RENAISSANCE REHABILITATION AND NURSING CARE CENTER
For profit - Limited Liability company
120 Beds
Independent
Data: November 2025
Trust Grade
45/100
#550 of 594 in NY
Photo by Terriann Albrecht
Photo by Terriann Albrecht
Photo by Soyla Daccarett
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Renaissance Rehabilitation and Nursing Care Center has a Trust Grade of D, indicating below average performance with some notable concerns. It ranks #550 out of 594 facilities in New York, placing it in the bottom half, and #9 out of 12 in Dutchess County, meaning there are only a few local alternatives that are better. The facility is worsening, as it went from 4 issues in 2023 to 32 in 2024, which raises significant red flags. Staffing is a relative strength with a turnover rate of only 20%, much lower than the state average of 40%, but there is less RN coverage than 76% of New York facilities, which is concerning. While there have been no fines recorded, recent inspections revealed serious cleanliness issues, such as overflowing garbage and sticky floors, and a malfunctioning elevator that has not been addressed, raising questions about the overall management and safety of the environment for residents.
- Trust Score
- D
- In New York
- #550/594
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 20% annual turnover. Excellent stability, 28 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New York facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 8%
No red flags
4 → 32 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 4 issues
2024: 32 issues
The Good
-
Low Staff Turnover (20%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (20%)
28 points below New York average of 48%
Facility shows strength in staff retention, fire safety.
The Bad
1-Star Overall Rating
Below New York average (3.0)
Significant quality concerns identified by CMS
The Ugly 48 deficiencies on record
Sept 2024
32 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
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure 1 of 1 residents (Resident #161) reviewed for death, had the right to formulate advance directives. Specifically, Resident #161's Medical Orders for Life Sustaining Treatment were completed by Resident #161 who presented with changes in cognition, and there was no documentation that the physician determined the resident's capacity at the time of the Medical Orders for Life Sustaining Treatment completion.
Findings include:
1) Resident #161 was admitted [DATE] with diagnoses including diabetes mellitus, status post left above knee amputation, osteomyelitis and rheumatoid arthritis.
The 5/21/24 Medical Orders for Life Sustaining Treatment (MOLST) form documented Do Not Resuscitate and Do Not Intubate, send to hospital, trial intravenous treatment, trial feeding tube and antibiotics. The MOLST form was not signed and documented 'resident gave verbal consent'.
The 5/30/24 Social Work Psychosocial documented the resident's cognitive status was stable, and able to understand and be understood. It further documented a Medical Orders for Life Sustaining Treatment was in place with advance directives being Do Not Resuscitate/Do Not Intubate. A Health Care Proxy was not in place to assist with care related decisions as needed.
The 6/14/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 had a Brief Interview for Mental Status score of 13 indicating intact cognition.
The 6/19/24 care plan note documented a care plan meeting was held on 6/4/24, during the meeting the MOLST was reviewed with the resident. Resident representative #1 did not respond to call for care plan meeting. There was not a Health Care Proxy on file and resident declined completing paperwork at this time and expressed they hoped to return home.
The 6/19/24 Social Work note documented Resident Representative #2 requested to be taken off Resident #161's contact list.
Review of the Resident Face Sheet in the resident's record documented Resident Representative #1 was the primary contact and was designated as full access to protected health information.
The 7/2/24 Social Services note documented the resident's Brief Interview for Mental Status was redone and the resident scored 6 (severely impaired cognition).
The 7/10/24 at 12:57 PM Psychology Note documented the resident was unable to participate in psychological services due to cognitive deficits, unable to engage today.
The 7/10/24 at 5:18 PM Psychiatric Evaluation documented it was an initial psychiatric evaluation and based on assessment the resident was psychiatrically stable. The resident had difficulty with speech but when taking time to offer them water, they were clear in content and orientation. Witnessed comfort care added to Do Not Resuscitate Medical Orders for Life Sustaining Treatment form.
The 7/10/24 Medical Orders for Life Sustaining Treatment form documented Do Not Resuscitate and Do Not Intubate /Comfort Measures, Do Not Hospitalize, and no intravenous treatment or feeding tube. Not signed, resident gave verbal consent witnessed by the social worker and psychiatric nurse practitioner.
The 7/12/24 Advance Directive Care Plan updated to Comfort Measures only, Do Not Hospitalize.
The 7/17/24 Social Service note documented Medical Orders for Life Sustaining Treatment were updated to comfort care and palliative care a new Medical Orders for Life Sustaining Treatment completed, and resident representative made aware.
The 7/24/24 Nursing note documented Resident Representative #1 was notified of the resident's death and stated they were not aware of Resident #161's deteriorating condition and was upset that the resident was not sent to the hospital. Explained that her Medical Orders for Life Sustaining Treatment stated do not send to hospital. Resident Representative #1 stated they did not approve that and wanted to know who and how it was done.
On 9/11/24 at 4:27 PM during an interview, the Director of Social Work stated there was a Medical Orders for Life Sustaining Treatment previously done after admission and it was updated, stated it was Do Not Resuscitate/Do Not Intubate and then updated to Comfort Care/ Do Not Hospitalize. Stated the resident started to decline, did not want to name the the resident's representative as Health Care Proxy. Director of Social Work stated when they went to discuss changes to the Medical Orders for Life Sustaining Treatment they initially refused to speak about comfort care. Director of Social Work stated the room was a little warm, they engaged resident with a little water and resident perked up a little. Director of Social Work stated psychiatric nurse practitioner asked the resident to explain their wishes to help determine if the resident could make the decisions. Psychiatric nurse practitioner felt the resident was clear in their desire for comfort care, no pain and requested not to be hospitalized . Director of Social Work stated the resident was aware their medical condition was declining. Director of Social Work stated they were unsure why there were conflicting assessments between the psychologist and the psychiatric nurse practitioner's progress notes regarding the resident's cognition on 7/10/24. Director of Social Work stated when the Psychologist did their evaluation they were alone and the resident might have only responded better with the Psychiatric Nurse Practitioner and Director of Social Work because they gave the resident time to speak. Director of Social Work stated the nurse practitioner and Director of Nursing were on the phone with physician and they were talking to Resident Representative #1, when they attempted to speak to Resident Representative #1 first about comfort care but Director of Social Work stated they stopped them from continuing the conversation about the Medical Orders for Life Sustaining Treatment because the resident expressed they did not want the resident representative as the health care proxy and decided to use psychiatrist to assist with Medical Orders for Life Sustaining Treatment.
On 9/12/24 at 1:26 PM, Psychiatric Nurse Practitioner stated that they would not have done capacity for a resident they met with for the first time. Psychiatric Nurse Practitioner stated the resident had delusional disorder. Psychiatric Nurse Practitioner stated the resident was able to say yes, when they wanted water. Psychiatric Nurse Practitioner stated the resident cognition was waxing and waning but the resident was able to say what their wishes were and did not want to be rushed off to the hospital. Psychiatric Nurse Practitioner stated they felt resident was very clear that day the changes were made to the Medical Orders for Life Sustaining Treatment .
On 9/13/24 at 3:55 PM, Director of Rehab stated resident was seen for dysphagia therapy initially. Director of Rehab stated when resident was declining they attempted a cognitive communication assessment but was unable to really participate well. Director of Rehab stated on 6/27/24 was the last time they completed a Brief Interview Mental Status assessment and stated they were only completed quarterly. Director of Rehab stated the resident was not clear enough to discuss changes in advance directives due to having fluctuating cognition.
10NYCRR 415.3(e)(1)(ii)
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
Notification of Changes
(Tag F0580)
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 (NY00346428) from [DATE] t...
