [MEDICAL CONDITION] medications to identify those who: - Have not undergone a GDR, if clinically appropriate. - Lack documentation of behavioral symptoms or a specific [DIAGNOSES REDACTED]. - Have PRN orders for [MEDICAL CONDITION] medications exceeding 14 days without proper evaluation and documentation. 2) Immediate corrective actions will be implemented for identified residents, including care plan updates, medication reviews, and staff education. Systemic Changes 1) Review and revise the facility's policy on [MEDICAL CONDITION] medication use to include: - Guidelines for initiating and documenting GDRs. - Processes for handling refusals by family or residents, including obtaining written refusal documentation. 2) Provide training to RN's, LPN's, Psychiatrist and Dr's on the following: - Regulatory requirements for [MEDICAL CONDITION] medications and PRN orders. - Documentation standards, including behavioral monitoring and physician rationales. - Effective communication strategies for engaging families in care decisions. 3) Develop standardized communication audit to educate families about the benefits of GDRs and the risks of long-term [MEDICAL CONDITION] medication use. 4) The facility’s medical director will review the case to ensure adherence to regulations and provide oversight for future interventions. Quality Assurance 1) The pharmacy consultant will conduct monthly reviews of [MEDICAL CONDITION] medication use for all residents, including compliance with GDRs and PRN order limits. 2) The interdisciplinary team (IDT) will review [MEDICAL CONDITION] medication cases during quarterly care plan meetings. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.
Failure to Develop Comprehensive Care Plan for Resident's Skin Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with ongoing skin issues, specifically Prurigo Nodularis, as identified during a recertification survey. The resident, who was admitted with diagnoses including Chronic Liver Disease and skin conditions, reported itchy skin since admission and noted that the facility was supposed to provide cream but did not. A dermatology consult confirmed the presence of erythematous papules and diagnosed the resident with Prurigo Nodularis, yet no care plan addressing these skin issues was created or implemented. Interviews with facility staff revealed a lack of coordination and responsibility in addressing the resident's skin condition. The Medical Doctor acknowledged the resident's chronic liver condition and its potential link to itchiness but did not renew the Cortisone cream due to concerns about skin thinning and the resident's intermittent complaints. The Director of Nursing indicated that the Minimum Data Set Coordinator and nurse supervisors were responsible for care plan initiation and revision, yet this was not done for the resident's skin condition, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) On 12/30/24, An MD assessment was completed on Resident #111 who addressed the itchy skin condition by giving the resident a cream. 2) On 12/10/24, A comprehensive care plan was developed and implemented to address Resident #111’s ongoing skin condition. 3) On 12/26/24, Education was completed for the staff responsible for initiating clinical care plans. Identification of Others 1) A facility-wide audit tool will be developed to identify all residents with skin conditions or similar complaints who may not have a comprehensive care plan in place. 2) All identified residents will have their care plans reviewed, developed, or updated to address their individual needs. Systemic Changes 1) The facility policy on Comprehensive Care Planning was reviewed and revised by Facility Administrator to include specific guidelines for the development and implementation of care plans addressing chronic conditions, including skin conditions. 2) Clear timelines for initiating care plans upon admission and updating them quarterly or as conditions change were added to the policy. 3) Minimum Data Set (MDS) Coordinator, RN's and LPN's were re-educated on: - The process of developing, implementing, and updating comprehensive care plans. - Identifying resident needs through assessments, observations, and interdisciplinary collaboration. - Incorporating physician recommendations, specialist input, and resident preferences into care plans. 4) A checklist audit tool was introduced to ensure care plans address all identified medical, nursing, psychosocial, and other resident needs. 5) The care plan includes measurable objectives and specific interventions, such as: - Monitoring the skin condition for changes or flare-ups. - Ensuring availability and application of prescribed topical creams or other dermatologic treatments as needed. - Coordinating with dermatology for follow-up consultations and recommendations. - Educating staff on proper skin care techniques and resident preferences. Quality Assurance (QA) 1) The Director of Nursing (DON) or designee will review care plans weekly to ensure all identified conditions are addressed in comprehensive care plans. 2) Random audits of care plans will continue quarterly for one year, ensuring compliance with federal regulations and timely updates to care plans as resident needs change. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.
