THE GRAND REHABILITATION AND NURSING AT GREAT NECK
For profit - Corporation
214 Beds
THE GRAND HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
43/100
#461 of 594 in NY
Photo by The Grand Rehabilitation and Nursing at Great Neck
Photo by The Grand Rehabilitation and Nursing at Great Neck
Photo by The Grand Rehabilitation and Nursing at Great Neck
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Grand Rehabilitation and Nursing at Great Neck has received a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #461 out of 594 facilities in New York, placing it in the bottom half overall, and #33 out of 36 in Nassau County, meaning only a few local options are worse. The facility is showing signs of improvement, with problems decreasing from 12 in 2022 to 8 in 2024. Staffing is relatively stable with a turnover rate of 17%, which is much lower than the state average of 40%, but the overall staffing rating is only 2 out of 5 stars, suggesting there may be challenges in meeting resident needs. Notably, there were critical incidents involving inadequate monitoring of residents' nutritional status and delays in medication administration, raising some concerns about safety and care quality. However, it's worth mentioning that there have been no fines issued, which is a positive sign.
- Trust Score
- D
- In New York
- #461/594
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 17% annual turnover. Excellent stability, 31 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New York facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 23%
Review needed
12 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2022: 12 issues
2024: 8 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (17%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (17%)
31 points below New York average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below New York average (3.1)
Below average - review inspection findings carefully
Chain: THE GRAND HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 24 deficiencies on record
1 life-threatening
Jul 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment. This was identified for one (Resident #71) of three residents reviewed for skin conditions. Specifically, Resident #71 was observed with tissues and rubber bands wrapped around two fingers on multiple occasions and Nursing staff did not revise the comprehensive care plan to address the resident's behavior.
The finding is:
The facility's policy, titled Behavioral Assessment, Intervention, and Monitoring, last reviewed in January 2024, documented behavior symptoms will be identified using a facility-approved behavior screening tool and a comprehensive assessment. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.
The facility's policy titled Care Planning, last reviewed in January 2024, documented the facility's care planning/interdisciplinary team is responsible for the development of an individualized Comprehensive Care Plan for each resident.
Resident #71 was admitted with diagnoses including Dementia, Chronic Kidney Disease, and Chronic Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #71 had a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment.
The Impaired Cognitive Function related to Dementia Comprehensive Care Plan initiated on 2/15/2022 and last revised on 4/28/2023 documented interventions for the Certified Nursing Assistant to report any changes in cognitive function to the Nurse and notify the Physician of inappropriate behavior.
The Potential to Exhibit Behavior Symptoms Comprehensive Care plan initiated on 4/28/2022 and last revised on 5/10/2023 documented Resident #71 had the diagnoses of Psychosis and Dementia. The interventions included to administer psychotropic medications as ordered and notify the Physician of inappropriate behavior.
A review of Resident #71's Comprehensive Care Plans revealed there were no updates or revisions to address the resident's behavioral symptoms including the habit of wrapping tissues and rubber bands around two fingers.
Resident #71 was observed in their room sitting in a chair on 7/11/2024 at 11:02 AM. Resident #71 had tissues and rubber bands wrapped around their left thumb and right middle finger. Resident #71 removed the rubber bands and tissues, in the presence of the Surveyor, and no cuts or bruises were observed on the resident's fingers. Resident #71 stated facility staff cut their fingernails and when doing so, cut their fingers. The resident stated they had a treatment in place to their fingers for three days.
A review of the resident's Physician's Orders and Progress Notes revealed Resident #71 did not require skin treatments to their fingers.
Resident #71 was observed in their room sitting in a chair on 7/11/2024 at 12:54 PM with tissues and rubber bands wrapped around the same two fingers, their left thumb and right middle finger. Resident #71 removed the rubber bands and tissues, in the presence of the Surveyor, to expose their fingers, and nothing unusual was observed. Resident #71 stated they put the tissues and rubber bands on their fingers because facility staff cut their fingernails too short.
Resident #71 was observed in their room sitting in a chair on 7/12/2024 at 9:27 AM with their two fingers wrapped in tissues and rubber bands. Resident #71 stated they prefer to leave their fingers covered so they do not hurt and they must do this for three days.
Resident #71 was observed in their room coming out of the bathroom and then sitting in a chair on 7/15/2024 at 10:09 AM with the Registered Nurse Manager (Registered Nurse #5) present. The resident had tissues and medical tape wrapped around their two fingers (the left thumb and the right middle finger). Resident #71 stated that Certified Nursing Assistant #1 put the tissues and tape on their (Resident #71's) fingers for them. Registered Nurse #5 stated they would remove the tissues and tape from Resident #71's fingers. Registered Nurse #5 stated the Certified Nursing Assistant should not have wrapped the resident's fingers and should have reported the behavior of Resident #71 to the Nurse for them to assess the resident's fingers. Registered Nurse #5 stated Resident #71's behavior of wrapping their fingers should have been documented in a progress note and the Comprehensive Care Plan for Behavior should have been updated.
Certified Nursing Assistant #1 was interviewed on 7/15/2024 at 10:11 AM and stated they regularly provide care for Resident #71. Certified Nursing Assistant #1 stated Resident #71 was distressed because their (Resident #71) fingers were not wrapped and asked if Certified Nursing Assistant #1 could help the resident wrap their fingers. Certified Nursing Assistant #1 stated they calmed Resident #71 down and did not put the tissues and tape on Resident #71's fingers and the resident must have done it themself. Certified Nursing Assistant #1 stated they should have told the Nurse about the resident wrapping their fingers. Certified Nursing Assistant #1 stated everyone has seen Resident #71 with wrapped fingers and the resident always wraps their fingers with tissues and tape or rubber bands.
The Director of Nursing Services was interviewed on 7/17/2024 at 12:02 PM and stated they were unaware of Resident #71's behavior of wrapping their fingers which should have been monitored and documented accordingly. The Director of Nursing Services stated Resident #71 should have had their behavior of wrapping their fingers added to their Behavior Comprehensive Care Plan. The Director of Nursing Services further stated Certified Nursing Assistant #1 should have brought this behavior to the attention of the Nurse on duty or the Nurse Supervisor.
10 NYCRR 415.11(c)(2)(i-iii)
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #260) of three residents reviewed for Choices. Specifically, Resident #260 was admitted on [DATE] after a Micra Leadless Pacemaker Implantation (electronic device that is implanted in the body to monitor heart rate and rhythm) and required pacemaker remote monitoring. The facility did not initiate the pacemaker remote monitoring until 7/11/2024 and there was no documented Physician Order for the monitoring until 7/15/2024, seven days after Resident #260 was admitted to the facility.
The finding is:
The facility's admission Notes policy dated 1/2022 documented preliminary resident information shall be documented upon a resident's admission to the facility including a brief description of any disabilities, prosthesis required, nursing history, and a preliminary assessment, the presence of a catheter, dressings, etc., Physician's orders that were received and verified and the general condition of the resident upon admission.
There was no documented evidence that the facility had a policy and procedure that addressed Pacemaker monitoring.
Resident #260 was admitted with diagnoses of the Presence of Cardiac Monitor, Atrial Fibrillation, and Fracture of the Left Acetabulum (hipbone). The Minimum Data Set assessment was not available as the resident was newly admitted .
A Comprehensive Care Plan dated 7/8/2024 documented Resident #260 had an Alteration in Cardiovascular Function and the Presence of a Cardiac Pacemaker. An intervention dated 7/9/2024 documented to check the Medtronic pacemaker monitoring device (a device that sends information on the pacemaker battery status, heart rhythm and heart rate to the Physician) was connected to the resident and was plugged in every shift. The care plan instructed to report if the device is not connected and if there are any changes to the resident's condition. Additionally, the care plan instructed to monitor blood the resident's blood pressure and vital signs.
The hospital discharge instructions dated 7/8/2024 at 10:08 AM documented to schedule a follow-up to evaluate Resident #260's pacemaker and to check the pacemaker battery.
A Baseline Care Plan dated 7/9/2024 documented that Resident #260 was alert and oriented to time, place, and person, cognitively intact, and could communicate with staff.
A review of the medical and nursing progress notes revealed routine checks of Resident #260's pacemaker monitoring device were not performed from 7/8/2024 to 7/11/2024.
Resident #260 was observed lying in bed on 7/11/2024 at 10:35 AM. A pacemaker monitoring device was observed on Resident #260's nightstand and plugged into the wall. Resident #260 was subsequently interviewed and stated they (Resident #260) had a procedure for pacemaker implantation at the hospital and was admitted to the facility on [DATE]. Resident #260 stated they were concerned because the Registered Nurse Unit Manager (Registered Nurse #1) just came into their room [on 7/11/24] and set up the pacemaker monitoring device. Resident #260 stated that since their admission, the pacemaker monitoring device was not set up and was not transmitting any data to their Physician at the Cardiac Clinic.
Registered Nurse #1 was interviewed on 7/12/2024 at 3:12 PM and stated they (Registered Nurse #1) completed the admission intake for Resident #260 on 7/8/2024 when the resident was admitted from the hospital. Registered Nurse #1 stated the pacemaker monitoring device came with Resident #260 upon admission. Registered Nurse #1 stated they plugged the monitor into the wall on 7/8/2024 and did not know they had to set up the machine for the Physician to receive a transmission. Registered Nurse #1 stated they did not call the Physician to verify if a transmission was received. Registered Nurse #1 stated they went to Resident #260's room to check the pacemaker monitoring device on 7/11/2024 at around 10:00 AM and they noticed the panel of the device was not set up. Registered Nurse #1 stated they (Registered Nurse #1) read the setup instructions for first-time transmission on 7/11/2024. Registered Nurse #1 stated they should have read the instructions when they completed the admission intake for Resident #260 on 7/8/2024.
Physician #1 was interviewed on 7/15/2024 at 12:09 PM and stated they expected nursing staff to monitor Resident #260's vital signs. Physician #1 stated the Nurses should report if Resident #260 had abnormal vital signs or Atrial Fibrillation symptoms, including a pulse rate of more than 90 rate per minute or less than 60 rate per minute. Physician #1 stated that on 7/15/2024 they (Physician #1) ordered to monitor the pacemaker monitoring device's connection to the resident and ensure that the device was plugged in every shift. Physician #1 stated it was an error that the order was not placed upon admission on [DATE]. Physician #1 stated they entered the order on 7/15/2024 after it was brought to their attention [by the surveyor] that the physician's order was not in place.
Registered Nurse #2 (Nurse at the Cardiac Clinic) was interviewed on 7/16/2024 at 9:10 AM and stated the Cardiac Clinic received the first transmission from Resident #260's pacemaker monitoring device on 7/11/2024 at 10:00 AM. Registered Nurse #2 stated the facility is expected to set up the pacemaker monitoring device immediately after admission to ensure that the Cardiac Clinic Physician receives transmissions after the pacemaker implantation procedure.
The Director of Nursing Services was interviewed on 7/16/2024 at 10:22 AM and stated that when the facility received pacemaker monitoring devices, the Nurses would just plug it on the wall because they assumed the device was already set up. The Director of Nursing Services stated it was unfortunate that Resident #260's pacemaker monitoring device was not set up. The Director of Nursing Services stated the facility did not know the device was not functioning until Registered Nurse #1 had called the Cardiac Clinic on 7/11/2024 to confirm the data transmission. The Director of Nursing Services stated that Registered Nurse #1, who admitted Resident #260, should have called the Cardiac Clinic to confirm the transmission was received and should not have assumed that the pacemaker monitoring device did not need any setup. The Director of Nursing Services stated the facility does not usually enter a Physician's Order for a pacemaker monitoring device; however, an order was entered for Resident #260 to ensure that the nurses check the device's functioning.
10 NYCRR 415.12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interviews during the Recertification Survey, initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that each resident with limi...
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Based on observation, record review, and staff interviews during the Recertification Survey, initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. This was identified for one (Resident #135) of two residents reviewed for Rehabilitation Services. Specifically, the Rehabilitation Department recommended a floor ambulation program for Resident #135, however, the floor ambulation program was not completed.
The finding is:
The facility's Restorative Nursing Rehab Program Floor Ambulation policy, last reviewed on 1/2023, documented each resident will receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care including but not limited to restorative services. The ambulation program refers to the activity of walking that provides weight-bearing that promotes bone health and joint mobility. Recommendations for nursing rehabilitation such as floor ambulation will be transcribed to the tasks in the resident's chart. The task should include frequency, distance, and assistive devices recommended for ambulation. After a successful ambulation session, the aide should document the resident's ambulation, and any concerns that occurred during the event should be reported to the nurse.
Resident #135 was admitted with diagnoses including Non-Alzheimer's Dementia, Difficulty in Walking, and Congestive Heart Failure. The 6/16/2024 quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident needed partial/moderate assistance of one person to walk 10 feet and could not walk 50 feet due to a medical condition.
A progress note from the Rehabilitation Department dated 7/3/2024 recommended a Nursing Floor Ambulation Program twice a day for Resident #135 to walk 30 feet with a rolling walker with partial/moderate assistance of one person.
The facility Task List Report (Certified Nursing Assistant Instructions) as of 7/18/2024 documented a Floor Ambulation Program for Resident #135 to walk 30 feet with a rolling walker with partial/moderate assistance of one person twice a day.
The seven-day lookback of the resident's Certified Nursing Assistant Accountability Record documented a Floor Ambulation Program was performed on eight of ten opportunities from 7/12/2024 to 7/17/2024.
Resident #135 was observed lying in bed in their room on 7/11/2024 at 10:23 AM with their Private Aide (Private Aide #1) seated at the bedside. Resident #135 stated that they had been receiving therapy from the facility's Rehabilitation Department, but their therapy had ended. Resident #135 stated that they (Resident #135) wanted to walk more, but could not, since their Rehabilitation Therapy had been discontinued. Private Aide #1 stated that they have cared for Resident #135 for the past 11 years and the resident used to be very active.
The Director of Rehabilitation was interviewed on 7/18/2024 at 9:04 AM and stated Resident #135 started Physical Therapy on 3/18/2024 and was discharged from Physical Therapy on 7/3/2024 due to reaching their (Resident #135) therapy goals. The Director of Rehabilitation stated the resident was discharged from therapy with a recommendation for a Nursing Floor Ambulation Program to walk a distance of 30 feet twice a day. The Director of Rehabilitation stated rehabilitation staff educate the Certified Nursing Assistants and the Nurses when a resident is discharged from therapy and placed on a Floor Ambulation Program. The Director of Rehabilitation stated rehabilitation staff are expected to add the floor ambulation program task to the Certified Nursing Assistant Accountability Record and the Certified Nursing Assistant Care Instructions to ensure the task is done on a daily basis. The Director of Rehabilitation stated the facility does not use Physician's orders to implement a Nursing Floor Ambulation program.
Private Aide #1 was interviewed on 7/18/2024 at 9:30 AM and stated they are with Resident #135 from 7 AM to 5 PM every day and have not seen anyone perform floor ambulation with the resident.
Certified Nursing Assistant #2, regularly assigned to Resident #135 on the 7 AM to 3 PM shift, was interviewed on 7/18/2024 at 10:25 AM and stated that they had not completed floor ambulation with the resident and the documentation on the Certified Nursing Assistant Accountability Record of them doing so was a mistake. Certified Nursing Assistant #2 stated they have never walked with the resident on the unit when caring for them during the 7 AM to 3 PM shift.
Certified Nursing Assistant #3 was interviewed on 7/18/2024 at 10:40 AM and stated they have never provided floor ambulation for Resident #135. Certified Nursing Assistant #3 stated they were not regularly assigned to Resident #135 and covered various units. Certified Nursing Assistant #3 stated they documented that they had completed that task on 7/15/2024 and 7/16/2024 because they thought the resident walked with a Rehabilitation Therapist.
Registered Nurse Unit Manager #1 was interviewed on 7/18/2024 at 10:48 AM and stated they were not aware of Resident #135's Floor Ambulation Program. Registered Nurse Unit Manager #1 stated that if the Floor Ambulation Program was part of the Certified Nursing Assistant's instructions, the Certified Nursing Assistants were expected to perform the task and report if it was not completed. Registered Nurse Unit Manager #1 stated the Rehabilitation Department educates and informs the Nursing Staff which residents are on a Floor Ambulation Program.
Licensed Practical Nurse #2 (Resident #135's Medication Nurse) was interviewed on 7/18/2024 at 11:03 AM and stated the resident was not on a Floor Ambulation Program and the resident goes to Rehabilitation Therapy every day.
The Director of Rehabilitation was re-interviewed on 7/18/2024 at 11:41 AM and stated the Rehabilitation Staff provides education to the Nursing Staff using a paper lesson plan that outlines the material being taught and the nursing staff then signs off on it. The Director of Rehabilitation stated they could not find the lesson plan for Resident #135's Floor Ambulation Program.
