CORTLAND PARK REHABILITATION AND NURSING CENTER
For profit - Partnership
120 Beds
UPSTATE SERVICES GROUP
Data: November 2025
Trust Grade
35/100
#387 of 594 in NY
Photo by Cortland Park Rehabilitation and Nursing Center
Photo by Cortland Park Rehabilitation and Nursing Center
Photo by Avrumy Biston
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Cortland Park Rehabilitation and Nursing Center has received a Trust Grade of F, indicating significant concerns regarding care quality and safety. They rank #387 out of 594 facilities in New York, placing them in the bottom half of the state, and #2 out of 3 in Cortland County, meaning only one local option is better. While the trend shows improvement from 15 issues in 2023 to 3 in 2025, the facility still faces serious challenges, including a concerning staffing turnover rate of 59%, which is higher than the state average. Additionally, the nursing home has incurred $76,339 in fines, which is higher than 93% of other facilities in New York, suggesting ongoing compliance issues. Recent inspections revealed that several residents with pressure ulcers did not receive timely treatment, and medications were improperly stored, raising concerns about overall care and safety. Despite these weaknesses, it is worth noting that the facility's health inspection rating is average, which may indicate some level of compliance with basic care standards.
- Trust Score
- F
- In New York
- #387/594
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $76,339 in fines. Lower than most New York facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 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.
35/100
Bottom 35%
Needs review
15 → 3 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 15 issues
2025: 3 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below New York average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 59%
13pts above New York avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $76,339
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: UPSTATE SERVICES GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above New York average of 48%
The Ugly 20 deficiencies on record
1 actual harm
May 2025
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-5/30/2025, the facility did not ensure residents received services with reasonable accommodat...
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Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-5/30/2025, the facility did not ensure residents received services with reasonable accommodation of needs for one (1) of one (1) resident (Resident #94) reviewed. Specifically, Resident #94 did not have their call bell in reach.
Findings include:
The facility policy Call Bell, last reviewed 3/1/2024, documented each resident needed a call bell at their bedside and the call bell should be within reach of the resident.
Resident #94 had diagnoses including muscle weakness, compression fracture of thoracic vertebra (mid-spine), and dementia. The 5/1/2025 Minimum Data Set assessment documented the resident was cognitively intact, required supervision or touching assistance with activities of daily living.
The 4/29/2025 Comprehensive Care Plan documented the resident was at risk for falls due to muscle weakness. Interventions included the call bell should be in reach.
The following observations were made of Resident #94:
- on 5/27/2025 at 11:44 AM the call bell was on the floor between the bed and the wall. The resident was lying in bed and stated they were not able to locate the call bell. At 3:21 PM in bed with the call bell between the bed and the wall towards their feet. The resident stated if they needed assistance, they would use their call bell but that they could not locate it. They stated they would just yell out for help if needed.
- on 5/28/2025 at 8:10 AM, lying in bed with the call bell on the floor between the bed and the wall at the foot of the bed. The resident stated if they needed something they would use their call bell. The resident stated they were unable to locate their call bell. At 12:00 PM in bed with the call bell between the wall and the bed on the floor at the foot of their bed. They stated they tried not to call unless they really needed something to eat and drink, as they could get to the bathroom independently. At 10:50 AM, the resident was lying in bed, the call bell was on the floor between the wall and the bed.
During an interview on 5/28/2025 at 9:39 AM, Certified Nurse Aide #4 stated if residents needed something or required assistance, they should use their call bell. Call bells should be kept within reach of the resident. If a call bell was out of reach of a resident, it should be placed back within reach. Resident #94 was able to use their call bell.
During an interview on 5/29/2025 at 10:34 AM, Licensed Practical Nurse #6 stated residents should use their call bell if they needed help. Call bells should be in reach and usually clipped to their bed. Resident #94 could use their call bell.
10NYCRR 415.5(e)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-5/30/2025, the facility did not ensure residents received treatment and care in accordance wi...
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Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-5/30/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan one (1) of four (4) residents (Resident #76) reviewed. Specifically, Resident #76 had an unwitnessed fall and was not assessed timely by a qualified professional; their call bell was observed out of reach; and they were not assisted with toileting by Licensed Practical Nurse #9 as planned.
Findings include:
The facility policy Fall Prevention Program, revised 2/2025, documented remind the resident to call for assistance with transfers or ambulation; do not leave unattended in the bathroom until ability/compliance with call cord use was verified and adequate sitting balance and postural stability were established; and call bell within resident's reach at all times. High risk falls interventions included ensure toileting needs were care planned for and call bell was within reach. If a resident sustained a fall or was found on the floor, staff were not to move the resident. They were to call for assistance, the charge nurse would complete an initial evaluation. The Registered Nurse would do a secondary and more thorough assessment. If there was no Registered Nurse in the facility, emergency medical services (EMS) would to be contacted immediately to assess the resident.
Resident #76 had diagnoses including dementia, brain tumor, and osteoporosis (weak bones). The 4/7/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, used a walker and wheelchair, was independent with sitting to lying and lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers, required supervision or touching assistance with toileting hygiene, refused toileting transfers, was frequently incontinent of bladder and bowel, and had a fall in the last 2-6 months prior to admission/entry or reentry.
The Comprehensive Care Plan documented:
- on 4/1/25 the resident was at risk for falls related to recent illness and decline in activities of daily living. Interventions included to complete fall risk assessments, ensure proper lighting, clear pathway, low position bed, ensure resident was comfortably positioned in bed with the head of the bed elevated as appropriate, remind to call for assistance as needed, post visual prompt to remind resident to call for assistance, staff to round frequently while resident slept, encourage to stay in common areas when awake, and staff to help position back to bed.
- on 4/2/2025 documented the resident was dependent with toileting and was incontinent of bladder and bowel.
The 4/1/2025, 4/12/2025, and 4/22/2025 fall risk assessments documented the resident was at high risk for falls.
The 5/8/2025 Registered Nurse #22 progress note documented they responded to the unit for a call that Resident #78 had an unwitnessed fall at 11:26 AM. The resident was assessed, and medical and family were notified of the fall.
The 5/8/2025 Registered Nurse #22 late entry progress note documented while they responding to the fall that occurred at 11:30 AM, a certified nurse aide (unidentified) reported the resident had another fall at 6:45 AM and was found on the ground in their room. There were no reported symptoms or concerns from the initial incident. The resident was at their baseline.
The 5/8/2025 staffing schedule documented there was no Registered Nurse in the building from 6:00 AM - 7:00 AM and Licensed Practical Nurse #20 worked 6:00 AM - 2:00 PM.
The 5/8/2025 Incident/ Accident form completed at 11:30 AM, by Registered Nurse #22 documented at 11:30 AM, Resident # 78 had an unwitnessed fall from their bed and was discovered lying on the floor by Licensed Practical Nurse #20. A certified nurse aide (unidentified) reported to Registered Nurse #22 at 11:30 AM the resident had another fall that occurred around 6:45 AM, the resident was found out of bed on the ground and was in no distress. There were no reported concerns or symptoms. Licensed Practical Nurse #20 statement completed at 11:00 AM on 5/8/2025, documented they entered the resident's room at 6:45 AM, and the resident was on the floor. The resident was last seen at 6:15 AM, lying in their bed. At the time of the incident the resident's call bell was in reach, call bell was not on, and the resident was soiled. They took the resident's vital signs and helped to clean up the resident and sit them in their chair. Licensed Practical Nurse #20's statement did not document if they notified anyone of the resident's unwitnessed fall.
There was no documented evidence the resident was assessed by a registered nurse, a medical provider was notified, or emergency medical services was contacted after the resident was found on the floor at 6:45 AM.
The following observations of Resident #76 were made on 5/28/2025:
- from 9:47 AM-11:16 AM, lying in bed, their call bell was clipped to the privacy curtain and was not within reach.
- at 11:58 AM, standing next to the right side of their bed holding onto the foot of the bed with their wheelchair behind them, their wheelchair was not locked, and they sat down in the wheelchair. Their call bell was clipped to the privacy curtain.
- at 12:01 PM, seated in their wheelchair rocking back and forth attempting to scoot closer to the foot of the bed. At 12:03 PM, they pulled themself up from their wheelchair to a standing position holding onto the foot of the bed with their left hand and their right hand was placed on the mattress. At 12:05 PM, they sat back down in their wheelchair. Their call bell was clipped to the privacy curtain.
- at 2:06 PM, in their room seated in their wheelchair eating a cookie. Their call bell was clipped to the privacy curtain.
The following observations of Resident #76 were made on 5/29/2025
- at 8:57 AM, sitting in the dining room. The call bell in their room was clipped to the privacy curtain and there was a sign on their dresser to call help.
- at 9:13 AM, wheeling themself into their room from the dining room. The call bell was clipped to the privacy curtain
- at 9:37 AM seated in their wheelchair in their room. The call bell was clipped to the privacy curtain.
- at 10:50 AM, the resident lying in bed. The call bell was clipped to the privacy curtain
- at 11:36 AM, standing up at the side of their bed and sat down in their wheelchair. They brought themself to the bathroom unsupervised by staff.
- at 11:39 AM, Licensed Practical Nurse #9 knocked on the resident's door and looked into the resident's bathroom and exited the room without assisting the resident in the bathroom.
- at 11:42 AM, Licensed Practical Nurse #9 looked in the resident's room and did not enter the room. After the nurse walked away the toilet seat was heard closing with a loud bang.
- at 11:44 AM, Licensed Practical Nurse #9 entered the resident's room, looked in the bathroom and walked out without assisting the resident in the bathroom.
- at 11:47 AM, the resident wheeled themself out of the bathroom and was not wearing pants.
During an interview on 5/29/2025 at 12:34 PM, Certified Nurse Aide #26 stated Resident #76 was on their assignment, had a lot of falls and could use their call bell, but did not use it. When residents were in their room their call bell should be within reach. They stated after getting the resident up for the day they clipped the call bell to the privacy curtain while they made the resident's bed. If the call bell was attached to the privacy curtain the resident could not access it while lying in bed. It was important for the residents to have access to the call bell to call for assistance.
During an interview on 5/29/2025 at 1:01 PM, Licensed Practical Nurse #20 stated Resident #76 was known to be noncompliant with asking for assistance when getting up. They worked on the unit as an agency nurse on 5/8/2025 and recalled the resident had two falls that day. The first fall occurred early in the morning and the resident was last seen at change of shift lying in their bed. A certified nurse aide alerted them the resident was on the floor. They notified a registered nurse (could not identify) who came to assess the resident, and the resident was then assisted up from the floor. The registered nurse started the investigation. They stated the resident was able to use their call bell, but did not use it. It was important for residents who could use their call bells to have them in reach for safety reasons.
During an interview on 5/29/2025 at 1:35 PM, Licensed Practical Nurse #9 stated Resident #76 had falls and could use their call bell, and it was important for the call bell to be within reach so they could use it. They stated on 5/29/2025 they observed the resident alone in the bathroom when they attempted to administer the resident's medications. They left the resident's room without assisting them in the bathroom and did not tell anyone the resident was in the bathroom by themself.
During an interview on 5/29/2025 at 2:20 PM, Licensed Practical Nurse Unit Manager #21 stated they were unsure if Resident #76 could use their call bell but had a sign in their room to remind them to call for help. Call bells should be accessible to the resident. Resident #76 was a fall risk and had multiple falls. They stated if a resident had a fall a registered nurse and the medical provider should be notified. There was a procedure in place if a registered nurse was not in the building at the time of a fall.
During an interview on 5/29/2025 at 3:57 PM, Registered Nurse #22 stated any nurse in the building could respond to falls. A registered nurse should assess the resident and notify medical and the family. They should also start the investigation, obtain witness statements, and document in the resident's medical chart. All falls were reviewed with the interdisciplinary team. They stated they responded to a call Resident #76 had fallen on 5/8/2025 around 11:30 AM. While responding to that fall a certified nurse aide told them the resident had another fall earlier in the day around 6:45 AM. They stated they were not in the building at the time of the first fall and was unsure which registered nurse was notified of the fall. Licensed practical nurses could not assess a resident and the resident should not be moved until they were assessed.
During an interview on 5/29/2025 at 6:01 PM, the Director of Nursing stated the facility had at least 12 hours of registered nurse coverage a day. It was the policy of the facility if a resident fell and there was no registered nurse in the building emergency services would be called to assess the resident and assist with moving the resident. Staff should start the incident report and obtain statements. Resident #76 was impulsive and had multiple falls. They stated on 5/8/2025 at 6:45 AM, there was no registered nurse in the building. They were unaware the resident fell at 6:45 AM on 5/8/2025 and was just notified of the incident earlier today. They reviewed the incident report and there was no documentation a registered nurse assessed the resident. The resident was moved from the floor without being assessed, and staff should not move a resident until they were assessed for injuries. They stated medical and nursing were not notified until the resident had a second fall later that day when Registered Nurse #22 was notified about the incident by a certified nurse aide. Additionally, the resident's call bell should be within reach while in their room for safety reason.
10NYCRR 415.12
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure drug...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure drugs and biologicals were stored in accordance with professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable to include proper labeling of medication with resident information and expiration date for 3 (three) of 3 (three) medication carts (Maplewood Unit Cart 1, Parkside Unit Cart 2, and Whispering Pines) reviewed. Specifically, Maplewood Unit Cart 1 contained opened, unlabeled insulin pens and inhalers; Parkside Unit Cart 2 contained eye drops without a resident identifier, and opened, unlabeled insulin pens, eye drops, and inhalers; and Whispering Pines contained opened, unlabeled eye drops.
Findings include:
The facility policy Storage in the Facility-Medications, revised 2/2025, documented medications were stored safely, securely, and properly following manufacturer's recommendation or those of the supplier. All over the counter medications, inhalers, eye drops, nasal sprays, and insulin pens were dated when opened.
The facility policy Insulin Injection Pen, revised 2/2025, documented injection pens may be stored at room temperature in the medication cart once opened. Any un-opened pens were stored in the refrigerator until opened. The policy did not include dating of opened insulin pens.
During a medication cart observation and interview on [DATE] at 10:47 AM the Maplewood Unit Cart 1 had undated, opened insulin pens for Residents #34, #426, #415, #421, and #51, and for a discharged resident. Inhalers (breathing medicine) for Residents #424, #49, #51, and #415 were open and undated. Licensed Practical Nurse #7 stated insulin pens should be labeled with the open date and expiration date by the nurse who used the pen first. They were not sure when the pens were opened, and insulin pens were good for 28 days after opening. They used the pens earlier in the morning and did not notice they were not labeled. They stated they should not have used them because they might not be as effective if they were opened more than 28 days ago. Licensed Practical Nurse #7 stated inhalers were not required to be labeled when opened and were used until all the medication contained in the inhaler was administered.
During a medication cart observation and interview on [DATE] at 11:05 AM, Parkside Unit Cart 2 had artificial tears eyedrops in boxes for Residents #55, #65, #70, and #86. The eyedrops inside the boxes did not have an open date or pharmacy label for resident identification. There were undated insulin pens for Residents #86 and #1. Licensed Practical Nurse #8 stated whoever opened the eyedrop boxes was responsible for labeling the bottle with the resident's name and expiration date. They were not sure when the bottles were opened or why they were not labeled. If the medications fell out of the box, they could not be sure which resident it belonged to. Licensed Practical Nurse #8 stated the insulin pens were used that morning, and they did not notice they were not labeled and should have been. They could not be sure if the insulin was expired because it did not have an open date and insulin expired 30 days after opening. They should not have used the insulin pens. The Inhalers for Resident # 7, Resident #23, Resident #52, and Resident #65 were not labeled when they were first used. Licensed Practical Nurse # 8 said they used the inhalers this morning and did not notice they were not labeled with the date opened or the expiration date. They were not effective when used after 30 days.
During a medication cart observation and interview on [DATE] at 11:44 AM, the Whispering Pines cart contained Resident #11's eye drops labeled as opened on [DATE]; Resident #28's timolol 0.5% eye drops were opened on [DATE] and latanoprost 0.005% eye drops were opened and not labeled with an open date; and Resident #41's Dopzol eye drops were labeled as opened on [DATE] and lantanoprost 0.005% eye drops were not labeled when opened. Licensed Practical Nurse #9 stated medications were good for different times frames, some were good for 30 days and others 90 days which was confusing to them. They stated when they returned from a recent vacation the medication cart was not in order and they were trying to get it back in order. Medications were not labeled with open dates or expiration dates, and they should have been labeled.
During an interview on [DATE] at 2:31 PM, Assistant Director of Nursing #18 stated they expected medication carts to be clean, locked, and organized. Stock medications were labeled when opened and the expiration date used was the manufacturers expiration date on the bottle. Eye drops were patient specific, should be labeled and placed in a zip lock bag, and could not be shared between residents. They were not sure if the actual bottle of eye drops had to be labeled with the resident's name or just the zip lock bag and would defer to the policy. Inhalers were dated when they were used for the first time and the expiration date should be written on the inhaler. They were not sure when eye drops or inhalers expired and would defer to policy but believed it was 30 days. Insulin pens should be labeled with the date opened and they deferred to the policy for expiration date time frames but believed insulin was good for 30 days. If a resident received medication that was expired, it might not be as potent and could be an infection control issue.
10 NYCRR 483.45 (g)(h)
Dec 2023
1 deficiency
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the abbreviated survey (NY00329552), the facility did not ensure a resident with pressure ulcers received the necessary treatment and services...
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Based on observation, record review, and interview during the abbreviated survey (NY00329552), the facility did not ensure a resident with pressure ulcers received the 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 3 residents (Resident #2) reviewed. Specifically, Resident #2 was found with a skin impairment and was not assessed timely by a qualified professional, and the medical provider was not notified timely of the areas for consideration of a treatment order.
Findings include:
The reviewed/revised 6/2023 Skin/Pressure Injury Prevention & Intervention Program documented when a resident developed a new skin/pressure injury, the resident would be placed on the 24-hour report for interdisciplinary awareness and follow-up and reported to the Assistant Director of Nursing/Director of Nursing, and Wound Nurse. The registered nurse Unit Manager or registered nurse designee would track the skin/pressure injury weekly. The medical provider would be notified when new skin/pressure injury developed and the medical provider's response, including treatment ordered, would be documented in the nursing notes.
Resident #2 had diagnoses including prostate cancer with metastasis (cancer that spread to other parts of the body) to the bone and the spinal cord. The 6/21/2023 Minimum Data Set assessment documented the resident's cognition was intact, they required extensive assistance with bed mobility and transfers, and they had no pressure ulcers.
The 8/21/2023 comprehensive care plan documented the resident was at risk for skin impairment. Interventions included barrier cream after incontinence (loss of bladder function), turning and repositioning every 2 hours, and weekly head to toe skin checks.
The 10/28/2023 at 1:59 PM, agency licensed practical nurse #1's progress note documented the resident had a quarter size open area on the right hip. The area was cleansed, and a clean dressing was applied.
There was no documentation of an assessment by a qualified professional and no documented evidence the medical provider was notified to determine if a treatment order was needed.
The 10/31/2023 at 9:36 AM Wound registered nurse #2's progress note documented they were informed of an abrasion on the resident's right hip and there was a 1.5 centimeter by 1.5 centimeter wound. The area was cleansed, a liquid barrier was applied, and the area was covered with a foam dressing.
The 10/31/2023 physician's order documented to the right hip abrasion: cleanse with wound wash, pat dry, apply liquid barrier to peri wound (tissue surrounding the wound) and apply a bordered gauze every 7 days and as needed.
During an interview on 12/14/2023 at 12:15 PM, licensed practical nurse #1 stated when they found a new skin issue, they documented it, and notified wound registered nurse #2. If a skin issue was found on a weekend, wound registered nurse #2 reviewed progress notes on Monday mornings and would see the note regarding the resident's skin issue. They stated they typically notified the Supervisor, and the Supervisor notified the medical provider. They did not recall if they notified the Supervisor on 10/28/2023.
During an interview on 12/14/2023 at 12:45 PM, wound registered nurse #2 stated they expected staff to notify them of a new skin issue and if they were not available, they would expect the Supervisor to be notified to do an assessment. The medical provider also needed to be notified so they were aware of the skin issue and to approve the treatment. They stated licensed practical nurse #1 should have notified the Supervisor on 10/28/2023 for an assessment as it was a weekend, and they were not at the facility. When they evaluated the resident's right hip on 10/31/2023, that was the first time they had seen the wound, the wound was caused by pressure and a treatment order was not obtained timely.
10 NYCRR 415.12(c)(2)
Oct 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure an ongoing program to support residents in their choic...
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Based on observation, interview, and record review during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 3 residents (Residents #31 and #100) reviewed. Specifically, Residents #31 and #100 resided on the dementia unit and were not offered meaningful activities and were not provided with activities of their choosing. Additionally, Resident #31's room was not personalized with preferred activity items, such as a television or radio.
Findings include:
The facility policy Dementia Unit Programming revised 9/2021 documented that activities staff was responsible for ensuring that the needs of the residents living on the unit can be met through unit-specific programming which focuses on the residents' unique needs and capabilities. Activities staff was to prepare a monthly activity calendar of program which addressed the physical, cognitive, creative/expressive, spiritual, and emotional needs of the residents who live there. The programs were to include large and small groups and individual visits and would focus on a variety of activities (i.e., cooking, music, active games, pets, gardening, entertainment, outings, socials, etc.).
1) Resident #31 was admitted to the facility with diagnoses including dementia and contractures (loss of joint mobility) of both right and left ankles. The 6/14/2023 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, no behavioral issues, felt it was somewhat important to have items to read and to do group activities, and very important to listen to music they liked, do their favorite activities, have family or a close friend involved in discussions about their care, and get fresh air when the weather was nice.
The 2/12/2022 comprehensive care plan (CCP), updated 6/22/2023, documented Resident #31 would participate in activities of their choosing with staff assistance as needed. Interventions included the resident was to be encouraged to attend group activities, ensure that bedside activities were available daily, offer individual activities designed to match goals of therapy to enhance fine motor skills, offer interesting and contemporary movies, provide one-to-one visits with staff, and show areas of quiet the resident might enjoy getting out of their room.