Failure to Revise Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team after each assessment, as required by their policy. This deficiency was identified during a recertification and abbreviated survey, specifically affecting a resident who was reviewed for dental care. The resident, who had diagnoses including Anxiety Disorder, Dysphagia, and Type 2 Diabetes Mellitus, had a care plan for oral/dental care that was created on August 11, 2023. However, there was no documented evidence that this care plan had been reviewed or revised following the quarterly assessments conducted on April 18, 2024, July 10, 2024, and October 2, 2024. The facility's policy mandates that care plans be reviewed at intervals not exceeding 92 days after the last assessment reference date. Despite this requirement, the care plan for the resident's oral/dental care was not updated as necessary. During an interview, the Director of Nursing acknowledged the oversight, stating that while they strive to review and revise care plans, it sometimes does not get done. The responsibility for developing and updating care plans was attributed to the Minimum Data Set Coordinator and the Registered Nurse supervisors, but no interview with the MDS Coordinator was conducted to further explore the issue.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) On 12/30/24, Resident #17 was assessed by MD. 2) Dental Consult was done on 12/19/24 at the hospital. 3) On 12/10/24, The comprehensive care plan for Resident #17 related to oral/dental care was reviewed and revised by the interdisciplinary team (IDT) to reflect the current assessment and oral health status. 4) The care plan now includes measurable goals, updated interventions, and a schedule for follow-up evaluations. 5) On 12/30/24, The Minimum Data Set (MDS) Coordinator and the registered nurse supervisor responsible for Resident #17’s care plan were counseled and re-educated on care plan timing and revision requirements. Identification of Others 1) A facility-wide audit in the last 30 days will be conducted to identify residents whose care plans had not been reviewed or revised within the required timeframes. 2) Care plans for all residents identified in the audit will be reviewed and revised as needed. Systemic Changes 1) The facility's policy on Comprehensive Care Planning was reviewed and revised by the Facility Administrator to explicitly include: - Care plan reviews and updates must occur after every comprehensive and quarterly assessment. - A checklist for MDS Coordinators and the IDT to ensure compliance with the 92-day review requirement. - Documentation requirements for resident and/or representative participation in care plan meetings or reasons for their absence. 2) MDS Coordinator, RN's and LPN's were re-educated on care plan timing and revision regulations by the Director of Nursing (DON). 3) Training emphasized the importance of timely care plan updates, interdisciplinary collaboration, and accurate documentation. 4) IDT meetings were restructured to include a dedicated review of residents due for care plan updates within the next 30 days. 5) The MDS Coordinator will send reminders to IDT members seven days prior to quarterly care plan review deadlines. 6) A care plan audit tool was developed and implemented to ensure that all care plans are reviewed, revised, and updated as required. 7) The tool will track care plan creation, review dates, and changes made during assessments. Quality Assurance (QA) 1) The DON or designee will complete random care plan audits quarterly for one year to monitor ongoing compliance. 2) Resident council meetings will include a discussion on care plan updates to ensure resident participation and satisfaction with their care plans. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.
