ONONDAGA CENTER FOR REHABILITATION AND NURSING

217 EAST AVENUE, MINOA, NY 13116 (315) 656-7277
For profit - Corporation 82 Beds CENTERS HEALTH CARE Data: November 2025
Trust Grade
20/100
#544 of 594 in NY
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Last Inspection: May 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Onondaga Center for Rehabilitation and Nursing has received a Trust Grade of F, indicating significant concerns and poor quality of care. They rank #544 out of 594 facilities in New York, placing them in the bottom half statewide, and #11 out of 13 in Onondaga County, suggesting very few local options are better. Unfortunately, the facility is worsening, with issues increasing from 6 in 2023 to 19 in 2024, and a troubling staffing turnover rate of 69%, much higher than the state average of 40%. They have incurred fines totaling $76,428, which is concerning as it is higher than 95% of New York facilities, indicating repeated compliance problems. Specific incidents include a resident with a brain bleed who was not monitored properly and later died, as well as another who developed an infection due to a lack of treatment for a surgical wound. While there is some RN coverage, it is only average, and overall, families should be cautious when considering this facility due to these serious deficiencies.

Trust Score
F
20/100
In New York
#544/594
Bottom 9%
Safety Record
Moderate
Needs review
Inspections
Getting Worse
6 → 19 violations
Staff Stability
⚠ Watch
69% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
○ Average
$76,428 in fines. Higher than 59% of New York facilities. Some compliance issues.
Skilled Nurses
⚠ Watch
Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
40 deficiencies on record. Higher than average. Multiple issues found across inspections.
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 6 issues
2024: 19 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below New York average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 69%

22pts above New York avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $76,428

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: CENTERS HEALTH CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (69%)

21 points above New York average of 48%

The Ugly 40 deficiencies on record

1 actual harm
May 2024 19 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure a resident's ability to safely self-administer medication...

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Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 had lidocaine-prilocaine cream (topical cream used to numb skin before a medical procedure) at their bedside and there was no documented evidence the resident was assessed for their ability to safely self-administer the medication. Findings include: The facility policy Medication-Self Administration reviewed 7/2019 documented the staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident. If the team determined that a resident could not safely administer medications, all medications would be administered by a nurse from the stored medication in the med cart. Staff would identify and give the charge nurse any medications found at the bedside that were not authorized for self-administration, for return to the family or responsible party. Resident #45 had diagnoses including end stage renal disease (kidney disease) and dependence on hemodialysis (a treatment that filters waste and water from the blood). The 4/16/2024 Minimum Data Set assessment documented the resident was cognitively intact, received hemodialysis, and required supervision/touching assistance with personal hygiene, oral hygiene, upper body dressing, and transfers. The comprehensive care plan initiated 4/11/2024 documented the resident required assistance with self-care and mobility related to impaired balance, limited mobility, and dialysis. Interventions included the resident was independent with personal hygiene. The comprehensive care plan initiated 4/11/2024 documented the resident needed hemodialysis related to end stage renal disease and nonadherence to prescribed fluid restrictions. Interventions included the resident received dialysis on Monday, Wednesday, and Friday; monitor left arm arteriovenous fistula (tube or device surgically implanted to create an artificial connection between an artery and a vein for dialysis access) for bruit (rumbling or whooshing sound heard with a stethoscope) and thrill (rumbling or buzzing sensation that is felt) every shift; monitor/document/report signs and symptoms of infection to access site; and check and change dressing daily at access site if ordered by the provider. There was no documented evidence the resident had a plan in place to self-administer medications including lidocaine-prilocaine cream. During an observation and interview on 5/6/2024 at 9:42 AM, Resident #45 was sitting in their room on the edge of their bed. There was a white tube of lidocaine-prilocaine 2.5% cream on their nightstand. The resident stated they applied the cream on their left upper arm access site (fistula) before dialysis on Monday, Wednesday, and Friday so the area was fully numb before the site was accessed. Facility staff was aware they applied the cream before dialysis and sometimes after if the access site was still sore. They stated they were unsure if they could keep the medication in their room, staff had not said anything about keeping it on their nightstand. The May 2024 physician order listing report did not include an order for lidocaine-prilocaine 2.5% cream or instructions for self-administration of any prescribed medications. During observations on 5/8/2024 at 11:03 AM, and 5/9/2024 at 10:15 AM and 3:19 PM a white tube of lidocaine-prilocaine 2.5% cream was on the resident's nightstand in their room. There was no documented evidence that a medication self-administration assessment was completed for the resident. During an interview on 5/9/2024 at 1:53 PM, certified nurse aide #3 stated they were responsible for keeping resident rooms tidy so housekeeping could clean the room. If they found medication in a resident's room, they would notify the medication nurse. They did not notice any medication or creams in Resident #45's room, or they would have notified the nurse. During an interview on 5/9/2024 at 1:59 PM, licensed practical nurse #2 stated before a resident went to dialysis, they were responsible for obtaining vital signs and filling out the dialysis communication log. Sometimes dialysis centers would request the facility to put lidocaine cream on a resident's access site before they left for dialysis, but they had not requested it for Resident #45. They stated if the dialysis center had requested the cream, it would need a medical order. Resident #45 should not apply it themselves, and the nurse should keep the medication in the cart and apply it for them. Residents could only keep medications at their bedside if they had a physician order to self-administer medications, and Resident #45 did not have an order. They stated it was not safe for Resident #45 to keep the medication at their bedside because they could have used it incorrectly or another resident could take it. During an interview on 5/10/2024 at 10:31 AM, Regional Registered Nurse #1 stated residents could have medications in their room if they were evaluated and deemed safe for self-administration. A licensed nurse could evaluate the resident, but a physician order was required to keep medications at the bedside. Resident #45 did not have an order for self-administration so no medications should have been kept in their room. If staff saw medications in Resident #45's room, they should remove them and lock them in the medication cart for safe keeping so no residents had access to them. They were unsure how it happened because staff did rounds on the unit and would go through resident drawers to look at things. 10NYCRR 415.3(e)(1)(vi)
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 interviews during the recertification survey conducted 5/6/2024-5/10/2024, the facility...

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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 conducted 5/6/2024-5/10/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 of resident (Resident #72) reviewed. Specifically Resident #72 did not have resident-specific interventions for their language barrier or for their potential to become a victim of verbal or physical abuse. Findings include: The facility policy Translation Services last revised 1/2020, documented the facility's language access program would ensure that individuals with limited English proficiency shall have meaningful access to information and services provided by the facility. The facility policy Residents Rights last revised 2/2020, documented residents had the right to communication with and access to people and services, both inside and outside the facility The facility policy Behavior Management last revised 5/2020, documented the facility must provide an interdisciplinary approach for the care of residents who exhibit problem behavioral symptoms which could lead to negative consequences for themselves or others. The facility policy Activities of Daily Living Care and Support last revised 3/13/2024, documented care and support would be provided for residents who were unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that included but was not limited to supervision and assistance with hygiene, mobility, elimination, dining, and communication. Resident #72 had diagnoses including dementia and depression. The 3/12/2024 Minimum Data Set assessment documented the resident's preferred language was [not English] and they needed/wanted an interpreter. The 4/20/2024 Minimum Data Set, dated documented the resident was not interviewed to determine cognitive status and staff assessed the resident to have severely impaired decision making abilities, had unclear speech, was rarely/never understood, rarely/never understands, required substantial/maximum assistance for transfers, and ambulation was not attempted due to medical condition or safety concerns. The 3/12/2024 admission Nursing Assessment completed by Registered Nurse Unit Manager #5 documented the resident was confused, did not speak English, an interpreter was required, spoke [a foreign language], and needed or wanted an interpreter to communicate with a doctor or health care staff. The comprehensive care plan initiated 3/13/2024 documented the resident required assistance with self-care and mobility. Interventions included the resident was to participate to the fullest extent possible with each interaction. There was documented evidence of a plan of care for the resident's language barrier. The 4/19/2024 speech therapy discharge summary did not document therapy or interventions regarding a language barrier. The comprehensive care plan problem initiated 4/22/2024 documented the resident exhibited behavioral symptoms such as agitation and restlessness. Interventions included acknowledging the resident's feeling and encouraging them to express their feelings. The 5/2/2024 Physician Assistant #13 progress note documented the resident had a weight loss and they were unable to assess their appetite as the resident did not speak English. The comprehensive care plan did not include a communication problem or potential for victimization. During an observation on 5/6/2024 at 7:34 AM, the resident was brought to the nursing station in their wheelchair. The resident repeatedly tried to get up unassisted and attempted to talk to licensed practical nurse #6 who replied, I don't know what you are saying honey. Sit down. Breakfast will be here soon then walked away. The resident continued to attempt to stand. At 8:32 AM, the resident remained at the nursing station attempting to stand from their wheelchair. Another resident repeatedly told the resident to sit down, and the resident continued to attempt to stand up. The same resident yelled harshly at Resident #72 to sit down. When Resident #72 did not sit down, the other resident yelled even louder and slammed their hand on a table in front of Resident #72 with enough force that it caused a loud crashing noise and the table to shake. There was no staff in the hall at the time of the incident and staff did not respond to the loud sound. The resident continued to attempt to get up and repeatedly looked up and down the hall. During an interview on 5/6/24 at 11:15 AM, Resident #60 (Resident #72's roommate) stated Resident #72 resident moaned and talked all the time, but no one could understand what they were trying to say. They stated the resident was very unstable on their feet and came over to their side of the room all the time. When they tried to tell the resident to return to the other side of the room Resident #72 did not always respond. Resident #60 recalled an incident when they had to yell, scream, and raise their fist at the resident to make them turn around. They denied any physical altercations with the resident. During an observation on 5/8/2024 at 1:25 PM the resident was in bed pulling at the closed privacy curtain between them and their roommate, Resident #60. The resident was calling out indiscernible words. Resident #60 was on the other side of the curtain watching television. Staff entered the room and Resident #72 was brought to the central area of unit. The resident was alert, fiddling with their shirt, and speaking unintelligible words. The comprehensive care plan initiated 5/9/2024 documented the resident's primary language was not English. Interventions included provide a communication tool in the resident's room and at the nursing station for staff to use, provide telephone translator service information at nursing station, speak slowly, and face the resident, and use gestures and visual cues as appropriate. During an observation on 5/9/2024 at 11:30 there was no picture or communication tools in the resident's room or at the nursing station. During an interview on 5/9/2024 at 11:58 AM, certified nurse aide #11 stated if a resident needed any aids to help with communication it would be listed as a task for them to sign for. They believed the resident spoke English at one time. The resident had been combative during care delivery, and they used hand motions, gestures, and spoke in short sentences to try to better communicate with resident. They were unaware of any specific interventions for communication like a picture chart and had never seen one in the resident's room. During an observation on 5/10/2024 at 9:14 AM telephone translator service directions were not posted at the nursing station. Licensed practical nurse #6 stated they were unable to find the directions and thought it might be in the Nurse Manager's office. During an interview on 5/10/24 at 9:30 AM, certified occupational therapist assistant #26 stated they used gestures, a picture communication/picture board, and Google interpreter (a phone/computer application used to translate languages) to communicate with resident with some success. They had tried the language line but, because the resident was soft spoken, the interpreter was unable to hear the resident clearly. They thought the picture communication tool was kept on the resident's chair but could not find. They recalled an instance when the resident appeared frustrated and pointed to a mad emotion face on the picture chart to communicate this. They stated they were going to get the resident a new picture chart as they would feel better knowing the resident had one with him. During an interview on 5/10/2024 at 10:40 AM, licensed practical nurse #6 stated if a resident had a communication barrier identified on admission a picture/communication chart should be given to the resident and it would be reflected on the [NAME]. They stated occupational therapy had the picture boards and anyone could ask for one as communication was everyone's responsibility. It was important to be able to communicate with residents or needs might not be met or even ignored. They did not see a picture/communication tool at the nursing station area but believed there was information pertaining to the language line on the bulletin board. They stated the resident has been frustrated a lot because of the communication barrier. The resident had lashed out, yelled, and kicked at staff. They could sometimes understand simple things the resident said and tried to speak simply and use gestures. They called for the assistance of a staff member that spoke the same language to help communicate with resident. They had not used a picture chart. They believed when the resident was on the rehabilitation unit, they had a picture/communication chart, but it did not come with the resident when they were transferred the current unit. During an interview on 5/10/2024 at 11:36 AM, Registered Nurse Manager #5 stated if a resident had a communication barrier identified on admission there should be a care plan developed by the Nurse Manager. Interventions could include using an interpreter phone and asking family to interpret. They did not know if the resident was care planned for a language barrier or if there were any person specific interventions. I was important barriers were identified so the resident could communicate their needs. They were aware the resident has been frustrated at times and has been aggressive towards staff and the resident's roommate did not like the resident because they made a lot of noise. They were not aware of any physical altercations between the resident and their roommate but thought there was a risk for this to happen. They also felt there was a risk for the resident to be yelled at by the roommate. They did not know if the resident was care planned to be at risk to be a victim or if there were any specific interventions to keep the resident safe. They stated that all residents in the nursing home had a potential to be a victim and should be care planned for this. 10NYCRR 415.11(c)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interviews during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure ongoing provision of programs to support each resident i...

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Based on observation, record review, and interviews during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 2 residents (Residents #13 and #36) reviewed. Specifically, Residents #13 and #36 were not offered meaningful activities of their choosing as care planned. The facility policy Recreational Services last reviewed 5/2019 documented the facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. 1) Resident #13 was had diagnoses including depression and left lower leg amputation. The 8/17/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, mood symptoms were present 7-11 of 14 days, required assistance of 2 staff for transfers, was non-ambulatory, and felt that listening to music, pets, group activities, current events, and going outside were very important. The 8/16/2023 comprehensive care plan documented Resident #13 was able to make recreation and leisure preferences known. Their interests included music, Bingo, cards, animals, watching television and word searches. Interventions included provide the resident with independent leisure supplies and assist the resident to find programs of interest. The 11/1/2023-5/31/2024 Multi-Month Participation Report documented Resident #13 had two 15-minute one to one social visits for a total of 30 minutes. The 3/26/2024 Recreation Assessment and Documentation completed by Activities Director #29 documented Resident #13 preferred independent pursuits in their own room and current participation included puzzles and reading. The remainder of assessment was blank. The 5/9/2024 recreational calendar documented pet therapy was scheduled at 10:30 AM. During an observation on 5/9/2024 at 10:59 AM, Resident #13 was not in attendance at the pet therapy activity. During interviews on 5/6/2024 at 10:33 am, 5/9/2024 at 9:26 AM, and 5/9/2024 at 10:24 AM, Resident #13 stated they would like to go to activities but stayed in bed because the chair caused them back discomfort. They stated they did not receive any specific activities in their room, did not attend pet or music groups, and had not been outside since their admission. They were interested in pet therapy and mocktails that was on the 5/9/2024 activity schedule. During an interview on 5/9/2024 at 2:04 PM certified nurse aide #30 stated Resident #13 had voiced interest in getting up for activities, but when it came time to get up, Resident #13 would refuse to do so. The only activity they witnessed Resident #13 do was watching television. They had not witnessed any in room activities being provided. During an interview on 5/9/2024 at 2:45 PM Activities Director #29 stated on admission they visited residents to determine their preferences. Those preferences were entered in the initial assessment and care plan. A daily chronicle, that included that day's activity schedule, was dispersed to each resident daily. The chronicle was reviewed with the resident by activities staff when they passed the chronicle out. They would ask the resident which activities they wanted to attend and would alert staff so the resident would be ready on time. If a resident could not or would not get up for an activity, they would bring items based on individual preferences and do a one to one activity in the room. They saw Resident #13 every day when they delivered the chronicle. Resident #13 was always watching television and often refused to get out of bed. They were unsure if Resident #13 was invited to the pet group that morning. There was no specific preference based activities provided to the resident. They felt one to one room visits, which should be done three times a week, were strongly lacking. After they reviewed the activity log, they stated only 1 one to one room visit with Resident #13 occurred since 8/10/2023. During an interview on 5/10/2024 at 10:40 AM licensed practical nurse #6 stated it was important that residents get up for activities and they expected if a resident declined, they would be informed. They stated Resident #13 should get up but often refused to do so or wanted to go back to bed almost immediately after they got up. They stated Resident #13 did not attend group activities, liked to watch television, and did not read the chronicle that was delivered daily. They had not observed any in room activities for the resident. During an interview on 5/10/2024 at 11:36 AM registered nurse Manager #5 stated their expectation was every resident got up and if not, it was reported to them. They documented refusals but was unsure if it should be care planned. They stated Resident #13 often refused to get out of bed. They had talked to the resident about this but was never given a reason for the refusals. There were no specific interventions to address the refusals and they did not know if Resident #13 was or should be care planned for refusals. They stated Resident #13 did not attend activities but thought a dog had been brought to them. 2) Resident #36 had diagnoses including metabolic encephalopathy (a chemical imbalance in the brain) and dementia. The 3/30/2024 Minimum Data Set assessment documented the resident had severely impaired cognition and was totally dependent for activities of daily living. The 10/24/2023 Minimum Data Set admission assessment documented the resident was interviewed for preferences for activities. The resident felt it was very important to listen to music, to be around animals, to do favorite activities, and to go outside to get fresh air when the weather was good; and felt it was somewhat important to keep up with the news and do things with groups. On 11/3/2023 Activities Director #29 documented in comprehensive care plan that resident was able to make recreation and leisure preferences known and interests included word searches, crosswords, animals, and music. Interventions included to invite and escort the resident to activities of choice/interest and provide independent leisure supplies. The 3/20/2024 Recreation Assessment and Documentation form completed by Activities Director #29 documented Resident #36 preferred independent pursuits in their room or on the unit, current participation included family visits, and participation type was independent. The remainder of assessment was blank. Resident #36 was observed at the following times: - on 5/6/2024 at 8:53 AM sitting in their chair in the hall outside of their room. At 11:32 AM sitting in the hall outside of their room in the same position as the earlier observation. - on 5/8/2024 continuously from 8:55 AM until 12:15 PM sitting in the hall outside their room. No staff interaction was observed, and no activities were offered or provided. - on 5/9/2024 at 9:52 AM sitting in their chair outside their room in the hall. During an interview on 5/10/2024 at 8:35 AM, Activities Director #29 stated activities provided daily socialization and activities. Activity care plans were based on resident preferences that were assessed on admission. If a family was interviewed regarding preferences, it would be reflected in the care plan. They provided a chronicle containing a puzzle and coloring activity to residents daily. Resident #36 would require assistance to complete the word search or coloring activity. At that time residents were asked what activities they would like to attend. If a resident had music listed as a preference, and they had a musical activity occurring, they would include that resident even if they were unable to respond. They stated Resident #36 typically sat in the hall. The resident's spouse visited daily and occasionally brought the resident to entertainment. The resident did not attend the music on 5/6/2024 and was not offered the option to attend. They stated Resident #36's care planned interests were animals, word searches, and crosswords and current abilities and interests should be reflected. The care plan did not document that a family interview was conducted, but they believed they talked to the resident's spouse. There were no one to one visits with Resident #36. They were lacking on those visits. The activity attendance log was marked for 5 minutes a day for 30 days for time spent delivering and reviewing the daily chronicle with Resident #36, but they were probably only in the room for a minute. 10NYCRR 415.5(f)(1)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

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 interview during the recertification and abbreviated (NY00340114, NY00310431, NY0033636...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00340114, NY00310431, NY00336364, and NY00310702) surveys the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #60) reviewed. Specifically, Resident #60 had a recommendation for a follow up appointment with nephrology (kidney specialist) and there was no documented evidence the follow-up appointment was scheduled or occurred. Findings include: The facility policy Residents Rights last revised 2/2020 documented residents had the right to communication with and access to people and services, both inside and outside the facility. Resident #60 was admitted to the facility with a diagnose including chronic kidney disease, and acute kidney failure. The 2/22/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and required partial to moderate assistance with transferring and ambulation. The 8/24/2023 hospital discharge summary documented the resident was hospitalized from [DATE]-[DATE] and was found to have bilateral (both sides) occlusion (blockage) of their renal arteries as well as severe acute kidney injury. The resident likely had chronic kidney disease stage 5 (end stage kidney failure) and would need close nephrology follow up within 1 week of discharge. The 8/25/2023 physician admission orders did not include a nephrology consult. The comprehensive care plan initiated 8/28/2023 documented the resident had impaired renal function related to chronic kidney disease. Interventions included referral to nephrology. Physician assistant #12 documented: - on 8/28/2023 an initial visit progress note. The resident had chronic kidney disease stage 5 and required a follow-up with nephrology in 1 week. Follow-up as directed in hospital discharge summary. - on 8/29/2023 and 9/1/2023 diagnosis and assessment included chronic kidney disease, required follow-up with nephrology. An order summary report documented a 9/1/2023 order to follow to follow up with nephrology. Physician assistant #12 documented: - on 9/8/2023, 9/25/2023, 9/29/2023, and 10/2/2023 diagnosis and assessment included chronic kidney disease, required follow-up with nephrology. - on 10/10/2023 seen for an interval visit for review of medications and management of chronic disease. The resident wished to have their diet liberalized however, still did not have a nephrology consult. - on 10/30/2023 resident requested to be taken off renal diet. The resident still required follow-up with nephrology given chronic kidney disease and recommendations to follow up with nephrology initially upon admission. Interdisciplinary Team meeting note documented: - on 11/3/2023 plan to continue to attempt to secure a renal consult that week to assess liberalization of restricted diet. - on 11/10/2023 the resident was a high risk for weight loss, on a renal diet, and the resident wanted their diet liberalized but required a nephrology consult first. Physician assistant #12 documented: - on 12/21/2023, 1/22/2024, and 2/23/2024 diagnosis and assessment included chronic kidney disease, required follow-up with nephrology. - on 3/22/2024 interval visit had not followed up with nephrology yet. Stable required follow-up with nephrology. The Consultation Tracker for Resident #60, documented the following comments and did not include dates: - attempted to schedule with [local nephrology group]-unwilling to accept as a new patient as already established in [another city]. - attempted to get an appointment with nephrology in [another city]-office would not schedule appointment. - attempted to get appointment with [a second local nephrology group] who reported it was clinically not necessary. There was no documented evidence the medical provider was informed of the failed attempts for a nephrology consult. During an interview on 5/6/2024 at 11:15 AM and 5/7/2024 at 9:15 AM, Resident #60 stated they were supposed to see a kidney doctor and had been waiting since August and it had never happened. They stated they were on a special diet and did not like it. They were upset over their breakfast because they wished they had bacon or sausage, but their diet did not allow it. During an interview on 5/10/2024 at 11:36 AM registered nurse Unit Manager #5 stated when a resident was admitted they would read through the discharge summary and orders. If there was a recommendation for a consult, they would enter an order for it for the physician to review and approve. They would personally notify the scheduler who would then schedule the appointment and update the order with the specific appointment details. They believed appointment information was entered into a spread sheet and they did not know the process for monitoring the spreadsheet to ensure appointments were followed up on. They did not routinely read the medical provider notes. They were aware Resident #60 needed a nephrology consult. During an interview on 5/10/2024 at 1:17 PM, physician assistant #12 stated when there was a new admission, nursing would review the discharge summary with them for approval. They expected what was being reviewed with them was accurate. If they wanted to order a consultation, they would write a note in the provider communication book and the nurse would enter the order which they would cosign. Once a consult had occurred, a copy of the consult form with the visit summary was left in the provider communication book for them to review. They expected their orders to be followed and notified if the orders were not followed. They did not have a process to follow up on consultations they ordered. They were aware Resident #60, did have a nephrology consult. Given a prior diagnosis of stage 5 renal failure, the resident should be seen by nephrology. Even a telemedicine appointment (appointment via phone call or video chat) would be acceptable. They were aware that the resident wanted to have a diet change and they felt a nephrologist should be the one to make that decision. During an interview on 5/10/2024 at12:25 PM, the Director of Nursing stated if a consult was recommended on a discharge summary the medical provider would review it. If they agreed, the appointment would be scheduled, and the information would be placed in a tracker. The consult tracker had been in place for the past three months and they had been conducting performance improvement audits on the tracker as they had received similar deficiencies in the past. They stated Nurse Managers had access to the tracker. They expected Nurse Managers to review provider notes and they reviewed them as well. They were aware the resident needed a nephrology consult and several places had been approached but would not see the resident because the resident did not have a need. The resident was in the process of transitioning to another group of providers and was hopeful once that happened the new providers would be able to facilitate the nephrology appointment. They stated if a resident did not attend the recommended appointments there could be a break in the continuation of care and a decline in medical status. 10 NYCRR 415.12
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