The Director of Nursing Services was interviewed on 7/18/2024 at 12:02 PM and stated Certified Nursing Assistants should not document that they provided Floor Ambulation to a resident if they did not do it. The Director of Nursing Services stated there was a clear disconnect between Nursing and Rehabilitation Staff in regards to Resident #135's Floor Ambulation Program. The Director of Nursing Services stated Resident #135 should have received Floor Ambulation as per the program recommended by the Rehabilitation Department.
10 NYCRR 415.12(e)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 during the Recertification Survey initiated on 7/11/2024 and completed on 7/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that residents who are incontinent of bowel and bladder received the appropriate treatment and services to prevent Urinary Tract Infection. This was evident for one (Resident #117) of three residents reviewed for Activities for Daily Living. Specifically, Resident #117 required total assistance from one caregiver for toileting and was frequently incontinent of bowel and bladder. Resident #117 was observed wearing a urine-soaked brief and had wet linens underneath them on 7/11/2024 at 11:11 AM. The resident was last changed on the 11:00 PM to 7:00 AM shift before the observation.
The findings is:
The facility Resident Care with Activities of Daily Living policy and procedure, last updated on 1/2024, documented the resident will be offered toileting assistance or incontinent care twice per shift and as needed. The policy documented that staff must report any changes in the resident prior to, during or after toileting or incontinence care such as refusal to the Charge Nurse/Supervisor.
Resident #117 was admitted with diagnoses that included Dementia with Agitation, Insomnia, and Major Depressive Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderately impaired cognition. The resident had no mood symptoms and did not reject care. The resident was not on a toileting program, was frequently incontinent of bowel and bladder, and required total assistance from one caregiver for toileting.
A Comprehensive Care Plan for Activities of Daily Living dated 11/8/2023 and last updated on 5/6/2024 documented Resident #117 required assistance with self-care and mobility due to impaired mobility. The interventions included to encourage the resident to participate to the fullest extent possible with each interaction. The care plan documented the resident was dependent on the care of one staff member for toileting and personal hygiene.
A Comprehensive Care Plan for Resident Choice dated 11/9/2023 and last revised on 4/12/2024 documented Resident #117 refused activities of daily living care. The interventions included to assess the underlying reason for the resident's choices. There were no instructions for staff to report refusal of care to the Charge Nurse and/or Supervisor.
The Certified Nursing Assistant Task Report (Certified Nursing Assistant Instructions) last revised on 3/23/2024 documented the resident required incontinence care, used a large-sized brief, and depended on one caregiver for toileting hygiene. There were no instructions for Certified Nursing Assistants to report refusals of care to the Charge Nurse and/or Supervisor.
Review of Resident #117's progress notes on 7/11/2024 revealed there were no documented care refusals before 11:00 AM.
Resident #117 was observed in their room lying in bed while awake and wearing sleepwear on 7/11/2024 at 11:11 AM. There was a strong urine odor in the resident's room. Resident #117 stated that their Certified Nursing Assistant had not come in to perform morning care all morning. Resident #117 stated they were wet, needed to be changed and assisted out of bed. At 11:12 AM, the resident was observed ringing the call bell and Certified Nursing Assistant #5 responded within one minute. Certified Nursing Assistant #5 stated that they (Certified Nursing Assistant #5) were assisting another resident and would help Resident #117 after they were finished. The resident stated they were last changed on the 11 PM to 7 AM shift.
Certified Nursing Assistant #5 was observed assisting the resident with morning care on 7/11/2024 at 12:26 PM. There was a strong odor of urine in the hallway, and upon entering the resident's room, the pungent urine odor permeated the resident's room. The resident's soiled brief was observed to be saturated with urine and the inner lining of the diaper was balled up. The resident's bed linen was also observed to be wet and smelled of urine.
Certified Nursing Assistant #5 was interviewed on 7/11/2024 at 12:53 PM and stated they had not cared for Resident #117 all morning and that the resident was last changed on the 11 PM to 7 AM shift. Certified Nursing Assistant #5 stated that they regularly worked with the resident, and they (the resident) were difficult to work with. Certified Nursing Assistant #5 stated the resident refused morning care on 7/11/2024.
Certified Nursing Assistant #5 was re-interviewed on 7/16/2024 at 2:32 PM and stated Resident #117 usually gets out of bed around 11:00 AM daily. Certified Nursing Assistant #5 stated that the resident was incontinent of bowel and urine and had frequent urination. Certified Nursing Assistant #5 stated that on 7/11/2024, they (Certified Nursing Assistant #5) served the resident their breakfast tray after 8 AM and the resident did not complain about being wet. Certified Nursing Assistant #5 stated that they went into the resident's room after breakfast, at around 9:30 AM, and after 11:00 AM, and the resident stated that they were not ready to get out of bed. Certified Nursing Assistant #5 stated that they did not report to the Nurse that the resident was refusing care. Certified Nursing Assistant #5 stated that at 11:25 AM, they went to the resident and informed them (Resident #117) that they were with another resident and would come in after they had completed the other resident's care. Certified Nursing Assistant #5 stated when they returned to care for Resident #117 at around 11:45 AM, the resident's brief was soaked with urine and the bed linen was also wet. Certified Nursing Assistant #5 further stated they should have report to the Charge Nurse when a resident refuses care and encourage the resident to accept care.
Certified Nursing Assistant #7, who cared for the resident on the 11:00 PM to 7:00 AM shift on 7/10/2024 into 7/11/2024, was unavailable for an interview.
Registered Nurse #7, the Nurse Manager for the second floor Nursing Unit, was interviewed on 7/16/2024 at 3:03 PM and stated they were not made aware that Resident #117 was refusing care. Registered Nurse #7 stated Certified Nursing Assistant #5 should have checked the resident at the beginning of the shift to ensure they were dry. Registered Nurse #7 stated that the Certified Nursing Assistants are instructed to check the residents every two hours to ensure timely and appropriate incontinence care is rendered. Registered Nurse #7 stated if a resident refuses care, the Certified Nursing Assistant should re-approach the resident. Registered Nurse #7 stated if the resident continues to refuse care, the Certified Nursing Assistant should go to the Charge Nurse. The Charge Nurse and the Certified Nursing Assistant should report to the Nurse Manager if they were unable to encourage the resident to accept care and document the refusal in the progress notes.
The Director of Nursing Services was interviewed on 7/17/2024 at 12:08 PM and stated Certified Nursing Assistant #5 should have reported to the Charge Nurse that Resident #117 refused care after they (Certified Nursing Assistant #5) approached the resident twice. The Director of Nursing Services stated the Charge Nurse should report to the Registered Nurse Manager that the resident continued to refuse care and document the incident in a progress note. The Director of Nursing Services stated they expect Certified Nursing Assistants to check and change a resident's brief every two to three hours.
10 NYCRR 415.12 (d)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 7/11/2024 and comp...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #57) of four residents reviewed for Respiratory Care. Specifically, Resident #57 had a Physician's Order to receive 4 liters of oxygen therapy per minute via mist collar to a tracheostomy continuously. However, on multiple occasions, Resident #57 was observed receiving 6 liters of oxygen per minute via mist collar to their tracheostomy.
The finding is:
The facility's Assessing Oxygen Saturation Policy, last revised in January 2024, documented to assess the resident for the following signs and symptoms of impaired oxygen saturation: altered respirations, difficulty breathing, and abnormal breath sounds. The policy further documented to notify the Physician if the oxygen saturation level is less than an acceptable level for the resident's condition.
Resident #57 was admitted with diagnoses including Acute Respiratory Failure with Hypoxia, Quadriplegia, and Cerebral Infarction. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident had severe cognitive impairment. The Minimum Data Set further documented the resident received oxygen therapy.
The Alteration in Respiratory System Care Plan, last revised on 3/21/2024, documented interventions which included to provide oxygen therapy via humidified air at 4 liters per minute via tracheostomy collar at all times, as per Physician's Orders.
A Physician's Order dated 7/11/2024 documented oxygen therapy to be administered at 4 liters per minute via a tracheostomy collar continuously.
Resident #57 was observed sleeping in a Geri chair (a large padded chair with wheeled bases designed to assist individuals with limited mobility) in their room with a mist collar delivering 6 liters of oxygen per minute to their tracheostomy on 7/11/2024 at 1:08 PM.
Resident #57 was observed lying in bed in their room with a mist collar delivering 6 liters of oxygen per minute to their tracheostomy on 7/12/2024 at 8:53 AM.
Resident #57 was observed sleeping in a Geri chair in their room with a mist collar delivering 6 liters of oxygen per minute to their tracheostomy on 7/12/2024 at 11:56 AM.
Resident #57 was observed in their room in a Geri chair with Nurse Manager #5 on 7/16/2024 at 10:42 AM. The display window on the oxygen concentrator indicated the resident was receiving 6 liters of oxygen per minute via a mist collar to their tracheostomy.
Registered Nurse #3 was interviewed on 7/16/2024 at 10:46 AM and stated they just checked the oxygen level and thought it was set to 4 liters per minute. Registered Nurse #3 stated that the oxygen therapy setting was checked on each shift by a Nurse. Registered Nurse #3 stated they would speak to the Physician about the Oxygen order. Registered Nurse #3 stated they would set the oxygen therapy to 4 liters per minute and check Resident #57's oxygen saturation level (measurement of the amount of oxygen in your blood). Registered Nurse #3 stated they would continue to monitor the resident's oxygen saturation level during the 7 AM - 3 PM shift and if Resident #57's oxygen dropped, they would increase the oxygen and call the Physician.
The Registered Nurse Manager (Registered Nurse #5) was interviewed on 7/16/2024 at 10:49 AM and stated the Nurse caring for Resident #57 should monitor the resident's oxygen saturation levels and notify the Physician that the resident required more oxygen. Registered Nurse #5 stated the Nurse caring for Resident #57 was responsible for monitoring and documenting the resident's oxygen level every shift. Registered Nurse #5 checked Resident #57's Physician's Orders and verified the resident should have received 4 liters per minute and not 6 liters per minute as observed.
Physician #2 was interviewed on 7/17/2024 at 11:22 AM and stated they expect the Nursing staff to follow their Physician Orders as they were written for Resident #57. Physician #2 stated when a resident is not receiving enough oxygen, they can become hypoxic (a condition in which the body does not have enough oxygen at the tissue level), have difficulty breathing, and have a rapid heart rate. Physician #2 stated too much oxygen therapy can cause problems with vision and dizziness. Physician #2 stated they expect the Nursing staff to monitor the respiratory levels of the residents and to notify them (the Physician) if a resident continues to be hypoxic. Physician #2 stated they would then put in an order for an increase in oxygen therapy if needed. Physician #2 further stated that they expected the nursing staff to continue monitoring the resident's oxygen saturation level after the increase in oxygen therapy was made.
The Director of Nursing Services was interviewed on 7/17/2024 at 12:00 PM and stated they expect the Nursing staff to frequently monitor the oxygen levels and the settings of oxygen therapy as per the Physicians' Orders. The Director of Nursing Services stated if a Nurse observes changes in the oxygen level of a resident, they are expected to notify the resident's Physician.
10 NYCRR 415.12(k)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure it obtained laboratory services to ...
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Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not ensure it obtained laboratory services to meet the needs of each resident. This was identified for one (Resident #41) of three residents reviewed for Transmission-Based Precautions. Specifically, Resident #41 was receiving the antibiotic Vancomycin for Methicillin-Resistant Staphylococcus aureus (a bacteria that causes serious infection) in the urine and mastoid bone (the bone behind the ear) and the Physician ordered a Vancomycin trough level (a laboratory test used to determine therapeutic dosage) to be drawn on 7/9/2024. There was no documented evidence in the resident's medical record that the laboratory order was completed.
The finding is:
The facility's Laboratory and Diagnostic Test Results Clinical Protocol, last reviewed 1/2024, documented the Physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory will report test results to the facility. Nursing staff are expected to review all results and relay results to the medical professional. A nurse will identify the urgency of communicating with the Attending Physician based on the Physician's request, the seriousness of any abnormality, and the individual's current condition. Nursing staff will consider the following factors to help identify situations requiring prompt Physician notification concerning lab or diagnostic test results: High or toxic drug levels. A Physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance.
Resident #41 was admitted with diagnoses including Cancer, Acute Mastoiditis, and Infection with Multi-Drug Resistant Organism. The 6/19/2024 significant change Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented that the resident was taking an antibiotic.
A Physician's Order dated 6/12/2024 documented Resident #41 required Strict Contact Precautions for an Active Methicillin-Resistant Staphylococcus Aureus Infection in Urine. The physician's order directed all services to be completed in the resident's room.
A Comprehensive Care Plan effective 6/15/2024 documented Resident #41 was on Contact Precautions due to a Methicillin-Resistant Staphylococcus Aureus Infection to Mastoid Bone and Urinary Tract. The interventions included administering medications or treatments as per the Physician's Order.
A Physician's Order dated 6/15/2024 documented to administer Vancomycin Hydrochloride in Sodium Chloride Intravenous Solution 750-0.9 milligram per 150 milliliter, use 750 milligram intravenously every 12 hours for Methicillin-Resistant Staphylococcus Aureus until 7/19/2024.
Bloodwork for Resident #41's Vancomycin trough level was collected on 7/5/2024 and the result was reported to the facility on 7/5/2024. The result was 35.7 micrograms per milliliter and was flagged by the laboratory as critically high (meaning above peak levels as the normal reference range is between 10.0 and 20.0).
A Progress Note written by Physician #1 dated 7/6/2024 documented a high Vancomycin level of 35.7 on the Vancomycin trough test. Physician #1 recommended decreasing the Vancomycin to once a day and repeating the Vancomycin laboratory test in three days.
A Physician's Order dated 7/6/2024 documented to give Vancomycin Hydrochloride in Sodium Chloride Intravenous Solution 750-0.9 milligram per 150 milliliter, use 750 milligrams intravenously in the evening for Methicillin-Resistant Staphylococcus Aureus for 13 days.
A Physician's Order dated 7/6/2024 documented to obtain a Vancomycin trough level on 7/9/2024.
A review of Resident #41's medical record revealed no documented evidence of bloodwork collection for a Vancomycin trough level test on 7/9/2024.
Resident #41 was observed in their room in their wheelchair on 7/12/2024 at 10 AM. There was a contact precaution sign at the doorway and a full personal protective equipment cart outside the resident's room door.
The Registered Nurse Unit Manager (Registered Nurse #1) was interviewed on 7/15/2024 at 9:24 AM and stated they were not sure if the 7/9/2024 Vancomycin trough level had been ordered.
A review of the resident's medical record revealed that another order for a Vancomycin trough level was entered on 7/15/2024 at 9:34 AM.
The Registered Nurse Unit Manager (Registered Nurse #1) and Licensed Practical Nurse #2 were interviewed concurrently on 7/15/2024 at 10:38 AM. Licensed Practical Nurse #2 stated the order for the 7/9/2024 Vancomycin trough was entered in the laboratory-ordering system and for some reason, the laboratory did not collect it. Registered Nurse #1 stated an immediate (STAT) order for a Vancomycin trough level was just placed today (7/15/2024) to be collected as it was never done on 7/9/2024 and should have been. Registered Nurse #1 stated the Vancomycin trough level for Resident #41 was last collected on 7/5/2024.
Physician #1 was interviewed on 7/15/2024 at 11:25 AM and stated the Methicillin-Resistant Staphylococcus Aureus infection was in Resident #41's urinary tract and mastoid bone. Physician #1 stated they did not follow up on the Vancomycin trough level they ordered on 7/9/2024 because they were addressing another health issue Resident #41 had. Physician #1 stated that monitoring the Vancomycin trough level was important to ensure the resident received a therapeutic dose.
The Registered Nurse Unit Manager (Registered Nurse #1) was re-interviewed on 7/15/2024 at 12:41 PM and stated the Laboratory Technician may have missed the resident when coming in to draw the blood. Registered Nurse #1 stated the Nurse who entered the laboratory work order or the Physician should have followed up on the status of the order.
The Laboratory Technician (Laboratory Representative #1) was interviewed on 7/15/2024 at 1:36 PM and stated they did not see Resident #41's order for the 7/9/2024 Vancomycin trough level. Laboratory Representative #1 stated they only saw an order for the Vancomycin trough from today, 7/15/2024, and another from 7/5/2024.
Licensed Practical Nurse #2 was interviewed on 7/16/2024 at 9:47 AM and stated they entered the Vancomycin trough level order on 7/9/2024 via the laboratory's website. Licensed Practical Nurse #2 stated they could not explain why the bloodwork was not collected and they did not follow up with the laboratory.
The Director of Nursing Services was interviewed on 7/16/2024 at 10:49 AM and stated that they (the Director of Nursing Services) were unable to determine why Resident #41's Vancomycin trough level was not collected on 7/9/2024. The Director of Nursing Services stated that the facility ordered Resident #41's laboratory work, so there may have been an issue on the laboratory's side in not completing it. The Director of Nursing Services stated the Nurse on the unit and the resident's Physician were supposed to follow up the next day to ensure that laboratory work was completed.
