SUNSET NURSING AND REHABILITATION CENTER, INC
For profit - Limited Liability company
120 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
53/100
#336 of 594 in NY
Photo by Sunset Nursing & Rehab Center
Photo by patti partridge
Photo by Elaine Roberts-Ballard
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Sunset Nursing and Rehabilitation Center, Inc. has a trust grade of C, which means it is average and in the middle of the pack compared to other facilities. It ranks #336 out of 594 in New York, placing it in the bottom half, but it is #5 out of 17 in Oneida County, indicating only four local options are better. The facility's performance has been stable, maintaining six issues in both 2023 and 2025. Staffing is rated at 3 out of 5 stars, with a turnover rate of 37%, which is better than the state average, suggesting that staff generally stay longer and build relationships with residents. However, there are concerning areas, such as less RN coverage than 95% of facilities, which can impact the quality of care. Specific incidents from recent inspections highlight some weaknesses. In one critical finding, the facility failed to provide a safe environment, leading to a resident being observed with cigarette butts in their room, indicating a lack of proper disposal methods. Additionally, there were concerns regarding medication management, such as improperly labeled and stored medications. Food safety also raised flags, with unclean kitchen conditions and unlabeled food items, suggesting that sanitation practices need improvement. While there are strengths in staffing stability, these weaknesses should be carefully considered by families researching this facility.
- Trust Score
- C
- In New York
- #336/594
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 37% turnover. Near New York's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New York facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
53/100
Bottom 44%
Review needed
6 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 6 issues
2025: 6 issues
The Good
-
Licensed Facility · Meets state certification requirements
-
No fines on record
-
Staff turnover below average (37%)
11 points below New York average of 48%
This facility meets basic licensing requirements.
The Bad
3-Star Overall Rating
Near New York average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 37%
Near New York avg (46%)
Typical for the industry
The Ugly 20 deficiencies on record
1 life-threatening
Jun 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for one (1) of one (1) resident (Resident #99) reviewed. Specifically, Resident #99 was independent with activities of daily living and was not allowed to shave independently.
Findings include:
The facility policy Resident Rights and Responsibilities, revised 1/13/2025, documented the facility rendered services that demonstrated belief in the dignity and worth of each individual. It was the objective of the facility the patient/representative was provided with optimal nursing and psychosocial care. Every effort was made by the staff to meet the patient/representative individual needs and requirements.
The facility policy Activities of Daily Living, revised 10/2023, documented each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care consistent with the residents needs and choices.
Resident #99 had diagnoses including dementia, hypertension (high blood pressure), and chronic kidney disease. The 4/15/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment was independent with personal hygiene including combing hair, shaving, and washing/drying face and hands.
The Comprehensive Care Plan initiated 1/13/2025 documented Resident #99 had a self-care deficit related to delirium with no performance deficit. Interventions included the resident was independent with hygiene needs until a revision on 1/24/2025 when the resident required set up assistance (helper sets up and resident completes activity, helper assists only prior to or following the activity).
The undated care instructions documented the resident required set up assistance with hygiene.
Observations and interviews with Resident #99 included:
- on 6/23/2025 at 12:43 PM, they had stubble on their face. The resident stated they asked an unidentified staff earlier that day for a razor to shave as they had been shaving independently since admission several months ago. They were told by the staff they had to shave in front of them. The resident stated they gave the razor back to the staff and was upset because they shaved themself since they were [AGE] years old.
- on 6/24/2025 at 8:52 AM, in the dining room with stubble on their face.
- on 6/25/2025 at 9:52 AM, in the hall with stubble on their face.
During an interview on 6/25/2025 at 11:30 AM, Certified Nurse Aide #11 stated they were responsible for assisting residents with their hygiene needs. Individual hygiene requirements were documented on the care plan which generated the residents care instructions. Resident #99 was independent with all their hygiene needs. They gave the resident a towel, hygiene supplies, and a razor and the resident completed all tasks including shaving and dressing. They were assigned to Resident #99 on several occasions and never watched them shave and the resident was always clean shaven. They observed the resident in the hallway and stated the resident needed a shave. They were not sure why staff did not allow the resident to shave independently and stated it was a dignity issue for the resident.
During an interview on 6/25/2025 at 1:53 PM, Registered Nurse Unit Manager #13 stated certified nurse aides were responsible for assisting with activities of daily living care for all residents which included shaving. Care was completed according to the care plan and if a resident required set up only, they should be set up and not supervised.
10 NYCRR 415.5(d)(1)(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews during the recertification survey conducted 6/23/2025 -6/27/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of t...
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Based on observations and interviews during the recertification survey conducted 6/23/2025 -6/27/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of three (3) units (A Unit) reviewed. Specifically, the ice/water dispenser in the A Unit dining room had standing fluids backed up in the drip tray and a public drinking fountain located at the A Unit nurses' station had standing fluids in the drink well.
Findings include:
During an observation on 6/23/2025 at 11:40 AM, the A Unit ice/water dispenser had a buildup of white scaley debris behind the dispenser chute. There was clear fluid built up to the very top of the drip tray. When water was dispensed it caused the water to overflow over the sides of the drip tray.
During an observation on 6/23/2025 at 11:53 AM, Licensed Practical Nurse #4 filled two water pitchers with ice and water from the ice/water dispenser by placing the bottom of the pitcher over the drip pan that was filled to the top with fluid. The pitcher was in direct contact with the stagnant water.
During observations on 6/23/2025 at 12:33 PM and 6/24/2025 at 8:52 AM, the water fountain near the nurses' station area had a sign that said, do not pour anything down it but water. There was standing brownish/pink fluid accumulated at the bottom of the drinking well.
During an observation on 6/25/2025 at 12:20 PM, the ice/water dispenser drip tray was empty. The drip pan grate was rusty. When water was dispensed the drip tray filled quickly to the top and slowly began to drain.
During an interview on 6/26/2025 at 10:51 AM, Licensed Practical Nurse #4 stated they practically had to smash the ice/water dispenser to get it to work and often had to go to dietary to get ice. The ice machine was like that for a month or two and they thought a new machine was ordered. It backed up in the past and had to be cleaned out in order to get it to drain. They did not recall the drain being full to the top on 6/23/2025 when they filled the ice pitchers. The drinking fountain did back up sometimes, and they thought it was because thickened liquids were poured down it. It was important the ice machine and the drinking fountain drained because there could be debris floating in the water/fluids which could be unhealthy.
During an interview on 6/26/2025 at 11:02 AM, Registered Nurse Unit Manager #3 stated they did not notice the ice/water dispenser drip tray backed up and there were no work orders submitted they were aware of. The drinking fountain should be unplugged and was out of use for sanitary reasons.
10 NYCRR 415.29(b)(j)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents were provided food and drink that was palata...
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Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) meals reviewed (Lunch meals on 6/24/2025 and 6/25/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meals on 6/24/2025 and 6/25/2025. Additionally, nine (9) of fifteen (15) anonymous residents during a resident council meeting and one (1) resident (Resident #12) interviewed stated the food did not taste good and was cold.
Findings include:
The facility policy Food Preparation, Service and Distribution, initiated 7/1/2008 and revised 10/2/2022, documented the facility would serve hot foods hot and cold foods cold in accordance with resident preference.
During an interview on 6/23/2025 at 1:02 PM, Resident #12 stated the food was not good, they did not like the way food was prepared, and the food was never hot.
During a resident council meeting on 6/23/2025 at 2:00 PM, nine anonymous residents stated the food was not good.
During an observation on 6/24/2025 at 11:53 AM, Resident #77's meal was tested in the presence of Certified Nurse Aide #5, and a replacement tray was ordered. Food temperatures were measured as follows: sausage 113.4 degrees Fahrenheit, milk 60.4 degrees Fahrenheit, pudding 79.3 degrees Fahrenheit, and chocolate milk 59.5 degrees Fahrenheit. The lettuce in the lettuce and tomato salad was brown, wilted, and watery. Certified Nurse Aide #5 stated the lettuce was brown and did not look appetizing, the pudding was warm, and the sausage was cold.
During a meal observation on 6/25/2025 at 1:03 PM, Resident #25's meal tray was tested in the presence of Nurse Educator #6, and a replacement tray was requested. Food temperatures were measured as follows: pasta 131.9 degrees Fahrenheit, milk 49.3 degrees Fahrenheit, beans 119.7 degrees Fahrenheit, mandarin oranges 71.2 degrees Fahrenheit, and tea 135.3 degrees Fahrenheit. The resident stated the food was not good and was cold.
During an interview on 6/27/2025 at 9:07 AM, Dietary Aide/Cook #7 stated they did test trays once a month, which included temperatures. Hot temperatures should be over 145 degrees Fahrenheit and cold food should be below 40 degrees Fahrenheit. Pudding and mandarin oranges were considered cold and should be below 40 degrees Fahrenheit; sausage should be hotter than 113 degrees Fahrenheit; the milk was too warm at 60.4 degrees Fahrenheit; and the chocolate milk was too warm at 59.5 degrees Fahrenheit. They used shredded lettuce, and it should not have been wilted, brown, or watery. Food should be hot and palatable.
During an interview on 6/27/2025 at 9:22 AM, the Food Service Director stated they did four test trays a month at different mealtimes to test temperature and palatability. They heard residents complained about the food. Hot food should be 140 degrees Fahrenheit and cold food should be below 40 degrees Fahrenheit. Sausage at 113.4 degrees Fahrenheit and was not hot enough; milk at 60.4 and 49 degrees Fahrenheit was not cold; chocolate milk at 59.5 degrees Fahrenheit was too hot; mandarin oranges at 71.2 degrees Fahrenheit was not palatable; and brown, wilted, and watery salad was not palatable.
10NYCRR 415.14(d)(1)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not establish and maintain an infection prevention and control pr...
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Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of one (1) resident (Resident #75) reviewed. Specifically, Resident #75 was on transmission-based precautions (contact precautions) and Housekeeper #9 cleaned Resident #75's room without wearing all required personal protective equipment, did not remove gloves or perform appropriate hand hygiene upon leaving the room, and cleaned another resident's room while wearing the same gloves; and Certified Nurse Aide #10 provided toileting care to Resident #75 without wearing appropriate personal protective equipment or washing their hands prior to leaving the resident's room.
Findings include:
The facility policy Policy Transmission Precautions, revised 7/2009, documented when it was determined that a resident needed isolation or special infection precautions to prevent the spread of infection, the appropriate precautions were utilized. Isolation and special infection precautions were carried out in accordance with Centers for Disease Control and Prevention guidelines and were designed to protect residents, employees, and visitors.
The facility policy Infection Prevention and Control-General Statement, revised 11/2024, documented staff were trained regarding proper hand washing and proper use of personal protective equipment. The appropriate signage and personal protective equipment stations were present and stocked.
The facility's Contact Precaution signage posted near resident room doors documented everyone must clean their hands, before entering and when leaving the room; providers and staff must put on gloves and gown before room entry and discard gloves and gown before room exit; do not wear the same gown and gloves for the care of more than one person; use dedicated or disposable equipment and clean and disinfect the reusable equipment before use on another person.
Resident #75 had diagnoses including chronic kidney disease and adult failure to thrive (decline in overall health). The 4/25/2025 Minimum Data Set assessment documented the resident was cognitively intact and required partial/ moderate assistance with most activities of daily living.
The Comprehensive Care Plan initiated 1/27/2025, and revised 6/26/2025, documented the resident had methicillin-resistant staphylococcus aureus (an antibiotic resistant bacteria) in a wound and vancomycin-resistant enterococci (an antibiotic resistant bacteria) in their urine. Interventions included transmission-based precautions per policy.
The 6/17/2025 physician order documented contact precautions for methicillin-resistant staphylococcus aureus.
During an observation on 6/24/2025 at 12:50 PM, the door to Resident #75's room had a contact precaution sign with the letter A on it. Housekeeper #9 knocked on Resident #75's door, put on gloves, grabbed a mop, and entered the room without putting on a gown. Housekeeper #9 mopped the floor in the room, exited the room with the mop, placed a wet floor sign, picked up a pen and made a notation on a piece of paper on their housekeeping cart, moved their housekeeping cart down the hallway, entered another resident room with the same mop, and touched the privacy curtain with their gloved hand. They did not change their gloves or perform hand hygiene between the two resident rooms. Housekeeper #9 exited the second room wearing the same gloves, placed the mop in the bucket, and removed their gloves. They did not perform hand hygiene. Housekeeper #9 took a roll of toilet paper and a clean trash bag from their housekeeping cart and re-entered the second room with those items.
During an observation on 6/24/2025 at 1:02 PM, Certified Nurse Aide #10 entered Resident #75's room without performing hand hygiene or putting on a gown or gloves. They turned off the resident's call light and went behind the privacy curtain. When they exited the room they used an alcohol-based hand rub and proceeded down the hall.
During an interview on 6/24/2025 at 1:08 PM, Certified Nurse Aide #10 stated there was a sign that told them what to put on before they entered a precaution room. The sign pertained to all staff and there was never a time the sign should not be followed. It was important precautions were followed because they prevented the spread of germs. After looking at the door, they stated Resident #75 was on precautions. They put Resident #75 on the bedpan, and did not wear a gown or wash their hands before they exited the room. They stated they should have done those things but was not paying attention.
During an interview on 6/24/2025 at 1:15 PM, Housekeeper #9 stated they wore gloves when they cleaned resident rooms, and the gloves should be changed before entering another resident's room. They did not think they needed to wash their hands between glove changes. They were not sure if Resident #75 was on precautions, but they just cleaned their room. They saw the sign on the door and the bin outside the door, but did not think it applied to them as a housekeeper because it was for direct care staff only. They should have changed their gloves in between cleaning different resident rooms because they could transfer germs and chemicals from one room to the other.
During an interview on 6/26/2025 at 11:02 AM, Registered Nurse Unit Manager #3 stated if a resident was on contact precautions hand hygiene was performed and a gown and gloves were put on before the room was entered. Before leaving the room, the gown and gloves should be removed and hand hygiene performed. Contact precautions applied to all staff who entered the room. Resident #75 was on contact precautions. They finished their antibiotic on 6/24/2025 and that was why the precaution order was discontinued 6/24/2025 at 11:59 PM. Housekeeper #9 should have followed the sign and should not have left the room with gloves, walked down the hall, and cleaned another resident's room wearing the same gloves. Certified Nurse Aide #10 should not have placed the resident on the bedpan only wearing gloves and should not have left the room without washing their hands. It was important contact precautions were followed to prevent the spread of infection and to protect residents, families, and staff.
During an interview on 6/26/2025 at 12:53 PM, the Director of Nurses stated every staff member in the building was required to follow the directives on the signs to protect themselves and the residents from the spread of infection. Infection control training was an annual mandatory training for all employees. Staff should wear a gown while placing a resident who was on contact precautions on a bedpan. If their hands were not visibly soiled, then hand sanitizer was sufficient. Staff should never leave a contact room wearing the same gloves and proceed to touch their pen, cleaning cart, mops, or go into other resident rooms as that could spread infection.
10NYCRR 415.19(a)(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not maintain an effective pest control program so that the facility was free of p...
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Based on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not maintain an effective pest control program so that the facility was free of pests in the main kitchen. Specifically, mouse droppings were observed in the kitchen dry storage room.
Findings include:
The facility policy Pest Control, revised 12/2006, documented a competent authority addressed issues of pest control on a monthly and as needed basis. Rodents were kept away by keeping dumpsters away from the facility, garbage from the kitchen was taken directly to the dumpster, and general garbage was taken out four times daily.
Observations of mouse droppings under shelving in the dry storage room were made on:
- 6/24/2025 at 12:25 PM
- 6/25/2025 at 2:04 PM
- 6/26/2025 at 12:04 PM
During an interview on 6/26/2025 at 12:04 PM, Food Service Director #8 stated that kitchen floors were cleaned twice daily, and the walls were cleaned as needed. The dry storage room was swept and mopped nightly. Mice were occasionally found in the facility, and someone came routinely to check for pests. Mouse droppings should not be on the floor in dry storage.
10 NYCRR: 415.29(j)(5)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with curre...
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Based on observations and interviews during the recertification survey conducted 6/23/2025-6/27/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for one (1) of three (3) medication carts (Unit A cart) and two (2) of two (2) medication rooms (Units A and B) reviewed. Specifically, the Unit A medication cart had one opened and undated insulin pen, one opened and undated multidose eye drop, and one opened and expired multidose eye drop; and the medication refrigerator temperatures on Units A and B were not consistently monitored.