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, record review, and interview during the recertification and abbreviated (NY00312922 and NY00314056) sur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00314056) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for 2 of 9 residents (Residents #42 and #379) reviewed. Specifically, Resident #379's bed was not maintained in the low position and their call bell was not in reach and Resident #42 was observed wandering, unsupervised, into other resident rooms without interventions in place for monitoring; Findings include: The facility policy Falls Management and Prevention revised 11/2019 documented the interdisciplinary team would identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The staff would implement goals and interventions with resident/ family for inclusion in the interdisciplinary care plan based on the resident's individual needs. The facility policy Behavior Management revised 5/2020 documented the facility provided an interdisciplinary approach for care of residents who exhibited problem behavioral symptoms which could lead to negative consequences for themselves or others. Residents should be evaluated that appropriate interventions were instituted in a timely manner. Approaches included (but not limited to), increased supervision. Behavioral symptoms and approaches were placed in the resident specific plan of care. 1) Resident #379 had diagnosis including legal blindness. The 5/1/2024 Minimum Data Set Assessment documented the resident had intact cognition, had severely impaired vision, did not reject care, required partial/moderate assistance rolling left to right, was dependent for transfers from sitting to standing and chair to bed transfers, and had 1 fall with injury since admission. The 4/25/2024 Admission/readmission Evaluation completed by the Director of Nursing documented the resident had 1-2 falls in the past six months, had severely impaired vision, and was totally incontinent of bladder and bowel. The resident was unable to independently come to a standing position and used assistive devices such as a cane or walker. Interventions included occupational therapy evaluation, physical therapy evaluation, and nonskid socks. The 4/26/2024 comprehensive care plan documented the resident had impaired visual function related to blindness. Interventions included to arrange room/personal items per resident preference and tell the resident where their items were placed. The resident required assistance with self-care related to confusion and limited mobility. Interventions included encourage the resident to use the call bell for assistance. The resident was at risk for falls/ had an actual fall. Interventions included to anticipate and meet the resident needs. The 4/27/2024 Initial Event Documentation completed by the Director of Nursing documented the resident had a fall at 8:51 AM on 4/27/2024 while attempting to self-transfer out of bed. The resident was lying on the floor on the left side of the bed. The resident had no apparent injuries but did complain of 10/10 pain to their low back and neck. The resident reported hitting their head on the floor. Neurological checks were at baseline. The resident refused to move their upper and lower extremities and an order was obtained to send the resident to emergency room for evaluation. A 4/27/2024 licensed practical nurse #27 progress note documented a fall risk evaluation was completed and the resident was at moderate risk for falls. A 4/27/2024 registered nurse #28 progress note documented the resident returned from the emergency department for a fall. The resident was alert and orientated. A 4/29/2024 Director of Nursing progress note documented the resident had a fall out of bed on 4/27/24 without injury. The resident was sent to emergency room for evaluation of pain and returned. The resident's care plans were reviewed, and it was determined it was appropriate to initiate a low bed to prevent recurrence. On 4/29/2024 the comprehensive fall care plan interventions were updated to include bed in low position. The undated care instructions ([NAME]) documented the resident's bed was to be in the lowest position. During an observation on 5/6/2024 at 7:57 AM, the resident was in bed. The bed was at hip height with two fall mats on each side of the bed. The resident was lying on their left side with their knees hanging over the edge of the bed approximately 4- 6 inches. At 8:04 AM, the resident stated they felt like they were going to fall. They were holding onto the edge of the bed. Their call bell was activated. At 8:09 AM, certified nurse aide #10 entered the resident's room, without knocking and did not introduce themselves. They positioned the resident toward the center of the bed without telling them what they were doing. They then lowered the bed to the floor and exited the room. During an observation on 5/8/2024 at 8:41 AM, the resident was lying in bed. The bed was positioned at mid-thigh height and their call bell was on the floor. During an interview on 5/8/2024 at 9:26 AM certified nurse aide #3 stated Resident #379 was not on their assignment, but they provided the resident their meal tray. They did not notice if the resident's bed was in a low position and did not observe their call bell on the floor. They thought the resident had a vision impairment and was unsure if the resident was a fall risk. During an interview on 5/8/2024 at 9:32 AM certified nurse aide #10 stated Resident #379 was on their assignment. The care instructions listed in the computer alerted staff to any safety precautions needed, such as a low bed and fall mats. They dressed the resident that morning but did not observe their call bell on the floor. Their bed was not in a low position, and they had to lower it just as they had to do on 5/6/2024. They thought the resident had a recent fall but was unsure. They did not always check to ensure the bed was in a low position. The resident liked to lie on their side close to the edge of the bed and if the bed was in the high position, it could be a safety issue. During an interview on 5/9/2024 at 4:40 PM Regional Registered Nurse #1 stated they expected staff to follow the care plans for safety reasons. If a resident had a history of falls staff should follow the fall care plan to ensure the resident was safe otherwise it posed a safety risk. Resident #379 was care planned for a low bed. The resident was visually impaired, so it was important their call bell was in reach. 2) Resident #42 had diagnoses including dementia and glaucoma (eye disease causing vision loss). The 3/29/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision or touching assistance for ambulation, used a wheelchair, and was able to wheel themself with supervision or touching assistance. The comprehensive care plan initiated 8/11/2021 and revised 4/30/2024 did not include risk for wandering or risk for victimization. The undated care instructions ([NAME]) documented the resident used a 2 wheeled walker, used a wheelchair, and required set up for wheeling in their wheelchair (resident needed no help during the activity). The instructions did not include wandering risk or use of a wander alert device. The 3/29/2024 quarterly elopement evaluation completed by the Director of Nursing documented the resident was dependent for mobility and therefore was a low risk for elopement. Resident #42 was observed at the following times: - on 5/6/2024 at 7:27 AM and at 7:35 AM, self-propelling in their wheelchair down the South unit hallway. - on 5/6/2024 at 8:34 AM in their wheelchair self-propelling into room [ROOM NUMBER]. - on 5/6/2024 at 9:23 AM in their wheelchair self-propelling into room [ROOM NUMBER]. Resident #65 was in the hallway and stated the resident had once gotten in their bed while they were sleeping. Resident #65 was yelling in the hallway that they wanted Resident #42 out of their room. At 9:29 AM, the resident self-propelled in their wheelchair back out into the hallway. - on 5/8/2024 at 11:14 AM and at 12:09 PM self-propelling in their wheelchair down the south unit hallway. During an interview on 5/9/2024 at 2:05 PM certified nurse aide #9 stated residents who wandered had a wander alert device. They stated Resident #42 had a wander alert device and this information was found on the [NAME]. They had seen the resident in Resident #65's and Resident #280's bed. The resident should not be in other residents' rooms or beds for safety reasons. They could get sick if they went into a room with precautions. The resident was also found in other resident beds on the North Unit. During an interview on 5/10/2024 at 10:10 AM licensed practical nurse #6 stated certified nurse aides would know if a resident was a wandering risk by referencing the [NAME]. If they were a wander or elopement risk, they would have a wander alert device, and this was checked and documented on the Treatment Administration Record by the licensed practical nurse. Resident #42 wandered on the unit into other residents' rooms and beds but did not leave the unit. They did not know of any wandering interventions for the resident, but they should have interventions. The resident was at risk for victimization and could get hurt either verbally, physically, or could even be mistaken for another resident in their bed and receive the wrong medications. They should be monitored for their safety and the safety of other residents. The registered nurse Unit Manager was responsible for completing the wandering and elopement assessments. During an interview on 5/10/2024 at 11:20 AM Registered Nurse Unit Manager #5 stated wandering was included in the care plan as well as behaviors or elopement. They and the Director of Nursing were responsible for updating care plans. Staff should know if a resident wandered to prevent injury. They were aware Resident #42 wandered into other resident's rooms. The resident was at risk for victimization because another resident could get upset if they were in their room. Appropriate monitoring of the resident should have been included in the care plan. During an interview on 5/10/2024 at 12:15 PM the Director of Nursing stated wandering and victimization were included on the care plan for safety to ensure that the resident's needs were met. They knew Resident #42 wandered and was at risk for victimization because they could make another resident verbally or physically upset. Registered Nurse Unit Manager #5 was responsible for updating care plans. 10 NYCRR 415.12(h)(2)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated (NY00312922) surveys conducted 5/6...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated (NY00312922) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #75) reviewed. Specifically, Resident #75 was not weighed as ordered, did not received fortified pudding, and was not assisted with meals as care planned. Findings include: The facility policy Nutrition Assessment revised 8/2020 documented the nutritional assessment would be a systematic, multidisciplinary process that included gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Once current conditions and risk factors for impaired nutrition were assessed and analyzed, individual care plans would be developed that addressed or minimized to the extent possible the resident's risks for nutritional complications. Such interventions would be developed within the context of the resident's prognosis and personal preferences. The facility policy Weight Management revised 2/2023 documented the resident's weight would be obtained within 24 hours of admission, weekly for 4 weeks, then monthly thereafter and more frequently, as clinically indicated for the resident and documented in the clinical record. The facility policy Meal Service revised 4/2022 documented staff would check the individual name and diet on the meal identification card/ ticket to verify that the meal was served to the correct person, and check items on the plate/ tray to assure accuracy for therapeutic diets or texture or consistency modifications. Resident #75 had diagnosis including unspecified severe protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy status (artificial opening to stomach for feeding tube). The 4/24/2024 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, was dependent for eating, weighed 109 pounds, had no significant weight changes in the past 30 to 180 days, received a mechanically altered diet, had a feeding tube, received 51% or more of total calories through parenteral or tube feeding, and 501 or more cubic centimeters of fluid daily by tube feeding. The resident received 150 minutes of speech-language pathology and audiology services and 180 minutes of occupational therapy during the 7-day period. The 4/18/2024 Nursing admission Evaluation signed by the Director of Nursing documented the resident weighed 109.2 pounds and had lower extremity trace edema. The 4/19/2024 physician orders documented: - The resident was to receive enteral feedings via percutaneous endoscopic gastrostomy (feeding tube) of Jevity 1.5 (tube feeding formula) at 50 milliliters starting at 5:00 PM for a total volume of 1000 milliliters. Administer 100 milliliters of water 4 times daily before and after each tube feeding administration. - weigh on Admission/readmission on ce, then weekly for 4 weeks, and then monthly. Weight must be obtained by the 7th of the month. The comprehensive care plan initiated on 4/19/2024 documented the resident required assistance with self-care and received nothing by mouth. The resident had a tube feeding due to difficulty swallowing and tube feedings and water flushes were to be administered as ordered. The resident had a nutritional problem or potential nutritional problem. Interventions included the resident received nothing by mouth and received Jevity 1.5 at 50 milliliters for 1000 milliliters total volume. The 4/19/2024 progress note by registered diet technician #13 documented the resident had a diagnosis of aspiration pneumonia (inhalation of food/fluid into the lungs), received nothing by mouth, received tube feedings of Jevity 1.5 at 50 milliliters an hour for a total of 1000 milliliters, and weighed 109.2 pounds. A Mini-Nutritional Assessment was completed, and the resident score was 5.0, which was considered malnourished. The 4/19/2024 registered dietitian #14 nutritional assessment documented the resident received nothing by mouth, weighed 109.2 pounds, their body mass index was 21.3 which was considered low, and had impaired swallowing. Their estimated daily nutritional needs were 1500-1750 calories, 50-60 grams of protein, and 1500-1750 milliliters of fluids. The resident received tube feedings of Jevity 1.5 at 50 milliliters an hour for total volume of 1000 milliliters with 50 milliliters water flushes before and after tube feeding administration. This provided 1500 calories, 49.6 grams of protein, and 1860 milliliters of water. The tube feeding met greater than 100% of the resident's daily nutritional needs and weights would continue to be monitored. The 4/19/2024 occupational therapist #19 evaluation and plan of treatment did not address the resident's eating ability. The 4/19/2024 speech language pathologist #18 therapy evaluation and plan of treatment documented the resident received nothing by mouth and the recommendation was to continue nothing by mouth and they would trial honey thick liquids and pureed solids. The 4/22/2024 speech language pathologist #18 evaluation and plan of treatment documented recommendations for puree textured solids and honey thick liquids. The 4/23/2024 physician order documented the resident was to receive a pureed texture solids and honey thick liquid diet, in addition to enteral feedings. On 4/24/2024, the comprehensive care plan was updated to include the resident was dependent on 1 person for eating. The 4/24/2024 registered diet technician #13 progress note documented the resident was seen by the speech language pathologist and was upgraded to pureed solids and honey thick liquids. On 4/26/2024 the resident's record documented they weighed 106.3 pounds, a loss of 2.9 pounds/ 2.66% in 8 days. There were no additional documented weights after 4/26/2024. The 4/30/2024 physician order documented puree texture and nectar thick liquids, in addition to enteral feedings. The 5/1/20204 registered diet technician #13 progress note documented the resident preferred only naturally pureed items on their pureed diet, the meal plan was updated to only included naturally pureed items such as applesauce, mashed potatoes, pudding, etc. The 5/1/2024 licensed practical nurse #22 progress note documented the resident complained of nausea and vomiting and wanted their tube feeding stopped. The 5/3/2024 registered dietitian #14 progress note documented the resident was refusing their tube feeding related to nausea and vomiting. Bolus (given all at once) tube feedings of Osmolite 1.5 would be provided 4 times daily at 237 milliliters for a total volume of 948 milliliters with 100 milliliter water flushes before and after tube feeding administration. The tube feeding would provide 1420 calories, 60 grams of protein, and a total of 1540 milliliters of water. Additionally, the resident received puree solids and nectar thick meal trays. The progress note did not address the resident's weight. The 5/3/2024 physician order documented enteral feedings were changed to Osmolite 1.5 (tube feeding formula) at 237 milliliters 4 times daily via gastrostomy tube. Administer 100 milliliters of water 4 times daily before and after each tube feeding administration. The undated care instructions ([NAME]) documented the resident was dependent for eating. The resident's meal intakes from 5/6/2024-5/9/2024 documented intakes ranged 0-25% for 3 meals and 2 refusals. During an observation on 5/7/2024 at 12:45 PM, certified nurse aide #10 brought the resident's lunch tray to their room then left the room. The resident's meal tray included fortified pudding, yogurt, fortified mashed potatoes, nectar thick water, and nectar thick juice. Their food was unopened, and the resident stated they would not eat their meal. At 1:21 PM, the resident's meal tray remained untouched, and they were not in their room. During an observation on 5/9/2024 at 8:44 AM, the resident was in their room with a breakfast tray. The meal ticket documented nectar thick coffee, yogurt, nectar thick juice, and fortified pudding. The resident had a white colored drink in a cup and their fortified pudding was missing. All items were unopened and there was no staff present in their room. The resident was drinking 1 carton of Boost very high calorie (oral nutritional supplement). At 9:33 AM, certified nurse aide #15 removed the resident's tray from their room. The resident had only consumed 100% of their Boost very high calorie supplement and 0% of the other items. During an interview on 5/9/2024 at 11:05 AM certified nurse aide #15 stated weights were obtained as ordered. The registered diet technician puts up a weight list and staff obtained the weights of the residents on their assignment. During an interview on 5/9/2024 at 11:58 AM registered diet technician #13 stated new admission's weights were obtained on admission, weekly for 4 weeks, then monthly if not clinically indicated to be weighed more frequently. If a resident refused to be weighed staff should document the refusal. If weights were missing, they sent an email to the Nurse Managers and the Director of Nursing to help aide with obtaining missing weights. Resident #75 weighed 109.2 pound on admission and on 4/26/2024 they weighed 106.3 pounds. There was 1 week of missing weights and the current week's weight had not yet been done. The resident received fortified foods to aide with nutritional support at mealtimes but received most of their nutritional needs from their tube feeding. The resident was care planned to receive fortified foods and they should be provided. The resident's nutritional needs had not been reassessed since admission. It was important to obtain weights as ordered to establish a baseline weight and to monitor the resident's nutritional status. During an interview on 5/9/2024 at 12:35 PM the Director of Therapy stated the nursing department assessed the resident's eating status on admission. The therapy department would make recommendations for activities of daily living, including eating status. It was important for the care plan to reflect the resident's status to provide the correct level of assistance. Resident #75 was not assessed for their eating ability on admission due to their order of nothing by mouth. Nursing staff documented they were dependent for eating related to their need for tube feedings. The therapy department did not address their eating status once the resident was started on a pureed diet, but they were followed by the speech language pathologist who recommended their current diet. It was nursing staff's responsibility to update the care plan. If the care plan indicated, they were dependent for eating that meant someone should be with the resident assisting them with their meals. During a telephone interview on 5/9/2024 at 12:46 PM registered dietitian #14 stated they worked remotely and did not come to the facility. Staff should be obtaining weights as ordered as it was important to establish a baseline weight and to monitor the resident's nutritional status. The resident currently received tube feedings and meal trays of pureed solids and nectar thick liquids. Their tube feedings were meeting their estimated needs without their meal trays so if they did not eat a meal, it was ok. The resident should be receiving all their ordered items on the meal tray. During an interview on 5/9/2024 at 1:51 PM certified nurse aide #17 stated a resident's eating status was listed in the care plan in the computer. If a resident was listed as dependent that meant staff should open their items and assist them with their meal. They stated Resident #75 did not eat well but fed themselves after set-up. The resident was on their assignment today and ate 50% of their breakfast. Staff should make sure the meal ticket matched the items on the tray. During an interview on 5/9/2024 at 1:59 PM Regional Registered Nurse #1when Resident #75 was admitted it was documented they were dependent for eating due to their need for tube feeding as they did not receive anything by mouth. The resident's current care plan documented they were dependent for eating and they now received meal trays. If staff noticed a discrepancy in the care plan, they should tell the nurse so it could be fixed for safety reasons. The care plan should be specific to the resident's needs and be accurate. Residents should be weighed as ordered and receive all items on their meal tray. If staff was unable to weigh a resident or the resident refused it should be documented. If an item was missing from a meal tray, staff should tell a nurse and the items should be obtained from the kitchen. If the care plan documented the resident was dependent for eating staff should be in the room assisting them with their meal. During an interview on 5/9/2024 at 4:52 PM the Director of Nursing stated Resident #75 was admitted with a tube feeding and received nothing by mouth. When their diet order changed to include meal trays, they should have been evaluated to determine their level of assistance for feeding. Their current care plan documented they were dependent with meals which meant staff should be assisting them. Staff should be checking the meal trays to ensure all items are on the tray and ask the kitchen to send any missing items. Staff should obtain weights as ordered and let a nurse know if the resident refused. 10NYCRR 415.12(i)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure that a resident who required dialysis received services c...

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Based on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 received hemodialysis (a treatment that filters the blood), had a physician order to remove the dialysis access site dressing 6-8 hours after dialysis and the dressing was scheduled to be removed prior to going to dialysis and was not completed. Findings include: The Entrance Conference Worksheet provided to the facility on 5/6/2024 included information needed from the facility regarding dialysis contracts, agreements, arrangements and policies and procedures. The facility responded they did not currently have any residents who received dialysis. There was no documented evidence of a hemodialysis agreement or policy and procedures. Resident #45 had diagnoses including end stage renal disease (kidney disease) and dependence on renal dialysis. The 4/16/2024 Minimum Data Set assessment documented the resident was cognitively intact and received hemodialysis. The comprehensive care plan initiated 4/11/2024 documented the resident needed hemodialysis related to end stage renal disease and nonadherence to prescribed fluid restrictions. Interventions included the resident received dialysis on Monday, Wednesday, and Friday. Monitor left arm arteriovenous fistula (tube or device surgically implanted to create an artificial connection between an artery and a vein for dialysis access) for bruit (rumbling or whooshing sound) and thrill (a rumbling or buzzing sensation) every shift; monitor/document/report signs and symptoms of infection to access site including redness, swelling, warmth, drainage, or bleeding; and check and change dressing daily at the access site if ordered by the provider. The 4/12/2024 physician orders documented: - Hemodialysis: remove arteriovenous dressing 6-8 hours post (after) dialysis on Monday, Wednesday, and Friday. - Arteriovenous fistula: monitor for bruit and thrill every shift and notify provider for absence. Monitor for bleeding, if noted, apply pressure, and notify provider. No blood pressure in left arm. - dialysis 3 times a week on Monday, Wednesday, and Friday. Pick up time at 10:00 AM for a chair time of 11:00 AM. During an observation on 5/6/2024 at 8:53 AM, Resident #45 was sitting in their room on the edge of their bed. They stated they went to dialysis Monday, Wednesday, and Friday. They stated their fistula access site was on their left upper arm, and they removed their fistula dressing themself on Sunday night. The nursing staff rarely looked at their fistula and never removed the dressing so they would remove it themselves before they returned for their next dialysis session. During an observation and interview on 5/9/2024 at 1:08 PM, Resident #45 was in their room wearing a short sleeve shirt, with a white gauze dressing fully covering their left upper arm from their armpit to their elbow. They stated nursing staff had not looked at their access site or offered to remove their dressing since they returned from dialysis late in the afternoon on 5/8/2024. They planned on removing their own dressing Friday morning before they went back to dialysis. The May 2024 Treatment Administration Record from 5/1/2024- 5/9/2024 documented the arteriovenous shunt dressing was to be removed 6-8 hours post dialysis on Monday, Wednesday, and Friday between 7:00 AM and 10:00 AM. The order was signed by licensed practical nurse #2 with a 3 (resident out of facility) on 5/8/2024 (Wednesday, the resident's scheduled dialysis time was 11:00 AM). The May 2024 Treatment Administration Record from 5/1/2024-5/9/2024 documented the resident was to be monitored every shift for complications: check for bruit, thrill, bruising, and bleeding. The order was signed as completed by licensed practical nurse #2 on 5/9/2024 for the 6:00 AM- 2:00 PM shift. During an interview on 5/9/2024 at 1:59 PM, licensed practical nurse #2 stated before Resident #45 went to dialysis, they were responsible for obtaining their vital signs and filling out their dialysis communication book. When the resident returned from dialysis, they would have a dressing covering their access site and they would monitor the site for complications and bleeding every shift. The dressing would remain on for a few hours after dialysis before the nurse would remove it. They stated the resident had not returned last evening on 4/8/2024 before they left and if the dressing was still on the following day, they would have removed it. They monitored the access site during the day shift and did not think the dressing was still in place or they would have removed it. If there was a big bulky dressing covering Resident #45's upper arm, it would make it more difficult to monitor the access site, but they thought they could still listen for bruit and thrill. They stated it was important to monitor the access site and remove the dressing as ordered so the dialysis site could be seen and monitored for bleeding, or signs of infection. During an observation on 5/9/2024 at 3:19 PM, Resident #45 was lying in bed with their eyes closed. They had a white gauze dressing fully covering their left upper arm from their armpit to their elbow. During an interview on 5/10/2024 at 10:26 AM, Regional Registered Nurse #1 stated if there was an order to remove a dialysis access site dressing, they expected it to be removed per the physician order. If the dressing was still on the following day, they expected the nurse to remove it as soon as possible. They stated there was no reason the dressing should have remained in place the following day if the nurse documented they monitored the access site as ordered. It would have made it difficult to see the site with a dressing covering it. They stated it was important to remove the dressing as ordered so the access site could be visualized and monitored for complications and signs and symptoms of infection. 10 NYCRR 415.12(K)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordan...

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Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Medication cart #2 on South unit) reviewed. Specifically, medication cart #2 on the South unit had an insulin lispro pen (short acting insulin) for Resident #25 that was not dated with an opened or expiration date; an insulin glargine pen (long acting insulin) for Resident #62 that was not dated with an opened or expiration date; and an Anoro Ellipta inhaler (used to treat chronic lung disease) for Resident #72 that was not dated with an opened or expiration date. Findings include: The facility policy Medication Storage revised 1/2019 documented medications were stored in a manner that maintained the integrity of the product, ensured the safety of residents and was in accordance with department of health guidelines. Expired medications were removed from the medication storage areas and disposed of. During an observation of the South unit medication cart #2 on 5/7/2024 at 2:25 PM with licensed practical nurse #31 there were 4 insulin pens stored in the top drawer of the cart. 2 of 4 had no date opened (Resident #25 insulin lispro pen, and Resident #62 insulin glargine pen). There was an Ellipta Anoro inhaler labeled for Resident # 72 that did not have a date opened or discard date on the inhaler. Licensed practical nurse #31 stated insulin expired 28 days after opening and the nurse that opened the medication was responsible for dating the insulin. Insulin opened/ expiration dates should be checked prior to the medication being administered. Expired insulin may not work as intended and may not control blood sugars appropriately. They stated they were not sure if inhalers required an opened or expiration date. During an interview on 5/7/2024 at 2:40 PM registered nurse Unit Manager #5 stated they performed cart audits once a month and checked for expired medications. Insulin pens needed to be dated with an opened date as they expired 28 days after being opened. Without an opened date it would be unknown if the insulin's integrity was maintained. The nurse that opened the insulin was responsible for dating it. Any nurse that administered insulin should check the date on the pen and ensure the medication was not expired prior to it being administered. If expired medications were administered, they could be less effective and could result in unintended side effects. They were not sure if inhalers needed a date opened. During a follow up interview on 5/7/2024 at 3:30 PM with registered nurse Unit Manager #5, an unnamed pharmacist reported to them that the Anoro Ellipta inhaler expired 6 weeks after being opened. 10NYCRR 415.18(d)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and appetizing for 2 of 2 test trays (5/7/2024 and 5/8/2024 lunch trays) reviewed. Specifically, on 5/7/2024 the beef stew was 114 degrees Fahrenheit and the green and yellow bean mix was 108 degrees Fahrenheit; and on 5/8/2024 the French-fried potatoes were cold and undercooked. Findings include: The facility Beef Stew recipe documented hold food for service at an internal temperature of 140 degrees Fahrenheit. The facility policy Meal Service last revised 1/2023, documented meals would be served promptly to maintain adequate temperature and appearance. During an interview on 5/6/2024 at 8:37 AM, Resident #66 stated the food was cold. During the lunch meal observation on 5/7/2024 at 12:00 PM, the temperature of the food on the meal service line was checked. The beef stew was 173 degrees Fahrenheit, yellow and green bean mix was 168 degrees Fahrenheit, vegetable soup was 180 degrees Fahrenheit, and mashed potatoes were 182.5 degrees Fahrenheit. During an observation on 5/7/2024 at 12:31 PM, the meal cart left the kitchen and was brought to the North unit. At 12:37 PM, the last meal tray was tested for taste, temperature, and appearance (the resident was provided a replacement meal tray). The beef stew was 114 degrees Fahrenheit, the yellow and green bean mix was 108 degrees Fahrenheit, the coffee was 123 degrees Fahrenheit, and the milk was 46 degrees Fahrenheit. During the lunch meal observation on 5/8/2024 at 12:29 PM, the temperature of the food on the meal service line was checked. The barbecue chicken was 165 degrees Fahrenheit, mashed potatoes were 153 degrees Fahrenheit, and the mixed vegetables were 146 degrees Fahrenheit. During an observation on 5/8/2024 at 12:51 PM, room [ROOM NUMBER]'s lunch tray was tested for taste, temperature, and appearance (the resident was provided a replacement tray). The barbecue chicken was 128 degrees Fahrenheit, the mixed vegetables were 118 degrees Fahrenheit, the milk was 54 degrees Fahrenheit, and the coffee was 132 degrees Fahrenheit. The French-fried potatoes were cold and undercooked. During an interview on 5/8/2024 at 2:03 PM the Food Service Director stated the French fries from lunch were a frozen product and baked in the oven. They stated they were checked by staff before they were served, and they were not sure why the fries were not fully cooked. They stated test trays were completed 1-2 times a week and documented. The facility did not provide documentation of test trays when requested on 5/10/2024 from the Administrator. During a follow up interview on 5/10/2024 at 11:18 AM the Food Service Director stated the appropriate serving temperatures for hot food items was 140-145 degrees Fahrenheit. The facility did not have plate warmers so that could lead to food not holding proper temperature. They stated the beef stew and bean mix were not served at proper temperatures. They made sure the food tasted good, and the [NAME] Supervisor also tasted the food prior to serving meals to ensure it was cooked completely and appealing to the residents. 10NYCRR 415.14(d)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents received and the facility provided a diet in a ...

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Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents received and the facility provided a diet in a form designed to meet individual needs for 1 of 1 resident (Resident #33) reviewed. Specifically, Resident #33 was provided food items that were not consistent with their physician ordered diet. Findings include: The facility policy Modified Food Consistency last reviewed 2/2023, documented the texture and consistency-modified diets would be individualized with modifications made by the speech/language pathologist and physician in conjunction with the registered dietitian nutritionist and Director of Food and Nutrition services. A written order was needed. Resident #33 had diagnoses including dementia, diabetes, and cervicalgia (neck pain). The 4/25/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required supervision or touching assistance with eating, did not have a swallowing disorder, and did not receive a mechanically altered diet. The comprehensive care plan initiated 4/24/2024 documented the resident had potential nutritional problems related to stroke, dementia, and diabetes. Interventions included diet and consistency as ordered, mechanical soft, thin liquids. The 5/3/2024 physician order documented a controlled carbohydrate, mechanical soft texture diet, thin (regular) consistency diet. During an observation on 5/7/2024 at 12:37 PM, the tray for Resident #33's lunch tray was selected as a test tray as it was delivered by Certified Nurse Aide #15 (a replacement tray was requested). The resident's meal ticket documented a mechanical soft diet and thin liquids. Menu items included ground beef stew, no peas, and a biscuit cut up and moistened. The tray contained cut up biscuit covered by beef stew with chunks of beef larger than one inch. The facility menu extension sheets for Week 3, Tuesday Day 17 documented the mechanical soft beef stew was to be ground with no peas. During an interview on 5/9/2024 at 11:26 AM, Certified Nurse Aide #15 stated they gave the trays to the residents, set them up, and asked if they had any questions. They stated they did not check the tray and ticket for every resident, only if someone was new to the facility. During an interview on 5/9/2024 at 4:34 PM, [NAME] Supervisor #36 stated they prepared the beef stew on 5/7/2024. The regular stew was prepared with roasted beef tips and the mechanical soft and puree was prepared with sliced roast beef, two different meat products. They stated the mechanical soft was sliced thin, then ground, and put through a food processor. They stated the described stew on Resident #33's tray was for the regular diet and had roasted chunks of beef tips. During an interview on 5/10/2024 at 11:18 AM, the Food Service Director stated the kitchen staff were responsible for checking the trays and ensuring each resident received the correct consistency. Staff were trained on correct consistencies. The modified diet order came with the resident from the hospital, the registered dietitian would put that into the system, and speech therapy would check the resident when they came into the facility. They stated it was important for residents to receive the correct consistency to prevent them from choking. During an interview on 5/10/2024 at 1:27 PM Speech Language Pathologist #18 stated residents were screened upon admission, and they made recommendations for food consistency. It was important the resident received the correct consistency because they could be at risk of complications such as aspiration (inhaling food/fluid into the lungs), weight loss, and malnutrition. 10NYCRR 415.14(d)(3)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents had a means of directly contacting staff for assistance for 1 of 1 resident (Resident #35) reviewed. Specifically, Resident #35's call bell was out of reach and not accessible. Findings include: The facility policy Call Bells revised 8/2019 documented timely response was provided to residents in need of assistance and was essential that high quality resident outcomes were ensured. When the resident was in bed staff ensured the call light was within easy reach of the resident. Resident #35 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (lung disease), heart failure, and atrial fibrillation (irregular heartbeat). The Minimum Data Set assessment dated [DATE] documented the resident had moderately impaired cognition and was dependent for toileting, bathing, transfers, and dressing. The comprehensive care plan initiated 12/30/2022 documented the resident was at risk for falls due to immobility. Interventions included call bell within resident's reach and use was encouraged for assistance as needed. The resident was observed with their call bell on the floor and out of reach: - on 5/6/2024 at 7:00 AM and 8:46 AM. - on 5/7/2024 at 9:05 AM, 12:02 PM, 12:52 PM and 1:44 PM. - on 5/8/2024 at 9:07 AM, 10:00 AM, and 11:14 AM. - on 5/9/2024 at 9:48 AM. During an interview on 5/9/2024 at 10:24 AM certified nurse aide #11 stated call bells were supposed to be in residents' reach. If the call bells were not in reach, they would not know if residents needed help, and this put them at higher risk for falls. Resident #35 was able to use their call bell and it should have been in reach. During an interview on 5/10/2024 at 9:00 AM licensed practical nurse #6 stated call bells should be in reach of the resident so their needs could be responded to, or a potential emergency could be communicated. Resident #35 was able to use their call bell and nursing staff should ensure call bells were within reach. During an interview on 5/10/2024 at 9:53 AM registered nurse Unit Manager #5 stated Resident #35 was able to use the call bell and it should have been in their reach. It was important they had their call bell in reach so their needs could be communicated, and all staff were responsible to ensure call bells were in reach. 10NYCRR 415.5(e)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 1 of 1 resident room. Specifically, there was evidence of mice in resident room [ROOM NUMBER]. Findings include: The third-party pest control vendor service reports documented resident room [ROOM NUMBER] was treated for mice and rodents on 1/17/2024, 3/6/2024, 3/13/2024, and 3/20/2024. The third-party pest control log dated 5/8/2024 did include documentation about mice or treatments for rodents in the facility. The log documented the facility was inspected and serviced. During an interview on 5/6/2024 at 8:22 AM, Resident #66 who resided in room [ROOM NUMBER] stated they had caught a mouse in their room recently but there was another they were still trying to catch. They stated they had a mouse come out of the heater the past two nights in a row. The mouse ran out of their room and into the hall. Resident #66's roommate, Resident #45, confirmed the mice sighting. During an observation and interview on 5/6/2024 at 9:12 AM, the Director of Housekeeping and Laundry opened the cover to the heater in resident room [ROOM NUMBER]. Rodent droppings and chewed candy wrappers were inside and throughout the heater. The top of the heater had an open hole through the casing material which allowed potential pests to enter and exit the unit. The Director of Housekeeping and Laundry stated that housekeeping was responsible for cleaning the outside of the units and maintenance did routine cleaning of the interior of the units every 6 months. During an observation on 5/6/2024 at 9:30 AM, the exterior of the heater to resident room [ROOM NUMBER] was observed. The exterior of the unit was angle metal slats approximately 1 inch apart. No other barrier could be seen to prevent pests from entering the heater units. During an interview on 5/20/2024 at 12:09 PM, the Administrator stated both housekeeping and maintenance were responsible for pest management. The Director of Maintenance was not available during survey. They stated when they had sightings, they were documented and relayed to their pest control vendor who would come out the same day or the next day. The Administrator stated it was important the facility was kept free of pests to prevent the spread of diseases. 10NYCRR 415.29(j)(5)
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents were treated with respect and dignity in a mann...