10 NYCRR 415.20
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 during the Recertification Survey initiated on 7/11/2024 and completed on 7/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #112) of six residents reviewed in the Medication Administration Task. Specifically, Resident #112 had a physician's order for Strict Contact Precautions for Pseudomonas Aeruginosa (a type of bacteria) in the urine which required the use of Personal Protective Equipment including a gown and gloves. The Licensed Practical Nurse (Medication Nurse) #1 was observed on 7/12/2024 entering the room without wearing a gown and gloves and administered medications to Resident #112.
The finding is:
The facility's Initiation of Transmission-Based Precautions policy, last revised on 1/2024, documented it is the policy of the facility to prevent the spread of infection within the facility through the use of isolation precautions. Contact Precautions in addition to standard precautions are used for residents known or suspected to be infected with microorganisms that can easily be transmitted by direct or indirect contact such as handling environmental surfaces or resident care items. Special instructions are to be explained to all staff involved. Education will be provided to the resident if applicable, and visitors/family members regarding the use of isolation precautions.
Resident #112 was admitted with the diagnoses of Urinary Tract Infection, Epilepsy, and Schizoaffective Disorder. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13 which indicated Resident #112 had intact cognition. The Annual Minimum Data Set assessment documented that Resident #112 was incontinent of both bowel and bladder. Resident #112 was dependent on staff for all activities of daily living including toileting, personal hygiene, and bathing.
A Urinary Culture Report dated 7/7/2024 documented Resident #112 had Pseudomonas Aeruginosa (a bacteria) of 10,000 to 49,000 colony-forming units per milliliter and needed Ciprofloxacin (an antibiotic).
The Comprehensive Care Plan for Urinary Tract Infection dated 7/8/2024 documented interventions which included implementing Transmission-Based Precautions as per Physician Order, specifically contact precautions; performing hand hygiene before and after contact with residents; using Personal Protective Equipment; and encouraging fluid intake and diet compliance.
A Physician's Order dated 7/11/2024 documented to implement Strict Contact Precautions for an active infection and to complete all services in the resident's room.
A Physician's Order dated 7/11/2024 documented to administer Ciprofloxacin Hydrochloride (an antibiotic) 500 milligrams one tablet by mouth once a day for one day and one tablet by mouth every 12 hours for 7 days to treat a Urinary Tract Infection.
A sign posted outside Resident #112's room on Unit 2 that read Contact Precautions was observed on 7/12/2024 at 8:49 AM in Unit 2 during the Medication Administration task. The sign instructed everyone must clean their hands before and after entering and when leaving the room. The sign also instructed to use Personal Protective Equipment including wearing a gown and gloves. Licensed Practical Nurse #1 was subsequently observed entering Resident #112's room to administer medications to the resident without a gown and gloves. Licensed Practical Nurse #1 proceeded to administer medication to Resident #112, who was lying in bed.
Licensed Practical Nurse #1 was interviewed on 7/12/2024 at 9:00 AM and stated they (Licensed Practical Nurse #1) did not wear gloves and a gown when entering Resident #112's room because Resident #112 had an infection in the urine. Licensed Practical Nurse #1 stated they were not providing care at the time and were just giving medications to Resident #112. Licensed Practical Nurse #1 stated they read the signage outside Resident #112 room, but thought it only pertained to high-contact care such as toileting. Licensed Practical Nurse #1 stated they were not aware that a gown and gloves were needed for medication administration.
The Registered Nurse Infection Preventionist was interviewed on 7/12/2024 at 3:38 PM and stated Licensed Practical Nurse #1 should have worn a gown and gloves before entering Resident #112's room. The Registered Nurse Infection Preventionist stated that Resident #112 was on Contact Isolation and the signage was very specific that everyone who entered the room must wear a gown and gloves.
The Director of Nursing Services was interviewed on 7/16/2024 at 10:35 AM and stated Licensed Practical Nurse #1 should have worn gloves and a gown as indicated on the Contact Precautions signage outside Resident #112's room. The Director of Nursing Services stated that all the staff and visitors should follow the Contact Precautions signage outside Resident#112's room and wear a gown and gloves when entering the resident's room.
10 NYCRR 415.19 (a) (1-3)
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
Based on observation, record review, and staff interviews during the Recertification and Abbreviated (NY00323936) Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not maintai...
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Based on observation, record review, and staff interviews during the Recertification and Abbreviated (NY00323936) Survey initiated on 7/11/2024 and completed on 7/18/2024, the facility did not maintain medical records on each resident that were complete and accurate for one (Resident #91) of one resident reviewed for Abuse. Specifically, Resident #91's family member reported bruising to Resident #91's left eye on 9/13/2023. However, the resident's skin assessment and medical evaluation to rule out trauma were not documented in the medical record.
The finding is:
The facility's Charting and Documentation policy, last reviewed in 1/2024, documented objective observations, treatments or services performed, events, incidents or accidents involving the resident are to be documented in the medical record.
Resident #91 was admitted with diagnoses including Unspecified Dementia, Type 2 Diabetes Mellitus, and Venous Insufficiency. The 7/21/2023 annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview. The staff assessment for mental status documented the resident had impaired short-term memory and long-term memory as well as moderately impaired cognitive skills for daily decision-making.
Resident #91's family member was interviewed on 7/15/2023 at 11:58 AM and stated during a virtual videoconferencing meeting on 9/13/2023, they observed Resident #91 with a discoloration under their left eye. The family member reported the discoloration to the Director of Nursing Services and the Administrator on 9/13/2023. The family member stated they were informed that the Director of Nursing Services assessed the resident and concluded the skin condition was an old discoloration. The family member alleged the Director of Nursing Services compared the resident's discoloration to an admission photograph from 2016.
A review of Resident #91's medical records for September 2023 revealed no documented evidence of any evaluation of the left or right eye areas for discoloration.
Resident #91 was observed with the Director of Nursing Services present in the second-floor main dining room on 7/16/2024 at 1:15 PM. The resident's complexion showed varying pigmentation across different areas of the face, with no signs of bruising.
The Director of Nursing Services was interviewed on 7/16/2024 at 1:20 PM and stated they spoke to Resident #91's family member on 9/13/2023 and immediately assessed Resident #91's eye area. The Director of Nursing Services stated they concluded that the discoloration was related to a birthmark or pigmentation. The Director of Nursing Services stated they did not document the skin assessment or the communication with the family member in the resident's medical record. The Director of Nursing Services stated they should have documented the family member's allegation and Resident #91's skin assessment.
The Physician Assistant was interviewed on 7/18/2024 at 12:24 PM and stated the Director of Nursing Services reported the family member's allegation to them immediately on 9/13/2023. The Physician Assistant stated they assessed Resident #91 the next day (9/14/2023) and concluded that the discoloration around the resident's eye was not the result of trauma, but rather a birthmark or pigmentation. The Physician Assistant stated they did not feel it was necessary to document their evaluation in Resident #91's medical record because it was a verbal concern expressed by the Director of Nursing Services. The Physician Assistant did not report the family member's allegation to the attending Physician because they did not observe a change in Resident #91's condition.
The Administrator was interviewed on 7/18/2024 at 12:51 PM and stated they were made aware of the family member's allegation but could not recall the exact date. The Administrator stated licensed providers are expected to document all medical assessments in the resident medical records.
10 NYCRR 415.22(a)(1-4)
Apr 2022
12 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0692
(Tag F0692)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a Recertification Survey and Abbreviated Survey initiated on 3/23/2022...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a Recertification Survey and Abbreviated Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility failed to Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; the facility failed to reassess the resident after the weight loss was identified and failed to notify the Physician and the Dietician to implement interventions to address and monitor the unplanned weight loss. The facility's failure to implement an existing weight monitoring policy and failure to monitor each residents' nutritional intake was identified for two (Resident #45 and Resident #80) of seven residents reviewed for Nutrition. Specifically, 1) Resident #45 with diagnoses of Alzheimer's Disease, Legal blindness, and a recent history of COVID-19 infection was identified as at risk for weight change and malnutrition, and poor oral intake. The facility staff were not accurately monitoring the resident's food consumption and failed to reassess the resident after a significant weight loss was identified. The resident had a 23.5 % unplanned weight loss in one month. The facility also failed to notify the physician and the dietician of the significant weight loss to implement interventions to address and monitor the unplanned weight loss. Additionally, the facility failed to have an effective system in place to monitor residents with significant weight loss. 2) Resident #80 (NY 00290462) had a significant weight loss after being admitted to the facility; the resident was not reweighed timely and was not assessed by the Dietician after the weight loss was identified. This resulted in actual harm and Immediate Jeopardy to the resident's health and safety with Substandard Quality of Care for Resident #45.
The findings are:
The Weight Assessment and Interventions policy, last revised on 1/2022, documented the nursing staff will measure the resident's weight on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted, weights will be measured monthly thereafter. Weights will be recorded in each unit weight record chart or notebook and in the individual residents' medical record. The policy further documented any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight loss is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The policy documented the dietitian will respond within 24 hours of receipt of written notification. The dietitian will review the unit weight record by the 15 th of the month to follow individual weight trends overtime. The policy documented the interventions for undesirable weight loss shall be based on careful consideration of resident choice and preferences, nutrition and hydration need of the resident, functional factors that may inhibit independent eating, environmental factors that may inhibit appetite or desire to participate in meals, chewing and swallowing abnormalities and the need for diet.
The Nutritional Assessment policy last revised on 1/2022 documented the dietitian, in conjunction with the nursing staff and health care practitioners, will conduct nutritional assessment for each resident upon admission and as indicated by changes in condition that places the resident at risk for impaired nutrition. The policy documented the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for impaired nutrition. The policy further documented that the Physician is to assess the presence of chewing or swallowing abnormalities, conditions of the mouth, teeth, gums, pharynx, or esophagus that affects the residents' ability to chew or swallow food.
1) Resident #45 has diagnoses including Legal Blindness, Alzheimer's Disease, and a recent history of COVID-19 infection (January 2022). The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #45 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severely impaired cognition. The resident had moderately impaired vision. The MDS documented Resident #45 did not reject care and required supervision with set up help only for eating. The MDS documented the resident had no broken or loosely fitting full or partial dentures or pain. The resident was 60 inches tall, weighed 99 pounds, and no weight loss was identified. The resident was not on a Physician prescribed weight loss regimen.
The Comprehensive Care Plan (CCP) dated 7/21/2019, titled Risk for weight change/Malnutrition due to underlying medical condition included advanced age, Alzheimer's Disease, hearing loss, Poor oral intake, low Body Mass Index (BMI), and vitamin deficiency. The interventions included to identify and honor food preferences, monitor meal consumption records, monitor weights monthly or as frequently as resident will allow. The CCP was revised on 1/30/2022 documented interventions to include to feed self with supervision, observe for chewing and swallowing problems and to provide regular diet, chopped texture with thin liquid consistency. The CCP did not have revised interventions related to monitoring of the weights due to poor intake.
The Dietary progress note dated 1/12/2022 documented resident's supplements adjusted to 120 cubic centimeter (cc) Health Shake.
There was no Physician's order for the Health Shakes that were recommended by the dietician on 1/12/2022 until 1/30/2022.
The quarterly dietary progress notes by Dietician #1 on 1/30/2022 at 3:11 PM documented Resident #45 weighed 97 pounds and was 60 inches tall. The resident's BMI was 19.3, indicating borderline underweight. There was no significant weight change noted this quarter however, progressive weight gain would be beneficial due to the resident being borderline underweight. The resident was receiving regular diet, regular texture with thin Liquid consistency and was consuming mostly 26%-50% of their meals which indicated poor to fair oral intake with no difficulty chewing or swallowing. The dietician recommended to continue Health Shakes 4 ounces (oz), 120 cubic centimeter (cc) five times a day as a supplement.
The Physician orders dated 1/30/2022 documented to administer Health Shakes 4 oz, 120 cubic centimeter (cc) five times a day as a supplement.
Speech evaluation by the Speech Language Pathologist (SLP) #3 dated 2/1/2022 at 1:27 PM documented Resident#45 comprehension likely impacted by language barrier in addition to their visual impairment and Hard of Hearing (HOH). Speech therapist recommended to downgrade the diet to a soft-chopped with thin liquid diet. Resident #45 typically avoids regular hard solids at baseline. The resident has mild to moderately prolonged oral prep and anterior to posterior (AP) transit for regular solids likely impacted by edentulous (toothless) status and visual impairment. Resident would likely benefit from a soft-chopped diet to promote ease of mastication (chewing) and increased intake.
The Physician's order dated 2/1/2022 documented to provide Regular diet, chopped/soft texture with thin liquid consistency.
The primary Physician's progress note dated 3/11/2022 at 3:08 PM documented Resident #45 had normal age-related changes and was at risk for Malnutrition. The progress note documented that the resident weighed 98.0 pounds on 2/25/2022.
Speech evaluation by SLP #1 dated 3/18/2022 at 1:50 PM documented Resident #45 was screened for the appropriate and safest diet consistency. Resident #45 was previously tolerating a soft-chopped diet with thin liquids. Recommended to continue diet with Chopped consistency and thin liquids. The Registered Dietician (RD) and nursing were informed. There was no documented evidence related to the resident's weight loss.
The Physician's order dated 3/18/2022 documented regular diet, chopped texture with thin liquid consistency.
The Certified Nursing Assistant Accountability Record (CNAAR) from December 2021 to March 2022 was reviewed.
In December 2021 there were 93 meal opportunities. The resident consumed 0-25% of their meals on 29 occasions; 26-50% on 29 occasions; 51-75 % on 4 occasions; 76-100% on one occasion. The resident refused meals on 4 occasions and there were 26 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank.
In January 2022 there were 93 meal opportunities. The resident consumed 0-25% of their meals on 28 occasions; 26-50% on 26 occasions; 51-75 % on 3 occasions; 76-100% on zero occasion. The resident refused meals on zero occasions and there were 36 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank.
In February 2022 there were 84 meal Opportunities. The resident consumed 0-25% of their meals on 19 occasions; 26-50% on 12 occasions; 51-75 % on 6 occasions; 76-100% on zero occasion. The resident refused meals on zero occasions and there were 47 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank.
The March 2022 CNAAR from March 1st through March 30 th had 90 meal opportunities. The resident consumed 0-25% of their meals on 32 occasions; 26-50% on 12 occasions; 51-75 % on 2 occasions; 76-100% on zero occasion. The resident refused meals on 12 occasions and there were 32 occasions the staff did not document the resident's meal consumption and the CNAAR was left blank.
There was no documented evidence of additional interventions in the resident's medical record for poor meal consumption.
Resident #45 was observed in bed on 03/23/22 at 12:50 PM with their lunch meal tray that was opened and untouched on the resident's overbed table. The meal tray was out of the resident's reach. There were no staff members observed in the resident's room.
The staff did not document the resident's meal consumption and the CNAAR was left blank on 3/23/2022 for the breakfast and the lunch meal.
Resident #45 was observed on 3/25/2022 at 1:00 PM lying in bed in their room with a sheet covering the resident's face with. The lunch meal tray was opened and untouched on the resident's overbed table. The meal tray was within the resident's reach. The resident was not eating the meal. There were no staff members observed in the resident's room.
Resident #45 was re-weighed on 3/25/2022 after the lunch meal. The resident's weight was 75 pounds.
The unit weight book was reviewed on 3/25/2022 at 3:00 PM with the RD #2. RD #2 stated that the weight book was last updated in 2020. Resident #45's name was not listed in the weight book.
-On 2/25/2022 the resident's weight was recorded as 98.0 pounds with a Hoyer (Mechanical Lift) scale.
-On 3/12/2022 the resident's weight was recorded as 85.6 pounds with a Hoyer (Mechanical Lift) scale. -On 3/25/2022 the resident's weight was recorded as 75 pounds with a Hoyer (Mechanical Lift) scale
LPN #1, who was the 7 AM to 3 PM medication and treatment nurse on Unit 2 and was assigned to Resident #45, was interviewed on 3/25/2022 at 11:36 AM and stated they (LPN #1) knew Resident #45 was a picky eater and requires only setup help and does not require assistance with meals. LPN #1 stated Resident #45 receives mighty shakes 4 oz 5 times a day and the resident was alert and eats what they want, when they want. LPN #1 stated they (LPN #1) encouraged Resident #45 to eat throughout the day.
RD #2 was interviewed on 03/25/2022 at 12:03 PM and stated they started working at the facility on 3/14/2022 and were not made aware of Resident #45's weight loss. The resident weighed 98 pounds on 2/25/2022 and weighed 85.6 pounds on 3/12/2022. RD #2 stated that they should have been made aware of the weight loss. RD #2 stated the nurses are supposed to notify the RD if a resident loses 5 percent of their body weight in one month. RD #2 stated reporting the weight loss is nurse's job. RD #2 stated it is hard to track the weights because of room changes, and the facility always have staffing issues since the facility is short staffed. RD #2 stated residents' weights have not been tracked since 2020 in the weight book. RD #2 stated that the facility does not have a system to identify and track the residents with weight loss.