Findings include:
The facility policy, Medication/ Treatment Labeling and Storage, revised 7/2013, documented medications were stored under proper temperature. The policy did not include instructions for labeling multidose vials or discarding expired medications.
During an observation of the Unit B medication room on 6/25/2025 at 8:31 AM, the June 2025 medication refrigerator log was missing documentation of temperature readings on 6/14/2025, 6/18/22025, 6/19/2025, and 6/20/2025.
During an observation of the Unit A medication cart and medication room on 6/25/2025 at 8:48 AM, the medication cart contained one opened and undated Lantus (long-acting) insulin (regulates blood sugar) pen, one opened and undated Latanoprost (reduces eye pressure) eye drops, and one opened and expired brinzolamide (reduces eye pressure) eye drops dated 4/13. The June 2025 medication refrigerator log was missing documentation of temperature readings on 6/1/2025, 6/6/2025, and 6/15/2025.
During an interview on 6/25/2025 at 8:48 AM, Licensed Practical Nurse #4 stated the Lantus insulin pen was only good for 28 days after it was opened, and it did not have an opened date. Without being labeled there was no way of knowing when it was opened. The Latanoprost eye drops also did not have an opened date but should have. Eye drops were good for 30 days, so the brinzolamide eye drops with an opened date of 4/13 were expired. They stated the nurse who opened the medication was responsible to label them with an opened date. It was important the medication refrigerator temperatures were checked to ensure the stability of medications.
During an interview on 6/27/2025 at 9:42 AM, Registered Nurse Unit Manager #3 stated medications should be dated when opened and discarded when expired. Insulin and eye drops required an opened date and expired 28 days later to ensure stability and safety. The day shift nurses were responsible for checking and documenting the medication refrigerator temperatures. If the temperatures were not documented, there was no way to ensure they were in the proper range for medication stability.
During an interview on 6/27/2025 at 9:50 AM, the Director of Nursing stated medication carts should not have expired medications. Medications such as insulin, nasal sprays, eye drops, and inhalers should be labeled when opened and expired in 28 days after opening. The medication refrigerator temperatures should be monitored daily by the day shift nurse to ensure the medications inside were safe to administer. If the temperatures were missed by the day shift nurse the evening or night nurse should document the temperatures.
10NYCRR 415.18(d)
Nov 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review during the recertification and abbreviated (NY00323453 and NY00306251) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure residents ...
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Based on observation, interview, and record review during the recertification and abbreviated (NY00323453 and NY00306251) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 1 of 4 residents reviewed (Resident #95). Specifically, Resident #95's bed, overbed table, and power strip had dried debris build-up and the floor on the side of the bed next to the overbed table and nightstand was coated with dried, brown-colored debris.
Findings include:
The facility policy Room Cleaning Procedures effective 6/1/2000 documented the facility provided an environment that fostered a positive self-image for the resident and preserved their human dignity. The cleaning of every resident room was done daily and included:
- Handrails and bedrails were wiped down with a cloth dampened with a disinfectant cleaner.
- Furniture would be dusted with a cloth slightly dampened with a disinfectant cleaner.
- Flooring was dust mopped and then wet mopped with the specified floor cleaner.
- Walls and doors were spot washed with a disinfectant cleaner when soiled.
- Pull Room Procedure: a thorough cleaning of every room would be done not less than once every ninety days.
Resident #95 had diagnoses including chronic obstructive pulmonary disease (COPD, lung disease), adult failure to thrive, and unsteadiness on feet. The 9/5/2023 Minimum Data Set (MDS) assessment documented the resident was moderately impaired cognitively, independent with bed mobility, required supervision of one for transfers and ambulation in their room and required supervision of one for eating.
The following observations of Resident #95's room (A Unit) were made:
- on 10/30/2023 at 1:01 PM the resident was lying in bed. There was dried, thick, brown debris on the frame of the bed, the frame of the overbed table, on the power strip, and on the floor near the bed.
- on 10/31/2023 at 9:41 AM the resident was in bed with a family representative present. There was dried, thick, brown debris on the frame of the bed, frame of the overbed table, on the power strip, and on the floor near the bed. The floor was sticky. The family representative stated they had mentioned the unclean areas on the bed, overbed table, and floor to the housekeeper many times in the past but they had not done a thorough job of cleaning.
- on 11/1/2023 at 9:55 AM the resident was ambulating from the bathroom to their bed. There was dried, thick, brown debris on the frame of the bed, frame of the overbed table, on the power strip, and on the floor near the bed.
- on 11/1/2023 at 3:08 PM the resident was lying in bed. There was dried, thick, brown debris on the frame of the bed, frame of the overbed table, on the power strip, and on the floor near the bed.
- on 11/2/2023 at 10:14 AM the resident was standing in the doorway of their room. There was brown debris on the frame of the bed and the frame of the overbed table.
The facility Daily Housekeeping Room Disinfection Check List documented the following areas were cleaned daily in resident rooms: light switches, overbed tables, door handles, sinks, toilets, nightstands, dressers, sweep/mop floor, sweep under bed, remove garbage, stock paper towels and stock toilet paper. Resident #95's daily check list documented:
- on 10/30/23 all areas on the check list were checked as completed.
- on 10/31/23 areas not checked as completed included light switches, door handles, nightstand, and dresser.
- on 11/1/23 areas not checked as completed included light switches, door handles, nightstand, and dresser.
- on 11/2/23 areas not checked as completed included light switches, door handles, nightstand, and dresser.
During an interview on 11/1/2023 at 11:08 AM housekeeper #28 stated there were usually two housekeepers on the A Unit three times a week. The second housekeeper was was out for a while. They stated they cleaned all the rooms on the A Unit during the day shift which consisted of sweeping, mopping, taking out the trash, and cleaning the bathrooms. They stated they cleaned Resident #95's and wiped the top of the overbed table frequently as the resident spilled things. They stated they also cleaned/wiped down the lower parts of the overbed table and the frame of the bed.
During an interview on 11/3/23 at 10:06 AM Housekeeping Supervisor #29 stated that all resident rooms were cleaned every day, and included overbed tables, floors, toilets, sinks, and tiles, and trash was removed. If there was something housekeeping could not clean, such as fans, they would put in an electronic work order. They stated there should not be a build-up of debris on the overbed tables as cleaning beside tables would include the whole table. Deep cleanings of rooms were done every month. They had not heard of Resident #95 ever refusing to have their room cleaned. They stated because of the cleaning spray odor they sometimes went into Resident #95's room when they were in the shower to do a more thorough cleaning. Housekeeping would approach Unit Managers if a resident refused to have their room cleaned. A hard copy log of the daily cleaning of rooms was kept in a binder. Thy stated If debris build-up remained on items in resident rooms there could be potential for infection control issues.
During an interview on 11/3/23 at 10:29 AM registered nurse (RN) Unit Manager #14 stated they had never heard of Resident #95 ever refusing housekeeping to come into their room. They were aware of the dried debris on the overbed table and floor, the resident was untidy and due to their vision limitations, they spilled food and drinks a lot, including sticky soda. Housekeeping was supposed to do deep cleanings. They stated they had discussed with staff to clean up and wipe things down in Resident #95's room as they came across them.
10 NYCRR 415.29(j)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 10/30/2023-11/6/2023, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #74) reviewed. Specifically, Resident # 74 developed a facility acquired pressure ulcer and had a low air loss mattress (a specialty mattress used to relieve pressure and provide airflow) and the settings on the mattress were not consistent with the physician ordered settings.
Findings include:
The facility policy Low Air Loss Mattress effective 11/18/2019, documented:
- Upon initial placement of the mattress, the wound care nurse/designee will determine appropriate settings.
- Identification of weight setting is noted in the order.
- Nursing staff will visually check settings every shift.
- Nursing will update orders as weight changes.
Resident # 74 was admitted to the facility with diagnoses including unspecified dementia, Parkinson's disease (a progressive neurological disorder) and acute viral hepatitis (liver inflammation). The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderately impaired cognition, required extensive assistance of 2 for bed mobility and transfers, was at risk for developing pressure ulcers, had one Stage 2 (partial thickness skin loss) pressure ulcer that was not present on admission, and received daily pressure ulcer care, applications of ointments/medications other than to feet, and did not have a pressure reducing device for the bed or chair.
The comprehensive care plan (CCP) initiated on 9/25/2021 and revised on 10/9/2023 documented the resident was at risk for impaired skin integrity related to dementia, edema, impaired mobility, and non-compliance. Interventions included applying moisture barrier as needed, pressure reduction device for bed: air mattress, skin and feet check with daily care, document weekly on shower day, and skin risk tool completed per policy.
An 8/31/2023 progress note by Wound Care nurse practitioner (NP) # 21 documented a Stage 2 pressure ulceration on the right buttocks was present, measured 0.5 centimeters (cm) x 0.6 cm x 0.1 cm, and the wound bed was 100% moist epithelial (new tissue) without drainage or odor. Recommendations were to cleanse the site with NS (normal saline) or wound cleanser, apply Medi honey (a honey based topical wound treatment) to open areas daily and as needed (PRN), and cover with bordered dressing. Continue repositioning in accordance to assessed needs and off-load pressure to affected areas. Additionally, upgrade mattress to alternating pressure air mattress and continue gel wheelchair cushion.
An 8/31/2023 physician #46 order documented the resident was to have a low loss air mattress. The order did not include settings for the mattress.
Wound Care NP #21 progress notes documented:
- on 9/11/2023 a Stage 3 ulceration of right buttocks (reclassified, previously Stage 2), measuring 1.5 x 1.5 x 0.1cm. Recommendations included to continue repositioning in accordance to assessed needs and off load pressure to affected areas. Upgrade to alternating pressure air mattress and continue gel wheelchair cushion.
- on 9/19/2023, Stage 3 pressure ulcer measuring 1.4 x 1.6 x 0.1 cm with wound bed 100% granular. Recommendation was to continue with alternating pressure air mattress and continue gel wheelchair cushion.
- on 9/28/2023, surgical debridement (removal of dead, damaged, or infected tissue) was performed on the Stage 3 pressure ulcer. Recommendations included to continue with alternating air/ low mattress for pressure redistribution as well as gel wheelchair cushion. Ensure settings were maintained at an appropriate level based on the resident's needs and body habitus.
- on 10/5/2023, Stage 3 pressure ulcer measuring 1.2 x 1.4 x 0.3 cm with wound base 100% granulation and a moderate amount of serosanguinous (both clear and bloody) drainage. Recommendations included to continue with alternating air/ low mattress for pressure redistribution and ensure settings are maintained at an appropriate level based on patient's needs and body habitus.
- On 10/19/2023 and 10/26/2023 the wound bed of the pressure ulcer on the right buttock had a heavy slough (moist, dead tissue) burden, without peri wound erythema, edema, or tenderness. Stage 3 was improving with delayed wound closure. Preventative measures included to continue with alternating air/low air loss mattress for pressure redistribution. Ensure settings were maintained at an appropriate level based on patient's needs and body habitus.
The 10/26/2023 NP #15 order documented low loss air mattress check every shift. Weight set to 185 lbs. Static not on.
The October 2023 treatment administration record (TAR) documented low loss air mattress check every shift. Weight set to 185 pounds. The mattress was documented as checked from 10/26/2023 evening shift through 10/28/2023 evening shift and 10/29/2023 day shift. The TAR documented 9 (other, see progress notes) on 10/28/2023 night shift, and 10/29/2023 evening on night shifts.
A 10/29/2023 licensed practical nurse (LPN) #47 progress note documented low loss air mattress check every shift. Weight set to 185 lbs (pounds), static not on. Set at 180 supervisor aware.
The 10/30/2023 NP #15 order documented low loss air mattress check every shift. Weight set to 180 pounds, static not on.
Resident #74's low loss air mattress was observed at the following times:
- on 11/1/2023 at 9:31 AM set to a weight of 210 pounds.
- on 11/2/2023 at 9:32 AM and 3:42 PM set to 210 pounds.
The November 2023 TAR documented low loss air mattress check every shift. Weight set to 180 pounds. The TAR documented the mattress was checked 11/1/2023 for the day and evening shift by LPN #22, for the night shift by LPN #47, and on 11/2/2023 for the day and evening shift by LPN #23.
During an interview on 11/2/2023 at 3:32 PM, LPN # 23 stated a low loss mattress should be set to the resident's current weight to reduce pressure. They stated therapy and the physician determined if an air mattress was needed, and maintenance would deliver the air mattress to the resident. The settings and parameters of use were monitored daily and documented in the treatment administration record (TAR). They stated they checked mattress inflation and made sure no warning lights were activated. If the ordered settings were not followed it was a safety risk that could cause injury and have negative effects on the resident's skin integrity. They stated Resident #47 was at risk for pressure and had a low loss air mattress. LPN #23 reviewed the TAR, and stated Resident #47's air mattress was supposed to be set for 180 pounds and not at 210 pounds that it was currently set on. They stated they would only check to make sure it was on, inflated and running, and they should have checked the settings. The LPN stated when they signed the mattress check on the TAR it meant that the settings were also checked.
During an interview on 11/2/23 at 3:50 PM registered nurse (RN) # 19 stated that the low loss air mattress was used for residents who had skin issues or skin breakdown and was set for the resident's weight. The settings were checked every 8 hours by the LPN and documented in the TAR. The LPNs should check that it was on, plugged in, inflated, the weight matched the order, and the static was not on. Resident # 47 was at risk for pressure and had the air mattress on their bed for a long time. During an audit at the end of October 2023 the resident did not have the low loss air mattress order entered in the TAR and there was no documentation of the air mattress checks prior to the order being entered on 10/26/2023. They stated if the LPN saw an incorrect setting, they expected the LPN to change the mattress to the correct setting. RN #19 stated if the weight was set too high or too low, the mattress could be too firm. They were unaware resident's air mattress was set at the wrong setting on 11/1/2023 and 11/2/2023.
During a telephone interview on 11/3/2023 at 11:37 AM Wound Care NP #21 stated they saw Resident # 47 for the first time in August. They stated air mattress settings were a recommendation, and policies and procedures should be followed per the facility. Incorrect settings should be brought to their attention to assess if changes would be appropriate.
During an interview on 11/6/2023 at 1:43 PM LPN # 22 stated if a resident required an air mattress the settings were on the TAR. When they checked the mattress, they should check that the order matched the weight setting on the air mattress machine. They stated if it was signed for on the TAR it meant that the numbers on the machine were checked with the orders in the computer and this was checked once a shift. If the settings did not match the orders, the settings should be adjusted, and the supervisor should be notified. If the settings did not match the orders the resident could have negative effects.
During an interview on 11/6/2023 at 2:25 PM the Director of Nursing (DON) # 2 stated if a mattress check was signed on the TAR, it meant the settings were checked to match the orders. If the settings did not match, they expected that the order and the setting be reviewed and addressed immediately. Settings should be corrected if they did not match the orders. The expectation was that staff signing for the air mattress checks visualized the settings.
10NYCRR 415.12(c)(1)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the recertification and abbreviated (NY00323453) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure each resident received ad...
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Based on observation, record review, and interview during the recertification and abbreviated (NY00323453) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #95) reviewed. Specifically, Resident #95 had a history of falls and did not have their wheelchair or rolling walker available as planned.
Findings include:
The facility policy Accident/Incident Investigation and Prevention revised 6/2023 documented the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. It was the responsibility of the licensed nursing staff to document and complete follow-up investigations for each incident and to implement care plan changes to prevent repeat incidents.
Resident #95 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease), unsteadiness on feet, and other reduced mobility. The 9/5/2023 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required supervision of 1 for transfers, ambulation in room and toilet use, and used mobility devices including a walker and wheelchair.
The 7/27/2023 (start date) comprehensive care plan (CCP) documented:
- Transfers: self-performance deficit related to COPD, adult failure to thrive, limited range of motion and limited mobility. Interventions included supervision, rolling walker, toilet transfers same as transfer assist, and out of bed to wheelchair.
- Ambulation: self-performance deficit related to COPD, adult failure to thrive, limited range of motion and limited mobility. Interventions included: ambulation in corridor and room, supervision with rolling walker.