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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 (NY00346428) from [DATE] to [DATE], the facility did not ensure that the designated representative of 1 of 3 residents (#161) reviewed for notification of change was promptly informed of a change in the resident's declining condition and change in advance directives. Specifically, there was no documented evidence that the resident representative was promptly informed of the resident's change in advance directives to Do Not Hospitalize on [DATE] and was not notified until [DATE], and the resident expired on [DATE].
The finding is:
Resident #161 was admitted with diagnoses including metabolic encephalopathy, white matter disease, and delusional disorder.
The [DATE] Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 had had a Brief Interview of Mental Status score of 13 that indicated resident cognition was intact.
The [DATE] Social Work note documented Resident Representative #2 requested to be taken off Resident #161's contact list.
Review of the Resident Face Sheet in the resident's record documented Resident Representative #1 was the primary contact and was designated as full access to protected health information.
The [DATE] Social Services note documented the resident's Brief Interview for Mental Status was redone and the resident scored 6 (severely impaired cognition).
The [DATE] Medical Orders for Life Sustaining Treatment form documented Do Not Resuscitate and Do Not Intubate /Comfort Measures, Do Not Hospitalize, and no intravenous treatment or feeding tube. Not signed, resident gave verbal consent witnessed by the social worker and psychiatric nurse practitioner.
The [DATE] Advance Directive Care Plan updated to Comfort Measures only, Do Not Hospitalize.
The [DATE] Social Service note documented Medical Orders for Life Sustaining Treatment were updated to comfort care and palliative care a new Medical Orders for Life Sustaining Treatment completed, and Resident Representative #1 was made aware.
The [DATE] 3:46 PM Nursing Note documented resident blood sugar was 541. A message was left for Designated Representative #1.
No documented evidence of further contact made with Resident #161's son regarding resident's declining condition.
The [DATE] Nursing note documented Resident Representative #1 was notified of the resident's death and stated they were not aware of Resident #161's deteriorating condition and was upset that the resident was not sent to the hospital. Explained that her Medical Orders for Life Sustaining Treatment stated do not send to hospital. Resident Representative #1 stated they did not approve that and wanted to know who and how it was done.
On [DATE] at 4:27 PM during an interview, the Director of Social Work stated there was a Medical Orders for Life Sustaining Treatment previously done after admission and it was updated, stated it was Do Not Resuscitate/Do Not Intubate and then updated to Comfort Care/ Do Not Hospitalize. Stated the resident started to decline, did not want to name the the resident's representative as Health Care Proxy. Director of Social Work stated the resident was aware their medical condition was declining. Director of Social Work stated the nurse practitioner and Director of Nursing were on the phone with physician and they were talking to the Resident Representative #1, when they attempted to speak to the Resident Representative #1 first about comfort care but Director of Social Work stated they stopped them from continuing the conversation about the Medical Orders for Life Sustaining Treatment because the resident expressed they did not want Resident Representative #1 as the health care proxy.
On [DATE] at 10:48 AM, during a phone interview, Resident Representative #1 stated the facility did not notify them of the change in Medical Orders for Life Sustaining Treatment to include do not hospitalize or the resident's declining condition. They stated when the resident was admitted they were instructed to call Resident Representative #1 if something needed to be signed as they want to read it first. They stated they were never informed of any Medical Orders for Life Sustaining Treatment forms.
On [DATE] at 11:35 AM during an interview, the Director of Social Work stated the social work note dated [DATE] was a late entry for [DATE] and stated the Resident Representative #1 was called the day they updated the Medical Order Life Sustaining Treatment. The Director of Social Work stated they were very busy and could not get to the note done earlier. Stated they never met Resident Representative #1 and only spoke to them on the phone.
415.3(e)(2)(ii)(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents and/or their designated representative were fully inform...
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Based on record review and staff interview during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage form CMS-10123. This was evident for one (1) of three (3) (Resident #43) residents reviewed for Beneficiary Protection Notification.
The findings are:
Review of the medical record for Resident #43 on 09/11/2024, revealed the resident last received rehabilitative services on 03/26/2024 and Resident #43's designated representative was given Notice to Medicare Provider Non-coverage via telephone to inform them of their right to an expedited review of a service termination on 03/25/2024, one day prior to the termination of services.
On 9/12/24 at 6:02 PM, the Social Worker stated the reason why notice of non-coverage Notice to Medicare Provider Non-coverage was provided to the designated representative via telephone only 1 day prior to last covered day was because that was the day they were given the notice to get the signature.
10 NYCRR 415.3 (g)
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure residents right to be free from abuse for 1 of 3 residents (Resident #14) reviewed for abuse. Specifically, on 7/30/2024 Resident #14 who was known to be physically/verbally abusive punched Resident #45 in the stomach, and new intervention of 30-minute safety checks were not initiated or carried out to prevent further abuse.
Findings include:
The undated facility policy titled abuse, neglect, mistreatment, and misappropriation of resident property included documentation that abuse is defined as the willful infliction of injury or intimidation with resulting physical pain or mental anguish. Willful is defined as meaning the individual must have acted deliberately. The facility leadership will assess the needs of the residents and the facility to be able to identify concerns in order to prevent potential abuse. The 'overview of seven components' included prevention and protection.
Resident #14 was admitted with diagnoses which included vascular dementia with behavioral disturbances, schizoaffective disorder, and sexual dysfunction.
The Quarterly Minimum Data Set (assessment tool) dated 3/8/24 documented severely impaired cognition, physical behavioral symptoms 4-6 days, verbal behavioral symptoms 1-3 days, other behavioral symptoms 1-3 days. Resident #14 required setup with eating, dressing, transfers. Resident #14 required supervision with ambulation.
The Social Work note dated 3/13/24 documented they contacted the hospital for admittance for evaluation after an incident with another resident, psychiatrist and physician aware.
The Nurse's note dated 3/13/24 documented Resident #14 was making sexually inappropriate behaviors towards another resident.
The Nurse's note 3/14/24 documented resident was transferred to the hospital.
The Quarterly Minimum Data Set, dated [DATE] documented severely impaired cognition, behavioral symptoms not directed at others, no wandering. Resident #14 required supervision with transfers and moderate assistance with ambulation.
The facility Accident Incident report dated 7/30/24 documented a witnessed resident to resident altercation where Resident #14 was the aggressor. Interventions included separate residents, monitoring every 30 minutes for aggressor, and psychiatry consult.
The Care Plan, Potential to be an Aggressor, last updated 8/27/24 documented interventions which included separate residents as needed, allow resident to de-escalate, refer to psych as needed. A care plan note dated 8/2/24, by the Director of Nursing, documented the resident-to-resident altercation incident, new physician's orders for Ativan (anti-anxiety medication) 1 milligram three times a day for 4 days, and that Naltrexone (used to manage alcohol or opiod use disorder) and Invega (antipsychotic medication) administration time was changed to 9:00 AM, psychiatry follow-up, and monitor resident every 30 minutes for safety.
No evidence of a physician's order documented monitoring every 30 minutes.
There was no documented evidence that 30 minutes monitoring was conducted.
On 9/10/24 at 9:40 AM during an interview with the Director of Nursing, they stated they could not locate any documented evidence that 30-minute monitoring occurred. They stated the order should have been placed.
On 9/9/24 at 9:50 AM during an interview with Licensed Practical Nurse #3, after checking Resident #14's chart, they stated no new order was placed on 7/30/24 for monitoring every 30 minutes. They stated they wrote the Accident Incident report and gathered staff statements and handed it to the Director of Nursing. They stated they did not have authority to update resident care plans. They stated that the Director of Nursing reviewed the care plans and made any new interventions. They stated they would have placed new orders if they had been asked to.