The 6/22/2023 progress note by the Activities Director documented that Resident #31's interests included kickball/balloon volleyball, socials, music concerts, pet visits, trivia, watching movies, socializing, going outside, and coloring. The resident would be invited, assisted, and encouraged to attend activities, programs of interest, and be provided with materials needed for independent leisure so that they would remain actively engaged during the day.
The following observations were made of Resident #31:
- on 10/16/2023 at 9:49 AM sitting in a wheelchair angled toward the wall, next to their dresser. There was no TV or other activity/personalization in their room other than one personal picture above the bed.
- on 10/17/2023 at 8:34 AM sitting in a wheelchair, alone in their room.
- on 10/18/2023 at 9:42 AM sitting in a wheelchair with the bedside table in front of them, staring out the window. There were no other stimuli in front of them or in room. The room light was not on, and the only light in the room was from the window; at 10:03 AM sitting in their wheelchair with the bedside table in front of them, staring straight ahead, with the lights off and no other stimuli in the room; at 10:49 AM and 11:25 AM sitting in a wheelchair sleeping; and at 11:49 AM sitting in their wheelchair, awake and looking out the window.
The 10/2023 Activities Log documented Resident #31 participated in activities 10 out of 18 days and included group activities, food activities, and on-unit generalized entertainment of unit music and movies.
2) Resident #100 had diagnoses including COVID-19, depression, and Alzheimer's disease. The 7/5/2023 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition; exhibited delusions, verbal behavioral symptoms, and wandering behaviors; felt it was very important to have snacks between meals, to have books, newspapers, and magazines to read, to listen to music they liked, and to do their favorite activities.
The 7/3/2023 Activities Assessment documented that Resident #100 preferred to do activities in their room or in the day/activity room one to one, in small groups, or independently. The resident's interests included cards, crafts, music, reading, watching TV, gardening, and talking/conversing.
The 7/3/2023 Activities progress note documented that activity staff would invite, assist, and encourage the resident to attend group activity programs of interest, and would provide materials needed for independent leisure for the resident to remain actively engaged throughout the day.
The comprehensive care plan (CCP) documented:
- on 7/3/2023 the resident preferred activities that identified with their prior lifestyle. Interventions included to encourage resident to participate in activities to include games, music, and socials, to provide resident with verbal reminders and escort to activities, and to provide materials of interest. An intervention added 10/3/2023 included to offer individual activities to resident while quarantined due to infectious process.
- on 10/8/2023 the resident had the COVID-19 virus. Interventions included to encourage the resident to remain in their room on isolation precautions, encourage a mask if the resident left their room on isolation precautions, and to provide emotional support with care.
The facility COVID-19 positive list titled Facility Total Positive Line List Active documented that Resident #100 was on isolation precautions from 10/8/2023 to 10/18/2023.
During an interview and observation on 10/16/2023 12:05 PM, Resident #100 stated that they were not offered any activities for in-room entertainment while they were on isolation for COVID-9. A TV was observed in the room. No other forms of individual activity items were observed.
During an interview on 10/17/2023 at 10:43 AM, the resident's representative stated the resident enjoyed being able to interact with people and watch TV.
Resident #100's Activity Logs dated 10/8/2023-10/18/2023 documented the resident was under isolation precautions, the resident was recorded in an activity 6 out of 10 days which included food activity passed to room, being educated to stay in room, one happy hour, music/movie played in common area on unit, and walking around room and hallway.
The following observations were made on 10/18/2023:
- at 9:39 AM activity leader #24 walked down the hallway and peeked into resident rooms but did not go into the rooms to invite anyone to activities.
- at 10:21 AM activity leader #24 was passing out drinks and snacks in the dining room to residents present.
- at 10:27 AM activity leader #24 went to the hallway to offer drinks and snacks with a diet list on the cart.
- at 10:38 AM activity leader #24 did not offer drinks or snacks to residents in COVID-19 positive rooms.
- at 10:43 AM activity leader #24 did not enter the right wing of the hallway to offer drinks and snacks and returned to dining room.
- at 1:30 PM activity leader #24 led a painting activity in the dining room. Residents who were in the hallway were invited to the activity. The activity leader did not go to each room or check in the rooms to invite other residents to attend.
During an interview on 10/19/2023 at 10:19 AM, activity leader #24 stated they were the primary activity leader on the resident's unit except for alternating weekends. Activities attended by residents were charted on paper first then entered into the electronic record by the end of the day. Activity leader #24 stated that with COVID-19 on the unit they could not do a lot of activities the residents enjoyed, but mostly only small group activities like painting and coloring. Activity leader #24 stated they would go to the rooms of residents not on COVID-19 precautions and offer coloring, sensory items, stuffed animals, or turn on TV or radios. They stated they did not go into COVID-19 rooms. Activity leader #24 stated that Resident #31 has been in their room most of the time, and the resident could not do most independent activities by themselves. Activity leader #24 stated Resident #31 liked big group activities. Activity leader #24 stated if they do one-to-one activities, it was only very brief as they were the only one on the unit.
During an interview on 10/19/2023 at 11:29 AM Activities Director stated they assisted on the Resident #31's and #100's unit as needed with one-to-one activities, management of behaviors, or re-approaches. The Activities Director stated they expected activities to run as usual on the unit unless a resident had COVID-19. If residents had COVID-19, they should be offered one-to-one activities such as cards, coloring, TVs, and radios. The Activities Director stated that they expected activity staff to reach out to them if they needed assistance with completing one-to-one activities. The Activities Director stated that the Activities department had radios they could give residents to use and if there was no TV in the room, a work order should be filled out. Families could bring TVs in, but the facility was supposed to provide them. The Activities Director stated that Resident #31 used to have a TV and that they would put in a work order for the room if there was no TV. They stated they were aware it was a favorite activity of Resident #31. Activities Director stated they expected all non-COVID-19 positive residents to be invited to all group activities and all residents, including COVID-19 precaution residents, to be offered food activities as everyone could participate in those activities.
10NYCRR 415.5(f)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure that residents who required dialysis received such ser...
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Based on observation, record review, and interview during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #32) reviewed. Specifically, Resident #32 received hemodialysis (a process of purifying blood when kidneys do not work normally) treatments at a community based dialysis center and did not have ongoing monitoring after dialysis treatments, and there was no evidence of ongoing communication, service coordination, or collaboration between the facility and dialysis staff.
Findings include:
The facility policy, Dialysis Policy and Procedure revised 11/2022, documented procedures included developing a care plan, maintaining communication with the dialysis team to ensure quality of care, monitoring catheter/shunt for bleeding after dialysis treatment, a licensed nurse will check thrill/bruit (thrill a vibration felt when placing fingers over an arterio-venous fistula used for dialysis access, bruit a whooshing sound heard with a stethoscope over the fistula) each shift as ordered and document on the MAR (Medication Administration Record)/TAR (Treatment Administration Record)/nurses' notes. Residents will be monitored on an ongoing basis and any change in condition will be reported to the medical provider.
The Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement dated 9/16/2023 documented for purpose of care coordination, in advance of each resident's dialysis treatment, the facility shall furnish all information, and documentation necessary for the dialysis facility to provide safe and appropriate care.
Resident #32 was admitted to the facility with diagnoses including end stage renal disease (ESRD, kidney disease) dependent on renal (kidney) dialysis. The 8/25/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, received dialysis, and required supervision and set up assistance with activities of daily living (ADLs).
Medical orders by physician #1 documented on 9/18/2023 the resident was to receive dialysis on Tuesday, Thursday, and Saturday; obtain vital signs and document them in the resident's dialysis binder; update dialysis book and send to dialysis with the resident; review book when resident returned and enter a progress note. Monitor for bleeding from dialysis port after dialysis treatments.
The comprehensive care plan (CCP) dated 9/26/2023 documented the resident was scheduled for dialysis on Tuesday, Thursday, and Saturday every week. The resident refused dialysis occasionally, was on enhanced barrier precautions due to a dialysis catheter and was on a renal diet.
Nursing progress notes from 7/1/2023 to 10/18/2023 did not document the dialysis book was reviewed upon return from dialysis or the resident's medical condition was evaluated and documented as ordered.
Resident #32's vital signs record after dialysis from 7/1/2023-10/20/2023, documented 1of 12 days of vital signs recorded for July 2023; 5 of 14 days of vital signs recorded for August 2023; 0 of 13 days recorded for September 2023; and 0 of 8 days recorded for October 2023.
Resident #32's dialysis communication sheets from 7/1/2023 to 10/20/2023 included 8 partially completed sheets and 1 fully completed sheet for October 2023. There were no dialysis communication sheets available for July, August, or September 2023.
During an interview on 10/20/2023 at 8:20 AM Resident #32 stated they went to dialysis on Tuesday, Thursday, and Saturday since March 2023. They stated when they left for dialysis, they took a dialysis book. The nurses were supposed to check their vital signs and document in the book before they left, and the nurses sometimes checked their vital signs before they left. The resident stated they returned to the facility at around 1:00 PM and they could not remember a time when their blood pressure was checked upon return to the facility. The resident stated they sometimes felt weak when they returned but the feeling subsided as the day progressed and they had experienced very low blood pressure readings after dialysis. They stated their blood pressure had been as low 70 or 80 and the dialysis center had delayed their departure to maintain close follow up.
During an interview on 10/19/2023 at 11:19 AM certified nurse aide (CNA) #19 stated the resident left the building on Tuesday, Thursday, and Saturday for dialysis before their shift started. They stated when the resident returned from dialysis, they ate their lunch and socialized with other residents. They stated the nurse was responsible to take vital signs when the resident returned from dialysis.
During an interview on 10/20/2023 at 8:44 AM licensed practical nurse (LPN) #22 stated the resident left the faciity on Tuesday, Thursday, and Saturday for dialysis before the start of their shift. They stated when the resident returned from dialysis, the licensed nurse should check the dialysis book for any changes or concerns noted by dialysis staff. They stated the resident's vital signs and thrill/bruit needed to be checked. They stated it is important to check the thrill/bruit to be certain the resident was not bleeding after dialysis as well as checking the resident's vital signs to be certain they were stable. They stated they documented the thrill/bruit check in the medication administration record (MAR) and the vital signs were recorded in the CNA care area of the electronic medical record (EMR).
During an interview on 10/18/2023 at 2:30 PM, with LPN Unit Manager (LPN/UM) #2 stated the facility staff documented on a dialysis communication sheet to share information with the dialysis center staff. The sheet included a part for the facility staff to complete, and a part for the dialysis center staff to complete. They stated the dialysis center had not been completing their portion of the dialysis communication sheet. They stated they called the dialysis center yesterday and reminded them the communication sheet needed to be completed before the resident returned to the facility. They stated they did not think facility staff called for a report when the sheet was not completed. They expected to see the communication sheet completed with the information obtained from the dialysis center. LPN/UM#2 stated they expected staff to complete a set of vital on the resident when they returned from dialysis and check in with the resident to see how they were feeling. They stated if the vital signs and a check were not completed the resident could have a low blood pressure or bleeding that could be a problem for the resident.
During a telephone interview on 10/18/2023 at 2:50 PM dialysis center registered nurse (RN) #23 stated they were made aware by the facility that the dialysis center had not been completing their portion of the dialysis communication sheets. RN #23 stated the facility had not called to obtain verbal reports when the dialysis communication sheet was not completed by dialysis. RN #23 stated it was important to check the resident's vital signs when they returned to the facility to be certain the resident remained stable after the dialysis procedure.
During an interview on 10/20/2023 at 12:49PM the Director of Nursing (DON) stated a resident needed a medical order to go to dialysis. A resident should have their vital signs taken, offered a meal, and sent with a communication book before they left for the dialysis center. The communication book should be kept at the nursing desk and include vital signs obtained on the morning before dialysis, and any other pertinent information for the dialysis center. They stated when the resident returned from the dialysis center, it was expected that the nurse checks the resident's vital signs and document them in the electronic medical record, and review any notes sent back from the dialysis center. They stated it was expected that the facility nurse calls the dialysis center for a verbal report after dialysis if there was not a communication sheet completed. They stated it was important to obtain vital signs because the resident had a lot of fluid removed from their body during the dialysis procedure and could cause the resident's blood pressure to be low possibly causing the resident to pass out, become lightheaded and dizzy.
10NYCRR415.12(k)
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification and abbreviated (NY00324417) surveys th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification and abbreviated (NY00324417) surveys the facility did not ensure residents were free of significant medication errors for 2 of 5 residents (Residents #59 and #68) reviewed. Specifically, Resident #59 had an order to hold their insulin if their finger stick blood glucose (FSBG) level was less than 120 milligrams/deciliter (mg/dl) and the resident received insulin when their FSBG was 77 mg/dl; Resident #68 did not receive nebulizer treatments as ordered.
Findings include:
The facility policy, Medication Administration revised June 2023, documented that medications would be administered as prescribed and nursing staff would strongly adhere to the five rights of medication administration (right resident, medication, dose, route, and time) to ensure safety.
1) Resident #59 was admitted to the facility with diagnoses including diabetes and dementia. The Minimum Data Set (MDS) dated [DATE], documented that the resident had moderately impaired cognition, and received insulin injections 7 of 7 days.
Physician orders documented:
- on 5/4/2023 by physician #1 check finger stick blood glucose (FSBG) level before meals and at bedtime on Wednesdays at 8:00 AM, 12:00 PM, 4:30 PM, and 9:00 PM, call the physician or nurse practitioner (NP) if FSBG was less than 60 (milligrams/deciliter, mg/dl) or greater than 450 mg/dl.
- on 5/8/2023 by physician assistant (PA) #35 Humalog (fast acting insulin) pen subcutaneous injection 5 units before meals at 8:00 AM, 12:30 PM, and 4:30 PM, hold if BG (blood glucose) is less than 120 mg/dl. There was no corresponding order for daily FSBGs before meals.
During a medication administration observation and interview on 10/18/2023 at 11:34 AM with licensed practical nurse (LPN) # 20, Resident #59 was wheeled into their room from the dining room where they were eating a dessert food item. LPN # 20 obtained the FSBG blood sugar and stated the results were 77 and would administer the insulin unless the resident's glucose was below 40. LPN #20 administered Humalog insulin 5 units subcutaneously into the resident's left lower abdomen. At 11:38 AM, while documenting for the administered medication, LPN #20 stated that the insulin should not have been given as the resident's blood glucose result was 77 which was less than 120 as documented on the physician order.
The 10/1/2023-10/20/2023 Medication Administration Record (MAR) documented Humalog insulin 5 units subcutaneously hold if BG is less than 120. On 10/3/2023 at 4:30 PM the resident's BG was documented as 112 mg/dl and was administered 5 units of insulin in the left arm by LPN #47. On 10/16/2023 at 8:00 AM the resident's BG was documented as 105 mg/dl and was administered 5 units of insulin in the left lower quadrant (LLQ) by LPN #6. On 10/16/2023 at 12:20 PM the resident's BG was documented as 105 mg/dl and was administered 5 units of insulin in the LLQ by LPN #6. On 10/18/2023 at 12:30 PM the resident's BG was documented as 77 mg/dl and was administered 5 units of insulin in the LLQ by LPN #20.
During an interview on 10/18/2023 at 12:03 PM, LPN UM #21 stated additional orders had been obtained to monitor residents blood glucose levels and Resident #59's blood glucose was now 85 and they had finished their dessert.
During an interview on 10/20/2023 at 1:44 PM, the DON stated that the provider should be called with any medication error or omission. The facility had a hypoglycemic policy and staff could access the policies on their computers.
2) Resident #68 was admitted to the facility with diagnoses including Parkinson's disease (a progressive neurological disorder), chronic obstructive pulmonary disease (COPD, lung disease), and wheezing. The 9/27/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact.
During an interview and observation on 10/16/2023 at 12:07 PM, Resident #68 had a deep, congested, productive cough with white/yellowish sputum. The resident stated they had difficulty lying flat in bed and sleeping due to the increased cough. They stated the symptoms were present for 3 days and were getting worse. They stated they told a nurse (no identifier) on 10/15/2023.
A 10/17/2023 at 9:51 AM, registered nurse (RN) #4 progress note documented the resident was assessed for complaint of increased cough and congestion. The resident reported they had the cough for a couple of days. The resident's lung sounds were diminished throughout all fields. The left lower lobe of the lung was noted to have fine crackle sounds. The plan was for the licensed practical nurse (LPN) Unit Manager (LPN/UM) #2 to contact the medical team.
A 10/17/2023 at 12:10 PM LPN/UM #2 progress note documented a phone call was made to the on-call medical provider. The LPN/Unit Manager #2 received orders for a STAT (immediate) chest Xray, and additional blood work was to be performed.
A 10/17/2023 at 12:45 PM nurse practitioner (NP) #7 progress note documented they assessed the resident after they received a phone call from staff that the resident had a cough and congestion. The resident's vital signs were stable, and the oxygen saturation (percentage of oxygen in the blood) was 93%. On physical exam, they documented the resident's lung sounds were diminished, and no rhonchi (abnormal lung sounds), wheezes or cough were heard. The plan was to wait for the results of the chest Xray, and blood work ordered for definitive diagnosis. NP #7 ordered DuoNeb (a combination medication) nebulized (an aerosol treatment) every 6 hours.
A 10/17/2023 at 7:59 PM RN #5 progress note documented they received a call from the on-call medical provider. The resident's chest Xray was positive for a left lower lung pneumonia. RN #5 received verbal orders from NP #38 for doxycycline (an antibiotic) and DuoNeb inhalation treatment every 6 hours for treatment of pneumonia. RN #5 completed entry of new orders electronically on the medication administration record (MAR).
A 10/17/2023 at 10:02 PM LPN# 6 progress note documented they gave the resident the first dose of doxycycline 100 (milligram) mg. There was no entry on the medication administration record (MAR) documenting doxycycline was given.
The October MAR documented DuoNeb nebulizer treatment every 6 hours ordered on 10/17/2023. The 10/17/2023 doses due at 12:00 PM and 6:00 PM were documented by LPN #6 as not administered, the reason was discontinued. The 10/18/2023 dose due at 12:00 AM was documented by LPN #8 as not administered, the reason was documented as discontinued. The 10/18/2023 6:00 AM dose was documented by LPN #8 as given. The original DuoNeb order was discontinued by NP #7 on 10/18/2023 at 11:19 AM. NP #7 wrote a new order on 10/18/2023 at 11:19 AM for ipratropium-albuterol nebulized every 6 hours
During an interview on 10/18/2023 at 9:07 AM, the resident stated they were told by the nurse that the chest Xray performed on 10/17/2023 showed they had pneumonia. The resident stated the nurse gave them an antibiotic last night to treat the pneumonia. They stated they received the first nebulizer treatment that morning around 5:30 AM.
During an interview on 10/18/2023 at 10:02AM, NP #7 stated the resident had left lower lobe pneumonia. The resident was prescribed doxycycline 100 mg two times a day for 7 days and DuoNeb nebulized every 6 hours for one week. They stated no follow up care was required if the resident continued to improve.
During a follow up telephone interview on 10/18/2023 at 4:02 PM NP #7 stated they discontinued the orders for DuoNeb and placed new orders for the same medications today to reflect accuracy in medication name, dose, and duration. NP #7 stated LPN/Unit Manager #2 entered an erroneous verbal medication order for ipratropium on 10/17/2023 and that order was also discontinued. NP #7 stated the original verbal order was for DuoNeb.
During an interview on 10/18/2023 at 4:10 PM, LPN/Unit Manager #2 stated they made a medication error by placing a verbal order for ipratropium nebulized on 10/17/2023. They stated they thought DuoNeb was ipratropium. They stated that the medication error could have caused the resident to have difficulty breathing.
During a telephone interview on 10/18/2023 at 4:46 PM, LPN #8 stated they received in nurse to nurse report at the start of the shift on 10/17/2023 at 7:00 PM that the resident was being treated for pneumonia with doxycycline. They stated they were told by the off going LPN that the DuoNeb nebulizer treatment was discontinued. They stated they documented the treatment was discontinued at the 12:00 AM. They stated that the pharmacy delivered DuoNeb for the resident on 10/18/2023 at 4:35 AM and when the delivery was received, they checked the order and realized it was an active order. They stated they gave the resident the DuoNeb nebulizer treatment on 10/18/2023 at 5:30 AM.
During an interview on 10/20/2023 at 1:00 PM, the Director of Nursing (DON) stated a provider (physician, NP, or PA) must order all medications for the residents. They stated verbal medication orders could be obtained by a registered nurse (RN) only. When a RN received a verbal order, the order must be placed in the electronic medical record (EMR) immediately. The verbal order must be verified by another RN to be certain the order was entered correctly. They stated if a verbal order was entered incorrectly, it was considered a medication error. They stated there should be no delay in administering a DuoNeb nebulized treatment after the order was entered in the EMR as DuoNeb medication was kept in the facility pyxis (a locked cabinet where medication is stored).
10NYCRR 415.12(m)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure drugs and biologicals were labelled and stored in acco...
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Based on observation, interview, and record review during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 1 of 3 medication carts (Maplewood medication cart) reviewed. Specifically, the top drawer of the medication cart contained a cup of unlabeled medications that were removed from their original packaging.
Findings include:
The facility policy, Storage in the Facility-Medication revised 6/2023 documented medications would be stored safely, securely, and properly, following the manufacturer's recommendations, or those of the supplier.
The facility policy, Medication Administration reviewed 6/2023 documented medications are administered at the time they are prepared from the med cart or in the med room. Medications are not pre-poured.
Resident #24 had diagnoses including cerebral vascular accident (CVA, stroke), seizure disorder, and depression. The 7/1/2023 Minimum Data Set (MDS) assessment documented the resident received antidepressants and diuretics 7 of 7 days.
During an observation on 10/18/2023 at 11:58 AM with licensed practical nurse (LPN) #20, the Maplewood medication cart top drawer contained a medicine cup that was nearly full of various unlabeled pills.