Failure to Maintain Kitchen Fire Extinguishing System
Penalty
Summary
The facility failed to ensure that the kitchen's automatic extinguishing system was maintained according to the 2009 NFPA 17A standards. During a document review, it was discovered that the last inspection and maintenance report for the Ansul extinguishing system in the kitchen was dated January 24, 2024, which exceeded the required six-month interval for maintenance. The report from Fire Command Co. indicated that they were unable to perform the inspection due to a lack of protection for the cheese melter and noted that the system needed to be legalized following a change in equipment by the customer. Upon interviewing the Facilities Director, it was revealed that the Ansul equipment had been replaced and a new vendor was contracted for maintenance and inspections. However, it was unclear if the local fire department had inspected and certified the new equipment, and no recent vendor inspection report was available. At the exit conference, the Administrator mentioned that the vendor had recently visited the facility, but the report was not yet available.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Correction: 1) Upon discovering the missed 6-month maintenance interval for the Ansul automatic extinguishing system, the facility immediately contacted a licensed and certified vendor to perform a full inspection and servicing of the system. 2) The facility will ensure the new kitchen equipment (including the Cheese Melter) is properly integrated into the Ansul system. Following the inspection, a report and work quote from the Fire Command Co. vendor was obtained and approved. Identification of Others: 1) The facility will conduct a comprehensive review of all cooking equipment in the kitchen, including checking for proper installation, fire extinguishing system coverage, and compliance with NFPA 96 and NFPA 17A. 2) The Director of Maintenance will ensure that a list of all equipment and associated fire suppression systems is updated. Additionally, the facility will maintain regular communication with the vendor and the local fire department to ensure that all future inspections are performed in a timely manner and that the equipment is certified according to the latest standards. Systemic Changes: 1) The Director of Maintenance will implement a new automated maintenance tracking system audit tool to ensure that all fire suppression and extinguishing systems are inspected at the required intervals. 2) The Director of Maintenance and all relevant maintenance staff will undergo training on the NFPA 96 and NFPA 17A standards, specifically focusing on the requirements for maintaining automatic extinguishing systems in kitchens. Quality Assurance (QA): 1) The facility will implement monthly audits of all fire safety equipment in the kitchen, including automatic extinguishing systems, fire suppression systems, and related equipment. These audits will verify that all equipment is functional and maintained according to NFPA standards, and that service reports are up to date. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan.
Egress Lighting Deficiency Due to Timer Control
Penalty
Summary
The facility failed to ensure continuous illumination of the means of egress, as required by the 2012 NFPA 101 standards. During a life safety survey conducted on December 3, 2024, it was observed that the lighting at the first-floor exit discharge at the West stair and the adjacent dining room exit was controlled by a timer. This setup did not comply with the requirement for continuous illumination, as the lights were not operable without the use of a timer. The deficiency was identified through both observation and interview, where the Facilities Director acknowledged the issue. The lighting arrangement at these egress points did not meet the standard that requires illumination to be continuous during occupancy and not compromised by energy-saving devices like timers. The failure to provide continuous lighting could potentially affect the safety of the egress paths, although the report does not specify any direct consequences or risks that occurred as a result of this deficiency.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Correction: 1) On 12/4/2024, the timers that controlled the lighting at the West stairs were immediately deactivated and replaced with photocell sensors. 2) The new photocell sensors now ensure that the lighting remains continuously operational, without the need for manual intervention, and fully meets the requirements. 3) The newly installed photocell sensors were tested on-site to confirm that the egress lighting now operates continuously during hours of occupancy, in compliance with the required illumination standards. The lighting was inspected to ensure that no failure of any single lighting unit resulted in an illumination level of less than 0.2 ft-candle in any designated area. 4) The Director of Maintenance documented the replacement of the timers and the installation of photocells, confirming that all lighting in the means of egress is now continuously illuminated. Identification of Others: 1) A comprehensive review of all lighting systems controlling means of egress throughout the facility was conducted to identify any additional instances where timers or other manual control systems might be in place. This included all exit access areas such as corridors, stairs, aisles, and exits. Systemic Changes: 1) As a systemic change, the facility will ensure that all areas requiring illumination of egress pathways are equipped with photocell sensors to guarantee that lighting will remain continuously on, even if power is lost or if there is a failure of an individual lighting unit. 2) The Facility Director will ensure that all maintenance and operations staff are trained in the requirements, specifically regarding continuous illumination for means of egress. This training will emphasize the proper installation and maintenance of lighting systems and photocell sensors. Quality Assurance (QA): 1) The Director of Maintenance will implement a monthly audit tool to verify that all means of egress lighting remain continuously operational and is in compliance. The audits will include checking that photocell sensors and lighting units function properly without any timers or manual switches. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving a resident and a maintenance employee to law enforcement, as required by their policy and federal regulations. The incident occurred when a resident, who had intact cognition as per their Minimum Data Set assessment, reported that a maintenance employee inappropriately touched them. The resident identified the employee by name to the Administrator. Despite the facility's policy mandating that suspicions of abuse be reported to local law enforcement and the New York State Department of Health, the facility did not report the alleged abuse to law enforcement. The resident involved had a medical history including Non-Alzheimer's Dementia, Depression, and Major Depressive Disorder. The facility's Potential for Victimization Comprehensive Care Plan for the resident included interventions such as providing emotional support and reality orientation. The Administrator, upon learning of the allegation, asked the resident if they wanted law enforcement to be contacted, and the resident refused. Consequently, the facility did not proceed with contacting law enforcement, which was a deviation from their established procedures and regulatory requirements.