On 9/10/24 at 10:18 AM during an interview, Registered Nurse Unit Manager #1 stated that the new intervention which was documented on the Accident Incident Report dated 7/30/24 of monitoring every 30 minutes should have been documented in the physician's orders and should have populated in the Medication Administration Record, but they were unable to provide evidence that it had been documented. They stated the Licensed Practical Nurses did not update care plans. They stated the Registered Nurse on duty was responsible to review and update care plans and initiate any new interventions.
On 9/10/24 at 11:22 AM during a follow-up interview with the Director of Nursing, they stated they were responsible for entering the order for monitoring every 30 minutes, but they did not do so.
10 NYCRR 415.4(b)
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 conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure that all alleged violations involving...
Read full inspector narrative →
Based on record review and interview conducted during the recertification and abbreviated surveys (NY00346428) from 9/5/24 to 9/13/24, the facility did not ensure that all alleged violations involving abuse and neglect were thoroughly investigated to rule out abuse/neglect and were reported to The New York State Department of Health for 1 of 3 residents (Resident #161) reviewed for abuse. Specifically, Resident #161 went to a Vascular appointment on 6/24/24 and alleged abuse by a staff member when the provider inquired about a bruise on their forehead. The provider contacted the facility regarding the alleged abuse on 6/24/24 and spoke to the Social Worker and Nurse Practitioner who determined the bruise was from a fall and did not investigate or document the allegation until 7/2/24.
The findings are:
Resident #161 was admitted with diagnoses including diabetes, status post left above knee amputation, osteomyelitis and rheumatoid arthritis.
The 6/14/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 was independent in cognition. The assessment further documented lower extremity impairment on one side. Resident #161 was dependent with chair and bed transfers. The assessment documented Resident #161 was documented to have no falls.
The 6/24/24 Vascular surgery clinic note documented Resident #161 was noted to have large bruise on their left forehead and was covered in feces. Upon discussion with Resident #161 they stated they were physically attacked at the facility where they resided. Resident #161 reported that it happened a few weeks ago but Resident #161 did not report it. Resident #161 stated they informed their son, although the Vascular Nurse Practitioner was unable to confirm. Facility was telephoned but unable to reach Nursing Director or Medical Director, spoke with social worker and nursing staff who reported that resident fell a few days ago but no documented bruise on forehead at that time and no further workup initiated. The resident had documented history of delusional disorders based on documentation provided by the nursing facility. Despite this the resident was adamant that someone attacked them at the facility and that is the reason they had a bruise on their head. Vascular Nurse Practitioner recommended a visit to the Emergency Room, but resident declined and requested to be sent back to the facility.
Review of Resident #161's medical record, including nursing progress notes from 6/18/24 to 6/24/24, revealed no documented evidence of a bruise on the forehead. Nursing progress notes and social work notes dated 6/24/24 to 7/1/24 revealed no documentation regarding the call from the Vascular clinic or follow up when the resident alleged abuse.
An investigation dated 7/2/24, documented the facility received a call on 7/2/24 from the Attorney General's office regarding an allegation of physical abuse that was made on 6/24/24. Resident #161 went to Vascular appointment on 6/24/24 and the resident was noted to have a large bruise on her forehead by the Vascular physician. As per the consult report the bruise appeared old and the resident was not exhibiting neurological deficits during examination. The resident stated they were physically attacked at the facility and when asked if they reported the incident to the facility staff, they stated they did not tell the facility but told their son about it. The resident was interviewed (7/2/24) and informed the social worker that the bruise on their head was from falling on the ground hitting their head. When asked a second time stated, the floor hit my head. Staff did not witness fall but responded to roommate calling for help who observed resident on the floor. No signs of injury from nursing assessment. Conclusion: Based on resident, roommate and staff statements about the resident's alleged abuse incident, the facility is not able to substantiate if the physical assault allegation did occur. Resident was seen by Nurse Practitioner prior to the fall incident and stated the resident had intermittent confusion due to underlying onset of possible urinary tract infection. The resident's roommate who is alert and oriented and stated resident fell out of her bed.
The facility Nurse Practitioner's note dated 7/2/24 at 12:59 PM documented on 6/24/24 the Vascular facility staff called stating that they noted the resident had a large bruise on their forehead. Reportedly the resident told the Vascular Nurse Practitioner that they were assaulted at this facility hence the bruising. Staff at Vascular facility called an ambulance to transport the resident to the emergency room for neurological evaluation. They (facility Nurse Practitioner) advised them to hold off on transportation to the emergency room while they obtain more details of event from staff. Per staff, resident had an old bruise on forehead from a fall they sustained on 6/18/24. No suspicion or evidence of physical attack reported. The bruise on the forehead was light greenish in color and was almost fading away. Vascular Nurse Practitioner was made aware that the bruise was from a previous fall.
When interviewed by phone on 9/10/24 at 11:29 AM, the Vascular Nurse Practitioner stated when the resident arrived for the Vascular consult on 6/24/24, they noticed a bruise to forehead. The Vascular Nurse Practitioner stated they called the facility and were told the bruise was from a fall. They stated the bruise may have been there for 7 days, it was hard to determine, but it was not from the same day. The Vascular Nurse Practitioner stated initially the resident seemed lucid in describing events but was unable to determine as the story progressed if the incident occurred.
When interviewed on 9/10/24 at 11:54 AM, Licensed Practical Nurse #11 stated the resident had a fall prior to the appointment on 6/24/24 and the bruise was from the fall. Licensed Practical Nurse #11 stated they remember getting call about the bruise on resident's forehead and informed them the bruise was old from a previous fall.
When interviewed on 9/12/24 at 1:04 PM, the Director of Nursing stated the reason they may not have done an abuse investigation was because they attributed the allegation of abuse to the resident's confusion and correlated the bruise with the recent fall. Director of Nursing stated they just thought the resident was confused and did not know why the bruise was not documented in the resident's record prior to the call from the Vascular Nurse Practitioner.
When interviewed on 09/13/24 at 12:37 PM, the facility Nurse Practitioner stated they received the call from the Vascular Nurse Practitioner on 6/24/24. They spoke to staff were informed that the bruise was from a previous fall. They stated the resident was seen later that day and did not have a bruise at the time of fall and had a latent bruise. The bruise was greenish and fading. They stated the resident was not abused and resident was simply confused about the story.
When interviewed on 9/13/24 at 1:26 PM, Transporter #26 stated they accompanied the resident to the Vascular consult on 6/24/24. Transporter #26 stated the Vascular Nurse Practitioner informed them that resident alleged they were beat up by facility staff. Transporter #26 stated they called the Director of Social Work to ask them what to do and the Director of Social Work went to find a nurse manager. The nurse manager explained to the Vascular Nurse Practitioner that the resident had a recent fall. Transporter #26 stated the Vascular Nurse Practitioner spoke to the Unit Manager using Transporter #26's cell phone. Transporter #26 stated people came to take resident to the emergency room but after the call they just decided to return the resident to the facility. (The facility investigation did not include a statement or interview with Transporter #26).
When interviewed on 9/13/24 at 1:40 PM and 2:03 PM, Registered Nurse Unit Manager #1 stated they did not receive a call from the Vascular Nurse Practitioner about the resident and did not assist the Director of Social Work. Registered Nurse Unit Manager #1 reviewed the typed statement that was included in the facility investigation and stated they did not give that statement.