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Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promotes maintenance or enhancement of quality of life for 6 of 11 residents (Residents #19, #36, #59, #379, and 2 anonymous residents) reviewed. Specifically, - Activities aide #7 and licensed practical nurse #2 had a verbal confrontation in front of Resident #19 after they ran out of portable oxygen during a group activity; - Certified nurse aide #8 stood over Resident #36 while assisting them with eating; - Resident #59 exhibited continuous disruptive verbal behaviors in a common area with other residents and was not removed from the space timely as planned. Additionally, the resident was transported in their wheelchair facing backwards by certified nurse aide #9; - 2 anonymous residents stated during a group meeting that staff would tell them they could not leave their rooms because portable oxygen was not available; - Certified nurse aide #10 entered Resident #379's room, who was legally blind, without announcing themself or informing the resident of care being provided. Findings include: The facility policy Resident Rights revised 2/2020 documented all employees treated residents with kindness, respect, and dignity. Residents in the facility had a right to a dignified existence, privacy and confidentiality and equal access to quality care. The facility policy Behavior Management revised 5/2020 documented residents who exhibited behavior symptoms were taken aware to a quiet controlled space. This could be a utility room, or any area that served as a time out space and the resident was given time to calm down. 1) Resident #36 was admitted to the facility with diagnoses including dementia, Parkinson's disease (a progressive neurological disorder), and dysphagia (difficulty swallowing) The 3/30/2024 Minimum Data Set assessment dated documented the resident had severely impaired cognition, was dependent for eating, and received a mechanically altered diet. The comprehensive care plan initiated 10/23/2023 and revised 3/25/2024 documented the resident had an activities of daily living deficit related to limited mobility and was dependent on 1 for eating. During observations on 5/6/2024 at 11:33 AM and on 5/8/2024 at 8:51 AM Resident #36 was observed in their reclining chair in the hallway being fed by certified nurse aide #8 who stood while they were feeding the resident. During an interview on 5/10/2024 at 9:17 AM licensed practical nurse #6 stated staff should assist residents with meals while seated next to the resident and should not stand next to them. Staff should be at eye level with the resident so chewing and swallowing were visualized. They had seen certified nurse aides stand over Resident #36 during meals and this was not appropriate. During an interview on 5/10/2024 at 10:08 AM registered nurse Unit Manager #5 stated staff should be seated and interacting with residents while they assisted with feeding. It gave the resident a sense of comfort for staff to be at eye level during feeding. During an interview on 5/10/2024 at 10:44 AM certified nurse aide #8 stated they stood while feeding Resident #36 because it was more comfortable for them than sitting. 2) Resident #59 was admitted to the facility with diagnoses including Alzheimer's disease. The 4/30/2024 Minimum Data Set assessment dated documented the resident had severely impaired cognition, had daily behavioral symptoms not directed towards others, was dependent for most activities of daily living, and used a manual wheelchair. The comprehensive care plan initiated 8/18/2023 and revised 10/26/2023 documented the resident exhibited behavior symptoms. Interventions included determine the cause of behavior and remove the resident, distract with activities of interest, redirect negative behavior as needed, use 2 caregivers when the resident exhibited behaviors. Staff would intervene to attempt to calm the resident when they displayed escalating behaviors. Resident #59 was observed: - on 5/7/2024 during a continuous observation from 11:36 AM-12:14 PM, seated in their reclining wheelchair in the hallway outside of their room. There were other residents and families in the area. The resident continued with repetitive verbal behaviors. Certified nurse aide #9 was seated next to the resident. - on 5/7/2024 at 12:14 PM, seated in their reclining chair. Certified nurse aide #9 transported the resident from the hallway to the courtyard while the resident was facing backwards. - on 5/7/2024 during a continuous observation from 12:42 PM-1:22 PM, seated in their reclining wheelchair in the hallway outside of their room. The resident exhibited repetitive verbal behaviors with other residents and families present in close proximity. Certified nurse aide #11 was seated next to the resident. - on 5/8/2024 during a continuous observation from 10:09 AM-11:46 AM, seated in their reclining wheelchair in the hallway outside of their room, exhibiting repetitive verbal behaviors with other residents and families present in close proximity. Certified nurse aide #9 was seated next to the resident. - on 5/8/2024 at 11:46 AM, seated in their reclining chair. Certified nurse aide #9 transported the resident from the hallway to the courtyard while the resident was facing backwards. During an interview on 5/9/2024 at 1:31 PM certified nurse aide #9 stated they attempted to distract Resident #59 when behaviors were exhibited. It was common the resident yelled out in the hallway. It was not respectful the resident displayed continuous verbal behaviors in the hallway with an audience. The resident should have been moved to a quiet environment timelier. They stated they should not have transported the resident backwards because it was not dignified or respectful to the resident. They should have pushed the resident in front of them for safety reasons. During an interview on 5/10/2024 at 10:20 AM licensed practical nurse #6 stated they expected the certified nurse aides to remove residents from public areas when disruptive behaviors were displayed. Resident #59 often displayed verbal behaviors and it was disruptive to other residents and often caused other residents to escalate if they had behavioral symptoms. It was not respectful or dignified the resident was not moved from the public space timely. Residents should not be transported backwards, and it could increase the chance of a fall. During an interview on 5/10/2024 at 11:20 AM registered nurse Unit Manager #5 stated Resident #59 yelled out in the hallway frequently and should have 1 on 1 care but there was not enough staff. It was not dignified, or respectful to other residents and families who witnessed the behaviors. They were not sure if it was appropriate if the resident was transported backwards. During an interview on 5/10/2024 at 12:15 PM the Director of Nursing stated if Resident #59 was not easily calmed down they should be moved to another area. It was not dignified or respectful they were kept in the hallway while others witnessed the behaviors. Staff should push, not pull, residents in their wheelchairs for safety and dignity. 3) Resident #379 was admitted to the facility with diagnoses including legal blindness. The 5/1/2024 Minimum Data Set assessment documented the resident was cognitively intact, had severely impaired vision, required partial/ moderate assistance with eating and oral/personal hygiene, substantial/maximum assistance with toileting and bathing, and was dependent for transfers. The comprehensive care plan initiated 4/21/2023 and cancelled on 4/28/2023 documented the resident was legally blind in both eyes. Interventions included knock on the resident's door before entering and introduce yourself each time when entering their room. The comprehensive care plan initiated 4/26/2024 documented the resident had impaired visual function related to blindness. Interventions included room and personal items were arranged per resident preference and the resident was told where their items were placed. On 4/21/2023 During an observation on 5/6/2024 at 8:09 AM, certified nurse aide #10 entered the resident's room without knocking. The resident asked what their name was. Certified nurse aide #10 identified themselves and proceeded to reposition the resident in bed without explaining prior to touching and moving the resident in their bed. The bed was then lowered. Resident #379 stated they wanted to be told what was being done to them since they could not see. During an interview on 5/8/2024 at 11:46 AM licensed practical nurse #2 stated they expected staff to knock and introduce themselves before entering a resident's private space. It was especially important for Resident #379 because they had a visual impairment. It was not homelike if staff did not knock before entering a resident's room. During an interview on 5/9/2024 at 1:59 PM Corporate registered nurse #1 stated they expected staff to knock and introduce themselves before entering a resident's room. Residents should know who entered their room. 10NYCRR 415.(a)
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00340114) survey...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00340114) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 (North and South units) resident units and the main dining room. Specifically, on the North unit resident rooms [ROOM NUMBERS] had used incontinence briefs on the floor and nightstand; resident 209 smelled of urine; resident room [ROOM NUMBER]'s door handle was broken; and resident rooms [ROOM NUMBER] had sliding glass door restrictors that were not maintained. On the South unit resident rooms [ROOM NUMBERS] light fixtures were missing covers, had open light sockets, and exposed wiring; and there was a broken table in the main dining room. Additionally, residents received cold beverages in disposable cups at meals. Findings include: The facility policy Resident Rights revised 2/2020 documented the residents had a right to a dignified existence. The facility policy Elopement-Prevention revised 3/13/2024 documented the physical plant should be secured to minimize the risk of elopement and may include but was not limited to the following: functional alarm system or magnetic locks with egress alarms for egress and stairwells, interior courtyards, safety locks or key-pad entry that restrict access to dangerous areas, securement and/or monitoring of the main entrance or lobby, and restricted window openings. Resident Rooms The following observations were made on the North unit: - on 5/6/2024 from 7:04 AM-9:52 AM, a used brief was laying on the floor next to an occupied bed in resident room [ROOM NUMBER]. - on 5/7/2024 at 8:32 AM, resident room [ROOM NUMBER] smelled of urine. - on 5/8/2024 at 12:14 PM, resident room [ROOM NUMBER]'s door handle had sharp metal edges and the door would not open. - on 5/9/2024 at 7:57 AM, a used brief was on the bedside table of room [ROOM NUMBER]. During an interview on 5/10/2024 at 9:02 AM certified nurse aide #15 stated after staff changed a resident's brief it should be placed in a bag and brought to the soiled utility room. Used briefs should not be left on the floor or on bed side tables. It was not dignified or homelike and could lead to odors in the room. Any staff that observed used briefs left in the room should remove them. During an interview on 5/10/2024 at 9:10 AM licensed practical nurse #27 stated used briefs should be removed from the resident's room after care was provided. It was not dignified or homelike for used briefs to be left in a room. During an interview on 5/10/2024 at 10:17 AM Regional Registered Nurse #1 stated they expected staff to remove used briefs from resident rooms once care was provided. It was not dignified or homelike for the residents to have used briefs in their rooms. The following observations were made on the South unit: - on 5/7/2024 at 10:47 AM, resident room [ROOM NUMBER]'s light over the sink was missing the cover and the light did not turn on. - on 5/7/2024 at 10:50 AM, resident room [ROOM NUMBER]'s dome light over the sink and closet area were missing the covers, the lights did not work, and there were open sockets hanging by the wires a few inches below the light. - on 5/8/2024 at 12:10 PM, resident room [ROOM NUMBER]'s door handle to the sliding door was broken and the door would not open. - on 5/9/2024 at 12:20 PM, resident room [ROOM NUMBER] had tape on the window and sliding door. During an interview on 5/7/2024 at 10:47 AM Regional Director of Housekeeping and Laundry Services #23 stated lights should be covered and not exposed. During an interview on 5/9/2024 at 11:54 AM housekeeper #43 stated if they noticed broken equipment in a resident room or throughout the facility they would alert another staff member, but they would not fill out a work order form. They had not noticed any broken light fixtures or issues with door handles. During an interview on 5/10/2024 at 11:09 AM Regional Director of Housekeeping and Laundry Services #23 stated the tape on the window and sliding door in resident room [ROOM NUMBER] prevented a draft from the glass panels. A resident could not open the window if it was taped and would need staff assistance. The tape had been got 1-2 years. There was no documentation regarding the tape on the window and sliding glass door. Sliding Door Restrictors During an observation on 5/8/2024 at 11:51 AM, resident room [ROOM NUMBER] was equipped with a sliding glass door to the outside that functioned as the room's operable window. The door was tested by the Director of Housekeeping and Laundry and opened about 9 inches wide. They stated the door was equipped with a stopper which was intended to restrict the door opening to at most 6 inches, but the stopper had been moved. During an observation on 5/8/2024 at 11:53 AM, resident room [ROOM NUMBER]'s sliding glass door to the outside was tested by the Director of Housekeeping and Laundry and opened about 10 inches wide. The surveyor was able to fit their head and shoulders through the opening. The stopper was visibly moved beyond where the original hole was drilled in the window tract which was intended to restrict the width of the opening. During an observation on 5/8/2024 at 12:16 PM, the sliding door in room [ROOM NUMBER] was opened 12 inches and led to the yard that surrounded the facility. The surveyor could easily fit their head and shoulders through the door opening. During an observation on 5/8/2024 at 12:20 PM, the Regional Director of Housekeeping and Laundry moved the sliding glass door restrictor in room [ROOM NUMBER] and the door opened 6 inches. During an interview on 5/9/2024 at 1:53 PM, certified nurse aide #3 stated the staff opened the sliding glass doors in the resident rooms upon request because it was hard for the residents to open them. The lock was on the handle and each door had a restrictor on them, so they did not open all the way. They stated they had not heard or seen any resident's fit through the door opening and they thought they were only supposed to open a few inches. If the door opened too far, they would notify the nurse or the Administrator because a resident could get out without staff knowing. During an interview on 5/9/2024 at 2:11 PM, licensed practical nurse #2 stated the residents' sliding glass doors had restrictors so they would only open to a certain point. If a door opened further than the rest, they would shut the door and notify the Administrator or maintenance immediately so the resident could not get out or allow another person to get in the room. During an interview on 5/10/2024 at 12:09 PM, the Director of Housekeeping and Laundry, the Regional Director of Housekeeping and Laundry, the Regional Administrator, and the Administrator were present. The Director of Housekeeping and Laundry stated the sliding glass door to the outside was the window in the resident's rooms and those doors were supposed to be restricted to open no more than six inches. They stated the windows were supposed to be checked by the Director of Maintenance, who was unavailable during survey. The inspections were monthly and should have been documented. The Regional Administrator stated they were unable to find any documentation. The Director of Housekeeping and Laundry stated it was important to maintain the sliding doors at the appropriate width to prevent the residents from eloping. Dining The following observations were made during mealtimes: - on 5/6/2024 at 9:37 AM the North unit meal trays had cold beverages in plastic disposable cups. - on 5/8/24 at 12:51 PM the North unit had cold apple raspberry juice in plastic disposable cups. During an interview on 5/10/2024 at 10:56 AM the Food Service Director stated food and drinks should not be served using disposable dishes. Disposable dishes should only be used in an emergency. It was not homelike to receive food and drinks in disposable dishes and cups. This is something staff had been doing since they started a couple of months ago and the kitchen was short staffed. Broken Table During an observation on 5/6/2024 at 7:56 AM, there was 1 severely broken table in the corner of the main dining room by the fish tank. During an interview on 5/6/2024 at 7:56 AM the Director of Housekeeping stated staff did not remove the table after it was broken and pushed it into the corner of the dining room. During an observation on 5/9/2024 at 4:31 PM there was 1 severely broken table located in the corner of the main dining room by the fish tank. During an interview on 5/10/2024 at 12:09 PM the Administrator, the Director of Housekeeping, and Regional Director of Housekeeping and Laundry Services #23 stated if staff observed any broken items in resident rooms or throughout the facility a work order should be filled out. It was important to maintain a safe and clean environment to promote resident safety. 10 NYCRR 415.29(j)(1)
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00212922, NY00310702, and NY003...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00212922, NY00310702, and NY00310431) surveys conducted 5/6/2024-5/10/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 10 residents (Resident #1, #12, #35, and #37) reviewed. Specifically, Resident #1 was not assisted with dressing; Resident #12 was not assisted with bathing; Resident #35 was not assisted out of bed or supervised with meals; Resident #37 had unclean and untrimmed fingernails. Findings include: The facility policy Activities of Daily Living Care and Support revised 3/13/2024 documented residents received activities of daily living care and support in accordance with current standards of practice based on the resident's assessed needs, personal preferences, and goals of care. Care and support were provided to residents who were unable to carry out activities of daily living independently and included hygiene (bathing, dressing, grooming, and oral care), mobility, toileting, transfers, dining, and communication. The resident's bath or shower was scheduled per resident preference and was completed at a minimum of weekly. Nail care was provided as needed. The amount of assistance provided to the resident was documented in the clinical record. 1) Resident #1 was admitted to the facility with diagnoses including dementia, major depressive disorder, and glaucoma (progressive loss of vision). The 3/1/2024 Minimum Data Set assessment dated documented the resident had severely impaired cognition, required supervision for upper body dressing, and partial/ moderate assistance for lower body dressing, and did not reject care. The comprehensive care plan initiated on 10/26/2021 and revised 10/6/2023 documented the resident had an activity of daily living deficit related to dementia. Interventions included supervision, verbal cues or touching assistance of 1 for upper body dressing, and partial assistance of 1 for lower body dressing. The undated care instructions ([NAME]) documented the resident received a shower/ bath on Tuesday and Friday on the day shift, received morning and evening personal hygiene care, and required assistance for dressing. Resident #1 was observed at the following times: - on 5/7/2024 at 12:19 PM sleeping in bed wearing a black nightgown with pink flowers; at 12:54 PM sitting up on the side of the bed wearing a black nightgown with pink flowers; and at 2:35 PM sleeping in bed wearing a black nightgown with pink flowers. - on 5/8/2024 at 8:55 AM sleeping in bed wearing a black nightgown with pink flowers; at 10:01 AM in the hallway asking for water wearing a black nightgown with pink flowers; at 12:02 PM sleeping in bed wearing a black nightgown with pink flowers; at 1:19 PM sitting on the side of the bed eating lunch wearing a black nightgown with pink flowers; and at 2:43 PM sleeping in bed wearing a black nightgown with pink flowers. - on 5/9/2024 at 9:11 AM sleeping in bed wearing a black nightgown with pink flowers; and at 9:24 AM walking out into the hallway asking for water wearing a black nightgown with pink flowers. The May 2024 certified nurse aide documentation for Resident #1 included: - on 5/7/2024 a bath was provided by certified nurse aide #11 at 10:00 AM. - on 5/7/2024 care was provided per [NAME] by certified nurse aide #11 at 10:00 AM and at 8:19 PM. - on 5/8/2024 care was provided per [NAME] by certified nurse aide #20 at 1:59 PM and by certified nurse aide #21 at 5:41 PM. - On 5/9/2024 care was provided per [NAME] by certified nurse aide #20 at 11:59 AM and by certified nurse aide #9 at 3:08 PM. During an interview on 5/9/2024 at 12:43 PM certified nurse aide #11stated they gave Resident #1 a bath on 5/7/2024. They always took the resident to the shower room, and they assisted with bathing the entire body and then placed on a black nightgown with pink flowers. The resident was supposed to receive new clothing every morning or when soiled. This was charted electronically in the certified nurse aide documentation. The resident required assistance with bathing and dressing because they had poor vision. They stated certified nurse aide #20 was assigned Resident #1 today, but the resident was wearing the same nightgown they assisted with putting on after the shower a couple of days ago. During an interview on 5/9/2024 at 1:18 PM certified nurse aide #20 stated they were expected to follow the [NAME] and document tasks if they were completed. If a resident refused, it was documented as a refusal. They stated the residents only got clean clothing on shower days, but they should get clean clothing every day. They were assigned Resident #1 but had not been in their room at all today because they were too busy. They were also assigned the resident yesterday and did not assist them with dressing. During an interview on 5/10/2024 at 10:10 AM licensed practical nurse #6 stated residents got clean clothes twice daily, once in the morning and once at night, or more if soiled. This was important for good hygiene and residents should get the care they needed and should feel clean. They expected all residents to be clean and dressed daily. During an interview on 5/10/2024 at 11:20 AM registered nurse Unit Manager #5 stated certified nurse aides were expected to change residents clothing daily and if it was documented, it meant it was completed. It was not appropriate for Resident #1 to be in the same nightgown for 3 days. It was not proper hygiene and put the resident at risk for infection. 2) Resident #12 had diagnoses including major depressive disorder, anxiety disorder, and chronic obstructive pulmonary disease (restrictive lung disease). The 4/28/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial/ maximum assistance with bathing, and did not reject care. The comprehensive care plan initiated on 4/23/2024 documented the resident preferred a sponge bath. Interventions included assistance with daily routine as needed. The resident required assistance with self-care related to impaired balance and limited mobility. Interventions included shower/ bath on Tuesday and Friday evening shift. The undated care instructions ([NAME]) documented the resident required substantial/ maximum assistance of 1 for bathing and the helper completed more than half of the activity. The May 2024 certified nurse aide documentation included a shower/ bath was completed by certified nurse aide #3 at the following times: - On 4/23/2024 at 9:06 PM - On 4/26/2024 at 9:59 PM - On 4/30/2024 at 8:28 PM - On 5/3/2024 at 9:20 PM. During an interview on 5/6/2024 at 11:20 AM Resident #12 they stated they had been at the facility for 3 weeks and had not been offered or received a shower until today. Certified nurse aide #3 had told them they could have a shower tomorrow. The May 2024 certified nurse aide documentation included a shower/ bath was completed by certified nurse aide #3 on 5/7/2024 at 9:02 PM. During a follow up observation and interview on 5/9/2024 at 11:47 AM, certified nurse aide #3 exited the resident's room with a bag of dirty linens. Resident #12 was lying in their bed wearing a clean hospital gown and stated they just got cleaned up in bed by the certified nurse aide. They stated they asked when their next shower day was, and the certified nurse aide stated they would let them know. They would like to get their showers in the morning and now that they received their first shower a couple of days ago (5/7/2024), they wanted to receive them regularly as they felt much better afterwards. During an interview on 5/9/2024 at 1:46 PM certified nurse aide #3 stated the [NAME] provided the level of assistance needed and listed shower days. They had given Resident #12 a shower on 5/7/2024 and it was their first shower since admission. They did not think the resident had been there that long. The resident did not refuse care. They thought they had given bed baths on the other documented days, and they did not always have time to give showers as planned. Showers were important for hygiene and dignity. During an interview on 5/9/2024 at 2:21 PM licensed practical nurse #2 stated certified nurse aides were expected to reference the [NAME] for shower days and showers should be given as scheduled. They were not notified of any refusals by the resident. It was dignified to receive showers and the residents felt better and deserved good hygiene. During an interview on 5/10/2024 at 10:26 AM registered nurse #1 stated the [NAME] was where information regarding shower days was located. They stated showers should always be offered and if a resident refused a bed bath should be offered. It was not acceptable the resident had been offered one shower since admission as residents were scheduled for showers twice a week. All residents deserved showers for proper hygiene. 3) Resident #35 had diagnoses including protein-calorie malnutrition, major depressive disorder, and normal pressure hydrocephalus (a brain disorder). The 3/1/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision with eating, was dependent with toileting, dressing, bathing, and transfers, and did not reject care. The comprehensive care plan initiated 12/30/2022 and revised 11/29/2023 documented the resident required assistance of 2 with a mechanical lift for transfers, and required supervision, verbal cues or touching assistance of 1 for eating. The May 2024 Documentation Survey Report for activities of daily living documented care was provided per the [NAME] on all shifts from 5/6/2024-5/9/2024. Resident #35 was observed at the following times: - on 5/6/2024 at 7:00 AM and at 8:46 AM lying in bed in a hospital gown - on 5/7/2024 at 9:05 AM sitting up in bed eating breakfast in a hospital gown, no staff was present in the room supervising the resident. - on 5/7/2024 at 12:02 PM lying in bed in a hospital gown. - on 5/7/2024 at 12:52 PM, sitting up in bed in a hospital gown eating lunch, no staff was present in the room to supervise the resident's lunch meal. - on 5/8/2024 at 8:51 AM sitting up in bed in a hospital gown with their breakfast on the overbed table, there was no staff present in the room to supervise the resident's meal. - On 5/8/2024 at 9:07 AM sitting up in bed in a hospital gown with breakfast tray untouched. At 9:12 AM, an unidentified certified nurse aide walked into the room and asked why they were not eating and then exited the room without providing assistance. The 5/8/2024 at 8:28 AM percentage of meals eaten documented the resident consumed 51-75% of the morning meal and 166-239 cubic centimeters of fluid. There were no documented staff name to accompany the percentages. During an interview on 5/9/2024 at 10:24 AM certified nurse aide #11 stated the level of care residents required was in the care plan. They were responsible for getting residents out of bed daily. They stated Resident #35 required supervision and verbal cues with meals and they should not have eaten alone in their room. They were not sure if they had offered to get the resident out of bed, but all residents should be offered to get up every day. During an interview on 5/10/2024 at 9:00AM licensed practical nurse #6 stated the level of care assistance residents needed was located on the care plan and included transfers, meals, and personal care. Resident #35 required supervision with meals and should not have been left alone. If the resident did not eat, the certified nurse aides should provide encouragement. The resident had eaten alone in their room this week and should not have. It was their responsibility to ensure the certified nurse aides completed the tasks as outlined in the care plan. They expected residents to get up and out of bed daily and if they refused, they should be notified, and the resident should be reapproached. During an interview on 5/10/2024 at 9:53 AM registered nurse Unit Manager #5 stated it was important that residents got out of bed to prevent pneumonia, bed sores, and it provided socialization. They stated one of the certified nurse aides informed them on 5/8/2024 that Resident #35 refused to get out of bed and the resident was not reapproached by them but should have been. The resident was also supposed to be supervised for meals and it was not appropriate they ate in their room alone. The resident needed varying levels of assistance with eating. During an interview on 5/10/2024 at 10:32 AM certified nurse aide #8 stated it was important for residents to get out of bed as it prevented decline. Resident #35 sometimes refused to get out of bed, and they would tell the nurse. They stated some days the resident could feed themselves and other days they could not. Because the resident required supervision with meals, they should not have been left alone in their room. 10NYCRR 415.12(a)(3)
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00312922) surveys conducted 5/6...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00312922) surveys conducted 5/6/2024-5/10/2024 the facility did not ensure each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests and plans of care for 2 of 2 nursing units (North unit and South unit) observed. Specifically, resident meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes. Findings include: The facility policy Meal Service revised 4/2022 documented meals would be delivered promptly to assure quality. During an interview on 5/6/2024 at 8:30 AM Resident #19 stated sometimes the meals came late due to the kitchen being short staffed. The facility's posted schedule documented the following mealtimes: Breakfast: -North Unit 8 AM. -South Unit 8:15 AM. -Dining room [ROOM NUMBER]:35 AM and 8:45 AM. Lunch: -Dining room [ROOM NUMBER]:15 PM and 12:25 PM. -North Unit 12:35 PM. -South Unit 12:45 PM. The following observations were made on the North Unit: - on 5/6/24 at 9:25 AM, the 1st breakfast cart arrived on the unit, and at 9:37 AM, the second breakfast cart arrived on the unit. - on 5/8/24 at 8:51 AM, the 1st breakfast cart arrived on the unit and the 2nd breakfast cart arrived on the unit at 9:08 AM. - on 5/9/24 at 8:21 AM, the 1st breakfast cart arrived on the unit and at 8:57 AM, the 2nd breakfast cart arrived on the unit. - on 5/10/2024 at 8:57 AM, the 1st breakfast cart arrived on the unit and at 9:24 AM the 2nd breakfast cart arrived on the unit. The following observations were made on the South Unit: - on 5/6/24 at 8:49 AM, the breakfast cart arrived on the unit. - on 5/8/2024 at 8:43 AM, the breakfast cart arrived on the unit. During an interview on 5/8/2024 at 11:46 AM licensed practical nurse #2 stated the breakfast meal trays should be delivered to the North Unit at 8:30 AM and the lunch meal trays should be delivered to the North Unit 12:15 PM-12:30 PM. The meals sometimes did not come on time as the kitchen was short staffed. The nursing units were not made aware if the meals were going to be late. During an interview on 5/8/2024 at 12:28 PM registered diet technician #13 stated 9:25 AM was late to be served breakfast as the meal was scheduled to come to the unit at 8:00 AM. Meals should be served as close as possible to the scheduled times. During an interview on 5/9/2024 at 12:46 PM registered dietitian #14 stated they worked remotely and did not come into the facility. They did not provide any oversight to the foodservice staff and meals should be served per the facility's schedule. During an interview on 5/10/2024 at 10:56 AM the Food Service Director stated the meal schedule indicated the 1st cart was to arrive to the North Unit at 8:00 AM. The kitchen had staffing issues and they were told it was ok if the North Unit was not served until 8:30 AM. They had just started at this facility a couple of months ago and had not been able to observe what time the meal carts were leaving the kitchen as they were short staffed. It was difficult to get the meals out on time if staff called in since they were already short staffed. Staff should be following the posted mealtime schedule. 10 NYCRR 415.14(f)(3)(4)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in acc...

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Based on observation, record review, and interview during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler floor and door, walk-in freezer door, hood filters, the wall beside the coffee station, and the ceiling were in disrepair and there were several unclean surfaces present throughout the kitchen. Findings include: The Food Service Department policy Cleaning Policy last reviewed 1/2023 documented the nutrition and food service staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. There was no documented evidence of a kitchen cleaning schedule. During an initial main kitchen tour on 5/6/2024 the following was observed: - at 6:11 AM, one filter was out of place at the right end of the hood above the flat top stove. - at 6:20 AM, the door to the walk-in freezer would not shut completely and there was notable frost inside the door. The door was broken and separated at the bottom where it hit the floor of the walk-in cooler. There was significant food debris and a small puddle of liquid on the floor on the inside of the walk-in freezer. - at 6:22 AM, the walk-in cooler floor tiles were cracked and shattered, most of the floor was covered by black rubber mats but moved freely and was loose from the broken tiles beneath the mats. There were large brown spills (mostly dried but still slightly tacky) under the back right rack. The broom and dustpan were in the middle of the cooler perched over a puddle of liquid. The door to the walk-in cooler was ajar and would not close completely. - at 6:37 AM, there was water dripping through a light fixture by the hand wash sink. There was a water leak between the tray line and the upright double door cooler coming through a light fixture. Both of those lights were not working. Both leaks were over the aisles on either end of the tray line service area. Staff walked through the puddles to get to the tray line and cook areas. During an additional tour of the kitchen on 5/7/2024 the following was observed: - at 11:37 AM, there was a hood filter at the end above the flat top that was out of place and two filters on the opposite side were broken. - at 11:39 AM, there were some loose canned goods and food debris under the shelving unit and between the equipment on the cookline. - at 11:41 AM, there were heavy coffee stains dried onto the table below the coffee machine. - at 11:43 AM, there were unfinished drywall patched areas of wall penetrations to the left of the coffee area, they were not smooth and easily cleanable. The wall behind the coffee station was soiled by brown dried on water marks that ran from the shelf to the floor. - at 11:51 AM, the walk-in cooler floor was in disrepair with numerous broken, cracked tiles, and the floor moved under foot as staff stepped across the parts that were covered by black rubber mats. The walk-in freezer floor was soiled by puddles of unknown liquid and there was food debris under the shelving. The walk-in cooler door hit the latching mechanism at the top of the door which prevented it from closing completely. The walk-in freezer door was falling apart and was unable to be closed completely. The door was split at the bottom and separated when it hit the floor of the walk-in cooler as it was opened. During an observation on 5/08/24 at 12:26 PM, there was water dripping through a light fixture by the hand wash sink. There was a water leak between the tray line and the upright double door cooler coming through a light fixture. Both of those lights were not working. Both leaks were over the aisles on either end of the tray line service area. Staff walked through the puddles to get to the tray line and cook areas. During an interview on 5/09/2024 at 4:34 PM, [NAME] Supervisor #36 stated when something was broken, or required maintenance they would verbally report that to the Food Service Director and then to the maintenance staff. They stated the walk-in cooler floor had been shattered for a couple of months which the Maintenance Director was supposed to replace. The ceiling had been leaking for at least a year and was a problem since last winter. The walk-in freezer door was scheduled to be fixed or replaced and had been broken for the last couple of months. They were not sure if there was documentation for any of the repairs that were needed in the kitchen. The kitchen was supposed to be cleaned every day, and they did not document the cleaning anywhere. During an interview on 5/10/2024 at 11:18 AM, the Food Service Director stated the walk-in cooler floor, walk-in freezer door, and ceiling leaks had been like that since they started a few months ago. They were told they were in the process for getting them fixed or replaced. They stated they had some documented emails regarding some of the repairs. They stated they were not aware of the hood filter that was out of place, or the two that were broken. It was not a safe sanitary environment with the broken equipment and leaks in the kitchen. The kitchen was supposed to be cleaned every day and that was not documented. They stated it was important for the kitchen equipment to be properly maintained and cleaned to prevent the spread of germs, cross contamination, and food borne illness. During an interview on 5/10/2024 at 5:30 PM, the Administrator stated they did not have any documentation for the repairs that were planned and needed in the kitchen. NYCRR10 415.14(h)
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00310431) surveys conducted 5/6/2024-5/10/2024, the facility did not establish and maint...