Medication Error: Incorrect Tube Feeding Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who administered tube feeding to the wrong resident. On the specified date, the LPN did not verify the identity of the resident before starting the tube feeding process. This resulted in the administration of approximately 50 milliliters of feeding formula through the Gastrostomy tube of a resident who did not have a medical order for such feeding. The facility's policy on medication administration requires verification of the resident's identity, which was not adhered to in this case. The resident involved in the incident had a medical history that included cerebral infarction, aphasia, and hemiplegia, and was cognitively impaired with a low score on the Brief Interview on Mental Status. The resident's care plan and physician orders specified only the flushing of the Gastrostomy tube with water, not the administration of feeding formula. Despite the error, the resident was assessed and monitored for any adverse effects, and none were observed. Interviews with facility staff revealed that the LPN prepared the feeding for residents with medical orders and mistakenly connected the feeding pump to the wrong resident. The LPN did not check the identification bracelet of the resident before administering the feeding. The error was discovered when the resident's spouse alerted the Registered Nurse Supervisor, who then stopped the feeding. The incident was reported to the Assistant Director of Nursing and the Director of Nursing, who confirmed that the LPN did not follow the facility's medication administration policy.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident with severe cognitive impairment. On the morning of 09/12/2023, Resident #1, who was admitted with diagnoses including Metabolic Encephalopathy and Cerebral Infarction, left the facility undetected. The resident was last seen by the night nurse at approximately 7:00 AM in their room. However, by 7:15 AM, video surveillance captured the resident leaving their room and exiting towards the back door, eventually disappearing from camera view. The staff's inaction contributed to the deficiency. LPN #2, who arrived on the unit at 7:25 AM, was informed by the night shift nurse that the resident was in the bathroom. However, neither LPN #2 nor CNA #2 checked the bathroom or confirmed the resident's whereabouts. It wasn't until around 8:15 AM that staff realized the resident was missing, prompting a search and the activation of Code E for elopement. The resident was eventually located by police at a family member's house later that afternoon. Interviews with staff revealed a lack of adherence to the facility's policies on resident checks and elopement prevention. The Assistant Director of Nursing and the Director of Nursing both emphasized the responsibility of staff to visually monitor residents and ensure their safety. However, the failure to conduct routine checks and verify the resident's location led to the oversight that allowed the resident to leave the facility undetected.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Flushing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sapphire Center For Rehab & Nursing | 0 mi | ★★★★★ | 0 | 0 |
| Woodcrest Rehab & Residential H C Center, L L C | 0 mi | ★★★★★ | 0 | 0 |
| Cliffside Rehab & Residential Health Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Cypress Garden Center For Nursing And Rehabilitati | 0 mi | ★★★★★ | 0 | 0 |
| Union Plaza Care Center | 0 mi | ★★★★★ | 0 | 0 |
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