- Bed mobility: independent.
- Falls: at risk for falls related to prior falls in the last 90 days and vision deficits. Interventions included ensure proper fitting footwear, remind to call for assistance, and see transfer/ambulation section.
An 8/24/2023 evaluation by physical therapist (PT) #43 documented the resident's prior functioning status was independent with all areas of bed mobility and supervision with rolling walker for transfers and ambulation. The resident was known to ambulate without assistive equipment. Recommendations included transfers and toilet transfers supervision with rolling walker, ambulation supervision with rolling walker for a distance of 10 feet, out of bed to wheelchair, and wheelchair mobility dependent.
An Accident/Incident report dated 9/9/2023 at 7:00 AM by registered nurse (RN) #40 documented:
- Resident #95 was found on the floor sitting at the base of their bed. They had gone to the bathroom and fallen on the way back to bed. They had full range of motion (ROM) within normal limits (WNL), denied any new pain, and the skin check was negative for any new areas. The resident was assisted up and back to bed with assistance of 2.
- Mobility: ambulatory without assistance.
- Predisposing environmental factor included other (describe): the resident had plain socks on and could use slipper socks. There was no documentation regarding the use of a rolling walker or wheelchair as care planned.
- A statement from certified nurse aide (CNA) #45 documented Resident #95 was independent with transfers to the bathroom.
A physical therapy post-fall review dated 9/11/2023 and signed off by PT #44 on 9/13/2023 documented the resident had a fall going to the bathroom. The resident's functional status prior to the fall was independent and their current functional status was independent. There were no changes at this point and the resident was educated with call bell when needing help. The post-fall review did not include documentation of the use of any assistive equipment.
The care instructions dated 9/29/2023 documented to use a rolling walker for transfers, and out of bed to wheelchair. The resident was to use a rolling walker with supervision for ambulation.
The 10/19/2023 CCP documented the resident was independent with bed mobility transfers, required supervision with rolling walker for ambulation, and out of bed to wheelchair.
The following observations of Resident #95 were made:
- on 10/30/2023 at 12:48 PM lying in bed, the resident stated they had not had their wheelchair for 3 months and the facility could not find it. No assistive equipment (rolling walker or wheelchair) was observed in the room.
- on 10/31/2023 at 9:41 AM lying in bed with a family representative visiting. The family representative stated the resident's wheelchair had been missing for 3 months. Resident #95 stated their wheelchair had been missing, and they just took it away. No assistive equipment was observed in the room.
- on 11/1/2023 at 9:55 AM the resident was standing by the window in their room trying to close the curtains. They ambulated towards the bathroom. At 9:59 AM the resident ambulated from the bathroom back to their bed. No assistive equipment was observed in the room. At 12:45 PM the resident was sitting on the edge of their bed eating lunch. No assistive equipment as care planned was observed in the room, however, a quad cane was observed near the nightstand. There was no documentation in the CCP for the use of a quad cane. At 3:08 PM the resident was lying in their bed and no assistive equipment was observed in the room.
- on 11/2/2023 at 10:14 AM the resident was standing in the doorway to their room and there was no assistive equipment observed in the room.
- on 11/3/2023 at 10:20 AM the resident ambulated from their bed to the bathroom. No assistive equipment was observed in the room.
During an interview on 11/1/2023 at 9:49 AM certified nurse aide (CNA) #41 stated they would know a resident's assistance level from the care plan. Resident #95 was independent with their transfers and ambulation. They kept the resident's wheelchair down the hall so the resident would not trip on it. They stated they had never seen a rolling walker in the resident's room.
During an interview on 11/2/2023 at 10:23 AM licensed practical nurse (LPN) #30 stated Resident #95's wheelchair was kept down at the end of the hall and was used for transport purposes only as the resident did not use it a lot. They stated they had never seen a rolling walker in the resident's room, and it should probably be taken out of their care plan.
During an interview on 11/2/2023 at 11:41 AM CNA #42 stated they would know how a resident transferred and ambulated from the care plan. Resident #95 was independent with their ambulation and transfers. The resident had a wheelchair, but it was not kept in their room. They had never seen a rolling walker in their room. The resident was able to take themself to the bathroom. When the resident took a shower, they were transported via a shower chair.
During an interview on 11/3/2023 at 10:29 AM with RN Unit Manager #14 they stated the resident was care planned for a rolling walker and they had gone down to physical therapy on 11/2/2023 to get one. They had not been previously aware the resident was supposed to have a rolling walker or that the resident had a quad cane in their room that was not documented in the care plan.
During an interview on 11/6/2023 at 11:05 AM the Director of Therapy stated Resident #95's current assistance level was supervision for transfers and ambulation with a rolling walker. They did not keep the wheelchair in the resident's room due to space limitations and it was a tripping hazard. They would expect the rolling walker to be in the resident's room so the resident could use it when getting out of bed and ambulating.
During a phone interview on 11/6/2023 at 12:27 PM RN #40 stated when they filled out an electronic accident/incident report they did not review the care plan and relied on the CNAs to tell them what a residents' assistance level was. They had never seen a rolling walker or wheelchair in Resident #95's room and the resident would get up on their own.
During an interview on 11/6/2023 at 12:45 PM the Assistant Director of Nursing (ADON) stated they reviewed the accident/incident reports to make sure everything was addressed. The care plan should be reviewed, and the resident and their room would be assessed in person to make sure the resident had the appropriate assistive equipment as planned. They stated normally therapy went to a residents' room to check on the appropriate assistive equipment after a resident fall.
During an interview on 11/6/2023 at 2:03 PM the Director of Nursing (DON) stated they reviewed accidents and incidents in the morning with the ADON then met with the interdisciplinary team. They reviewed care plans for each incident and revised as necessary. When staff filled out the electronic accident/incident report they should have checked the care plan for the Resident #95's assistance level with transfers and ambulation and any assistive equipment that was to be used. After an incident the RN, PT or Unit Manager should be going to the residents' room to see if interventions were in place. They were not aware that Resident #95 did not have a rolling walker and wheelchair in their room.
10 NYCRR 415.12(h)(1)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 10/30/2023-11/6/2023, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure residents maintained acceptable parameters of nutritional status for 2 of 5 residents (Resident #81 and 102) reviewed. Specifically, Resident #81's hydration needs were not reassessed by clinical nutrition staff after they had urinary tract infections (UTI). Resident #102 had a significant weight loss, was not reweighed, did not have their nutritional needs reassessed, did not receive fortified milk as recommended by the registered dietitian (RD), and did not receive adaptive feeding equipment as planned.
Finding include:
The facility policy Hydration revised 10/2023 documented the facility would provide each resident sufficient fluid intake to maintain proper hydration and health. All residents' fluid needs would be assessed upon admission, annually, and with each significant change in condition. On an as needed basis, the dietitian would reassess resident intake and adjust in fluids provided. Risk factors for dehydration included diuretic use and urinary tract infections (UTI).
The facility policy Adaptive Eating Equipment revised 1/2000 documented the dietary department was responsible for seeing that the adaptive equipment/self-help devices were supplied for a specified resident's use at mealtimes.
The facility policy Weight Monitoring revised 5/2013 documented weekly or more frequent weight checks may be indicated for residents with anorexia, dehydration, obesity, edema, significant change or as indicated by certain medications. Weight frequency would be increased as deemed necessary by nursing, dietary or a physician. Weight changes of 5 pounds (gain or loss) required a re-weight. Significant weight change was indicated by a gain or loss of 5% in one month or less; 7.5% in 3 months; or a 10% change over a 6-month period.
1) Resident #81 was admitted to the facility with diagnoses including cellulitis of the right leg (skin infection caused by bacteria) and urinary tract infection (UTI). The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, required set-up assistance for eating, and had a UTI in the last 30 days.
The comprehensive care plan (CCP), revised 8/24/2023, documented Resident #81 was at risk for alteration in nutrition related to medical diagnoses. Interventions included regular consistency food/fluids and offering a snack in the evening of cheese and crackers.
The 8/24/2023, registered dietitian (RD) #13's admission nutrition assessment documented Resident #81's fluid needs were assessed at 30 milliliters (ml) per kilogram (kg) or 2340 ml per day and they would continue to monitor outcomes, including meal intakes, weight trends and adjust plan of care as needed.
The 9/4/2023 registered nurse (RN) #14's progress note documented the resident was complaining of burning with urination and an order was obtained for a urinalysis (urine test to detect a urinary tract infection).
The 9/6/2023, nurse practitioner (NP) #15's progress note documented the resident was seen for a positive UTI and complaints of burning pain, burning with urination, and they would be treating with antibiotics when the urine culture resulted.
The 9/8/2023, RN #14's progress note documented the urinalysis was positive and an antibiotic was ordered by NP #15.
There was no documented evidence Resident #81's CCP was updated, or fluid needs reassessed in view of the UTI diagnosis and no documented evidence the resident's fluid intake and fluid plan were assessed to determine appropriateness.
The 10/25/2023, physician #17's progress note documented the resident reported they thought they still had a UTI and acknowledged they were recently treated with antibiotics. The resident reported continued difficulty while urinating as well as urinary incontinence, which was not their baseline, and a urinalysis was ordered.
The 10/30/2023, RN #14's progress note documented the resident's urine culture was positive and a different antibiotic was ordered.
There was no documented evidence Resident #81's CCP was updated, or fluid needs reassessed given the UTI diagnosis and no documented evidence fluid intakes and fluid plan were assessed to determine appropriateness.
During an interview on 11/6/2023 at 12:12 PM, RN #14 stated if a resident had a UTI, was prone to UTIs, or was on an antibiotic, it should be included in the resident's CCP. Interventions should include increasing fluid intake if it was determined the resident was not on a fluid restriction. They stated Resident #81 had 2 or 3 UTIs and they forgot to put this information into the CCP. They stated they were responsible for all nursing aspects of the CCP, including initiating and updating them.
During an interview on 11/6/2023 at 1:36 PM, RD #13 stated they would want to be notified by email or telephone call if a resident had a UTI and the notification would be done by a Nurse Manager or Supervisor. They wanted to be notified so they could look at the resident's fluid intakes to determine fluid needs and to look for signs of altered hydration. They stated a resident with a UTI or frequent UTI's had the potential for increased hydration needs. They stated they saw Resident #81 on admission and updated meal preferences but was not made aware of any changes or UTIs. They stated if they were notified, they might have encouraged fluids or added additional fluids to the resident's trays at mealtimes.
2) Resident #102 was admitted with diagnoses including anxiety, muscle weakness, and depression. The 9/1/2023 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required supervision, and set-up at meals, weighed 113 pounds (lbs), had not had any significant weight changes, and received a therapeutic diet.
The 5/30/2023 physician's orders documented the resident received a no added salt diet.
The 8/24/2023 physician's orders documented weekly weights on Thursdays.
The 6/4/2023 comprehensive care plan (CCP) documented the resident had a self-performance eating difficulty related to the presence of cervical collar (neck brace). The goal was to consume greater than 51% at meals, the resident's weight goal was 115 - 125 lbs. Interventions included a therapeutic diet of no added salt and monitor meal intakes and weights.
The resident's record documented their weight in pounds (lbs):
- 5/31/2023, 118 lbs.
- 6/1/23, 119 lbs.
- 6/7/2023, 116.2 lbs.
- 7/18/2023, 114.4 lbs.
- 8/3/2023, 115.2 lbs.
- 8/24/2023, 116 lbs,
- 8/31/2023, 114.6 lbs
- 9/1/2023, 113.4 lbs.
The 9/1/2023, Nutrition Assessment completed by registered dietitian (RD) #37 documented the resident weighed 111.4 lbs and was free of significant weight changes. They received a no added salt diet, consumed 25-100% of meals and RD #37 would consider additional interventions if weight loss trend occurred. Their estimated daily nutritional needs were 1200 - 1250 calories, 56 grams (g) protein, and 1545 - 1648 milliliters (mls) of fluid.
The resident's record documented:
- No recorded weight the week of 9/7/2023.
- 9/14/2023, 114.2 lbs.
- No recorded weight the week of 9/21/2023.
- 9/28/2023, 107.6 lbs (6.6 lbs/ 5.78% loss in 2 weeks). There was no documented reweight obtained and the resident's nutritional needs were not reassessed.
- 10/5/2023, 111.4 lbs.
-10/12/2023, 110.1 lbs.
On 10/15/2023, RD #13 documented the resident's current weight was 110 lbs and their goal was weight maintenance. Meal intakes were fair to good. They continued to receive a no added salt diet. RD #13 recommended to change the diet order to regular to promote oral intakes and they would add fortified milk to all meals for additional calories and protein. They would continue to monitor the resident's weight trends.
On 10/17/2023, registered nurse (RN) Manager #19 documented staff reported the resident had difficulty with their drinks and was spilling them at times. They alerted they therapy for an elevation.
On 10/17/2023, occupational therapist (OT)/ Director of Therapy #34 documented they recommended Kennedy cups (cup to prevent spilling) at meals. The resident's CCP was updated, and the kitchen was notified. They would monitor for effectiveness of the adaptive mealtime equipment.
On 10/17/2023, Kennedy cups was added to the CCP.
The undated care instructions documented the resident received a no added salt diet, required set-up at meals, and Kennedy cups at meals to prevent spilling.
On 10/19/2023, The resident's record documented their weight was 108 lbs.
On 10/23/2023, licensed practical nurse (LPN) #22 documented the resident would not chew or swallow for breakfast or lunch. They required frequent encouragement, was offered a variety of food, but was not chewing or swallowing anything and only spit out their food.
On 10/24/2023, nurse practitioner (NP) #15 documented the resident weighed 108 lbs and was seen for lethargy. Nursing staff reported the resident was sleeping on and off throughout the day and at times did not eat because they were so sleepy. Their medications were adjusted, and family was updated.
On 10/25/2023, physician #17 documented the resident was seen for a follow-up visit and was on comfort care. The resident's weight was checked at least once per month and has trended down recently. The resident received fortified foods and had low weight.
On 10/26/2023, the resident's record documented their weight was 103.8 lbs (4.2 lbs/ 3.98% loss in 1 week, 6.3 lbs/ 5.72% loss in 2 weeks, and 7.6 lbs /6.82% loss in 3 weeks). There was no documented reweight obtained and the resident's nutritional needs were not reassessed.
On 10/27/2023, RN Manager #19, documented the resident required increased assistance at meals, needed more reminders to eat, and at times, required physical help with meals.
On 11/1/2023 at 11:48 AM, the resident was observed seated at a table in the unit dining room. Certified nurse aide (CNA) #35 provided the resident their lunch tray and cut up their meal for them. The resident's meal ticket documented they were to receive baked ham, scalloped potatoes, cauliflower, peaches, water and a 2 handled cup with straw. The resident did not receive their 2 handled cup. Their water was in a clear plastic cup with no handles or lid. The resident attempted to feed themselves but unable to do so. At 11:55 AM, an unknown therapy staff member sat down with the resident to assist them with their meal. At 12:00 PM, RN Manager #19 sat down next to the resident and assisted them with the meal. At 12:20 PM, CNA #38 sat down with the resident to assist them with the meal. CNA #38 had to hold the plastic cup for the resident while they took small sips from the cup via the straw. The resident completed their meal at 12:46 PM, they had consumed 75% of their potatoes, less than 25% of their baked ham, cauliflower, and peaches. They drank 100% of their water.
During an interview on 11/1/2023 at 12:48 PM, CNA #35 stated when they passed meal trays, they were to check the meal ticket to ensure the items matched what was on the tray. The meal ticket indicated if the resident needed any adaptive equipment, and they should also ensure that was on the tray as well. It was important for the residents to receive their adaptive equipment to help main their ability to feed themselves. They provided the resident their meal tray and the resident's adaptive mealtime equipment was missing. The resident was supposed to have a 2 handled cup and it was not on the tray. They typically let the kitchen know if the resident was missing equipment, but they did not do that today and stated they should have. They also did not tell anyone on the unit that the cup was missing. They stated the resident had a recent decline in their ability to feed themselves and needed a lot of help at meals. The resident tended to drink better with their 2 handled cup, and they were unsure if the resident had any recent weight changes. The CNAs obtained the resident's weights monthly or more as directed by the nurse.