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Based on observation, record review, and interview during the recertification and abbreviated (NY00312922 and NY00310431) surveys conducted 5/6/2024-5/10/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 10 residents (Residents #36 and #45) reviewed and the facility lacked a water management plan to reduce the risk of growth and spread of Legionella (a bacteria found in water systems). Specifically, staff was observed not wearing the required personal protective equipment in Resident #45's room who was on transmission-based precautions; and Resident #36 had extended-spectrum beta-lactamase (enzyme resistant to most antibiotics) in their urine with an indwelling medical device and enhanced barrier precautions were not properly maintained. Additionally, the facility did not have a water management plan that detailed their policy and procedures for reducing the risk of growth and spread of Legionella and other opportunistic pathogens. Findings include: The facility policy Enhanced Barrier Precautions reviewed 5/18/2023 documented staff was required to wear a gown and gloves while high-contact care activities were performed. Face protection might be needed if they were performing activities with a risk for splashing or spraying. Enhanced barrier precautions would be initiated for residents with any of the following: infection or colonization with a multi-drug resistant organism, indwelling medical devices including but not limited to, urinary catheters, feeding tubes, central lines, and wounds. High-contact resident activities included bathing/showering in a resident room or shared/common shower room, transfers, hygiene, dressing, changing bed linens, changing briefs, assisting with toileting, care of an indwelling medical device, and wound care. Hand hygiene was performed before and after resident contact and after removing gown and gloves within the resident's room. Initiation or discontinuation of enhanced barrier precautions did not require a physician order but would be initiated or discontinued by the infection preventionist or designee. An enhanced barrier precautions sign was placed outside the resident's room to indicate precautions were in place and personal protective equipment would be readily available near the entrance to the resident's room. The facility policy Transmission-Based Precautions revised 4/25/2024 documented transmission-based precautions was a second tier of infection control which was implemented in addition to standard precautions based upon modes of transportation (contact, droplet, airborne). Droplet precautions referred to actions designated to reduce the spread of pathogens through close respiratory or mucous membrane contact with respiratory secretions. Upon entering the room of a resident on droplet precautions, healthcare personnel and visitors would put on a face mask. Additional personal protective equipment was recommended based on anticipated risks of exposure. Hand hygiene was performed before and after resident contact and after removing personal protective equipment within the resident's room. Single resident equipment would be used if possible and shared resident equipment would be cleaned and disinfected between each resident. Transmission based precautions would be initiated or discontinued by the infection preventionist or designee. Signage was placed outside the resident's room and would provide instruction to the type of precautions implemented with guidance to healthcare personnel and visitors (hand hygiene, gown, gloves, mask, or eye protection). Personal protective equipment would be readily available near the entrance to the resident's room. 1) Resident #45 had diagnoses including pneumonia (infection in the lungs), sepsis due to methicillin susceptible staphylococcus, and end stage renal disease (kidney disease). The 4/16/2024 Minimum Data Set assessment documented the resident was cognitively intact, had intravenous access (thin tube inserted into a vein), was on intravenous antibiotics, required partial/moderate assistance with toileting hygiene, shower/bathing self, and supervision/touching assistance with personal hygiene, oral hygiene, upper body dressing, and transfers. The comprehensive care plan initiated 4/11/2024 documented Resident #45 had suspected/actual infection- pneumonia in bilateral lungs. Interventions included administer antimicrobials (medications used to treat infections) as ordered, monitor for symptoms/sepsis, applicable personal protective equipment was to be worn by staff, providers, and visitors, and maintain proper infection control precautions. The comprehensive care plan imitated on 4/11/2024 documented Resident #4 had a central line catheter. Interventions included change dressing weekly, explain purpose of intravenous therapy including infusion pump, and to monitor every shift for abnormalities. Physician orders documented: - on 4/23/2024- change central line dressing every 7 days. - on 5/1/2024- Cefazolin (antibiotic) solution 1 gram intravenously once a day for pneumonia until 5/11/2024. The orders did not include transmission-based precautions. During an observation and interview on 5/6/2024 8:53 AM, Resident #45 was seated on the edge of their bed, in their room. They stated they were admitted to the facility after being hospitalized for pneumonia and continued to get antibiotics once a day through the central line catheter on the right side of their neck. No transmission-based precaution sign or personal protective equipment was observed outside of their room. During an observation on 5/7/2024 at 9:16 AM, Resident #45's room had a green droplet precaution sign and a 3-drawer plastic container filled with gloves, gowns, eye protection, and facemasks outside of their room. The green sign had pictures of gloves, yellow gown, eye protection goggles, and a facemask. Instructions included: clean hands before entering and leaving the room, make sure eyes and mouth were fully covered before entry, remove face protection before exiting. During an observation on 5/7/2024 at 12:44 PM, a green droplet precaution sign was on the wall outside Resident #45's room. Certified nurse aide #3 entered the room carrying the resident's lunch tray. They did not perform hand hygiene, their blue facemask was below their nose, and they did not put on any additional personal protective equipment. Certified nurse aide #3 exited the room without performing hang hygiene, their mask was below their nose, and they walked to the meal cart and picked up another resident's lunch tray. During an observation on 5/7/2024 at 1:12 PM, a green droplet precaution sign was on the wall outside Resident #45's room. Licensed practical nurse #32 entered the room wearing a blue facemask and pushing a portable vital sign machine. They did not perform hand hygiene or put on any additional personal protective equipment. They obtained vital signs from Resident #45, walked over to Resident #66, and obtained vital signs without cleaning or sanitizing the machine. At 1:16 PM licensed practical nurse #32 exited Resident #45's room wearing the same blue facemask and did not perform hand hygiene. They left the vitals machine outside the door and did not disinfect it. During an observation on 5/8/2024 at 11:15 AM, a green droplet precaution sign was on the wall outside Resident #45's room. licensed practical nurse #2 entered the room wearing a blue facemask, did not perform hand hygiene, and did not put on any additional personal protective equipment. At 11:19 AM licensed practical nurse #2 exited the room wearing the same blue facemask and performed hand hygiene using the wall dispenser. During an observation on 5/9/2024 at 1:06 PM, Resident #45 did not have a droplet precaution sign or personal protective equipment outside of their room. During an interview on 5/9/2024 at 1:56 PM, certified nurse aide #3 stated they received training upon hire and yearly on infection control which included transmission-based precautions. They would know what residents were on transmission-based precautions from their morning report. There should be bins with personal protective equipment, and signs outside the resident's room telling them that what type of precautions they were on. The signs were specific and told the staff what personal protective equipment was needed to enter a resident's room. They were unsure what the difference was between enhanced barrier precautions and droplet precautions. They were unsure if they should change their facemask when they went in and out of Resident #45's room. They stated they should read the sign before they entered the room. They stated it was important to wear their mask correctly covering their nose and mouth and to wear the appropriate personal protective equipment into Resident #45's room to prevent the spread of infection. During an interview on 5/9/2024 at 2:06 PM, licensed practical nurse #2 stated they would know a resident was on transmission-based precautions by the signage on their door and they would be told in morning report. They were unsure who was responsible for placing the transmission-based precautions signage on resident's doors. They stated it was important to wear appropriate personal protective equipment into resident rooms to prevent the spread of infection. Resident #45 was not supposed to be on droplet precautions, and they were unsure who hung or removed the droplet precaution sign from Resident #45's room. They stated they received training on infection control and transmission-based precautions, but they were unsure what the difference was for contact, droplet, or enhanced barrier precautions. They would read the instructions on the signage outside the room and wear the appropriate personal protective equipment. During an interview on 5/10/2024 at 10:38 AM, regional registered nurse #1 stated the infection prevention nurse was not available and they were covering for them. There were multiple layers of staff involved in infection control so all residents should have the appropriate signage on their rooms. Annual infection control education was provided to staff and all staff were reeducated when there was any kind of outbreak within the facility. Any resident with an open wound, device, catheter, peg tube, multidrug-resistant bacteria, or intravenous catheter should be on enhanced barrier precautions. Resident #45 had a dialysis access site and an intravenous catheter, so they be on enhanced barrier precautions. They stated if staff saw a droplet precaution sign or any transmission-based precaution on a resident's door they expected staff to wear the appropriate personal protective equipment. Once the type of transmission-based precaution was verified a physician order would be put in the electronic medical record and the residents care plan would be updated. They stated all staff should stop and read the signage before entering a resident room. The signs were specific and indicated what personal protective equipment was needed to enter the room. 2) Resident #36 had diagnoses including sepsis (system wide infection) and extended-spectrum beta- lactamase resistance (a resistant enzyme found in some strains of bacteria). The 3/30/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for activities of daily living, had an indwelling catheter, and a multidrug-resistant bacteria. The comprehensive care plan initiated 10/19/2023 documented the resident was at risk for infection related to a history of urinary tract infections, urosepsis, and multidrug-resistant bacteria. Interventions included enhanced barrier precautions and applicable personal protective equipment was to be worn by staff, providers, family, and visitors. The 3/25/2024 physician orders documented contact precautions for extended-spectrum beta-lactamases in the urine. Enhanced barrier precautions every shift. During an observation on 5/6/2024 at 7:47 AM, Resident #36 had an enhanced barrier precaution sign on their door. Certified nurse aide #37 entered Resident #36's room without performing hand hygiene or putting on a gown. At 7:55 AM certified nurse aide #37 exited the room without a gown on and their facemask was below their nose, only covering their mouth. During an observation on 5/8/2024 at 12:06 PM, Resident #36 had an enhanced barrier precaution sign on their door. Certified nurse aide #37 and 2 unidentified certified nurse aides brought Resident #36 into their room for incontinence care, and they did not put on gowns. At 12:15 PM they exited the room with Resident #36, and they did not have gowns on. During an interview on 5/9/2024 at 10:43 AM, certified nurse aide #37 stated they were unsure if Resident #36 was on precautions. They stated they did not wear a gown while they provided care and it was not communicated to them that Resident #36 was on precautions. They stated they wore a facemask because they were told to, they did not have a flu shot, and sometimes the mask would fall below their nose. It was hard to breathe with the mask over their nose, but they made sure it was pulled up when they were around residents. They stated it was expected for them to always have the mask in place while on the unit and to wear gowns in precaution rooms to prevent the spread of infection. During an interview on 5/10/2024 at 10:38 AM, regional registered nurse #1 stated the infection prevention nurse was not available and they were covering for them. There were multiple layers of staff involved in infection control so all residents should have the appropriate signage on their rooms. Annual infection control education was provided to staff and all staff were reeducated when there was any kind of outbreak within the facility. Any resident with an open wound, device, catheter, peg tube, multidrug-resistant bacteria, or intravenous catheter should be on enhanced barrier precautions. They stated if staff saw a droplet precaution sign or any transmission-based precaution on a resident's door they expected staff to wear the appropriate personal protective equipment. They stated all staff should stop and read the signage before entering a resident room. The signs were specific and indicated what personal protective equipment was needed to enter the room. 3)Legionella The facility provided sample testing results for Legionella. In 2022, 14 samples were collected by the Director of Housekeeping and Laundry, with one positive result. On 9/6/2023, 14 samples were collected by the Maintenance Director and sent to the lab, but 2 samples were rejected. The chain of custody and the lab results did not identify why the two samples were rejected. One of the two samples that was not analyzed was the same location as the positive result in 2022. During an interview on 5/10/2024 at 12:18 PM, the Director of Housekeeping and Laundry stated they were not sure why all the samples sent in 2023 were not analyzed by the lab and they were told by the Maintenance Director that all the samples came back good. During an interview on 5/10/2024 at 12:18 PM, the Administrator stated the Maintenance Director was not available for interview during survey. They stated they did not find documentation for their water management plan and was unable to provide any documentation to show why not all the samples were analyzed in 2023. They stated they were unaware that one of the rejected samples was the same location as the positive sample in 2022. It would have been an important site to retest. The Administrator stated it was important that the facility maintained a proper water management plan for the health and safety of the residents and staff to prevent the spread of Legionella. 10NYCRR 415.19(a)(2)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not maintain equipment in safe operating condition for 2 of 2 unit k...

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Based on observation, interview, and record review during the recertification survey conducted 5/6/2024-5/10/2024, the facility did not maintain equipment in safe operating condition for 2 of 2 unit kitchenette refrigerators. Specifically, the unit kitchenette refrigerators did not maintain proper temperatures. Findings include: During an observation on 5/6/2024 at 7:30 AM, the South Unit kitchenette had an upright white refrigerator labeled, out of order-do not use. The refrigerator portion was empty. The thermometer inside read 65 degrees Fahrenheit. The freezer portion held some frozen food items that included ice cream bars, frozen drinks, and individual portions of ice cream. Additionally, there was a small black refrigerator that had the door left ajar a few inches. There were drinks for resident use had a measured temperature of 41.7 degrees Fahrenheit. The door hit the side of the cooler and had to be physically pushed closed for the door to seal properly. During an observation on 5/6/2024 at 7:13 AM, the North Unit kitchenette refrigerator thermometer read 58 degrees Fahrenheit. The refrigerator contained 4 cottage cheese containers, 2 brownish pureed food containers, 3 tuna sandwiches, 2 jugs of thickened water, 1 plastic carafe of honey thick juice, and an unreadable plastic carafe with undated orange drink. During an observation on 5/6/2024 at 8:53 AM, the North Unit kitchenette refrigerator thermometer read 58 degrees Fahrenheit. The thickened dairy beverage was removed from the shelf and the temperature was measured at 55 degrees Fahrenheit. The temperature log on the refrigerator was documented as 36 degrees Fahrenheit 5/6/2024 by the Food Service Director. During an interview on 5/6/2024 at 9:00 AM, the Food Service stated they checked the North Unit kitchenette refrigerator. They stated they read the internal thermometer, which was brand new, and it read 36 degrees Fahrenheit at about 7:45 AM. The thermometer was now reading 60 degrees Fahrenheit. They stated someone may have left it open. The surveyor asked them to leave the refrigerator closed for 30 minutes to have the unit rechecked to see how the temperature would adjust. They stated they would see that no one opened the refrigerator. During an observation on 5/6/2024 at 9:05 AM, staff wheeled a new refrigerator down the hall to the North Unit kitchenette. At 9:25 AM the refrigerator was replaced. During an observation on 5/7/2024 at 10:06 AM, with the Director of Housekeeping and Laundry the South 100s kitchenette small refrigerator was removed, and the existing refrigerator was no longer labeled as do not use. The thermometer in the upright refrigerator read 60 degrees Fahrenheit and was confirmed by the surveyor's thermometer and measured at 58 degrees Fahrenheit. There was no food stored in the refrigerator. The freezer portion contained ice cream bars and the thermometer read 12 degrees Fahrenheit. During an interview on 5/07/24 at 10:06 AM, the Director of Housekeeping and Laundry stated when there was an issue with facility equipment the staff should fill out a maintenance request form. They were not sure if a form was completed for the refrigerator. During an interview on 5/10/2024 at 11:18 AM the Food Service Director stated the kitchenette refrigerator temperatures were checked by the kitchen staff twice daily and recorded on the log on each refrigerator. They stated the South Unit refrigerator went down last week; they had ordered a replacement which came in the morning of 5/6/2024. When they were informed the North Unit was not holding temperature, they sent the new one there instead and did not need to see if it was just left open. They thought they had some documentation regarding the timing of the South Unit going down and ordering the new one. Documentation regarding the temperature logs and the South Unit kitchenette refrigerator were not provided by the facility when requested from the Administrator on 5/9/2024 and 5/10/2024. 10NYCRR 415.29 10NYCRR 713-2.5
Dec 2023 3 deficiencies 1 Harm
SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00310562 and NY00321915), the facility did not ensure resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00310562 and NY00321915), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 4 residents (Residents #7, 9 and 10) reviewed. Specifically, , Resident #7 was admitted to the facility with a subdural hematoma (brain bleed) and there was no documentation a plan was implemented to monitor the resident for signs and s ymptoms of worsening subdural hematoma. Subsequently, Resident #7 exhibited a change in condition, was not assessed by a qualified professional, and was found unresponsive 12 hours later. The resident was sent to the hospital, diagnosed with an acute (sudden onset) left sided subdural hematoma that was larger in size, and the resident expired the next day. Resident #9 was admitted to the facility with a surgical wound (incision site) to the spine and no treatments were ordered for 2 days. Recommended follow-up with the surgeon did not occur and the resident required a surgical procedure to remove the infection that developed along with intravenous antibiotics (antibiotics given directly into the vein). Resident #10 was admitted to the facility with a right side below-the-knee amputation and no treatments were ordered for 3 days. The resident required hospitalization for the infection and debridement (surgical removal of dead tissue) of the wound. This resulted in actual harm to Residents #7 and 10 and no actual harm with potential for more than minimal harm that was not Immediate Jeopardy to Resident #9. Findings include: The 5/2019 Change in Resident's Condition Policy documented the facility would promptly notify the resident, attending physician, and representative of changes in the resident's condition or status. Prior to notifying the physician, the nurse would make detailed observations and gather relevant information. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when there was a significant change in the resident's status. When a consultant was needed, the consultant would perform the requested evaluation and provide a consultant's note. The attending physician would consider the recommendations relative to the resident/patient's current condition. 1) Resident #7 was admitted to the facility with diagnoses including traumatic subdural hematoma (brain bleed) with loss of consciousness and history of falls. The [DATE] Minimum Data Set assessment documented the resident's cognition was moderately impaired, they had clear speech, could express ideas and wants, and understood others. It was very important to the resident to have family or close friends involved in discussions about their care. The [DATE] comprehensive care plan documented the resident required assistance with activities of daily living related to limited mobility and a history of falls with a subdural hematoma. Interventions included extensive assistance with bed mobility and transfers. There was no documentation of signs and symptoms staff should monitor for related to the subdural hematoma as noted in the hospital discharge summary, no documentation of the follow up needed with neurosurgery, and no documentation when the medical provider should be notified of changes. The [DATE] hospital discharge summary documented the resident was hospitalized with a subdural hematoma after a fall at home. No surgical interventions were recommended, and the resident was to follow-up with neurosurgery in 2 weeks for a repeat computerized tomography (specialized x-ray). The summary also documented to notify the medical provider for nausea and vomiting, difficulty breathing, headache or visual disturbance, extreme fatigue, and weakness. The [DATE] registered nurse Manager #18's admission Evaluation documented the resident was admitted to the facility for short term rehabilitation, their cognition was intact, range of motion was within normal limits in arms and legs, hand grasps were equal, and they could bear weight fully. The [DATE] physician's assistant #12's progress note documented prior to admission, the resident was walking in their home from the bathroom when they became dizzy and fell. A neighbor found them approximately 7-12 hours later, they were taken to the hospital, and were diagnosed with a subdural hematoma that was stable. Staff were to monitor the resident and alert medical of any changes . The [DATE] 9:41 AM, licensed practical nurse #19's progress note (entered on [DATE] at 7:48 AM) documented therapy staff alerted them there was something wrong with resident. The resident appeared disoriented, and their words were sluggish. They could not answer questions and were talking out of the left side of their mouth. They had trouble holding up their right arm and could not stick out their tongue when asked. Licensed practical nurse #19 went to get the Nurse Manager (unidentified) out of morning report to assess the resident . There was no documented evidence the resident was assessed and no documented evidence the medical provider or the resident's family were notified of the residents change in condition. The [DATE] at 9:55 PM, registered nurse Manager #18's progress note documented they were called to the resident's room because they were unresponsive. The resident was unresponsive to verbal or tactile (touch) stimulation and unresponsive to numerous sternal rubs (painful stimulus using knuckles on the center of the rib cage to elicit response). The resident also had hemorrhaging (bleeding) from their nose. The on-call medical provider was notified and ordered to send the resident to the hospital. The resident's family was notified, and the resident left facility at 9:55 PM via ambulance. On [DATE] at 10:36 PM hospital physician #35 documented the resident presented with altered mental status, a right sided nosebleed, and was ill appearing. The resident was unable to answer questions and was intermittently grunting with painful stimulation. A stroke code (rapid response to patient with symptoms of a stroke) was called and the resident was taken for a computed tomography scan. Neurology was immediately consulted and evaluated the resident. Their condition was critical. The [DATE] hospital admission physician #36's progress note documented, per the nursing facility at around 7:30 AM, the resident was found to have slurred speech which was present the whole day. At around 7:15 PM, when a certified nurse aide went into the resident's room, they were unresponsive and only able to lift their left arm to painful stimulation. The resident also had a nosebleed and dried blood over their chest. A computed tomography scan showed a subdural hematoma with midline shift (displacement of brain tissue across the center line from increased pressure) and obstructive hydrocephalus (blockage of cerebral spinal fluid in brain causing pressure that can damage brain function). The [DATE] 11:40 PM, hospital neurologist #37's progress note documented the resident required surgical intervention for the brain bleed, but the resident's family wished comfort measures (interventions that aide in the dying process) only. The hospital record documented the resident expired on [DATE] at 8:10 AM . During a telephone interview on [DATE] at 8:45 AM, the complainant stated the resident was alert and oriented and able to clearly communicate when they were home and at the facility. On [DATE] at 9:15 PM, they received a call saying the resident was being sent to the hospital and the resident expired the next day. They learned from the autopsy report that the resident was having symptoms of the brain bleed earlier that day. Nobody at the facility notified them when the resident's symptoms first started, only when they were sent to the hospital. If they had known the resident was having symptoms earlier that day, they would have insisted on sending them to the hospital. The autopsy report showed the resident died from a brain bleed. During a telephone interview on [DATE] at 10:09 AM, certified nurse aide #22 stated the resident was alert and oriented and could clearly communicate their needs. On [DATE], they worked the day and evening shifts and when they came in that morning, the resident was still in bed and that was not their normal. The resident was usually up in their wheelchair moving about the unit when the day shift started. That morning, they observed the resident confused and they did not know what day it was or where they were. They recalled going into the resident's room later, did not recall what time, and the resident had a nosebleed and was not responsive. The resident's eyes were rolled back in their head, and they went to get licensed practical nurse #19 who evaluated the resident. They thought the resident was sent to the hospital at some point and did not recall if a registered nurse assessed the resident. During a telephone interview on [DATE] at 2:45 PM, licensed practical nurse #19 stated at around 9 AM on [DATE], occupational therapist #20 told them the resident was not acting like themself. They saw the resident and they seemed sluggish. When they asked the resident their name and where they were, the resident did not answer appropriately. This behavior was a change in condition from the previous day. Licensed practical nurse #19 stated they immediately went and interrupted the nursing meeting and believed registered nurse Manager #18 did an assessment. They asked registered nurse Manager #18 if they were sending the resident to the hospital and registered nurse Manager #18 stated they were not. They did not recall the reason for not sending the resident to the hospital that morning and stated registered nurse Manager #18 instructed them to let the resident rest. They were not sure if the resident's condition was reported to a medical provider. Licensed practical nurse #19 stated they monitored the resident the rest of the shift and occupational therapist #20 was also in and out of the resident's room. Licensed practical nurse #19 reported to the oncoming shift (did not recall who) the resident's symptoms and that registered nurse Manager #18 was aware. There was no documented evidence of monitoring of the resident as stated by licensed practical nurse #19. During a telephone interview on [DATE] at 9:42 AM, former registered nurse Manager #18 stated when a resident had an acute issue, they expected an assessment to be done, the medical provider notified, and a note documented in the chart. On [DATE], they did not recall the resident's change in condition, and they probably did an assessment if licensed practical nurse #19 asked them to. They were not sure if they notified a medical provider of the resident's condition, was not sure why they did not document a progress note and was not sure why the resident was not sent to the hospital. They did not recall if they provided instruction to staff to monitor the resident. They did not recall if they saw the resident over the remaining 12 hours of the shift until staff reported the resident was unresponsive and they sent them to the hospital. They were not aware the resident had no care planned interventions for monitoring their subdural hematoma and stated they should have. They stated the resident's family should have been notified timelier of the resident's condition. During a telephone interview on [DATE] at 9:19 AM, occupational therapist #20 stated they did not work with the resident a lot as they were per diem (as needed) staff however on [DATE], the resident was acting differently than previously. On [DATE] in the morning, they went to see the resident in their room and they were not acting like themself. They had slurred speech, was unable to follow commands, and they notified licensed practical nurse #19 of the change in Resident #7's condition. Occupational therapist #20 reported the change in condition to their department and to registered nurse Manager #18. They kept an eye on the resident during the day and went to licensed practical nurse #19 multiple times because they were concerned about the resident's condition. They stated licensed practical nurse #19 assured them that everyone knew and they were working on it, which occupational therapist #20 took to mean the resident was being sent to the hospital. Occupational therapist #20 was not aware the resident was not sent to the hospital during the day shift. During a telephone interview on [DATE] at 12:46 PM, physician's assistant #12 stated if a resident was admitted to the facility with a brain bleed, they expected staff to monitor for neurological signs and symptoms such as a change in mental status, headaches and seizures and if the hospital made recommendations for signs and symptoms to monitor for, then they would hope the facility would have implemented a plan of care using those recommendations. They were not aware the facility did not implement a plan of care for monitoring the resident for signs and symptoms of the brain bleed. On [DATE], they were on call from 7 AM to 7 PM and they did not recall being notified of the resident's symptoms. If they had been notified, they would have immediately sent the resident to the hospital. The [DATE] Wound Identification and Wound Rounds Policy documented the facility would identify, assess, and manage residents with pressure injuries/skin impairment in accordance with current standards of practice. New admissions would have a complete body check on admission. Upon discovery of skin impairment, the registered nurse would complete a skin assessment, including size, depth, stage, and appearance of the skin impairment. The licensed nurse would notify the attending physician and obtain a treatment order. The registered nurse/interdisciplinary team developed the care plan. The wound nurse/designee and wound care provider were notified of pressure ulcer or skin impairment and the resident was scheduled for weekly wound rounds. The 8/2019 Physician Consultations Policy documented the attending physician would indicate the appropriate time frame within which the specialist physician should see the resident and would include that in the order. 2) Resident #10 had diagnoses including amputation of right lower leg, osteomyelitis (bone infection) of the right leg and end stage kidney disease. The [DATE] Minimum Data Set assessment documented the resident's cognition was intact, they required maximum assistance rolling in bed and were dependent on staff for transfers. The resident had a surgical wound and received intravenous antibiotics. The [DATE] comprehensive care plan documented the resident osteomyelitis, a surgical wound and needed assistance with activities of daily living. Interventions included activity of daily living assistance, documentation of the location, drainage and measurements of the wound weekly, and treatments per order. The [DATE] hospital discharge summary documented the resident had osteomyelitis of the right leg and an amputation on [DATE]. The discharge summary did not document a dressing change or treatment recommended to the right lower leg amputation site (surgical site), did not document the resident had sutures (staples) to the surgical site, and recommended a follow-up with the primary care physician in 1 week. The [DATE] registered nurse #30's admission assessment documented the resident was admitted for rehabilitation and intravenous antibiotics. The resident had a surgical incision wound on the right knee that measured 18 centimeters x 1.6 centimeters x 0 centimeters with 20 sutures present to that incision. The [DATE] physician's assistant #12's admission orders did not include a treatment order for the resident's right below knee incision site. Attending physician #34's orders documented on [DATE], to the right knee, cleanse surgical wound with normal saline, cover with a bordered gauze dressing one time and on [DATE], to the right knee, cleanse surgical wound with normal saline, cover with a bordered gauze dressing every day-shift and consult with the wound provider. There was no documented evidence of a physician's order to follow up with vascular surgery. The [DATE] physician's assistant #12 progress note documented nursing reported concerns of possible wound dehiscence (opening of surgical incision) for the resident's right below-the-knee amputation. Multiple staples and sutures were present however there was an area that was about 2 centimeters x 3 centimeters of yellow stringy material and foul odor. The resident was on intravenous antibiotics and nursing was instructed to contact the resident's vascular surgeon as soon as possible to determine if they could see the resident that week or to see if the surgeon wanted them sent to the hospital. There was no documented evidence the resident's vascular surgeon was contacted. The [DATE] Infectious Disease nurse practitioner #35's consult note documented the resident had stump skin changes and staff were to call vascular surgery for follow-up. Intravenous antibiotics were to be extended until [DATE] and follow-up in 1 week. The [DATE] physician's assistant #12's order documented to the right knee, cleanse surgical wound with normal saline, apply a petroleum dressing over wound, cover with an abdominal pad and wrap with gauze wrap daily. The [DATE] Infectious Disease nurse practitioner #35's consult note documented the resident needed to follow- up with vascular surgery for the right below knee amputation stump site. There was no documented evidence the resident had follow up with vascular surgery. The [DATE] Infectious Disease nurse practitioner #35's consult note documented the resident's right below knee amputation stump was worse despite being on antibiotics. The outer and midline of the incision were dehisced with dead tissue and foul-smelling drainage. The resident was not receiving adequate wound care and despite repeated requests, the nursing facility had not followed up with the vascular surgeon. The resident was transported to the hospital for urgent surgical evaluation. The [DATE] hospital record documented the resident presented for evaluation of the right below knee amputation with concerns for infection. The resident had surgery in 10/2023 and had not seen their vascular surgeon since. There were still staples intact to the site and evidence of non-recent wound dehiscence at the inner and outer margins of the wound. The smaller inner area had some fibrinous drainage (thick, yellowish fluid that forms from tissue injury or inflammation), and the larger outer area had fibrous drainage and a central area of eschar. The resident was evaluated by vascular who debrided the wound. During a telephone interview on [DATE] at 12:43 PM, registered nurse Manager #33 stated if the attending physician wanted a resident seen by an outside consultant, then registered nurse Manager #33 would enter the order in the record. Transport Coordinator #38 would make the appointment and they were not sure how Transport Coordinator #38 was notified to do so. When an outside consultant made a recommendation, the resident came back with a note documenting the recommendations. The facility's medical provider reviewed the consult note and decided whether they agreed with recommendations. If they agreed, they let nursing know to enter the orders. When physician's assistant #12 recommended to call the vascular surgeon on [DATE], they did not believe they were notified. When the resident returned from the Infectious Disease appointment on [DATE] with Infectious Disease appointment on [DATE] with recommendations to follow-up with vascular surgery, they believed an order was entered. They were not aware there was not an order entered and not aware the resident was not seen by vascular surgery. The resident was currently at the hospital after being sent there directly from the Infectious Disease appointment on [DATE]. During a telephone interview on [DATE] at 3:27 PM, licensed practical nurse #5 stated if the facility medical provider wanted a resident to see an outside consultant, the medical provider would write an order in the communication book and notify registered nurse Manager #33 to schedule the appointment. On [DATE], they left a note in the communication book for physician's assistant #12 about the resident's stump. They saw the stump that morning and it looked like the staples were attached to the scab and not the skin and it had some areas of slough (dead tissue). Physician's assistant #12 might have mentioned to them they wanted the vascular surgeon called however registered nurse Manager #33 was responsible and physician's assistant #12 would have communicated that to registered nurse Manager #33. They saw the resident's right below knee amputation incision the day prior to their Infectious Disease consult on [DATE] and the staples were embedded in eschar, and it looked like the wound was not healing. During a telephone interview on [DATE] at 2:20 PM, registered nurse #30 stated on admission, if a resident had a surgical wound with no treatments ordered they would notify the medical provider to obtain an order. When they did the resident's skin assessment on [DATE], they believed all of the admission orders were already in place and they were asked to only complete the skin assessment. The resident should have had a treatment ordered on admission and they were not sure why they did not. During a telephone interview on [DATE] at 12:46 PM, physician's assistant #12 stated on [DATE], they instructed registered nurse Manager #33 or possibly a Corporate staff who was assisting with managing the unit to call vascular surgery. They recalled being told the resident had an appointment the next day and they thought it was with the vascular surgeon. The resident had slight wound dehiscence with an increased risk of infection, even though they were on antibiotics. They thought the surgeon needed to assess the resident. They reviewed nurse practitioner #35's consults on [DATE] and [DATE] and stated they did not initial the consult notes which they did when they reviewed notes and did not recall being aware of the recommendations to follow-up with vascular surgery. They stated if they were aware of the recommendation, they would have written an order. They were not aware the resident never followed up with vascular and the vascular consult was not obtained. 3) Resident #9 had diagnoses including a fractured neck, quadriplegia (inability to move the limbs) and orthopedic after care. The [DATE] Minimum Data Set assessment documented the resident's cognition was moderately impaired, they were dependent on staff for activities of daily living and received surgical wound care. The [DATE] comprehensive care plan documented the resident was at risk for alteration in physical function related to cervical fracture. Interventions included to follow-up with the orthopedic surgeon as ordered and incision wound care to prevent infection and promote healing. The [DATE] hospital discharge summary documented the resident was driving a scooter without a helmet when they fell and sustained profound trauma of the cervical spinal cord (area of the spine in neck) and had spinal surgery that permanently joined the spine together. Recommendations included follow-up with the surgeon in 1 week for repeat imaging and for wound re-check. The [DATE] at 12:30 PM, Corporate Director of Nursing #16's admission Evaluation documented the resident was admitted to the facility with a fractured neck with neurologic injury (an injury to the brain, spine, or nerves) and instability. The resident had a posterior (back) neck incision with 22 visible sutures (stitches), the site measured 14 centimeters x 0.5 centimeters and a clean dry dressing was in place. The [DATE] attending physician #34's admission order documented weekly skin evaluations on Monday and Thursday done by a licensed nurse. There was no documentation of a treatment for the resident's surgical incision or to follow-up with the surgeon in 1 week. The comprehensive care plan, updated [DATE], documented the resident had impaired skin integrity related to a spinal incision. Interventions included to document the location/amount of drainage weekly and monitor and report signs and symptoms of infection (green drainage, foul odor, redness and swelling). The [DATE] physician assistant #12's progress note documented the resident was a new admission who sustained profound trauma of the neck and was status post spinal fusion surgery. The resident was lying flat in bed, skin was warm and dry, and a full skin check was not performed. The resident needed to follow-up as an outpatient with the surgeon per the hospital discharge summary. The [DATE] physician assistant #12's order documented to the surgical spine incision, cover with dry non-stick dressing, and monitor for signs/symptoms of infection every evening. There was no documented evidence of a treatment being done on [DATE]. The [DATE] Treatment Administration Record documented the resident's surgical spine dressing was changed (2 days after admission). There was no documented evidence the 1 week follow up with the surgeon was ordered or occurred . The [DATE] and [DATE] Assistant Director of Nursing #10's weekly wound assessments documented the resident's spinal incision was measured, sutures were in place, and surgical follow-up was needed. The [DATE] physician's assistant #12's progress note documented they were notified to evaluate the resident via a note left in the communication book. The resident was seen with a rash and blisters on their back. There was greenish-brown drainage on the resident's pillow and sheets, the surgical dressing was soaked through, and the smell was concerning for surgical site infection. The resident was sent to the hospital. The [DATE], emergency room physician #32's progress note documented the resident presented to the emergency room for evaluation of neck drainage and there was copious (large) amounts of skin irritation including redness and skin breakdown likely from buildup of purulent (pus) fluid. Mild pus was expressed from the wound and they were having increased pain from the site. emergency room physician #32 documented they found it very unlikely the copious amounts of drainage started that day given the extensive skin breakdown on the resident's back. The [DATE] color photograph attached to the report and noted as taken in the emergency room showed the resident turned to their right side; a large area of bright red skin was noted extending from the upper to mid back, the chux pad (large washable absorbent pad) the resident was rolled from in the picture had a large amount of yellow green drainage that nearly covered the pad. The [DATE], hospital surgeon #14's progress note documented the resident reported they were doing well at the nursing facility until 4-5 days ago when they developed drainage from their incision that had increased since then. The drainage was serous (clear liquid mixed with blood) but was now green and purulent. The surgical incision had moderate redness and induration (abnormal skin hardening that could be due to infection) around the incision with a small area of breakdown of the incision at the level of the posterior neck crease. Serous fluid with purulent debris was able to be expressed. The plan included surgical debridement (removal of dead tissue) of the surgical site in the operating room. Cultures grew bacteria and the resident was given intravenous (through the vein) antibiotics and they were recommended for 6 weeks. During a telephone interview on [DATE] at 2:41 PM, licensed practical nurse #17 stated when they did a dressing change, they looked for inflammation, redness, drainage, and was supposed to write a note when something abnormal was found. They would also notify the medical provider if they found something abnormal. They stated they could not recall back to 7/2023 or the condition of the resident's incision and did not recall if they were the one that left a note regarding the incision in the physician communication book. During a telephone interview on [DATE] at 8:55 AM, emergency room physician #32 stated they evaluated the resident on [DATE]. The resident had a cervical spinal incision with sutures in place and they were covered from the suture line all the way to their hip in a cloudy thick greenish drainage. The bedding under the resident was soaked in greenish drainage. The resident had skin breakdown that suggested they had been sitting in the soaked bedding for a while and there was no way someone could get that amount of drainage over the course of a shift. The resident was taken to the operating room where they re-opened the cervical incision and flushed out the site with a goal to get infected material out of the site. They stated they had never seen sutures intact in a cervical spine incision for over a month. During a telephone interview on [DATE] at 12:14 PM, former corporate Director of Nursing #16 stated when they did an admission assessment and a resident had no recommendations for a treatment for their surgical wound, they would notify the medical provider and obtain an order. If the hospital discharge summary documented follow up appointments were needed, they would obtain orders from the medical provider and schedule the appointment. On [DATE], they did the resident's admission assessment and assumed another nurse obtains orders for a treatment and the treatment order was not obtained timely. If an order was not found for a follow up appointment with the resident's surgeon, they were not sure what happened, not sure why it was not ordered and it was not done timely. They stated sutures typically were removed after 14 days though the resident's surgeon would have made that determination. On [DATE] and [DATE], surgeon #14 was not reached in an interview. During a telephone interview on [DATE] at 12:46 PM, physician's assistant #12 stated they evaluated the resident on [DATE] for a rash they observed on the right upper arm and thought it was from yeast. As they were getting ready to write notes, they noticed some discoloration on the resident's pillowcase near their head and shoulders and it was wet. When the resident sat up so they could assess, they observed their dressing and pillowcase was soaked with drainage and it smelled so bad. They did not remove the dressing because they did not have gloves on and they had not assessed the resident's surgical site since they were admitted . They did not observe the skin on the resident's back so was not sure if there was any skin breakdown. They immediately sent the resident to the hospital. If the resident's dressing was changed the prior evening, it did not seem likely they would have that much drainage over that course of time. They stated they were upset when they assessed the resident that day and it was not every day you saw something like that. 10 NYCRR 415.12
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review and interview during the abbreviated survey (NY00320770), the facility did not ensure services provided met professional standards of quality for 1 of 4 residents reviewed (Resi...