When interviewed on 9/13/24 at 2:22 PM, the Administrator stated they were unaware of the abuse allegation until 7/2/24 when they received a call from the Attorney General. They stated they did an investigation and found out Resident #161 had a fall on 6/18/24 and an allegation of abuse at an appointment was a few days after fall. The Administrator stated they ruled out abuse by statements of residents or staff, resident never alleged abuse while at facility, and when interviewed by Director of Social Work, Resident #161 stated they fell, and the floor hit their head. The Administrator stated they did not feel it needed to be reported to New York State Department of Health as it was already reported by the Vascular Nurse Practitioner. The Administrator stated they were not sure if they must report every allegation of abuse. The Administrator stated that if an allegation of abuse was reported out of the facility, the facility must first validate whether or not the abuse occurred before reporting to the New York State Department of Health.
415.4(b)(1)(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not e...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood for 2 of 2 residents (Residents #38 and #18) reviewed for hospitalization. Specifically, Resident #38 and Resident #18 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident representatives.
Findings include:
The facility policy, 'Admission, Transfers, and Discharge; last revised November 26th, 2022, documented that when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as possible.
1.Resident #38 was admitted to the facility with diagnoses which included urinary tract infection, retention of urine, and type 2 diabetes mellitus.
The Minimum Data Set (assessment tool) discharge assessments dated 5/17/24 and 5/29/24 documented Resident #38 was discharged to hospital on 5/17/24 and 5/29/24.
Medical note dated 5/13/24 documented Resident #38 requested to go to hospital for evaluation status post.
A Nursing Progres Note dated 5/18/24 documented unable to flush catheter, removed & replaced, only minimal drops of output. Abdominal X-Ray resulted in gross distension, resident presents with altered mental status, minimal urine output despite intravenous fluids, transferring to hospital.
When requested, documentation could not be provided that the facility notified Resident #38 and their representative in writing of the reason for the transfer to hospital on 5/17/24 or 5/29/24.
On 9/11/24 at 4:15 PM during an interview with the Director of Social Work, they stated they are not responsible to provide written notification to the resident and their representative for the reason for transfer to hospital or written notification of the facility bed hold policy. They stated that nursing is responsible.
On 9/11/24 at 4:20 PM, written notification was requested from the Director of Nursing, for the reason for transfer to hospital which had been provided to the resident/representative for transfers to the hospital on 5/17/24 and 5/29/24. The Director of Nursing stated the facility does not provide written notification for the reason for transfer to hospital.
2. Resident #18 was admitted to the facility with diagnoses which included vascular dementia, chronic obstructive pulmonary disease, and muscle weakness.
The Minimum Data Set (an assessment tool) discharge assessment dated [DATE] documented Resident #18 was discharged to hospital on 8/3/2024.
A Nursing Progress Note dated 8/3/2024 at 11:36 am documented bruising noted to right side of face. Resident complained of nausea and right hip pain. Nurse Practitioner made aware and new order to send resident to Mid [NAME] Regional Hospital and give Zofran 4 mg.
When requested, documentation could not be provided that the facility notified Resident #18 or their representative in writing of the reason for the transfer to hospital.
10NYCRR 415.3 (i)(1)(ii)(a)(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and interviews during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents or resident's representatives were notified in writing of the...
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Based on record review and interviews during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that residents or resident's representatives were notified in writing of the facility policy for bed hold for 1 of 2 residents (Resident #38) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility was unable to provide evidence that written notice of the facility policy for bed hold was given to the resident or their representative.
The findings are:
The undated facility policy, Bed Hold and Return to Facility documented that it is the policy of the facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the state's bed hold duration and payment amount before the transfer. Residents and their representative will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave.
Resident #38 was admitted to the facility with diagnoses which included urinary tract infection, retention of urine, and type 2 diabetes mellitus.
The Minimum Data Set (assessment tool) discharge assessments dated 5/17/24 and 5/29/24 documented Resident #38 was discharged to hospital on 5/17/24 and 5/29/24.
Medical note dated 5/13/24 documented Resident #38 requested to go to hospital for evaluation status post.
Nursing note dated 5/18/24 documented unable to flush catheter, removed & replaced, only minimal drops of output. Abdominal X-Ray resulted in gross distension, resident presents with altered mental status, minimal urine output despite intravenous fluids, transferring to hospital.
When requested, documentation could not be provided that the facility notified Resident #38 and their representative in writing of the facility bed hold policy on 5/17/24 or 5/29/24.
On 9/11/24 at 4:15 PM during an interview with the Director of Social Work, they stated they are not responsible for providing notification of the facility bed hold policy to be to the resident and their representative.
On 9/11/24 at 4:20 PM, written notification was requested from the Director of Nursing, for the facility bed hold policy which had been provided to the resident/representative for transfers to the hospital on 5/17/24 and 5/29/24. The Director of Nursing stated the facility does not provide written notification of the facility bed hold policy when residents are transferred to the hospital.
10NYCRR 415.3 (i)(3)(i)(a)
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the development and impl...
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Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the resident highest practicable physical mental and psychosocial well-being for 1 of 2 residents (Resident #162) reviewed for dialysis. Specifically, Resident #162 did not have a care plan for dialysis.
The findings are:
The 10/2/21 Policy titles Comprehensive Care Plan documented the facility will utilize an interdisciplinary team approach to provide an individualized and comprehensive, resident assessment and care planning process to maximize and maintain every resident functional potential and quality of life. The team will update the comprehensive care plan to keep it current on an ongoing basis.
Resident #162 had a diagnosis of chronic kidney disease, diabetes and obesity.
The 3/25/24 Quarterly Minimum Data Set (assessment tool) documented Resident #162 was cognitively intact and had renal insufficiency.
The 12/18/23 physician order documented hemodialysis on Tuesday, Thursday, and Saturday.
The 12/21/23 dialysis communication binder documented for vitals signs to be taken prior to dialysis and upon return from dialysis.
The 1/21/24 physician progress note documented Resident #162 will be attending dialysis.
During a review of the Resident's medical health record, there was no documented evidence of a care plan to address the plan of care required for Resident #162, while they were dependent on hemodialysis.
During an interview on 9/6/24 at 4:30 PM, the Director of Nursing stated that nursing was responsible for updating the care plan. The Director of Nursing stated there was no care plan addressing Resident #162 was dependent on dialysis.
During an interview on 9/6/24 at 4:35 PM, Registered Nurse Unit Manager #2 stated they were responsible for updating the resident's care plans. They stated they were passing medications frequently and sometimes they were unable to update the care plans.
10 NYCRR 415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not review and revise the comprehensive care plan with measurable objectives, time frames and appropriate interventions for 2 of 5 residents (#87, #18) reviewed for accidents. Specifically, 1) Resident #87 had falls on 2/8/24 and 2/29/24 and the fall care plan was not updated with new interventions to prevent recurrence of falls, and 2) Resident #18 had a fall on 8/2/2024 and sustained a hip fracture the fall care plan was not updated with new interventions to prevent a recurrence.
The findings are:
1) Resident #87 was admitted on [DATE] with diagnoses and conditions including other displaced fracture of upper end of right humerus, subsequent for fracture with nonunion, Non-Alzheimer's Dementia, and Depression.
The quarterly Minimum Data Set (resident assessment tool) dated 9/1/24 documented the resident's cognition was intact; the resident required partial to moderate assist for bed mobility and transfers, substantial to maximal assist of one person for toilet use and was occasionally incontinent of bladder.