During a telephone interview on 10/19/2023 at 1:51 PM, LPN #20 stated the medications in the medicine cup left in the top drawer were for Resident #24 and were the resident's 11:00 AM medications. LPN #20 stated when they went to administer the medications, the resident was not ready to receive them and when they re-approached the resident later, they were not in their room. LPN #20 stated Resident # 24 was in therapy. LPN #20 stated they could not recall what the individual medications in the cup were, only that they were for 11:00 AM and they did not pre-pour the medications.
The 10/2023 Medication Administration Record (MAR) documented Resident #24 was scheduled to receive the following medications between 11:00 AM and 1:00 PM:
- amlodipine 10 milligrams (mg) for hypertension;
- vitamin C 500 mg for vitamin deficiency
- atorvastatin 20 mg for hyperlipidemia (high blood fat levels)
- baclofen 10 mg for polyneuropathy (malfunction of nerves)
- captopril 50 mg for hypertension
- ferrous sulfate 325 mg for anemia
- folic acid 1 mg for vitamin deficiency
- furosemide 20 mg for hypertension
- gabapentin 300 mg for neuropathy
- levetiracetam 500 mg for convulsions
- magnesium oxide 400 mg for low magnesium levels
- omeprazole 20 mg for gastro-esophageal reflux disease
- potassium chloride 20 milliequivalents (mEq) for low potassium levels
- senna 8.6 mg 2 tabs for diarrhea
- sertraline 50 mg for depression
During an interview on 10/19/2023 at 2:26 PM LPN Unit Manager #21 stated medications should be administered at the time they were due to be given, medications should not be pre-poured, and they expected to be notified if a resident was unable to take their medications. LPN #21 stated if Resident #24 was unable to take their medications, then the medications should have been discarded and prepared later when the resident was available to take them.
During an interview on 10/20/2023 at 1:44 PM, the Director of Nursing (DON) stated they were not aware of any medications being stored in the top drawer of a medication cart. They stated the best practice would be to resupply the medications if the resident was unavailable to take them or stay with the resident until their medications were taken and not move on to another resident's medication pass. They stated they would not want another resident getting the incorrect medications.
10 NYCRR 415.18(d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the recertification survey conducted from 10/16/2023-10/20/2023, the facility did not ensure food was stored and prepared in accordance with p...
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Based on observation, record review, and interview during the recertification survey conducted from 10/16/2023-10/20/2023, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen and on 1 of 3 units (Parkside Unit) reviewed. Specifically, the walls and floor of the dry storage room in the main kitchen were uncleanable, and there were expired food products in the Parkside Unit nourishment room.
Findings include:
The facility policy Food Storage reviewed 1/2022, documented all foods were checked to assure that foods were consumed by their safe use by dates, or discarded.
The undated facility Food Storage and Retention Guide did not include a specific storage time limit for juice. The guide documented to refer to manufacturer's instructions for product specific guidelines.
1) Uncleanable kitchen surfaces
During an observation on 10/17/2023 at 11:59 AM, the wall of the dry storage room off the back of the kitchen was in disrepair. In the corner behind the shelving there was a section of wall approximately 2 feet by 5 feet that was missing drywall and it was open into the wall cavity between the studs. On the adjacent wall there was a section approximately 3 feet by 10 feet that had unfinished dry wall. In the same area, under the shelving, there were several cracked and broken floor tiles and one missing tile. These surfaces were not smooth and easily cleanable as required.
The facility's work order system documented on 10/4/2023, routine maintenance was requested for loose floor tiles by the door of the dry storage room. This was due to be corrected on 10/6/2023, but the status of the work order remained open.
The facility's work order system documented on 2/28/2023, the dry storage room wall in the kitchen needed patch and paint. This work order was due on 2/28/2023 and no activity was documented including who was assigned by maintenance or when the work order was closed.
During an interview on 10/19/2023 at 11:59 AM, the Food Service Director stated the wall in the dry storage room was damaged from a leak sometime between January 2023 and April 2023. They stated they had not worked at the facility during that period and when they returned to work in April 2023, the leak had been fixed, but the walls still needed to be fixed. They stated if a repair was needed, they put in a maintenance work order in the computer system. They did not know if a work order was ever done for the damaged wall, or flooring. The Food Service Director stated that the walls and floors of the dry storage room were not smooth and easily cleanable because of the unfinished drywall, missing drywall, and the damaged floor tiles.
During an interview on 10/19/2023 at 2:40 PM, the Administrator stated open status on work orders were not completed according to their system. Work orders were submitted in the system and should have been closed out when the work was completed.
2) Expired Food Products
During an observation on 10/16/2023 at 9:30 AM, a 46 ounce (oz) container of prune juice with the expiration date of 9/18/2023 and a 64 oz container of prune juice with the expiration date 10/1/2023 were in the nourishment room on the Parkside Unit.
During an observation on 10/17/2023 at 10:24 AM, a 64 oz bottle of prune juice with a best by date of 10/1/2023, a 46 oz carton of orange juice with a best by date of 8/23/2023, and a carton of prune juice with a best by date of 9/18/2023 were in the cabinets of the nourishment room on the Parkside Unit. The refrigerator contained one open carton of prune juice with a best by date of 9/18/2023 which was visibly soiled around the cap and not labeled or dated other than the original packaging information.
During an interview and observation on 10/19/2023 at 11:18 AM, licensed practical nurse (LPN) #22 stated the Parkside Unit nourishment room was accessible and available to the residents. The kitchen staff supplied the room with snacks and juices for the residents, but nursing staff would occasionally go to the kitchen to get something for a resident who requested it. They stated they would label the juice containers with a date when opened, and that date was important to maintain freshness. They stated that juices and foods were only kept for three days from the time they were opened, and if they were not labeled, the items would be discarded because there was no way to know how old something was.
During an interview on 10/19/2023 at 11:50 AM, certified nursing assistant (CNA) #31 stated the nourishment room was for the residents to get snacks, condiments, drinks, and sandwiches outside of mealtimes, or as an addition to a meal. They stated they would often pour drinks for the residents from the nourishment room. CNA #31 stated they always checked the dates on the packages and anything beyond the packaging labeling date, or a staff member's open date notation, they would throw that item out. They added, they would only use something if it was within a week of the expiration date, and they would refer to the facility's Food Storage and Retention Guide that was posted in the nourishments room.
During an interview on 10/19/2023 at 11:59 AM, the Food Service Director stated that there were two dietary staff who were responsible for stocking snacks and drinks in the nourishment areas on the Units. They stated that they would often personally check the expiration dates on products and most items were limited to 72 hours after opening. Dry goods went by the labeling on the packaging. The Food Service Director stated juices past their expiration dates should not have been available for the residents on the units. Opened containers in the refrigerator were required to be labeled with a permanent marker by the person who opened them with the opened date.
10NYCRR 415.14(h)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure call systems were accessible to residents for 1 of 1 r...
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Based on observation, record review, and interview during the recertification survey conducted 10/16/2023-10/20/2023, the facility did not ensure call systems were accessible to residents for 1 of 1 resident (Resident #12) reviewed. Specifically, Resident #12 did not have their manual tap bell within reach.
Findings included:
The facility policy Call Bells effective 6/1/2020 documented that call bells would be used when a resident needs to request and/or attain assistance.
Resident #12 was admitted to the facility with Alzheimer's disease, chronic obstructive pulmonary disease (COPD, lung disease), and need for assistance with personal care. The 5/8/2023 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required supervision for most activities of daily living (ADLs).
The comprehensive care plan (CCP) revised 6/9/2023 documented Resident #12 was at risk for falls related to decreased endurance and advanced dementia. Interventions included to always keep the call bell within reach of the resident when in their room. The revised 10/19/2023 CCP documented the resident preferred the bed up against the wall on the opposite side of the room from the call bell. Interventions included use a tap bell to request assistance from staff.
Resident #12 was observed:
- on 10/16/2023 at 11:28 AM, in their bed against the right wall, with the corded call light on the left wall of the room. The tap bell was on the nightstand and was not within reach of the resident.
- on 10/17/2023 at 2:25 PM, in their wheelchair in their room. The corded call light was clipped to the wall on the opposite side of room and the tap bell was not within reach of the resident.
- on 10/18/2023 at 8:39 AM, in bed asleep with the tap bell not within reach.
- on 10/19/2023 at 1:36 PM, in bed and the tap bell was not within reach.
During an interview on 10/19/2023 at 10:23 AM, certified nursing assistant (CNA) #34 stated call lights were clipped to the resident's shirt or blanket so a resident would have access to them when in their rooms. CNA #34 stated Resident #12 had a tap bell due to their preference of having the bed on the opposite wall of the corded call bell. CNA #34 stated they put the tap bell in bed with the resident for easy access of use. CNA #34 stated that the tap bell should not be on the nightstand while the resident was in bed.
During an interview on 10/19/2023 at 1:38 PM, licensed practical nurse (LPN) #37 stated the facility had regular call bells, paddle call balls, and a tap bell if needed. If a resident were in their room, the call light should be on their person or within reach. Staff should round verify the call bells were in reach. LPN #37 stated that Resident #12's tap bell should be on their bedside table next to the bed at a low height to be within reach. LPN #37 stated that the tap bell on the nightstand while the resident was in bed could be a fall risk.
During an interview on 10/19/2023 at 2:22 PM, LPN Unit Manager #28 stated residents who do not have corded call lights were provided with tap bells. The residents were educated on how to use the tap bells and demonstrated use to nursing staff. Staff were educated to answer tap bells when heard, to round more frequently on rooms with tap bells, and make sure the tap bells were within reach of the resident.
10NYCRR 415.29
CONCERN
(E)
📢 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 multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00324417) surveys conducted 10/...
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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 abbreviated (NY00324417) surveys conducted 10/16/23-10/20/23, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 3 resident units (Parkside and Whispering Pines Units including resident rooms 201, 202A, 203, 206, 318A and 320A, and Residents #31, #47, and #64). Specifically, there were unclean wheelchairs, medical equipment, common areas, and damaged walls.
Findings include:
The undated facility policy Complete Room Cleaning documented the procedure for daily room cleaning and bathroom cleaning which included emptying wastebaskets, dusting, and mopping. The daily complete room cleanings will be inspected by the Director of Housekeeping to ensure necessary cleanliness and sanitation levels have been achieved. In the event a complete room cleaning is unsatisfactory, the housekeeper responsible is expected to return to the area immediately and remedy the situation.
The following observations were made on Parkside Unit:
- on 10/16/2023 at 10:25 AM, the wall behind the recliner in room [ROOM NUMBER]A was scraped along the length of the wall behind the bed.
- on 10/19/23 at 7:56 AM, the wall across from the nurse's station had scraped paint.
- on 10/16/2023 at 11:08 AM, the wall behind the handrail next to the kitchen entrance was in disrepair.
The following observations were made on Whispering Pines Unit on 10/16/2023:
- at 9:49 AM there were visible crumbs in room [ROOM NUMBER] on bed B and a green lettuce leaf stuck to the floor next to the bed. Resident #31 had a piece of bread in their wheelchair footrest.
- at 10:13 AM, room [ROOM NUMBER] had brownish-black matter smeared on the floor by the wheel of bed A and on the left side at the head of the bed. The tube feeding pump had dried brownish fluid on the face of the machine. The continuous positive airway pressure (CPAP) machine in the room was dusty.
- at 10:28 AM, Resident #47's wheelchair arm was dirty with dusty brown matter and had dirty wheels.
- at 10:42 AM, room [ROOM NUMBER] had food matter on the floor near bed C and by the door, and the bottom of the quarter wall by the sink had cracked and jagged edges.
- at 10:44 AM Resident #64's wheelchair was dirty with dried matter on the seat, left arm, leg rest, and wheel well.
- at 12:29 PM, the main dining room wall was scuffed, the entryway door was scuffed, and the rubber base was separated from the wall.
The following observations were made on Whispering Pines Unit on 10/17/2023:
- at 8:31 AM, room [ROOM NUMBER] had partially wiped, medium sized food matter on the floor.
- at 09:16 AM, room [ROOM NUMBER] had brownish-black matter smeared on the floor under the wheel of the bed near the head of bed A; the bottom of the tube feeding pump pole was dirty with a dried light brown substance and the CPAP machine was dusty.
- at 9:33 AM, the floor between rooms [ROOM NUMBERS] was dirty with dried liquid drip spots and dirt, dried food, and crumbs.
- at 10:38 AM, the sink in room [ROOM NUMBER] was loose and the caulking was coming off the wall on the back of the sink.
- at 2:03 PM, room [ROOM NUMBER] had a blood sugar monitoring strip on the floor, blackish-brown matter smeared on the left side of bed A, the floor under the bed was dirty, dried brownish fluid was on the face of the feeding pump, and the CPAP machine was dusty.
- at 2:06 PM, the inside of Resident #31's wheelchair foot cradle was dirty with skin flakes, crumbs, and dried liquid spills.
The following observations were made on Whispering Pines Unit on 10/18/2023:
- at 08:36 AM, room [ROOM NUMBER] had quarter sized spots of food matter in the middle of the floor and near the bed.
- at 1:59 PM, Resident #31's wheelchair foot cradle was dirty with dried liquids, food debris, and a fork.
The following observations were made on Whispering Pines Unit on 10/19/2023:
- at 8:00 AM, Resident #31's wheelchair arm rest, wheel well, and brake were unclean.
- at 8:03 AM, the floor between resident room [ROOM NUMBER] and resident room [ROOM NUMBER] had dried liquid drip spots and dirt. The floor in front of the TV across from the nurse's station had dried liquid spots and dried food matter.
- at 8:04 AM, the floor along the front of the nurse's station had dried liquid and matter.
The following observations were made on Whispering Pines Unit on 10/20/2023:
- at 8:47 AM, Resident #31's wheelchair foot cradle had food crumbs and skin flakes.
- at 8:49 AM, the floor along the front of the nurse's station had dried dirt, dark spots, and liquid spills. The floor in front of the TV across from the nurses' station had dried white spot and dark matter stains.
- at 8:53 AM, room [ROOM NUMBER] had dried food matter and liquid spill stains next to bed A.
- at 8:56 AM, Resident #47 had dried spilled liquid on the right arm rest of their wheelchair.
- at 9:09 AM the quarter wall by the sink in room [ROOM NUMBER] had cracked and jagged edges and there was food debris on the floor between beds A and B.
- at 9:11 AM, Resident #31's wheelchair wheels and connecting metal were dirty with dried food and dried liquid matter.
During an interview on 10/19/2023 at 8:05 AM, certified nursing assistant (CNA) # 44 stated housekeeping was responsible for cleaning resident rooms, emptying trash and washing floors. If a CNA or other staff noticed walls that needed repair, then a work order was placed into the computer. CNA #44 stated any staff could enter a work order and they were unsure if one had been placed for Resident #3's wall.
During an interview on 10/19/2023 at 9:19 AM, housekeeper #42 stated they were on the unit Whispering Pines every day. Housekeeper #42 stated they were responsible for the daily cleaning of resident rooms which included dry and wet mopping floors and under beds. Housekeeper #42 stated all staff were responsible for common area spills. They stated there was a floor technician but on days the technician was not there, and they were responsible for floors in common area. Housekeeper #42 stated they tried to get all rooms on one hall done before lunch, and all rooms were completed prior to them leaving the facility. They stated that the spot in room [ROOM NUMBER] by bed A was an oil mark from the bed after a strip and wax of the room. There were plans to strip and wax the room again and fix the wall. Housekeeper #42 stated the CNAs were responsible for wheelchair cleaning.
During an interview on 10/19/2023 at 10:23 AM, CNA #34 stated everyone was responsible for cleaning wheelchairs. Overnight nursing staff were primarily responsible, but all staff should ensure they were cleaned.
During an interview on 10/19/2023 at 2:22 PM, licensed practical nurse (LPN) Unit Manager #28 stated that nightshift nursing staff was responsible for cleaning wheelchairs. LPN Unit Manager #28 stated there was no log or formal schedule for cleaning wheelchairs but should be cleaned weekly. If a wheelchair was visibly dirty, it should be cleaned by any staff who saw it.
During an interview on 10/20/2023 at 8:24 AM the Director of Maintenance stated the walls in the facility were looked at every week to try and match up paint if painting needed to be done. They stated it was not homelike for walls to be scraped up and in need of paint. The Director of Maintenance stated they had new staff working on repairing walls every week and if staff would report them, they would follow up as soon as they were aware. The Director of Maintenance stated all the issues were not homelike and should be repaired.
During an interview on 10/20/2023 at 9:00 AM with the Regional Director of Housekeeping, they stated dirty wheelchairs and medical equipment were supposed to be cleaned by nursing. If there were substances spilled on the floor nursing staff knew how to clean them up. They stated dirty floors and walls should be cleaned daily by housekeeping. Housekeeping had a list of areas to clean daily that included washing and mopping floors, emptying trash, cleaning windowsills, cleaning sinks, and washing the rubber baseboards. They stated some of the rubber baseboards needed to be replaced, they were pulling away from the walls and no amount of cleaning would make them appear clean.
During an interview on 10/20/2023 at 9:32 AM, LPN #37 stated the overnight shift should clean medical equipment and tube feeding poles. LPN #37 stated that if a nurse used the machine/pole, they should have cleaned it.
During an interview on 10/20/2023 at 9:36 AM, LPN Unit Manager #28 stated housekeeping was responsible for cleaning feeding poles and machines.
10NYCRR 415.29 (j)(1)
May 2023
7 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00310805, NY00296452, and NY00308875), the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00310805, NY00296452, and NY00308875), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 3 of 6 residents (Resident #4, 5 and 6) reviewed. Specifically:
- Resident #5 was found with a pressure ulcer by an outside consultant, orthopedic recommendations were not implemented timely, and the orthopedic device was not monitored. When the wound worsened, treatments were not implemented, and an ordered wound culture was not obtained.
- Resident #4 developed pressure ulcers without documented evidence of assessments by qualified professionals for consideration of treatments and treatments were not ordered timely.
- Resident #6 was assessed with pressure ulcers on admission, treatments were not ordered, and an assessment was not completed on a new wound on the thigh for consideration of a treatment.
This resulted in actual harm to Residents #4 and 5 that was not immediate jeopardy of new pressure ulcers that worsened to unstageable (full thickness, depth unknown) ulcers and an infected wound for Resident #5.
The revised 4/2014 Skin/Pressure Ulcer Prevention and Intervention Program policy documented weekly skin evaluations would be done on every resident. When pressure ulcers were identified, a registered nurse (RN) was to assess the wound and notify the provider for a treatment. When a new pressure ulcer was identified, the resident would be placed on the 24-hour report for interdisciplinary awareness/follow-up and reported to the ADON (Assistant Director of Nursing), DON (Director of Nursing) and WCC (Wound Care Consultant). The Unit Manager/RN or designee tracked the pressure ulcer weekly.
The revised 10/2022 admission of a Resident/Patient policy documented when a resident was admitted , forms would be completed within 8 hours of entrance. A Registered Nurse (RN) must do the skin assessment. If a skin issue was present on admission, the wound was to be followed weekly until resolved for 4 weeks. It was essential that the physician and family be notified and an order for a treatment be put in place.
Resident #5
Resident #5 was admitted with diagnoses of dementia, diabetes, and a fractured ankle. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, they required extensive to total assistance with activities of daily living (ADL), and had 3 unstageable (full thickness, unable to determine depth) pressure ulcers and a surgical wound.
The [DATE] hospital discharge summary documented the resident was being discharged to the nursing facility that date after undergoing surgery to repair a left ankle fracture. The resident received care to a pressure ulcer in the hospital with recommendations for wound care and orthopedic follow-up after discharge. The hospital discharge summary did not note the location/stage of the resident's pressure ulcer(s) and the medication list did not document what treatments were applied to the resident's pressure ulcer(s) in the hospital. There was no documentation the resident or family were non-compliant with treatment in the hospital.
The [DATE] at 6:24 PM, the Director of Nursing's (DON) progress note documented the resident had a cast on their left foot. The family refused a full body assessment but reported the resident had a pressure ulcer to the right heel and coccyx (tailbone). The DON documented they reviewed medication orders with physician's assistant (PA) #3. There was no documentation treatment orders were reviewed with PA #3 and the DON noted an RN would re-attempt a skin assessment.
The [DATE] admission physician's orders did not contain orders for pressure ulcer treatment(s).
The [DATE] physician's orders documented the following treatments:
- to the coccyx deep tissue injury (DTI, injury to underlying tissue from prolonged pressure); cleanse, apply skin prep (liquid skin barrier), and a foam dressing every 3 days.
- To the right heel DTI; cleanse, apply skin prep every 3 days.
- To the left heel DTI; cleanse, apply skin prep and foam dressing every day.
The [DATE] at 8:05 PM, the DON's progress note documented the resident was assessed to have 32 stitches to the left ankle incision that was clean and intact with scabbing; a DTI to the left heel that was 2 centimeters (cm) x 2.5 cm and deep purple; a DTI to the right heel that was 0.3 cm and purple, and a DTI to the coccyx that was 0.5 cm with maceration (prolonged contact with moisture). The DON noted treatments were rendered per physician's order.
The [DATE] comprehensive care plan (CCP) documented the resident had pressure ulcers to both heels and the coccyx. Interventions included weekly wound rounds and to update the physician weekly and as needed.
The [DATE] at 6:24 PM, registered nurse (RN) #37's progress note documented skin prep was applied to the resident's right heel DTI. The left heel DTI was now unstageable and black, and skin prep and a foam dressing were applied. The note contained no documentation whether an RN or the provider were notified of the changes in the resident's left heel wound's appearance.
The [DATE] at 12 PM, former Assistant Director of Nursing (ADON) #1's progress note documented the resident complained their heels hurt. The right heel DTI was 3.5 cm x 3 cm and was deep purple/black and the surrounding area was red. The ADON noted nursing to continue to monitor. There was no documentation a medical provider (physician or physician's assistant) was notified of the resident's complaints of pain at the pressure ulcer site.