Nurse Practitioner (NP) #1 was interviewed on 3/25/2022 at 4:03 PM and stated they were not notified about Resident #45's weight loss until 3/25/2022. NP #1 stated there were no progress notes regarding Resident #45 weight loss in the resident's medical record. NP #1 stated they if they were notified of the weight loss on 3/12/2022 they (NP #1) would have notified the dietitian and ordered blood work. NP #1 stated they (NP #1) would have asked the nurses to feed Resident #45 every meal. NP #1 stated they (NP #1) do not know if other residents have had a significant weight loss. NP #1 stated the facility should have a protocol for reporting weight loss and all staff should know what to do in case weight loss is identified. NP #1 stated as soon as a weight loss is identified the nurses should notify the NP, the MD, and the Dietician. NP #1 stated they will order intravenous fluids for 24 hours for Resident #45 for possible dehydration and order to obtain daily weights. NP #1 further stated that they will instruct staff that Resident #45 be fed by staff.
LPN #2 the 3 PM-11 PM shift medication and treatment nurse was interviewed on 3/25/2022 at 4:22 PM and stated they (LPN #2) did not know if Resident #45 was eating their meals as no one made them aware of the resident's poor meal intake. They (LPN #2) stated if they knew Resident#45 not eating the meals and lost weight they would have called the doctor, dietitian, and the family. LPN #2 stated they (LPN #2) put all residents' weights in the Electronic Medical Record (EMR) but do not check the weights previously entered to identify if any residents had changes in weights. LPN #2 stated they do not know if there are other residents who have weight loss because the LPNs are not responsible to monitor weight loss. LPN #2 stated the Dietitian and the Registered Nurse (RN) managers, or the RN Supervisors are supposed to monitor the residents' weights.
Certified Nursing Assistant (CNA) #1, who was the regularly assigned 7 AM-3PM CNA for Resident #45, was interviewed on 3/25/2022 at 4:44 PM and stated they (CNA#1) set up Resident #45's meal tray, but they do not have to feed the resident because the resident eats independently. CNA #1 stated for a couple weeks, Resident #45 has been refusing to eat their meals and was not eating like before. CNA #1 stated they (CNA #1) notified LPN #4 that Resident #45 was not eating and LPN #4 tried to feed the resident by giving the resident oatmeal and shakes. CNA #1 stated Resident #45's meal intake did not improve after LPN # 4 was notified. CNA #1 stated they would have reminded Resident #45 to drink and eat if they (CNA #1) knew the resident was losing weight. CNA #1 stated they (CNA #1) did not let other nurses know Resident #45 was not eating because LPN #4 was the regular nurse. CNA #1 stated they (CNA #1) do not know if there are any other residents that have weight loss because the nurses record the weights in the EMR and can see the previous weights.
During an observation on 3/28/2022 at approximately 10 AM Resident #45 was weighed in their room with a Hoyer lift with two CNAs present. The resident weighed 75 pounds.
The Dietary progress note dated 3/28/2022 documented as per speech evaluation downgrade diet to puree consistency.
The Physician's order dated 3/28/2022 documented to provide Resident #45 a regular diet, puree texture with thin liquid consistency.
Assistant Nurse Aide (ANA) #1 was interviewed on 3/29/2022 at 10:12 AM and stated Resident #45 was an independent eater and they (ANA #1) only set up Resident #45's meal trays. ANA #1 stated the LPNs knew Resident #45 was not a good eater. ANA #1 stated after they weigh the residents, they (ANA #1) give the resident's weight results to the nurses on a piece of paper and the nurses put the weights in the EMR. ANA #1 stated their responsibility is to report to the nurses when they see residents refusing to eat or eating less; however, they (ANA #1) did not report the resident's poor intake to the nurses because it was normal for the resident to not eat their meals and all the nurses knew that the resident was not eating.
LPN #4, who is the regularly assigned medication nurse on Unit 2, was interviewed on 03/29/2022 at 11:08 AM and stated Resident #45 has been on their floor since January 2022. They stated they received a report from the 4th floor where Resident #45 previously resided and were informed that Resident #45 was not a good eater. LPN #4 stated Resident #45 needs assistance to eat, and LPN #4 has to go back and forth to encourage the resident to eat but, was busy passing medications and administering treatments. LPN #4 stated CNA#1 did not report that Resident #45 was not eating their meals therefore LPN #4 did not report to the Dietitian or the Physician that Resident #45 was not a good eater. LPN #4 stated the Registered Nurse Manager (RNM) was usually responsible to monitor the CNAAR for meal intake recording. LPN #4 stated Unit 2 does not have a full time RNM assigned for a while now. LPN #4 stated they expected CNAs to report Resident #45's meal intake to them (LPN #4). LPN #4 stated there is a weight sheet on the Unit and the CNAs were responsible to record the residents' weights on that sheet. LPN #4 stated the Dietician was responsible for checking the residents' weight every month and collecting the weight sheets and then recording the residents' weights in the EMR. If a resident loses or gains 5 pounds, the Dietitian will then request a reweigh. LPN #4 stated that the Dietician (RD #1) did not request a reweigh for Resident #45 from LPN #4.
SLP #1 was interviewed on 3/29/2022 at 12:18 PM and stated in March 2022, the facility's corporate office changed the names of diets. SLP #1 stated they wrote a note on 3/18/2022 to reflect that change in Resident #45's medical record, however, there were no changes made to the diet consistency that the resident was already receiving. SLP #1 stated it was the same consistency but with a different name. SLP #1 stated they were not made aware of the resident's weight loss. If there was a weight loss, SLP #1 should have been notified by the Dietitian and nurses to evaluate the resident for difficulty swallowing and to perform a full evaluation to rule out dysphasia (difficulty swallowing).
The Director of Nursing Services (DNS) was interviewed on 3/29/2022 at 12:00 PM and stated Unit 2 does not have an assigned unit manager. If there are any emergencies the DNS, wound nurse, and RN #8 Unit Manager chip in to help. The DNS stated the facility is short of staff.
The Wound Nurse, RN # 7, was interviewed on 03/29/22 at 1:18 PM and stated they (RN #7) help out on the 2nd floor as needed because Unit 2 does not have an RNM. RN #7 only goes to Unit 2 when the unit staff members call them (RN #7) for an emergency. RN #7 stated CNAs are responsible for weighing the residents and the Dietitian and nurses are responsible to review the weights. Each unit has a full time RN to complete the weight task however, there is no full time RN on Unit 2. RN #7 does not know which RN is responsible for checking the resident's weights on that unit. RN #7 stated they were not made aware of Resident #45's weight loss. RN #7 stated they (RN #7) do not know who is responsible to review the CNAAR for completion and monitoring of meal intake.
RN # 8, the Unit Manager from the first floor, was interviewed on 3/29/2022 at 2:09 PM and stated they (RN #8) have been working at the facility for 4 months. RN #8 stated the second floor staff calls them when there is a fall or a resident requires medications to be administered by an RN. RN #8 stated they did not know who monitors the residents' weights on the second floor since the second floor does not have an RNM. RN #8 stated they were not made aware of Resident #45's weight loss. RN #8 stated that they checked the CNA accountability to make sure they complete the tasks on their own unit but did not know who checks the second floor CNAARs.
RN #9, who was a per-diem Nursing Supervisor, was interviewed 03/29/2022 at 2:39 PM and stated they (RN #9) were the RN Supervisor for the entire building and works various shifts. RN #9 stated that RN #9 received a list of residents to weigh or reweigh from the DNS on 3/10/2022. The list was given to the DNS by the previous Dietitian (RD #1). RN #9 stated that the weights were completed on 3/10/2022 and the completed list was placed in the DNS's mailbox. RN #9 stated they received a call from the DNS on 3/12/2022 requesting the residents' weights. RN #9 stated they observed the weight list was still in the DNS's mailbox on 3/12/2022. RN #9 stated they (RN #9) updated the weights in the EMR on 3/12/2022 and then noticed Resident# 45 had a weight loss however, RN #9 did not notify any one of the weight loss because they (RN #9) assumed the DNS and the Dietitian would follow up with Resident #45's weight loss. RN #9 stated they (RN #9) do not check the CNAAR or the weight records because the Unit RN managers are responsible to check the CNAAR and the weight records.
CNA #5 who usually works on the 3 PM to 11 PM nursing shift, was interviewed on 3/29/2022 at 6:00 PM and stated Resident #45 does not like the food that is served to them (Resident #45). CNA #5 stated Resident #45 required only set up help for meals. Resident #45 could not chew their meals and liked soup. The resident's family used to come and feed the resident with their ethnic food, however, since COVID-19 started Resident #45's family does not come to feed the resident. CNA #5 stated they reported Resident#45's decreased appetite to the Unit nurse (Could not recall to who and when) a while ago. CNA #5 stated if this facility provided Resident #45 with their own cultural food the resident would have eaten.
On 3/29/2022 at 6:00 PM, Resident #45 was observed in bed in their room with the bedside table out of the resident's reach. The bedside table contained an Ensure carton that was opened and was half full and one cup of water. There was no staff member present.
RD #2 was re-interviewed on 3/30/2022 at 10:35 AM and stated the facility did not provide them (RD #2) a list of residents with significant weight loss and a list of residents who were at risk for weight loss when they first started on 3/14/2022. They stated the facility and nurses failed to alert the Doctor of any residents who had a weight change of over 5 pounds in a month. RD #2 stated nurses are the core for weight monitoring. RD #2 stated if they were made aware of Resident #45's weight loss when they started working at this facility Resident #45 would have benefited from the interventions they would have initiated. RD #2 stated the facility failed to have a structure in place and have consistency of weight monitoring. RD #2 stated they do not know if there are other residents with significant weight loss. RD #2 stated the facility's EMR cannot capture the weight loss. The weight loss has to be calculated manually one resident at a time. RD #2 stated if they were made aware of Resident#45's weight loss they would have talked to the primary Physician to discuss the possibility of a feeding tube insertion. RD #2 stated had they known Resident #45 lost a significant amount of weight they would have started a three-day calorie count, reviewed laboratory reports, increased supplements and asked the SLP to evaluate the resident for swallowing issues or problems to determine if anything was preventing the resident from eating.
The Primary Physician (MD) was interviewed on 3/30/22 at 12:34 PM and stated they (MD) do not remember when they last saw Resident #45. The MD stated they (MD) were not made aware of Resident #45's weight loss and if they were aware they (MD) would have ordered blood work. The MD stated that they would expect the facility staff to inform them (MD). The MD further stated that Resident #45 would have benefited from dietary interventions if they (MD) were made aware of Resident #45's weight loss on 3/12/2022.
The DNS was re-interviewed on 3/30/2022 at 1:22 PM and stated since 2019 every unit has had a unit manager assigned, however, the second-floor unit manager left in January 2022. The DNS stated RN managers are responsible to monitor weights. The DNS stated the Dietitian is in control of monitoring the residents' weights. They stated the Dietitian would make a list of residents needing to be weighed at the beginning of month. The CNAs would weigh the residents and the Dietitian would pick up the list to update the EMR. The DNS stated they were not made aware of the weight loss for Resident #45. The DNS stated RN #9 should have notified the RD after identifying the weight loss for Resident #45. The DNS stated they were not aware that Resident #45's intake was poor and that the CNAs were not documenting the resident's food intake on the CNAAR. The DNS further stated that the RNMs should be reviewing the CNA accountability record, however, Unit 2 does not have an RNM.
RD #1 was interviewed on 3/30/2022 at 2:10 PM and stated they (RD #1) was a temporary Dietitian started on January 24, 2022, until March 10, 2022. RD #1 stated they (RD #1) sent an email to the DNS, Nurse Managers, RN Supervisors, and the Administrator on March 10 2022, at 2:55 PM with list of residents that needed to be weighed (could not recall why). RD #1 stated in that email they informed the recipients that RD #1 will not conduct a follow up on the weights because it was their last day to work at the facility. RD #1 would expect the nursing staff get the weights, record the weights in the EMR and to notify the Dietitian and the doctor of any weight changes.
SLP #2 was interviewed on 4/01/2022 at 2:17 PM and stated they screened Resident #45 on 3/28/2022 and completed the evaluation on 3/30/2022 to rule out if the resident had a decline in swallowing or had Dysphagia upon the request from the DNS and the Director of Rehabilitation. SLP #2 stated Resident #45's diet was downgraded to puree consistency on 3/28/2022 because of the resident's prolonged chewing and complaint of pain when they chewed. SLP #2 stated that Resident #45 reported to the nurse who spoke their language that they (Resident #45) had pain when they chewed the food. SLP #2 stated the pain in Resident #45's mouth when they chew could be the reason for the weight loss.
The Medical Director was interviewed on 4/01/2022 at 4:52 PM and stated they (Medical Director) did not know about Resident # 45's weight loss. The Medical Director stated the staff did not follow the system. The Medical Director stated they did not follow the facility's policy for weight loss. The Medical Director stated it was not acceptable that Resident #45's significant weight loss was not captured in a timely manner. The Medical Director stated they are very happy this issue was identified.
The Administrator was interviewed on 4/01/2022 at 5:55 PM and stated they (Administrator) would expect caregivers to complete their tasks as directed. The Administrator stated that they (Administrator) was not aware of a list provided to them by RD #1 and was not aware of Resident #45's weight loss. The Administrator stated that they (Administrator) was not aware of the issues related to monitoring of residents' weights and meal intake or staffing issues on Unit 2; however, they (Administrator) knew they needed to hire more staff.
The Immediacy was removed on 4/3/2022 when the facility provided evidence of:
-Dietary reassessment of Resident #45 including increasing the assistance needed for feeding, downgraded the diet to puree consistency. The facility initiated a calorie count to identify resident's intake and also increased weight monitoring. The facility updated the resident's Comprehensive Care Plan to address the dietary need.
-The facility weighed all residents and compared the current weight to the most recent previous weight to identify significant weight loss. The facility identified 10 additional residents with Significant weight loss. The newly identified residents with Significant weight loss were evaluated by the Dietician and the Physician by 04/03/2022 to update the residents plan of care and address the nutritional needs.
-The Facility revised the policies and procedure related to monitoring and reporting of weights and the residents' food intake.
-Inservice education was provided to 96% of the facility staff that included the Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Assistants (CNAs), Nurse Assistants (NAs) and the Dieticians.
-16 facility staff were interviewed during the 1st PSR visit. All interviewed staff were knowledgeable of the changes in the facility's revised Policies and Procedures including changes implemented related to resident food intake and weight monitoring and reporting.
2) Resident #80 was admitted on [DATE]th 2022, with diagnoses that include Malignant Neoplasm of the Bladder and Dementia without Behavioral Disturbance. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 3 which indicated the resident had severely impaired cognition. The resident had mood symptoms of poor appetite or overeating 2-6 days during the two -week look back period. The resident had no behavioral symptoms, did not reject care, and required the assistance of one staff member for eating. The MDS documented the resident had no swallowing problems and had a documented Height of 63 inches and weight of 130 pounds. The resident did not have significant weight loss or gain identified on the MDS and was not on a physician prescribed weight loss program.
Resident #80 was observed on 3/23/2022 at 1:10 PM in their room sitting in a wheelchair at the bedside during the lunch meal with a meal tray on the overbed table in front of the resident. The resident's family member was observed verbally encouraging the resident to eat.
The Comprehensive Care Plan (CCP) for at Risk for Weight Shift dated 1/7/2022 and last updated on 3/12/22 documented the resident was at risk for weight shifts and malnutrition due to underlying medical conditions that included advanced age, diagnosis of Bladder Cancer, low Body Mass Index (BMI), and a history of significant weight loss. The interventions included the resident feeds self with limited assist of one staff, encourage meal intake and completion, monitor oral (PO) intake and appetite, monitor meal consumption record, monitor weights monthly, and report significant weight loss to the Physician (MD) and the Interdisciplinary Team (IDT) team.
The Physician's progress note signed by a Physician's Assistant (PA) dated 1/7/2022 documented the resident's medical records were reviewed; the note did not document the resident's weights.
The Physician's order dated 1/8/2022 documented daily weight x 3 then weekly weight x 4.
The resident's weight record documented the following weights:
on 1/7/2022-130 pounds (lbs)
There was no documented evidence of weights on 1/8/2022, 1/9/2022 and 1/10/2022
on 1/11/2022-89.2 lbs a weight loss of 40.8 lbs since 1/7/2022
There were no documented weights between 1/12/2022 through 1/30/2022
on 1/31/2022-84.2 lbs a weight loss of 5 lbs since 1/11/2022
on 2/8/2022-82.0 lbs a weight loss of 2.2 lbs since 1/31/2022
on 3/13/2022-91 lbs a weight gain of 9 lbs since 2/8/2022
A Dietary Note written by RD #3 dated 1/7/2022 at 3:08 PM documented the resident's current weight was 130 pounds with a Body Mass Index (BMI) of 23. The resident required limited
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure resident rights to be free from neglect. This was identified for one (Resident #99) of five residents reviewed for Activity of Daily Living (ADL). Specifically, Resident #99 required staff assistance for ADL and incontinence care. The resident did not receive ADL and incontinence care on 3/25/2022 from 6:14 AM until 12:15 PM. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist.