The 9/6/22 Fall Risk Care Plan documented resident was at increased risk for falls related to weakness and pain. The care plan documented the resident had falls on 3/25/23 and 2/10/24.
The 2/8/24 Nursing note documented call to resident's son and daughter to notify about fall. No answer.
The 2/10/24 at 11:21 AM Nursing note documented a late entry for 2/8/24, the Certified Nurse Aide reported the resident just fell and hit their right elbow. The nurse went to investigate and the resident verbalized they were getting something from closet and fell. Resident #87 was seen by the nurse practitioner on unit and ordered x ray of right elbow.
There were no new documented interventions on the fall care plan following fall on 2/8/24.
There was no documented evidence of an Accident/Incident Report completed for 2/8/24.
On 9/11/24 at 11:58 AM, the Director of Nursing provided Accident and Incident Reports from for 2/29/24 and 5/8/24, the Director of Nursing stated they could not find the incident for 2/10/24.
On 9/12/24 at 11:46 AM, Registered Nurse Unit Manager #2 stated when a resident fell, they would asses the resident immediately, get their vital signs, call the physician and family. Registered Nurse Unit Manager #2 stated then they would update care plan. Registered Nurse Unit Manager #2 further stated if there was a care plan for falls, they would add new interventions.
On 9/13/24 at 12:22 PM, the Director of Nursing stated the care plans should be done by the unit manager, they were assigned to do the updates in the care plans. The Director of Nursing stated sometimes they were unable to come up with new care plan interventions as they were not as skilled in this area. The Director of Nursing stated most of the time they updated the care plans for the Unit Managers but stated they felt overwhelmed and could not do everything.
2. Resident #18 was admitted to the facility with diagnoses which included vascular dementia, chronic obstructive pulmonary disease, and muscle weakness.
The 5/7/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #18 had a moderately impaired cognition. The assessment further documented no impairments on the upper or lower extremities. Resident #18 received supervision with chair and bed transfers. The assessment documented Resident #18 was continent of bowel and bladder.
A review of the undated Comprehensive Care Plan Policy and Procedure, documented care plans are modified between care plan conference when appropriate to meet the resident's current needs, problems and goals. The care plan will be updated and revised for the following reasons:
a. Significant change in the resident's condition
b. A change in planned intervention
c. Goals are achieved and new goals established to meet current resident needs and/or goals
d. New diagnosis, new medication, or abnormal labs
A fall risk assessment dated [DATE] documented a score of 11 and indicated Resident #18 was a high fall risk.
A review of the Accident/ Incident Report dated 8/2/2024 documented Resident #18 was found on their back close to the bathroom door. Urine was on the floor. The resident stated they slid in their own urine on the way to the bathroom. The resident had an abrasion to face, and 8/10 pain to the right hip. New intervention put in place at the time of the event included to encourage resident to call for assistance.
A Nursing progress Note dated 8/3/24 at 11:36 AM documented Resident #18 complained on nausea and right hip pain, the Nurse Practitioner ordered to give Zofran 4 mg tablet for nausea and transfer to the hospital.
A review of the nursing progress note dated 8/4/2024 at 12:37 AM documented writer spoke with nurse at the hospital, Resident #18 was diagnosed with a right hip fracture and would have intramedullary nail femur surgery in the morning.
The Fall Risk Care Plan had no documented evidence of any new interventions added to the care plan after the fall on 8/2/24. The last two interventions were dated 5/24/24. The interventions included to place the bed in the lowest position and resident to be toileted at night.
On 09/12/24 at 11:50 AM during an interview, Licensed Practical Nurse #4 stated they worked in the facility for 7 years. They stated they were not familiar with the care plan for Resident #18. They stated in the past, Resident #18 attempted to get out of bed without help. Licensed Practical Nurse #4 stated that during a medication pass and at various times throughout the day they monitored Resident #18 for safety per their nursing judgment, although there were not current orders to do so. Licensed Practical Nurse #4 stated they were not aware of Resident #18 having recent falls, but after reviewing Resident #18 medical record, Licensed Practical Nurse #4 stated the resident had a fall and fractured the right hip in August. Licensed Practical Nurse #4 stated they could not recall any new interventions put in place to prevent Resident #18, after the fall in August, from falling again.
415.11(c)(2)(i-iii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record review, interview and observation during the recertification survey conducted from 9/5/24 to 9/13/24, the facility did not ensure that residents received the necessary services to main...
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Based on record review, interview and observation during the recertification survey conducted from 9/5/24 to 9/13/24, the facility did not ensure that residents received the necessary services to maintain good personal hygiene for 3 of 6 Residents ( Residents #45, #66, #78) reviewed for activities of daily living. Specifically, Resident #45, Resident #66, and Resident #78 who required staff assistance for personal hygiene and toileting did not receive morning cares in a timely manner.
The findings are:
An undated Facility Policy and Procedures titled: Quality of Care documented it is the policy of Renaissance and Rehabilitation and Nursing Care Center to ensure that each resident receive and provided the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan or care, in accordance with State and Federal Regulations. Based on the comprehensive assessment of the resident, the facility will ensure that the resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection prevent new ulcers from developing.
An undated Facility Policy and Procedures: The Activities of Daily Living /Maintain Abilities Policy (undated) documented: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered and honor and support each residents preferences, choices, values and beliefs. Procedure: The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.
1) Resident #45 has diagnoses which included cognitive communication deficiency, chronic kidney disease, and generalized anxiety disorder.
The 8/12/24 Quarterly Minimum Date Set assessment documented a Brief Interview for Mental Status of 6, indicating the resident had severe cognitive impairment. The assessment documented the Resident required partial to moderate assistance with personal hygiene and substantial / maximal assistance for toileting hygiene, shower/bath self, upper and lower body dressing, and putting on/taking off footwear.
A Resident Care Plan titled, Activities of Daily Living: Bathing, Dressing, Personal hygiene, Toileting, Feeding (last updated 8/27/24), documented Resident #45 required assistance with activities of daily living as follows secondary to dementia and cerebral ischemia. For bathing, dressing, toileting: extensive assistance of 1, for personal hygiene limited assist of 1. Interventions included to assist with bathing, dressing, grooming needs and provide privacy. Assist with toileting needs, daily sponge bath dress appropriately according to season and time of day.
A Resident Care Plan titled Urinary Incontinence and Indwelling Catheter (last updated 7/31/24) documented: Resident is at risk for skin breakdown, urinary tract infection, altered self-image, changes in behavior, and social isolation related to incontinence of bowel and bladder. Resident is unaware of/unable to make toileting needs know. The goals was the resident would be free of urinary tract infection and have no skin breakdown related to incontinence. Interventions included to assist with toileting needs, encourage fluid intake, monitor for signs and symptoms of urinary tract infection, hematuria, dysuria, fever, foul or cloudy urine, pelvic discomfort. Observed for changes in behavior or self-image or isolation, provide incontinence briefs.
During an observation on 09/05/24 at 11:49 AM, Resident #45 was sitting on side of bed in pajama top and soiled adult brief. Morning cares had not been provided and a soiled pajama bottom was on floor beside bed.
During an observation and interview on 09/05/24 at 12:08 PM, Resident #45 was standing in doorway of their room in pajama top with soiled adult brief falling off. Certified Nurse Aide #16 redirected the resident back to bedside. When interviewed at the time of observation, Certified Nurse Aide #16 stated morning cares had not been completed yet due to short staffing on the unit.
2). Resident #66 has a diagnoses which included dementia, bipolar disorder, and major depressive disorder.