The [DATE] nursing facility attending physician #41's progress note documented the resident recently underwent ankle surgery following a fractured ankle. The hospital discharge summary and facility nursing notes were reviewed. The resident's skin was warm, dry, and intact. The note did not document the resident had pressure ulcers or a plan for pressure ulcer management.
The [DATE] orthopedic PA #55's consult note documented the resident was seen for a post-surgical visit, was utilizing a leg splint, and was being treated for a right heel pressure ulcer. The splint and dressing were removed by PA #55, and they noted a pressure ulcer to the outside of the left lower leg, measuring 1 centimeters (cm) x 3 cm. The skin was deep red, with no opening or drainage. The Sutures were removed from the ankle and debridement (removal of dead tissue from a wound) was done. Antibiotic ointment was applied to the entire area, a non-stick bandage was applied, followed by a stockinette (tubular fabric bandage), and a tall, controlled ankle movement (CAM, removable orthopedic device that stabilizes foot) boot was applied. PA #55 noted care was taken to ensure the resident's heel was not touching the hard frame of the boot and a pad was applied to keep the pressure ulcer away from the frame of the boot. The resident was to always wear the CAM boot except for hygiene and nursing was to check the skin every day, including that the heel was not touching the frame of the boot, and verify the padding was applied to the side of the lower leg. PA #55 documented the resident needed a wound nurse to evaluate their leg and should follow-up with orthopedics in 4 weeks.
There was no documented evidence the recommendations made by orthopedic PA #55 for the resident to always wear the CAM boot except for hygiene and that nursing checked the skin every day, as well as ensuring the heel was not touching the frame of the boot, and verify the padding was applied to the side of the lower leg were evaluated by the facility or implemented by the facility physician until 6 days later on [DATE].
The [DATE] at 11:25 AM, Registered Nurse Supervisor (RNS) #36's progress note documented they spoke to someone at the orthopedic office regarding the resident's appointment on [DATE] and they would send the resident's consult from that visit (8 days after the orthopedic consult).
On [DATE] at 3:53 PM, RN # 36 documented the resident was seen at the orthopedic office on [DATE] and had a new pressure ulcer. A CAM boot was issued and was to remain in place except for hygiene.
The [DATE] physician's order documented to apply antibiotic ointment over the resident's pressure ulcer and on the suture line, cover with a non-stick bandage, and wrap with a gauze dressing.
The [DATE] at 12:51 PM, licensed practical nurse (LPN) #32's progress note documented the resident's left lateral leg wound had greenish yellow, sticky slough (non-viable tissue) in the wound bed. A note was left in the provider book. A non-stick bandage and sterile dressing were applied, and the area was wrapped with gauze. There was no documentation an assessment was completed to evaluate the LPN's concerns.
The [DATE] facility PA #3's progress note documented the resident was assessed to have an open area to the left lower leg with mild slough at the base of the wound. The plan was to initiate a petroleum-based wound care treatment (a wound treatment designed to keep the wound moist) and a foam dressing every other day.
The [DATE] to [DATE] Treatment Administration Record (TAR) documented nursing staff applied antibiotic ointment over the pressure ulcer and on the suture line and covered with a non-stick bandage daily. There was no documented evidence the treatment recommended by PA #3 on [DATE] was ordered.
The [DATE] at 12:34 PM, former ADON #1's progress note documented they assessed the resident's heel wounds, coccyx wound, and left lateral leg wound. They noted the left lateral leg wound was now a Stage 2 (partial thickness skin loss) with 80% slough (yellow, non-viable tissue).
The [DATE] facility attending physician #44's order documented to the left anterior ankle pressure ulcer, apply an absorbent dressing and cover with a foam dressing daily.
The [DATE] at 12:12 PM and 1:22 PM, former ADON #1's progress notes documented the resident's left lateral leg Stage 2 pressure ulcer had purulent (pus) drainage and wound edges were inflamed. The wound had 80% slough, 20% eschar (dry, dead tissue) and a foul odor. The treatment was changed, the provider was notified, and an antibiotic was ordered.
The [DATE] physician's order documented cephalexin (antibiotic) 500 milligram (mg) twice daily and to the left outer leg Stage 2 pressure ulcer, apply an ointment with silver (antimicrobial treatment) to the wound bed, and cover with a foam dressing daily.
The [DATE] facility PA #5's progress note documented the resident's family reported an odor from the right heel. The plan was to obtain C&S (culture and sensitivity, determines if bacteria was present and what antibiotics the bacteria was sensitive to) for the right heel wound.
The [DATE] facility attending physician #44's order documented wound C&S on the right heel.
The 3/22 and 4/22 TARs contained no documentation the C&S was completed. The order was discontinued from the TAR on [DATE].
In an email from the DON to the surveyor on [DATE] at 1:45 PM, they documented they were not able to locate results of a C&S for the resident.
The 3/22 TAR documented treatments to the resident's left and right heels, and left anterior ankle were not administered on 13 occasions during the month (3/1, 3/3, 3/8, 3/10, 3/14, 3/15, 3/16, 3/18, 3/21, 3/23, 3/25, 3/26, and [DATE] by LPNs #27, 32, 33, and 34.
The [DATE] PA #5's progress note documented the resident's family took the resident home against medical advice (AMA) due to insurance reasons.
During an interview on [DATE] at 9:30 AM, LPN #27 stated wound treatments should be done as ordered and if they could not get to them, the next shift should try to complete them. If there was an RN on duty, they were supposed to let the RN know they could not do them. On 3/3, 3/10, and [DATE], they documented the resident's treatment was not done due to staffing. They stated when there was 1 nurse on the unit, they did not have time to get to the treatments. They could not recall whether they told the oncoming shift they had not completed the resident's treatment.
During an interview on [DATE] at 1:10 PM, LPN #18 Unit Manager stated if nurses were unable to complete treatments, they should be notified. On an off shift, the nurse should call the physician or DON for direction. If staff found a new or worsening pressure ulcer, they expected an RN to be notified and to assess within 24 hours. If no RN was in the building, the nurse should call the physician for orders. LPN #18 stated staff made them aware they could not complete treatments in 3/22 and themselves and the DON re-educated the nurses that they needed to notify them when this occurred. On [DATE], when the nurse documented green, yellow, sticky slough, it could have been a sign of infection, and should have been assessed by an RN. They recalled a wound culture being ordered for the resident, but it was not completed as the resident's date of birth was incorrect. They expected it to be corrected and the test to be reordered. They were unsure of this was done. Nurses should not leave resident issues in the physician binder if the issue needed immediate follow-up. They should call the physician or notify an RN for assessment.
During an interview on [DATE] at 1:36 PM, the DON stated if treatments could not be completed as ordered, they expected the next shift to complete them. They were not aware that multiple staff documented in 3/2022 that treatments were not done for Resident #5. The DON stated the Nurse Managers ran reports that should trigger those treatments had not been completed and the Nurse Managers should be following up with the staff.
During an interview on [DATE] at 12:11 PM, RNS #36 stated when a resident returned from a consult, any nurse could review the paperwork, write a progress note, and leave the consult information for the provider to review in the communication book. When they reviewed the orthopedic consult on [DATE], that was the first time they saw the consult. They stated orders were not implemented timely following that consult as it took 8 days. RNS #36 stated they were not sure why the CAM boot order was not revised to include extra padding and it should have as it was recommended by the orthopedic office.
During an interview on [DATE] at 10:09 AM, PA #3 stated after the resident returned from the outside orthopedic consult, they expected a nurse to call a provider and review the recommendations. They were not aware the orthopedic recommendations were not implemented for 8 days. When a wound was found with yellow green slough, it should have been assessed by an RN. When they saw the resident on [DATE], nursing should have implemented the treatment orders and that antibiotic ointment was not an appropriate treatment for a wound with slough. PA #3 stated when the wound was not assessed timely, a treatment not ordered timely, the CAM boot not padded, and treatments not administered as ordered, it was possible those factors together could have contributed to wound deterioration and infection. They were not aware the C&S that was ordered was not obtained.
Resident #4
Resident #4 was admitted with diagnoses including dementia, diabetes, and lymphedema (abnormal swelling from excessive lymphatic fluid) in legs. The [DATE] admission Minimum Data Set (MDS) assessment documented the resident's cognition was intact; they required extensive assistance from 2 staff for most activities of daily living (ADL); was frequently incontinent of bowel and bladder; was at risk for pressure ulcers and had no unhealed pressure ulcers.
The [DATE] at 4:12 PM, registered nurse (RN) #36's progress note documented the resident was a new admission and their skin was intact.
The [DATE] comprehensive care plan (CCP) documented the resident was at risk for impaired skin integrity. Interventions included inspect skin daily, Braden (skin risk) assessments, and weekly head to toe skin checks to be documented.
The [DATE] at 7:41 PM, licensed practical nurse (LPN) #4's progress note documented a new open area was found on resident's right, mid, inner buttock that was circular and bleeding. The area was cleansed, skin prep (liquid skin barrier) was applied to the peri wound and it was covered with a foam dressing. The RN was notified.
The [DATE] at 6:17 AM, LPN #26's progress note documented the resident had an open area on the right buttock with no treatment ordered and a small abrasion to the resident's left lower back leg with no treatment ordered. The RN was made aware of both, a note was left in the physician's binder and for the Nurse Manager, and the oncoming shift was made aware.
The [DATE] at 6:40 AM, LPN #26's progress note documented the area of the resident's left lower back of the leg was in need of a treatment order and this information was in the physician binder awaiting physician review. The Director of Nursing (DON) was made aware of the issue.
The [DATE] facility attending physician #44's order documented to right buttock MASD (moisture associated skin damage), cleanse with soap and water and apply a protective barrier cream with zinc twice daily. There was no documented treatment to the left lower back leg.
The [DATE] at 9:45 AM, LPN #21's progress note documented the resident was found with blood clots in their brief, and they were sent to hospital.
The [DATE] emergency room report documented the resident presented to the hospital for an evaluation of bleeding from an unknown source which could have been vaginal, rectal, or from the sacral wound. The resident returned to the facility the same day.
The [DATE] at 9:08 PM, DON's progress note documented they were called to assess a wound to the resident's right heel that was unstageable (full thickness, depth unknown). The wound had 95% eschar (dry dead tissue) and 5% granulation with scant purulent (pus) drainage. The peri wound was macerated (prolonged contact with moisture). A new order was obtained for skin prep and cover with a foam dressing every 3 days. Assistant Director of Nursing (ADON) #25 was notified to add to wound rounds.
There was no documentation of an assessment of the sacral pressure ulcer or that a treatment was ordered.
The [DATE] at 7:02 PM, ADON #25's progress note documented wound rounds with the wound physician #55 were completed. In addition to the pressure ulcer on the right heel, the resident was noted with an unstageable right buttock pressure ulcer that was 11.5 centimeters (cm) x 3.3 cm. Also noted to have at the top of this wound an unstageable wound that was 4.8 cm x 2.5 cm with 100% eschar. Treatment orders were obtained by the wound physician.
The [DATE] wound physician #55's progress note documented they recommended a change to the resident's right heel pressure ulcer treatment to povidone-iodone (antiseptic treatment), cover with a dry dressing, and wrap with gauze daily.
The [DATE] physician assistant (PA) #5's progress note documented the resident had 2 unstageable pressure ulcers on the right heel and buttock. The resident seemed to be in quite a bit of pain. WBC (white blood cell count, could indicate infection) was elevated. The plan included increasing Tylenol, adding Mobic (pain reliever), and applying Lidocaine (topical numbing cream) in the area of the right heel and buttock. Doxycycline (antibiotic) was ordered for the elevated WBC.
The [DATE] at 10:58 PM, LPN #23's progress note documented the resident was observed with 2 new open areas to both their left and right buttocks and a red area to the left gluteal fold. The provider was made aware.
The [DATE] at 6:08 AM, agency LPN #39's progress note documented the resident had a large amount of thick black slough with strong foul odor in their wound bed. The RN, DON, and physician were updated about the resident's wound.
The [DATE] wound physician's progress note documented they assessed the resident's wounds that date and recommended a treatment change for the sacral pressure ulcer. The wound physician noted the resident had an unstageable pressure ulcer on the sacrum measuring 5 cm x 8 cm with odor and to change the treatment to calcium alginate and cover with dressing every 3 days.
The 12/29 to [DATE] TAR documented the sacrum wound had a treatment ordered of povidone-iodone (anti-microbial wound treatment) daily. There was no documented evidence the treatment to the sacrum was changed per the wound physician recommendations on [DATE].
The [DATE] at 2:40 AM, nursing note documented the resident expired at 1:10 AM.
During a telephone interview on [DATE] at 10:45 AM, LPN #39 stated when they documented on the change in the resident's wound on [DATE], they believed they were told the resident would be seen on wound rounds the following day. They did not recall who they reported to that day.
During an interview on [DATE] at 10:12 AM, LPN #4 stated if a resident was found with a new skin issue, the RN should assess the wound at the time they were notified. LPN #4 stated it was their understanding that LPNs could apply skin prep, treatments with zinc, and foam dressings to wounds without physician's orders and when residents were awaiting RN assessments. On [DATE], when they found the resident with a new skin issue, they applied skin prep and a foam dressing and notified an RN. They did not call a medical provider for an order for the treatment they applied.
During an interview on [DATE] at 3:11 PM, LPN #23 stated when they found a new skin issue, they reported it to the RN and if no RN was on duty, they would call the DON. When they documented on [DATE] that the provider was made aware, that meant they documented the concern in the physician binder for the next time the physician was in the building.
During an interview on [DATE] at 1:36 PM, the DON stated when a resident returned from the hospital and was gone for less than 24 hours, a skin assessment was not required. The Supervisor or Nurse Manager should have reviewed the resident's hospital paperwork on [DATE], saw that a sacral wound was noted, and should have assessed the wound and obtained treatment orders.
During an interview on [DATE] at 10:31 AM, ADON #25 stated they started as the wound nurse at the end of 11/22. If a resident developed a new skin issue, they expected an RN to assess, initiate a treatment, and notify the facility's attending physician. ADON #25 stated an assessment should have been done in 10/22 when the resident developed pressure ulcers, the pressure ulcers should have been monitored weekly, and the medical provider should have followed-up. On [DATE], when the resident returned from the hospital, ADON #25 was not informed of the resident's sacral ulcer and if they were aware, they would have assessed and obtained a treatment order. On [DATE], ADON #25 assessed the resident's skin after the DON told them the resident had a heel wound. The resident's family member was present and asked them to look at the resident's bottom. The family member reported they had been telling facility staff the resident had an open area on the buttocks for 2 weeks. When ADON #25 rolled the resident onto their side, a large area on the buttocks that was black in color was observed. ADON #25 stated they were not sure why the wound physician's recommendation were not implemented and they should have been.
During an interview on [DATE] at 11:09 AM, the resident's family member stated they first became aware the resident had wounds on their back/bottom in 11/22 when an unidentified certified nurse aide (CNA) told them the resident was incontinent and they were letting the wounds on their bottom dry out. On [DATE], they were notified by an unidentified nurse the resident returned from the hospital and the hospital was concerned about the sacral pressure ulcer. The first time they observed the resident's wounds was on [DATE] during wound rounds. The family member asked the wound team to look at the wound on the resident's backside. When the wound team rolled the resident onto their side, they all appeared speechless. There were 2 areas near the base of the resident's coccyx (tailbone) that connected and were about 4-5 inches each and were black in color. The resident was in a lot of pain when they tended to the wounds.
During an interview on [DATE] at 10:09 AM, facility PA #3 stated on 10/20, 10/21 and [DATE], they expected an RN to have assessed the resident's wound, determined an appropriate treatment, and notify the provider. On [DATE], when the resident returned from the hospital, a full skin assessment should have been completed and a treatment initiated for the resident's sacral wound. A treatment to the sacral wound was not initiated timely and the delay in treatment could have caused the wound to worsen. On 12/23 and [DATE], the resident should have been assessed by an RN.
During a subsequent interview on [DATE] at 9:50 AM, the DON stated on [DATE], they did not recall notifying the resident's family member of the pressure ulcer but they might have directed the nurse on the unit or ADON #25 to do it.
Resident #6
Resident #6 was admitted with diagnoses including diabetes and chronic kidney disease. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was intact, they required extensive assistance with activities of daily living (ADL) and had two Stage 1 pressure ulcers (intact skin, non-blanchable (inadequate blood flow) and two Stage 2 pressure ulcers (partial thickness loss of skin layers) present on admission.
The [DATE] at 4:33 PM, registered nurse (RN) Manager #8's progress note documented the resident's coccyx (tailbone) was red but blanchable with 3 small open areas measuring 0.5 centimeters (cm) x 0.5 cm and the right mid back was excoriated and measured 2 cm x 2 cm.
The [DATE] comprehensive care plan (CCP) documented the resident was at risk for impaired skin integrity and needed assistance with ADLs. Interventions included barrier cream after each episode of incontinence, pressure relieving cushion in chair, turn and reposition every 2 hours, weekly head to toe skin check, and extensive assistance of 1 staff for bed mobility/transfers.
The [DATE] at 8:27 PM, Director of Nursing's (DON) progress note documented the resident was seen on weekly wound rounds and the family reported an issue with the resident's heels. The resident had the wounds on the sacrum, right gluteal cleft (buttocks crease), and right and left heels. The wounds were assessed and measured at that time and the DON noted an air mattress would be obtained, and blue booties were ordered.
The [DATE] attending physician #44's orders documented treatments were ordered to the resident's pressure ulcers including skip prep (liquid skin barrier) to the left heel twice daily; skin prep and a foam dressing to the right heel every 3 days, and skin prep and a foam dressing to the sacral ulcer every 3 days. These orders were implemented 3 days after admission.
The [DATE] at 2:28 AM, licensed practical nurse (LPN) #4's progress note documented a new area on the resident's back left thigh. They applied skin prep and covered with a foam dressing.
There were no further documented wound assessments or wound treatment orders in the resident's record. The resident was discharged to the hospital on [DATE] (13 days later) with issues unrelated to their wounds.
During an interview on [DATE] at 10:12 AM, LPN #4 stated if a resident was found with a new skin issue, they would immediately evaluate the resident and come up with a plan. The RN should assess at the time they were notified, and the RN would notify the provider. They stated it was their understanding they could apply skin prep, foam dressings, and ointments with zinc to wounds without a physician's order and while residents were awaiting RN assessments. On [DATE], they thought the resident had a fluid filled blister though were not sure and they applied skin prep and a foam dressing. There was no RN on duty on [DATE]. They stated they thought the Assistant Director of Nursing (ADON) and DON would have read their nursing note and would have become aware of the skin issue that way.
During an interview on [DATE] at 1:36 PM, the DON stated they expected RN #8 to obtain a treatment order for the areas they noted on the resident's coccyx and right mid back on [DATE]. On [DATE], they completed a wound assessment and initiated a treatment. They were not aware there was no prior treatment orders in place for the resident. If an LPN found a new wound, the RN should be notified. The RN would determine the appropriate treatment and notify the facility medical providers (attending physician #44 or PA #3) for an order. They were not aware an LPN found a new wound on the resident's back left thigh and was not aware there was no RN assessment. The LPN should obtained an order before they applied skin prep and a foam dressing on [DATE]. They were not aware there was no documented treatment for the resident's back thigh from [DATE] until discharge on [DATE].
On [DATE] at 10:09 AM, physician assistant (PA) #3 stated in a telephone interview, they expected treatments to be ordered on admission if needed. If a resident had a new or worsening ulcer, they expected an assessment within 24 hours. Treatments should be implemented as soon as possible. On [DATE], an RN should have assessed the resident and recommended a treatment.
10NYCRR 415.12(c)(2)
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated surveys (NY00308875 and NY00313567), the facility failed to make pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated surveys (NY00308875 and NY00313567), the facility failed to make prompt efforts to resolve grievances for 2 of 6 residents reviewed (Residents #3 and 4). Specifically, Resident #3's family members reported the resident's bottom dentures were missing, and Resident #4's family reported a missing engagement ring and there was no documented evidence the grievances were investigated and followed-up on timely, and no documentation the facility followed-up with the individuals filing the grievances with an outcome.
Findings include:
The facility Grievance/Complaint Policy, revised [DATE], documented:
- Staff were expected to complete the forms including all information that was available and the forms were to be routed to the Director of Social Services or assigned social worker for review.
- The Director of Social Services or assigned social worker would direct the forms to the appropriate department head/designee who would attempt to resolve the grievance in a timely manner.
- The means by which the grievance was resolved would be recorded in the follow-up action and the completed form would be routed back to the Director of Social Services or social worker.
- The Director of Social Services or social worker would follow-up with the resident and/or representative to ensure resolution and would note the date this occurred on the grievance form.
- When a resolution was not attained, the form would be routed to the Administrator for appropriate action.
1) Resident #3 had diagnoses including a past cerebrovascular accident (CVA, stroke) and dementia. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired. The resident had no chewing or swallowing issues.
The Director of Nursing's (DON) admission assessment on [DATE] documented the resident had top and bottom dentures on admission.
The [DATE] Lost/Missing Item Report documented:
- The resident's son reported the resident's bottom dentures were missing since either [DATE] or [DATE].
- The family searched the resident's room and did not find the dentures.
- The portions of the form to document the search of the resident's roommate's side of the room and other rooms on the unit were not filled out nor were the portions of the form documenting that environmental services completed a search for the items.
- Social services follow-up with the responsible party and update of the Nurse Manager were not completed.
- Under results of investigation was documented resident received lower dentures and expresses no issues or concerns. The name/title of the person making that note was not documented and there was no date when the resident received their dentures back.
- The form was signed by the Administrator.
- Included with the form was a timeline signed by the Administrator documenting on [DATE], the resident was sent to the hospital and all belongings, including upper and lower dentures, were packed, and awaiting family pick up.
On [DATE], a complaint was filed with the New York State Department of Health (NYS DOH) documenting the resident's bottom dentures went missing the day of admission in 7/2022 and they were never located.
On [DATE] at 9:52 AM, certified nurse aide (CNA) #10 stated in an interview, the resident had top dentures when they were at the facility, and they were not aware the resident was admitted with bottom dentures that were reported missing. The CNA stated they never saw the resident with bottom dentures.