During an interview on 11/2/2023 at 11:36 AM licensed practical nurse (LPN) #23 stated nursing staff obtained residents' weights based off a list that was provided by the dietary department. Licensed staff entered the weights into the computer. There was a place in the electronic medical record that alerted the nurse if a resident was on daily or weekly weights. If reweights were needed, the RD would let the nurse know and they were unsure of the timeframe in which reweights should be obtained. They stated Resident #102 was on weekly weights, had a decline in their eating status and required more cues at mealtime and was supposed to receive adaptive equipment at meals. The resident also had weight loss recently. Any staff who passed out the meal trays should check to ensure the food items were correct and make sure their adaptive equipment is on the tray. If the adaptive equipment was missing, staff should notify a nurse or call the kitchen to let them know there are missing items. They stated the resident was able to drink out of a 2 handled cup when they received it. At times, the resident would refuse to have their weight obtained, but staff should reapproach and document the refusal.
During a telephone interview on 11/2/2023 at 12:02 PM, RD #13 stated weights were obtained by the nursing staff as ordered. Nursing staff entered the weights into the medical record. If reweights were needed or if a resident had missing weights, they sent an electronic notice to the Unit Managers and the Director of Nursing (DON) to let them know reweights were needed or missing weights needed to be obtained. They stated any weight changes of 5% or more at 1 month, 7.5% or more at 3 months, or 10% or more at 6 months was considered a significant weight change. Ideally, staff should be obtaining a reweight if there was a 5 lbs or greater change since the previous weight. They were unsure how soon a reweight should be obtained if there was a 5 lbs or greater change since the previous weight. They reviewed weights at least monthly, but if a resident was ordered to have weekly weights obtained, they reviewed those resident's weights weekly. When they made recommendations to change a resident's diet order, they communicated those recommendations via electronic communication to the Nurse Manager and physician. The physician would decide if a diet order should be changed. If they made any changes to the resident's meal pattern, they alerted the Food Service Director and Assistant Food Service Director electronically, who made the changes to the resident's meal pattern. They stated they had electronically notified RN Manager #19 that the resident had missing weekly weights previously. The stated the resident's 10/26/2023 weight of 103.8 lbs was odd. No reweight had been obtained. They were unaware the resident had a decline in their eating status, and they would want to be made aware. They were unaware the resident did not receive their fortified milk at all meals. They did not follow up to ensure that their recommendations had been put into place. They stated it was important for the resident to receive the fortified milk because it provided additional calories and protein. They were also unaware the resident's diet order remained no added salt.
During an interview on 11/2/2023 at 12:32 PM, the Assistant Food Service Director stated the RD would notify both themselves or the Food Service Director any changes they wanted made to a resident's meal pattern, this included adding or removing supplements or food items. When they reviewed Resident #102's meal pattern in the computer system, they stated the resident received whole milk at breakfast and was not receiving fortified milk at any meals. They stated fortified milk had dry milk added to it to increase its calorie and protein content. When they reviewed the electronic communication from RD #13 on 10/15/2023, they stated it should have been added and it was not added to the resident's meal plan. They stated it was important to add the recommendations made by the RD to help maintain the resident's nutritional status. They stated the therapy department let the kitchen staff know which resident's needed adaptive equipment. The RD let them, and the Assistant Food Service Director know what to add or remove from the resident's meal pattern. They did not review all the RD electronic communications. If the Assistant Food Service Director signed that they had completed the update they assumed, it was done. It was important to follow the RD's recommendations. The therapy department also let them know electronically what adaptive feeding equipment to add to the resident's meal pattern. Resident #102 was supposed to receive Kennedy cups, but the kitchen did not have any additional ones at this time, and they let the therapy department know. Therapy approved the use of the 2 handled cup until the Kennedy cups arrived. The breakfast cook was responsible for ensuring the adaptive equipment was on trays. If an item was missing unit staff should call and the kitchen would send it to the unit.
During an interview on 11/2/2023 at 12:49 PM, RN Manager #19 stated weights were obtained at least monthly or more as ordered by the physician. The RD reviewed the weights and let them know if any reweights were needed. Reweights should be obtained as soon as possible and if a resident refused to be weighed it should be documented. Weekly weights were supposed to be completed weekly. They reported Resident #102 had recently needed more help with eating and therapy was aware and recommended adaptive equipment. The resident was also seen by medical for lethargy. They were unsure if the resident had any weight changes recently. They expected staff to ensure the resident received the correct food items and adaptive equipment at meals, staff should let the kitchen know if anything was missing or they tell a nurse who could call the kitchen. If a resident had a significant weight change the RD would notify them and thy discussed the weight change with the medical team. If the RD made any recommendations to the resident's diet order, they also discussed it with the medical team, but it was up to medical to change the resident's diet order.
During an interview on 11/3/2023 at 9:47 AM, OT/ Director of Therapy #34 stated Resident #102 had inconsistent energy levels. The resident currently needed more cues and help at mealtimes. This has been a recent change in late October 2023. Nursing staff alerted therapy of the resident's increased needs and they had recommended Kennedy cups to help prevent spilling drinks at mealtime. The kitchen let them know they were not available, and they recommended the use of a 2 handled cup until the Kennedy cups were available. The resident should have been provided their adaptive equipment at mealtime to promote self-feeding.
10NYCRR415.12(i)(1)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the recertification and abbreviated (NY00306251) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure each resident received an...
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Based on observation, record review, and interview during the recertification and abbreviated (NY00306251) surveys conducted 10/30/2023-11/6/2023, the facility did not ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #25) reviewed. Specifically, Resident #25 exhibited a behavioral disturbance, and a plan was not developed or implemented to prevent reoccurrence and ensure the safety of staff and other residents.
Findings include:
The facility policy Care Planning Interdisciplinary Team revised 11/2016, documented a comprehensive, person-centered care plan that included individual care needs was developed and included by direct observation and communication with the resident and/or designated representatives as well as direct care staff.
The facility policy Change in a Residents Condition or Status revised 3/2020, documented the resident, the attending physician, and representative were notified of changes in the resident's condition or status within 24 hours. Nursing was to notify the physician when the resident was involved in any accident or incident that resulted in an injury and has the potential for requiring physician intervention including injuries of unknown origin or there was a significant change in the residents physical, mental, or psychosocial status. When a significant change in the residents conditioned occurred a comprehensive evaluation/assessment of the resident's condition was conducted and documented.
The facility policy Abuse Prohibition revised 2/2023, documented residents had the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, involuntary seclusion, misappropriation of property, and exploitation. It was the facility goal to achieve and maintain an abuse free environment. The facility would assess, care plan, and monitor symptoms of behavior problems and developed and implemented care plans that assisted in resolving behavioral issues.
Resident #25 was admitted to the facility with diagnoses including Huntington's disease (a progressive breakdown of nerve cells in the brain) and anxiety. The 8/2/2022 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, made self understood and understood others, felt down, depressed, or hopeless, had little energy, had trouble sleeping too little/too much on a daily basis, did not exhibit physical or verbal behavioral symptoms directed toward others, and was independent with most activities of daily living (ADL).
The comprehensive care plan (CCP) updated 9/21/2022, documented the resident had a psychosocial deficit due to feeling isolated and lonely from Covid-19. The resident had alterations in mood secondary to anxiety. Interventions included observation of mood, behavior, level of anxiety, and monitoring sleep pattern. Staff would encourage the resident to express feelings and maintain contact with family and friends to decrease loneliness with a psychiatric consult as ordered.
A 9/30/2022 at 7:14 PM licensed practical nurse (LPN) Supervisor #8 progress note documented the charge nurse (LPN #12) reported Resident #25 attacked them. LPN #12 reported they went into the resident's room to give them their medication. The resident was sitting in their chair and doing a puzzle. The resident stood up, grabbed LPN #12, pushed them to the ground and started punching them in the face and chest which resulted in a cut/bruising to the left side of LPN #12's face, their chest was red, and they were in pain. LPN #12 went to the ER (emergency room). The Administrator, doctor, and the on call provider were made aware.
A 9/30/22 at 7:39 PM LPN Supervisor #8 progress note documented Resident #25 stated that nurse was arguing with them, they did not remember what about, but they hit the nurse and felt bad for doing so.
There was no documented evidence the resident was assessed by a licensed professional, a plan was put in place to ensure the safety of residents and staff to prevent reoccurrence, or the incident was investigated.
A 10/01/2022 at 6:28 PM registered nurse (RN) #18 progress note documented Resident #25's family member was notified of the incident on 9/30/22 and the police were investigating the incident.
A 10/3/2022 at 11:24 AM RN #19 progress note documented they spoke with the nurse practitioner about what occurred over the weekend. New orders were obtained for a urinalysis (evaluation of urine), culture (determines if bacteria are present) and sensitivity (determines what medicines will kill the bacteria), complete blood count (blood test), and complete metabolic panel (blood test) as well as a psychiatric evaluation.
A 10/3/2022 at 1:28 PM, social worker (SW) #3 progress note documented they spoke to the resident regarding their mood and the incident over the weekend. Resident #25 stated they were tired after going out with their family and they felt nervous when they returned to the facility. They felt good today and appeared calm and pleasant throughout the visit. Family was in to visit, and the resident remained moderately cognitively impaired.
A 10/3/2022 at 1:49 PM, SW #3 progress note documented Resident #25 was to be moved to a different room with a roommate related to Covid-19.
There was no documentation the resident had been assessed for safety to have a roommate.
A 10/4/2022 at 2:01 PM SW #3 progress note documented the resident was seen by a psychiatric nurse practitioner on that date.
There was no documented evidence the psychiatric nurse practitioner evaluated the resident.
A 10/10/2022 physician #20 progress note documented the resident was evaluated for a routine visit. Since the last visit the resident had been stable until attacking staff on 9/30/2022. There were no incidents prior to or since the incident. The resident was pleasant when evaluated and had a history of Huntington's chorea and was confused at times with poor short term memory.
There was no documentation the CCP was updated following the incident with interventions for increased monitoring or person-centered interventions related to the resident's behaviors.
The undated care instructions documented the resident had behavior symptoms. The instructions did not include the behavioral symptoms the resident displayed. Interventions included to redirect, respect, and listen to expression of feelings, report changes, and separate from others when agitated.
During an observation on 10/31/2023 at 2:27 PM, the resident was in their room and stated they had never been hit or hit anyone.
During an interview on 10/31/2023 at 6:50 PM, LPN #12 stated the resident had returned from an outing with their family on 9/30/2022 and stated they were tired. The LPN stated they brought in medications to the resident, the resident lunged at them knocking them to the ground, and with a closed fist hit them in the face and chest. Eventually the resident stopped, and they were able to get out of the room. They reported bruising to the head and chest and a 1-2 inch cut to the left side of their face. They reported the incident to LPN Supervisor #8 and went to the ER for evaluation. The following day they filed a police report and resigned from the facility.
During an interview on 11/1/2023 at 2:28 PM the Administrator stated they had no Accident/Incident reports for the resident. They did not do Accident/Incident reports when a resident was aggressive towards staff, they just updated the care plan.
During an interview on 11/2/2023 at 10:35 AM LPN #27 stated if a resident hit staff or another resident they would separate the individuals and notify a nursing supervisor. They would expect the resident to be evaluated by a physician and orders to be implemented. The care plan should be updated so staff knew what interventions were in place to address behaviors.
During an interview on 11/2/2023 at 11:59 AM, RN Unit Manager #7 stated for any types of abuse, resident to resident, resident to staff, staff to resident, an incident report was completed. After all incidents the physician was notified to complete an assessment for safety of the resident, staff, other residents, and visitors. The CCP should be updated by a RN following any incident. If the supervisor was an LPN, the Unit Manager or Director of Nursing (DON) should assess the residents.
During an interview on 11/02/2023 at 4:22 PM the DON stated incidents that involved resident to resident, staff to resident, or resident to staff were investigated, however resident to staff incidents did not have an incident report. They stated after any incident the resident should be assessed and documented in a progress note. A plan should be put in place for safety of residents and staff. If the resident was not assessed and the care plan was not updated, the safety of the resident, staff, and other residents could be in jeopardy.
During an interview on 11/2/2023 at 04:15 PM LPN #8 stated they were working 9/30/2022 when Resident #25 attacked a staff. They could not remember if they were the supervisor or if they were just working that night. They would have notified the supervisor, physician, family, the DON, and completed an incident report. They could not recall when the resident was assessed by a physician or what interventions were put in place for resident and staff safety.
During an interview on 11/3/2023 at 12:31 PM SW #3 stated for resident to resident abuse they would make sure residents were safe, notify the nursing supervisor and the DON, and put interventions in place to prevent it from happening again. For resident to staff abuse they would notify the nursing supervisor, medical provider, and the DON. After the incident they were not sure if the medical provider or DON were notified, or if interventions were put in place to prevent it from happening again to staff or other residents. They stated they would want to make sure the resident was safe to have a roommate.
During an interview on 11/03/2023 at 02:19 PM SW #3 stated they coordinated the telehealth appointment with psychiatry on 10/4/2022. They stated there was no documentation of the visit because the psychiatric nurse practitioner resigned prior to completing documentation regarding the evaluation. They stated without the documentation staff would not know what interventions were recommended for safety of the residents and staff.
During an interview on 11/6/1023 at 8:58 AM physician #20 stated if a resident injured a staff an incident report was completed, and they were notified. They would want to be notified as this behavior was uncharacteristic of the resident. They stated they would want to make sure the resident did not have an infection or something medical going on that could have caused the behaviors. They would also want to make sure residents and staff were safe.
10 NYCRR 415.12
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure storage, preparation, distribution, and service of food...
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Based on observation, interview, and record review during the recertification survey conducted 10/30/2023-11/6/2023, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in the main kitchen. Specifically, pans, trays, the exhaust hood, and floors in the main kitchen were unclean; and the reach in cooler contained sandwiches that were not labeled or dated.
Findings include:
The facility policy Cleaning of Hood Filters dated 1/1/2023, documented the hood filters located above the cooking equipment island will be cleaned once a week. This would allow adequate draw from the fans and would also lessen the chance of fire.
The facility policy Food Receiving and Storage effective 7/2008, documented refrigerator storage of potentially hazardous foods (PHF) or time/temperature control for safety (TCS) foods, required time/temperature control for safety to limit the growth of pathogens or toxin formation. All opened items would be labeled and dated and discarded after three days once opened. All non PHF/TCS food items would be labeled and dated and discarded after five days once opened.
The facility policy Dishwashing/Pot Washing dated 10/2013, documented allow dishes to dry on racks. Do not dry with towels. Air dry all clean and sanitized pots and wares and do not wipe dry.
During observations on 10/30/2023 at 10:15 AM and 10/31/2023 at 12:24 PM, the kitchen exhaust hood was dust and grease laden. The floors under the cookline and double ovens were soiled and unclean with food debris.
The semiannual hood cleaning preventative maintenance audits dated 1/5/2023 and 7/21/2023, documented the hoods were free of dust and grease.
There was no documented evidence of weekly cleaning for the kitchen hood.
During an interview on 10/30/2023 at 10:15 AM, the Food Service Director stated logs were not being kept for completed duties like deep cleanings under and behind equipment. They stated there should have been a policy and procedure for what should be cleaned. They stated deep cleaning should be conducted once a month. The floors should have been cleaned better than they were.
During an observation on 10/30/2023 at 10:18 AM, there were four unlabeled and undated sandwiches in the prep reach in cooler.
During an interview on 10/30/2023 at 10:18 AM, the Food Service Director stated they were not sure what the sandwiches were, when they were made, or who made them. The sandwiches should have been labeled with identification and the date. They stated food items were held for 72 hours and then discarded. The sandwiches should be discarded since it could not be determined when they were made.
During an observation on 10/30/2023 at 10:30 AM, there was a stack of 4 x 4 inch-2 inch deep, and 6 x 8 inch-2 inch deep trays that were wet and stored inside one another on a storage rack adjacent to the cook line.
During an interview on 10/30/2023 at 10:30 AM, the Food Service Director stated the storage rack was used for clean and dry cookware. The trays should have been fully air dried over the three bay sink before they were moved to the storage rack.
During an interview on 10/31/2023 at 1:09 PM, the Food Service Director stated maintenance cleaned the hoods semi-annually.