The 8/5/24 Annual Minimum Date Set assessment documented a Brief Interview for Mental Status of 6, indicating the resident had severe cognitive impairment. The admission Minimum Data Set documented the Resident required partial to moderate assistance with toileting.
A Resident Care Plan titled, Activities of Daily Living Function/Rehabilitation (last updated 8/27/24) documented that Resident #66 required assistance with activities as follows: bathing maximum assist, dressing 1 person assist, toileting minimal assist, and personal hygiene one person assist. Interventions included assisting with bathing, dressing, grooming, toileting needs, and to provide privacy.
A resident care plan titled, Urinary Incontinence and Indwelling Catheter (updated 9/18/23) documented Resident #66 was incontinent of urine related to forgetfulness. The goals was for the resident to maintain continence of urine during waking hours. Interventions included to monitor labs as ordered, monitor post void residuals as ordered, and urology consult as needed.
During an observation of Resident #66 on 09/05/24 at 10:07 AM, a soiled adult brief was observed lying on floor on the left side of resident bed. Resident #66 was sleeping in bed.
During an observation 09/05/24 11:08 AM, Resident #66 was observed sitting on side of bed, and soiled adult brief remained on floor.
During an observation on 09/05/24 at 12:22 PM, Resident #66 room had a strong smell of urine.
3). Resident #78 was admitted with diagnoses which included dementia, insomnia, and anxiety.
The 6/27/24 admission Minimum Date Set assessment documented a Brief Interview for Mental Status of 3, indicating the resident had severe cognitive deficits. Resident required partial to moderate assistance with toileting. Urinary continence was documented as Resident occasionally incontinent and bowel continence was not rated.
A Resident care plan titled, ADL Bathing Dressing Personal Hygiene, Toileting (last updated 8/27/24) documented: Resident #78 required assist of 1 person assist for toileting, personal hygiene, bathing, dressing, and grooming.
During an observation and brief interview with the Director of Nursing on 09/05/24 at 11:34 AM, the Resident was observed with feces on hands, on tray table, on floor along with torn adult brief. The resident's room smelled of urine and bowel movement. The Director of Nursing requested a Certified Nurse Aide to perform morning cares which had not been provided. The Director of Nursing stated morning cares were running late and that the resident would be provided with morning cares immediately.
During an interview on 09/13/24 at 11:25 AM, the Director of Nursing stated that staffing could be challenging, they were aware that resident cares were often completed late or not completed when certified nurse aide staffing was low. They stated the Licensed Practical Nurses and Registered Nurses would assist with cares during low staffing.
During an interview on 09/13/24 at 12:00 PM, Administrator stated that staffing was challenging and that they felt that staffing shortages may affect resident care in terms of wait time and that the employees that were present during staff shortages worked hard to cover deficits.
10 NYCRR 415.12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure the resident received treatment and care in accordan...
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Based on observation, record review, and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #45) reviewed for skin conditions. Specifically, Resident #45 was not assessed and a care plan was not put in place in a timely manner for changes in the Resident's skin condition.
Resident #45's diagnoses included cognitive communication deficiency, chronic kidney disease, and generalized anxiety disorder.
The 8/12/24 Quarterly Minimum Date Set assessment documented the resident had severe cognitive impairment. The annual Minimum Data Set documented the Resident no ulcers, wounds and skin problems.
A resident care plan titled Wound Prevention / Skin Care Plan effective 10/12/2020 documented Resident #45 was at risk for impaired skin integrity, pressure wounds, ulcer, skin tears, etc. secondary to impaired mobility, vitamin deficiency dementia. The goals were the resident would maintain intact skin and would not develop pressure ulcers or wounds. Interventions included to moisturize dry skin, observe skin for changes in color, temperature, rash, irritation, loss of dermis and address promptly; weekly comprehensive skin assessment and documentation.
The Physician's orders documented: on 5/6/24 for Claritin 10 mg tablet, give 1 tablet once a day for allergic rhinitis. On 9/13/21 for weekly skin checks with intstructions to document any open areas in comment box, every day at 7:00 AM, 7:00 PM, and to notify Registered Nurse on duty of any skin changes immediately.
During an observation on 09/05/24 at 11:49 AM, Resident #45 was observed sitting on side of bed in top portion of pajamas. Resident was scratching right shoulder and upper arm. Four red, pencil eraser sized open areas were observed (two on back of right shoulder, and two on right upper arm). Resident was observed scratching upper rear area of left leg. Two pencil eraser sized open red areas observed on upper rear area of left leg.
During an observation and interview on 09/09/24 at 10:11 AM, Resident#45 was in bed resting, and scratching their right upper arm. The resident's roommate stated they observed Resident #45 scratching all weekend. Resident #45 stated they are itchy on arms and back.
Review of Resident #45's medical record revealed no documented evidence the open areas, that the resident was scratching, were assessed or that the Physician/Nurse Practitioner were notified.
During an interview on 09/10/24 at 11:19 AM with Licensed Practical Nurse #4, they stated they had observed Resident #45 scratching their arms and neck in the past; it was over a month ago. They stated they applied A and D ointment to a scab on right neck when observed. They stated that observation occurred over a month ago and they did not report to Registered Nurse Unit Manager or facility Nurse Practitioner. They stated they believe itching was reported by another staff member (unable to name) and a medication may have been prescribed. They stated that reports of changes in a Resident's status observed or reported by Certified Nurse Aides were reported to Registered Nurse Unit Manager or facility Nurse Practitioner. Licensed Practical Nurse #4 stated the facility Nurse Practitioner rounds the unit daily Monday to Friday and as needed when a change in status is reported. They did not recall the Nurse Practitioner assessing Resident #45 for skin changes recently. Licensed Practical Nurse #4 stated they were not aware of a Resident care plan being implemented or Nurse Practitioner/Physician assessment being completed recently for Resident #45 in regard to skin changes and itching.
During an interview on 09/10/24 at 03:33 PM, the facility Nurse Practitioner stated when a change in Resident status was reported to them, they would assess the resident as soon as possible, usually the same day, if Monday to Friday. They stated they did not receive a report of Resident #45 regarding skin changes or itching/scratching recently and therefore a skin assessment was not conducted. The Nurse Practitioner stated that the expectation was that floor staff would report all changes in a resident skin immediately. The Nurse Practitioner reported that residents were assessed at least once a month by facility Physician.
During an interview on 9/11/24 at 11:14 AM, Certified Nurse Aide #17 stated weekly skin checks were completed for residents by nursing staff during showers and that Certified Nurse Aides also complete skin checks during cares. They stated they had observed scabs on Resident #45's right shoulder and itching/scratching which they reported to Licensed Practical Nurse #3 about one month ago.
During an interview on 09/11/24 at 12:19 PM with Licensed Practical Nurse #3, they stated they believe Resident #45 has seasonal allergies and had Claritin and Zysol prescribed in the past. Licensed Practical Nurse #3 stated that all changes in a resident's condition would be reported to the facility Nurse Practitioner and / or Physician immediately. Skin changes requiring wound consult are reported to Director of Nursing and Resident would be included on facility weekly rounds. Weekly skin checks during showers were completed by Certified Nurse Aide and Licensed Practical Nurse on the unit. Licensed Practical Nurse #3 stated they had not completed weekly skin check for Resident #45 in a while as they were assigned to other side of the unit and did not recall reports of changes in Resident #45's skin recently.
10NYCRR 415.12
.
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
Based on observation, record review, and interviews during a recertification survey from 9/5/24 to 9/13/24/202, the facility did not ensure each resident received care, consistent with professional st...