On [DATE] at 9:00 AM, the resident's family member was interviewed and stated themselves and their sibling were present the date they reported the resident's dentures missing in 7/2022. They stated the resident was in the hospital for the past month and had their top dentures with them but never got their bottom dentures back.
On [DATE] at 12:42 PM, licensed practical nurse (LPN) Unit Manager #29 stated in an interview, during the resident's admission they only had top dentures. They were not aware the resident had bottom dentures until the surveyors were at the facility a few weeks ago in 4/2023 and asked for the grievance information. The LPN stated on that day in 4/2023, they found bottom dentures in the resident's room.
On [DATE] at 2:08 PM, the resident's family member was re-interviewed and stated they picked up all the resident's belongings from the facility over the weekend ([DATE]). They stated there were top and bottom dentures in the box, but they were not the dentures reported missing in 7/2022. They stated when the resident's dentures were not found, the family brought in some old dentures from home to see if they would fit the resident, but they did not fit. They stated the resident's dentures had not been found and there was no follow-up from the facility on the bottom dentures they reported missing in 7/2022.
During an interview on [DATE] at 12:55 PM, the Administrator stated they were unaware of when the grievance regarding the resident's missing dentures was completed. The expected time to address grievances was within 7 days, and if it took longer, the family or resident should be updated. The Administrator was not aware the dentures found in 4/2023 when the DOH surveyors were present were not the resident's missing dentures. The Administrator stated they thought the dentures were found and no further follow-up was needed. They were unaware of the discrepancy regarding the resident having only upper dentures in the hospital when they went on [DATE] and the missing items report documenting the dentures were found at the facility.
2) Resident #4 had diagnoses including dementia, diabetes, and lymphedema (abnormal swelling from excessive lymphatic fluid) in legs. The [DATE] admission Minimum Data Set (MDS) assessment documented the resident's cognition was intact, they required extensive assistance from 2 with bed mobility, dressing, and personal hygiene.
The [DATE] progress note entered by Director of Social Work (DSW) #54 documented they saw the resident for admission. There was no documentation related to the resident's personal belongings or valuable items.
The resident's record contained no documented personal property inventory.
The [DATE] at 2:40 AM nursing progress entered by registered nurse Supervisor (RNS) #2 documented they were called in to pronounce the resident (deceased ) at 1:10 AM.
The [DATE] Grievance and Complaint Form documented:
- the date of occurrence was [DATE] ([DATE]).
- The form was completed on [DATE] by DSW #54.
- The person raising the concern was the resident's relative.
- The concern was a missing engagement ring after the resident was transferred to the funeral home.
- The follow up action included interviewed nursing staff as well as housekeeping staff, staff were not aware of an engagement ring.
- The social service follow-up date/time and whom section was blank.
- The summary documented the local police arrived on [DATE] regarding the missing ring. The investigation was closed based on the facility being unable to confirm if the loss occurred at the facility or if the rings were ever in the resident's possession. The summary was signed by the Administrator and DSW #54 on [DATE].
- One staff statement was dated [DATE], three statements were dated [DATE], five statements were dated [DATE], and one statement was dated [DATE].
On [DATE], a complaint was filed by the resident's family member with the New York State Department of Health (NYS DOH) which documented on [DATE] at 1:00 PM, the family arrived at the funeral home where the funeral home reported the resident did not arrive wearing any rings. On [DATE] at 3 PM, the family went to the nursing facility to pack up the resident's belongings and did not find the ring in the room. They spoke to RNS #2 who checked the facility's safe and did not find the ring. They filed a complaint with RNS #2 about the missing ring. At 4:30 PM that day, the Director on Nursing (DON) or Assistant Director of Nursing (ADON) called the family to gather information about the missing ring and they stated they would receive a follow-up call by [DATE]. As of [DATE], the family received no follow-up call from the facility on the investigation into the missing ring.
There was no documented evidence the investigation was initiated from the time of the complaint on [DATE] or from [DATE] to [DATE] after the complaint form was initiated. There was no documented evidence the facility followed up with the family regarding the outcome of their complaint.
During an interview with RNS #2 on [DATE] at 11:50 AM, they stated after the resident passed away, the family arrived at the facility on [DATE] and reported the resident's engagement ring was missing. The RNS reported it to the DON and later submitted a statement to the Administrator.
During an interview with the Administrator on [DATE] at 12:55 PM, they stated the grievance form should include follow-up and a signature of the person who followed up with the person who made the complaint. They were not aware of the timeline for the grievance investigation regarding the missing ring. They collected statements from staff, and it may have taken some time to track down the employees. The Administrator was not aware if the facility followed up with the family and stated they expected DSW #54 would have. The police told the Administrator they would also follow up.
10 NYCRR 415.3(c)(1)(i)
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interviews during the abbreviated survey (NY00299057), the facility failed to ensure all alleged violations including injuries of unknown origin, were thoroughly investigate...
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Based on record review and interviews during the abbreviated survey (NY00299057), the facility failed to ensure all alleged violations including injuries of unknown origin, were thoroughly investigated to rule out abuse or neglect for 1 of 6 residents (Resident #1) reviewed. Specifically, staff identified a bruise on Resident #1 and there was no investigation completed to rule out abuse or neglect.
Findings include:
The facility policy Freedom from Abuse, Neglect, and Exploitation reviewed 3/22, documented all incidents of potential abuse/neglect should be investigated which included obtaining statements from employees or other witnesses, resident interviews, review of personnel files, review of education records, and nursing facility documentation.
Resident #1 had diagnoses including Alzheimer's disease. The 7/13/22 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and the resident did not exhibited behaviors.
The 7/8/22 Director of Nursing's (DON) progress note at 1:15 PM, documented the resident's family member was in and reported the resident had increased back pain when transferring. The DON noted the resident with a large, faded bruise on the lower back and the licensed practical nurse (LPN) gave the resident Tylenol (pain reliever) around 11:45 PM. A recent fall on 6/27/22 was noted and at that time the resident denied pain and had no bruising or redness. On 7/5/22, therapy reported to the Unit Manager the resident had a large bruise and was noted with increased pain. A provider visit was completed, and the resident had a history of compression fractures in the lower back. X-rays were ordered to the lumbar (lower back) spine.
The 7/8/22 at 3:57 PM, registered nurse (RN) #52's progress note documented the resident had bruises over the left back. There was mild tenderness on palpation. The RN noted they were unaware of how the bruising occurred and the DON and family were informed.
The 7/8/22 DON's progress note at 4:55 PM, documented the X-ray report was received and no acute abnormalities were noted.
On 4/18/23 at 10:11 AM, LPN Unit Manager #18 stated in an interview, PT reported the resident's bruise to nursing on 7/5/22, and an x-ray was done. LPN #18 stated they did not see that an Accident and Incident Report was completed but the resident had a recent fall so it was assumed the bruise was related to that fall. LPN #18 stated typically if a bruise of unknown origin was found, they would go back 72 hours and try to see what could have caused it. They added if this bruise was noticed 13 days after the last recorded fall, they should have started an investigation into the cause of the bruise.
On 4/28/23 at 12:51 PM, physical therapist (PT) #52 stated in an interview, they recalled noting a bruise on the resident in 7/2022 and the resident's complained of pain. They were not sure who they notified and could not access the record at the time of the interview. They stated if they found an injury on a resident, they would issue a stop and watch form and notify nursing. They would start an Accident and Incident Report if they were directed to. They did not know if they initiated an Accident and Incident Report in this case as it would be determined after the nursing evaluation of the issue as nursing may have already been aware of the bruise when the PT reported it.
On 5/1/23 at 1:36 PM the DON stated in an interview, when an incident occurred, the LPN was supposed to notify the RN so an assessment could be done. The RN was responsible for initiating an investigation and an Accident and Incident Report. If there was no RN in the building at the time, the LPN could start the process and leave the reports for the DON to complete. During the interview, the DON was asked for any additional Accident and Incident Reports for the resident.
On 5/2/23 at 12:30 PM, PT #52 called the surveyor back and reported they checked the resident's record and had additional information. They stated on 7/5/22, they issued a stop and watch, which was an alert for nursing, letting them know about the resident's bruise and complaints of pain. They stated to their knowledge, the bruise was new, and the resident also complained of back pain at the same time. They stated they thought the resident had a recent fall, but the bruise and pain were new, so they felt it needed to be evaluated.
On 5/3/23 at 10:12 AM, the surveyor sent an email to the DON and Administrator requesting any additional Accident and Incident Reports for the resident and an investigation into the bruise of unknown origin in 7/2022 was not received.
10NYCRR 415.4(b)(3)
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the abbreviated survey (NY00310805), the facility failed to ensure residents receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the abbreviated survey (NY00310805), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 residents reviewed (Resident #6). Specifically, Resident #6:
- had no documented evidence that hospital recommendations were reviewed or implemented on admission for a diuretic medication (helps rid the body of fluid), a 1500 cubic centimeter (cc) fluid restriction, daily weight monitoring, and twice daily blood sugar monitoring.
- had no documented interventions for monitoring for signs and symptoms of congestive heart failure (CHF), fluid overload (too much fluid in the body), and edema (swelling).
- had no documented evidence a plan for fluid intake was implemented after a fluid restriction was ordered and the resident received fluids in excess of the 1500 cc per day ordered restriction.
- had an oral blood sugar medication ordered on admission that was not available for 2 days and was not administered as ordered.
- had documented pitting edema (leaving an indentation in skin when pressure was applied caused by excess fluid build up) on 2 occasions with no documented assessments by qualified professionals.
- had no documentation of a skin assessment on admission and when their skin was assessed 3 days later, the resident were found with multiple venous ulcers (ulcers from poor bloodflow). After the venous ulcers were identified, there were no further documented skin assessments during the resident's admission.
Findings include:
The Change of Resident Condition facility policy revised 3/2022 documented resident's were to be assessed by the registered nurse (RN) and the legal representative notified when there was a significant change in the resident's status (i.e., deterioration in health, mental status, or psychosocial status in either life threatening conditions or clinical/medical complications). Nursing staff were to notify the attending physician and legal representative, and document in the progress notes and 24-hour report.
The Medication Administration facility policy revised 3/2022 documented medications would be administered by a licensed nurse and documented in the medical record. If a medication was not available, the RN Supervisor (RNS) was to be notified and the RNS would contact the pharmacy and notify the physician as necessary.
The Care Planning facility policy revised 3/2022 documented the facility utilized an interdisciplinary team (IDT) in conjunction with the resident/representative as appropriate to provide an individualized assessment and care planning process. The baseline care plan was to be developed and implemented within 48 hours of admission and included instructions to provide effective and person-centered care. They should include at a minimum the information necessary to properly care for the resident. The comprehensive care plan (CCP) should describe the residents' medical, nursing, physical, mental, and psychosocial needs, and preferences and how the facility would assist in meeting those needs and preferences.
The admission of a Resident/Patient facility policy revised 10/2022 documented when a resident was admitted , there were forms which would be completed within 8 hours of admission. The admission observation would be filled out on admission and all areas completed. An RN must do the skin assessment on admission. An RN admission note would be written which included items discovered that were not addressed on the admission Data Form. If there was a skin issue upon admission, the wound management section would be completed for an initial wound assessment and would be followed weekly until resolved for 4 weeks. It was essential that the physician and family be notified and an order for treatment be put in place.
Resident #6 had diagnoses including CHF, diabetes, and chronic kidney disease. The [DATE] admission Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance with activities of daily living (ADL), and had 5 venous ulcers.
The [DATE] hospital discharge summary documented the resident was seen at cardiology on [DATE] with weight gain from their baseline of 180 pounds to 196 pounds and cardiology sent them to the emergency department (ED). The resident was in fluid overload and underwent thoracentesis (procedure that removes fluid from lungs) with removal of 1.2 liters (L) of fluid. Discharge medications included: metoprolol XL (antihypertensive) 25 milligrams (mg) daily, midodrine (antihypertensive) 5 mg 3 times daily, torsemide (diuretic, removes fluid) 100 mg daily, metolazone (diuretic) 2.5 mg every other day, insulin glargine (long-acting insulin) 10 units every evening, Januvia (oral antidiabetic) 50 mg daily, and blood sugar monitoring twice daily. The report documented to check weights daily, monitor for shortness of breath, increased leg swelling, and low oxygen saturation levels. The resident's weight on [DATE] was 204 pounds, they were on a 2 gram (g) sodium diet and a 1500 cc fluid restriction.
The [DATE] at 4:33 PM, RN #8's progress note documented the resident was admitted to the facility. The resident's lungs were clear in the upper lobes and diminished in the bases. Their skin was warm and pink, and they had skin alterations on the coccyx (tailbone) and mid-back.
The [DATE] at 6:23 PM, Director of Nursing's (DON) progress note and admission Nursing Assessment documented the resident had trace edema in their legs. Medications were reviewed and reconciled with the provider and entered into electronic medical record by the licensed practical nurse (LPN).
The [DATE] admission physician's orders included:
- insulin glargine, 100 units/milliliter (ml), 10 units subcutaneously at bedtime;
- metolazone, 2.5 mg by mouth every other day;
- metoprolol XL, 25 mg by mouth daily;
- midodrine, 5 mg by mouth 3 times daily; and
- Nesina (oral antidiabetic, blood sugar medication) 12.5 mg by mouth daily.
There was no documentation the hospital recommendations for daily weights, a 1500 cc fluid restriction, torsemide 100 mg daily, and twice daily blood sugar monitoring were reviewed with a provider and no documented rationale for not continuing those recommendations.
The [DATE] CCP and Resident Profile Sheet (care instructions) did not include a plan to monitor for signs and symptoms of fluid overload.
The [DATE] physician's orders documented the diet order was: pureed with thin liquids, limit sodium, and carbohydrate controlled. There was no documentation a fluid restriction was ordered.
The [DATE] Medication Administration Record (MAR) documented:
- on [DATE], LPN #7 documented Nesina 12.5 mg was not administered, not available from the pharmacy and delivery was pending.
- on [DATE], LPN #4 documented Nesina 12.5 mg was not administered due to waiting on the pharmacy. The provider was notified.
There was documented evidence the provider was notified of the unavailability of Nesina.
The [DATE] physician's order documented a 1500 cc fluid restriction.
There was no documented evidence the CCP or Resident Profile Sheet were updated with the 1500 cc fluid restriction.
There was no documented evidence the resident was assessed by the registered dietitian (RD) and no evidence a plan was implemented to ensure the resident maintained the 1500 cc fluid restriction.
The [DATE] at 8 PM, RNS #2's progress note documented the resident had 3+ (severity level from 1 [least] to 4 [most]) pitting edema in both lower legs and up to the thighs, and 1 to 2+ edema up to the neck. The resident's skin wept (fluid leaking from skin) in areas such as their elbow and both lower legs. The resident's family was concerned the resident was not on a diuretic, the on-call physician was notified and ordered torsemide 100 mg every morning and monitor blood pressure (BP) closely, so the resident's BP did not bottom out.
The [DATE] physician's order documented torsemide, 100 mg every morning.
The Vital Signs Report documented on [DATE], the resident consumed 2320 cc of fluid.
The [DATE] physician assistant (PA) #3's progress note documented the resident was admitted post hospitalization for fluid overload, acute exacerbation of CHF on chronic CHF, and a history of diabetes. The resident was stable since arrival with no specific complaints reported. Lungs were clear and the resident had 1+ edema in both lower legs. Medications were reviewed and reconciled with no changes made at this time. The progress note did not include information from RNS #2's [DATE] progress note describing the extent of the resident's edema.
The [DATE] physician's order documented fasting blood sugars before meals and at bedtime for 5 days and update the provider with blood sugars on [DATE].
The [DATE] at 6:06 AM, LPN #4's progress note documented the resident had 3+ pitting edema to both lower legs from feet to hips. Lung sounds were clear and diminished. Vital signs were stable. The resident continued torsemide every morning and was not in respiratory distress. Lower legs were elevated on pillows. LPN #4 documented they placed this information in the medical binder for the provider to see. There was no documentation the resident was assessed timely by a qualified professional.
The Vital Signs Report documented the resident consumed:
- 1880 cc of fluid on [DATE];
- 2060 cc of fluid on [DATE];
- 1920 cc of fluid on [DATE];
- 2000 cc of fluid on [DATE]; and
- 2340 cc of fluid on [DATE].
The [DATE] PA #5's progress note documented the resident was being followed for diabetes and hyperglycemia (high blood sugar). Blood sugars were reviewed and in the 300 to 400 range and the resident denied hyperglycemic symptoms. Insulin glargine was increased from 10 to 15 units and glucose level was noted with a slight improvement. The plan was to continue insulin glargine 15 units, monitor fasting blood sugars before breakfast and bedtime twice weekly to reduce nursing load, and reassess next week. There was no documented evidence the resident's fluid status was assessed by the PA.
The [DATE] physician's order documented fasting blood sugar twice daily on Monday and Thursday for 5 days.
The Vital Signs Report documented the resident consumed:
- 2180 cc of fluid on [DATE]; and
- 1920 cc of fluid on [DATE].
The [DATE] at 12:28 PM, certified occupational therapy assistant (COTA) #6's progress note documented they observed the resident with pitting edema in both lower legs during their therapy session. The LPN and Assistant Director of Nursing (ADON) were made aware.
There was no documented evidence the resident was assessed by a qualified professional after COTA #6 notified nursing of the resident's edema.
The [DATE] at 6:41 PM, the DON's progress note documented they were made aware by phone the family requested the resident be sent to the ED (emergency department). The RNS reported to the DON the resident had increased edema, crackles (abnormal lung sounds), altered mental status, and a 79% oxygen saturation (low blood oxygen level) with oxygen applied. The PA was notified and the resident was sent to the hospital.
There were no other documented progress notes regarding the resident's change in condition and subsequent transport to the hospital.
The [DATE] hospital report documented the resident presented to the ED for evaluation for a possible stroke. Staff reported the resident was leaning toward the left and had generalized weakness today and was last seen well at 2:00 AM. The resident was in respiratory distress, had rhonchi (abnormal lung sounds) and swelling was present. Labs revealed elevated lactic acid (a build up of acid in the blood), elevated troponin (increases when heart muscle is damaged), low sodium level, elevated blood urea nitrogen/creatinine (indicates kidney function) and glucose level of 517 (milligrams/deciliter, mg/dl, goal for diabetics less than 140). They did not have evidence of diabetic ketoacidosis. Urinalysis was frankly purulent (pus). Given the resident's extensive history and recent admission for heart failure, they would be monitored very closely and given additional intravenous fluids as tolerated. The resident was made comfort care and expired 9 days later.
On [DATE] at 10:58 AM, COTA #6 could not be reached for an interview.
On [DATE] at 12:03 PM, certified nurse aide (CNA) #40 stated in a telephone interview, they knew a resident was on a fluid restriction by looking at the care plan or meal ticket, or when the nurse told them. They thought the nurse was responsible to tell them how much fluid they could give during the shift, the only fluids offered to residents were the fluids on their trays, and they did not offer any further fluids in between meals. They did not recall if the resident was on a fluid restriction. They recalled the resident was swollen and their skin wept in their arms and legs.
On [DATE] at 10:12 AM, LPN #4 stated in an interview, they knew a resident was on a fluid restriction by looking at physician's orders, the meal ticket, or the Resident Profile Sheet. The RD calculated how much fluid nursing could give with medications, how much was given with meals, and the meal ticket documented the total amount of fluid that could be given per day and what was allowed at each meal. CNAs tracked fluids with meals. They believed they were verbally told the resident was on a fluid restriction. If they wanted the physician notified about a concern, they left a note in the medical binder. Providers reviewed the medical binders when they were in the facility 3 times weekly. On [DATE], the resident's edema was their normal. The resident had some weeping they had not noticed before, they did not believe there was an RNS in the building that night and if there was they would have notified them and documented in their note. They were concerned the resident's condition was not getting better so they left a note in the medical binder to alert the provider and thought the resident would have been seen the next day.
On [DATE] at 1:36 PM, the DON stated in an interview:
- The resident was admitted with CHF and should be addressed in the CCP. The admission nurse was responsible to update the CCP. Fluid restrictions were physician ordered and also in the CCP.
- They were not aware there were no notes from a RD regarding the resident's fluid restriction and were not sure if the facility had a RD during the resident's admission. The RD was responsible to calculate daily fluid intakes and alert someone if the resident was going over the restriction. If there was no RD available, they were not sure who was responsible. They stated they were not aware the resident was receiving more fluid than what was ordered.
- They were not aware Nesina was not administered for 2 days. Nursing should have notified the provider and documented what they wanted done.
On [DATE] at 9:21 AM, LPN #7 was not reached in an interview.
On [DATE] at 10:09 AM, PA #3 stated in a telephone interview:
- nursing reviewed hospital discharge recommendations with the provider and while recommendations were considered, the provider reserved the right to make changes.
- for insulin dependent diabetics, they typically ordered blood sugar monitoring before meals and bedtime for 5 days until the resident could be reassessed. It was not timely when the resident went 6 days without an order for blood sugar monitoring.
- When the resident's insulin was increased from 10 to 15 units, they would not have expected blood sugar monitoring to be decreased to twice weekly monitoring. They were not aware the resident was discharged to the hospital with a blood sugar over 500.
- the 1500 cc fluid restriction recommended by the hospital upon admission should have been ordered and was not ordered timely.
- Torsemide and daily weights should have been ordered upon admission and they were not aware they were not. When the resident developed edema and Torsemide was added, it was not done timely.
- They expected dietary involvement for fluid calculation and monitoring and were not aware they were not involved.
- When the fluid restriction was ordered, they expected nursing to ensure intakes were not going over 1500 cc. They expected to be notified when the resident went over their restriction.
- On 2/2 and [DATE], they expected a RN assessment and provider notification.
Venous Ulcers
The [DATE] hospital discharge summary documented the resident was discharged to rehabilitation and should be observed for redness, swelling or drainage of their left leg wound.