During an interview on 10/31/2023 at 1:15 PM, the interim Maintenance Director stated they kept logs for cleaning the kitchen hoods. The logs indicated they were last cleaned in July 2023. If the hoods needed to be cleaned more often the kitchen staff should let maintenance know.
10NYCRR 415.14(h)
Jul 2021
8 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (Residents #28 and #22) reviewed. Specifically, Resident #28 was observed in their room with a peanut can that contained 8 cigarette butts with ashes. Resident #28 reported that after smoking the resident would routinely bring the peanut can with cigarette butts and ashes into the facility and empty the contents into a plastic trash can in the unit kitchenette across from their room. The housekeeper reported the plastic trash can routinely contained smoked cigarette butts and ashes and that they had not reported this finding to anyone.
The facility's failure to provide an approved metal disposal container with a self-closing lid in the smoking area and the resident's improper disposal of smoking materials in an unapproved container inside the facility puts all 97 residents and others in the building at immediate risk for injury as those materials could cause a fire.
This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm to Resident #28 and the facilities other 97 resident's health and safety.
-Resident #22 was observed smoking unsupervised and had smoking materials, including cigarettes and a lighter, unsecured in their room.
Findings include:
The facility's Smoking Policy documented there were two residents grandfathered into a smoke free facility. Regularly designated smoking session will take place at the southwest corner of the Garden Courtyard, which is more than 50 feet from the building entrance. Residents must turn in all smoking supplies (cigarettes, cigars, tobacco, pipes, lighters, and matches) to the nurse's station where they will be properly labeled with the resident's name. All smoking supplies will be stored in a container at the nurse's station to be distributed to the residents by a designated employee at the designated smoking time. Facility personnel shall report the finding of any smoking article found on the resident that had not been turned into the nursing station.
1) Resident #28 had diagnoses including paraplegia (paralysis), chronic obstructive pulmonary disease (COPD) and major depressive disorder. The 4/19/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance from 2 persons for most activities of daily living (ADL), supervision of one person for locomotion off the unit, did not ambulate, required a wheelchair.
The residents current daily care guide (care instructions) last updated 2/12/18 documented the resident required assistance with dressing, grooming, and hygiene; was non-ambulatory; used a high back wheelchair; must be supervised at all times while smoking; and must wear a smoking apron at all times while smoking.
The comprehensive care plan (CCP) initiated 1/21/20 and revised 5/7/21 documented the resident had self-care performance deficits related to paraplegia and limited range of motion (ROM). Interventions included extensive assistance of 1. The CCP included smoking, resident used tobacco with the goal the resident would smoke in a safe environment through next review. The smoking CCP did not document an initiated date. Interventions included: provide resident with smoking policy, resident was a responsible smoker, smoking data collection tool was completed per policy, smoking safety equipment/apron provided during smoking times and the resident refused a smoking apron.
The 1/22/21 comprehensive nurse practitioner (NP) exam documented Resident #28 was stable and continued to smoke daily.
The 5/6/21 Smoking Data Collection tool completed by social worker (SW) #5 documented the resident would smoke in the designated smoking area. The resident did not need assistance to smoke, was a safe smoker, and had never had any unsafe smoking incidents. The resident was able to get to the smoking area, knew how to obtain cigarettes/lighter, could hold a cigarette securely, disposed of ashes in the ashtray, could extinguish the cigarette, returned cigarettes and lighter to appropriate designated area/staff and was able to call for emergency assistance if needed. Recommendation included the resident could smoke safely and did not require supervision or assistance.
The 6/2/21 physician progress note documented the resident was evaluated for a routine visit, the resident complained of pain on and off in the lower extremities. However, the resident was up in their chair for long periods of time outside smoking cigarettes.
The 6/25/2019 physician order documented use smoking apron while outside unattended. There were no additional orders related to resident smoking.
During an interview on 7/13/21 at 1:00 PM, the Assistant Administrator/Director of Maintenance and Administrator both stated there were two residents at the facility who smoked, and both were grandfathered in to be allowed to smoke. Resident #28 could hold their cigarette in their hand and used a peanut to extinguish cigarettes. The resident was supposed to empty their ashes and cigarettes into the metal self-closing unit attached to the exterior wall adjacent to the courtyard exit door (approximately 10 feet from the door), before entering the facility.
The 7/14/21 electronic [NAME] (care instructions for the nursing assistant) documented under the safety category the resident was unable to ambulate, was a responsible smoker, and refused the smoking apron.
During an interview on 7/14/21 at 9:31 AM, Resident #28 had a peanut can with cardboard sides, a metal bottom, and a plastic lid, that contained 8 cigarette butts and ashes was observed in the resident's room. The can was located on the table just inside room by the door. The resident stated that they dumped the cigarette butts in a receptacle outside in the smoking area. Resident #28 stated that propped the can beside their legs when they were in their wheelchair when going to smoke. The resident stated they had a full box of self-rolled cigarettes. The resident said that their lighter was in the soft bag that was currently on the floor in their room. Resident #28 stated that they were very careful when they extinguished a cigarette and made sure they put out all the embers before it went in the peanut can.
During an observation on 7/14/21 at 1:54 PM, Resident #28 was outside in the courtyard behind the tent. The resident was lighting a cigarette and was not wearing a smoking apron. The resident was interviewed and said they kept their smoking supplies safe, and there were no residents that wandered into their room. The resident demonstrated scraping the tobacco off the end of the cigarette when they put the cigarette out. The peanut can was observed to have no lid. The resident stated that they did not usually keep the cigarette butts in the can but would get rid of them by throwing them away in the garbage in the staff break room/kitchenette located across the hall from their room.
When observed on 7/14/21 at 2:30 PM, Resident #28 was coming back in from the main courtyard area and could not open the door. The resident was knocking on the door and the Assistant Administrator opened the door for the resident to come in. The resident was in a wheelchair and had a box of cigarettes, a peanut can, and a plastic bag on their lap.
When observed on 7/14/21 at 3:56 PM, there were 3 cigarette butts and ashes in the B Unit staff breakroom plastic trash can just inside the doorway to the room. The cigarette butts and ashes were lying on top of a paper towel in the trash can.
During an interview on 07/14/21 at 4:34 PM, temporary nurse aide (TNA) #1 stated that they were assigned to Resident #28 that evening. The resident went to their room and unloaded the bag off their lap and the peanut can was set on a table by their door. Staff did not empty the peanut can and that was usually already done by the resident. TNA #1 stated they were not sure where the resident disposed of the contents of the can. The TNA stated the resident usually stayed outside until 8-8:30 PM and the doors to the courtyard locked at 8:00 PM. When Resident #28 wanted to come inside, the resident would knock on the window and the supervisor would either hear the resident, or the resident would use a cell phone and call the main number.
The resident was observed on 7/14/21 at 4:40 PM smoking unsupervised outside in the courtyard.
During an interview on 07/15/21 at 11:28 AM, B Wing housekeeper #11 stated Resident #28 did not want anyone to touch their things. The resident kept lighter and cigarettes in a bag. Housekeeper #11 stated that Resident #28 had an empty peanut can they put the cigarette butts in outside and when the resident came inside, the resident dumped the can in the staff break room trash. Housekeeper #11 stated that they observed the resident doing this every day while in the breakroom. The housekeeper stated that they were not sure how the resident extinguished their cigarettes. Housekeeper #11 stated the trash can in the breakroom was plastic with a plastic bag liner and had a swing top and was used to dispose of cups, papers, paper plates, napkins, and plastic silverware.
During an interview on 07/15/21 at 11:33 AM, licensed practical nurse (LPN) #2 stated the smoking area was out the back door where the solarium was located. LPN #2 stated there was another resident besides Resident #28 that went out there to smoke. LPN #2 stated they were not sure if there was a receptacle for the residents to put cigarette butts in. The LPN stated aides usually let Resident #28 out there and would bring the resident back in. LNP #2 stated the resident's lighter was kept in the top drawer of the medication cart. There was a lighter observed in the top drawer when the LPN opened the medication cart. The LPN stated that they were not sure if the resident had more than one lighter. LPN #2 stated they did not know where Resident #28 currently was located, and the resident had not asked for their lighter. The LPN stated there were no cigarettes kept in the medication cart and the resident kept their cigarettes in the bottom drawer of the dresser in their room. LPN #2 stated that they were not aware of the peanut can in the resident's room.
During an observation on 07/15/21 at 11:51 AM, Resident #28 was outside in the far courtyard area, accompanied by physical therapy, doing upper body exercises. The resident had the peanut can at their side and there was one cigarette butt in the can. There was no smoking receptacle in the immediate area where the resident was sitting.
During an interview on 07/15/21 at 11:51 AM, housekeeper #29 stated there were 2 residents that smoke outside by the gazebo area and thought there was a container outside for the cigarette butts which was emptied by maintenance.
During an interview on 07/15/21 at 11:59 AM, certified nurse aide (CNA) #3 stated Resident #28 would go outside to smoke by themselves. The CNA stated the resident did not turn in their cigarettes or lighter when they came in from smoking and they did not know what the resident did with them. CAN #3 stated the peanut can was for the resident to put the cigarette butts in so the resident would not drop them. The CNA said that they thought the resident usually emptied the can outside but was not sure where. The CNA stated that they do not do anything with the peanut can as the resident took care of those things.
During an interview on 07/15/21 at 1:25 PM, the DON stated the facility had two residents that smoked, Resident #28, and Resident #22. The DON stated there was a smoking assessment for each resident in the computer. The SW had been completing the assessments and then nursing reviewed them during the care plan meeting. Both residents were determined to be safe smokers and did not require supervision. The residents had smoking aprons to wear, and Resident #28 would wear the apron if staff would insist. The DON stated there were no scheduled smoking times. Resident #28 goes out before lunch and then again in the evening. The nursing staff were supposed to have the lighters at the nurse's station, in the medication cart. The residents had been keeping their cigarettes in their rooms but did not have access to light them in their rooms. The DON stated the smoking area was just off the entrance to the garden or courtyard, and there was a receptacle there connected to the building. That was where the residents sit to smoke. The DON stated Resident #28 went out to the gazebo at times to smoke, but usually sat by the area where the receptacle was. The DON was not aware of Resident #28 was using a peanut can for cigarette butts or that the resident was emptying the can in the trash can in the kitchenette. The DON stated the facility Administrator had asked residents to put the cigarette butts in the proper receptacle. The DON stated staff were supposed to go get the lighter from the resident when the resident came inside. The facility smoking policy specified the resident should be 50 feet away from the building and that staff should be getting the lighter from the resident or that the resident should be giving it back to the staff. The DON stated when Resident #22 goes to dialysis their lighter was kept at the nursing station, and their cigarettes stayed in their room. The DON stated that they assumed resident #22's lighter was in the medication cart.
2) Resident #22 had diagnoses including chronic obstructive pulmonary disease (COPD) and cerebrovascular accident (CVA) with generalized muscle weakness and left side hemiparesis (partial paralysis). The 5/8/21 Minimum Data set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of one person for activities of daily living (ADL), extensive assistance of one person for locomotion off the unit and utilized a wheelchair.
Nursing progress notes dated 4/1/21 through 7/14/21 did not include documentation the resident was a smoker, went outside to smoke and/or where their cigarettes and lighters were kept.
The Smoking Data Collection Tool completed by social worker #5 on 5/6/21 documented the resident designated smoking area was outside in the designated area. The resident did not need assistance while smoking, was a safe smoker and was able to state where the designated smoking area was and where smoking was not permitted. The resident was able to identify appropriate clothing for outdoor smoking. The resident had no physical limitations and used oxygen but was able to remove the oxygen prior to smoking times. The resident knew how to obtain cigarette/lighter, could light a cigarette, hold the cigarette safely, dispose of ashes in an ashtray, extinguish cigarette and return cigarettes and lighter to the appropriate designated area/staff. It was recommended the resident could smoke safely and did not require supervision or assistance. Staff would assist the resident with transport to and from the designated smoking area.
The comprehensive care plan (CCP) initiated on 5/19/20 documented the resident smoked tobacco products. The resident was educated on safe smoking procedures by the Director of Nursing (DON) and the social worker. The resident declined to use the smoking apron. On 5/28/21 the resident continued to smoke and refused the apron. The goal documented was the resident would smoke in a safe environment through the next review and would utilize the proper smoking receptacle for disposal of cigarette butts. The resident was a responsible smoker and was to be supervised by staff when smoking. The resident would surrender their lighter to the staff so it may be locked in the medication cart during times when the resident was not smoking.
The 6/8/21 Resident Daily Care Guide (care instructions) documented the resident required extensive assistance of 2 staff to assist the resident to the wheelchair. The resident required a smoking apron on when smoking and required supervision with smoking.
The [NAME] (care instructions) active on 7/14/21 documented under safety-smoker- responsible; smoking materials to be kept at nursing station; and supervise resident during smoking.
During an interview on 7/13/21 at 11:33 AM, Resident #22 stated they smoked in the courtyard three times a day and staff would take them and leave them outside for about 15 minutes. The resident stated that they were able to remove their oxygen independently prior to smoking.
On 7/13/21 at 12:38 PM, Resident #22 was observed alone on the courtyard patio smoking. The resident was wearing a smoking apron.
During an interview on 7/13/21 at 1:56 PM, Resident #22 stated they keep their cigarettes and lighter in their nightstand drawer.
During observation on 7/14/21 at 9:00 AM, Resident #22 was not in their room, their room door was wide open, and there was a lighter visible inside an empty tissue box in a basket on the rolling bed side tray table.
During an interview on 07/14/21 at 2:11 PM, Resident #22 stated that they have always kept their cigarettes and lighter in the dresser/nightstand drawer. The lighter was observed in the basket on the bedside table.
During an interview on 07/14/21 at 2:16 PM, CNA #6 stated Resident #22 went outside with a smoking apron on, and that the resident always sat on the pavement (patio) and was near the ash tray. The CNA stated that the resident kept their cigarettes and lighter in the top drawer of the nightstand. CNA #6 stated, as soon as the resident got up for the day, the resident put the lighter inside their top undergarment. The CNA stated the resident was safe to be left alone to smoke and the CNA set a timer on their phone to know when to go get the resident. The CNA stated that the resident had always kept their smoking supplies in their room. The resident's family would bring cigarettes and lighters to the resident. The CNA stated that they have never seen the lighter in plain sight when the resident was not there, and the resident's room door was usually closed.
During an observation on 07/15/21 at 11:40 AM, Resident #22 had a lighter in their undergarment and cigarettes in their pant pocket. The smoking apron was folded and tucked next to their leg. Resident #22 stated that they only had one lighter, and the nursing staff trusted them. The resident stated, I am a safe smoker.
During an interview on 7/15/21 at 1:22 PM, the Administrator stated the Quality Assurance committee wrote and reviewed the smoking policy and it was approved for two residents (Residents#22 and #28). The Administrator stated the facility was a non-smoking facility but Residents #22 and #28 had been grandfathered in. The social worker completed a smoking assessment which included checking the residents' cognitive ability with regards to safety. Physical therapy and occupational therapy would assess the residents to ensure their dexterity was acceptable. The Administrator stated Resident #28 goes further into the courtyard than Resident #22 to smoke. The two Residents could be outside alone because they were deemed independent. The Administrator stated the designated smoking area was right outside the door near the ashtray. There had been no accident or incidents with burns to clothes and/or personal materials. The Administrator stated that Resident #28 refused to wear the smoking apron and Resident #22 would wear the smoking apron. Resident #22 disposed of their cigarette butts in the ashtray on the wall ashtray near the courtyard door. Resident #28 used a can and emptied the ashes or butts in the ashtray on the wall on the way back in the building. The Administrator stated residents should not bring ashes or butts inside the building and they needed to be disposed of in the ashtray outside and not inside the building. The Administrator stated that the residents should keep their smoking supplies at the nurse's station and there was no documented log-in for smoking supplies. The Administrator was not aware that the residents were keeping their smoking supplies in their rooms or that Resident #28 was disposing of their cigarette butts in the trash can inside the building. The Administrator stated the facility social worker provided the smoking policy information to the residents. Nursing staff would be able to look at a resident's care plan and [NAME] to know who smoked and what the supervision requirements were.