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Based on record review and interview during the abbreviated survey (NY00320770), the facility did not ensure services provided met professional standards of quality for 1 of 4 residents reviewed (Resident #8). Specifically, Resident #8 had orders to apply a condom catheter (urinary collection device) in the evening and the order was not implemented timely. Findings include: Resident #8 had diagnoses including benign prostatic hyperplasia (inability to completely empty urine from the bladder) and Parkinson's disease. The 7/8/2023 Minimum Data Set assessment documented the resident's cognition was moderately impaired, they required extensive assistance with most activities of daily living and were frequently incontinent of urine. The 7/6/2023 comprehensive care plan documented the resident had an alteration in the urinary system related to diagnoses and a history of urinary tract infections. Interventions included monitoring intake and output per policy, monitoring and reporting signs and symptoms of urinary tract infections, and a urology consult as needed. The 7/6/2023 physician's order documented the resident was to have a condom catheter applied in the evening and removed in the morning. The 7/2023 Treatment Administration Record documented an order for a condom catheter on 7/6/2023, apply in the evening and remove in the morning. The record documented other/see nurses notes on 9 occasions and there was no documentation whether the condom catheter was applied on 2 occasions. Corresponding nursing notes documented: - on 7/7/2023 at 8:29 PM and 7/8/2023 at 7:46 PM, licensed practical nurse #28 noted unable to put on condom catheter due to old supply that broke and full brief on. - On 7/9/2023 at 9:32 PM, licensed practical nurse #17 did not document a reason. - On 7/10/2023 at 9:22 PM, licensed practical nurse #29, unable to locate condom catheter. - on 7/12/2023 at 8:46 PM, licensed practical nurse #28, awaiting delivery. - on 7/14/2023 at 8:28 PM, licensed practical nurse #28, unavailable currently, on order. - on 7/15/2023 at 8:42 PM, licensed practical nurse #17 did not document a reason. - On 7/16/2023 at 5:52 PM, licensed practical nurse 29, on order. - on 7/22/23 at 4:39 PM, licensed practical nurse #19 did not document a reason. During a telephone interview on 12/4/2023 at 1:35 PM, licensed practical nurse #29 stated when a medication or treatment was ordered, it was entered electronically, and the order was automatically sent to the pharmacy. If they found a medication or treatment was not available, they would search for it, call the pharmacy, and if it was still not found, they would call the medical provider to get an order to hold the medication/treatment. On 7/10/2023 and 7/16/2023, the facility did not have the condom catheter available for the resident. They did not recall who they notified and if they notified someone, they would have documented that in a nursing note. They recalled the facility had a supply issue with the condom catheters. During a telephone interview on 12/4/2023 at 3:22 PM, licensed practical nurse #28 stated when a physician's order was received, the Nurse Manager verified the order, entered the order in the electronic medical record, and the order was automatically sent to the pharmacy to be filled after transcribing. If a medication or treatment was not in the medication or treatment cart, they would check the facility supply. If it was still not available, they would document the medication/treatment was not available and would notify a Supervisor if there was one was on duty. They stated on 7/7/2023, they found condom catheters in the supply room and when they applied it to the resident, it broke and disintegrated. The facility rarely used condom catheters and the supply was outdated and old. They notified Central Supply Staff #31 to order new condom catheters. On 7/8/2023, 7/12/2023 and 7/14/2023, there were no condom catheters available, and they were awaiting delivery. The resident's family member eventually brought in a supply of condom catheters, and they were not sure if the facility ever obtained a supply for the resident. They stated when the resident went 16 days without a condom catheter, it was not timely. During a telephone interview on 12/5/2023 at 9:06 AM, licensed practical nurse Manager #6 stated when a medical provider ordered items that could not be filled by the pharmacy, Central Supply Staff #31 was notified to place an order. Sometimes a family would be asked to bring in supplies from home until stock could be obtained. They were aware there was an issue obtaining the resident's condom catheters from the supplier and recalled family brought in catheters to get them through. They stated 16 days was a long time to go without the ordered condom catheter. During a telephone interview on 12/5/2023 at 9:16 AM, Central Supply Staff #31 stated they did an inventory of the supply room and ordered items on Fridays. Occasionally, staff let them know to order things when an item was low or not in stock. When an item was not available from their supplier, they let the corporate office know to order the item. They believed the former Director of Nursing notified them to obtain condom catheters for the resident. They found the facility's supplier did not stock condom catheters, so they emailed the corporate office to order them. They believed a supply was eventually delivered and could not provide documentation because corresponding emails sent between them, and the corporate office were automatically erased after 3 months. 10NYCRR 415.12(d)(1)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on record review and interview during the abbreviated survey (NY00324772), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional ...

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Based on record review and interview during the abbreviated survey (NY00324772), the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was admitted with a continuous positive airway pressure machine (applies pressure to keep airway open when sleeping) and the facility did not clarify the hospital discharge instructions and did not consult with the medical provider to have the resident's need for the machine evaluated. The resident's continuous positive airway pressure machine was removed by the family prior to any clarification of the resident's needs. Findings include: The Respiratory-PAP (positive airway pressure) Equipment policy revised 3/2021 documented: - Patients with obstructive sleep apnea use continuous positive airway pressure or bilevel positive airway pressure to force air through their obstructed airways. - A sleep study should be done to determine the proper pressure levels. - The physician's order is to be verified and should state the continuous positive airway pressure. - If the patient is admitted to the facility with existing equipment, the nurse should contact the contracted respiratory therapist for instruction. - The facility should obtain all necessary paperwork and instruction to manage. Resident #1 had diagnoses including obstructive sleep apnea and Alzheimer's disease. The 9/19/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment and did not exhibit behavioral symptoms, including rejection of care. The resident required extensive assistance of 2 for bed mobility and dressing and was dependent on 2 for transfers and hygiene. The resident utilized a non-invasive mechanical ventilator (continuous positive airway pressure or bilevel positive airway pressure) The resident did not receive respiratory therapy services in the7 days prior to the assessment date. The 9/13/2023 hospital discharge summary documented the resident had obstructive sleep apnea and to continue use of the continuous positive airway pressure machine. The discharge instructions did not include settings or parameters for the machine. Another area on the discharge summary documented: continuous positive airway pressure at bedtime and as needed for naps, respiratory distress, nebulizer treatments and was checked no following the entry. There were no physician orders for use of the continuous positive airway pressure machine and no documented evidence the facility clarified the hospital discharge orders with the medical provider. The 9/13/2023 admission Evaluation completed by licensed practical nurse Manager #6 and former Assistant Director of Nursing #10 did not contain any documentation related to any respiratory care or devices. The comprehensive care plan, initiated 9/14/2023, documented the resident had an alteration in their respiratory system related to sleep apnea and cough. Interventions included: administer treatments and medications per physician orders; observe for signs/symptoms of poor airway clearance and gas exchange; observe secretions for abnormalities and report changes; observe vital signs and report if not within normal limits. There was no documentation the resident utilized a continuous positive airway pressure machine. The 9/15/2023 physician's assistant #12's progress note documented they saw the resident for the initial evaluation. Nursing staff had not reported any medical concerns via the communication book. There was no documentation related to the resident's diagnosis of sleep apnea or the use of the continuous positive airway pressure machine. The 9/19/2023 team meeting progress note entered by the Director of Social Services documented a care plan meeting was held with the resident's siblings and the health care proxy (medical decision maker) was in attendance. There was no documentation related to the use or discontinuation of the continuous positive airway pressure machine. Nursing and social work progress notes from 9/13/2023 through 11/14/2023 did not contain documentation related to the continuous positive airway pressure machine. Physician's assistant #12's progress noted on 9/25/2023 and 9/26/2023 did not contain documentation related to the resident's sleep apnea diagnosis or the use of the continuous positive airway pressure machine. During an interview with the resident's significant other on 11/13/2023 at 11:00 AM, they stated themself and the resident resided together prior to the resident's hospitalization. The resident had sleep apnea and used a continuous positive airway pressure machine since their sleep study in 2014. When the resident went to the hospital, the significant other informed the hospital staff and the hospital provided a continuous positive airway pressure machine on the first night of the resident's admission and after that, the significant other brought in the resident's continuous positive airway pressure machine from home. The resident used the machine while in the hospital and it was brought to this facility when the resident was admitted . The resident's health care proxy reported they did not want the resident to use it, did not believe the resident needed it, and took the machine home on 9/20/2023. Prior to that, the significant other did not know if it was used in the facility as they only visited during the day. They stated they observed the machine in the resident's room from admission to 9/20/2023. During an interview with Regional registered nurse #7 on 11/14/2023 at 3:30 PM, they stated they recently became aware the resident had a continuous positive airway pressure machine when they were preparing an assessment for the resident. They stated the use of the machine was on the hospital discharge paperwork and they asked unit nursing staff about it. They could not recall what happened and thought the former Director of Nursing said something about it and may have called the hospital at that time to clarify. They were unable to locate any documentation related to clarification of the hospital discharge summary or what the outcome of the inquiry about the machine was. They stated if the family no longer wanted the resident to use it, then a medical provider should have assessed the resident to determine if it was needed. Family members could not discontinue treatments without the medical provider evaluating the resident's need. During an interview with licensed practical nurse Manager #6 on 11/14/2023 at 3:51 PM, they stated the resident had a continuous positive airway pressure machine when they were admitted , and they were going to ask the registered nurse to clarify. They stated the resident's siblings did not want the resident to use it and said the resident did not need it. The were uncertain if anyone followed up and the siblings took the continuous positive airway pressure machine home. During a telephone interview with physician's assistant #12 on 11/15/2023 at 12:25 PM, they stated when they initially saw the resident, they were unaware the resident had a continuous positive airway pressure machine. To their understanding, the nurses were told by the family the resident's physician (unnamed) said they did not need the machine. The hospital discharge paperwork was not clear regarding the use of the machine and staff should have clarified with the hospital related to whether the resident used it and what the orders were. The only way for the facility to adequately determine if the resident still needed the continuous positive pressure machine was to complete a sleep study with a referral to a pulmonologist (lung physician). In order for the family to be able to state they no longer wanted the continuous positive airway pressure machine used, they should be offered the pulmonology referral and have a discussion with the medical provider about risks and benefits of not using it. This should have been clarified at admission. An individual who requires use of a continuous positive airway pressure machine could be at risk of heart disease. Other potential short-term effects included fatigue and impact on energy level, especially if the resident was participating in physical therapy. 10NYCRR 415.12(k)(5)
Aug 2023 3 deficiencies
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on record review and interview during the abbreviated survey (NY00317600), the facility did not ensure all alleged violations were thoroughly investigated for 1 of 19 residents reviewed (Residen...

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Based on record review and interview during the abbreviated survey (NY00317600), the facility did not ensure all alleged violations were thoroughly investigated for 1 of 19 residents reviewed (Resident #12). Specifically, the facility identified that controlled substances for Resident #12 were unaccounted for and the facility's investigation was not thorough and complete. All involved staff were not re-educated on the process for accounting for controlled substances to prevent reoccurrence and the incident was not reported to the New York State Department of Health (NYS DOH) as required. Findings include: The facility Narcotic Count policy dated 8/2018 documented the on-coming and off-going nurse assignment to the medication cart will be responsible for ensuring the accuracy of the controlled drug count. The policy further documented the 2 nurses would look at the medication cards, bottles, etc. together and would verify and document the count. If the amount documented and the number of pills did not match, nurses were to stay on the unit, determine why there was a discrepancy, call the Director of Nursing (DON), and not sign the controlled drug count sheets. The DON was to initiate an investigation when notified. It was the responsibility of the off-going nurse to account for any missing medication. The facility would determine if drug testing was needed along with notification of law enforcement or pharmacy. Any disciplinary action would go to the nurse who was in possession of the keys. The DON was to notify the Executive Director and Director of Clinical Services. Resident #12 had diagnoses including a past cerebrovascular accident (CVA, stroke) and anxiety. The 5/4/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired. The 5/2023 Medication Administration Record (MAR) documented an order dated 4/28/2023 for Modafinil, 100 milligrams (mg), 1 tablet daily to promote alertness. During an interview on 7/13/2023 at 11:24 AM, the Director of Nursing (DON) stated about 2 weeks ago, it was found that two Modafinil pills were unaccounted for. The DON stated they gathered staff statements and reviewed the area looking for the pills. The pills were not found. The DON stated all involved staff had been interviewed except licensed practical nurse (LPN) #13. The Investigation Summary, completed by the DON on 7/18/2023, documented on 5/30/2023, the 2 PM to 10 PM shift's oncoming nurse reported 2 Modafinil pills were unaccounted for. The top of the medication card was found on the medication cart and the count sheet showed 2 pills remaining in the card. Statements obtained by the facility included: - LPN #18's statement documented on 5/29/2023, they counted with the off-going nurse when they came in and on-coming nurse when they left, and no issues were found. They administered one dose of Modafinil during their shift and documented the administration. There were 2 pills left in the blister pack, so they ordered more from the pharmacy. - LPN# 19's statement documented on 5/29/2023, they took the controlled medication keys from LPN #13 at 10 PM. When they arrived for their shift, LPN #13 was standing near the medication cart and stated they counted everything already and signed the book. LPN #19 took the keys and documented they completed a count of controlled medications on their own. They further documented the count for the blister packs was correct, but they must have overlooked the Modafinil as there was no blister pack for the medication. At 6 AM on 6/30/2023, they counted with LPN #10 and noticed the Modafinil blister pack, and the pills were not there. They searched, did not find them, and assumed they would turn up. - LPN #13's statement, documented by the DON, noted LPN #13 reported they counted when they worked, and the count was not off. - LPN #10's statement documented on 5/30/2023, they counted with LPN #19 at 6 AM and noted 2 Modafinil pills were unaccounted for. - A summary of an interview with LPN #20, written by the DON, documented LPN #20 worked 5/30/2023 from 2 PM to 10 PM and reported the 2 missing Modafinil pills to the DON. The Investigation Conclusion written by the DON documented the facility was unable to determined how the medication was unaccounted for; there were areas of opportunities identified that played a contributing factor; there were no adverse effects to the resident, and licensed nursing staff were re-educated on the procedures for narcotic counting on each shift. The facility's Shift Count (signatures of off going and oncoming nurses when controlled substances are counted)documented: - on 5/29/2023 at 6 AM, LPN #18 was the oncoming nurse and there was no signature from LPN #18 or the off- going (night shift) nurse verifying that controlled drugs were counted. - On 5/29/2023, LPN #19 was the oncoming nurse at 10 PM and LPN #13 was the off-going nurse. Both signed they counted together but LPN #19 documented in their statement they did not count with LPN #13 as LPN #13 counted prior to them arriving to the facility. - On 5/30/2023, LPN #10 was the oncoming nurse at 6 AM and noted the medication was missing. LPN #10 and LPN #19 both signed that the count was verified. On 5/31/2023, the DON documented on an in-service record they provided education to nursing staff on The Narcotic Count Policy and Procedure. There was no documentation LPNs #13 or 19 participated in the education session. During an interview on 7/20/2023 at 1:06 PM, LPN #18 stated on 5/29/2023, they knew they counted and did not know why they did not sign the controlled substance book verifying the count. The stated they did not know who they counted with as the signature was not documented. They knew the resident had 3 Modafinil pills at the start of their shift; they administered one pill; signed for the administration and ordered more from the pharmacy. During an interview on 7/20/2023 at 1:37 PM, LPN #10 stated on the day they noted the pills were missing, they were working by themselves, and LPN #19 was the Supervisor, so they counted with LPN #19. They assumed LPN #19 would report the issue to the Assistant Director of Nursing (ADON) or DON as LPN #19 was the Supervisor. Later on that day, registered nurse (RN) Manager #5 came into work and LPN #10 told them about the missing Modafinil pills. Later on, the DON asked them why they did not report to them directly. They responded that the Supervisor was aware. They stated they should not have signed the shift count book when the count was off but did so because they counted with a Supervisor. Later on, they counted with LPN #20 and noticed again that the Modafinil pills were missing so LPN #20 reported it to the DON. During an interview on 7/28/23 at 1 PM, LPN #13 stated at the beginning of the shift 2 nurses were supposed to count controlled medications together and verify the count. They did not recall who they counted off with on 5/29/2023. The surveyor read LPN #13 their statement which documented they counted with LPN #19 and LPN #13 stated they were present with LPN #19 when the count was done. They stated they did not receive any re-education on controlled substances following this incident. During an interview on 7/31/23 at 1:35 PM, LPN #19 stated when they came into work on 5/29/2023, LPN #13 said they counted, signed the book, and the count was correct, so LPN #13 handed LPN #19 the keys. LPN #19 went into the medication room and verified all controlled drugs were accounted for. They thought the whole blister pack of Modafinil was missing at that time and they did not notice. They looked around for the pills when they became aware they were missing including checking the trash. LPN #19 stated they should have called the DON when this occurred as they were the Supervisor. During an interview on 8/1/2023 at 9:45 AM, RN Manager #5 stated nurses were supposed to count controlled medications with the oncoming shift prior to leaving the facility although not all nurses did this. They did not recall LPN #10 reporting missing Modafinil pills to them. They stated if there were missing controlled medication, normal business would stop, and they would try to figure out what happened. Missing controlled medications should be reported to the DON. During an interview on 8/1/2023 at 3 PM, the DON stated the nurses should have notified the DON immediately when the 2 Modafinil pills were noted to be missing and the nurses did not do this. When the DON was notified, an investigation was initiated. The DON stated they noted missing signatures on the shift-to-shift count log but stated that did not necessarily mean that the nurses did not count controlled medications, it meant they did not sign that they counted. Since this incident, they did a lot of education of all nursing staff especially the nurses involved and tightened up the process. They stated they educated LPN #13 via telephone when they interviewed them about the incident. The DON stated they were not sure this incident should have been reported to the NYS DOH and the investigation was almost fully done when the surveyor asked for it and was completed on 7/18/2023. 10NYCRR 415.4(b)(3)
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the abbreviated survey (NY00306191), the facility did not ensure residents received ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the abbreviated survey (NY00306191), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 7 residents(Resident #7) reviewed. Specifically, Resident #7 had abnormal laboratory values and there was no documented evidence the medical provider was notified. Findings include: The facility policy Lab Procedure revised 5/2021 documented lab results were checked by the clinical nurse and the physician was notified of the results. The notification would be written on the Lab Results form. All lab results were kept in a designated place until seen and signed by the physician. Resident #7 was admitted to the facility with diagnoses including stroke, diabetes, and end stage renal disease (ESRD). The 8/16/2022 admission Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance with most activities of daily living (ADL). The 10/15/2022 comprehensive care plan (CCP) documented the resident was at risk for infection and interventions included to monitor labs. The 10/21/2022 at 11:29 AM, licensed practical nurse (LPN) #10's progress note documented the resident was not eating, refused to be fed, and refused medications. They were diaphoretic (sweating heavily) and were to have STAT (immediate) labs done that day. The 10/21/2022 physician assistant (PA) #6's progress note documented the resident was seen for chest congestion. An x-ray, obtained on 10/20/2022, was negative despite the resident having coarse lungs sounds that were diminished in both lungs. The plan was to obtain STAT labs including complete blood count (CBC, counts the different type of cells in the blood), basic metabolic panel (BMP, provides information about chemical balance and metabolism), and urinalysis (UA, a test that examines urine properties). The resident was to receive Rocephin (antibiotic), 1 gram (g) intramuscularly (IM), 1 dose for high suspicion of infection. Staff were to check vital signs every shift. The 10/21/2022 physician's order documented STAT CBC, BMP, Digoxin (cardiac, antiarrhythmic medication) level, UA, vital signs every shift, and Rocephin 1 g IM one time for infection. The 10/21/2022 at 7:36 PM, laboratory report, faxed to the facility on [DATE] at 7:41 PM documented: - WBC (white blood cell, potential indicator of infection) 14.4 ul (microliter) H (high), normal range 4.1 - 11.0; - Sodium (potential indicator of dehydration) 152 mmol/L (millimoles per liter) H, normal range 136 - 145; - BUN (blood urea nitrogen, potential indicator of dehydration) 46 mg/dl (milligrams per deciliter) H, normal range 9-23; - Creatinine (potential indicator of dehydration) 1.81 mg/dl H, normal range 0.55 - 1.02; and - Digoxin level (indicator of the amount of Digoxin in the blood) 2.5 ng/dl (nanograms per milliliter) HH (critical result), normal range 0.8 - 2.0. The lab report documented the Digoxin level was called and reported to registered nurse (RN) Manager #5 on 10/21/2022 at 7:29 PM. The lab report included undated initials of RN Manager #5, and PA #6 initialed and dated the reports on 10/25/2022 and documented the resident was in the hospital. There was no documented evidence RN Manager #5 notified the medical provider on 10/21/22 of the abnormal lab values. The resident's October 2022 medication administration record (MAR) documented the resident received Digoxin on 10/22/2022: The 10/23/2022 at 1:14 PM, LPN #11's progress note documented the resident was not responding to verbal stimuli, was diaphoretic, lung sounds had crackles (abnormal lung sound), and oxygen saturation was 80% (low blood oxygen level). The medical provider, Director of Nursing (DON) and the family were notified, and the resident was sent to the hospital. The 10/23/2022 hospital report documented the resident presented to the hospital with altered mental status, oxygen levels at 80%, increased respirations, and was diaphoretic. Labs done included the following high levels: WBC, BUN, creatinine, and sodium. The resident was placed on supplemental oxygen and received 5 liters (L) of intravenous (IV) fluid with improvement. During an interview on 7/17/2023 at 11:53 AM, RN Manager #5 stated, labs were faxed to the unit fax machines and they were responsible for notifying the medical provider of abnormal results and documenting in the record. When a resident had a critical lab result, the results were called emergently by the laboratory and the process was to notify the medical provider and obtain orders. On 10/21/2022, they documented their signature on the lab report and that meant they spoke to PA #6. They did not recall the phone call to PA #6 but if there were no orders then PA #6 must not have ordered anything. During an interview on 7/17/2023 at 2:24 PM, PA #6 stated, they were on-call for the facility from 7:00 AM to 7:00 PM Monday through Friday. After 7:00 PM, an on-call service took over. They stated staff called them or the on-call service for critical lab values. High WBCs indicated an infection. High sodium, BUN, and creatinine indicated a kidney issue or dehydration. They stated minimally, they would order clysis (infusion of fluid under the skin) or encourage fluids for high sodium, BUN, and creatinine levels or the resident might require a hospital evaluation depending on the severity of the labs or symptoms. If a resident had a critical Digoxin level, they would hold their next dose of the medication and from there, their action would depend on the resident's symptoms. They stated on 10/21/2022 when the lab reported the resident's critical Digoxin level at 7:29 PM, they would not have been notified as they were not on-call after 7:00 PM. If they had been on-call and received report regarding the resident's labs, they would have ordered clysis, held the next dose of Digoxin and would have considered sending the resident to the hospital for evaluation. The PA stated they would have also extended the resident's antibiotics for the high WBCs. They stated when they gave the resident Rocephin on 10/21/2022, they had concerns with infection and the high WBC lab result confirmed that. They expected if the on-call provider was notified on 10/21/2022, the on-call provider would have intervened regarding the abnormal lab values. 10 NYCRR 415.12
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview during the abbreviated survey (NY00315289), the facility did not ensure a resident who entered the facility with an indwelling catheter or subsequent...