The [DATE] at 4:33 PM, RN #8's progress note documented the resident was alert and oriented to person, place, and time, their left knee was wrapped, and they were unable to assess the area.
The [DATE] admission Nursing Assessment completed by the DON documented the resident's left knee was wrapped and they were unable to assess.
The [DATE] CCP documented the resident was at risk for impaired skin integrity and they needed assistance with ADLs. Interventions included barrier cream after each episode of incontinence, pressure relieving cushion in chair when out of bed, RN to complete Braden weekly for 4 weeks, and reposition every 2 hours, weekly head to toe skin check, and extensive assistance of 1 for bed mobility and transfers.
The [DATE] at 8:27 PM, DON note (3 days after admission) documented the resident was seen on weekly wound rounds and they had:
- a left lower leg proximal (closest) venous ulcer, 4.5 centimeters (cm) x 4.5 cm, 90% slough (non-viable tissue);
- a left lower leg mid (towards midline) anterior (front) venous ulcer, 3.5 cm x 2 cm, 30% slough;
- a left lower leg distal (furthest) anterior venous ulcer, 2.9 cm x 5.5 cm, 100% epithelial (new skin);
- a left lower leg posterior (back) venous ulcer, 1.5 cm x 1.5 cm with copious (large) amount of drainage secondary to weeping 4+ pitting edema; and
- a right top foot venous ulcer, 0.6 cm x 1.1 cm
The family was present and reported the left venous ulcers were present in the hospital.
The [DATE] physician's order (3 days after admission) documented to cleanse the lower left leg vascular wounds with wound cleanser, apply skin prep (skin protectant) to periwound, cut Xeroform to wound bed, wrap with CoFlex (dressing) 2-layers, then Medigrip (tubular support bandage) and change every 3 days, top right foot venous ulcer, skin prep peri-wound and cover Optifoam every 3 days.
The [DATE] CCP documented the resident had venous ulcers to the left lower leg and top of right foot. Interventions included to obtain RD/dietary consult, wound rounds weekly to assess and record the stage, condition and size of wound and update physician weekly.
They
There were no further documented wound assessments for the resident's left lower leg and top right foot wound. They were discharged to the hospital on [DATE] unrelated to their wounds.
On [DATE] at 1:36 PM, the DON stated in an interview, when ADON #25 was not available for wound rounds, they were responsible to complete them. RN #8 completed the resident's initial skin assessment on [DATE] and they no longer worked for the facility. They assessed the resident's skin and initiated treatment orders on [DATE] because ADON #25 was not available. They were not aware treatment orders were not initiated upon admission and they were not aware ongoing weekly skin assessment did not occur.
On [DATE] at 10:31 AM, ADON #25 stated in a telephone interview, they started as the wound nurse in late 11/22 and they typically learned a resident had wounds by attending morning report or by reading progress notes. A resident should be assessed weekly when they had wounds and the stage, wound characteristics and measurements should be documented in the progress notes. They stated they never saw the resident during their admission because they were on a leave of absence, and they expected another RN to have assessed the resident's wounds during their admission and weekly thereafter.
On [DATE] at 10:54 AM, RN #8 was not reached in an interview.
On [DATE] at 10:09 AM, PA #3 stated in a telephone interview, they expected a full skin assessment to be completed on admission to make sure that if wounds were present, there was a treatment ordered. Nursing should have removed the resident's bandages on [DATE] to determine if treatment orders were needed and it was not timely when wounds were assessed 3 days later. They expected wounds to be assessed weekly to ensure progress and healing and to determine if treatments should be changed.
10 NYCRR 415.12
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
Based on record review and interviews during the abbreviated surveys (NY00313567 and NY00299057) the facility failed to maintain acceptable parameters of nutritional status, and failed to recognize, e...
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Based on record review and interviews during the abbreviated surveys (NY00313567 and NY00299057) the facility failed to maintain acceptable parameters of nutritional status, and failed to recognize, evaluate, and address the needs of residents, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration for 2 of 9 residents (Residents #1 and 3) reviewed. Specifically:
- For Resident #3, there was no documented evidence of clinical nutrition assessments or reassessments when the resident consumed foods and fluids poorly, had weight loss, was treated for a urinary tract infection (UT), developed pressure ulcers, and had issues with nausea and vomiting.
- For Resident #1, there was no documented evidence of clinical nutrition assessments or reassessments when the resident consumed foods and fluids poorly, was treated for a UTI, and developed a pressure ulcer.
Findings include:
The Skin/Pressure Ulcer Prevention & Intervention Program facility policy revised 4/2014 documented:
- Residents with new skin/pressure ulcers would be referred to the dietitian for nutritional assessment with special attention given to malnutrition, weight loss and hydration. Nutritional supplements may be added prior to assessment if deemed necessary by clinical staff.
1) Resident #3 had diagnoses including a past cerebrovascular accidents (CVA, stroke) and dementia. The 12/5/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required supervision (cueing/oversight) and assistance of 1 for eating. The resident had no weight loss and no unhealed pressure ulcers. The 2/22/23 MDS assessment documented the resident had 1 Stage 2 pressure ulcer (partial thickness tissue loss) and did not have nutrition or hydration interventions to manage skin problems. The 3/24/23 MDS assessment documented the resident had a weight loss of 5% or more in the last month or 10% or more in the last 6 months.
The comprehensive care plan (CCP), initiated on 7/14/22 documented the resident was underweight and interventions included a regular diet, and encouraging and monitoring intakes.
The 7/21/22 admission registered dietitian (RD) #19's assessment documented the resident was underweight at 106.6 pounds; consumed 74% at meals, and the goal was to maintain or gain weight. The resident's protein and fluid needs were assessed at baseline for elderly of 1 gram (g) per kilogram (kg) of body weight of protein per day (48 g) and a minimum of 1500 cubic centimeters (cc) of fluid per day (minimum recommended for elderly). The resident's plan included providing 240 cubic centimeters (cc) of extra fluids per three times per day.
On 8/18/22, the CCP was revised and documented to provide the appropriate food consistency for ease of chewing.
The 8/24/22 RD #19's progress note documented the resident's intake was poor at 21% at meals. Boost (supplement), 120 cc twice a day was added to the plan of care.
The 8/25, 8/31, and 9/8/22 RD #19's progress notes and the 9/20/22 and 10/27/22, licensed practical nurse (LPN) #18's progress notes documented the resident's had low fluid intakes.
The 10/29/22 progress notes documented:
- at 9:36 AM, by LPN #22, the resident had medium amount of emesis (vomit) and their skin was warm to touch.
- At 9:17 PM, by LPN #23, the resident had a medium amount of liquid emesis twice. Staff attempted to feed the resident at meals and intakes were poor.
The 11/1/22 RN #24 and 11/11/22 Director of Nursing (DON) progress notes documented the resident had low fluid intakes of 960 cc and 836 cc per day and fluids were to be encouraged.
On 11/18/22, the speech language pathologist (SLP) evaluation documented a mechanical soft diet was recommended.
The 11/22/22 and 11/28/22 RN #24's progress notes documented the resident had low fluid intakes and poor meal intakes of 37.5% at meals. Staff were to encourage intakes, snacks, and alternate meals.
The 12/7/22 LPN #23's progress note documented the resident had emesis and medical was made aware.
The 12/9/22 Assistant Director of Nursing (ADON) #25's progress note documented the resident was found with an unstageable (unable to visualize the wound base) right heel pressure ulcer that was 100% eschar (dry, dead tissue).
The 12/17/22 RN #26's progress note documented the resident was found with an open area on their buttocks.
The weight record documented:
- on 1/2/23, 104 pounds
- on 1/18/23, 97.6 pounds (9 pound/8.4% loss in 6 months)
There was no documented evidence a nutrition reassessment was completed following ongoing poor fluid intakes, poor food intakes, weight loss, the development of 2 pressure ulcers, and the recommendation to downgrade the resident's diet consistency.
Progress notes documented:
- on 1/11/23, per LPN #27, the resident consumed breakfast poorly and ate 50% of lunch.
- on 1/18/23, per LPN #27, the resident had a large emesis after lunch.
- on 1/18/23, per the attending physician, the resident had sudden projectile vomiting after lunch, and they were told by nursing the resident could have consumed expired milk. Zofran (medication for nausea) was ordered.
- on 2/2/23, per LPN #27, the resident was vomiting at dinner and unable to eat. Zofran was given.
- on 2/5/23 at 11:54 AM, per RN #28, the resident had 3 episodes of vomiting, fluids were encouraged, and the resident took 60 cc of Boost from the RN.
- on 2/8/23, per LPN #18, the resident's urine results were reviewed with medical and Macrobid (antibiotic) was ordered for a urinary tract infection (UTI).
There was no documented evidence of a nutrition reassessment following the resident's issues with nausea/emesis, being treated for a UTI, and in response to the resident potentially being given expired milk.
The 3/2/23, LPN #29's progress note documented the resident had emesis after breakfast, attempted to eat and could not.
The 3/21/23 RD #30's progress note documented the resident was on a regular mechanical soft diet with 120 cc Boost twice a day and 240 cc of extra fluid three times per day. Appetite was good at 76-100% at most meals but was less earlier in the month. The resident had a significant weight loss at one and three months and a skin issue on their bilateral buttocks. The plan included increasing Boost to 3 times per day and adding Super cereal (fortified cereal) to increase calories and protein.
On 3/24/23, the resident was sent to the hospital following a fall. The hospital record documented the resident was treated for dehydration in addition to the fall evaluation.
On 4/17/23 at 3:15 PM, RD #19 stated in an interview, they cut down their hours in 9/2022, and worked 5 hours per week remotely from 9/2022 to 1/2023. They stopped working at the facility altogether in 1/2023. Between 9/2022 and 1/2023, they did not attend morning meetings or wound meetings because they had another full-time job. They stated to their knowledge, nursing, mainly the DON, took over the nutritional follow-up when they left the facility in 9/2022. When they worked 5 hours per week, they were not notified of new wounds but if they were notified, they would try to reassess the resident. They stated the basic meal plan provided adequate protein and then supplements would usually be added such as Boost or Prostat (protein supplement). They stated if a resident had a UTI, they would also reassess fluid needs if they were aware.
On 4/20/23 at 1:33 PM, CNA #9 stated in an interview, the resident needed assistance at meals and was a poor eater. They stated the resident received mechanical soft foods. They recalled issues with nausea and vomiting but did not know what was done for the resident as that was a nursing issue.
On 4/21/23 at 9:52 AM, CNA #10 stated in an interview, the resident had issues with nausea and vomiting and when that happened, they let the nurses know. The CNA stated it could have been something the resident ate because there was a time when residents received spoiled milk and the resident drank it. CNA #10 stated this was discussed with Administration and the kitchen and they took all the milks off of the unit at that time.
On 4/25/23 1:42 PM, LPN #27 stated in an interview, they were an agency nurse and barely recalled taking care of the resident. They stated they remembered when the resident had nausea and vomiting and stated they thought they had a UTI at that time. They stated they recalled a time when the resident had vomiting and there was an issue with spoiled milk. LPN #27 stated it was reported to Administration and they were instructed to go around the unit and remove all the milk.
On 4/28/23 at 12:12 PM, RD #30 stated in an interview:
- They started working at the facility in 2/2023, worked 16 hours per week, and assisted with admissions, weight changes, and wounds.
- When issues arose, the DON or Administrator emailed them, and they also participated in meetings on Fridays where they would hear about issues.
- Residents would be seen by the RD for weight loss, pressure ulcers, nausea/vomiting, and poor intakes.
- If a resident had a pressure ulcer, they would check how much protein was being provided in the meal plan and would add more if needed.
- If a resident's fluid intake was low, they would have staff encourage fluids or add fluids between meals or at medication passes.
- When someone had a UTI, they would encourage fluids and offer cranberry juice at meals.
- Prior to them starting in 2/2023, they did not know who was following up on clinical nutrition issues.
- They noted on Resident #3 in 3/2023. They became aware of the resident's weight loss after they ran the monthly report of weight changes. The resident was also noted on the wound update they received.
- The RD stated they did not see a nutritional reassessment after the resident's pressure ulcer was identified prior to the one they completed in 3/2023.
- From 2/2023 when they started to 3/2023 when they noted on the resident, they were not sure if they were aware of the resident's weight loss and skin issues. They stated they pulled the report and tried to follow up on as many residents as they could.
- They did not provide a time frame for following up on residents with new pressure ulcers when asked.
On 5/1/23 at 12:42 PM, LPN Manager #29 stated in an interview the resident was difficult to feed and became distracted at meals. When the resident did not eat well, they offered them Boost and sometimes the resident took it.
On 5/1/23 at 1:36 PM, the DON stated in an interview:
- When the facility did not have an RD, they had RDs from corporate helping and from sister facilities. They stated those RDs completed assessments on new residents, and they knew for sure that one of the RDs documented in the medical records, they did not know about other ones that helped.
- The DON also reviewed weights and fluid intakes and entered orders for supplements when needed and called those other RDs when needed and when issues arose.
- When asked if there was a plan for coverage when reassessments were needed, the DON did not respond.
2) Resident #1 had diagnoses including Alzheimer's disease. The 7/13/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required supervision and assistance of 1 for eating. The resident had no or unknown weight loss or gain, had 1 Stage 2 (partial thickness tissue loss) pressure ulcer, and did not have nutrition or hydration interventions to manage skin problems. The 7/26/22 MDS assessment documented the resident had a weight loss of 5% or more in the last month or 10% or more in the last 6 months.
The comprehensive care plan (CCP), initiated on 3/1/22, documented the resident was slightly underweight and the goal was for a gradual weight gain. Goals included consuming at least 1500 cubic centimeters (cc) of fluid per day (baseline for elderly) and 50-75% at meals. Interventions included providing the diet and supplements as ordered.
The 3/7/22 registered dietitian (RD) #19's assessment documented the resident was on a regular diet with mechanical soft solids. The resident weighed 168.6 pounds on 3/1/22 and received 120 cc of Boost (supplement) twice a day with meals, an afternoon snack, and 240 cc of extra fluids three times per day. The resident's protein needs were assessed at baseline for elderly of 1 gram (g) per kilogram (kg) of body weight or 76 g per day, and fluid needs were assessed to be 2280 cc per day (30 cc per kg body weight). The plan included to monitor weights, labs, and intakes.
In 3/2022, RD #19's progress notes documented 7 times that the resident triggered for low fluid intakes. Fluids were to be encouraged and were provided at and in between meals.
The 4/19/22 quarterly RD #19's assessment documented the resident weighed 161 pounds and had a non-significant weight loss. The resident consumed 1096 cc of fluid per day and ate 44% at meals. The resident received Boost twice a day with lunch and dinner and would be monitored.
The 4/21/22 licensed practical nurse (LPN) Unit Manager #18's progress note documented the resident was being treated with an antibiotic for a urinary tract infection (UTI).
The 4/27/22 RD #19's progress note documented the resident was consuming 737 cc of fluid per day and eating 38% at meals. There was no documentation regarding the UTI and no documented evidence the resident was reassessed after being diagnosed with a UTI.
In 5/2022, RD #19's progress notes documented on 9 occasions, the resident triggered for low food or fluid intakes. The resident was to be encouraged.
The weight record documented the resident weighed 150.2 pounds and 149.2 pounds on 6/1/22.
The 6/15/22 RD #19's progress note documented the resident with a non-confirmed significant weight loss of 14.2 pounds in 1 month. There was no documentation of a reassessment or review of the resident's weight loss. The plan was continued without changes.
In 6/2022, RD #19's progress notes documented on 8 occasions the resident triggered for low food or fluid intakes. The 6/15/22 progress note documented the resident weighed 149.2 pounds which was a significant weight loss since last month. The resident ate 38% at meals and received Boost twice a day.
The 7/13/22 quarterly RD #19's assessment documented the resident weighed 146 pounds. The resident consumed 45% at meals and 943 cc of fluid per day. The resident also had a Stage 2 (pressure ulcer) to the buttocks. There was no documented evidence the resident's nutritional needs were reassessed to account for a pressure ulcer.
In 8/2022, RD#19's progress notes documented 4 occasions of low fluid intakes.
There were no additional nutrition notes in the resident's record
The weight record documented:
- on 8/3/22, the resident weighed 147 pounds.
- on 9/2/22, the resident weighed 144.3 pounds.
The nursing progress notes documented on 9/19/22, the resident continued to be treated for a Stage 2 on the coccyx.
The weight record documented the resident weighed 126.6 pounds on 10/14/22.
The resident was discharged home to the care of hospice on 10/17/22.
On 4/17/23 at 3:15 PM, RD #19 stated in an interview:
- They left the facility in 9/2022 for another full-time position and worked about 5 hours per week from 9/2022 through 1/2023.
- The resident had dementia and would be distracted at meals.
- The resident would not allow staff to feed them.
- Boost was added to meals as the resident would eat a few bites and then lose interest.
- Residents were usually weighed monthly and if there was a 5-pound difference, they would be re-weighed within a day.
- If there was a trending loss, the RD would note it and if a drastic loss such as 15-20 pounds, they would reassess. Residents at high nutritional risk of losing weight would be charted on weekly.
- They had wound meetings but since working remotely from 9/2022 to 1/2023, they were not always notified of wounds.
- If residents developed pressure ulcers, they would reassess and look at the meal plan. Residents with pressure ulcers usually received supplementation with Prostat (a protein supplement) or Boost.
- With a UTI, they would reassess fluid needs but were not always notified.
- After 9/2022, nursing took over nutrition follow-up.
- If the resident had a significant weight loss between 5/2/22 and 6/1/22 they should have been reassessed and the RD should have found out what supplements they would do better with.
On 4/18/23 at 10:11 AM, LPN Unit Manager #18 stated in an interview the resident fed themself after set-up. Some days the resident ate 100% and other days barely ate. The resident accepted the Boost supplement. The LPN stated they did not think the resident looked like they lost a significant amount of weight.
10 NYCRR 415.12(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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on interview and record review during the abbreviated survey (NY00302520), the facility failed to ensure a resident who needed respiratory care was provided such care consistent with professiona...
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Based on interview and record review during the abbreviated survey (NY00302520), the facility failed to ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #2) reviewed. Specifically,
- when Resident #2 had an order for continuous oxygen and refused to wear it, there was no documentation medical was notified.
- when the resident was provided with supplemental oxygen at rates higher than ordered there was no documentation that medical was notified.
- when the resident was changed from continuous to as needed oxygen there was no documented evidence a plan was developed and implemented to monitor oxygen saturation levels to determine if supplemental oxygen was needed.
Findings include:
The Oxygen Therapy policy, reviewed 8/26/14, documented the purpose of the policy was to act as a preventive or curative measure in conditions such as acute respiratory distress, COPD (chronic obstructive pulmonary disease), and in circulatory failure such as CHF (congestive heart failure). The procedures included:
- assess the need for oxygen and apply if saturation (amount of oxygen carried in the blood) is less than 90% or with signs of respiratory distress.
- explain the purpose of the treatment to the resident.
- the resident wearing oxygen was to be checked frequently.
- the physician was to be notified if the staff could not maintain saturations above 90% on 2 Liters (L) of oxygen.
- documentation was to include the assessment of reason for oxygen therapy, time oxygen was started, rate of oxygen, time oxygen was discontinued, and the resident's response to oxygen.
- licensed nurses were responsible for oxygen delivery to residents.
The Vital Signs policy, revised 3/2022, documented:
- on admission/readmission, vital signs were done for 7 days and then monthly thereafter.
- if there was a change in condition, vital signs were to be done.
- licensed nurses and certified nurse aides (CNA) were able to obtain vital signs on residents.
Resident #2 had diagnoses including COPD and a history of acute respiratory infections. The 2/9/23 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of 1 for dressing and hygiene, supervision for eating, and did not receive oxygen therapy. The 11/10/22 MDS (prior) assessment documented the resident was on oxygen therapy.
The comprehensive care plan (CCP), initiated on 2/17/22, documented the resident had cognitive loss/dementia and chooses/prefers not to wear oxygen. The goals included providing care as allowed and allowing the resident to have their wishes honored and respected. Approaches included educating the resident and family on the need for treatments and consequences of refusals and to notify medical of refusals. Staff were to reapproach the resident as needed. On 10/17/22, the CCP was updated by the Director of Nursing (DON) and documented they met with the family and reported the resident at times did not want to wear their oxygen.
The 1/2023 Treatment Administration Record (TAR) documented:
- an order (initiated on 10/20/22) for 2 L (liters) of oxygen AAT (at all times). Under frequency was noted every shift - prn (as needed).
- An order on 1/4/23 for 2 L supplemental oxygen prn, sats (oxygen saturations) above 90%.
The TAR did not include documentation that oxygen was applied in 1/23.
The Vitals Report documented:
- on 1/3/23, the resident's oxygen saturation level was 96% and the resident was using 2.5 L of supplemental oxygen.
- on 1/4/23, 1/8/23, 1/9/23, 1/11/23, 1/16/23, 1/18/23, and 1/22/23, the resident's oxygen saturation level was above 90% and they were not using supplemental oxygen.
- on 1/7/23, 1/12/23, 1/13/23, 1/14/23, 1/16/23, 1/22/23, and 1/24/23, the resident's oxygen saturation level was above 90% and they were using 2 L of supplemental oxygen.
- on 1/26/23 at 2:26 AM, the resident's oxygen saturation level was 91% and they were using 3 L of supplemental oxygen.
- on 1/26/23 at 12:07 PM, the resident's oxygen saturation level was 84% and the resident was not using supplemental oxygen.
The 2/2023 TAR documented an order (initiated on 1/4/23) for 2 L supplemental oxygen prn, sats (oxygen saturations) above 90%. The TAR did not include documentation that oxygen was applied in 2/2023.
The Vitals Report documented:
- on 2/1/23, 2/8/23, 2/11/23, and 2/12/23, the resident's oxygen saturation level was above 90% and the resident was using 2 L of supplemental oxygen.
The 3/2023 TAR documented an order (initiated on 1/4/23) for 2 L supplemental oxygen prn, sats (oxygen saturations) above 90%. The TAR did not include documentation that oxygen was applied from 3/1/23 through 3/8/23.