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Based on observation, record review, and interviews during a recertification survey from 9/5/24 to 9/13/24/202, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 4 residents (Resident #78) reviewed for pressure ulcers. Specifically, Resident #78 had care plan interventions and physicians order recommendations to offload heels while in bed; however, the resident was observed in bed with their heels resting directly on the mattress and there was no pillow on the mattress for the resident's feet.
Findings include:
Resident #78 had diagnoses which included osteomyelitis, dementia, and insomnia.
The 6/27/24 admission Minimum Date Set assessment documented a Brief Interview for Mental Status of 3, indicating the resident had severe cognitive deficits. The admission Minimum Data Set documented the resident was a risk for pressure ulcers.
The Facility policy and procedure titled, Managing Skin Integrity (dated 10/2023) documented that nursing, in collaboration with the health care team will assess and manage skin integrity for all patients throughout the stay. Patients are to be encouraged by care providers to participate to the extent possible in the care and prevention of skin breakdown. Plans for the maintenance of skin integrity will include the patient and family whenever possible and may include, but are not limited to the following: daily inspections, cleansing, and moisture management as needed. Patient movement and activity focused on pressure redistribution of bony prominences that may result in skin breakdown, recognition of early signs of skin breakdown with prompt interventions to minimize tissue damage.
A physician order dated 8/30/24 documented to elevate heels off bed, and to monitor heels closely for changes (non-blanching areas, dark areas, blisters, etc.) each shift.
A Skin integrity Care Plan created 6/23/24 documented Resident #78 was at risk for skin breakdown related to Braden scale score, decreased mobility, incontinence. The goals was Resident #78 would maintain intact skin. Interventions included to off load heels when in bed.
There was no documented evidence of Resident #78 refusals to off-load heel when in bed.
During observations on 9/05/24 at 11:34 AM, 09/06/24 at 09:49 AM, and 09/09/24 at 10:06 AM, Resident #78's bilateral heels were observed directly on the mattress, and not off-loaded on pillows or a device.
During an observation and brief interview on 09/10/24 at 10:56 AM, end of morning cares were being performed for Resident #78. The resident's heels were observed on the mattress, not off-loaded. During an interview with Certified Nurse Aide #17, they stated they were not aware Resident #78's heels should be off-loaded. They stated heel off-loading was not discussed during morning rounds.
During an observation on 09/11/24 at 11:23 AM, Resident #78's bilateral heels were observed on mattress, not off-loaded on pillows or a device.
During an interview on 09/10/24 10:59 AM, Certified Nurse Aide #18 stated they did not review the electronic medical record or inquire with nursing staff regarding heel offloading for Resident #78. They also stated they did not routinely check electronic medical record until approximately 11:00 AM because they started morning cares as soon as they arrive to work.
During an interview on 09/10/24 at 11:27 AM, Licensed Practical Nurse #4 stated they were not aware Resident #78 had order for bilateral heel off-loading. They stated they did not see it on Sigma (electronic record system) because it did not pop up. They stated they did not receive information regarding heel-off-loading during change of shift rounds. They stated they did not routinely check care plans on Sigma.
During an observation and interview on 09/13/24 at 10:18 AM with Certified Nurse Aide #18, the Sigma kiosk (electronic medical record used by certified nurse aide staff) was observed. There were no Certified Nurse Aide tasks listed regarding off-loading heels for Resident #78. Certified Nurse Aide #18 stated aide duties were entered into the electronic medical record by the Unit Manager and that they were unaware that Resident #78 had an order to off-load heels.
During an interview on 09/13/24 11:25 AM, the Director of Nursing stated they were aware that the entering of resident care plans could sometimes be delayed by Unit Managers. Director of Nursing stated that they assisted with entering/updating resident care plans when this occurs which was frequently. They did not know why the Certified Nurse Aide tasks regarding heel-off-loading was not entered into electronic medical record for Resident #78.
10NYCRR 415.12(c)(1)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure residents who required dialysis ...
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Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure residents who required dialysis (a process that filters blood for the kidneys) received such services, consistent with professional standards of practice for 2 of 2 residents (Resident #13 and #162) reviewed. Specifically, 1) Resident #13 had no dialysis communication book, and 2) Resident #162 received hemodialysis treatments at a community-based dialysis center and did not have on going assessments and oversight before and after dialysis treatments.
Findings include:
The undated facility policy, title Dialysis documented, after dialysis monitor for and report hypotension ( low blood pressure) tachycardia ( fast heart rate) complaints of dizziness or light headedness or headache.
1. Resident #13 had diagnoses of end-stage renal (kidney) disease and dependence on renal dialysis and polycystic kidney adult type.
The 5/13/2024 Minimum Data Set (assessment tool) documented the resident had intact cognition and required hemodialysis treatments.
The 6/14/24 Comprehensive Care Plan documented the resident had end-stage renal disease and required hemodialysis. Interventions included hemodialysis at Community Dialysis Center on Monday, Wednesday, and Friday.
The 6/12/24 Physician's order documented Hemodialysis on Monday, Wednesday, and Friday. Monitor vital signs prior to and return from dialysis.
On 9/11/24 and 9/12/24, the resident's dialysis communication book was unable to be located in their room or on the nursing unit
On 9/11/24 at 4:00 PM during an observation and interview, Resident #13 was sitting in their room in a wheelchair. They stated they received dialysis. A dry sterile bandage was observed on the resident's left lower arm. They stated they did not know where their dialysis communication book was.
On 9/11/2024 at 4:14 PM during an interview with Registered Nurse Unit Manager #2, they stated they did not know where the resident's communication book was. They stated that sometimes the vital signs were taken, and they would continue to look for the book. They stated that residents on dialysis were supposed to be assessed before and after dialysis treatments. They stated they did not know why it was not done consistently, and stated it may have been a staffing issue .
On 9/11/24 at 4:30 PM during an interview, the Director of Nursing stated they were familiar with Resident #13, and confirmed the the Resident they received dialysis treatments three days per week. They stated that were aware that a resident who went to dialysis required an assessment before and after returning from dialysis. They stated they thought that it was being done. The Director of Nursing stated they will in-service the staff about assessing the residents before and after dialysis treatments.
2. Resident #162 had diagnoses which included kidney disease, type 2 diabetes, and obesity.
The 5/13/2024 Minimum Data Set (assessment tool) documented the resident had intact cognition, and required hemodialysis treatments.
There was no Comprehensive Care Plan to document the care they required related to requiring hemodialysis treatments.
The 12/18/23 Physician's order documented Hemodialysis on Tuesday, Thursday and Saturday. Monitor vital signs every shift.
The 2/2/24 Medical Progress note documented Resident #162 received dialysis from 12/21/23 to 1/25/24.
A review of the communication book revealed no communication sheets on 12/30/23, 1/2/24, 1/4/24,1/6/24 1/9/24, 1/11/24, 1/13/24, 1/16/24, 1/18/24, 1/20/24, 1/23/24, or 1/25/24.
On 9/9/2024 at 1:06 PM during an interview, the Clinical Manager of the Community Dialysis Center stated the resident was admitted to the kidney center on 12/21/23 and was discontinued on 1/25/24 for the reason that their kidney function recovered. They stated they did not remember if the communication sheets were filled out.
10 NYCRR 415.12(k)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure timely identification and removal of expired medicat...
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Based on observation, record review, and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure timely identification and removal of expired medications. Specifically, two bags of IV Vancomycin had expiration dates of 7/17/24, one bag of IV Vancomycin had an expiration date of 7/18/24, one bag of IV Vancomycin had an expiration date of 8/7/24, and two bags of IV Vancomycin had expiration dates of 8/10/24 were located in the first floor unit medication room.