The finding is:
The Abuse Prohibition policy last updated January 2022 documented Neglect is defined as the failure of the facility and its employees and service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect typically means the refusal or failure to provide a resident with such life necessities as food, water, clothing, shelter and personal hygiene.
The Urinary Incontinence policy dated January 2022 documented, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status.
Resident # 99 has diagnoses that include Dementia, Difficulty walking and Muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident was frequently incontinent of bowel and bladder and required extensive assistance of one person for bed mobility and dressing, extensive assistance of two persons for transfers and limited assistance of one person for personal hygiene.
The Comprehensive Care Plan (CCP) dated 12/30/2021 documented the resident had bowel incontinence related to the aging process. Interventions included to check the resident every two hours and to assist with toileting as needed; Provide bedpan/bedside commode and provide perineal care after each incontinent episode.
The CCP dated 9/11/2021 documented the resident had bladder incontinence related to the aging process. Interventions included to apply incontinence devices as identified as appropriate for the resident.
The CCP dated 9/13/2021 for at risk for Pressure Ulcer development related to actual swelling and edema to the left hip and the left hand; impaired mobility; incontinence and fragile skin included interventions to turn and reposition the resident every two hours and as needed.
On 3/25/2022 at 10:30 AM, Resident #99 was observed in their room in their bed.
On 3/25/2022 at 11:20 AM, Resident #99 was again observed in their bed. A strong urine odor was detected. Resident #99 appeared upset as evidenced by the resident clenching their lips. Resident #99 stated they were upset and angry. Resident #99 stated in a loud tone that they have been waiting all morning to get changed and to be taken out of bed. Resident #99's concern was brought to the Unit clerk's attention. The Unit clerk stated CNA #2 was the assigned CNA for Resident #99.
On 3/25/2022 at 11:30 AM CNA #2 was interviewed and stated that they (CNA #2) were not assigned to the resident.
The CNA assignment sheet dated 3/25/2022 documented five CNA assignments for the 7 AM-3PM nursing shift (assignment A, B, C, E and F) with corresponding CNA names, except for assignment C. Resident # 99's room number was included under assignment C.
On 3/25/2022 between 11:20 AM and 12:00 PM there were no nursing staff present at the nurses' station. At 12:00 PM the unit clerk was asked who the RN Manager or Supervisor was assigned to the resident's unit. The unit clerk stated they will call the supervisor. The Director of Nursing Services (DNS) arrived on the Unit 10 minutes later at 12:10 PM. The DNS stated there was no RN manager or Supervisor assigned to the resident's Unit. The DNS reviewed the CNA staffing sheet and could not determine who the assigned CNA was for Resident #99. The DNS then stated that CNA #1 was the assigned CNA for Resident #99. Between 12 PM to 12:20 PM, CNA #1 could not be located on the Unit. At 12:15 PM CNA # 2 was observed providing care to the resident.
The CNA accountability record for March 2022 documented the resident was toileted and last received hygiene care on 3/25/2022 at 6:14 AM. The bed mobility section documented the resident last received assistance with bed mobility at 6:14 AM. There was no documented evidence that Resident #99 was turned and positioned every two hours and as needed.
CNA # 1 was interviewed on 3/25/2022 at 12:30 PM and stated that they were not assigned to Resident # 99. CNA #1 stated that although Resident #99 was on their assignment on the unit assignment sheet, they (CNA #1) traded off Resident # 99 with CNA # 3 who is normally assigned to assignment F. CNA #1 stated they (CNA #1) did not inform Licensed Practical Nurse (LPN) # 2, who was responsible for the assignments, of the trade off of Resident #99.
LPN # 2, who was the Unit charge nurse, was interviewed on 3/25/2022 at 3:35 PM and stated they (LPN #2) were responsible to make the CNA assignments. CNA #1 was supposed to be assigned to Resident #99. LPN #2 stated that the CNA assignment did not have a CNA's name assigned for assignment C and it was an oversight. LPN #2 stated the assignment sheet should reflect CNA # 1 for assignment C. LPN #2 further stated that they (LPN #2) were not aware that CNA # 1 and CNA # 3 were trading residents on their assignments.
CNA # 3 was not available to interview.
The DNS was re-interviewed on 3/25/2022 at 4:10 PM and stated no resident should have to wait till 12 noon to be provided AM care and to be taken out of their bed.
415.4(b)(1)(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that the comprehensive person-centered care plan (CCP) for each resident was implemented. This was identified for one (Resident #110) of seven residents reviewed for nutrition. Specifically, Resident #110 had a Physician's (MD) order for daily weights for 3 days and weekly weights every 7 days for four weeks for weight monitoring. There was no documented evidence the weights were completed according to the Physician's order.
The finding is:
The facility Weight Assessment and Intervention policy reviewed on 1/2022 documented the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weight will be measured monthly thereafter.
Resident #110 was admitted with diagnoses that include Hemiplegia/Hemiparesis, Dysphagia, and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short- and long-term memory problems and had no behavioral symptoms. The resident utilize a gastric feeding tube. The resident weighed 224 pounds. A Quarterly MDS assessment dated [DATE] documented the resident had short- and long-term memory problems. The MDS documented the resident The resident's weight was 176 and had no weight loss or gain.
A Comprehensive Care Plan (CCP) for risk for weight shift dated 1/28/2022 and last updated on 3/12/2022 documented the resident was at risk for weight changes due to underlying medical conditions. Intervention included to monitor caloric intake. There were no interventions related to weight monitoring,
A Physician's order dated 1/28/2022 documented daily weight for x 3 then weekly weight x 4 one time a day for monitoring for weight for 3 days then one time a day every 7 day(s) for monitoring for weight for 4 weeks.
The resident weight record documented the following weights:
-1/28/22 224.0 pounds (lbs),
There was no documented evidence that the resident was weighed on 1/29/2022, 1/30/2022 and on 1/31/2022.
-2/1/22 weight recorded as 224.0 lbs,
A Physician's order dated 3/11/2022 documented daily weight x 3 days for weight monitoring, then weekly weight x 4 weeks one time a day every 7 day(s) for weight monitoring.
The resident weight record documented the following weights:
there was no documented evidence that the resident was weighed on 3/11/2022 and 3/12/2022.
-3/13/22 weight recorded as 224.0 lbs.
-3/14/22 weight recorded as 176.0 lbs.
-3/21/22 weight recorded as 176 lbs.
-3/28/22 weight recorded as 176.3 lbs.
The Dietary note dated 3/12/2022 documented the weight recorded on the Patient Review Instrument (PRI-a hospital record) was 164 pounds on 3/10/2022.
The Dietary note dated 3/29/2022 documented the weight on the PRI-hospital record was 183 pounds on 1/28/2022.
Registered Nurse (RN #2), Nurse Manager, was interviewed on 3/29/2022 at 12:11 PM and stated that the Certified Nursing Assistant (CNA)s were responsible for weighting the residents. RN #2 stated that residents are weighed on the day of admission then daily for 3 days and weekly for four weeks as per the facility protocol. RN #2 stated the weights should have been taken as per the Physician's orders.
Registered Dietitian (RD #2) was interviewed on 3/29/2022 at 2:09 PM and stated that in their professional opinion, the resident's initial weight of 224 pounds was not a true weight. RD #2 reviewed both PRIs information dated 1/28/2022 and 3/10/2022 and stated that they (RD #2) did not believe the resident was weighed on admission. RD #2 stated that the resident could not have lost 48 pound in one day and that staff might have just entered random numbers on the weight sheet. RD #2 further stated when the resident was weighed on 3/14/2022 the weight of 176 pounds was the resident's true weight. Additionally, RD #2 stated that they witnessed a reweight of Resident #110 on 3/29/22 and the resident weighed 178 pounds.
Physician#1 was interviewed on 4/1/2022 at 2:53 PM and stated that the expectation is that the Physician's orders needed to be followed. The Physician stated although there was no medical indication for daily weight the facility has a protocol that should be followed.
The Director of Nursing Services (DNS) was interviewed on 4/1/2022 at 6:15 PM and stated if there was a Physician's order for the weight to be done then the staff should have followed the Physician's ordered as written. The DNS stated if there is a facility protocol for resident's weight that the staff should follow the protocol.
415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADL) receive the necessary services to maintain grooming and personal hygiene. This was identified for one (Resident #99) of five residents reviewed for ADLs. Specifically, Resident #99, who was alert and oriented and required staff assistance for ADL care, did not receive morning care on 3/25/2022 during the 7 AM-3 PM nursing shift until 12:15 PM because no Certified Nursing Assistant (CNA) was assigned to provide care for the resident. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist.
The finding is:
The Urinary Incontinence policy dated January 2022 documented, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status.
Resident # 99 has diagnoses that include Dementia, Difficulty walking and Muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident was frequently incontinent of bowel and bladder and required extensive assistance of one person for Bed Mobility and Dressing, Extensive Assistance of two persons for transfers and Limited assistance of one person for personal hygiene.
The Comprehensive Care Plan (CCP) dated 12/30/2021 documented the resident had bowel incontinence related to the aging process. Interventions included to check the resident every two hours and to assist with toileting as needed; Provide bedpan/bedside commode and provide perineal care after each incontinent episode.
The CCP for Activities of Daily Living dated 9/11/2021 related to swelling and pain to the left hip and left hand; Left distal Humeral fracture; and Fracture of left Femur related to a fall included interventions to encourage the resident to use the call bell for assistance.
The CCP dated 9/11/2021 documented the resident had bladder incontinence related to the aging process. Interventions included to apply incontinence devices as identified as appropriate for the resident.
The CCP dated 9/13/2021 for at risk for Pressure Ulcer development related to actual swelling and edema to left hip and left hand; impaired mobility; incontinence and fragile skin included intervention to turn and reposition the resident every two hours and as needed.
On 3/25/2022 at 10:30 AM, Resident #99 was observed in their room in their bed.
On 3/25/2022 at 11:20 AM, Resident #99 was again observed in their bed. A strong urine odor was detected. Resident #99 was upset as evidenced by the resident clenching their lips. Resident #99 stated they (Resident #99) were very upset and angry. Resident #99 stated in a loud tone that they have been waiting all morning to get changed and to be taken out of bed. Resident #99's concern was brought to the Unit clerk's attention. The Unit clerk stated CNA #2 was the assigned CNA for Resident #99.
On 3/25/2022 at 11:30 AM CNA #2 was interviewed and stated that they (CNA #2) were not assigned to the resident.
The CNA assignment sheet dated 3/25/2022 documented five CNA assignments for the 7 AM-3PM nursing shift (assignment A, B, C, E and F) with corresponding CNA names, except for assignment C. Resident # 99's room number was included under assignment C.
On 3/25/2022 between 11:20 AM and 12:00 PM there were no nursing staff present at the nurses' station. at 12:00 PM the unit clerk was asked who the RN Manager or Supervisor was assigned to the resident's unit. The unit clerk stated they will call the supervisor. The Director of Nursing Services (DNS) arrived on the Unit 10 minutes later at 12:10 PM. The DNS stated there was no RN manager or Supervisor assigned to the resident's Unit. The DNS reviewed the CNA staffing sheet and could not determine who the assigned CNA was for Resident #99. The DNS then stated that CNA #1 was the assigned CNA for Resident #99. Between 12 PM to 12:20 PM, CNA #1 could not be located on the Unit. AT 12:15 PM CNA # 2 was observed providing care to the resident.
The CNA accountability record for March 2022 documented the resident was toileted and last received hygiene care on 3/25/2022 at 6:14 AM. The Bed Mobility section documented the resident last received assistance with bed mobility at 6:14 AM. There was no documented evidence that Resident #99 was turned and positioned every two hours and as needed.
CNA # 1 was interviewed on 3/25/2022 at 12:30 PM and stated that they were not assigned to Resident # 99. CNA #1 stated that although Resident #99 was on their assignment on the unit assignment sheet, they (CNA #1) traded off Resident # 99 with CNA # 3 who is normally assigned to assignment F. CNA #1 stated they (CNA #1) did not inform Licensed Practical Nurse (LPN) # 2, who was responsible for the assignments, of the trade off of Resident #99.
LPN # 1 was interviewed on 3/25/2022 at 3:30 PM and stated they were assigned to Resident #99 this morning. LPN #1 stated they (LPN #1) were a float LPN and were not regularly assigned to the unit. LPN #1 stated that they (LPN #1) were not aware of Resident #99's routines.
LPN # 2, who was the Unit charge nurse, was interviewed on 3/25/2022 at 3:35 PM and stated they (LPN #2) were responsible to make the CNA assignments. CNA #1 was supposed to be assigned to Resident #99. LPN #2 stated that the CNA assignment did not have a CNA's name assigned for assignment C and it was an oversight. LPN #2 stated the assignment sheet should reflect CNA # 1 for assignment C. LPN #2 further stated that they (LPN #2) were not aware that CNA # 1 and CNA # 3 were trading residents on their assignments.
CNA # 3 was not available to interview.
The attending Physician was interviewed on 4/01/2022 at 11:33 AM and stated that their expectation would be that the resident would receive timely ADL care as planned. The Physician was unaware that Resident #99 had not received morning ADL care on Friday, 3/25/2022.
The DNS was re-interviewed on 3/25/2022 at 4:10 PM and stated CNAs should not be trading residents amongst each other by crossing out names on assignments. LPN #2 also made a mistake by not assigning a CNA to Assignment C. The DNS stated that LPN # 2 told the DNS that CNA # 1 was assigned to Resident #99 in error. A better system of ensuring the CNAs are assigned to each resident will be implemented. No resident should have to wait till 12 noon to be provided AM care and to be taken out of their bed.
415.12(a)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that all residents received adequate supervision to prevent Accidents. This was identified for one (Resident #85) of three residents reviewed for Accidents. Specifically, Resident #85 was observed shaving themselves with a razor without supervision and had blood on their face.
The finding is:
The facility Hazardous Areas, Devices and Equipment Policy dated July 2017, documented all hazardous devices in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: sharp objects that are accessible to vulnerable residents. Monitoring to ensure that recommendations are implemented consistently and correctly will be a component of the safety and accident prevention program.
Resident #85 was admitted with diagnoses of Alzheimer's Disease, Depression and Sensorineural Bilateral Hearing Loss. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #85 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also documented that Resident #85 required Supervision with setup help for personal hygiene including shaving.
The Skin Integrity care plan dated 1/21/2022 documented that Resident #85 is at risk for impaired skin integrity related to fragile skin and Peripheral Vascular Disease. The interventions documented to avoid mechanical trauma, including improper shaving.
The Activities of Daily Living care plan dated 1/21/2022 documented that Resident #85 required Supervision for Activities of Daily Living secondary to generalized muscle weakness, impaired cognition, history of Multiple fractures of ribs and falls, and Alzheimer's Disease. The interventions included to provide Resident #85 with supervision and setup help for personal hygiene.
On 3/25/22 at 12:27 PM, Resident #85 was observed sitting in a chair in their room dry shaving their (Resident #85's) face with a disposable razor. Resident #85 was observed to dab their face with a tissue with frank blood spots on the tissue and face. When approached, Resident #85 refused to state how they obtained the disposable razor. Resident #85 repeatedly stated What do you want? and refused to respond.
Registered Nurse (RN) #2, the Unit 1 Manager, was immediately informed by the surveyor of Resident #85's possession of the disposable razor on 3/25/22 at 12:27 PM. RN #2 approached Resident #85 and observed Resident #85 facial bleeding and shaving. Resident #85 became angry, refused to answer RN #2 and repeatedly said What do you want? RN #2 stepped out of the room and stated that Resident #85 did not want to give up the razor. RN #2 stated that Resident #85 should not have the razor and the Certified Nursing Assistant (CNA) should be supervising the resident for shaving. Resident #85 usually gets shaved after the shower, but the CNA was busy showering another resident at the time of the observation. RN #2 stated that they would re-approach the resident with the CNA to remove the razor and tend to the facial cuts. RN #2 further stated that they (RN #2) would also document the incident and the resident skin assessment.
CNA #13 was observed walking to Resident #85's room with RN #2 five minutes later at 12:32 PM after the observation.
CNA #13 was interviewed on 3/25/22 at 12:48 PM and stated they (CNA #13) did not give Resident #85 the razor. CNA #13 stated that they would not normally give Resident #85 a razor because shaving the resident is their (CNAs) task to do with Resident #85. CNA #13 stated that they did not know where the razor came from. CNA #13 stated that the family often visits Resident #85, and the razor may have come from a visitor.