During an interview on 07/15/21 at 1:33 PM, social worker (SW) #5 stated that they had 2 resident who smoked, Residents #22 and #28. The social worker stated that they completed a quarterly smoking evaluation for the two residents. SW #5 stated that the smoking assessment tool assessed for the resident's ability to properly extinguish, ability to light and dispose of butts properly. SW #5 stated during the smoking evaluation the social worker would have the resident explain the process of smoking and where the resident was supposed to extinguish and dispose of their butts. The SW stated the residents should keep their smoking supplies locked at the nursing station and not in their rooms. SW #5 stated Resident #22 used the ash tray outside of the building for cigarette butt disposal and Resident #28 had their own personal can and would empty it outside. Cigarette butts should not be disposed of in a trash can inside the building because it was fire hazard.
During an interview on 07/19/21 at 3:01 PM, the Medical Director stated they were not aware the two residents and facility staff were not following the facility smoking policy. The Medical Director was familiar with Residents #28 and #22 and they were the only two smokers in the building. The Medical Director stated there should be smoking posts or pots for the garden area where Resident #28 preferred to smoke.
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Immediate Jeopardy was identified, and the facility Administrator was notified on 7/15/21 at 6:01 PM.
The Immediate Jeopardy was removed on 7/17/21 based upon the following corrective actions taken:
- Resident #28 and #22 were instructed that the only approved disposal receptacle was located on the patio attached to the building. The facility indicated they would have additional approved receptacles available for use within 7 days.
- The facility educated and provided a test with pictures of the appropriate smoking area and receptacle to a total of 74 of 124 employees. Education was provided by the shift supervisors. Staff who had not received education would be educated by the Director of Nursing.
10 NYCRR 415.12(h)(1)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview during the recertification and extended surveys conducted 7/13/21-7/21/21, the facility did not ensure residents had the right to be free from physica...
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Based on observation, record review and interview during the recertification and extended surveys conducted 7/13/21-7/21/21, the facility did not ensure residents had the right to be free from physical restraints not required to treat the resident's medical symptoms for 1 of 2 residents (Resident #61) reviewed. Specifically, Resident #61 had a wheelchair seat belt in place without a physician order, a restraint assessment, parameters for use of the seat belt including frequency of releasing the restraint, and ongoing re-evaluation of the need for the restraint.
Findings include:
The facility policy Restraints procedure for application and removal revised 11/2016 documented:
Physical restraints will not be used for staff convenience or for the purposes of discipline or as a substitute for direct care, activities, and other services. Restraints are applied after a physician's order is obtained, will be the least restrictive for the least amount of time. Restraints will be released, and the resident will be repositioned every 2 hours, as needed, and during mealtimes. Restraints may be applied without a physician order by a registered nurse (RN) after consultation with the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). The physician must be notified as soon as possible of the restraint application.
Resident #61 was admitted to the facility with diagnoses including Schizoaffective disorder, reduced mobility, and generalized muscle weakness. The 6/20/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance for activities of daily living (ADLs), and did not use a restraint.
The comprehensive care plan (CCP) revised 4/13/21 documented the resident had a noted decline in ambulation, was to be out of bed to a tilt and space wheelchair and used a Dycem seat (non-slip pad) while in wheelchair. The resident had no recent falls since 9/1/2020. There was no documentation the resident used a seat belt in their wheelchair.
The 5/18/21 certified nurse aide (CNA) assignment summary (care instructions) documented the resident used a wheelchair and did not have any restraints.
The resident was observed on 7/13/21 at 10:09 AM and 11:31 AM sitting in a tilt and space wheelchair with a black strap around their upper body (above their stomach and below their chest). The black strap went behind the wheelchair back and was wrapped around the right handle of the wheelchair. At 11:47 AM the resident was observed in the dining room, at a table being assisted by licensed practical nurse (LPN) #21. The resident had a black strap around their upper body (above their stomach and below their chest). The black strap went behind the wheelchair back and was wrapped around the right handle of the wheelchair.
There was no documented evidence of a physician order for the use of a seat belt or a restraint assessment for the seat belt.
The resident was observed in their wheelchair with the black belt attached to the wheelchair without the strap around their body on 7/14/21 at 08:22 AM; on 7/15/21 at 8:51 AM; on 7/16/21 at 9:08 AM; on 7/17/21 at 8:17 AM; and on 7/19/21 at 8:42 AM.
During an interview with LPN #21 on 7/20/21 at 9:23 AM, they stated there were no physical or chemical restraints used on this unit. Resident #61 used a tilt and space wheelchair and the LPN did not think it had a seat belt on it. When LPN observed Resident #61's wheel chair, the LPN stated the black belt was a seat belt, it would be considered a restraint, and the resident would not be able to physically remove the seat belt. They had never observed the seat belt in use and did not recall the resident having the seat belt on during the lunch meal on 7/13/21. LPN #21 stated the resident would need a physician order for a seat belt and the resident did not have an order for a seat belt.
During an interview with CNA #24 on 7/20/21 at 9:28 AM, they stated staff was not allowed to use a seat belt on Resident #61 and they had never observed it in use.
During a telephone interview with LPN Unit Manager #27 on 7/20/21 at 11:10 AM, they stated Resident #61 had a Velcro seat belt on their wheel chair. They had never observed the seat belt on. The seat belt needed to have an order from the physician and should be care planned for parameters of use if it was being used. If the seat belt did not have a physician order and was not care planned, then it should not be used.
During an interview with the Resident #61's attending physician on 7/20/21 at 12:43 PM, they stated they have never observed a seat belt on the resident's wheelchair and the resident would be unable to remove the seat belt if it went behind the back of their wheelchair. The resident had no medical orders for a seat belt and staff should not be using a seat belt unless there were medical orders and parameters for use.
During an interview with occupational therapist (OT) #28 on 7/20/21 at 2:16 PM, they stated they were not aware of any residents in the facility who required the use of seat belts. They had heard other therapists discussing a seat belt, but could not recall which therapist, when this discussion took place, or which resident was being discussed. They stated if therapy was trialing a seat belt it should be care planned for and the resident would need to be assessed to see if they could release the seat belt, otherwise it would be considered a restraint and a medical order would be needed.
During an interview with LPN #13 on 7/20/21 at 2:49 PM, they stated they were in charge of the nursing portions of the care plans throughout the facility. They had not updated Resident #61's care plans since 4/13/21. If a resident required a seat belt it would be considered a restraint if the resident was unable to release it. There should also be parameters for releasing the seat belt. They stated therapy would need to notify the nursing staff if they were trialing a seat belt or if the resident required a seat belt. The therapy department would add the seat belt to the resident's care plan.
During an interview with the Director of Nursing (DON) on 7/20/21 at 4:18 PM, they stated they had never observed the seat belt in use with Resident #61, and it should be listed on the care plan if therapy was trialing the resident with a seat belt. The resident would also need a medical order for use of the seat belt.
10 NYCRR 415.4(a)(2-6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure the development an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 5 residents (Resident #61) reviewed. Specifically, Resident #61's comprehensive care plan (CCP) did not reflect the use of anticoagulation (blood thinner) and include interventions to ensure the resident received appropriate monitoring.
Findings include:
The facility's Interdisciplinary Care Planning Policy, revised 1/18/21, documented a comprehensive resident-centered care plan plan (CCP) is initiated by the interdisciplinary team (IDT) upon admission and is reviewed and updated on a regular basis throughout the resident's stay. The CCP is reviewed with changes and at least on a quarterly basis. CCP focuses are addressed for every resident, as appropriate and include cardiac, circulatory, and anticoagulation therapy if indicated. The CCP and [NAME], certified nursing assistant (CNA) care guides, must always be current and accurately reflect the resident's status.
Resident #61 had diagnoses including unsteadiness on feet and history of DVT (deep vein thrombosis, a blood clot). The 6/20/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance with most activities of daily living (ADLs) and received an anticoagulant 7 of 7 days.
Physician orders dated 5/28/21 documented Eliquis (anticoagulant) 2.5 milligram (mg) twice daily for DVT.
A 6/1/21 physician progress note documented the resident had increasing edema of the left lower extremity over the weekend. A venous Doppler (ultrasound) was done and the results were positive for a DVT. The plan was to start either an ACE (elastic) wrap or TED stockings to help with the edema. The resident was started on Eliquis 2.5 mg twice a day.
Physician orders dated 6/20/21 documented TED hose stockings (anti-embolism, compression) to be worn on BLE (bilateral lower extremities) for DVT prophylaxis, remove every evening shift.
The Resident's Daily Care Guide (care instructions) did not include the use of TED stockings.
The comprehensive care plan (CCP) revised on 4/13/21 documented the resident was at risk for falls related to cognition and decreased mobility; and readmitted from the hospital with a diagnosis of upper GI (gastrointestinal) bleed. The CCP was not revised to include a history of DVT and use of anticoagulation or TED stockings.
During an interview with licensed practical nurse (LPN) Unit Manager #27 on 7/20/21 at 11:10 AM, they stated they had not been doing the resident care plans lately because they had other duties. The LPN Unit Manager on C wing had been completing care plans. LPN Unit Manager #27 stated the CCP has a medical diagnosis plan and everything goes on there. Anticoagulant medication would be included in the care plan as it was important for staff to know how to care for the residents. Staff should be observing Resident #61 for signs of bruising and bleeding.
During an interview with LPN #13 on 7/20/21 at 2:49 PM, they stated anticoagulant should be included on Resident #61's CCP so staff can monitor for adverse effects. The LPN stated they had not updated Resident #61's care plan since 4/13/21.
During an interview with the Director of Nursing (DON) on 7/20/21 at 4:18 PM, they stated that the main care areas and the interventions each triggers, such as bathing, anticoagulation, advance directives, pulmonary status, transfers, bowel and bladder, smoking and nutrition should all be included in the CCP. The DON and LPN #13 were responsible for updating care plans. The DON stated they tried to review LPN #13's care plans as a part of RN oversight, and to audit them. Changes to care plans should be done within 24-48 hours of the change in care for the resident.
10NYCRR 415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview during the recertification and extended survey conducted from 7/13/21-7/21/21, the facility did not ensure a resident with an indwelling catheter rece...
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Based on observation, record review and interview during the recertification and extended survey conducted from 7/13/21-7/21/21, the facility did not ensure a resident with an indwelling catheter received the necessary services and treatment for catheter use for 1 of 4 (Resident #38) residents reviewed. Specifically, Resident #38 did not have physician orders in place for an indwelling urinary catheter (tube to drain urine).
Findings include:
The facility policy Catheter (Urinary and Suprapubic) Insertion and Removal dated 1/1/2000 documented catheters are utilized when necessary, based upon current professional standards of practice. Insertion of a catheter must have a physician order including catheter and balloon size. Inserted catheters are maintained by a licensed nurse following physician orders and changed every six weeks and as needed. A physician order is obtained for straight catheterization.
Resident #38 had diagnoses including dementia, urinary retention, and benign prostatic hyperplasia (BPH, enlarged prostate). The 5/23/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 1-2 with most activities of daily living (ADLs) and had an indwelling catheter.
The 5/17/21 hospital discharge summary documented a urinary catheter was placed in the hospital due to BPH and possibly the nursing home could do a voiding trial.
The 5/18/21 physician progress note documented the resident had BPH, urinary obstruction and had an indwelling Foley catheter.
There was no documented evidence the resident had a physician order for an indwelling urinary catheter.
The 5/19/21 comprehensive care plan (CCP) documented the resident had a urinary catheter related to obstructive uropathy and urinary retention. Interventions included an 18 French (Fr- size) with a 10 milliliter (ml) balloon, urinary catheter care every shift, change urinary bag weekly on shower day, follow physician orders for catheter irrigation, leg bag worn during daytime hours, and urology consult as ordered.
Nursing progress notes on 5/23/21 documented the following:
- at 11:11 AM there was no output in the Foley (type of catheter) catheter and it was changed after irrigation with no return. The resident pulled the Foley catheter out and an order to monitor output with urology consult was obtained. - at 1:32 PM the resident left for the hospital with their family.
- at 6:55 PM the resident returned from the hospital with the Foley catheter intact and hematuria (bloody urine) continued. A new order for an antibiotic was obtained and the physician was made aware.
The 5/23/21 physician order documented urology consult for hematuria (bloody urine). There was no order for a urinary catheter.
The 5/27/21 at 6:34 AM nursing progress note documented the Foley catheter was flushed with no return. The 16 Fr catheter was removed, and a new 16 Fr catheter was inserted.
The 5/30/21 at 4:01 PM nursing progress note documented the resident pulled the Foley catheter out this AM and it was not reinserted. The 4:12 PM note documented a new order was obtained to leave the catheter out.
The 5/2021 treatment administration record (TAR) documented the resident had a Foley catheter with care and a leg drainage bag from 5/18-5/31/21.
The 6/2/21 physician order documented to discontinue all Foley catheter orders.
Nursing progress notes documented:
- on 6/4/21 at 10:45 PM the resident had not voided, an order was obtained for straight catheterization, and 1000 ml was obtained from the catheterization.
- on 6/5/21 at 2:52 PM the resident had not voided as of 2:00 PM. A new Foley was inserted, and staff would monitor.
- on 6/6/21 at 8:12 PM the Foley catheter was pulled out by the resident and a new order was obtained to reinsert if the resident had not voided for 1 shift.
- on 6/7/21 at 00:17 AM a 16 Fr Foley catheter with a 10 ml balloon was inserted.
- on 6/14/21 at 10:28 PM and 10:41 PM the resident had a bulge in their penis due to the Foley catheter balloon, the catheter was removed, the physician was made aware and an order was obtained to remove for the night.
- on 6/17/21 at 6:34 PM the resident returned from urology at 5:00 PM. Family stated a new catheter was placed at urology, the physician was made aware, and there were no new orders.
The 6/17/21 urology consult documented the resident recently had left hip surgery, retained urine, and a catheter was inserted in the hospital. The catheter was removed after discharge, did not have a catheter in when he arrived for this consult, and a 16 Fr Foley catheter was reinserted at the consult. The catheter needed to be changed every 4-5 weeks on a regular basis and it was important the resident did not pull the catheter out again as pulling it out caused significant bleeding and additional damage.
The 6/18/21 at 2:13 AM, 6/21/21 at 2:13 AM, 6/24/21 at 1:46 AM, 6/25/21 at 2:33 AM, and 6/27/21 at 6:58 PM nursing progress notes documented the Foley catheter remained in place with no concerns.
The 6/2021 TAR documented the resident did not have a Foley catheter, care instructions or a leg drainage bag from 6/2/21-6/30/21 as they were discontinued. The 6/6/21 physician order to reinsert Foley if the resident had not voided for 1 shift was unsigned.
On 7/13/21 at 10:41 PM, the resident was observed dressed and groomed with no catheter drainage bag observed.
Physician orders with an order date of 7/15/21 documented Foley catheter 18 Fr with 10 ml balloon change day shift every 42 days; irrigate Foley with Acetic acid 0.25% 30 ml as needled to maintain patency; Foley catheter care every shift; use leg bag for Foley catheter only as resident pulls Foley out if having a regular drainage bag on; and change urinary leg drainage bag every Thursday on bath day.
When interviewed on 7/15/21 at 9:26 AM, licensed practical nurse (LPN) #14 stated she thought the resident had orders for a Foley catheter. The LPN reviewed the medical records and stated the resident did not have Foley catheter orders but did have a Foley catheter. The LPN stated any nurse could enter the physician orders in the resident's char but usually it was a supervisor or unit manager. The LPN stated the order set included the size of the Foley, the amount of saline in the balloon, how often it needed to be changed, the type of drainage bag and the care for the catheter and drainage bag.
When interviewed on 7/15/21 at 11:14 AM, LPN #13 stated the resident should have an order set for a Foley catheter. The LPN stated the resident had orders when transferred from another unit due to bladder retention. The LPN stated any nurse could enter the orders into the medical record. The LPN stated they were aware of the catheter being discontinued on 6/2/21. The resident went to a urology consult, came back with a catheter reinserted and the LPN did not know why new orders were not obtained and entered in the medical record. At 2:43 PM, the LPN stated the nurse reading the urology consult should have ensured the resident had new orders. The LPN stated physician orders were reviewed every 60 days and there was no consistency as to who was responsible to do so.
When interviewed on 7/20/21 at 12:45 PM, the physician stated the resident should have had an order set for the Foley catheter prior to 7/15/21 and did not know why the resident did not. The physician stated the nurse should check for orders prior to putting a catheter in and when a resident returned from a consult.