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Based on observation, record review, and interview during the abbreviated survey (NY00315289), the facility did not ensure a resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 1 of 3 residents (Resident #11) reviewed. Specifically, Resident #11 returned to the facility with an indwelling urinary catheter (a tube that removes urine from the bladder into a drainage bag) after a hospital stay, was not assessed for continued need of the urinary catheter and did not receive a urology consultation per medical recommendation. Findings include: The facility policies Catheter-Female Insertion, revised 2/2019; Catheter Care revised 5/2019; and Catheter Guidelines created 8/2019 did not include documentation related to indications for catheter use and/or catheter removal. Resident #11 was admitted to the facility with diagnoses including multiple sclerosis (MS, a progressive central nervous system disease), urinary tract infection (UTI), and encephalopathy (brain function affected by disease/illness). The 5/29/2023 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, was dependent on 2 for toileting, had an indwelling catheter, and a trial toileting program had not been attempted since admission or re-entry. The comprehensive care plan (CCP) created 5/18/2023 documented the resident had bladder incontinence related to the MS disease process and chronic UTIs. Interventions included to apply incontinence devices as identified appropriate for the resident and medications as ordered. The 5/19/2023 physician assistant (PA) #6's progress note documented the resident was seen for an initial visit and had no acute concerns. There was no documentation related to a catheter. The 5/22/2023 PA #6's progress note documented the resident was seen for altered mental status, a UTI was suspected, and they were sent to the hospital for evaluation. The 5/25/2023 hospital discharge summary documented the resident had discharge diagnoses including UTI and urinary retention. Urinary retention was noted on the night following admission and the resident was catheterized. The urinary retention was suspected as temporary and related to the UTI and encephalopathy. The discharge instructions did not address the urinary catheter. The 5/25/2023 facility physician's order documented the resident had an indwelling catheter, change as needed, and catheter care every shift. There was no documented diagnosis for the use of a catheter. The CCP, created 5/26/2023, documented the resident had an indwelling catheter related to a neurogenic bladder (lack of bladder control related to a nerve problem) and urinary retention. Interventions included catheter care every shift and change as ordered. The 5/30/2023 PA #6's progress note documented the resident was seen following their readmission from the hospital where the resident was treated for a UTI. There was no documentation related to the presence or indication for the indwelling catheter. The 6/1/2023 physician #7's progress note documented the resident had an indwelling catheter and recurrent UTIs. Recommendations included follow-up with urology and ask about a suprapubic pubic catheter (inserted directly into the bladder). There was no documented evidence an appointment was made for a urology consultation. The 6/20/2023 and 7/3/2023 PA #6's progress notes did not include documentation related to the catheter or its indication. Resident #11 was observed in bed with a catheter in place on 7/11/2023 at 5:00 PM and 6:23 PM; on 7/12/2023 at 11:12 AM and on 7/13/2023 at 2:00 PM. During an interview with Resident #11 on 7/12/2023 at 11:12 AM, they stated they received the catheter when they were hospitalized in 5/2023, and it had been in place since that time. The resident was unaware of the reason for the catheter. Prior to the hospital stay, the resident did not have a catheter and used incontinence briefs. The resident was unaware of any upcoming appointments. During an interview with registered nurse (RN) Manager #5 on 7/12/2023 at 3:10 PM, they stated the resident returned from the hospital with the catheter. They have not attempted to discontinue the catheter to date. They stated typically there would be a trial removal when the resident returned from the hospital. The RN Manager was unaware of a diagnoses for the resident's catheter. The RN Manager reviewed Resident #11's record and was unable to identify a diagnosis or reason for the catheter. The RN Manager was unaware if the resident had an appointment with urology and stated the Medical Records Director scheduled appointments. During an interview with the Medical Records Director on 7/12/2023 at 3:25 PM, they stated they did not make appointments for consultations due to the clinical information that was needed. The RN was responsible to make consultation referrals. They stated the Director of Nursing (DON) instructed them on this day to make an appointment for Resident #11 for a urology consultation. During a telephone interview with physician #7 on 7/13/2023 at 11:00 AM, they stated when a resident returned from the hospital with a catheter, the need for the catheter should be evaluated with a voiding trial as soon as possible. Urinary retention could be an indication for a catheter and could be a temporary condition and should be evaluated. If the resident was being seen by a urologist, the physician would defer to the urologist's recommendation, otherwise, they should try and remove the catheter. The physician stated if Resident #11 returned from the hospital on 5/25/2022 and had not seen urology and still had the catheter, they would expect a trial removal. They stated 6 weeks was too long to wait to evaluate or trial removal of the catheter. During a telephone interview with PA #6 on 7/14/2023 at 2:14 PM, they stated they were aware the resident returned from the hospital with a catheter. The PA made an error in their documentation by omitting a diagnosis of neurogenic bladder as a justification for the catheter. The PA stated they thought Resident #11 had urinary retention and the UTI was due to a neurogenic bladder. The PA did not refer the resident for a urology consultation. They stated they were made aware on this day, the resident refused to attend the appoint that was scheduled for the urologist. The PA stated the resident expressed they would like to keep the catheter due to it being easier. The PA stated their plan was to verify the resident refused to go to the urology appointment and then they would order a trial of voiding and encourage the resident to see the urologist. 10NYCRR 415.12(d)(2)
Mar 2022 10 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00292100 and NY00262523...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00292100 and NY00262523) conducted 3/6/22-3/14/22, the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote the healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #71) reviewed. Specifically, Resident #71 developed unstageable pressure ulcers (full-thickness tissue loss with the wound bed obscured by dead tissue) on their right and left heels and the planned intervention of heel protection boots was not consistently implemented. Findings include: The facility policy Pressure Wound Prevention revised 10/2021, documents to inspect skin on a daily basis when performing or assisting with personal care or ADLs. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.), moisturize dry skin daily, reposition resident as indicated on the care plan, and skin protection interventions as indicated on the care plan Identify risk factors for pressure ulcer development. For a person in bed, change position at least every two hours or more frequently if needed. For a person in a chair, change position at least every hour. Protect bony prominences as needed. When in bed, every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. Resident #71 had diagnoses including lumbar vertebrae fracture, congestive heart failure, and pulmonary hypertension. The 2/1/22 Minimum Data Set (MDS) admission assessment documented the resident had moderately impaired cognition, did not have behavioral symptoms, did not reject care, required extensive assistance of 2 bed mobility and toilet use, was totally dependent on 2 for bed mobility, personal hygiene, and dressing, was at risk for developing pressure ulcers, did not have pressure ulcers, and had pressure reducing devices for the bed and chair. The 1/26/22 Braden score (an assessment tool used to identify risk for pressure ulcers) documented the resident was at moderate risk for pressure ulcers. A 2/11/22 at 12:23 PM nursing clinical evaluation by RN Unit Manager #6 documented they were notified by therapy the resident had a wound on the left heel. Upon assessment the resident was noted to have a deep tissue injury wound on the left heel measuring 3 cm x 3.5 cm x 0 cm. Statasorb (waterproof dressing) was ordered. The Director of Nursing (DON) and physician assistant (PA) #32 were notified. The comprehensive care plan (CCP) initiated 2/12/22 documented the resident had alterations in skin integrity related to pressure injury (right heel DTI, purple or maroon localized area of discolored intact skin). Interventions included place heel protectors on resident (bilateral heels). The undated resident [NAME] (care instructions) documented to place heel protectors on resident's bilateral heels, adaptive devices foot booties on both heels when in bed. A wound assessment progress note by RN #28 dated 2/22/22 at 9:07 AM documented the resident had a suspected DTI on the right heel measuring 4.0 cm x 2.0 cm. The surrounding tissue was normal, and they were unable to visualize the wound bed. The plan was to paint with Betadine (antiseptic) twice daily and as needed (prn). The February 2022 ADL (activities of daily living) report documented foot booties on both heels when in bed every shift starting 2/12/22. From 2/12/22-2/28/22 the boxes to indicate if the booties were used as ordered were blank 12 times on the 10 PM-6 AM shift; 11 times on the 2 PM-10 PM shift; and 3 times on the 6 AM-2 PM shift. The Initial Wound Evaluation and Management Summary by wound physician #26 dated 2/22/22 documented at the request of attending physician #9 a thorough wound care assessment and evaluation was performed. The resident had an unstageable DTI to the right heel for at least 7 days duration. The DTI measured 2.5 cm X 3.5 cm and was 100% eschar (thick adhered black necrotic tissue). The resident had support surfaces including bed, pressure reduction cushion in chair, and non-skid socks and pillow for feet. The dressing treatment plan was skin prep (skin protectant) once daily for 30 days and recommendations for the plan of care included off-load wound and float heels in bed. On 3/1/22 wound physician #26 documented an unstageable DTI to the right heel which measured 3 cm X 5.0 cm X 0 cm. The wound had deteriorated, and the recommendation was for skin prep daily, off load the wound, and float heels in bed. EZ boot (worn to eliminate pressure on the heel) to be worn in bed and chair to off load the wound. On 3/8/22 wound physician #26 documented an unstageable DTI to the right heel measured 5.5 cm X 5.0 cm X 0.2 cm. The wound had deteriorated. There was an unstageable DTI to the left heel of at least 2 days duration, measuring 0.5 cm X 0.7 cm X 0 cm. The cause was listed as pressure, and the wound was 100% eschar (dry, dead tissue). Treatment recommendation was for skin prep daily to areas, off load wound, float heels in bed, and EZ boot to be worn in bed and chair to off load wound. A 3/8/22 at 2:00 PM wound progress note by RN #28 documented interventions being utilized included repositioning, care plan was updated. The right heel measured 5.0 cm x 5.5 cm x 0.2 cm and was a suspected DTI. Skin prep twice daily and prn, no covering; float heels while in bed; heel protector boots. Response to treatment: Deteriorated. The left heel had suspected DTI measuring 0.5 cm x 0.7 cm. Skin prep daily and prn, no covering, float heels in bed, heel protector boots. The March 2022 ADL report documented foot booties on both heels when in bed every shift starting 2/12/22. From 3/1/22-3/14/22 the boxes to indicate if the booties were used as ordered were blank 6 times on the 10 PM-6 AM shift; 8 times on the 2 PM-10 PM shift; and 12 times on the 6 AM-2 PM shift. The March 2022 TAR documented: - float heels while in bed every shift for pressure relief with a start date of 3/8/22. - heel protection boots on as tolerated every shift for heel protection with a start date of 3/8/22. The TAR documented the heel protection boots were in place 3/8/22-3/9/22. Observations of the resident included: - On 3/7/22, at 8:54 AM, the resident was in bed with their right foot elevated on a rolled blanket. There were no foot booties observed on either foot. -On 3/8/22 at 11:21 AM the resident was in bed with no socks and no heel booties or positioning to off load heels. There were no heel booties observed in the resident's room. -On 3/9/22 at 8:38 AM, the resident was in their wheelchair with no heel protection boots on. The certified nurse aide (CNA) had just completed care. - On 3/11/22 at 10:03 AM, the resident was in their wheelchair in their room with nonskid socks on their feet and was not wearing heel protection boots. The resident's lower extremities appeared edematous and there were no wheelchair pedals on the wheelchair. The resident's feet were resting directly on the floor. On 3/8/22 at 12:07 PM during an interview with RN Unit Manager #6 they stated the resident had no skin issues on admission. The pressure area on the right heel was discovered during a shower by physical therapy. When the wound was discovered, the interventions were for a Maxorb dressing every 3 days, and to float heels and wound care was notified at that time. The task to elevate heels was assigned to the certified nurse aides (CNA) and would be in the care record. Heel booties were recommended by wound care and the RN would get the boots and make sure it was on the [NAME]. CNAs were responsible for making sure the boots were in place. RN Unit Manager #6 stated the booties should be put in as a treatment order so that a nurse could visualize their presence. Licensed staff should be visualizing the correct interventions were in place. During the interview at 12:32 PM the resident remained in bed with no booties observed on their feet. The RN Unit Manager was unable to locate booties in the resident's room and stated they last saw the booties on Friday 3/4/22. On 3/8/22 at 12:54 PM during an interview with wound care physician #26 they stated this was their 3rd visit for the resident's right heel DTI. Recommendations were for EZ boot in and out of bed, in addition to previous treatment. The physician stated today the wound had become slightly larger. They could not recall if there was a boot in place on the resident's foot. The wound on the right heel measured 75 -80 % larger than last week. The physician stated today they had also identified a new DTI on the left heel. They recommended skin prep once daily and an offloading boot. There were several factors that may have influenced lack of healing including resident compliance, compromised vasculature, nutritional status, or proper use of interventions. On 3/8/22 at 1:36 PM during an interview with physical therapy assistant (PTA) #26 they stated they had never seen blue booties on the resident and the resident was wearing non-skid socks. On 3/8/22 at 4:10 PM, during an interview with RN #28, they stated they accompanied the wound care physician on weekly wound rounds. They were responsible for inputting treatment orders and updating the care plan. They stated interventions included elevating heels, heel boots, and turning and positioning. They stated they did not see blue booties on the resident that morning when entering the room for wound rounds. On 3/10/22 at 12:11 PM during an interview with licensed practical nurse (LPN) #29 they stated the resident did not need blue booties when they were admitted . The blue booties were ordered about 2 weeks ago and were to be worn in and out of bed. It was the responsibility of the LPNs and the CNAs to make sure the booties were on and being worn. The resident would wear them but could remove them. On 3/10/22 at 12:21 PM during an interview with CNA #31 they stated resident information was found in the computer in the [NAME]. The resident had boots for their feet to be worn when they were in bed and the resident had received them about 2 days ago. The boots were used to protect the heels, and the resident had a wound on the right foot. The CNA stated they remembered seeing the boots 2 days ago. They stated they were not sure if the boots had to be documented in tasks. On 3/10/22 at 1:06 PM during an interview with CNA #9 they stated the resident should have booties on their feet, but they were not sure they should be on one or both feet. The CNA stated the boots had been ordered for about a week or two. Any adaptive equipment was to be documented in the computer. The resident would wear the boots, and they were important to prevent skin breakdown, ulcers, or sores. On 3/14/22 at 10:10 AM, during an interview with the Director of Nursing, they stated Resident #71 was identified with pressure on 2/11/22. The interventions were in the care plan and visible to all nursing. CNAs signed for interventions including the blue boots. The blue boots were documented as tolerated by the resident, with no notes stating refusal. Wound deterioration would depend on many factors including infections, and resident compliance. 10NYCRR 415.12(c)(1,2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on observation, record review and interview during the recertification and abbreviated (NY00280940 and NY00285834) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents maint...

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Based on observation, record review and interview during the recertification and abbreviated (NY00280940 and NY00285834) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 6 residents (Resident #71) reviewed. Specifically, Resident #71 developed a pressure ulcer, and a timely nutritional assessment was not completed, and weights were not obtained as ordered. Findings include: The facility policy Weight Assessment and Interventions revised 5/2021 documents the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for the residents. Obtaining weights: the nursing staff will measure the resident weight within 24 hours of admission, weekly for four weeks, and then monthly. Weights will be recorded in the medical record for each resident. Any weight change of 5 pounds (lbs) in a month and 3 lbs in a week since the last weight assessment will be retaken within 48 hours. The licensed nurse will notify the dietitian of the weight change once reviewed. The dietitian notification should be documented in the resident's medical record. The dietitian will respond within 72 hours of notification. The threshold for unplanned and undesired weight change will be based on the following: 1 month, 5% weight change is significant, greater than 5% is severe; 3 months, 7.5% weight change is significant, greater than 7.5% is severe; and 6 months, 10% weight change is significant, greater than 10% is severe. Individual care plan shall address the identified cause of weight change, goals, benchmarks for improvement, and time frames and parameters for monitoring and reassessment. The facility policy Pressure Wound Prevention revised 10/2021 documents general prevention measures for pressure ulcers included ensuring the resident drinks plenty of fluids and eats a well-balanced diet. The dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment, monitor nutrition and hydration status, monitor laboratory values, and notify physician when appropriate. Resident #71 had diagnoses of congestive heart failure (CHF), lumbar fracture (mid lower spine), and pulmonary hypertension (HTN). The 2/1/22 Minimum Data Set (MDS) assessment documented the resident had mildly impaired cognition, required extensive assistance of 2 for bed mobility and toilet use, total dependence of 2 for transfers, limited assistance of 1 for eating, no weight was documented, the resident did not have weight loss/gain, was at risk for developing pressure ulcers, and did not have unhealed pressure ulcers. The Admission/readmission Evaluation signed 1/26/22 by the Director of Nursing (DON) documented the resident's most recent weight was 170 pounds taken with the wheelchair scale weight on 2/4/22. The resident had blanchable erythema (red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed) at the coccyx (end of spine). The resident's usual food intake pattern was adequate. The comprehensive care plan (CCP) initiated 1/27/22 documented the resident had a nutritional problem or potential nutritional problem related to CHF and pulmonary hypertension. Interventions included diet and consistency as ordered, follow weights as ordered, monitor skin condition, and reassess nutritional needs as indicated, report significant weight changes to physician and IDC (Interdisciplinary Team) for input, review meal/fluid consumption records, monitor labs as available, and offer the resident a snack every HS (hour of sleep). Physician orders dated 1/27/22 documented weights on admission/readmission, then weekly for 4 weeks, then monthly. A 1/27/22 registered diet technician (DTR) #18 progress note documented the resident was admitted with no dietary restrictions and meal preferences were obtained. Skin assessment and weight were pending. The 2/2/22 admission nutrition assessment by registered dietitian (RD) #19 documented the resident had orders for regular diet, regular consistency, and thin liquids. No supplements were ordered. No weight gain or loss of greater than 5% in past month or 10% in past 6 months. Skin was intact, with scratches on coccyx and left foot. The resident was identified as being at nutritional risk due to chronic CHF, HTN, and recent hospitalization. Goals included maintenance of weight. On 2/11/22 the weekly nursing wound assessment by RN Unit Manager #6 documented an Unstageable deep tissue injury (DTI) to the right heel 3.5 cm x 3.0 cm., cause was pressure. There was no documented evidence the clinical nutrition staff were notified of the resident's DTI. The CCP initiated 2/12/22 documented the resident had an actual pressure ulcer (right heel DTI). Interventions included place heel protectors on bilateral heels. There were no documented nutritional interventions. The weight record documented the resident weighed: - on 2/4/22, 170 lbs - on 3/8/22, 173.7 lbs. There were no documented weekly weights between 2/4/22 and 3/8/22. There was no documented evidence a nutritional assessment was completed after the discovery of the pressure ulcer on the right heel between 2/11/22 and 3/8/22. The resident was observed seated in the hallway feeding themselves lunch meal on 3/7/22 at 1:15 PM. On 3/8/22 the weekly nursing wound assessment by RN #28 documented an Unstageable DTI to right heel measured 5.0 cm x 5.5 cm x 0.2 cm., and response to treatment was deteriorated. The assessment documented a new Unstageable DTI to left heel 0.5 cm x 0.7 cm, cause was pressure. A progress note dated 3/8/22 by RD #19 documented suspected DTI to both heels, notification of dietary took place 3/8/22 by nursing. Current weight was 170 lbs, variable intakes of 26-100%. Estimated needs for skin were; energy 2318 kcals (calories), 96-108 grams of protein and 2318 cc (cubic centimeters) of fluid. Discussed with resident providing shakes and the resident agreed to try them. The plan was to add at all meals due to variable intake and skin concern. The care plan was updated. The resident was observed on 3/9/22 at 12:58 PM with their lunch meal. the resident's meal ticket noted lemonade, and they received iced tea. On 3/10/22 at 2:00 PM during an interview with registered dietitian (RD) #19 they stated they were here about 10 hours weekly, usually on Wednesdays. Communication typically took place by text as needed, and they also used a more secure texting application. The Director of Nursing (DON) or DTR were point persons if there were dietary needs. Tube feedings and weight changes were the big things that needed RD communication. If there was a pressure area the DTR did the initial note. Notification of pressure came from morning meetings. The 3/8/22 note was the first nutrition note regarding the resident's pressure because they had just been made aware that day. The pressure area was identified 2/11/22 by nursing and it was the expectation it would be communicated to nutrition as soon as it was identified. All high-risk concerns should be communicated. The RD stated it was important for nutrition staff to be notified of pressure injury due to the impact nutritional status had on wound healing. Wounds typically required additional calories, protein, and fluid. The RD stated the Director of Rehabilitation used to email notifications of wound care weekly and this was last done on 2/9/22 when the facility changed wound care providers. On 3/10/22 at 2:36 PM during an interview with the DTR #18, they stated the RD was notified of residents with difficulty chewing or swallowing, and new pressure ulcers. There used to be communication via a wound healing solutions spread sheet that was emailed by the Rehabilitation Director. There was a new wound care physician recently, and weekly skin update emails had stopped. The DTR stated they expected that a nurse manager or the DON would notify clinical nutrition of important changes. Nutrition staff needed to assess nutritional needs and review supplementation necessary for healing. The first notification they had received for the resident's pressure areas was on 3/8/22. If weights were not done timely, they told the nurse manager. The DTR stated staff were not being held accountable for weights that were not done and the DTR was not able to enforce the lack obtaining weights. They communicated to unit managers and the DON for help in getting response from staff. On 3/11/22 at 11:21 AM, during an interview with RN Unit Manager #6, they stated the right heel DTI was found on 2/11/22 during the resident's shower. The skin check form was not updated, but the initial event form was completed. When the area was found, the DON was notified. The stated they thought dietary had been notified. It was usually discussed in morning report. Any new admissions, falls, and any concerns are communicated at morning report. They were not sure how the communication with dietary was missed. On 3/14/22 at 10:10 AM during an interview with the DON, they stated nurse managers reported anything new in morning report every day. Morning report was to be attended by all departments, so resident status was communicated to team members. When pressure was identified, the Nurse Manager was to place orders from Tuesday wound rounds. Nutrition interventions were to be resident specific, after review of intakes, laboratory results, and weights. The DON was aware the resident's weights were not obtained as ordered. The list of weights was provided to dietary on Tuesdays. They would ask for reweights, or report weights that were still needed in morning report. The DON stated the Nurse Manager and the DTR kept reminding staff about weights. 10NYCRR 415.12(i)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview during the recertification and abbreviated (NY00287009) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents are free of any sig...

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Based on observation, record review, and interview during the recertification and abbreviated (NY00287009) surveys conducted 3/6/22-3/14/22, the facility failed to ensure residents are free of any significant medication errors for 1 of 12 residents (Resident #21) reviewed. Specifically, Resident #21 had a physician order for 1000 milligrams (mg) of Metformin (used to lower blood sugar) and was administered 500 mg of Metformin. Findings include: The facility policy Medication Administration, revised 12/2019, documents medications shall be administered in a safe and timely manner, and as prescribed. Resident #21 was admitted to the facility with diagnoses including diabetes. The 1/18/22 Minimum Data Set (MDS) assessment documented the resident had mild cognitive impairment and required extensive assistance for most activities of daily living (ADL). Physician orders dated 2/8/22 documented Metformin HCl tablet 500 mg, administer 1,000 mg by mouth two times a day for diabetes. The 3/2022 medication administration record (MAR) documented Metformin HCl 500 mg tablet starting 2/7/22. Staff were to administer 1,000 mg by mouth two times daily at 10:00 AM and 8:00 PM. During a medication administration observation on 3/9/22 at 9:00 AM, licensed practical nurse (LPN) #29 was observed giving one 500 mg tablet of Metformin to the resident. After administration, the LPN returned to the medication cart to sign for the medication. The surveyor asked them to review the order one more time before signing. The LPN stated, I missed it, I know they get two, they always get two. They stated that Metformin was used to treat diabetes and the resident's blood sugar could shoot up if not given correctly. 10NYCRR 415.12(m)(2)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to provide each resident with a nourish...

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Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 4 residents (Resident # 35) reviewed. Specifically, Resident #35 was not provided their soft salad sandwich at mealtime and was not offered a suitable substitution. Finding include: The facility policy Menu Substitution revised 4/2019 documents food substitutions will be made as appropriate and necessary. The Food Service Director, in conjunction with the clinical [registered] dietitian (RD) or registered diet technician (DTR) may make food substitutions as appropriate or necessary. The food service shift supervisor will make substitutions only when unavoidable. The resident's likes and dislikes will be considered when making substitutions. The 3/8/22 Lunch Production tally documented there were 2 orders of bite sized assorted ground salad sandwiches. Resident #35 had diagnoses including depression, dementia with behavioral disturbance, and general anxiety. The 1/20/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required supervision and assistance of 1 with eating, weighed 76 pounds (lbs.), received a mechanically altered diet, and did not have any significant weight changes. The physician's order dated 7/7/21 documented the resident was to receive a mechanical soft (ground meat) diet. During an interview with Resident #25 on 3/6/22 at 4:46 PM, they stated they had asked for ham salad or egg salad sandwiches and those types of sandwiches were listed on their meal ticket. The resident stated they always received peanut butter and jelly sandwiches and not ham, or egg salad as requested. During the lunch meal observation on 3/8/22 at 1:27 PM, Resident #35's meal ticket documented they were to receive a mechanical soft diet, 4 ounces (oz) cottage cheese, 8 oz ground turkey noodle casserole with no peas, 2 oz turkey gravy, 1 bite sized ground meat assorted salad sandwich, 2 oz mayonnaise, 2 oz melted margarine, 4 oz cinnamon applesauce, 8 fluid ounces (fl oz) cranberry juice, 4 fl oz water, 8 fl oz iced tea, 1 salt packet, 1 pepper packet, 2 sugar packets, and 1 creamer. The resident did not receive their bite sized ground meat assorted salad sandwich. Medical records staff #30 was observed telling Resident #35 the kitchen did not have any ground meat sandwiches made. Kitchen staff told them the blender was dirty and they could make the resident either a peanut butter and jelly sandwich or a grilled cheese sandwich. Resident #35 stated they did not want a peanut butter and jelly sandwich and would like a grilled cheese sandwich. During an interview on 3/10/22 at 11:06 AM, DTR #18 stated there was no sandwich rotation at the facility. They stated Resident #35's meal pattern documented they should receive a ground assorted meat sandwich, such as tuna salad, ham salad, turkey salad, chicken salad, or egg salad. If it was on the production tally the kitchen staff should have made it. The residents should receive all the items listed on their meal tickets for nutrition reasons and to honor their preferences. On 3/10/22 at 2:35 PM, RD #19 stated a resident should receive all the items listed on their meal ticket and the kitchen staff should follow the production tallies. An acceptable assorted ground meat salad sandwich would include sandwiches such as tuna salad, ham salad, turkey salad, chicken salad, or egg salad. Peanut butter and jelly and grilled cheese were not considered an assorted ground meat salad sandwich. Staff should not have told the resident the blender was dirty. It was important to provide the items listed on the meal ticket for resident rights and nutrition reasons. On 3/11/22 at 10:59 AM, the Food Service Director (FSD) stated kitchen staff should make all the items on the production tally. Staff should not have told the resident the blender was dirty. Acceptable ground meat salad sandwiches included sandwiches such as tuna salad, ham salad, turkey salad, chicken salad, or egg salad. Grilled cheese and peanut butter and jelly were not a ground meat salad sandwich. They were unaware the production tally was not followed, and the resident's rights and choices were not honored. 10NYCRR 415.14
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review during the recertification and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to ensure each resident was treated with...

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Based on observation, interview and record review during the recertification and abbreviated surveys (NY00288852) conducted 3/6/22-3/14/22, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of quality of life for 72 of 78 residents reviewed. Specifically, on during the lunch meal on Sunday 3/6/22, residents received their food on disposable dishes. Additionally, during the resident group meeting 1 anonymous resident stated meals were frequently served on plastic disposable dishes on the weekends. Findings include: The facility Your Rights as a Nursing Home Resident booklet dated 6/2010 documents each resident has the right to be treated with dignity, respect, and consideration at all times. The facility Meal Service Policy revised 9/2021 documents a comfortable and attractive atmosphere will be maintained. The 3/6/22 Food Service staff schedule documented: - 1 [NAME] scheduled 6 AM - 2 PM, - 1 Diet Aide scheduled 8 AM - 8 PM, - 1 Diet Aide scheduled 6 AM - 2 PM, which documented Called In, - 1 [NAME] scheduled 12 PM - 8 PM, - 1 Diet Aide scheduled 3 PM - 8 PM, and - 1 Diet Aide scheduled 4:30 PM - 8 PM. The facility's undated mealtime schedule documented: - the breakfast line started at 8 AM and the last meal cart left the kitchen at 8:45 AM and - the lunch line started at 12 PM and the last meal cart left the kitchen at 12:45 PM. On 3/6/22 at 1:21 PM, the lunch trays on the South unit were observed being served in plastic disposable containers. On 3/6/22 at 5:54 PM, an anonymous family member stated meals were served in plastic disposable containers on the weekends and showed a picture on their phone of a recent meal on a weekend. The picture showed macaroni and cheese served in a plastic container. On 3/7/22 at 9:44 AM during the resident group meeting an anonymous resident stated on the weekends they received their meals in plastic disposable containers instead of the regular dishes their meals were served on during weekdays and their meals were often cold. During an interview with registered diet technician (DTR) #18 on 3/10/22 at 11:06 AM, they stated they were unaware the lunch meal was served in plastic disposable dishes until they came into the building around 1 PM. They stated serving the resident's meals on disposable plastic dishes was not considered dignified if it was due to lack of staffing in the kitchen. During an interview with the registered dietitian (RD) #19 on 3/10/22 at 2:35 PM, they stated they were not aware the residents received their lunch meal on plastic disposable dishes and every effort should be made to use regular dishes. They stated it was not a dignified dining experience if plastic disposable dishes were used due to lack of staff in the kitchen. During an interview with cook #11 on 3/11/22 at 10:42 AM, they stated they worked on 3/6/22 and the kitchen was short staffed. One of the dietary aides called in, which resulted in only themself and 1 other dietary aide during the day shift. They stated on the weekends the kitchen was frequently short staffed due to staff calling in. They stated serving the resident's meals on plastic disposable dishes was not dignified, but there were only staff members working in the kitchen and there was a lot to do. During an interview with the Food Service Director (FSD) on 3/11/22 at 10:59 AM, they stated resident meals should only be served on plastic disposable dishes in an emergency and being short staffed was not considered an emergency. They were made aware the kitchen was short staffed on 3/6/22 at 9:15 AM and they approved kitchen staff to use plastic disposable dishes for the lunch meal. They stated it was not dignified to serve the resident's meal on disposable plastic dishes due to lack of kitchen staff. During an interview with the Administrator on 3/11/22 at 2:09 PM, they stated they were not aware the lunch meal on 3/6/22 was served on plastic disposable dishes due to lack kitchen staff and they did not consider that a dignified dining experience. During an interview on 3/14/22 at 1:11 PM, the Regional RD #20 stated lack of staff was not an appropriate reason to serve the resident's meal on plastic disposable dishes and they did not consider that a dignified dining experience. 10NYCRR 415.5(a)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification and abbreviated surveys (NY00262523, NY00280940...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the recertification and abbreviated surveys (NY00262523, NY00280940, NY00270167, NY00288852, NY00276986, NY00282348, NY00283195, NY00285834 and NY00290976) conducted 3/6/22-3/14/22, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 11 residents (Residents #35, 50, 71 and 75) reviewed. Specifically, Resident #50 did not receive incontinence care as requested; Resident #71 did not receive assistance with care and transfers out of bed as requested and missed therapy; Resident #75 did not receive a shower on their designated/care planned day: and Resident #35 did not have their call bell answered timely. Findings include: The facility policy ADL Support revised 10/2019, documents the residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLS independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility policy ADL- Personal Hygiene revised 10/2021 documents residents' baths or showers will be scheduled per resident preference but at least weekly. Nail care should be provided as needed for the resident. Toileting/incontinence care for a resident will be provided as needed for each individual resident per care plan and [NAME] (care instructions). The following should be recorded in the resident medical record: the name and title of person providing care. All observation data and care given will be documented in the POC (point of care) system for ADLs. The CNA should report to the licensed nurse any concerns/observations during care. The facility policy Call Light System - Resident Response dated 12/2017, documents providing timely response to residents in need of assistance is essential to ensuring high quality resident outcomes. Answer the resident's call light as soon as possible, listen to the resident request, and if able to perform task/request, turn call light off and complete the task/request. 1) Resident #75 had diagnoses including schizoaffective disorder and diabetes. The 2/20/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not reject care, felt it was very important to choose between a tub bath, shower, bed bath, or sponge bath, required extensive assistance of 1 with personal hygiene, extensive assistance of 2 for transfers, and was totally dependent on staff for bathing. The 3/2022 Activities of Daily Living (ADLs) Task Care Record documented the resident's shower/bath was scheduled on Monday day shift. There was no documented evidence the resident received a shower on 3/7/22. Additionally, there was no documentation for any ADL tasks for the 6:00 AM-2:00 PM shift on 3/7/22. There were no showers documented as being given to the resident in the ADLs Task Care Record between 3/1/22-3/11/22. The 3/11/22 care instructions documented the resident was totally dependent on 1 staff for bathing, the resident did not participate in the activity at all, and their shower day was Monday on the day shift (6:00 AM-2:00 PM). During an interview and observation on 3/7/22 (Monday) at 2:00 PM, the resident's hair was observed to be greasy. The resident stated they did not receive their shower that day and Monday was their shower day. On 3/8/22 at 2:26 PM, the resident was observed in the hall gathering washcloths from the linen cart. The resident's hair was greasy. They stated they had not received their shower on Monday, 3/7/22 and did not like feeling dirty. The resident started to cry. On 3/8/22 at 2:28 PM, licensed practical nurse (LPN) #7 was observed telling certified nurse aide (CNA) #3 to get a shower chair and take the resident to the shower. During an interview 3/10/22 at 11:26 AM certified nurse aide (CNA) #3 stated the resident's shower day was on Wednesday during the day shift. The resident required assistance of 2 staff for showering. If they were short staffed that would be a reason why the resident did not get their shower on their designated shower day. CNA #3 stated they gave the resident a shower on 3/8/22 after LPN #7 directed them to do so. LPN #7 assisted them with the resident's shower. During an interview on 3/10/22 at 1:40 PM, CNA #23 stated they were assigned to Resident #75 on 3/7/22 and did not recall giving the resident a shower that day. The resident attended a Resident Council meeting that morning. They did not offer the resident a shower later in the shift because they ran out of time and the resident required two staff to shower them. CNA #24 also worked on the unit Monday, 3/7/22, and had floated from the North unit. CNA #23 stated their resident assignments were posted on the corkboard near the unit nursing office. Residents who were to receive showers on that day would be listed on the board. During an interview on 3/10/22 at 1:42 PM with CNA #3, they stated Resident #75 did not usually refuse showers. If staff did not have time to give a resident a shower, they should notify the nurse. During an interview on 3/14/22 at 11:40 AM, LPN #7 stated the resident did not get their shower on 3/7/22 because they had attended a Resident Council meeting. Staff did not attempt to give the resident a shower the rest of the day and they should have. The resident had not refused showers. If a resident did not get a shower the CNA should notify the nurse. The LPN stated on 3/8/22 they told CNA #3 to give the resident a shower after seeing them in the hall upset about it. They assisted CNA #3 with the resident's shower, and they told CNA #3 to make sure it was documented as being given. The CNAs should be documenting showers otherwise it looks like it was not done. 2) Resident #71 had diagnoses including lumbar vertebrae fracture, congestive heart failure, and pulmonary hypertension. The 2/1/22 Minimum Data Set (MDS) admission assessment documented the resident had moderately impaired cognition, did not have behavioral symptoms, did not reject care, required extensive assistance of 2 bed mobility and toilet use, was totally dependent on 2 for bed mobility, transfers, personal hygiene, and dressing. The comprehensive care plan (CCP) initiated on1/26/22 documented the resident required assistance with activities of daily living (ADLs) related to confusion, fatigue, and limited mobility. Interventions included extensive assistance of 1 for personal hygiene. The CCP was updated on 2/8/22 and included extensive assistance of 1 for transfers, dressing, toilet use, and bed mobility. Observations of Resident #71 included: -On 3/7/22 at 8:54 AM the resident was in bed wearing the same shirt as 3/6/22. -On 3/8/22 at 11:21 AM the resident was in bed with no socks on. The resident stated they were upset because they did not go to physical therapy that morning. - On 3/8/22 at 12:32 PM the resident remained in bed. There was bloody drainage on the bedspread. They stated they did not attend therapy that morning because they were still in bed. The resident stated they were discouraged because they were at the facility to receive therapy. The resident complained of pain in their back and right heel. -On 3/8/22 at 1:15 PM The resident was lying in bed and had spilled their lunch tray. Staff was assisting the resident with clean up. The resident stated they preferred to eat meals sitting up in their wheelchair. - On 3/10/22 at 11:53 AM the resident was in their wheelchair in their room. The resident stated they wanted to go to bed at 7 PM the night prior, and it was 9:30 PM before they received help to go to bed. The resident stated this morning they were not helped to get up until 9:25 AM. The resident stated sometimes it takes as much as 2 hours to have their call bell answered. -On 3/14/22 at 10:57 AM the resident was in bed and stated they would like to get up for therapy. On 3/14/22 at 12:19 PM during an interview with certified nurse aide (CNA) # 31, they stated they assisted the resident with care that morning at about 7 AM. The CNA stated they did not assist the resident out of bed at that time because there were only 2 aides on the floor. They stated there was no overlap of night staff and day staff. The resident was supposed to be up for therapy. They stated the therapist came and got the resident up and took them to the gym for therapy. On 3/14/22 at 12:30 PM during an interview with physical therapy assistant (PTA) #38, they stated the resident attended therapy that morning. They had hoped staff would have the resident out of bed and ready for therapy. The PTA stated they got the resident up and assisted them to the therapy gym. They were not always able to find staff to assist with care and transfer, which had resulted in the resident missing therapy. 3)Resident #35 had diagnoses including dementia with behavioral disturbances, anxiety disorder, and severe protein-calorie malnutrition. The 2/23/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required limited to extensive assistance with most activities of daily living (ADLs) and was always incontinent of urine and bowel. The comprehensive care plan (CCP) initiated 7/8/21 documented the resident was at risk for falls related to the disease process. Interventions included anticipate and meets needs, be sure call light is within reach and encourage to use for assistance as needed, provide toileting assistance per resident's needs and therapy recommendations. The resident required assistance with ADLs related to generalized weakness, malnutrition, cachexia, and COPD. The resident required limited to extensive assistance with ADLS. The undated care instructions documented be sure the resident's call light is in reach and encourage to use for assistance as needed. The following observations were made of resident call bells not being answered appropriately and/or timely on 3/6/22: - At 1:48 PM, several call bells were ringing, while staff were picking up lunch trays. - At 2:08 PM, Resident #35's call bell was on, and the resident stated they were waiting on staff to assist with cleaning up. - At 2:21 PM (13 minutes later), Resident #35's call bell remained on. - At 2:28 PM, an unknown staff member walked by Resident #35's room while the call bell remained on. - At 2:33 PM, an unknown staff member entered Resident #35's room and turned off the call bell. The staff member immediately walked out of the room, and down the hall without providing care. - At 2:44 PM, Resident #35's call bell was on, and 2 unknown staff walked by the room and did not acknowledge the call bell. - At 2:45 PM, Resident #35's call bell remained on, and an unknown staff member walked by the room. The resident stated they had a wet brief and needed staff to assist them. - At 2:56 PM Resident #35's call bell remained on. An unknown staff member was observed walking in the room, the bell was shut off and the staff member walked out of the room without providing care. - At 3:03 PM, Resident #35 said their call bell was shut off by staff and they still needed assistance. - At 4:14 PM, Resident #35 turned their call bell on while the surveyor was in the room, and an unknown staff walked by the room without acknowledging the call bell. - At 4:20 PM, the call bell was shut off and the resident was assisted by staff. - At 5:17 PM, several call bells were ringing while 6 staff members were observed standing and talking around the 2 medication carts centrally located on the unit. On 3/10/22: - At 9:27 AM, Resident #35's call bell was on, and certified nurse aide (CNA) #3 entered the resident's room. The call bell was shut off. CNA #3 was observed walking out of the room at 9:27 AM without providing care. - At 9:29 AM, the resident stated they had asked the staff for some fresh ice water. - At 9:36 AM, CNA #3 stated the resident just mentioned there was no ice in their water and they shut off the call bell. The resident did not mention they wanted ice water. They stated answering call bells and assisting the resident's with requests was the responsibility of all the aides. During an interview on 3/14/22 at 9:51 AM, CNA #4 stated everyone was responsible for answering call bells. When they enter the room and shut the light off, they should address the resident needs or notify a nurse who can assist the resident. During interview on 3/14/22 at 10:12 AM, licensed practical nurse (LPN) Unit Manager #5 stated call bells were everyone's responsibility. Any level of staff member could answer a resident's call bell. When the resident's door was closed and the call bell was ringing, staff should knock and check in the room to see if staff and/or resident need assistance. The Director of Nursing (DON) was interviewed on 3/14/22 at 1:22 PM, they stated call bells were the responsibility of everyone. All staff, not just nursing, were required to answer call bells. Staff should ask the resident what they need and then reach out to appropriate staff person that would be able to assist with the task. 10NYCRR 415.12(a)(3)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review during the recertification and abbreviated (NY00288852) surveys conducted 3/6/22- 3/14/22, the facility failed to ensure the resident menus were foll...