The Director of Nursing Services (DNS) was interviewed on 3/28/2022 at 11:42 AM and stated that Resident #85 should have had a caregiver present to provide supervision so that Resident #85 can shave safely. Resident #85's care plan should also be revised to provide Resident #85 with an electric razor so that the resident could maintain independence.
Resident #85's medical record did not document the 3/25/2022 shaving incident, the cut to the resident's face or how the resident obtained the razor until 3/29/2022.
RN #2 was re-interviewed on 3/29/2022 at 9:35 AM and stated that they did not document the occurrence but did inform the Director of Nursing Services on 3/25/2022 of the incident.
The DNS was re-interviewed on 3/29/2022 at 10:15 AM and stated that an investigation was not completed, and the facility should initiate an investigation to determine how the resident had obtained the razor.
415.12(h)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy, titled Urinary Incontinence-Clinical Protocol, last revised in 1/2022, documented as part of the physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The facility's policy, titled Urinary Incontinence-Clinical Protocol, last revised in 1/2022, documented as part of the physical examination, the physician will look for findings related to continence, such as a prolapsed uterus, prostate enlargement, use of a urinary catheter, evidence of abdominal or urologic surgery, and/or diuretic use. The physician will identify situations where an indwelling urethral or suprapubic catheter are indicated and will document why other alternatives are not feasible. If a long-term indwelling catheter is needed, staff will monitor for and report complications such as evidence of a symptomatic infection. Virtually all individuals with indwelling urinary catheters eventually have bacteriuria. The staff and physician will monitor the individual for complications of an indwelling catheter such as a symptomatic urinary tract infection, urosepsis, or urethral erosion or pain, and for complications of medications used to treat urinary incontinence.
Resident #356 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Neurogenic Bladder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Section H of the MDS was completed on 3/25/2022 at 1:50 PM indicating the use of the indwelling catheter.
The Patient Review Instrument (PRI), hospital record, dated 3/9/2022 documented the resident had a 16 French urinary catheter in the hospital.
The admission Nursing assessment dated [DATE] documented the resident was incontinent of bladder related to an acute condition; however, there was no documentation regarding the resident having a urinary catheter.
The Physician History and Physical dated 3/11/2022 documented deferred under the Genitalia/Bowel/Bladder section. There is no documentation related to the use of the urinary catheter.
Resident #356 was observed laying in bed on 3/23/2022 at 11:18 AM with a urinary catheter drainage bag hanging from the side of bed containing yellow urine. A family member was present in the room
Review of the medical record from 3/11/2022 through 3/23/2022 revealed there were no physician's orders and no care plan developed for the urinary catheter for Resident #356. In addition, there was no documentation in the medical record that catheter care was being performed.
Resident #356 was observed laying in bed on 3/25/2022 at 8:23 AM. RN #3 who was the assistant unit manager, was present. RN #3 stated they (RN #3) would review the record to see if an order was in place. The drainage bag containing yellow urine was observed laying on the floor. There was no privacy bag present. RN #3 stated the bag should not be laying on the floor.
Resident #356's family member was interviewed on 3/25/2022 at 8:31 AM. The family member stated that the resident has been using the Foley catheter due to a blockage and has had the catheter for about seven years.
RN #3 was re-interviewed on 3/25/2022 at 10:51 AM. RN #3 stated the order for urinary catheter and care plan have just been initiated for Resident #356's urinary catheter. RN #3 stated they (RN #3) did not realize there was no order for the urinary catheter for Resident #356 and that the admitting nurse is supposed to enter the order for the urinary catheter.
RN #4 (admission RN) was interviewed on 3/25/2022 at 12:50 PM and stated when a resident is admitted with a urinary catheter, the use of the urinary catheter should be documented in the medical record, physician's orders should be obtained, and a care plan should be initiated for catheter use and care. If the admission nurse misses the catheter, the nurses on the following shifts should obtain the Physician's orders and initiate the care plan for the use of the urinary catheter. RN #4 further stated that they (RN #4) were only human.
Physician #1 was interviewed on 3/25/2022 at 1:05 PM and stated that the deferred comment in the History and Physical for the bladder and bowel assessment meant that the resident or family refused examination. The Physician stated they (Physician) were aware the resident had a catheter. The physician stated that if a Foley urinary catheter was just placed in hospital for a short-term basis, then an order will be placed for the catheter with a date for a trial void to be done. The physician further stated if the Foley urinary catheter is for a chronic condition or suprapubic and is long term, then the facility policy is just to continue the catheter and the order was not needed.
The Director of Nursing Services (DNS) was interviewed on 3/28/2022 at 10:33 AM and stated, we dropped the ball. The DNS stated different nurses were involved with different parts of the admission process and the nurses assumed the other nurses were documenting and care planning for the catheter. The DNS stated they (DNS) were in the resident's room a couple of days before the survey started and saw the catheter and assumed the order was in place.
RN #5 (MDS Assessor) was interviewed on 3/30/2022 at 3:50 PM and stated 3/25/2022 was when they first learned that the resident had a urinary catheter. RN #5 stated after they learned that Resident #356 had a urinary catheter, they completed Section H of the MDS indicating use of the urinary catheter.
415.12(d)(2)
Based on observations, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that residents who are incontinent of Bowel and Bladder receive appropriate treatment and services to prevent Urinary Tract Infections (UTI) and that a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. This was identified for one (Resident #99) of five residents reviewed for ADLs and one (Resident #356) of three residents reviewed for Urinary Catheter. Specifically, 1) Resident #99, who was alert and oriented and required staff assistance for incontinence care, did not receive morning care on 3/25/2022 during the 7 AM-3 PM nursing shift until 12:15 PM because no Certified Nursing Assistant (CNA) was assigned to provide care for the resident. The resident was observed in bed with a strong urine odor in their room. Resident #99 was visibly upset, clenching their lips, and stated with an elevated loud tone that no one took care of them today. The resident stated they were wet and had been asking for staff assistance all morning; however, no staff came to assist. 2) Resident #356 was admitted to the facility with a chronic long term Foley catheter; however, the catheter was not documented in the nursing admission assessment or the physician's history and physical, there was no physician's order in place for the catheter, there was no comprehensive care plan, and there was no documentation that catheter care was completed.
The findings are:
1) The Urinary Incontinence policy dated January 2022 documented, As appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status.
Resident # 99 has diagnoses that include Dementia, Difficulty walking and Muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The resident was frequently incontinent of bowel and bladder and required extensive assistance of one person for Bed Mobility and Dressing, Extensive Assistance of two persons for transfers and Limited assistance of one person for personal hygiene.
The Comprehensive Care Plan (CCP) dated 12/30/2021 documented the resident had bowel incontinence related to the aging process. Interventions included to check the resident every two hours and to assist with toileting as needed; Provide bedpan/bedside commode and provide perineal care after each incontinent episode.
The CCP dated 9/11/2021 documented the resident had bladder incontinence related to the aging process. Interventions included to apply incontinence devices as identified as appropriate for the resident.
The CCP dated 9/13/2021 for at risk for Pressure Ulcer development related to actual swelling and edema to left hip and left hand; impaired mobility; incontinence and fragile skin included intervention to turn and reposition the resident every two hours and as needed.
On 3/25/2022 at 10:30 AM, Resident #99 was observed in their room in their bed.
On 3/25/2022 at 11:20 AM, Resident #99 was again observed in their bed. A strong urine odor was detected. Resident #99 was upset as evidenced by the resident clenching their lips. Resident #99 stated they (Resident #99) were very upset and angry. Resident #99 stated in a loud tone that they have been waiting all morning to get changed and to be taken out of bed. Resident #99's concern was brought to the Unit clerk's attention. The Unit clerk stated CNA #2 was the assigned CNA for Resident #99.
On 3/25/2022 at 11:30 AM CNA #2 was interviewed and stated that they (CNA #2) were not assigned to the resident.
The CNA assignment sheet dated 3/25/2022 documented five CNA assignments for the 7 AM-3PM nursing shift (assignment A, B, C, E and F) with corresponding CNA names, except for assignment C. Resident # 99's room number was included under assignment C.
On 3/25/2022 between 11:20 AM and 12:00 PM there were no nursing staff present at the nurses' station. at 12:00 PM the unit clerk was asked who the RN Manager or Supervisor was assigned to the resident's unit. The unit clerk stated they will call the supervisor. The Director of Nursing Services (DNS) arrived on the Unit 10 minutes later at 12:10 PM. The DNS stated there was no RN manager or Supervisor assigned to the resident's Unit. The DNS reviewed the CNA staffing sheet and could not determine who the assigned CNA was for Resident #99. The DNS then stated that CNA #1 was the assigned CNA for Resident #99. Between 12 PM to 12:20 PM, CNA #1 could not be located on the Unit. AT 12:15 PM CNA # 2 was observed providing care to the resident.
The CNA accountability record for March 2022 documented the resident was toileted and last received hygiene care on 3/25/2022 at 6:14 AM. The Bed Mobility section documented the resident last received assistance with bed mobility at 6:14 AM. There was no documented evidence that Resident #99 was turned and positioned every two hours and as needed.
CNA # 1 was interviewed on 3/25/2022 at 12:30 PM and stated that they were not assigned to Resident # 99. CNA #1 stated that although Resident #99 was on their assignment on the unit assignment sheet, they (CNA #1) traded off Resident # 99 with CNA # 3 who is normally assigned to assignment F. CNA #1 stated they (CNA #1) did not inform Licensed Practical Nurse (LPN) # 2, who was responsible for the assignments, of the trade off of Resident #99.
LPN # 1 was interviewed on 3/25/2022 at 3:30 PM and stated they were assigned to Resident #99 this morning. LPN #1 stated they (LPN #1) were a float LPN and were not regularly assigned to the unit. LPN #1 stated that they (LPN #1) were not aware of Resident #99's routines.
LPN # 2, who was the Unit charge nurse, was interviewed on 3/25/2022 at 3:35 PM and stated they (LPN #2) were responsible to make the CNA assignments. CNA #1 was supposed to be assigned to Resident #99. LPN #2 stated that the CNA assignment did not have a CNA's name assigned for assignment C and it was an oversight. LPN #2 stated the assignment sheet should reflect CNA # 1 for assignment C. LPN #2 further stated that they (LPN #2) were not aware that CNA # 1 and CNA # 3 were trading residents on their assignments.
CNA # 3 was not available to interview.
The attending Physician was interviewed on 4/01/2022 at 11:33 AM and stated that their expectation would be that the resident would receive timely ADL care as planned. The Physician was unaware that Resident #99 had not received morning ADL care on Friday, 3/25/2022.
The DNS was re-interviewed on 3/25/2022 at 4:10 PM and stated CNAs should not be trading residents amongst each other by crossing out names on assignments. LPN #2 also made a mistake by not assigning a CNA to Assignment C. The DNS stated that LPN # 2 told the DNS that CNA # 1 was assigned to Resident #99 in error. A better system of ensuring the CNAs are assigned to each resident will be implemented. No resident should have to wait till 12 noon to be provided AM care and to be taken out of their bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, during the Recertification survey initiated on 3/23/2022 and completed on 4...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, during the Recertification survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure all medications and tube feedings were accurately labeled and medications were safely stored in 1 of 4 medication carts reviewed for Medication Storage Task and for 1 (Resident #110) of 3 residents reviewed for Tube Feeding. Specifically, 1) an unopened bottle of Latanoprost (glaucoma medication) eye drops was not refrigerated as per the pharmacy instructions; and an opened pro-source bottle was not labeled with the opened date. Additionally, two unmarked tablets were observed in the medication cart in an unlabeled souffle cup. 2) on 3/23/2022 Resident #110's tube feeding bottle was not labeled with the start time, the feeding rate, and the signature of nurse who initiated the feeding. Additionally, the feeding tube was not dated to indicate when the feeding tube was changed.
The findings are:
1) The facility Storage of Medication Policy and Procedure dated 1/2022 documented that medications requiring refrigeration must be stored in a refrigerator located in the medication room at the nurses' station or other secured location. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.
The Pfizer Xalatan (Latanoprost) Label Storage instructions document to store unopened bottle(s) under refrigeration at 2° to 8°Celcius (C) (36° to 46°F). Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks.
The Medication Label Storage instructions for ProSource No Carb Liquid Protein document to discard after 3 months of opening.
Resident #408 was admitted with diagnoses of Depression, Hypertension and Glaucoma. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #408 had a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. The MDS documented that Resident #408 received antidepressant medication 2 of the 7-day of the MDS look back evaluation period.
The Physician's Orders dated 3/24/2022 documented Lantanoprost Solution 0.005% instill 1 drop on both eyes at bedtime for Glaucoma; Sertaline HCL Tablet 50 mg by mouth one time a day for Depression and Lisinoprol Tablet 10 mg give 1 tablet by mouth one time a day for Hypertension.
On 3/25/2022 at 11:00 AM, the Unit 3 medication cart was observed with RN #1. RN #1 stated that they (RN #1) were the Medication Nurse on the unit on the 7AM-3PM shift. In the top drawer, RN #1 pulled out a dark plastic bag with a red warning label indicating to refrigerate until open. The enclosed medication was an unopened bottle of Latanoprost Eye Drop solution 0.005% for Resident #408 to be administered at bed-time. RN #1 stated that eye drops were on the cart when they arrived on their shift this morning and the eye drops should have been refrigerated and not in the medication cart as per the pharmacy instruction label. RN #1 was then observed to move unmarked small paper souffle cup containing two tablets. RN #1 stated that the tablets in the cup were Setraline 50 mg and Lisonopril 10 mg for Resident #408. RN #1 stated that Resident #408 refused the medication and that they (RN #1) will not throw out the medication. RN #1 stated that instead, they will store the medication cup in between the blister packs to re-approach the resident at a later time. RN #1 then opened the supplement drawer which revealed an undated opened bottle of ProSource No Carb Liquid Protein. RN #1 stated that the supplement drink was used amongst multiple residents on the unit and that without an opened date, they would not know when to discard it. The label on the bottle indicated to discard after 3 months after opening.
The Director of Nursing Services (DNS) was interviewed on 3/28/2022 at 2:25 PM. The DNS stated that the nurses are expected to discard the refused medications and to retrieve a new pill if the resident is willing to take the medication. The DNS also stated that opened medications are not to be stored in the medication cart and that was not a standard practice. Nurses are also expected to follow the pharmacy's storing instructions and any medication that requires refrigeration should be kept in the refrigerator until needed. The Pro-Source supplement should be clearly labelled with the opened date so that staff would know when to discard it.
2) The facility Enteral Feeding - Safety Precaution policy dated 1/2022 documented to prevent errors in administration: on the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.
Resident #110 was admitted with diagnoses that include Cerebral Infarction, Dysphagia, and Aphasia. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. The MDS documented the resident had a feeding tube.
During an initial tour conducted on 3/23/2022 on the 3rd floor nursing unit Resident #110 was observed at 10:45 AM and at 12:45 PM with the tube feeding (Glucerna 1.2) infusing. The tube feeding bottle was not labeled with the feeding rate, the time the feeding was started, nor the signature of the nurse that started the feeding. The tubing utilized to administer the feeding was also not labeled.
A Physician's order dated 3/10/2022 documented to administer Enteral Feeding (Glucerna 1.2) via a feeding tube at a rate of 70 cubic centimeter (cc)/ Hour (hr) to begin at 4 PM for a total volume of 1500 milliliters (ml).
Registered Nurse (RN) #2 was interviewed on 3/23/2022 at 12:50 PM and stated that the feeding tube label should have been filled out with the information that is required on the tube feeding label including the date, flow rate and the nurse's initials who had initiated the feeding.
The 3:00 PM-11:00 PM shift RN #6 was interviewed on 3/30/2022 at 6:50 PM and stated that they (RN #6) hung the tube feeding on 3/22/2022 for Resident #110 and forgot to fill out the tube feeding label. RN #6 further stated they (RN #6) were not aware that the tubing also had to be labeled because the tube is changed daily.
The Director of Nursing Service (DNS) was interviewed on 4/1/2022 at 4:31 PM and stated the nurses are supposed to date the tubing and sign the label on the feeding bottle, however, the DNS was not sure if the feeding rate should be documented on the feeding bottle.
415.18(d); 415.18(e)(1-4)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey completed on 4/1/2022 the facility d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey completed on 4/1/2022 the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one Resident (#357) of one resident reviewed for Infection Control and one (Resident #356) of three residents reviewed for urinary catheter. Specifically, 1) Resident #357 was a new admission and placed on droplet precautions due to partial COVID-19 vaccination status; on 3/24/2022 staff members were observed in the resident's room providing care and not wearing appropriate Personal Protective Equipment (PPE); and 2) on 3/25/2022 Resident #356's urinary catheter drainage bag was observed lying directly on the floor while the resident was in bed.
The findings are:
The facility's policy titled COVID Isolation, revised 1/2022, documented Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets and masks will be worn when entering the room and gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. The facility's policy titled Personal Protective Equipment--Using Gowns, revised 1/2022, documented when use of a gown is indicated, all personnel must put on the gown before treating or touching the resident. The facility's policy, titled Guidance on COVID-19, revised 1/2022, documented ensure that health care personnel are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.