10NYCRR 415.12(d)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview during the recertification and extended survey conducted from 7/13-7/21/21, the facility did ensure the drug regimen of each resident was reviewed at least once a ...
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Based on record review and interview during the recertification and extended survey conducted from 7/13-7/21/21, the facility did ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 1 of 5 residents (Resident #83) reviewed. Specifically, there was no documented evidence Resident #83's medication regime review was performed monthly by a licensed pharmacist.
Findings include:
The 1/1/2000 Unnecessary Medications Medication Regimen Review policy documented the consultant pharmacist conducts a medical record review and assesses the drug therapy of each resident monthly. The medication regime helps to promote the resident's highest practical mental, physical, and psychosocial well-being; each resident receives only those medications, in doses and for the duration clinically indicated to treat the assessed condition; and clinically significant adverse consequences are minimized. The pharmacy consultant reports irregularities to the attending physician, facility medical director, and Director of Nursing (DON). A copy of the Medication Regime Review Form with recommendations will be faxed to the facility for review and follow up.
Resident #83 had diagnoses including Alzheimer's dementia with behaviors, depression, and high blood pressure. The 7/1/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, received an antipsychotic, antidepressant, antianxiety medication daily and no gradual dose reduction (GDR) was attempted.
There was no documented evidence the resident's medication regime was reviewed by a licensed pharmacist monthly from 3/19/21 through 6/3/21 when the resident was discharged to the hospital.
The 7/18/21 pharmacy review note documented the medication regimen was reviewed, recommendations were made, and to see the Medication Regimen Review Report. This was the only pharmacy medication regimen review in Resident #83's medical record.
When interviewed on 7/20/21 at 10:55 AM, licensed practical nurse (LPN) #13 stated pharmacy was to do monthly medication reviews on each resident. The LPN stated the only Resident #83 medication regimen review in the chart was for 7/18/21.
When interviewed on 7/20/21 at 12:00 PM, DON #4 stated medication monthly reviews were done every 30/60/90 days by an offsite pharmacist who reviews the medications. Those reviews, as well as recommendations, should be documented monthly in the resident's progress notes and medical record. Any pharmacy recommendations were handed to the unit managers to give to the physician. There were no monthly medication regimen review audits being performed by the facility.
When interviewed on 7/20/21 at 1:29 PM, pharmacy consultant #15 stated medication reviews were to be done monthly but the consultant could not find documentation that Resident #83's reviews were done. There was no documentation review from admission until the 7/18/21 note. The pharmacist would review progress notes, medications received, how the medication was administered, consults, and laboratory results. The consultant did not know why the reviews were not documented in the record.
When interviewed on 7/20/21 at 1:03 PM, the physician stated pharmacy consultant #15 did each residents' monthly medication review and documented in signature notes the review was done. The physician stated Resident #83 should have the reviews completed and documented.
10NYCRR 415.18(c)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/21, the facility did not make available clinical records on each resident...
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Based on observation, record review and interview during the recertification and extended surveys conducted from 7/13/21- 7/21/21, the facility did not make available clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for all 95 residents of the facility. Specifically, upon survey entrance, resident-identifiable information including form CMS-802, Matrix for Providers, and an alphabetical listing of all residents was not provided to the Department of Health (DOH) in a timely manner. Additional information needed from the facility within one hour, four hours and 24 hours of entrance was not provided in a timely manner.
Findings include:
The Centers for Medicare and Medicaid Services (CMS) survey form Entrance Conference Worksheet documents:
- The complete matrix for new admissions in the last 30 days who were still residing in the facility and an alphabetical list of all residents be provided to surveyors immediately upon survey entrance.
- Schedule of mealtimes, schedule of medication administration, number and location of medication cart and storage rooms, actual working schedules for all staff, list of key personnel were to be provided in 1 hour
- The complete matrix for all other residents, admission packet, dialysis contract, infection prevention and control program standards policies and procedures, influenza and pneumonia immunization policy, QA (Quality Assurance) committee information and QAPI plan, facility assessment be provided to surveyors within 4 hours of survey entrance.
- Completed Medicare/Medicaid application (CMS-671) Completed Census and Condition information (CMS-672) to be provided to surveyors within 24 hours of entrance.
The DOH survey team entered the facility on 7/13/21 at 9:30 AM. The Team Coordinator (TC) met with the Facility Administrator at 10:00 AM to review the documents required for survey as outlined on the entrance conference worksheet. This included the time frame for providing CMS-802, and the alphabetical list of all residents. The administrator was unable to provide the completed matrix for new admissions in the last 30 days and the alphabetical list of all residents.
On 7/13/19 at 12:24 PM, the administrator asked for clarification about the CMS-802 and the complete matrix for all other residents. The administrator was provided a blank Matrix form and the instructions for completion.
On 7/13/21 at 1:22 PM, the administrator stated they were just starting to send all requested documents via secure file transfer and provided the team Coordinator (TC) with a hard copy of the current CMS-802. There was no separate CMS-802 for new admissions. The matrix was not completed accurately as requested.
When interviewed at 7/13/21 at 1:32 PM the Administrator stated they were going to have the Director of Nursing (DON) gather information and update the Matrix.
-On 7/13/21 at 1:58 PM, (4 1/2 hours after survey entrance) the administrator sent the new admission matrix via secure file transfer.
-On 7/13/21 at 1:59 PM, (4 1/2 hours after survey entrance) the administrator sent the information required from the facility within one hour of entrance via secure file transfer.
-On 7/13/21 at 2:12 PM, the revised Matrix was received via secure file transfer.
-On 7/14/21 at 11:32 AM (26 hours after survey entrance) the Administrator sent the disclosure of ownership (due within 24 hours of entrance).
-On 7/14/21 at 3:26 PM, the Administrator sent the alphabetical list of residents (due upon entrance to facility), list of medical providers, and census and condition (form CMS -672) both due within 24 hours of entrance.
-On 7/19/21 at 5:00 PM, the TC provided the Administrator a list of resident record/documents requested to be sent via secure file transfer to the electronic address listed on the request sheet.
-On 7/20/21 at 11:15 AM, the Administrator had not sent the requested resident records from 7/19/21.
-On 7/20/21 at 12:40 PM, the TC notified the Administrator that the documents requested on 7/19/21 should be provided to the survey team by 2:00 PM.
-On 7/20/21 at 3:30 PM surveyors still had not received the requested resident records.
-On 7/20/21 at 5:02 PM, the administrator sent an electronic mail documenting all [green] sheets are uploaded.
10 NYCRR 483.70(i)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on interview and record review during the recertification survey conducted from 7/13/2021 to 7/21/2021, the facility did not ensure that residents maintained acceptable parameters of nutritional...
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Based on interview and record review during the recertification survey conducted from 7/13/2021 to 7/21/2021, the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible for 4 of 5 residents (Residents #2, 17, 78, and 80) reviewed. Specifically, Residents #2, 17, 78, and 80 had significant weight loss and were not reassessed timely by clinical nutrition staff and there was no documented evidence the medical provider was made aware of the weight loss.
Findings include:
The facility Nutritional- Screen/Assessment policy, last revised 5/2017, documented the dietetic technician and dietitian are responsible for the nutritional screening, assessment, setting of measurable goals and implementing the nutritional plan of care to obtain the resident's optimal nutritional status. A nutritional plan of care is established and implemented as part of the interdisciplinary care plan. The resident is continually assessed, and findings are documented in the dietary progress notes and nutritional care plan.
The facility Weight Monitoring policy revised 5/2013 documented a weight record is used to facilitate monitoring of changes in weight on a weekly or monthly basis. Admission/re-admission weights are obtained weekly for the first four weeks, then monthly thereafter unless more frequent monitoring is indicated by the resident's condition. Weights will be obtained as soon as possible, but no later than 72 hours after admission. Weights will be recorded on the weight record sheet. Weight changes of 5 pounds (gains or loss) require a re-weight. A licensed nurse monitors the weight sheets and significant changes are reported to dietary and physician as needed. Significant change is indicated by a gain or loss of 5% in one month or less; 7.5 % in 3 months; or 10% change over a 6-month period. Dietary records the weight in the Electronic Medical Record (EMR).
The facility Weight Loss- significant policy revised 7/2008 documented the standard is to investigate and respond to a significant change is indicated by a gain or loss of 5% in 30 days or less; 7.5 % in 90 days; or 10% change over 180 days. If a resident has a weight loss of 5 pounds or more, they are automatically rescheduled for a re-weight by the Unit Coordinator. If the re-weight confirms the decrease, the unit coordinator notifies dietary. The dietitian /diet technician reviews the weight decrease to determine if it is significant. If the weight decrease is significant, appropriate staff is notified and resident is scheduled for short-term care plan review.
1) Resident #78 had diagnoses including anxiety, chronic obstructive pulmonary decide (COPD) and dysphagia (trouble swallowing). The 6/30/21 Minimum Data Set (MDS) Assessment documented the resident had moderately impaired cognition, complained of difficulty or pain with swallowing, required set-up and supervision at meals, weighed 90 pounds (lbs), had a significant weight loss, was not on physician-prescribed weight-loss regimen, and received a mechanically altered diet.
A physician order dated 2/23/21 documented the resident was to receive a house diet, puree texture and regular liquid consistency.
The comprehensive care plan (CCP) initiated on 8/30/19 documented the resident was at risk for alteration in nutrition related to advanced COPD with anxiety, a history of malnutrition, being below their ideal body weight, and the resident tended to be a finicky eater. Interventions included a pureed diet recommended by the SLP (speech language pathologist) and 8 ounces (oz) Ensure Clear (nutritional supplement) twice daily. On 4/16/21 interventions were revised to include Hi Cal (nutrition supplement) 60 milliliters (ml) once daily. On 4/30/21 the resident's appetite stimulant (Remeron) was increased from 22.5 milligrams (mg) to 30 mg daily.
The certified nurse aide (CNA) care guide documented the resident received a pureed consistency regular liquids house diet with no straws and staff were to promote consumption of a well-balanced diet.
The resident's weight recorded documented the resident's weights as follows:
- 1/7/21 114.8 pounds (lbs);
- 1/13/21 113.8 lbs (1 lbs loss) since 1/7/21;
- 2/23/21 110 lbs (3.3% loss or 3.8 lbs loss) since 1/13/21;
- 2/25/21 100.7 lbs (11.5% loss or 13.1 lbs) since 1/13/21;
- 3/5/21 99.7 lbs (1 lbs loss) since 2/25/21;
- 3/17/21 99.6 lbs;
- 4/21/21 96.2 lbs (16.2% loss or 18.6 lbs loss) since 1/7/21;
- 5/21/21 90.6 lbs (22.8% loss or 26.8 lbs) since 1/7/21, (17.6% loss or 19.4 lbs) since 2/23/21, and (5.8% loss or 5.6 lbs) since 4/21/21;
- 6/16/21 89.6 lbs (10% loss or 10 lbs) since 3/17/21;
- 7/1/21 89.2 lbs (22.3% loss or 25.6 lbs) since 1/7/21 and (7.8% loss or 7 lbs) since 4/21/21.
A Dietary Nutritional Screen completed by registered dietitian (RD) #25 on 3/8/21 documented the resident had an unintentional weight loss of 12% in 2 months. The plan was to trial HiCal (nutritional supplement) with med passes and to begin fortification of pureed foods to increase protein and calories. The goal was to cease weight loss and gain 1-2 pounds over the next 30 days.
A physician progress note dated 4/27/21 documented the resident continued with difficulty swallowing, said they could not eat and had a dry mouth. There was no documented evidence the physician was made aware of the significant weight loss.
The attending physician's progress note dated 5/25/21 documented the resident was seen for a routine visit and the resident looked better than the last visit. Intakes remained poor, but perhaps were a little better than before. The increase in the resident's alprazolam (Xanax, anti-anxiety) had seemed to help with the resident's anxiety. There was no documentation of the resident's significant weight loss.
A Dietary Nutritional Screen completed by RD #25 on 6/17/21 documented the resident's weight was 89.6 pounds. A significant weight loss was noted, and the RD met with the resident on 6/16/21 to discuss the resident's state of malnutrition. The resident had refused the HiCal supplement. The goal was for the resident to restore weight back to greater than 100 pounds over the next 3 months.
There was no documented evidence the RD reassessed Resident #78's nutritional status between 3/8/21 and 6/17/21 when the resident sustained a significant 10% weight loss.
During an interview with the attending physician on 7/20/21 at 12:54 PM they stated the resident had weight loss and was down to 89 lbs. They stated they may not have addressed the weight loss in their medical note, but they were aware the resident had a significant weight loss.
During an interview on 7/20/21 at 11:11 AM, RD #25 stated resident weights drive their nutrition assessments. A significant weight change was considered a gain or loss of 5% at 1 month, 7.5% at 3 months, and 10% at 6 months. They stated Resident #78 had a recorded weight of 90.6 lbs on 5/21/21.This was a significant weight loss. The RD stated they were aware of the significant weight loss and did not reassess the resident's nutritional needs or complete a nutrition assessment at the time of the significant weight loss.
2) Resident #80 had diagnoses including diabetes, vitamin D deficiency and cellulitis of bilateral lower limbs with venous stasis ulcers (ulcers from poor circulation). The 7/3/21 Minimum Data Set (MDS) Assessment documented the resident had severe cognitive impairment, required supervision after set-up for eating, was on a therapeutic diet, had 2 unstageable pressure ulcers, weighed 170 pounds, and had no weight loss or weight gain.
The 6/16/21 comprehensive care plan (CCP) documented the resident was at risk for alteration in nutrition related to diabetes mellitus type 2, low albumin (a blood protein) and poor oral intakes. Diet order was no added salt, regular texture foods and thin liquids. Goals included weight would be stable at 170 pound (lbs) plus or minus 3% and the resident would consume >50% of most meals through next quarter. Interventions included to monitor labs and weight as needed.
A 6/17/21 dietary progress noted documented the resident's admission weight had not been obtained and the resident was not sure of their weight.
The Dietary Nutritional Screen dated 6/27/21 and completed by registered dietitian (RD) #25, documented the resident's weight history and usual body weight was unknown. Current weight was 170.4 pounds and was the weight from the 6/7/21 hospitalization. The summary documented intakes had been poor since admission, poor meal acceptance as evidenced by intakes documented at <50% for meals with frequent refusals. The plan was to start a food fortification/supplementation program and offer Glucerna (nutritional supplement) shakes, fortified milk, and cooked cereal and to monitor intakes and weights, with a goal to prevent significant weight loss.
A 7/4/21 malnutrition risk tool documented weight status was unknown, and the resident ate 25%-50% of most meals and the resident was determined to be at high risk for malnutrition.
The resident's meal consumption records from 6/16/21-7/19/21 documented most meal intakes were between 0-25% or the resident refused meals.
Nursing progress notes documented the resident had a poor appetite on 7/16/21, 7/17/21, 7/18/21 and 7/19/21.
A 7/19/21 attending physician progress note documented nursing notes, labs and orders were reviewed. Continue current plan related to vitamin D deficiency, hypokalemia, edema, and unstageable pressure ulcers to the buttocks and venous stasis ulcers to the lower extremities. The resident's poor intake or lack of weights since admission were not addressed.
On 7/19/21 there was no documentation the resident had been weighed since admission the previous month.
An RD #25 progress note dated 7/20/21 at 2:19 PM documented they were notified by the Assistant Director of Nursing (ADON) that the resident had a significant weight change. On admission from the hospital the resident weighed 170 pounds. On 7/20/21 the resident's weight was 124 pounds (46 pound or 27% weight loss since admission). The resident would be reassessed based on the weight of 124 pounds. Some weight loss may have been related to fluid shift/loss. The resident's intake was poor.
During an interview on 7/20/21 at 10:25 AM, licensed practical nurse (LPN) #21 stated resident weights were kept in a binder at the nursing station. The LPN reviewed the binder and the electronic health record and stated the only weight they could locate for Resident #80 was 170.4 and was in a progress note dated 6/27/21 and the weight was from the hospital. The LPN stated weights should be taken on admission and they were not aware the resident had not been weighed since admission.