The Vitals Report contained no documentation that the resident's oxygen saturation levels were monitored in 3/2023.
The 3/9/23 Incident Report by licensed practical nurse (LPN) #45 at 1:49 AM, documented the resident was found on the floor next to the fish tank. The resident sustained a hematoma (bruise) and laceration (a deep cut) to the head. The resident was sent to the hospital for evaluation.
The 3/9/2023 hospital record documented the resident was admitted with pneumonia and a head laceration, and hematoma. The staff at the nursing facility reported the resident did not wear oxygen and oxygen saturation levels were 80% at the time of the fall.
During an interview on 4/24/23 at 2:30 PM, LPN #45 stated the resident frequently refused to wear oxygen. The resident was supposed to wear oxygen all the time but took it off and walked without it on. On 3/9/23, when the resident fell, they walked from their room to the common area without their oxygen on and was sitting in the common area prior to the fall. The LPN stated when the resident refused oxygen, they encouraged it. The resident's oxygen saturation levels were not checked regularly, and they were checked on 3/9/23 because following a fall, vital signs were obtained.
On 5/1/23 at 10 AM, CNA #49 stated in an interview, the resident did not agree to wear their oxygen often and when they saw the resident without oxygen on, they would tell a nurse. At one time, they were told the oxygen order was as needed but the nurses mostly handled the oxygen. As a CNA, they only applied oxygen to residents occasionally. The CNAs and nurses could check oxygen saturation levels and they did not know when or how often the resident was to have their levels checked. They stated if they checked the oxygen saturation, and it was low they would tell a nurse. The night the resident fell the resident did not have oxygen on. They recalled the oxygen saturation was low following the fall and they did not recall anyone attempting to apply oxygen at that time.
On 5/1/23 at 11:53 AM, CNA #50 stated in interview, when staff applied oxygen to the resident, the resident removed it, yelled, and swore at staff. The CNA stated If the resident did not have oxygen on and needed it, they would tell a nurse as CNAs did not apply oxygen. If an incident occurred such as a fall, oxygen saturation levels were checked, and CNAs or nurses could do that.
On 5/1/23 at 1:10 PM, LPN Unit Manager #18 stated in an interview:
- the resident's oxygen order was changed to as needed because they would not wear it.
- the resident's oxygen saturation levels were checked sporadically and if it was less than 90%, they were to apply oxygen. If the resident refused oxygen, they should reapproach them.
- as an LPN they could not update CCPs, and they were not sure what the resident's CCP was related to oxygen use. They stated they expected staff to monitor the resident for shortness of breath and changes in condition and reapproach if the resident refused oxygen.
During an interview on 5/1/23 at 1:36 PM, the Director of Nursing (DON) stated when the resident refused to wear oxygen staff would encourage the resident to wear the oxygen. The resident was stable for a while so the oxygen order was changed from continuous to as needed. If staff noted the resident was tired or not feeling well, they would apply oxygen. The DON stated after the resident's fall they learned the resident had pneumonia, but they saw them earlier in the day without issues, so they did not look into the fact the resident's oxygen saturation level was 80% at the time of the fall.
On 5/3/23 at 1:15 PM, nurse practitioner (NP) #51 stated they expected to be notified if a resident refused their oxygen and their oxygen saturations were below 90%. The NP would want to know to determine the resident's status. Medical providers were available 24 hours a day through the on-call number if the NP could not be reached.
10 NYCRR 415.12(k)(6)
CONCERN
(E)
📢 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 multiple residents
Based on interview and record review during the abbreviated survey (NY00313567) the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for ...
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Based on interview and record review during the abbreviated survey (NY00313567) the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed (Residents #1 and 3). Specifically, Resident #3 had multiple incidents of sliding out of their chair, their plan of care was unclear regarding fall prevention, and when they slid from the chair for the fifth time on 3/24/23, there was no documentation activity of daily living (ADL) care was provided on the day or evening shifts. Resident #1 had multiples falls where care planned interventions were not in place at the time of all falls and planned changes to fall prevention interventions were not immediately added to the care plan following falls.
Findings include:
1) Resident #3 had diagnoses including a past cerebrovascular accidents (CVA, stroke) and dementia. The 2/22/23 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance of 2 for bed mobility, transfers, toileting, and personal hygiene. The resident was incontinent of bladder and bowel and had no falls since the last assessment.
The comprehensive care plan (CCP), initiated on 7/13/22, documented the resident was at risk for falls and required assistance with activities of daily living (ADL). The resident needed extensive assistance of 2 for toileting and hygiene care and was to be toileted/checked and changed every 2 hours with specific times listed (every 2 hours) in the CCP.
The care instructions (resident profile), initiated 7/13/22, documented the resident needed extensive assistance of 2 for toileting and had a pressure relieving cushion on their wheelchair. The resident was to be toileted every 2 hours.
7/14/22 updates to the resident's CCP included a low bed and fall mats; on 8/5/22, Dycem (non-slip pad) in the resident's wheelchair; and on 9/5/22, a sign was hung in the resident's room to remind the resident to ring the call bell for assistance.
The care instructions, updated on 7/14/22 and 9/5/22, documented a low bed and fall mats and a sign hung in the resident's room to remind them to ring the call bell for assistance. There was no documented evidence Dycem was added to the instructions as noted on the CCP on 8/5/22.
Nursing progress notes and Accident and Incident Reports documented the resident had incidents of sliding from the wheelchair including:
- on 9/10/22 at 1:35 PM, the Accident and Incident Report documented the resident was found on the floor in front of their wheelchair by certified nurse aide (CNA) #13 and did not sustain an injury. Under fall prevention interventions, Dycem was not listed as being in place. The Director of Nursing (DON) signed as reviewing the report on 12/28/22.
- on 9/17/22 at 3:40 PM, licensed practical nurse (LPN) #12's progress note documented the resident slid from their chair and hit their head. LPN #12 noted the recliner legs of the chair were in the up position. The DON was notified by telephone. There was no documentation whether the resident's CCP was followed at the time of the fall. An Accident and Incident Report was requested, and the DON replied they did not have one.
- on 9/20/22 at 1:50 PM, the Accident and Incident Report documented housekeeper #14 found the resident on the floor and the resident slid from the chair and hit their head. Under fall prevention in place, Dycem was not listed.
In an interview on 4/24/23 at 10:23 AM, LPN #12, stated they worked weekends and did not know Resident #3 well. They recalled the 9/17/22 fall when the surveyor read them their progress note. They stated this fall occurred from a recliner in the resident's room. LPN #12 stated they were upset after this fall as the staff left the resident alone in their room in a recliner and they did not feel this was safe. They stated they called the DON and told them even with the recliner leg rests up, the resident still tried to get out of the chair. LPN #12 stated they did not think there was a plan in place related to the resident's recliner. The LPN asked the DON to put a plan in place following this incident so that the resident could be in a recliner in a common area where someone could watch them, but not in their room alone. LPN#12 stated LPNs started Incident Reports when incidents occurred and gave them to the DON. An RN needed to complete everything after the first portion of the report, which was the initial evaluation of the resident.
On 9/21/22, the resident's CCP was updated and documented to keep items the resident used within their reach, so they did not lean forward from the chair to reach things. The care instructions were updated on the same date with the intervention.
On 11/1/22, the CCP was updated by occupational therapist (OT) #15 and documented the resident had a gel cushion in their wheelchair with elevating leg rests with a foot board and wedge positioned inside/right side of chair. The resident was to be supervised while in the wheelchair.
On 11/1/22, the care instructions were updated to include the same positioning recommendations written by OT #15 and documented the resident was to be in supervised areas while in the wheelchair.
On 12/27/22, the resident's CCP was updated and documented to take the resident's meal ticket away at meals as they would bend over to try and pick it up.
The Accident and Incident Report dated 1/23/23 at 7:30 PM, documented the resident had an unobserved fall and was found by CNA #9 on the floor in the dining room. The resident was bent over the footrest of the wheelchair with their right arm tucked behind them and their face down on the floor. The resident sustained a bruise to their bottom lip and a scratch to their right upper lip. On 1/31/23, the DON documented on the Accident and Incident Report that the foot pedals were to be removed from the wheelchair to allow the resident to self-propel.
There was no documented evidence the CCP, or care instructions were updated to include discontinuing the foot pedals.
On 4/24/23 at 12:28 PM, OT #15 stated in an interview:
- The resident had a wedge cushion that had a strap and a pommel (positioning) cushion so they did not feel Dycem would be needed as those cushions prevented sliding.
- They did not recall the resident's leg rests being removed from the wheelchair but when residents had footboards such as Resident #3, they did not self-propel so the footboard would not be removed as they were used for comfort. A CCP change to remove leg rests did not make sense for this resident as they had a footboard.
- When in the wheelchair, at times, the resident was okay with their right side and other times, they did not have body control.
- The resident needed to be watched when in their chair. They did not have good balance and needed occasional repositioning.
- All residents needed to be watched so adding supervision to the CCP was redundant. It was a staff standard to supervise residents when in their wheelchairs and observe for positioning needs.
- They did not know about the resident's recliner and was unable to find an assessment related to the recliner.
The 3/24/23 at 3:45 PM Accident and Incident Report documented the resident slid from their wheelchair and sustained a large hematoma. The fall occurred in the dining room and was witnessed by a nurse and aide (CNA). The report documented CCP interventions were not in place at the time of the fall and the DON was notified that date of the incident. Registered nurse (RN #2) completed the report and documented res (resident) was so wet that (they) slid out of Hoyer pad and chair and fell on (their) face. The report further documented the facts of the investigation supporting the allegation of abuse as defined by the NYS DOH. Corrective measures were documented as toilet every 2 hours, notify medical and family, and send to the emergency room (ER).
Statements obtained by the facility included:
- CNAs #9 and 17 documented they were off the unit at the time of the fall and returned to see the resident on the floor. Both documented in their statements they thought the fall was due to the resident being wet and the resident should be toileted regularly to prevent this from occurring again.
- LPN #16's statement documented they were giving another resident medication and heard the resident fall. They noted the fall was due to the resident being wet and specified the resident was uncomfortable, soiled.
The 3/24/23 RN #2's progress note at 8:00 PM, documented the resident was assessed following the fall at 3:45 PM and had a bump the size of a nectarine on right forehead. The resident was sent to the hospital.
The 3/24/23 ADL documentation for the resident included one entry made at 9:37 PM which specified behaviors were not exhibited. There was no documented evidence the resident was toileted on 3/24/23 or that any ADL care was provided.
The 3/24/23 schedule documented:
- CNA #10 was assigned to the resident from 6:00 AM to 2:00 PM.
- CNA #11 was assigned to the resident from 2:00 PM to 4:00 PM.
The hospital record dated 3/24/23 documented per the family, the resident slid from their wheelchair, and this was the third incident in recent history. The resident sustained a large hematoma to the right side of the forehead measuring 2.3 centimeters (cm) by 6.3 cm and an abrasion on the right hand. The resident was admitted pending alternative placement as the family did not want the resident returned to the facility due to concerns with supervision and multiple falls.
In an interview on 4/20/23 at 1:33 PM, CNA #9 stated the resident had fall mats in place for fall prevention. On 3/24/23, when the resident fell from their chair in the dining room, they were drenched and wet through their clothes and found face down with a big knot on their head. CNA #9 stated they were not the resident's assigned CNA and did not know if the resident was on a toileting plan. They did not know when the resident was last toileted on that date but stated the fall was at 3:45 PM and they should have been toileted right before the evening shift came on duty at 2:00 PM. When CNA #9 was specifically asked if the resident had Dycem in the chair, they stated they thought so and did not know.
In an interview on 4/21/23 9:52 AM, CNA #10 stated for fall prevention, the resident had fall mats although the resident spent most of their time in their chair and did not go to bed until late at night. CNA #10 stated the resident had a special cushion next to them in the chair and when specifically asked about Dycem, CNA #10 stated they had it under the cushion the resident sat on. On 3/24/23, they worked days and the resident fell in the evening. They stated the resident was toileted every 2 hours and they never had an issue toileting them. They put them back to bed and changed them every 2 hours. CNA #10 stated they documented ADL care twice a shift, when they arrived to the facility and at the end of the shift but toileting should be documented in real time. They left at 2:00 PM that day and did not recall when the resident was last toileted.
On 4/24/23 at 12:02 PM, LPN #16 stated in an interview, at the time of the 3/24/2023 fall, they heard a loud bump, the resident moaned, and was on the floor. They felt the resident was uncomfortable due to being wet and thought maybe their squirming around in the chair could have caused the fall. They stated the resident smelled of urine at the time of the fall. The resident needed help with being changed and wore briefs. They did not know who was assigned to provide their care or when the resident was last toileted. They were unaware of any follow-up after this fall and stated they were not asked any further questions by management.
In an interview on 4/25/23 at 2:15 PM, Director of Rehabilitation #31 stated the resident was able to self-propel, at first, but eventually could not after a decline. It was safer to have their feet on a footboard and they did not want the resident's feet to fall in between leg rests or off to the side. The footboard was to prevent injury/skin tears. To their knowledge, the resident did not have a recliner in their room but had a reclining wheelchair.
In an interview on 5/1/23 at 3:07 PM, RN #2 stated when the resident fell on 3/24/23 they were very wet. Their pants and the lift pad they were sitting on were both wet. RN #2 stated it was their professional nursing opinion that the resident slid from the chair that day due to being so wet. RN #2 stated they were frustrated because care was not provided, and no one had called them and said they needed help caring for residents. They stated when they were the Supervisor, they were willing to help on the units if needed. They stated they saw the resident earlier that day at 2:00 PM, so they knew they were out of bed by 2:00 PM. They stated staff were expected to do rounds at the beginning of the evening shift and do care before dinner. If someone requiring a mechanical lift was already up for dinner, their care would likely be left for later, after dinner. After they assessed the resident, they asked staff when the last time they were toileted or changed. They also asked staff if the resident was normally that wet and staff stated no, that was unusual for the resident to be that wet. The staff told them they had not changed the resident since they got out of bed that day and they told this to the DON that a resident was not changed since they got out of bed and this fall was at dinner time.
On 5/1/23 at 12:42 PM, LPN Unit Manager #29 stated in an interview, on 3/24/23 when the resident fell, they were working on the unit as a floor nurse. They became Unit Manager in 4/2023. They stated as an LPN they could not update the resident's CCP or make any changes. They reviewed CCPs and then told the DON or ADON if they thought new/different interventions should be implemented. On 3/24/23, they worked from 6:00 AM to 2:00 PM on the unit as a medication nurse. From 6:00 AM to 8:00 AM, they had 2 CNAs working who they did not feel were the strongest CNAs. At 8:00 AM, another CNA came in and tried to help with resident care on the unit. They stated on 3/24/23 all the meals came super late. They stated lunch was supposed to come between 12:15 and 12:45 PM and came at 1:15 PM that day. They stated when lunch ended that late, and the shift ended at 2:00 PM, it was difficult to change residents before the change of shift. The LPN stated the resident was not changed prior to change of shift and the evening CNAs were told this. The next day when the LPN arrived, RN #2 told them about the fall, the resident slid form the chair, and that the resident was very wet at the time of the fall. The LPN stated RN #2 told them they were disappointed and felt the resident's wetness was a factor in the fall. The LPN explained to RN #2 the issues they faced and stated the evening shift should have changed the resident. The LPN stated after the surveyors were at the facility in early 4/2023, they looked at the ADL documentation and saw there was none for the resident. They stated they determined CNA #10 would have been responsible for providing the resident's care, so they wrote up the CNA. They stated they gave the write-up to the DON and did not know where it went after that. They stated they did not know if any follow up was done after the incident report was completed as the forms and statements went to the DON for review and finalization.
On 5/1/23 at 1:36 PM, the DON stated in an interview:
- At this time the Unit Manager where the resident resided was an LPN so the DON or the ADON were responsible for the CCPs.
- At times there was a RN Unit Manager on that unit who would have been responsible for the CCP.
- When incident reports were done, they were sent to the DON for review. The DON finalized them.
- The team met on Fridays to review incidents and CCP changes were made at those meetings if they were needed.
- The DON was not aware the resident had a recliner in their room and did not know if they were ever assessed for a recliner. They stated they did not have an incident report or investigation for the 9/17/22 fall from the recliner chair.
- When falls occurred, the RN Supervisor was responsible for completing the incident reports. If there was no RN in the building, the LPN would start the report and then leave it for the DON for completion.
- Following the fall on 1/23/23, the DON documented on the incident report the plan was to remove the resident's foot pedals so they could self-propel. The DON stated they implemented this intervention themselves and physically removed the resident's foot pedals from the chair. They stated they felt the resident wanted to move around and this was the safest option at the time. The DON stated they did not know if the pedals remained off for any length of time or just for that day.
- On 3/24/23 when the resident fell, they were not in the building. They were told the resident was sent to the hospital with a bump on their head and abnormal vital signs.
- They stated after the fact they were aware the resident was incontinent although they did not know how wet the resident was.
- The DON stated they talked with LPN #29 after the fall and re-educated staff on documenting ADL care and toileting.
- The DON stated they believed there was documentation the resident's CCP was followed at the time of the fall although did not state where the documentation was.
- The DON stated they were aware there was no CNA documentation that care was provided but they looked into it although they did not know when they looked into it.
- The DON stated they believed staff provided care to the resident as planned on 3/24/23 and the resident was on a 2-hour toileting plan.
During an interview on 5/4/23 at 12:55 PM, the Administrator stated they determined there was no care plan violation on 3/24/23 and that the resident was toileted according to their care plan. They educated staff on ensuring ADL documentation was completed. The Administrator was aware staff statements noted the resident was very wet and stated they did not believe that was indicative of the resident not being toileted. The Administrator stated being soaked could mean something different and depended on the situation. They were unaware of how wet the resident was and stated it could have been from a spill or possibly the resident held their bladder and had a large urine output at once.
On 5/10/23 at 10:09 AM, physician assistant (PA) #3 stated in an interview, if someone repeatedly slid from the chair, they would expect Dycem in the chair to prevent sliding and/or a therapy evaluation to see if they could implement interventions as well. PA #3 stated they expected the resident's toilet plan to be followed and if it could not, then the resident should have been placed in an area where staff could have monitored them so they could not get out of or slip out of their chair. They stated the impact/risks of sliding out of the chair included an intercranial injury or fracture.
2) Resident #1 had diagnoses including Alzheimer's disease. The 3/6/22 admission Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance from for bed mobility, transfers, walking in room, locomotion on the unit, dressing, toileting, and personal hygiene, and had no falls since admission
The comprehensive care plan (CCP), initiated on 3/1/22, documented the resident was at risk for falls related to decreased mobility and advanced dementia. Interventions included non-skid footwear at all times, medications as ordered, keep environment clean and clutter free, nightlight at bedtime, and call bell within reach.
Accident and Incident Reports documented:
- on 3/11/22 at 1:25 AM, the resident was found on the floor in their room. The fall was unobserved and happened when the resident attempted to ambulate from the bed. The resident stated they lost their balance. The resident had a red area to the cheek. Registered nurse (RN) #1 documented the resident was not wearing non-skid socks and the CCP was updated to include non-skid socks at all times. The report did not document why the non-skid socks were not on the resident as planned as they were added to the CCP on 3/1/22.
- On 3/18/22 at 6:00 PM, the resident was found on the floor in their room after being brought back to their room after dinner. No injuries were noted. Licensed practical nurse (LPN) #18 documented the plan included engaging in activities after dinner.
The CCP, updated on 3/18/22, documented to engage in activities after dinner in the common areas.
Accident and Incident Reports documented:
- on 3/26/22 at 3:40 PM, the resident fell in their room, and it was unobserved. The resident was found sitting on the floor mat with their head resting on the wheelchair. RN #1 documented the resident attempted to self-transfer.
- On 3/28/22 at 6:30 PM, the resident fell in the dining room, and it was unobserved. LPN #18 noted the plan included encouraging the resident to sit in visible areas and to apply Dycem (non-slip pad) to the wheelchair.
Revisions to the CCP included:
- on 3/29/22, encourage the resident to go to common areas after meals.
There was no documented evidence Dycem was added to the CCP as noted on the 3/28/22 Accident and Incident Report.
- On 4/12/22, the resident transferred with extensive assistance of 1 with a gait belt and rolling walker. The resident may need assistance from 2 when fatigued.
The 4/14/22 LPN #18's progress note at 7:51 PM, documented they observed the resident stand from the wheelchair and lower themselves to the floor on their knees.
The 4/14/22 Director of Nursing (DON) progress note at 8:44 PM, documented an assessment was done and the resident had skin discoloration to bilateral knees. The CCP was updated to include Dycem in the wheelchair and a urinalysis.
The CCP, revised 4/14/22, documented a urinalysis and culture and sensitivity was to be obtained and Dycem was to be added to the wheelchair. (The Dycem was added to the CCP 17 days after the 3/28/22 Accident and Incident Report documented it was to be implemented).
The 4/18/22 LPN #18's progress note documented a urine sample was obtained via straight catheterization (tube inserted into the bladder to obtain urine). (The sample was obtained 4 days after it was ordered).
The 4/21/22 LPN #18's progress note documented Macrobid (antibiotic) was ordered after the urine results were reviewed with medical.
Accident and Incident Reports documented:
- on 6/17/22 at 12:45 AM, the resident was found sitting on their buttocks on the floor and had no injuries. The resident attempted to self-ambulate and was found sitting in the middle of their room.
- On 6/22/22 at 11:00 PM, the resident fell from the wheelchair in their room and was found sitting on their buttocks sustaining a skin tear to the right forearm. The report documented the CCP was reviewed and included proper lighting and footwear and the call bell within reach. The report did not document if the Dycem was in place at the time of the fall. RN #1 noted a new intervention of encouraging the resident to go to bed on last rounds to decrease the risk of self-transferring.
Revisions to the CCP included on 6/23/22, encourage the reside to go to bed on last rounds; on 6/27/22, Dycem to the recliner chair; on 7/5/22, the resident was non-ambulatory; on 7/7/22, a low bed, and on 7/8/22, a scoop mattress and every 2 hour toileting schedule.