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Based on observation, interview, and record review during the recertification and abbreviated (NY00288852) surveys conducted 3/6/22- 3/14/22, the facility failed to ensure the resident menus were followed for 5 of 18 meals observed. Specifically, the facility ran out of preplanned menu items and substituted with items that were not nutritionally equivalent, served inadequate portion sizes, and did not inform the residents of menu substitutions. Finding included: The facility policy Portion Control dated 4/2019 documents the menu items shall be served according to pre-determined portion size. The portion size on spreadsheet reflects the amount of the menu item required to provide nutrient standards for that item when prepared according to the standardized recipe. The facility policy Menu Substitution revised 4/2019 documents food substitutions will be made as appropriate and necessary. The Food Service Director, in conjunction with the clinical [registered] dietitian (RD) or diet technician registered (DTR) may make food substitutions as appropriate or necessary. The food service shift supervisor will only make substitutions when unavoidable. The resident's likes and dislikes will be considered when making substitutions. The facility's undated, Food and Nutrition Services Director (FSD) job description documents the FSD maintains accurate records of food supplies, plans, designs, determine menu costs, and forecast the needs of the department. The facility's undated Cook job description documents the cook reviews menus prior to preparation of food, prepares meals in accordance with planned menus, serves food in accordance with established portion control procedures, and prepares food in accordance with standardized recipes and special diet orders. The menu substitution log documented on 3/6/22: - There were no carrots and peas were substituted. - The facility was short 10 chicken breasts and chicken salad was substituted. - The facility was short an undocumented amount of broccoli and cauliflower was substituted. - The facility was out of pudding and ice cream was substituted. - The facility was out of cottage cheese and Magic Cup (an oral nutritional supplement) was substituted. - The facility was out of Mighty Shakes (an oral nutrition supplement) and was substituted with Magic Cups (a frozen nutritional supplement). - The facility was out of orange juice and substituted apple juice. The 3/6/22 approved, pre-planned, and posted dinner menu documented chicken sandwich, mustard, potato steak fries, ketchup, broccoli, fruit cocktail, 2% milk and beverage of choice. The alternate meal items were tuna melt sandwich and carrots. During the dinner meal observation on 3/6/22: - At 5:12 PM, the Food Service Director (FSD) stated there were no carrots to serve and they would serve peas instead. They crossed off carrots and wrote peas on Resident #58's meal ticket. - At 5:24 PM, carrots were crossed off Resident #13's meal ticket and they received peas instead. - At 5:46 PM, broccoli was crossed off Resident #25's meal ticket by the registered diet technician (DTR) #18 and cauliflower was written on for the substitution. - At 6:01 PM, Resident #58 meal ticket had broccoli crossed off and cauliflower written on it, - At 6:03 PM, cook #12 stated there were no more chicken breasts for the sandwiches so they would serve chicken salad sandwiches instead. At that time 11 chicken salad sandwiches needed to be prepared. - At 6:04 PM, Resident #27's meal ticket had broccoli crossed off and cauliflower written on it. - At 6:10 PM, the FSD stated they were going to make10 chicken salad sandwiches for a total of 16 more to complete the dinner meal service. Residents were not observed being informed of the menu substitutions. During the resident group meeting on 3/7/22 at 10:00 AM, 1 anonymous resident stated the facility ran out of everything on the menu. The menu substitution log documented on 3/7/22: - The facility was out of yogurt and substituted applesauce. - The facility was out of Mighty Shakes and substituted Two Cal (an oral nutrition supplement). - The facility was out of carrots and peas were documented to be substituted, but broccoli was served instead. - The facility was out of Magic Cups and substituted Two Cal. - The facility was out of yogurt and substituted fruit cups. - The facility was out of lemonade and iced tea was substituted. - The facility was out of cottage cheese and 4 oz of Two Cal was substituted. - The facility was out of carrots and broccoli was substituted. - The facility was out of Mighty Shakes and 4 oz Two Cal was substituted. The 3/7/22 approved, preplanned, and posted lunch menu documented baked lemon pepper fish, lemon butter, garden rice, carrots, blonde brownie, and beverage of choice. The alternate food items were meat loaf sandwich and broccoli. During the lunch meal observation on 3/7/22: - At 12:37 PM, in the dining room an unknown number of residents received broccoli instead of carrots on their trays; and - At 12:43 PM, Resident #27's lunch received a fruit cup instead of cottage cheese and iced tea instead of lemonade. Residents were not observed being informed of the menu substitutions. The facility's 3/7/22 food purchase order to be delivered on 3/8/22 did not document any top round roast beef or bacon was ordered. The 3/8/22, approved, preplanned, and posted breakfast menu documented cranberry juice, cream of wheat, scrambled eggs, bacon slices, assorted muffins, margarine, 2% milk, and coffee. Alternative food items were farina, cold cereal, hard boiled eggs, white toast, and margarine. The facility's 3/8/22 breakfast production tally indicated there were 40 preplanned servings of 2 slices of bacon. On 3/8/22 at 8:43 AM during the breakfast meal observations the resident's received 1 slice of Canadian bacon instead of 2 slices of bacon documented on the approved, preplanned, and posted menu. The resident's meal tickets and posted menus did not indicate that a substitution had been made. The 3/8/22 lunch meal production tally did not document how many servings of lemonade were needed for the lunch meal. During the lunch meal observation on 3/8/22 at 1:03 PM iced tea was written on meal tickets and lemonade was crossed out. The menu substitution log documented: - On 3/8/22, the facility was out of mashed potatoes and a muffin was substituted, and - On 3/8/22, the facility was out of cauliflower and broccoli was substituted, and The substitution log did not document that Canadian bacon was substituted for bacon slices, or iced tea was substituted for lemonade. During an interview with cook #14 on 3/8/22 at 1:44 PM, they stated there was no bacon in the freezer for breakfast so they asked the Food Service Director what they should use for the substitute and was told to use Canadian bacon. They stated all menu substitutions should be documented on the substitution log, they were unsure who documented the substitutions, and they did not know who completed the food ordering for the facility. The 3/8/22, approved, preplanned, and posted dinner menu documented vegetable soup, grilled cheese, cauliflower with parsley, frosted chocolate cake, 2% milk and beverage of choice. The alternate food items were grilled turkey and cheese sandwich, garden rice, and broccoli. The dinner meal production sheet documented 18 servings of lemonade, 8 peanut butter and jelly sandwiches, 56 (6) oz servings of vegetable soup and 49 (4) oz servings of cauliflower. The facility's undated peanut butter and jelly sandwich recipe documented to spread 2 tablespoons of peanut butter on one slice of bread and spread 1 tablespoon of jelly on the other slice of bread. At 6:31 PM on 3/8/22, during an observation of the facility's main cooler and freezer there was no beef, other than beef patties, for the BBQ beef sandwich which was to be served on 3/9/22 at the dinner meal. There was no bacon for the breakfast meal to be served on 3/10/22. During the 3/8/22 dinner meal observation: - At 7:00 PM, diet aide #17 was observed making peanut butter and jelly sandwiches. The sandwich had a smear of peanut butter and a light coating of jelly. Diet aide #17 stated they did not follow a recipe when making the sandwiches and was unaware of how much peanut butter and jelly were needed to make the sandwich. - At 7:06 PM, cook #12 was observed ladling soup in bowls. They were using a 6 oz ladle but were not putting a full ladle into the bowls. The contents of the soup bowl was measured and contained 3.5 oz - At 7:11 PM, cook #12 stated there was no more vegetable soup. - At 7:13 PM, the facility Administrator and Regional Administrator were observed taking 4 cans of vegetable soup from the emergency food supply area. - At 7:37 PM, cook #12 was observed using a 4 oz scoop to dish cauliflower, the scoop was not a full scoop. The scooped cauliflower was weighed at 1.5 oz. - At 7:38 PM, cook #12 stated there was no more cauliflower and they would make broccoli for the remaining dinner trays. During an interview on 3/8/22 at 7:53 PM, cook #12 stated the production sheets indicated what scoop size to use for each food item. They used a 4 oz scoop for the cauliflower and a 6 oz scoop for the vegetable soup. They stated they were unaware they did not serve the correct portion sizes. During an interview with the Food Service Director on 3/8/22 at 7:56 PM, they stated the cooks used the production tally to determine what scoop size was needed for each food item being served. The cook should follow the production tally to ensure the correct quantity of food was made and the correct portion size was given. The production tally indicated a 6 oz serving size for the vegetable soup and 3.5 oz was not the correct serving size. The correct serving size for the cauliflower was 4 oz and 1.5 oz was not the correct serving size. The facility had a recipe for the peanut butter and jelly sandwich and there was not enough peanut butter or jelly on the sandwiches served. They were unaware of issues with the serving sizes or recipes not being followed. They stated it was important to follow the recipes and provide the correct portion sizes to ensure residents received adequate nutrition. They stated cook #12 was trained for a week by the previous cook. During an interview with the registered diet technician (DTR) #18 on 3/8/22 at 8:13 PM, they stated the serving size for the cauliflower was 4 oz and the vegetable soup serving size was 6 oz. It was not acceptable to serve 1.5 ounces of cauliflower and 3.5 oz of soup. They stated there was not enough peanut butter or jelly on the sandwiches. They were unaware the portion sizes or recipes were not being followed During an interview with registered dietitian (RD) #19 on 3/8/22 at 8:17 PM, they stated they looked at meal consumption and other factors when assessing the resident's nutritional status and they assumed the recipes and portion sizes were being followed to allow for an accurate assessment of intakes. The 3/9/22 approved, preplanned, and posted dinner menu documented BBQ beef on a bun with BBQ sauce, baked beans, corn, peach cobbler, 2% milk, and beverage of choice. The alternate meal items were grilled cheese and carrots. During an observation of the facility's main cooler and freezer on 3/9/22 at 8:25 AM, frozen beef patties were the only beef item in the freezer. The facility's undated BBQ beef recipe documented a top round roast was to be used. On 3/9/22 at 9:21 AM, the facility purchased $189.33 worth of roast beef at a local store for the BBQ beef to be served for dinner. The 3/10/22 approved, preplanned, and posted breakfast menu documented apple juice, cream of wheat, scrambled eggs, bacon slices, assorted muffins, margarine, 2% milk, and coffee. The alternate food items were cold cereal, farina, hard boiled eggs, white toast, and margarine. On 3/10/22 at the breakfast meal the residents were served breakfast sausage patties instead of bacon slices. During an interview with DTR #18 on 3/10/22 at 11:06 AM, they stated the facility did not complete any audits on portion sizes and they were unaware of any issues with portion sizes until the dinner meal on 3/8/22. They stated sometimes the cooks did not prepare enough food and would have to substitute items or cook more. Sometimes there was not enough food in the building. The DTR stated the Food Service Director informed them on Sunday there were no carrots in the building, and they told the Food Service Director to use peas for the substitution, but broccoli was used instead. On 3/7/22 at breakfast they were informed by the Food Service Director there was no bacon and Canadian bacon would be used instead. The DTR stated they were not consistency made aware of menu substitutions but expected to be. They stated if it is known an item needed to be substituted the residents should be made aware prior to the meal service. They stated if the residents received broccoli for 3 days that was not variety. They stated the Food Service Director did the ordering, but in the past, they had to place orders. They were asked by a corporate food purchaser to cut back $250 from their order and they let the facility Administrator know they needed the items they purchased. They had heard the Food Service Director was under budget recently and they were unsure what they do to keep the cost under budget. On 3/10/22 at 1:56 PM, the Dietary Purchasing Team Lead stated the facility's food budget depended on the facility's average census. The facility placed their food orders on Mondays and Wednesdays. The purchasing department did not oversee the facility's food orders. If they were made aware the facility needed items they would work with the facility and vendor to get the items. The last 4-5 orders the facility has been under their targeted spending. They stated the food vendor does send out an out of stock list and provides substitutions. They stated both bacon and roast beef were in stock and had not been purchased on the previous 2 invoices processed. They stated they had helped the facility's FSD when they were hired to learn the computerized ordering system. During an interview with RD #19 on 3/10/22 at 2:35 PM, they stated they were at the facility 1 day a week. When they completed meal round observations, they did not notice any issues with portion sizes or recipes not being followed. They expected to be notified if there were issues. The RD stated they were made aware of menu substitutions by DTR #18, and they signed off on substitutions when they were at the facility. If DTR #18 had any questions regarding substitutions, they would ask. Staff should be following the production tallies, recipes, and provide the correct portion sizes. During an interview with the Food Service Director on 3/11/22 at 10:59 AM, they stated the facility's food orders were placed twice a week, on Mondays and Wednesdays and the delivery was received the next day. The facility must have run out of bacon prior to 3/8/22. They stated when they placed the order on 3/2/22 there was bacon in the facility. Canadian bacon was an approved substitution, and the meal tickets should have reflected the change along with the posted menu, but they were unsure why that did not happen. On 3/7/22 they did not have enough carrots and broccoli was used instead. On 3/8/22 there was not enough cauliflower and DTR #18 suggested they use peas. The residents on mechanically altered diets could not have peas so they used broccoli instead. They used the substitution log when they placed the food order to determine if more of a product should be purchased. They were unsure why there had been so many recent substitutions and there was no official food inventory being done. They stated it was important for the cooks to follow the production sheets and serve the proper portion sizes to ensure the residents were receiving enough calories and their preferences were honored. The Food Service Director stated they did not order the top round beef for the BBQ beef sandwich, as they were going to use ground beef. They knew the BBQ beef sandwich called for top round beef, but the previous FSD taught them how to finagle the menu to cut cost. The Food Service Director stated they should be following the recipes and ordering the items the recipes called for. The recipes and menus were approved and preplanned to meet the resident's needs. The stated they never noticed any issues with portion sizes until 3/8/22 during the dinner meal. During an interview with the facility Administrator on 3/11/22 at 2:09 PM, they the facility did frequent test trays and there were no issues with portion sizes. They were unaware the proper portion sizes or recipes were not being followed. They expected the residents to receive the proper portion sizes and recipes to be followed. They were unaware there had been multiple menu substitutions and would expect to be notified. Meal substitutions should be documented, and the residents should be made aware. They stated the facility did not frequently purchase food from local stores. During an interview with Regional RD #20 on 3/14/22 at 1:11 PM, they expected the residents to receive the portion sizes documented on the production tallies and staff to be follow the recipes as the menu was preplanned and approved to meet the resident's nutritional needs. The Food Service Director should follow the recommendations DTR #18 and RD #19 made for menu substitutions. During a follow up interview with the Food Service Director on 3/14/22 at 3:35 PM, they stated the facility ran out of chicken breast during the 3/6/22 dinner meal and they needed to make a change on the fly and went with chicken salad as both residents who received a mechanical soft diet (ground), and regular diet could have it. It still met the resident's needs it was just different than what they were expecting. 10NYCRR 415.14(c)(1-3)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00288852 and NY00270167) conducted 3/6/22-3/14/22, the facility failed to ensure food and drink...

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Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00288852 and NY00270167) conducted 3/6/22-3/14/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 meals observed and for 1 of 2 meal test trays. Specifically, the cranberry juice served at dinner on 3/8/22 was watered down and not palatable, the chicken noodle soup served at lunch on 3/8/22, was not attractive, and the test tray for the dinner meal on 3/7/22 was bland and not served at safe and appetizing temperatures. Additionally, Residents #13, 34, 37, 44, 50 and 75 and several anonymous residents during the resident group meeting stated the food was not palatable, appetizing, and was often served cold. Findings include: The facility policy Food Safety-Food Handling revised 9/2021 documents the food will be stored prepared, handled, and served so that the risk of foodborne illness is minimized. The facility policy Meal Service revised 9/2021 documents meals will be served promptly to maintain adequate temperature and appearance. The facility policy Standardized Recipes revised 6/2021 documents only tested, standardized recipes will be used to prepare foods. The facility's printed recipes documented 2% milk should be chilled to 38-41 degrees Fahrenheit (F) and French fries should be held for service at 140 degrees F. 1) Palatability During an interview with Resident #44 on 3/6/22 at 5:16 PM, they stated the food was always cold and did not taste good. During an interview with Resident #13 on 3/6/22 at 5:54 PM, they stated the food was usually cold and did not look appealing. During an interview with Resident #34 on 3/6/22 at 6:15 PM, they stated French fries were served cold. On 3/6/22 at 6:31 PM, a test tray was completed at the end of the dinner service. The following temperatures were observed: - 2% milk was 43 degrees F, - broccoli was 120 degrees F and tasted bland, - French fries were 112 degrees F, and - chicken salad sandwich on white bread was 62 degrees F. The chicken salad tasted bland, contained a small amount of mayonnaise, and had little to no seasoning. On 3/7/22 at 10:00 AM, during the resident group meeting an anonymous resident stated, the food was not good and was cold. The resident stated the eggs and soup were cold and the juice tasted watered down. During an interview with Resident #50 on 3/7/22 at 11:52 AM, they stated the food was cold and did not always taste good. During an interview with Resident #37 on 3/7/22 at 1:21 PM, they stated the coffee did not always taste like coffee and their cake was hard. During an interview with Resident #75 on 3/7/22 at 2:02 PM, they stated the food was usually cold. During a meal observation on 3/8/22 at 6:40 PM, the cranberry juice poured into cups from the juice dispenser appeared light pink in color. When tasted the cranberry juice was not palatable and tasted watery. Dietary aide #13 observed the glasses of cranberry juice and stated they were very light pink in color. When dietary aide #13 poured another glass of cranberry juice from the dispenser they stated it looked very light pink. Dietary aide #13 checked the cranberry juice bag for the dispenser and stated the bag was empty. On 3/8/22 at 6:47 PM, the Administrator and Regional Administrator observed the cranberry juice and stated it was light in color. The Regional Administrator tasted the cranberry juice and said it was not flavorful. During an interview with registered diet technician (DTR) #18 on 3/10/22 at 11:06 AM, they stated acceptable serving temperatures for hot food items was 140 degrees F or above and cold food should be served 40 degrees F or below for palatability. The Food Service Director was responsible for ensuring the cooks were taking and recording the food temperatures. During an interview with registered dietitian (RD) #19 on 3/10/22 at 2:35 PM, they stated the cranberry juice appeared pale and did not look as though there was a lot of cranberry juice in the cup. If the juice looked pale, they would expect staff to check the bag and change it or ask someone to change it if they did not know how. During an interview with the Food Service Director on 3/11/22 at 10:59 AM, they stated hot food should be served at 140 degrees F or above and cold food and drinks should be served at 40 degrees F or below. On 3/8/22 at dinner the cranberry juice looked pale and when the juice appeared pale in color that meant the syrup in the bag was running out and staff should change the bag. They stated they expected staff to notice if the color was pale and to check the bag. 2) Appearance During the lunch meal observation on 3/8/22 at 12:37 PM, the soup of the day was observed on 1 anonymous resident's lunch tray. The soup contained only elbow macaroni in a very light color liquid and was unattractive in appearance. Additionally, the entree was turkey noodle casserole and contained elbow macaroni. During an interview with cook #14 on 3/8/22 at 1:50 PM, they stated the soup of the day was listed on the meal production tallies but did not specify what type of soup should be made. They stated the soup of the day served at the lunch meal was just chicken broth and cooked elbow noodles and they did not follow a recipe because the production tally did not indicate what type of soup to make. During an interview with the registered diet technician (DTR) #18 on 3/10/22 at 11:06 AM, they stated if a resident had soup of the day on their meal ticket they expected them to be served either canned chicken noodle soup, tomato soup, or vegetable soup. They stated a resident had questioned them about the soup of the day on 3/8/22 at lunch because it appeared to be just broth and noodles. They also stated they did not think the facility had any canned chicken noodle soup to serve that day. During an interview with registered dietitian (RD) #19 on 3/10/22 at 2:35 PM, they stated the soup of the day served on 3/8/22 at lunch did not look appealing and was unsure why it was served when it looked like that. During an interview with the Food Service Director on 3/11/22 at 10:59 AM, they stated the soup of the day at lunch on 3/8/22 was chicken noodle soup. The soup consisted of chicken broth and elbow noodles, and it did not look appetizing. 10NYCRR 415.14(c)(1-3)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated (NY00288852) surveys conducted 3/6/...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated (NY00288852) surveys conducted 3/6/22-3/14/22, the facility failed to ensure suitable, nourishing alternative meals and snacks were provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care for 2 of 2 nursing units (North Unit and South Unit) observed. Specifically, residents did not have snack items available on the nursing units. Findings include: The facility policy Clinical Operations dated 4/2020 documents snacks are available 24 hours per day for any resident based on customary routine, request or requires additional calories due to inadequate meal consumption, promote weight gain or maintenance, need for additional protein for wound healing, or other therapeutic considerations. Dietary is responsible for stocking each nursing pantry with a variety of snacks to be available between meals for those who desire them and/or need them for increased nutrients. Residents may request a snack at any time; however, nursing personnel will offer at least a bedtime snack to all residents. During a Resident Council Meeting on 3/7/22 at 9:44 AM, 6 anonymous residents stated the facility ran out of snacks. They were told by the facility Administrator and registered diet technician (DTR) #18 that snacks were not in the budget. Cheddar crackers would be the only snack that was offered to residents. They stated they once had peanut butter crackers, but they had not had those in some time. One of the residents stated they wanted chips, but chips were not available. The facility's 3/3/22and 3/8/22 food purchase orders did not document the purchase of any snack items. During an observation on 3/8/22 at 10:45 AM, no snack items were observed stored in the main kitchen. On 3/8/22 at 1:37 PM, the North Unit's kitchenette was observed. The freezer had 5 microwavable meals labeled with resident's names and the refrigerator had 10 cartons of Glucerna (oral nutrition supplement). There were no snack items observed in the kitchenette cupboards, refrigerator, or drawers. During an interview with certified nursing aide (CNA) #7 on 3/8/22 at 1:37 PM, they stated the facility had not had snacks to pass between meals in over a year. They had to call the kitchen if a resident wanted a snack. The CNA stated it would sometimes take 1-2 hours for the snack to be delivered to the unit unless they went to the kitchen to get it. On 3/8/22 at 2:12 PM, CNA #3 stated snacks were not provided to the unit. When residents asked for snacks, staff would go to the kitchen to get something. They stated there were not always items available in the kitchen for a snack. During an observation of the South Unit's kitchenette on 3/8/22 at 2:16 PM, the freezer was empty and only contained a thermometer. The refrigerator had multiple soft sided lunch boxes, 5 cartons of Jevity (oral nutritional supplement), 4 containers of applesauce, and 2 cartons of lactose free milk. During an interview with licensed practical nurse (LPN) #7 on 3/8/22 at 4:11 PM, they stated the unit used to get a cart between breakfast and lunch that had puddings, milk, waters, and snack items, but they were told it was cut because the facility was going over budget. If a resident wanted a snack they had to go to the kitchen and get it. Sandwiches were easier to get and things like cookies were hard to find. On 3/8/22 at 6:21 PM, 8 unopened boxes of cheese and crackers were observed in the main kitchen. During an interview with DTR #18 on 3/10/22 at 11:06 AM, they stated the facility had not been ordering as many snacks. Snacks used to be provided to the unit at 10:30 AM, 3:00 PM, and at HS (hour of sleep). The DTR stated the issue was discussed with the previous facility Administrator and was not addressed. There was a lot of waste because the snacks were not being passed to the residents by staff. They brought the issue up to Regional registered dietitian (RD) #20 who stated snacks should be provided on the units and residents should receive their HS snacks. They had made a list of snacks for the Food Service Director (FSD) to order but was unsure if the snacks were consistently purchased. During an interview with RD #19 on 3/10/22 at 2:35 PM, they stated snacks should be provided to the units, so residents had access to them when the kitchen was closed and to provide a homelike environment. They were unaware the unit kitchenettes were not consistently being stocked. They were under the assumption that snacks were being ordered. On 3/11/22 at 10:59 AM, the Food Service Director stated they had recently purchased peanut butter crackers. They had tried to purchase [NAME] Doons but was told they were out of stock. The facility did have bulk Jello and pudding mixes for staff to make, but they were not always prepared. They were made aware on 3/7/22 the nursing department was asking for snack items. It was the cook's responsibility to make sure the snacks were prepared, and the units were stocked. The FSD stated they did conduct audits on the unit kitchenettes. If kitchen staff noticed snack items were out, they should let them know so more could be made or ordered. It was important for the residents to have access to snacks. During an interview with the facility Administrator on 3/11/22 at 2:09 PM, they stated the unit kitchenettes should be stocked with snack items. They were unaware it was not happening on a consistent basis and the residents were asking for snacks. They stated snacks were in the food budget. During an interview with Regional RD #20 on 3/14/22 at 1:11 PM, they stated they were unaware of the lack of snacks, and they were not being purchased. They were unaware the residents were asking for snacks, and it was not resolved. It was important to provide residents with snacks especially residents who required them for medical reasons. 10NYCRR 415.14(f)(3)(4)
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, record review, and interview during the recertification survey conducted 3/6/22-3/14/22, the facility failed to store, prepare, distribute, and serve food in accordance with prof...