During an interview on 7/20/21 at 12:40 PM, the attending physician stated all residents should have their weight taken upon admission. Resident #80's hospital weight should not have been used and the resident should have been weighed on admission. The physician stated if a resident's weight was not brought to their attention, they could not address it.
During an interview on 7/20/21 at 1:10 PM RD #25 stated resident weights were supposed to be taken upon admission. Sometimes when they requested a weight it could take up to a week to get the weight. They used the hospital weight for Resident #80 because there were no other weights. The RD stated they had been asking for weights on Resident #80, but they still had not gotten them. RD # 25 stated Resident #80 was somewhat overweight on admission and very malnourished. They ordered supplements and nourishments for the resident based on the information they had.
3) Resident #2 had diagnoses including cerebral infarction (stroke) with hemiplegia and hemiparesis (paralysis) affecting left non-dominant hand. The 5/27/21 Minimum Data Set (MDS) Assessment documented the resident had severe cognitive impairment, required extensive assistance with activities of daily living (ADLs), received nothing by mouth (NPO) and received a continuous tube feeding (nutrition delivered through tube in stomach).
The 5/21/21 comprehensive care plan (CCP) documented the resident was at risk for alteration in nutrition related to cerebral vascular accident (CVA) with dysphagia (difficulty swallowing), abnormal labs, anemia, and history of percutaneous endoscopic gastrostomy (PEG, feeding tube) tube.
The physician order dated 5/25/21 documented Glucerna (tube feeding formula) 1.2 cal give 65 cc (cubic centimeters) via PEG-tube every shift for diet total amount in to be 1560/24 hours.
There was no documented evidence of a registered dietitian (RD) progress note including an assessment of nutritional needs and the adequacy of the tube feeding volume to meet the resident's needs.
The resident's weights were documented as 227.7 pounds (lbs) on 5/25/21 and 214 pounds on 6/15/21 (significant 6% loss in 3 weeks).
There were no documented dietary or nursing notes addressing the weight loss from 5/25/21-6/15/21 or interventions put in place to prevent or monitor weight loss. There was no documented evidence the physician was notified of the weight loss or the RD reassessed the resident's nutritional status.
During an interview on 7/20/21 at 12:43 PM, the attending physician stated Resident #2 was known to have fluctuations in weight due to edema and was aware of the weight fluctuation. The physician stated when a resident had a significant weight loss, they expected to be notified so interventions could be put into place.
During an interview on 7/20/21 at 1:34 PM, the RD stated they were not aware the resident had a weight loss between 5/25/21 and 6/15/21. They stated that there was no process in place for the RD to be notified by nursing when a resident was weighed and if there was a weight loss. The RD stated if they were not made aware the resident had a weight loss during this time frame, they would not be able to add any interventions.
10 NYCRR 415.12(i)1
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review during the recertification and extended survey conducted from 7/13/21-7/21/21 the facility did not maintain an infection prevention and control progra...
Read full inspector narrative →
Based on observation, interview and record review during the recertification and extended survey conducted from 7/13/21-7/21/21 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and to help prevent the development and transmission of COVID-19 for 2 of 8 residents (Residents #21 and 80) and 8 facility staff. Specifically, Resident #80's urinary catheter drainage bag was observed resting on the floor. Staff providing care for Resident #21, who was on transmission based precautions, was observed not performing hand hygiene or wearing their face mask appropriately. Staff were observed wearing face masks below their nose or not wearing the required face masks.
Findings include:
The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/20, documented all healthcare personnel (HCP) and other facility staff shall wear a facemask while within 6 feet of residents. Extended wear of facemasks is allowed; facemasks should be changed when soiled or wet and when HCP go on breaks.
The 4/2/20 New York State Department of Health (NYS DOH) Health Advisory: Options when Personal Protective Equipment (PPE) is in Short Supply or Not Available documented: Use of cloth masks or other homemade masks such as bandanas or scarves for health care providers (HCP) is not recommended. If used, they should be used with a face shield. The Health Advisory further documented: Homemade equipment should not be considered PPE, and the efficacy or possible harm of using such equipment is unknown.
The Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 2/23/2021, recommended the following additional strategies to minimize chances for exposure to COVID-19: Hand Hygiene: HCP [healthcare personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
The facility Coronavirus (COVID-19 policy revised 7/9/21 documented the following:
- a surgical mask will be worn by all staff, students, contractors, and visitors. Extended wear of facemasks is permitted. Face masks should be changed when soiled or wet and when staff members go on breaks.
- In-house salon services: the beautician must wear a face mask and face shield at all times.
- Facility staff performing health checks must wear facemask.
- Implement extended use of face masks .change only when soiled, wet or damaged and per facility policy.
- Use of cloth mask or other homemade masks (i.e., bandanas or scarves) for health care providers is not recommended. If they are used, they should be used with a face shield. It is unknown whether cloth masks provide effective source control for infectious residents.
The facility Infection Control policy dated 9/2018 documented when a resident is on contact precautions, there should be a sign on the door contact precautions, wear gloves when entering the room, wash hands with antimicrobial soap after removing gloves and when leaving the resident room.
The facility policy on Hand Washing dated 5/2021 documented proper hand washing technique was used for the prevention of transmission of infectious diseases. Alcohol based hand rub is preferred over soap and water in all clinical situation except when hands are visibly soiled or after caring for resident with known or suspected C-difficile or norovirus during an outbreak. Hand hygiene is required is the following situations but is not limited to: before and after direct resident contact, and before and after entering isolation precautions setting.
The Catheter Drainage Bag Care policy, revised 5/2013, includes:
- Caution should be taken not to allow the end of the spout (of the drainage bag) to touch anything that will contaminate it.
- Catheter and tubing must remain patent with the drainage bag kept below the level of the bladder to maintain unobstructed urine flow and prevent pooling and backflow of urine into the bladder. Care should be taken to make sure the tubing does not touch or drag on the floor.
Urinary Catheters
Resident #80 had diagnoses including urinary retention and diabetes. The 7/3/21 Minimum Data Set (MDS) Assessment documented the resident had severe cognitive impairment, required extensive assistance for most activities of daily living (ADLs) and had an indwelling urinary catheter.
The 6/16/21 comprehensive care plan (CCP) documented the resident had a urinary catheter due to urinary retention. Interventions included catheter care every shift and to change drainage bag weekly.
The resident's urinary catheter tubing and drainage bag was observed resting directly on the floor next to the bed:
- On 7/13/21 at 10:29 AM;
- On 7/15/21 at 8:20 AM; and
- On 7/16/21 at 10:03 AM.
During an interview on 7/19/21 at 2:19 PM, certified nurse aide (CNA) #24 stated urinary catheter bags should not be touching the floor because it was not clean and could pick up germs. The urine would not be able to properly flow into the drainage bag.
During an interview on 7/20/21 at 9:46 AM, CNA #18 stated the catheter bag should be hung on the bed frame and the bag should not be touching the floor so that it does not get stepped on.
During an interview on 07/19/21 at 4:36 PM, CNA #3 stated that a catheter collection bag should never be on the floor because the floor is dirty and can spread germs.
During an interview on 07/20/21 at 9:56 AM, licensed practical nurse (LPN) #22 stated the expectation was catheters should be off the floor to prevent contamination and leakage that could occur.
During an interview on 7/20/21 at 9:50 AM the Director of Nursing (DON) stated a urinary catheter should be placed hanging on the side of the bed. The drainage bag should never be placed on the floor because of the potential for infection or it could become dislodged.
Hand Hygiene
Resident #21 was placed on transmission based precautions Clostridium difficile (a contagious bacteria found in stool) on 7/15/21.
The following observation of CNA #18 was made on 07/19/21 at 11:13 AM:
CNA #18 was observed on 7/19/21 at 11:13 am. The CNA exited Resident #21's room and removed personal protective equipment (PPE) and re-entered Resident #21's room and wheeled Resident #21 to the nursing station. The CNA did not wash their hands with soap and water or use alcohol-based hand rub after removing PPE or transporting Resident #21 to the nursing station. The CNA then left Resident #21 at the nursing station, entered Resident #24's room and helping Resident #24 with their oxygen tubing. The CNA did not perform hand hygiene prior to entering Resident #24's room. CNA #18 then exited the room, retrieved an oxygen tank, re-entered Resident #24's room, and brought the resident to the nursing station for an activity. CNA #18 entered Resident #34's room without preforming hand hygiene. CNA #18's mask was below their nose. CNA used a stand lift to assist Resident #34 into their wheelchair.
During an interview on 7/19/21 at 11:26 AM, CNA #18 stated Resident #21 was on precautions, they thought it was for MRSA (Methicillin-resistant Staphylococcus aureus, a bacteria). The CNA stated that they were not sure of the difference between MRSA and C-difficile but thought they should gown up and wear gloves. CNA #18 stated that they had received an infection control in-service. For precautions they should wear PPE, doff PPE, and wash their hands and that hand sanitizer should always be used between residents. CNA #18 stated that when they brought Resident #21 to the nursing desk, they did not wash their hands but used hand sanitizer prior to entering the other residents' room. CNA #18 stated that could not remember if they completed hand hygiene in between each resident.
During an interview on 7/20/21 at 11:10 AM, LPN Unit Manager #27 stated staff members should perform hand hygiene before and after resident care and in between residents and anytime hands were soiled. Staff should use soap and water with any residents on precautions. Hand hygiene should be completed in between resident rooms. Hand hygiene helped to prevent the spread of infections.
During an interview on 7/20/21 at 10:09 AM, the Assistant Director of Nursing (ADON) stated if a resident was on precautions for C-difficile staff should wash hands with soap and water before doing any other care for another residents. It is important to wash hands because the c-difficile infection could spread to another resident and soap and water is the only way to kill the spores.
MASK USE
During the lunch meal observation on 7/13/21 at 12:07 PM, 3 of 6 residents (#10, 19, and 27) in the Unit A dining room were served their meals by dietary staff #35. Dietary staff #35 was observed with their surgical face mask below their nose.
On 7/14/21 at 8:20 AM, LPN #32 was observed administering medications and was wearing a black cloth mask, CNA #19 was observed wearing a pink cloth mask and hairdresser #37 was observed with a black bedazzled cloth mask.
During an interview on 07/14/21 at 3:12 PM, CNA #19 stated they were educated on COVID-19 infection control and PPE when the pandemic first started and have been re-educated. CNA #19 stated they can't wear the blue mask because they break out in hives and was told they did not have to wear the blue surgical mask. They stated the mask should be worn over the nose.
During an interview on 7/14/21 at 3:14 PM, LPN #32 stated they were educated about COVID-19 infection control and PPE when the pandemic first started. The LPN stated they could wear any mask, and it should cover the nose. The LPN stated they put their mask on before they walked into the facility because it needed to be always worn on the unit.
During an observation on 07/17/21 at 8:01 AM, receptionist #38 was at the check in/screening station and was not wearing a mask. There was a box of surgical masks located directly in front of the receptionist.
During an interview on 07/17/21 at 8:06 AM, receptionist #38 stated staff should wear a mask all the time. The receptionist stated staff can take their mask off to drink, take a break, or when using the bathroom. The receptionist stated they were not wearing a mask because they were not around anybody. The receptionist stated they received education on mask usage. They stated if a staff member comes in without a mask, they will hand them a mask and ask them to put it on.
On 07/17/21 at 8:35 AM, temporary nurse aide (TNA) #37 was observed speaking to Residents #21 and 26 during meal service. The TNA's mask was below their nose. The TNA walked into the hallway to put a tray in the dirty cart. TNA #37 came out of Resident #79's room with the meal tray with their mask below their nose. At 8:41 AM TNA #37 entered Resident #78's room, removed the meal tray wearing their mask below their nose.
During an Interview on 7/17/21 at 8:41 AM, TNA #37 stated all staff had to wear a mask while in the building, The TNA stated they received education on how to wear a mask and the surgical mask was supposed to be over the nose and mouth.
On 7/19/21 at 8:37 AM hairdresser #37 was observed wearing a black bedazzled mask while they were styling Resident #49's hair. At 8:44 AM, hairdresser #37 was shaving and cutting Resident #5's hair wearing a cloth mask.
During an interview on 7/19/21 at 11:54 AM, hairdresser #37 stated they were currently required to wear a surgical mask or N95 mask and a cloth mask was not appropriate. The hairdresser stated they were wearing a cloth mask and forgot they had it on, and they should be wearing a surgical mask.
CNA #18 was observed with their surgical mask below their nose:
-on 7/15/21 at 8:53 AM, going into Resident #41's room to provide care.
-on 7/15 21 at 9:19 AM, standing at the nursing desk.
-on 7/15/21 at 10:07 AM going in Resident #26's room.
-on 7/15/21 at 10:27 AM, entering Resident #50's room.
-on 7/16/21 at 9:08 AM coming out of Resident #79's room.
-on 7/16/21 at 10:38 AM, entering Resident #21's and #26's room.
-on 7/16/21 at 10:41 AM, in hallway to speak with another staff member. Mask was below both nose and their mouth. They did not fix it prior to reentering room A 18 with Resident in room.
-on 7/19/21 at 8:31 AM while feeding Resident #35 with mask below their nose.
-on 7/19/21 at 10:56 AM, coming out of Resident #50's room.
During an interview on 7/19/21 at 11:26 AM, CNA #19 stated during COVID-19 it was discussed how to wear a mask. CNA #19 stated correct mask wearing was over the nose and mouth, around residents and probably co-workers.
LPN Unit Manager #27 was observed wearing a mask below their nose:
-on 07/15/21 at 9:26 AM, at the nursing desk.
-on 07/16/21 at 9:16 AM, while bring medications to Resident #79.
-on 7/16/21 at 10:21 AM, while preparing meds at the medication cart in the hallway.
-on 7/16/21 at 10:22 AM, entering Resident's #21's and 26 's room with medications.
-on 7/16/21 at 10:23 AM, while standing at the medication cart.
-on 7/16/21 at 10:24 AM, entering Resident #42's and 82's room to administer medications.
-on 7/17/21 at 8:17 AM, while at the medication and entering Resident #41's room.
During an interview on 7/20/21 at 11:10 AM, LPN Manager #27 stated staff should always be wearing the mask over the nose and mouth and around residents and other staff. The LPN stated their mask slips down at times and if it keeps slipping off, they would replace the mask.
During an interview on 7/20/21 at 9:45 AM, the Director of Nursing (DON) stated surgical masks were available when entering the building and on the units. The only masks allowed were surgical masks. The DON stated the surgical mask should cover the nose and mouth to stop the spread of infection. The mask protected the staff and the residents from COVID-19 and other droplet-based infection. The DON stated the front desk receptionist/screener should always wear a surgical mask.
During an interview on 7/20/21 at 3:46 PM, with dietary aide #35 they stated they were required to wear masks over the nose and covering the mouth. The dietary aide stated if the mask kept falling down, they should get a new one. The dietary aide stated they may not have had their mask on when in the dining rooms and had walked within six feet of residents and had stopped to talk to them.
10NYCRR 415.19(a)(1 - 3)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New York facilities.
- • 37% turnover. Below New York's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 20 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.
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About This Facility
What is Sunset, Inc's CMS Rating?
CMS assigns SUNSET NURSING AND REHABILITATION CENTER, INC an overall rating of 3 out of 5 stars, which is considered average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Sunset, Inc Staffed?
CMS rates SUNSET NURSING AND REHABILITATION CENTER, INC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 37%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sunset, Inc?
State health inspectors documented 20 deficiencies at SUNSET NURSING AND REHABILITATION CENTER, INC during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 19 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Sunset, Inc?
SUNSET NURSING AND REHABILITATION CENTER, INC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 110 residents (about 92% occupancy), it is a mid-sized facility located in BOONVILLE, New York.
How Does Sunset, Inc Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, SUNSET NURSING AND REHABILITATION CENTER, INC's overall rating (3 stars) is below the state average of 3.1, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Sunset, Inc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Sunset, Inc Safe?
Based on CMS inspection data, SUNSET NURSING AND REHABILITATION CENTER, INC has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Sunset, Inc Stick Around?
SUNSET NURSING AND REHABILITATION CENTER, INC has a staff turnover rate of 37%, which is about average for New York nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Sunset, Inc Ever Fined?
SUNSET NURSING AND REHABILITATION CENTER, INC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Sunset, Inc on Any Federal Watch List?
SUNSET NURSING AND REHABILITATION CENTER, INC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.