Accident and Incident Reports documented:
- on 7/22/22 at 9 PM, the resident just slid out of wheelchair in the dining room. The report did not document whether Dycem was in place at the time of the fall. The resident had no injuries and was assessed by RN #36.
- On 8/2/22 at 12:20 PM, LPN #22 noted the resident was found on the floor in the dining room and Dycem is needed in wheelchair.
The 8/2/22 at 2:33 PM, RN #47's progress note documented the cushion in the resident's wheelchair slipped forward when the resident attempted to stand and Dycem was added to the wheelchair above and below the cushion to prevent sliding.
There was no documentation the facility investigated why the Dycem was not in place at the time of the 8/2/22 fall as it was added to the CCP on 4/14/22.
The CCP, revised 8/2/22, documented to provide supervision in wheelchair for short distances with verbal cues, apply Dycem in the wheelchair above and beneath the cushion, and the resident should be in a supervised area when in the wheelchair.
The 8/7/22 Accident and Incident Repot documented at 9:50 AM, the resident had an unwitnessed fall from the wheelchair in the small dining room. The plan included keeping in high visibility areas when out of bed. The report did not document whether the Dycem was in place and documented a new plan of a wedge cushion.
There was no documented evidence the use of the wedge cushion was added to the resident's CCP.
The CCP, updated 9/8/22, documented the resident was issued a Geri-chair for comfort with a gel cushion.
The 9/19/22 LPN #48's progress note at 6:06 AM documented the resident was found on the fall mat next to the bed.
On 10/17/22, the resident was discharged to home with Hospice.
On 4/13/23 at 10:25 AM, during an interview with RN #1, they stated they stopped working at the facility in 7/22 and could not recall specifics about the resident. Staff would know how to care for residents via the CCP as all interventions that were in place would be listed. When a fall occurred, they reviewed the CCP in place at the time of the fall and noted that on the Accident and Incident Report. They also assessed the resident and determined whether all planned interventions were in place at the time of the incident. If the interventions were not in place, they would discuss with the staff on the unit and find out why they were not in place and base the investigation on that. If they determined additional interventions were needed, they would add them to the CCP and let staff know. If a urinalysis was ordered for a resident, they would expect the specimen to be obtained within 24 hours, but the best practice would be to obtain it by the next shift.
On 4/18/23 at 10:11 AM, LPN Manager #18 stated in an interview, the resident was at risk for falls due to dementia, confusion, and poor strength. The resident would try to get up but did not have the strength to do it correctly. When a fall occurred, they would call the RN to assess and would start the Accident and Incident Report by looking at the CCP to make sure it was accurate and followed. If the interventions did not seem to be working, then they got together with the Director of Nursing (DON) and brainstormed new interventions. As an LPN they could make suggestions for the CCP but could not make changes. They tried to monitor the CCPs and residents to ensure all planned interventions were in place such as fall mats and scoop mattresses. When changes were made to interventions, they were added to the CCP and discussed with staff. They could not recall if the resident had Dycem in their chair or when it was added. When a urinalysis was ordered, any nurse could obtain the specimen and they expected it to be done as soon as possible. 2-3 days was not acceptable if the urinalysis came back positive for a UTI.
On 5/1/23 at 1:36 PM, the DON stated in an interview, when a fall occurred, the LPN On the unit should call the RN for an assessment and the RN was responsible for the Accident and Incident Report and CCP updates. The DON stated if an RN was not present in the building, the LPN should start the report and leave it for the DON to complete. The DON stated they reviewed the reports and statements and discussed falls with the team so that new interventions could be implemented for fall prevention. The DON stated the team met weekly on Fridays and CCP changes would be made during that meeting if needed.
415.12(h)(2)
May 2021
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview during the recertification and abbreviated (NY00262972, NY00269888, NY00275233) surveys, the facility did not ensure that residents who were unable to...
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Based on observation, record review and interview during the recertification and abbreviated (NY00262972, NY00269888, NY00275233) surveys, the facility did not ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and grooming for 2 of 5 (Residents #14 and 60) reviewed. Specifically, Resident #14 was not assisted at meals as planned to ensure adequate nutritional intake and Resident #60 was not shaved per their preference.
Findings include:
The facility policy ADLs dated 10/2009 documented CNAs (certified nurse aides) will assist or provide ADLs according to individual resident needs. The facility will adhere to professional standards, resident plan of care and ongoing assessment of resident needs.
1) Resident #60 had diagnoses including cancer of the bladder, Parkinson's Disease (a central nervous system disorder) and schizo-affective disorder. The 4/2/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of two staff for personal hygiene and was totally dependent for bathing.
The 2/6/21 updated comprehensive care plan (CCP) documented the resident required assistance with ADLs related to weakness. Interventions included assistance of one for dressing and grooming and styling hair daily; assistance of one for shaving/facial hair removal; the resident preferred showers and was showered per shower book. The 4/13/21 updated CCP documented to allow the resident control in their care routine (bathing, sleeping, eating, care providers).
The 10/2/20 resident profile (care instructions) documented the resident required extensive assistance for bathing, dressing, and toileting.
On 5/3/21 at 10:09 AM, the resident was observed wearing a hospital gown. They had a thick mustache and their cheeks and neck had whiskers. The resident stated they liked to be shaved but had only been shaved once a week.
The resident was observed unshaven on 5/3/21 at 11:43 AM, 5/4/21 at 8:12 AM and 2:01 PM, 5/5/21 at 10:07 AM, and 5/6/21 at 10:16 AM.
When interviewed on 5/4/21 at 2:01 PM, the resident stated they normally were shaved on their shower day, but they did not get a shower that week, only a bed bath. The resident stated they liked to be shaved more than once a week.
When interviewed on 5/6/21 at 1:49 PM, temporary nurse aide (TNA) #11 stated they took over care for Resident #60 at 10:00 AM that morning. Grooming residents included shaving them when they liked to be shaved. The TNA said they were aware the resident liked to keep their mustache and kept the rest mostly smooth shaven. The resident liked being shaved more frequently. The TNA noticed the resident had a lot of whiskers and they meant to shave the resident that day, but they had been called to another resident room. The TNA thought certified nurse aide (CNA) #12 was going to shave the resident and had gone to get the electric razor.
When interviewed on 5/6/21 at 1:58 PM, certified nurse aide (CNA) #12 stated they were helping TNA #11. The CNA stated grooming included shaving. They were not aware if the resident had a preference for shaving, and stated the resident had a lot of whiskers that day. The CNA had not offered to shave the resident but had offered to look for the electric razor for TNA #11.
When interviewed on 5/7/21 at 8:19 AM, CNA #7 stated grooming included shaving and the information was found on the resident's care plan in the electronic medical record. The CNA had not asked Resident #60 if they had a shaving preference and the resident liked their mustache. Residents were to be shaved on their shower day and they did not know the last time Resident #60 was shaved.
When interviewed on 5/7/21 at 10:55 AM, licensed practical nurse (LPN) #9 stated grooming involved morning shaving; residents with facial hair were to be shaved on their shower day and as needed. Resident #60 would be able to say if they wanted to be shaved and the LPN was not sure what the resident's preference was. If it was the resident's preference to be clean shaven then they should be.
When interviewed on 5/7/21 at 12:16 PM, the Director of Nursing (DON) stated personal care and grooming included shaving. The residents were to be shaved with their shower and as needed. If they preferred not to be shaved, it would be documented in the care plan. The DON expected the staff to shave residents when they needed it, not just when showered.
2) Resident #14 had diagnoses including anxiety disorder and dementia. The 1/30/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance for most activities of daily living (ADLs), supervision with one person assistance for eating, and the resident required a mechanically altered diet.
The resident vitals report documented the resident's weight was 104 pounds on 1/20/21 and 99.2 pounds on 4/23/21 (4.3 % loss in 3 months).
The comprehensive care plan (CCP) active in 5/2021 documented the resident consumed less than 75% at meals, was at risk for further weight loss; and required set-up help with eating.
The certified nurse aide (CNA) instructions active in 5/2021 documented the resident required limited assistance with eating and staff were to provide verbal cues to initiate and complete meals.
Resident #14 was observed on 5/3/21 between 12:10 PM and 12:54 PM. The resident was standing by another resident's tray table in the hall reaching for the other resident's items on the meal tray. The resident then sat in a chair with a bed side table by the nursing station with a meal in front of them. The resident took a bite of greens with a fork and took bites of half of a grilled cheese sandwich. The resident got up and walked around and went to another resident's table/tray. An employee got Resident #14's tray and set it by the resident and walked away. The resident sat in a chair by the nursing station and was not eating. LPN (licensed practical nurse) #14 asked if the table was too high, the resident did not respond, and the LPN walked away. Another staff member walked by and said to the resident, you good?. The resident gave a nonsensical response and the staff person walked away and did not assist or encourage the resident. The resident got up and stood near the nursing station and then walked into the dining room and sat at a table. Their meal tray remained by the nursing station. The resident walked out of the dining room.
and stood by a resident table located in kitchenette area where 2 residents and an occupational therapist (OT) were seated. An occupational therapist (OT) redirected the resident from the table and away from reaching another resident's meal items. The resident's tray was brought to the table where the resident remained seated at the table and was not eating or drinking. The resident stood up from the table and had not eaten any food items. Staff did not redirect or assist the resident with eating.
On 5/5/21 at 12:25 PM the resident was observed seated in the unit dining room eating. The resident stood up and started to leave the area, the registered dietitian (RD) talked to the resident and the resident sat back down. The resident's ice cream, 1 of the 2 milks, and 1 water were not opened. The RD let the resident know what items were on their plate and left the resident. The resident walked to another table without eating or drinking anything. The resident then left the dining room with an unidentified staff member, went to their room, and shut the door.
During an interview with RD #15 on 5/6/21 at 2:11 PM, they stated the resident was not picky with foods and was able to feed themself, however, the resident needed someone to encourage them to take bites. The resident was easily redirected and would eat if encouraged by staff. The resident had a low weight that was usually around 100 pounds and the resident was better at eating than drinking. Staff were supposed to open everything for the resident as the resident would not initiate on their own.
During an interview with licensed practical nurse (LPN) #14 on 5/7/21 at 9:42 AM, they stated the resident was able to feed themself. The resident did get up from their seat and staff would try to get them to sit down. Some days, the resident would sit and eat, and some days they would not. The resident usually sat in a chair by the nursing station and did not eat in one of the unit dining areas.
During an interview with CNA #7 on 5/7/21 at 10:06 AM, they stated the resident was confused and needed a lot of redirecting throughout the day. The CNA stated the resident was independent with eating and had a good intake.
10NYCRR 415.12(a)(3)
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, record review and interview during the recertification and abbreviated survey (NY00262972) completed on 5/6/2021, the facility did not establish and maintain an infection prevent...
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Based on observation, record review and interview during the recertification and abbreviated survey (NY00262972) completed on 5/6/2021, the facility did not establish and maintain an infection prevention and control program to ensure the health and safety of residents and to prevent the transmission of COVID-19 for 2 of 4 residents (Residents #8 and 9) observed during medication administration; for 1 resident (Resident #53) observed during a meal; for 2 of 2 residents (Residents #32 and #44) receiving oxygen; and for 1 of 1 resident (Resident #60) with a urinary catheter. Specifically, personal protective equipment was not worn correctly and hand hygiene was not performed during medication administration for Residents #8 and #9; Resident #53 was fed by a certified nursing assistant (CNA) who was not wearing a face mask correctly; Residents #32's and #44's oxygen tubing was not changed as ordered; and Resident #60's urinary catheter collection bag was placed directly on the floor.
Findings include:
The New York State Health Emergency Response Data System (HERDS) dated 5/3/2021 documented the facility did not have any positive or presumed positive cases of COVID-19.
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 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed.
The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
The facility policy Standard Precautions revised 6/1/20 documents standard precautions apply to the care of all residents regardless of suspected or confirmed presence of infectious disease. Hand hygiene is performed with alcohol based hand rub (ABHR) or soap and water before and after contact with the resident, the resident's environment and after removing personal protective equipment (PPE).
The facility policy COVID-19 action plan revised 11/10/20 documents all HCP (healthcare personnel) shall wear a facemask while within 6 feet of residents. HCP will be educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE.
The 5/2021 revised Oxygen Therapy policy documents tubing and humidifier bottle are to be changed weekly and PRN (as needed) and marked as stated in Steps 3-e and 3-g of this policy. The policy did not document steps 3-e or 3-g.
1) Medication Administration/Incorrect Use of PPE:
During a medication administration observation on 5/5/21 at 8:34 AM with licensed practical nurse (LPN) #6,
the LPN was standing within 6 feet of the surveyor. The LPN had a face shield on top of their head, like a baseball hat, and they wore a blue surgical mask. Their face was exposed, and their nose and mouth were not covered by the mask. The LPN prepared medications without completing hand hygiene. The LPN touched their mask to place it back over their nose and it would fall back down when the LPN spoke. The LPN pulled up their mask and placed their face shield over their face in the correct position then went to the common area. LPN #6 stood over Resident #8 and handed them their pill cup and a glass of water. The resident was unable to hear the LPN, so the LPN reached under their face shield and pulled their mask down and leaned closer to the resident's ear and face and asked them to drink their supplement. The LPN returned to the medication cart and did not perform hand hygiene. At 8:45 AM, LPN #6 removed their face shield and placed it on top of their head. Their mask did not cover their nose as they stood next to the surveyor. The LPN placed their face shield on, adjusted their mask then went to Resident #9's room. The LPN assisted the resident to a sitting position and gave the resident their pills. The LPN's mask was not covering their nose. They handed the resident an inhaler medication, reached under their face shield, wiped across their face, pushed their glasses up, pulled their mask up then took the inhaler back. The LPN returned to the medication cart and placed the inhaler back in the drawer and did not perform hand hygiene.
On 5/5/21 at 12:26 PM Resident #53 was observed being served their meal in their room by CNA #21. The CNA's surgical masked was not covering their nose or mouth. The CNA pulled the mask up when the surveyor came in the room. At 12:34 PM CNA #21 was continuing to assist Resident #53 with their meal and the CNA's mask was not covering their nose or mouth. The CNA placed the mask over their nose and mouth when they observed the surveyor.
During an interview on 5/5/21 at 1:08 PM LPN #6 was observed standing within 6 feet of the surveyor. Their face shield was sitting on top of their head, and their mask did not cover their nose or mouth. LPN #6 stated hand hygiene was to be performed in between residents and after three resident interactions staff were to wash their hands. The LPN stated they had not cleaned their hands and did not remember if they used hand sanitizer during the medication pass for Residents #8 and 9. They stated it was important to do this to prevent cross contamination or to keep residents from becoming sick. The LPN stated they had been shown the proper way to put on a mask. The LPN stated sometimes the residents were unable to hear so the LPN would pull their mask down so the resident could read their lips. The LPN stated the face shield was supposed to be down covering their face when they were around the residents and their mask was to cover the nose and mouth.
During an interview with CNA #21 on 5/5/21 at 2:54 PM they stated the surgical mask should cover the nose and mouth. CNA #21 stated they pull the mask down because their glasses fog up.
On 5/6/21 at 2:42 PM, LPN #6 was observed sitting at the nursing station with their face shield sitting on top of their head and their surgical mask not covering their nose. Resident #19 was seated against the wall and was within 4 feet of LPN #6.
When interviewed on 5/7/21 at 11:22 AM, the Assistant Director of Nursing (ADON) stated they were responsible for the infection control program. They stated during medication administration, staff were expected to perform hand hygiene before the med pass and between each resident interaction. On the units, staff were to be wearing the face shield and their mask. They recommended the face shields be on even when at the desk because the residents were always moving around. The ADON stated the surgical masks should cover the nose and mouth and were always worn while in the building.
2) Oxygen tubing:
Resident #32 was admitted to the facility with diagnoses including dementia and chronic obstructive pulmonary disease (COPD). The 9/26/20 Minimum Data Set (MDS) assessment documented the resident was mildly cognitively impaired, required extensive assistance for most activities of daily living (ADLs) and required oxygen.
The 11/23/20 provider orders documented Resident #32 was to receive oxygen at 2 liters (L) continuously, change oxygen tubing and label with date every week on Wednesday from 10:00 PM-6:30 AM.
Resident #44 had diagnoses including dementia with behavioral disturbance, shortness of breath and history of COVID-19. The 3/15/21 MDS assessment documented the resident was severely cognitively impaired and required extensive assistance of two staff for most ADLs.
The 4/6/21 provider order documented Resident #44 was to receive oxygen at 2L, adjust to keep oxygen saturations greater than 90%. Change O2 tubing and mask and label with date every week on Wednesday night.
Both resident treatment administration records (TAR) documented the oxygen tubing was changed by LPN #6 on 4/14/21 and 4/21/21. The TAR documented the oxygen tubing was changed by registered nurse supervisor (RNS) #8 on 4/28/21 and 5/6/21.
On 5/3/21 at 10:40 AM and 5/4/21 at 8:30 AM, Resident #32 was observed wearing oxygen. The oxygen tubing and the humidification bottle (bubbler) were dated 4/15/21.
On 5/3/21 at 1:35 PM and 5/5/21 at 10:06 AM Resident #44 was observed wearing oxygen. The tubing was dated 4/15/21.
When interviewed on 5/7/21 at 8:55 AM, registered nurse night supervisor (RNS) #8 stated the facility protocol for oxygen care was the tubing and bubbler bottles all had to be changed and the filters washed once a week. RNS #8 stated the night shift staff were responsible for changing the tubing and documenting on the TAR. RNS #8 stated if the tubing was not changed regularly, it could grow bacteria. RNs #8 expected staff to change the tubing and the bubbler bottles.
When interviewed on 5/7/21 at 9:49 AM, licensed practical nurse (LPN) #6 stated they were working nights during 4/2021. They stated the oxygen equipment was changed once a week on Wednesdays. LPN #6 stated once the tubing and bubbler bottles were changed it was documented in the TAR. If it was initialed, it meant LPN #6 had changed them. LPN #6 did not know why the tubing was dated 4/15/21 when she documented in the TAR it had been changed on 4/21/21. LPN #6 could not recall if they changed the tubing on 4/21/21. LPN #6 stated it was important to change the tubing, so they did not get clogged, or so that bacteria-wise, the tubing was clean.
When interviewed on 5/7/21 at 11:22 AM, the Assistant Director of Nursing (ADON) stated oxygen tubing should be changed weekly and the humidification bottles were also to be changed weekly.
3) Catheter care:
Resident #60 was admitted to the facility with diagnoses including bladder cancer and Parkinson's disease. The 4/2/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of one or two for most ADLs, total dependence for bathing and had an indwelling catheter.
The 2/16/21 provider order documented Foley catheter to gravity drainage for obstructive uropathy (urine flow obstructed) related to bladder cancer.
The 10/1/20 comprehensive care plan (CCP) documented the resident had an indwelling catheter. Interventions were to empty the catheter every shift and as needed, keep drainage bag below the level of the bladder and maintain standard precautions at all times.
On 5/3/21 at 10:11 AM and 5/4/21 at 1:58 PM, Resident #60 was observed in bed with their catheter hanging on the bed frame. The bottom of the urine drainage collection bag was resting directly on the floor.
When interviewed on 5/7/21 at 8:19 AM, CNA #7 stated Resident #60's catheter was to hang from the bedframe and should never be touching the floor. It was important to keep it off the floor because of bacteria.
When interviewed on 5/7/21 at 11:22 AM, the Assistant Director of Nursing (ADON) stated catheters were not to be left on the floor. CNAs were expected to notify the nurses so the bag could be changed if found on the floor.
When interviewed on 5/7/21 at 12:16 PM, the Director of Nursing (DON) stated the staff received training and there were competencies for care related to infection control. They also received education on hand hygiene and donning and doffing PPE. Staff were to have their mask covering their nose and their mouth and fitted to their nose. The DON expected staff to have their mask on all times in the buildings. Their face shields and masks were to be on when they were on the resident care areas. The DON expected the catheter collection bag to be off the ground or it should be replaced. Staff were supposed to change the oxygen and tubing weekly on the night shift.
10NYCRR 415.19(a)(1),(b)(2),(4); 400.2
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 20 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $76,339 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
- • Grade F (35/100). Below average facility with significant concerns.
- • 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Cortland Park Rehabilitation And Nursing Center's CMS Rating?
CMS assigns CORTLAND PARK REHABILITATION AND NURSING CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Cortland Park Rehabilitation And Nursing Center Staffed?
CMS rates CORTLAND PARK REHABILITATION AND NURSING CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the New York average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 69%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Cortland Park Rehabilitation And Nursing Center?
State health inspectors documented 20 deficiencies at CORTLAND PARK REHABILITATION AND NURSING CENTER during 2021 to 2025. These included: 1 that caused actual resident harm and 19 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Cortland Park Rehabilitation And Nursing Center?
CORTLAND PARK REHABILITATION AND NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by UPSTATE SERVICES GROUP, a chain that manages multiple nursing homes. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in CORTLAND, New York.
How Does Cortland Park Rehabilitation And Nursing Center Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, CORTLAND PARK REHABILITATION AND NURSING CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Cortland Park Rehabilitation And Nursing Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Cortland Park Rehabilitation And Nursing Center Safe?
Based on CMS inspection data, CORTLAND PARK REHABILITATION AND NURSING CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Cortland Park Rehabilitation And Nursing Center Stick Around?
Staff turnover at CORTLAND PARK REHABILITATION AND NURSING CENTER is high. At 59%, the facility is 13 percentage points above the New York average of 46%. Registered Nurse turnover is particularly concerning at 69%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Cortland Park Rehabilitation And Nursing Center Ever Fined?
CORTLAND PARK REHABILITATION AND NURSING CENTER has been fined $76,339 across 1 penalty action. This is above the New York average of $33,842. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Cortland Park Rehabilitation And Nursing Center on Any Federal Watch List?
CORTLAND PARK REHABILITATION AND NURSING CENTER 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.