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Based on observation, record review, and interview during the recertification survey conducted 3/6/22-3/14/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, the mechanical dishwasher was not clean and did not adequately sanitize dishware: expired milk was observed in the walk-in cooler for two days; and there was improper hot holding of hot dogs, mashed potatoes, and soup. Findings include: The facility policy Dish Washing and Storage updated 6/17/19, documents: - Dishes, pots, and pans will be washed and dried using procedures, chemicals and equipment that result in clean, sanitized dishes, pans, flatware, and utensils. - Low Temperature Dishwasher: Spray Type Dish Machines Using Chemicals to Sanitize Minimum Wash temperature: 120 degrees Fahrenheit (F). Final Rinse Temperature of 120 F and sanitization 50 parts per million (PPM) Hypochlorite. Dishes, pots, pans, utensils and flatware, must be air dried before being stored. Do not dry with towels. - Dish machine is drained and cleaned between each meal service period. - Employees are trained in proper dishwashing and drying procedures. Staff will be trained to report any problem with the dish machine to the director of food and nutrition services as soon as they occur. The facility policy Food Safety-Food Handling updated 9/2021, documents: - All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. - All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. - Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. The facility policy Food Storage revised 1/25/22, documents: - All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. - Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. - Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Dishwashing On 3/8/22 at 2:15 PM, dietary aide #13 was observed wiping dishes as they came out of the clean end of the mechanical dishwasher. Several dishes were visibly soiled with food debris. Dietary aide #13 wiped off the debris and placed the dishes on the carts for dinner service. A full rack of drink cups completed the dishwashing cycle, and some were upright and full of gray water with a film. Dietary aide #13 dumped the water back into the machine, wiped the cup with the towel, and set the cup on a tray for dinner service. On 3/8/33 at 2:35 PM, the mechanical dishwasher was observed completing several full cycles. The wash and rinse temperatures were measured at 130 degrees F. The dish machine's gauge read 112 F. The water within the machine was brownish to gray in color and had a visible grease ring at the high-water level. The sanitizer was measured at less than 10 ppm. The mechanical dishwasher's specifications documented a minimum wash and final rinse temperature of 120 F, and a sanitization level of 50 ppm was required. During an interview on 3/8/22 at 2:15 PM, dietary aide #13 stated they took the clean dishes from the machine and got them set for the next meal service. They stated they would check to make sure they were clean. If there was anything small that was not clean, they would wipe it off, but if it is big and crusty, they would send it back and run it through the machine again. Dietary aide #13 stated the clear plastic drink cups had a film on them from the dishwashing machine, but stated they were able to reach in and wipe them out due to their small hands. They stated they were trained by other staff at the facility but could not recall who because they had been doing this job for a few years. The dietary aide stated that checks were done on the mechanical dishwasher three times a day, and they occasionally had to complete them. They stated the checks included reading the temperature gauge and measuring the sanitizer level with the test strips and recording everything on the clipboard located on the rack at that end of the room. On 3/8/22 at 4:20 PM, dietary aide #13 was observed completing routine checks on the mechanical dishwasher. Registered diet technician (DTR) #18 was present for the checks. Dietary aide #13 depressed the fill button throughout the full cycle of the machine which continuously added hot water. They read the temperature from the gauge and reported 130 F. They then checked the sanitizer level with their test strips and measured the final rinse had a level of 10 ppm. The dish machine log documented for the midday check a level of 100 ppm. DTR #18 had dietary aide #13 repeat the process two more times which yielded the same results as the initial check. During an interview on 3/8/22 at 4:20 PM, dietary aide #13 stated they had performed the midday check a few minutes earlier and the level was fine. They stated they did not change anything with the machine and was not sure why they were getting a different result. On 3/8/22 at 4:49 PM, the Regional Administrator and the Director of Maintenance and Housekeeping were observed working on the mechanical dishwasher. The Regional Administrator stated they were still getting around 10 ppm for the sanitizer, and they would continue to work to fix the machine or get their vendor in to service it. During an interview on 3/8/22 at 5:09 PM, the Administrator stated that the dishes on the carts in the kitchen were set to be used for dinner and had been washed after lunch service that day through the mechanical dishwasher. The Administrator stated they would reset the dinner trays using disposable dishware because the dishes that currently were set were not cleaned properly. On 3/8/22 at 5:24 PM, kitchen staff were observed resetting the dinner trays with disposable trays, bowls, and takeout containers. During an interview on 3/8/22 at 6:41 PM, the Regional Administrator stated that the vendor had been on site to service the dishwasher. They stated the vendor replaced the lines, adjusted the output of sanitizer, and the machine was maintaining a level between 50-100 ppm. On 3/8/22 at 8:19 PM, on 3/9/22 at 10:02 AM and on 3/10/22 at 11:15 AM the mechanical dishwasher was observed visibly soiled with a ring of grease and a gray film inside. During an interview on 3/10/22 at 11:19 AM, the Food Service Director (FSD) stated that dishes were sprayed off in the hose area, then put through the machine, and run through the full cycle. If they were not clean, they were sent back through. Staff should allow dishes to dry in the racks, then stack them, or put them where they go. The Food Service Director stated that before each set of meal dishes were done, they checked the temperature and the ppm of the sanitizer and recorded the results on the log that was kept in the dish room. They stated they would walk through every morning and confirm that the checks had been done. The Food Service Director stated the dishwasher was cleaned every other Thursday, this was not documented on the kitchen cleaning schedule, but confirmed that it was last done on Thursday 3/3/22. Expired Milk On 3/8/22 at 9:44 AM and on 3/9/22 at 10:03 AM three crates of fat-free skim milk with an expiration date of 3/5/22 were observed within the walk-in cooler on the bottom shelf. Each crate contained approximately 50 (8 oz) cartons. During an interview on 3/10/22 at 11:19 AM, the Food Service Director stated that deliveries come in twice a week on Tuesdays and Thursdays, typically between 6:30 AM to 7:00 AM. They stated that expiration dates were checked routinely when deliveries were put away, organizing them so that first in are first out. The Food Service Director stated checking the dates on the food products was everyone's responsibility. Hot Holding 1) On 3/8/22 at 12:00 PM, cook #12 was observed preparing cauliflower and hot dogs in the back of the kitchen. Frozen cauliflower was poured into a half sheet, 6-inch deep, metal pan. Hot dogs were placed in a 6-inch by 6-inch by 6-inch pan with water in it. The pans were located on a rolling cart in the back of the kitchen without any temperature control. During an interview on 3/8/22 at 12:00 PM, cook #12 stated the cauliflower was frozen and the hot dogs came from the walk-in cooler. They stated these food items were being prepared for that night's dinner. On 3/8/22 at 12:32 PM, the hot dogs were measured at 58 F. On 3/8/22 at 2:12 PM, the pan of hot dogs was observed in a 6-inch by 6-inch by 6-inch pan with water in it, located on a rolling cart in the back of the kitchen. The hot dogs were measured at 65 F. On 3/8/22 at 2:38 PM, the pan of hot dogs was in the walk-in cooler and measured at 64.1 F. During an interview on 3/8/22 at 2:38 PM, cook #12 stated they put the hot dogs back in the walk-in cooler about 10 minutes prior because they did not intend to heat them up yet. On 3/8/22 at 5:30 PM, a 6-inch by 6-inch by 6-inch pan containing hot dogs was observed located on a stove burner with no flame beneath the pan. During an interview on 3/8/22 at 5:30 PM, cook #12 confirmed the pan on the stove containing hot dogs was the same pan of hot dogs they had pulled that afternoon during lunch and placed back in the walk-in cooler. On 3/8/22 at 6:27 PM, the Food Service Director was observed taking the pan of hot dogs from the unlit stove burner, checking the temperature, and moving them into the steamer to heat them for meal service. During an interview on 3/8/22 at 6:37 PM, the Food Service Director stated they were going to serve the hot dogs to a resident. They stated they did not know how long the hot dogs sat out of refrigeration in the kitchen that afternoon. The Food Service Director stated that food may remain out of refrigeration for up to two hours. The Food Service Director stated they were going to discard the hot dogs when they discovered the length of time the hotdogs had been out of the cooler. 2) The Menu Substitution Log documented that on 3/8/22 mashed potatoes were substituted with a muffin and the reason was noted as out. The log was initialed and had a registered dietitian (RD)acknowledgement initial. No quantity for the muffins was provided. On 3/8/22 at 12:00 PM, a 6-inch by 6-inch by 6-inch pan containing mashed potatoes, and a 6-inch by 12-inch by 6-inch deep pan of soup were observed in the steam table during lunch service. On 3/8/22 at 1:10 PM, cook #14 stated they made the soup of the day which consisted of reconstituted chicken base in water and added cooked macaroni. On 3/8/22 at 2:45 PM, a pan of mashed potatoes and pan of soup were observed in the steam table. The steam table's power was off. The mashed potatoes appeared dried out and brown in color. The soup was a very thin liquid with macaroni. The mashed potatoes were measured at 107 F, and the soup was measured at 89 F. On 3/8/22 at 2:45 PM, cook #12 stated that the mashed potatoes and the soup were made in the morning by cook #14. [NAME] #12 stated these items were left from lunch and they intended to discard them. On 3/8/22 at 2:50 PM, cook #12 was observed taking the soup from the steam table to the sink and adding water, placing it on the stove and adding a fork full of chicken base. They lit the burner and began to heat the soup. On 3/8/22 at 4:12 PM, the same mashed potatoes left from lunch were observed sitting on the shelf above the steam table on the meal service line. On 3/8/22 at 4:12 PM, cook #12 stated the mashed potatoes were going to get tossed (voluntarily discarded), but the soup that was in the steam table was just topped off by adding water and chicken base. They stated that leftovers usually get scrapped, but occasionally the hot dogs, soup of the day, and mashed potatoes would get carried over from lunch to dinner. The production sheet for dinner on 3/8/22 documented that 5 (6 oz) orders of soup of the day and 2 (4 oz) mashed potatoes were required. The facility soup recipe documented to hold food for service at an internal temperature of 140 F, and do not mix old product with new. On 3/8/22 at 5:30 PM, the mashed potatoes from lunch were observed in the steam table. The potatoes had a slightly darker brown appearance. During an interview on 3/8/22 at 5:30 PM, cook #12 stated that the mashed potatoes were left from lunch, but they only needed one serving for dinner. On 3/8/22 at 6:12 PM, the soup of the day located in the steam table was being portioned for service. During an interview on 3/8/22 at 6:12 PM, the Food Service Director stated that the soup was to be served to a resident. They continued, the temperature of the soup was not monitored throughout the day and the steam table was turned off between lunch and dinner. They stated the initial temperature of the soup was taken when it was made and during service, but they were not aware that this was the same soup from lunch. [NAME] #12 stated that they did top it off between lunch and dinner, and the steam table was turned off after lunch service therefore the temperature was not maintained. The Food Service Director stated they were not going to serve the soup to the residents and that it would be discarded. On 3/8/22 at 7:56 PM, the Food Service Director stated cook #12 had been trained by the previous cook for a week and half. During an interview on 3/8/22 at 8:10 PM, the Food Service Director stated that they did not hear any calls for mashed potatoes during service but would have served what was on the line because that was ready for service. [NAME] #12 confirmed that they too did not hear any calls for mashed potatoes. Both staff members stated they were not sure who was supposed to get mashed potatoes, or why they were not served. The Food Service Director stated that it was important to monitor food temperatures to ensure food health safety. They stated that hot food must be held above 140 F to prevent the growth of bacteria. The Food Service Director stated that no food should be carried over from one meal to the next, unless it was a large portion of the main dish that could be cooled and re-served when that came back on the menu rotation. During an interview with the FSD on 3/11/22 at 10:59 AM, they stated either they or the Regional RD signed off on the new cook training. [NAME] #12 had worked at the facility for 3 weeks and their Pineapple Academy (an in-house orientation training for cooks/supervisors food service employees totaling 9 hours of training) and their training had not been completed. During an interview with the facility Administrator on 3/11/22 at 2:09 PM, they stated the Food Service Director and other cooks provided training to the new cooks. [NAME] #12 was trained by the previous cook. On 3/14/22 at 10:28 AM, the facility's Administrator stated cook #12 had not completed their Pineapple Academy orientation and the cook was hired in 2/2022. During an interview on 3/14/22 at 1:11 PM, the Regional RD stated that since the summer they had been providing more oversight of training and sanitation. They stated they had done a lot of training with the previous cook, but nothing recently with cook #12. The Regional RD stated training and oversight of cooks was the responsibility of the Food Service Director. 10NYCRR 415.14(h)
Feb 2020 5 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure that the resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure that the resident had a right to a dignified existence for 2 of 2 units (North and South Units) reviewed for dignified existence. Specifically, facility staff were observed having personal conversations and using cell phones in the presence of residents. Findings include: The 4/2019 revised Cell Phone, E-Mail, Internet, and Social Media Use policy documents improper use of cell phones is strictly prohibited. There was no documentation regarding the use of cell phones for personal use in the presence of residents. The 9/2019 revised Quality of Life/Dignity policy documents residents shall be treated with dignity and respect at all times. During an interview on 2/20/20 at 2:20 PM, Resident #1 stated staff frequently used their cell phones while working and it occurred even more so after administration left for the day. On 2/20/20 at 4:23 PM, an unidentified certified nurse aide (CNA) and an unidentified licensed practical nurse (LPN) were observed having a personal conversation at a medication cart on the North Unit. A Hoyer lift (mechanical lift) was stationed in the middle of the hallway directly in front of the television three unidentified residents were watching. During an observation on 2/21/20 at 12:41 PM at the end of the hallway near the North Unit entrance and television area, an unidentified CNA was observed speaking loudly asking an unidentified food service worker regarding the CNA's hair. The food service worker told the CNA and 2 other CNAs that she would come to back to the unit after delivering carts to show them her hair. At 12:45 PM, the food service worker returned to the unit with her cell phone and was showing unidentified staff a picture. During an observation on 2/24/20 at 10:18 AM, the South Unit had a stretching activity led by activity aide #1 with 8 unidentified residents along the wall between rooms [ROOM NUMBERS]. An unidentified housekeeper was speaking loudly with another unidentified housekeeper outside of room [ROOM NUMBER] about purchasing a purse over the weekend. It was difficult to hear the activity instructions over the conversation. At 10:23 AM, a resident nearest to the housekeeper missed the exercise instructions and needed them repeated. The resident and put a hand to their ear to better hear activity aide #1. During a combined interview on 2/25/20 at 9:13 AM, the Director of Food Services and the diet technician, registered (DTR) both stated that employees should not have their cell phones on them at any time and it had been an ongoing problem. They stated the food service worker should not have been showing pictures of her hairstyle in the presence of residents. During an interview on 2/25/20 at 9:31 AM, CNA #2 stated personal conversations should be kept to a minimum on the units. Cell phones were not to be used on the units unless there was an emergency. The Hoyer lift should not be left in front of the television, which would block the view for the residents. During an interview on 2/25/20 at 9:32 AM, registered nurse (RN) Unit Manager #3 stated she expected staff to address residents with respect and dignity. The facility was the resident's home and she expected staff to act accordingly. Staff were not to have personal conversations in front of residents and should be talking with the residents instead. Staff were not to have cell phones on the unit and there had been a recent education regarding cell phones which staff had to read and sign. She stated that staff should not be having loud personal discussions on the unit and should not be showing pictures on their cell phones in the presence of residents. It was not polite, and it was a dignity issue. During an interview on 2/25/20 at 10:08 AM, activity aide #1 stated it was hard for her to do activities on the units at times due to staff interruptions. They had tried to conduct activities in the activity room, but that lead to decreased attendance as some residents did not want to leave the units. She stated that personal conversations by staff near the activity area were distracting and the residents could not hear what was going on. It was a common occurrence. During an interview on 2/25/20 at 10:11 AM, LPN Unit Manager #4 stated the Director of Nursing (DON) made decisions regarding the cell phone policy and she could not tell the surveyor what the policy for staff using cell phones was. During an interview on 2/25/20 at 10:50 AM, the DON stated the cell phone policy had been reviewed with the staff in the past month and cell phones were not allowed on the units. If a staff member needed to use their cell phone, they could go to the break room or outside the facility. Staff had been told that they should not talk over a resident and should instead be talking to the residents. The Hoyer lift should not have been left in front of the television and it would prevent the residents from seeing the television; they would not be able to move the lift themselves. The side conversation should not have happened near the activity and it was disruptive to the activity. The DON stated the food service worker and CNAs should not have been discussing hairstyles and looking at cell phone pictures as these were all dignity issues. 10NYCRR 415.3
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, interview, and record review during the recertification survey, the facility did not develop and implement...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for 2 of 21 residents (Residents #6 and 39) reviewed for care plans. Specifically, Resident #39 had a discrepancy in fall interventions documented on the care plan. Resident #6 did not have resident-specific interventions for their behavioral symptoms. Findings include: The 10/2019 Comprehensive Care Plans policy documents a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1) Resident #39 was admitted to the facility with Parkinson's disease (a neurological disorder) and dementia. The 12/25/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required limited assistance with most activities of daily living (ADLs), and had 2 or more falls without injury since the previous review. The 8/29/19 comprehensive care plan (CCP) in a previously used electronic system documented the resident was at risk for falls and floor mats were effective on 9/20/19. The 9/20/19 CCP in the new electronic medical record documented the resident was at risk for falls and was observed on the floor on 12/1/19. There was no documentation of fall mats used as an intervention. The 10/24/19 CCP update documented the resident was found in their room self-transferring from the floor mats to the bed. The 12/14/19 Accident/Incident Report documented the resident was found lying on floor mats beside their bed on their right side. The care plan had been followed as the fall mats had been down. The CCP active at that time had no documentation of fall mats as an intervention. The 10/2019 to 2/2020 nursing progress notes did not document that the resident no longer needed fall mats. On 2/20/20 at 12:43 PM and 4:10 PM, the resident's room was observed with fall mats. On 2/25/20 at 8:19 AM, the resident was eating breakfast in the hallway outside of their room. A floor mat was on the floor on the far side of the resident's bed nearest the wall. A thicker floor mat/mattress was leaning against the wall on the other side of the bed. The [NAME] (care card, care instructions) active on 2/25/20 did not document fall mats as an intervention for the resident. During an interview on 2/25/20 at 8:21 AM, CNA #2 stated there was a plan of care book available on the unit with the printed care cards that included fall interventions. If there were fall mats in the room, she would put them down and most residents on the unit had fall mats in their room. During an interview on 2/25/20 at 9:32 AM, registered nurse (RN) Unit Manager #3 stated she started working after the transition to the new electronic medical record. She was responsible for updating the care plan and the care cards. She looked in the electronic record and stated the resident did not have fall mats on their care plan or care card; it was never on the care plan as a now resolved issue. She was unsure if the resident still needed the fall mats and they had not been evaluated recently. During an interview on 2/25/20 at 10:50 AM, the Director of Nursing (DON) stated care plans painted a picture of what the resident's needs were. Interventions were implemented and revised as needed. If a resident fell, an intervention would be documented on the care plan which helped determine if further interventions were needed if the resident continued to fall. The resident was more ambulatory since admission and she thought maybe the resident no longer needed the fall mats. However, there was no documentation that the fall mats were no longer needed, and it appeared as though the fall mats fell off the care plan. 2) Resident #6 was admitted to the facility with diagnoses including dementia, delusional disorders, and anxiety. The 12/2/19 Minimum Data Set (MDS) Assessment documented the resident had severely impaired cognition, required extensive assistance with most activities of daily living, had verbal and wandering behaviors 1 to 3 days per week, and received antipsychotic and antidepressant medications. The 10/19/19 comprehensive care plan (CCP) documented the following - The resident exhibited socially inappropriate/verbally aggressive/abusive and wandering behaviors (documented twice on the CCP). Interventions include: administer psychotropic medications as ordered, check placement of wander guard each shift: right ankle, distract resident from wandering by offering pleasant diversions, distract resident with activities of interest, document all behaviors and attempt to identify pattern to target interventions, evaluate side effects of medications, initiate psychiatric evaluation as needed (written twice), and to provide a wander guard with location of tag: (specify). There were no resident specific interventions documented including specific instructions for pleasant diversions and activities of interest - The second behavioral CCP documented the same focus and interventions, documented a wander bracelet to be checked for functionality daily and the resident had wandering repetitive verbalizations. There were no resident specific interventions documented. - The resident had long term, non-correctable impaired cognitive function related to dementia. Eight interventions were documented, and none were specific to the resident's behaviors. - The resident used psychotropic medications for a diagnosis of depression. Interventions included to monitor/record occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards others, etc., and document per facility protocol. There were no resident specific behaviors or interventions documented. The 10/1/19 to 1/3/20 nursing progress notes were reviewed and documented the following - The resident was documented to have no behaviors 25 times. - The resident refused care, was exit seeking and/or asking to go home, asked for family members, or had verbal outburst 10 times. The resident was able to be redirected. - There was no documentation that the resident had been combative, disrobed, or had inappropriate verbal responses to communication. The 1/3/20 physician assistant progress note documented the resident had an increase in Remeron (antidepressant) the previous month due to worsening combative behaviors; it had not helped and the resident continued to be combative and wanted to leave to finish their paper route or thought someone had stolen their car. The resident became agitated and had a paranoid and delusional disorder. Seroquel (anti-psychotic) was increased and Remeron decreased as it was not beneficial. The 1/3/20 to 2/24/20 nursing progress notes documented the following: - The resident was documented to have no behaviors 24 times - The resident refused care, had verbal outburst, or aggression 9 times. One time the resident was noted to be very aggressive and was unable to be redirected once. The resident was able to be redirected for the other occurrences. - The resident often stayed in bed throughout the day. - There was no documentation that the resident disrobed or had inappropriate verbal responses to communication. On 2/24/20 at 10:45 AM and 2/25/20 at 7:41 PM, the resident was observed resting in bed. The [NAME] (care instructions, care guide) active on 2/25/20 documented that the resident had wandering and repetitive verbalization behaviors. There were no documented resident specific interventions. During an interview on 2/25/20 at 8:21 AM, CNA #1 stated the care guides documented if residents had behaviors and there should be resident-specific interventions documented. If there were none documented and she was floated to another unit, she would have to ask staff what works best for a resident. During an interview on 2/25/20 at 10:11 AM, licensed practical nurse (LPN) Unit Manager #4 stated as an LPN she was unable to initiate care plans, but she helped to implement the plans and updated them as needed. Behavioral care plans addressed the resident's target behaviors and some of the actions the resident might have displayed. The resident wandered at times, and sometimes became aggressive but it was not an everyday occurrence. Redirection was attempted and sometimes effective, though sometimes not. The LPN stated the resident received Seroquel because the resident's day and night cycle was reversed; the resident had a reduction in the anti-depressant dose at the same time the Seroquel was increased. During an interview on 2/25/20 at 10:50 AM, the Director of Nursing (DON) stated the care plan painted a picture of the resident's needs. The focus determined the goal and interventions were implemented; if the goal was not met, then the intervention needed to be revised. Care plans should have been personalized and centered on the resident to ensure the interventions were specific to the resident for effectiveness. Resident #6 thought they were a paper carrier at times and had repetitive behaviors. The resident was able to be redirected at times and the resident's family had been involved. The resident's roommate was a calming influence and often helped to redirect the resident when the resident repeatedly stated they wanted to leave. 10NYCRR 415.11(c)(1)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility did not ensure each resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 thereaf...

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Based on interview and record review, the facility did not ensure each resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 thereafter for 1 of 5 residents (Resident #39) reviewed for unnecessary medications. Specifically, Resident #39 was not seen by a medical provider (physician, physician assistant or nurse practitioner) every 60 days. Findings include: The 2015 Physician Visit policy documents the attending physician must make visits in accordance with state and federal regulations. - The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. - After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits may be established, but not to exceed every sixty (60) days. - A Physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. - A physician visit is considered timely if it occurs not later than ten (10) days after the date the visit was required. Resident #39 was admitted to the facility with Parkinson's disease (neurodegenerative disease) and Lewy-Body dementia (progressive dementia). The 12/25/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required limited assistance with activities of daily living and had been examined by a physician twice over the past 14 days. The 9/20/19 comprehensive care plan (CCP) documented the resident used psychotropic drugs for depression, had chronic obstructive pulmonary disease (COPD), had an alteration in comfort, had a cognitive deficit due to dementia, and medications were to be administered by physician order. The physician was to be updated on changes in condition. A 10/26/19 physician progress note documented the resident was seen and examined. A 10/30/19 physician assistant (PA) #5 progress note documented the resident was seen subsequent to 30-day follow up. A 12/3/19 PA #5 progress note documented the resident was being seen subsequent to 30-day follow up. There were no further medical progress notes after 12/3/19. During an interview on 2/25/20 at 9:32 AM, registered nurse (RN) Unit Manager #3 stated the guidelines said residents were to be seen by the medical team after 60 days. The electronic medical record flagged to the providers which residents were due to be seen and the providers managed their schedule. The provider dictated the note, which was transcribed and scanned into the electronic medical records. During an interview on 2/25/20 at 10:50 AM, the Director of Nursing (DON) stated the physician dictated the notes which were scanned into the electronic medical record. She looked at the resident's record and the last medical interval visit available in the system was 12/3/19 and the resident should have been seen by the physician since then. During an interview on 2/25/20 at 11:57 AM, PA #5 stated he and the physician used to alternate the 30 day visits and they were both doing the 60 day interval visits, but the physician had taken over most of the 60 day visits and the PA was responsible for the acute visits. He looked at his computer system for the dictated notes and stated that the resident was last seen for an interval visit on 12/3/19 and was due to be seen. During a follow up interview on 2/25/20 at 12:48 PM, the DON stated the electronic medical record triggered to the physician when the resident was due to be seen, and the physician would click a button in the system which would reset the countdown. The physician tracked their schedule and they had a medical clerk that could see the schedule. She did not know why the resident had not been seen every 60 days. 10NYCRR 415.15(b)(2)(ii)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review during the recertification survey, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted pr...

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Based on observation, interview, and record review during the recertification survey, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional standards, and the expiration date when applicable for 1 of 2 medication rooms (North Unit) and 1 of 3 medication carts (North Unit Cart 4) reviewed for medication storage and labeling. Specifically, a medication room (North Unit) had multiple expired opened and unopened medication bottles and a medication cart (North Unit Cart 4) had 2 opened expired medication bottles and 1 opened stock multi-dose medication vial that was not dated with the opened date. The 1/2019 revised Medication-Storage policy documents expired, discontinued, and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. There was no documentation regarding dating a medication when it was opened. During a North Unit medication cart 4 review on 2/21/20 at 9:29 AM with registered nurse (RN) #6, the following observations were made: - 1 opened bottle of lactase enzyme (for lactose intolerance) with manufacturer's expiration date of 10/19 and the RN stated he was not aware of any resident receiving it; - 1 opened bottle of aspirin 325 milligrams (mg) with the manufacturer's expiration date 12/19; and - 1 opened stock vial of Lidocaine (local anesthetic) 1% 200 mg/20 milliliters (ml) with the manufacturer's expiration date of 3/1/21 and no written opened date. During a North Unit medication room storage review on 2/21/20 at 9:31 AM with RN #6, the following expired medications were observed: - 1 unopened bottle of docusate sodium (stool softener) 100 mg with the manufacturer's expiration date of 8/19; - 1 unopened bottle of docusate sodium 100 mg with manufacturer's expiration date of 9/19; - 1 unopened bottle of docusate sodium 100 mg with manufacturer's expiration date of 11/19; - 1 unopened bottle of docusate sodium 100 mg with manufacturer's expiration date of 12/19; - 3 unopened and 1 opened bottle of docusate sodium 100 mg with manufacturer's expiration date of 1/20; - 1 unopened bottle of oyster shell calcium (supplement) 500 mg with manufacturer's expiration of 2/18; - 1 unopened bottle of Vitamin C 500 mg with manufacturer's expiration date of 11/19; - 1 unopened bottle of aspirin 325 mg with manufacturer's expiration date of 9/19; - 3 unopened bottle of aspirin 325 mg with manufacturer's expiration date of 12/19; and - 3 unopened bottles of Centrum (multivitamin supplement) liquid 236 ml with manufacturer's expiration date of 12/19; When interviewed on 2/21/20 at 9:40 AM, RN #6 stated the night shift had always been responsible for checking expiration dates of medications. He was not sure if it was written in the policy for them to check for expired medications in the carts and medication rooms. All nurses were to check the medication expiration dates when administering a medication. He stated all the medications were expired and was unaware if any resident received the medications from the opened bottles. When interviewed on 2/21/20 at 9:51 AM, RN Unit Manager #3 stated the night shift was responsible for restocking and checking expiration dates in the medication carts and rooms. She stated each medication nurse was responsible to check the expiration dates when giving each medication. All multi-dose vials should be labeled with the opened date and the medication would be considered expired if the opened date was not written on it. When interviewed on 2/24/20 at 3:19 PM, the Director of Nursing (DON) stated the night nurse and supervisor were required to put new received stock medications away and to check expiration dates of all the stock medications in the medication rooms, medication carts and medication refrigerators weekly. There was no specific form to document that they did it. The medication should have been discarded prior to the manufacturer's expiration or one month after opening the bottle. 10NYCRR 415.18(d)(e)(1-4)
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Based on interview, observation, and record review during the recertification survey, the facility did not provide food and drink that was palatable and at a safe and appetizing temperature for 2 of 2...

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Based on interview, observation, and record review during the recertification survey, the facility did not provide food and drink that was palatable and at a safe and appetizing temperature for 2 of 2 meal test trays (breakfast and dinner) reviewed. Specifically, food temperatures were not in a palatable range for lunch and breakfast trays (fish patty, grilled cheese, broccoli, fruit cup, eggs, toast, yogurt). Findings include: The 6/2019 revised Recording Food Temperatures policy documents temperatures of cold and hot food items will be recorded prior to service. Safe, acceptable service temperature range was below 41 degrees Fahrenheit (F) or above 140 degrees F. During an interview on 2/20/20 at 11:04 AM, Resident #10 stated the hot food was cold. During an interview on 2/20/20 at 12:23 PM, Resident #43 stated the hot food was cold. During an interview on 2/20/20 at 12:57 PM, Resident #11 stated that the eggs were always cold. During an interview on 2/20/20 at 2:22 PM, Resident #56 stated the hot food was cold. During an interview on 2/20/20 at 2:24 PM, Resident #1 stated that the hot food was cold when eaten in their room. During an interview on 2/20/20 at 4:13 PM, Resident #38 stated the hot foods needed to be hotter and the cold foods needed to be colder. During a resident council meeting on 2/21/20 at 2:15 PM, anonymous members of a resident council meeting stated that the food temperature was terrible. On 2/21/20 at 11:52 AM, the temperature log in the kitchen documented the fish patty was 170 degrees Fahrenheit (F), broccoli was 173 degrees F, and fruit cups were 45 degrees F. At 12:33 PM, the lunch cart was delivered to the South Unit. At 12:40 PM, the last tray was taken from the cart after all residents were served. The fish patty was measured to be 114 degrees F, the grilled cheese was 100 degrees F, the broccoli was 105 degrees F, the milk was 45 degrees F, and the fruit cup was 64 degrees F; all the hot foods tasted cold and the grilled cheese had started to harden. On 2/25/20 at 8:40 AM, Resident #1 was served breakfast in their room and the tray was obtained for temperatures and a replacement tray was ordered. The eggs were measured to be 116 degrees F and tasted lukewarm. The toast was 81.5 degrees F, the spread on the toast was not spread across the toast with a big swab in the center which was not melted on the toast. The toast was soggy, and it was cold to touch and taste. The fruited yogurt was 49 degrees F, the container of orange juice was 51 degrees F and the water was 58 degrees F. During a combined interview on 2/25/20 at 9:13 AM, the Food Service Director (FSD) and diet technician, registered (DTR) stated foods should be at least 140 degrees when coming off the hot tray service line. The FSD stated the eggs, fish patty, grilled cheese, and broccoli temperatures should have been better than that. The toast was made ahead of the meal and would be hard to keep the temperature. The yogurt and beverages were iced down, and they would expect the temperatures to be better. The FSD stated that the trays were open and the pallet the plates were placed on did not hold temperatures well. 10NYCRR 415.14
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • 40 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
  • • $76,428 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
  • • Grade F (20/100). Below average facility with significant concerns.
  • • 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.

About This Facility

What is Onondaga Center For Rehabilitation And Nursing's CMS Rating?

CMS assigns ONONDAGA CENTER FOR REHABILITATION AND NURSING an overall rating of 1 out of 5 stars, which is considered much 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 Onondaga Center For Rehabilitation And Nursing Staffed?

CMS rates ONONDAGA CENTER FOR REHABILITATION AND NURSING's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 69%, which is 22 percentage points above the New York average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 93%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Onondaga Center For Rehabilitation And Nursing?

State health inspectors documented 40 deficiencies at ONONDAGA CENTER FOR REHABILITATION AND NURSING during 2020 to 2024. These included: 1 that caused actual resident harm and 39 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Onondaga Center For Rehabilitation And Nursing?

ONONDAGA CENTER FOR REHABILITATION AND NURSING 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 CENTERS HEALTH CARE, a chain that manages multiple nursing homes. With 82 certified beds and approximately 76 residents (about 93% occupancy), it is a smaller facility located in MINOA, New York.

How Does Onondaga Center For Rehabilitation And Nursing Compare to Other New York Nursing Homes?

Compared to the 100 nursing homes in New York, ONONDAGA CENTER FOR REHABILITATION AND NURSING's overall rating (1 stars) is below the state average of 3.0, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Onondaga Center For Rehabilitation And Nursing?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Onondaga Center For Rehabilitation And Nursing Safe?

Based on CMS inspection data, ONONDAGA CENTER FOR REHABILITATION AND NURSING has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Onondaga Center For Rehabilitation And Nursing Stick Around?

Staff turnover at ONONDAGA CENTER FOR REHABILITATION AND NURSING is high. At 69%, the facility is 22 percentage points above the New York average of 46%. Registered Nurse turnover is particularly concerning at 93%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Onondaga Center For Rehabilitation And Nursing Ever Fined?

ONONDAGA CENTER FOR REHABILITATION AND NURSING has been fined $76,428 across 2 penalty actions. This is above the New York average of $33,843. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Onondaga Center For Rehabilitation And Nursing on Any Federal Watch List?

ONONDAGA CENTER FOR REHABILITATION AND NURSING 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.

ONONDAGA CENTER FOR REHABILITATION AND NURSING

217 EAST AVENUE, MINOA, NY 13116 | (315) 656-7277

F
Trust Grade (20/100)
1.0
CMS Rating
40
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 1-star rating
  • 40 deficiencies

Ask about: Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025