The facility's policy titled Urinary Catheter Care, last revised 1/2022, documented maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag and be sure the catheter tubing and drainage bag are kept off the floor.
1) Resident #357 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Metabolic Encephalopathy. The nursing admission progress note dated 3/21/2022 documented that the resident's orientation status was to Person only and the resident was confused. The Nursing admission assessment dated [DATE] documented only aware about a negative COVID test on March 21, 2022 under the COVID vaccination section of the assessment.
A physician's order dated 3/21/2022 documented Droplet Isolation Precautions.
A Comprehensive Care Plan (CCP) titled At risk for COVID 19 infection Related to Pandemic, Residing in Nursing Facility, and not fully vaccinated, effective 3/24/2022, documented implement isolation precaution when indicated.
The resident's COVID 19 immunization status in the electronic medical record (EMR) documented SARS-COV-2 (COVID-19) (Dose 1) 4/26/2021.
On 3/24/2022 at 9:27 AM Resident #357's medication pass was observed performed by Registered Nurse (RN) #1. A Droplet Precaution Stop sign was observed on the resident's doorway. The sign documented that everyone must wear an N95 mask, eye protection, and gloves. The sign also documented do not wear same gown or gloves for care of more than one person. There was no PPE cart outside the resident's room. In the room with the resident was physical therapy assistant (PTA) #5. The PTA was observed coming in contact with the resident and assisting the resident to walk with a walker and closely guarding the resident. The PTA was wearing a surgical mask, but no gown, eye protection, or gloves. RN #1 entered the resident's room and provided the medications to the resident. The RN was wearing an N95 mask and face shield, but no gloves or gown. While the PTA was in the room the PTA was asked by the surveyor about the droplet precaution sign on the door. The PTA stated that they (PTA #5) thought the sign was just left up there from a previous resident.
On 3/24/2022 at 9:35 AM RN #1 was interviewed. RN #1 stated that resident #357 is a new admission and was on droplet precautions for 14 days. RN #1 stated that they (RN #1) should have worn a gown and gloves while administering medications to the resident.
On 3/24/2022 at 9:44 AM RN #2, who is the unit manager, was interviewed. RN #2 stated Resident # 357 is not fully COVID vaccinated and is a new admission and is on droplet precautions for 14 days. RN #2 stated they (RN #2) was not sure what PPE the staff should be wearing in Resident #357's room and would have to check with the Director of Nursing Services (DNS), who is also the acting Infection Preventionist (IP).
On 3/24/2022 at 9:55 AM RN #2 was re-interviewed. RN #2 stated they (RN #2) spoke to the DNS and the staff need to wear full PPE, including gown and gloves, while in close proximity to Resident #357 in their room.
On 3/24/2022 at 9:57 AM PTA #5 was interviewed. PTA #5 stated that they (PTA #5) did not wear gown, gloves, and N95 mask in Resident #357's room because there was no PPE cart set up outside the room. PTA #5 stated they (PTA #5) should have worn gloves and gown in the resident's room.
On 3/25/2022 at 10:34 AM the DNS/IP was interviewed. The DNS/IP stated Resident #357 had one COVID vaccination and has agreed to take second dose, due for next week; The DNS/IP stated the staff should have followed what the signs say. The DNS/IP further stated that PPE is on the unit and the PTA could have gotten PPE on the unit if a PPE cart was not in front of the door.
2) Resident #356 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Neurogenic Bladder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The MDS documented use of the indwelling catheter.
The Patient Review Instrument (PRI), a hospital record, dated 3/9/2022 documented the resident had a 16 French urinary catheter in the hospital.
Review of the medical record from 3/11/2022 through 3/23/2022 revealed there were no physician's orders and no care plan developed for the urinary catheter for Resident #356. In addition, there was no documentation in the medical record that catheter care was being performed.
Resident #356 was observed laying in bed on 3/25/2022 at 8:23 AM. RN #3 who was the assistant unit manager, was present. RN #3 stated they (RN #3) would review the record to see if an order was in place. The drainage bag containing yellow urine was observed laying on the floor. There was no privacy bag present. RN #3 stated the bag should not be laying on the floor.
415.19(a)(1-3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident as determined by resident assessment and individual plans of care. This was identified through staff interviews, resident council task, review of facility assessment and staffing assignments. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the facility assessment; 2) Resident #136 did not receive wound care treatment as prescribed by the Physician on multiple occasions 3) Resident #358 received 6 medications and 1 supplement 3 hours later than the prescribed time to be administered; 4) Resident #99 did not have a Certified Nursing Assistant (CNA) assigned on the 7-3 shift to care for their needs on 3/25/2022; 5) during the resident council meeting held on 3/24/2022, 3 of 10 residents indicated delay in staff response to resident needs due to staffing shortage.
The findings include but were not limited to:
1) The Facility assessment dated [DATE] documented that based on the facility's resident population and their needs for care and support, the general plan for staffing is Licensed Nurses (Registered Nurses (RN), and Licensed Practical Nurses (LPN), providing direct care) 1 to 20-23 residents on the day shift, 1 to 30-33 residents on the evening shift, 1 to 50-55 residents on the night shift. Certified Nursing Aides 1 to 7-10 residents on the day shift, 1 to 9-12 residents on the evening shift, 1 to 18-22 residents on the night shift. Other staff includes 1 Director of Nursing, 1 Assistant Director of Nursing, 1 admission Nurse, 1 Wound Care Nurse, 1-2 Minimum Data Set (MDS) nurses, 1 Staff Development Nurse, 1 Evening RN Supervisor and 1 Night RN Supervisor. The facility has a total bed capacity of 214.
The Facility Staffing Sheets from 3/19/2022 to 3/28/2022 were reviewed. The staffing sheets provided documentation that there was 1 CNA or Assistant Nurse Aide (ANA) for the whole unit for the following dates and units:
Day shift: (Facility assessment indicated each CNA is to be assigned 7-10 residents on their assignment and each Licensed Nurse is to be assigned 20-23 residents on the day shift)
-1st floor on the 3/20/22 Day shift with a census of 29/49
-4th floor on the 3/21/22 day shift with a census of 32/37
-4th floor on the 3/24/22 day shift with a census of 29/47
On 3/25/22 during the day shift there was 1 Licensed Nurse for the 4th floor unit with a census of 27/47.
Night Shift: (Facility assessment indicated each CNA is to be assigned 18-22 residents on their assignment)
-1st floor (Census 29/49) and 2nd floor (Census 56/59) on the 3/19/2022 night shift
-2nd floor on the 3/20/22 night shift with a census of 56/59
-2nd floor on 3/23/22 night shift with a census of 57/59
-4th floor on the 3/23/22 night shift with a census of 28/47
-1st (Census of 29/49) and 2nd floor (Census 56/59) on the 3/24/22 night shift
-2nd floor on the 3/25/22 night shift with a census of 56/59
The Director of Nursing Services (DNS) and the Assistant Administrator were interviewed concurrently on 4/1/2022 at 3:38 PM. The Assistant Administrator stated that the Staffing Coordinator had quit on 3/31/2022 and the facility is currently in the process of interviewing to fill the position. The Assistant Administrator stated that they (Assistant Administrator) were covering for the Staffing Coordinator. The DNS stated that the facility does have staffing problems. The Assistant Administrator and the DNS both stated they were not aware of the Dear Administrator Letter from the New York State Department of Health advising about the Surge and Flex Center to inform the Department of Health of critical staffing levels. The Assistant Administrator stated that the facility did not have any success with staffing agencies that they reached out to. The DNS stated that they were aware of the facility assessment and took part in the assessment meeting but did not realize that the nursing staffing ratios were specified in the assessment. The DNS reviewed the staffing assignment from 3/19/2022 through 3/25/2022 and stated that the CNAs were not assigned the number of residents as indicated on the facility assessment and had been assigned an excessive number of residents to care for. The DNS stated that if the RNs and the LPNs cannot complete their assignments, they are expected to inform the nursing Supervisor and to pass on the assignments to the next shift.
2) Resident #136 was admitted with the diagnosis of Cutaneous Abscess, Moderate Protein-Calorie Malnutrition, and Osteoporosis. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #136 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition.
Resident #136 was interviewed on 4/1/22 at 12:20 PM. Resident #136 stated that the wound care is inconsistent but could not recall specific dates or times.
The March 2022 Treatment Administration Record (TAR) documented to cleanse the right buttock with normal saline, pat dry, apply Hydrogel, and cover with a dry protective dressing every day and evening shift for abscess. The treatment was not signed for as administered on the evening shift on 3/19/22, 3/25/22 and 3/28/22. The treatment was also not signed for as administered on the day shift on 3/20/22, 3/21/22, and 3/26/22.
RN #3 was interviewed on 4/1/2022 at 11:20 AM and stated that on 3/21/2022 during day shift, they (RN #3) were working at the facility, but did not work on the resident's unit as a medication and treatment nurse. RN #3 stated that LPN #1 was the medication and treatment nurse.
RN #9 an RN Supervisor, was interviewed on 4/1/22 at 11:35 AM. RN #9 stated that they (RN #9) worked on 3/26/2022 and administered medication because there was no nurse assigned to Unit 4. RN #9 stated they (RN #9) did not get to the wound care treatment for Resident #136 because they (RN #9) had to supervise the rest of the building also.
RN #2 was interviewed on 4/1/22 at 11:57 AM and stated that they (RN #2) worked on 3/19/22 during the evening and had to leave at 10 PM due to an emergency. RN #2 stated that they did not administer the wound care for Resident #136, that is why there is no signature. RN #2 stated that they told the DNS who took over as the Supervisor.
RN #8, an RN Supervisor, was interviewed on 4/1/22 at 12:41 PM. RN #8 stated that they (RN #8) worked 3/20/2022 during the day shift. RN #8 stated that when there is a bad shortage, RN #8 comes in to help for medication administration and wound care. RN #8 stated that on 3/20/2022, a nurse called out and RN #8 had to do medication administration on the 4th floor. RN #8 stated that 3/20/22 was a very hectic day and they did not get a chance to do the wound care because there were other resident emergencies.
LPN #1 was interviewed on 4/1/2022 at 1:24 PM and stated that they (LPN #1) worked on 4th floor on 3/21/22, but they only administered medications and not the treatments. LPN #1 stated that RN #3 was supposed to do the treatments.
The DNS and the Assistant Administrator were interviewed concurrently on 4/1/2022 at 3:38 PM. They both stated that the RNs and the LPNs should not have skipped Resident #136's wound care treatments. The DNS stated that the facility does have staffing problems and if the nurses had trouble completing their assignments, the nurses are expected to inform the DNS or their supervisor and endorse the unfinished tasks to the next shift.
3) Resident #358 was admitted with the diagnoses of Atrial Fibrillation, Hypertension and Gastroesophageal Reflux Disease (GERD). The admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #358 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented Resident #358 received anticoagulant medication 2 of 7 days in the MDS look back period.
On 3/25/2022 at 12:05 PM RN #3 was observed outside Resident #358's room preparing medications. RN #3 stated the medications were due to be given to Resident #358 at 9 AM. RN #3 further stated that they (RN #3) were the only nurse on Unit 4.
The following 9 AM medications that were ordered and the corresponding administration times on 3/25/2022 are as follows:
Fluticasone Propionate Aerosol 110 microgram (mcg) 1 puff inhale orally every 12 hours for Asthma. The medication was administered at 12:03 PM;
Apixaban Tablet 5 milligram (mg) Give 1 tablet by mouth every 12 hours for Atrial Fibrillation. The medication was administered at 12:03 PM;
Centrum Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. The medication was administered at 12:03 PM;
Pepcid Tablet 20 mg (Famotidine) Give 1 tablet by mouth two times a day for Gastro Esophageal Reflux Disease (GERD). The medication was administered at 12:03 PM;
Cozaar Tablet 50 mg (Losartan Potassium) Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 1:02 PM;
Amlodipine Besylate Tablet 10 mg Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 12:35 PM.
Budesonide-Formoterol Fumarate Aerosol 160-4.5 mcg two puff inhale orally two times a day for Asthma. The medication was administered at 12:35 PM.
RN #3 was re-interviewed on 3/28/2022 at 12:17 PM and stated the 9 AM medications for Resident #358 were late on 3/25/2022 because things were hectic, and they (RN #3) were the only nurse on the unit. RN #3 stated that being the only nurse on the unit is how it usually is. RN #3 stated it was not normal to deliver the 9 AM medications after 12 PM, and the medications should be administered one hour before or one hour after the prescribed time.
The Director of Nursing Services (DNS) was interviewed on 3/30/2022 at 8:45 AM and stated the medications are to be administered within one hour before or one hour after the ordered due time. The DNS stated the nurse could have asked for help.
415.13(a)(1)(i-iii)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022 the facility did not ensure that pharmaceutical services including administration of all medications was provided to meet the needs of all residents. This was identified for one (Resident #358) of one resident reviewed for Pharmacy Services. Specifically, on 3/25/2022 Registered Nurse (RN) #3 did not administer 9 AM Physician-ordered medications to Resident #358 timely.
The finding is:
The facility's policy titled Administering Medications, revised on 1/2022, documented medications must be administered in accordance with the [Physician's] orders, including any required time frame, and medications must be administered within one (1) hour of their prescribed time, unless otherwise specified.
As per the Physician's History and Physical dated 3/21/2022, Resident #358 was admitted with diagnoses including Asthma, Chronic Atrial Fibrillation, and Hypertension.
As per the Nursing admission assessment dated [DATE], Resident #358 had intact cognition and was oriented to person, place, and situation.
A Comprehensive Care Plan (CCP) effective 3/27/2022 documented the resident has an Alteration in Cardiovascular Function related to Heart Disease (Hypertension, Hyperlipidemia, status post-acute symptomatic Bradycardia, Edema, Atrial Fibrillation, history of sinus Bradycardia, and Pulmonary Embolism, with an intervention to administer medications as prescribed.
A CCP effective 3/27/2022 documented the resident has an alteration in respiratory system related to Asthma, Sarcoidosis, history of lung disease, and oxygen dependence, with an intervention to administer treatments (nebulizer) and medications as per physician orders.
On 3/25/2022 at 12:05 PM RN #3 was observed outside Resident #358's room preparing medications. RN #3 stated the medications were due to be given to Resident #358 at 9 AM. RN #3 further stated that they (RN #3) were the only nurse on the unit.
The following 9 AM medications that were ordered and the corresponding administration times on 3/25/2022 are as follows:
Fluticasone Propionate Aerosol 110 microgram (mcg) 1 puff inhale orally every 12 hours for Asthma. The medication was administered at 12:03 PM;
Apixaban Tablet 5 milligram (mg) Give 1 tablet by mouth every 12 hours for Atrial Fibrillation. The medication was administered at 12:03 PM;
Centrum Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for supplement. The medication was administered at 12:03 PM;
Pepcid Tablet 20 mg (Famotidine) Give 1 tablet by mouth two times a day for Gastro Esophageal Reflux Disease (GERD). The medication was administered at 12:03 PM;
Cozaar Tablet 50 mg (Losartan Potassium) Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 1:02 PM;
Amlodipine Besylate Tablet 10 mg Give 1 tablet by mouth one time a day for Hypertension. The medication was administered at 12:35 PM.
Budesonide-Formoterol Fumarate Aerosol 160-4.5 mcg two puff inhale orally two times a day for Asthma. The medication was administered at 12:35 PM.
RN #3 was re-interviewed on 3/28/2022 at 12:17 PM and stated the 9 AM medications for Resident #358 were late on 3/25/2022 because things were hectic and they (RN #3) were the only nurse on the unit. RN #3 stated that being the only nurse on the unit is how it usually is. RN #3 stated they (RN #3) called the physician to report the medications being late. RN #3 stated it was not normal to administer the 9 AM medications after 12 PM, and the medications should be administered one hour before or one hour after the prescribed time.
Physician #1 was interviewed on 3/29/2022 at 8:54 AM and stated that they (Physician #1) were made aware of Resident #358 medications for being late on 3/25/2022.
The Director of Nursing Services (DNS) was interviewed on 3/30/2022 at 8:45 AM and stated the medications are to be administered within one hour before or one hour after the ordered due time. The DNS stated the nurse could have asked for help.
415.18(a)
MINOR
(B)
Minor Issue - procedural, no safety impact
Administration
(Tag F0835)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY 00290462) initia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY 00290462) initiated on 3/23/2022 and completed on 4/1/2022 the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial wellbeing. Specifically, the facility did not ensure adequate linen supplies were available to meet the residents' needs on two (Unit 1 and Unit 2) of four units observed.
The finding is:
Resident #30 was admitted with diagnoses that include Hypertension, Type II Diabetes Mellitus and was Legally Blind. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. The resident had no behavioral symptoms and no rejection of care.
During an observation on 3/23/2022 at 1:10 PM and on 3/24/22 at 10:50 AM Resident #30 was observed in their room sitting on the side of their bed. The beds in the room were made and there were no blankets observed on the beds.
Resident #30 was interviewed on 3/24/2022 at 10:53 AM regarding why there was no blankets on the bed. The resident stated that they (Resident #30) requested blankets a couple days ago and the staff told the resident there were no blankets. Resident #30 stated that since their admission the lack of having blankets has been an issue.
Unit 2 was observed on 3/25/2022 between 10 AM and 1 PM. Eight of the ten rooms observed did not have blankets on the residents' beds.
Social Worker (SW) #2) was interview on 3/28/2022 at 11:45 AM and stated no concerns were brought to their attention regarding the lack of blanket availability.
Registered Nurse (RN) #6 was interviewed on 3/30/22 at 6:45 PM and stated that there have been times there were no blankets in the facility. RN #6 stated that sometimes staff had to go to other floors to get blankets and there were times when there were no blankets available in the facility.
Certified Nursing Assistant (CNA) #14 was interviewed on 3/30/2022 at 7:13 PM and stated that there were times staff were unable find blankets.
Housekeeper (HK) #1 was interviewed on 3/30/2022 at 8:03 PM and stated there was an increase request for the white thermal blankets. HK #1 stated about two weeks ago the facility was running out of the white blankets. HK #1 stated that the current stock of blankets available in the facility was not enough to supply each resident with a blanket based on the current facility census of 168. HK #1 stated the HK Supervisor is notified when there is a low supply of blankets.
HK Director was interviewed on 3/31/2022 at 3:34 PM and stated that two package blankets are sent to each floor and each packet contains 8 blankets. The HK Director stated that only the housekeepers have access to the blankets on the 3:00 PM - 11:00 PM and the 11:00 PM - 7:00 AM shifts. The HK director stated that the housekeepers did not report to them that the facility was running out of blankets.
The Director of Nursing Services (DNS) was interviewed on 4/1/2022 at 5:01 and stated that a blanket should be on every resident's bed. The DNS further stated that the blanket par level should match the facility current census.
The Administrator (ADM) was interviewed on 4/1/2022 at 5:46 PM and stated they were not aware that there was a concern with blanket shortage. The ADM stated if they were made aware of the concern regarding blankets they would have and adjusted the par levels accordingly.
415.26
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0888
(Tag F0888)
Minor procedural issue · This affected most or all residents
Based on observation, record review and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not implement policies and procedures to ensure ...
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Based on observation, record review and interviews during the Recertification Survey initiated on 3/23/2022 and completed on 4/1/2022, the facility did not implement policies and procedures to ensure that all staff were completely vaccinated for COVID-19 and did not include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19. Specifically, the facility allowed one unvaccinated staff member (Registered Nurse (RN) #10) to provide direct resident care and one unvaccinated staff, the Food Service Director, to interact in close proximity to residents while not wearing an N95 mask.
The finding is:
The facility policy, Vaccination Compliance Plan dated 8/16/2021, did not include a contingency plan that addressed actions the facility would take for staff with valid medical exemptions.
During the vaccination review, three staff members were identified to have valid medical exemptions for the Covid-19 Vaccine Mandate that included RN #10 and the Food Service Director.
On 3/25/2022 at 1:01 PM, the Food Service Director was observed in the 1st floor hallway, wearing a surgical mask. The Food Service Director was within 6 feet of residents during meal service.
The Food Service Director was interviewed on 3/28/2022 at 10:35 AM and stated they (Food Service Director) are medically exempt from the COVID-19 vaccination and are required to get tested twice a week. The Food Service Director stated there are no other limitations to their job. The Food Service Director stated they (Food Service Director) always wears a surgical mask and are not required to wear an N95 mask. The Food Service Director stated they (Food Service Director) maintain social distancing when in resident rooms.
RN #10 was interviewed on 3/28/2022 at 11:38 AM and stated they are medically exempt from the COVID-19 vaccination and get tested twice a week. RN #10 stated they wear an N95 mask and a face shield when rendering care to the residents. RN #10 stated their job duties include serving meal trays, administering medications and providing catheter care to residents. RN #10 stated there were no limitations to their job duties and they could provide direct care to the residents.
The Director of Nursing (DNS), who is the Infection Control Preventionist, was interviewed on 3/28/2022 at 2:41PM and stated that they provide in-service education to all staff on infection control, including COVID-19 policies and vaccination information. The DNS stated they also in-service the unvaccinated staff. The staff are told to wear an N95 mask when providing non-direct care and to wear an N95 mask and a face shield when in direct contact with a resident. The DNS stated education is provided on what types of Personal Protective Equipment (PPE) should be used and that the medically exempt staff can provide care without limitation when wearing PPE. The DNS stated they are involved in the formulation of policies and that little revision has been done to the policies.
The Administrator was interviewed on 3/28/2022 at 2:20 PM and stated that they are involved in the formulation of policies and procedures related to COVID-19. The Administrator stated that the facility policies do not indicate that the unvaccinated staff are required to wear an N95 mask. Per their policy, they do not wear an N95 mask unless working directly with residents. The Administrator further stated that the unvaccinated staff can provide direct care to residents, but social distancing must be implemented.
415.19(a) (1-3)
Oct 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and interventions to meet each resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for 1 (Resident #140) of 2 residents reviewed for vision/hearing. Specifically, Resident #140 was identified on the Minimum Data Set (MDS) assessment as having moderate difficulty with hearing. The CCP developed for hearing deficit did not include person-centered interventions to assist the resident to effectively communicate with staff.
The finding is:
The facility's policy and procedure dated March 2019 titled Care Plans, Comprehensive Person-Centered documented . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 14. The Interdisciplinary team must review and update the care plan .
The facility's policy and procedure dated March 2019 titled Care of Hearing Aid documented . Review the resident's care plan to assess for any special needs of the resident .
Resident #140 has diagnoses including Sensorineural Hearing Loss, Type 2 Diabetes Mellitus, and Atherosclerosis of Coronary Artery with Bypass Graft. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIIMS) score of 8 indicating the resident was moderately impaired in cognition. The MDS documented the resident had moderate difficulty hearing and had no hearing aid use. The MDS documented the resident had clear speech, made self understood, and usually understood others.
The CCP developed for Hearing Deficit dated 8/12/19 documented the resident was Hard of Hearing (HOH). The interventions included to anticipate the resident's needs; to be conscious of the resident's position when in groups, activities, dining room to promote proper communication with others; to provide a program of activities that accommodates the resident's hearing deficit, and to report to the nurse any changes in ability to communicate. The CCP for hearing deficit did not document using gestures/sign language and writing or the use of a communication board.
The resident was observed in his room on 10/10/19 at 10:57 AM. The resident had no hearing aids and had difficulty understanding and communicating with the surveyor. The surveyor had to write questions on a piece of paper for the resident to read. The resident had no difficulty reading the questions. The resident answered the questions concisely and coherently.
A subsequent interview was held with the resident on 10/16/19 at 8:35 AM. The resident stated he had no hearing aid and the nursing staff used gestures in communicating with him.
The resident's room was observed on 10/16/19 at 8:35 AM. There was no communication board, pen and paper at the resident's bedside for the resident and staff to utilize as a means of communication.
An interview was held with the 7:00 AM- 3:00 PM shift assigned Certified Nursing Assistant (CNA) on 10/16/19 at 8:45 AM. The CNA stated that she communicates with the resident using hand gestures. The CNA stated that she could write a question on paper, but the CNA did not know why there was no communication board or pen and paper at the resident's bedside.
An interview was held with the Registered Nurse (RN) Unit Charge Nurse on 10/16/19 at 9:00 AM. The RN stated that she would add the use of hand gestures/sign language and a communication board as interventions while waiting for the resident's hearing aid to be approved by Medicaid.
An interview was held with the Assistant Director of Nursing Services (ADNS) on 10/16/19 at 11:00 AM. The ADNS stated the CCP for hearing deficit should have incorporated the use of gestures/sign language, writing, and a communication board while the resident was waiting for his hearing aid to be approved by Medicaid.
415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on facility record review and staff interview during the recertification survey, the facility did not ensure that their policy regarding use and storage of foods brought to residents by family a...
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Based on facility record review and staff interview during the recertification survey, the facility did not ensure that their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption specifically included how facility staff would ensure that: 1) a resident is assisted in accessing and consuming the food, if the resident is not able to do so on his or her own and 2) family and visitors understood safe food handling practices; such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, and hand hygiene.
The finding is:
The facility's Personal Food Policy dated 3/19/18 was reviewed on 10/16/19 at 9:20 AM. The policy did not specifically include how the facility would ensure that: 1) a resident was assisted in accessing and consuming food brought in by family and other visitors, if the resident was not able to do so on his or her own and 2) family and visitors understood safe food handling practices; such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, and hand hygiene.
The Executive Chef/Food Service Director (FSD) was interviewed on 10/16/19 at 10:30 AM and stated that all food brought in by family and visitors must go through the Registered Nurse on the unit because she is the clinical person on the unit who knows the resident's diet order. The FSD stated that he was not involved in the process of how a resident would be given assistance in consuming food brought in from the outside or how family and friends would be given instruction on safe food handling procedures. The FSD stated that he was not aware that this information should have been included in the facility's Personal Food Policy.
415.14(h)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews during the Recertification Survey the facility did not ensure that for each resident infecti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews during the Recertification Survey the facility did not ensure that for each resident infection control measures were employed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #149) of two residents reviewed for Respiratory Care. Specifically, during the tracheostomy (trach) care observation the nurse removed the old dressing, did not change gloves or wash hands before proceeding with the cleaning process, and then applied the clean dressing with the same gloved hands that were used to remove the old dressing.
The finding is:
The facility's policy and procedure titled Tracheostomy Care, revised 5/2017, documented that after the old dressing is removed the soiled glove should be pulled over the dressing and then discarded followed by hand washing.
Resident #149 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Cerebrovascular Accident, and Tracheostomy Status. The 9/17/19 Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident was rarely or never understood. The MDS documented the resident was receiving oxygen, suctioning, and tracheostomy care.
Physician's orders, dated 9/4/19, included trach care every shift, trach suction as needed, and trach Portex #6.
A Comprehensive Care Plan (CCP) dated 9/4/19 titled, Resident has an alteration in respiratory status related to tracheostomy had an intervention to provide tracheostomy care daily and when needed using aseptic technique.
Resident #149's tracheostomy care was observed on 10/17/19 at 8:09 AM. The trach care was performed by the Licensed Practical Nurse (LPN) treatment nurse. The LPN was assisted by the Registered Nurse (RN) charge nurse. The LPN opened a sterile trach care kit and donned a pair of sterile gloves from the kit. The LPN then removed the old dressing using the sterile gloves. The LPN did not remove the sterile gloves but proceeded to cleanse the stoma area and trach using a brush soaked in normal saline. After cleansing the stoma and trach with the normal saline, the gloves were not removed. The LPN applied the new dressing without changing the sterile gloves.
The LPN was interviewed on 10/17/19 at 11:08 AM. He stated that it was not necessary to change gloves and wash hands because the dressing was not soiled. He stated that if the dressing was very soiled, he would change his gloves and wash his hands.
The RN charge nurse who assisted with the trach care was interviewed on 10/17/19 at 11:11 AM. She stated that she did not remember if the LPN changed his gloves and washed his hands.
The RN in-service coordinator was interviewed on 10/17/19 at 12:54 PM. She stated that it was necessary to wash hands and change gloves after removing the old dressing.
The RN unit supervisor was interviewed on 10/17/19 at 1:26 PM. She stated the gloves should have been removed and the LPN's hands should have been washed after removing the old dressing.
The Director of Nursing Services (DNS) was interviewed on 10/18/19 at 8:44 AM. She stated the LPN will have to be inserviced and should have maintained aseptic technique.
415.19(b)(4)
MINOR
(B)
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0584)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident's environment was safe, clean, and homelike. This was identified for two (Residents #16 and #70) of two residents reviewed for environment. Specifically, the floor mats designated for Residents #16 and #70 were dirty and heavily stained with grayish colored materials.
The findings are:
The facility's policy and procedure dated March 2019 titled Floor Mats documented . 2. Floor mats will be wiped daily by housekeeping staff. 3. When floor mats are visibly soiled, the nursing staff notifies the housekeeping staff. 4. Housekeeping staff will remove the floor mats and take them to be cleaned.
1) Resident #16 has diagnoses including Seizure Disorder and Parkinson's Disease. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 9 indicating the resident was moderately impaired in cognition.
The Comprehensive Care Plan (CCP) developed for falls dated 8/9/19 documented an intervention that included floor mats in place.
On 10/15/19 at 11:01 AM and on 10/16/19 at 8:30 AM the floor mat designated for Resident #16, which was located on the right side of the resident's bed, was dirty and heavily stained with a grayish colored material.
An interview with the 7:00 AM-3:00 PM shift assigned Certified Nursing Assistant (CNA) #1 was held on 10/16/19 at 8:55 AM. The CNA stated that she was not aware that the resident's floor mat was dirty. The CNA stated that she would notify the Unit's Housekeeping Staff to have the floor mat cleaned.
An interview with the Unit's Housekeeping Staff Member was held on 10/16/19 at 9:00 AM. The Housekeeper stated that nobody notified her of the resident's dirty floor mat. The Housekeeping Staff Member stated it was her task to clean the resident's room and she did not notice that the resident's floor mat was dirty. The Housekeeping Staff Member stated she will send the floor mat to the Housekeeping Department for cleaning.
2) Resident #70 has diagnoses including Coronary Artery Disease, Diabetes Mellitus, and Hypertension. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's BIMS score was 13 indicating the resident was cognitively intact for daily decision making.
The CCP developed for falls dated 8/26/19 documented an intervention that a floor mat was issued to the resident and was to be placed on the right side of the resident's bed.
On 10/15/19 at 9:30 AM and on 10/16/19 at 8:35 AM, the floor mat designated for Resident #70, which was located on the right side of the resident's bed, was dirty and heavily stained with a grayish colored material.
An interview with the 7:00 AM-3:00 PM shift assigned CNA #2 was held on 10/16/19 at 8:40 AM. CNA #2 stated that she was not aware that the resident's floor mat was dirty. The CNA stated that she would notify the Unit's Housekeeping Staff to have the floor mat clean.
An interview was held with the Unit's Housekeeping Staff Member on 10/16/19 at 9:00 AM. The Housekeeper stated that nobody notified her of the resident's dirty floor mat. The Housekeeping Staff Member stated it was her task to clean the resident's room and that she did not notice the resident's floor mat was dirty. The Housekeeping Staff Member stated she will send the floor mat for cleaning.
An interview was held with the Director of Housekeeping on 10/17/19 at 10:00 AM. The Housekeeping Director stated it was the assigned duty of the Unit's Housekeeping Staff Member to clean the residents' room including the floor mats. The Director stated the floor mats should have been removed for cleaning.
415.5(h)(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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New York facilities.
- • 17% annual turnover. Excellent stability, 31 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 24 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Grand Rehabilitation And Nursing At Great Neck's CMS Rating?
CMS assigns THE GRAND REHABILITATION AND NURSING AT GREAT NECK 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 The Grand Rehabilitation And Nursing At Great Neck Staffed?
CMS rates THE GRAND REHABILITATION AND NURSING AT GREAT NECK's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 17%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Grand Rehabilitation And Nursing At Great Neck?
State health inspectors documented 24 deficiencies at THE GRAND REHABILITATION AND NURSING AT GREAT NECK during 2019 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 19 with potential for harm, and 4 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Grand Rehabilitation And Nursing At Great Neck?
THE GRAND REHABILITATION AND NURSING AT GREAT NECK 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 THE GRAND HEALTHCARE, a chain that manages multiple nursing homes. With 214 certified beds and approximately 206 residents (about 96% occupancy), it is a large facility located in GREAT NECK, New York.
How Does The Grand Rehabilitation And Nursing At Great Neck Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, THE GRAND REHABILITATION AND NURSING AT GREAT NECK's overall rating (2 stars) is below the state average of 3.1, staff turnover (17%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting The Grand Rehabilitation And Nursing At Great Neck?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can 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 Immediate Jeopardy citations and the below-average staffing rating.
Is The Grand Rehabilitation And Nursing At Great Neck Safe?
Based on CMS inspection data, THE GRAND REHABILITATION AND NURSING AT GREAT NECK has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Grand Rehabilitation And Nursing At Great Neck Stick Around?
Staff at THE GRAND REHABILITATION AND NURSING AT GREAT NECK tend to stick around. With a turnover rate of 17%, the facility is 29 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 24%, meaning experienced RNs are available to handle complex medical needs.
Was The Grand Rehabilitation And Nursing At Great Neck Ever Fined?
THE GRAND REHABILITATION AND NURSING AT GREAT NECK has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Grand Rehabilitation And Nursing At Great Neck on Any Federal Watch List?
THE GRAND REHABILITATION AND NURSING AT GREAT NECK 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.