The findings are:
The facility policy last revised August 2023, 'Storage of Drugs' included documentation that discontinued drug containers shall be removed from the medication cart and marked to indicate that the drug has been discontinued. Discontinued drugs shall be disposed of in accordance with the procedures set forth in this manual under the section entitled disposal of drugs and supplies, and drugs should not be kept on hand after the expiration date on the label.
On 09/09/24 at 02:55 PM in the 1st floor unit medication room with Licensed Practical Nurse #5, two bags of IV Vancomycin 735 mg/250 mls Nacl with expiration dates of 7/17/24 and one bag of IV Vancomycin 1.75 mg/500 ml Nacl with an expiration date of 8/7/24 were observed in the refrigerator, one bag IV Vancomycin 735 mg/250 mls Nacl with an expiration date of 7/18/24 and two bags IV Vancomycin 1.75 mg/500 ml Nacl with expiration dates of 8/10/24 were observed on a shelf outside the refrigerator.
On 9/9/24 at 03:04 PM, Licensed Practical Nurse #5 stated they think maybe the facility wanted to send back the IV Vancomycin to the pharmacy, but they were not sure. They stated the Registered Nurses are responsible for IV medications administered via Peripheral inserted central catheters, and the Registered Nurses were responsible to check for expired IV medications.
On 9/09/24 at 3:21 PM on the 1st floor unit at the nurse's station, Registered Nurse Unit Manager #2 stated the IV vancomycin was not picked up by the pharmacy when they were called to do so. They stated since it was expired, it should have been discarded.
On 9/13/24 at 12:19 PM during an interview with the Director of Nursing, they stated the facility no longer uses multi-dose insulin vials. They stated the Licensed Practical Nurse should not have given insulin to another resident from an open insulin vial labeled for a different resident. They stated the Licensed Practical Nurse should have called the Nurse Practitioner, called the pharmacy, asked the Registered Nurse Unit Manager for assistance if needed.
10 NYCRR 415.18(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interviews during the recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that the attending provider documented in the resident's medical record ...
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Based on record review and interviews during the recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that the attending provider documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, actions had been taken to address it. This was identified for 1 of 5 residents (Resident #43) reviewed for unnecessary medications. Specifically, the Medication Regimen Review for Resident #43 dated 4/26/2024 documented a recommendation from the consultant pharmacist for Enoxaparin 40 mg injection to be reviewed for a stop date and appropriate use based on diagnosis and patient mobility. The provider agreed with the recommendation and documented that the medication was discontinued; however, did not address the recommendation and did not document the plan in Resident # 43's medical record.
The findings are:
The undated facility policy for the Drug Regimen Review documented it is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist needs to conduct the medication regimen review more frequently depending on the resident condition, review of short stay residents and risk of adverse consequences. The licensed pharmacist will report in writing, any irregularities to the attending physician, the facility's medical director and the Director of Nursing to be acted upon.
A Physician Order with a renewal dated 8/30/2024 and was originally ordered 2/20/2024 documented Enoxaparin 40 milligrams (MG) inject 0.4 milliliters (ml) QD (everyday) at 9 pm for a diagnosis of sepsis due to streptococcus.
A Pharmacy Medication Regimen Review Recommendation dated 4/26/2024, documented the resident was currently on Enoxaparin 40 mg injection without a stop date as appropriate based on diagnosis and patient mobility. FDA approved durations were listed. The facility provider checked off Agree: Please write order on the recommendation and hand wrote Med has been discontinued The pharmacy recommendation was signed and dated by the facility's Family Nurse Practitioner on 9/9/2024 (over 4 months later).
A review of medical progress notes from 4/1/2024 to 9/13/2024 did not document the provider's plan to address the Enoxaparin 40 mg in Resident #43's medical record.
During an interview with the Nurse Practitioner on 09/13/24 at 12:19 PM they stated they have worked in the facility since 5/6/2024. They stated that the drug regimen review dated 4/26/2024 was reviewed by them when they signed it on 9/9/2024. They stated they did not discontinue the medication because it had been previously discontinued. They stated they never intended to discontinue the medication because the patient is bed bound and needs the medication. The Nurse Practitioner acknowledged that they should start writing a note in the patient's chart after they review it and make any changes. The Nurse Practitioner stated, It is not easy to write a note because of the large volume.
10NYCRR 415.18 (c)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used...
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Based on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used for anticoagulation. This was evident for 1 of 5 residents (Resident # 43) reviewed for unnecessary medications. Specifically, there was inadequate monitoring of an anticoagulant medication.
The findings are:
The undated facility policy for the Drug Regimen Review documented it is the policy of the facility that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist needs to conduct the medication regimen review more frequently depending on the resident condition, review of short stay residents and risk of adverse consequences. The licensed pharmacist will report in writing, any irregularities to the attending physician, the facility's medical director and the Director of Nursing to be acted upon.
A Physician's Order dated 8/30/2024, documented Enoxaparin 40 milligrams (MG) inject 0.4 milliliters (ml) QD (everyday) for a diagnosis of sepsis due to streptococcus.
A Pharmacy Medication Regimen Review Recommendation dated 4/26/2024, documented the resident was currently on Enoxaparin 40 mg injection without a stop date as appropriate based on diagnosis and patient mobility. The Federal Drug Administration approved durations were listed. The facility provider checked off Agree: Please write order on the recommendation and hand wrote Med has been discontinued. The pharmacy recommendation was signed and dated by the facility's Family Nurse Practitioner on 9/9/2024.
A review of the medical progress notes from 4/26/2024 to 9/11/2024 did not document that the provider reviewed the drug regimen review recommendation, and the action that was taken to address the Enoxaparin 40 mg injection in the resident's medical record.
A review of all active care plans documented no evidence of an anticoagulant care plan, or interventions that included monitoring for signs and symptoms of bleeding, hematuria, or ecchymosis.
A review of the Medication Administration Record documented that Enoxaparin 40 mg injection was administered every day at 9 pm from 4/1/2024 to 9/12/2024 with no documentation of administration on 5/3/24, 7/19/24, and 8/3/24.
On 09/13/24 at 09:30 AM during an interview, the Director of Nursing stated there is a binder that reflects the monthly drug regimen reviews conducted. The Director of Nursing stated that the pharmacy sends an email to the Medical Director and Director of Nursing with its recommendations and any irregularities. The Minimum Data Set Coordinator reviews and makes a copy for the binder and a copy for the providers to review. If there are any changes made to the medication the provider will give the copy to the Director of Nursing, Nurse Managers or Nurses on the unit to enter the changes into the electronical medical record (Sigma Care). The order would usually be picked up the same day the provider signed it, or the next day. The Director of Nursing reviewed the Drug Regimen Review dated 4/26/2024 for Resident #43's Enoxaparin 40 mg injection. They acknowledged that the order should have been picked up and addressed. They stated there was an overlap in Nurse Practitioners and the drug regimen review may have been in the binder for the Nurse Practitioners that were leaving to review. They stated that the new full time Nurse Practitioner did not start until May or June of 2024. They stated that when there is a medication order that is not picked up by the provider, they will consult the Director of Nursing about the order.
During an interview with the Nurse Practitioner on 09/13/24 at 12:19 PM they stated they have worked in the facility since 5/6/2024. They stated they review the recommendations from the pharmacy. They stated they can agree or disagree with the recommendations from the pharmacy and give a reason why they do not agree. The drug regimen review dated 4/26/2024 for Resident # 43's Enoxaparin 40 mg injection was handed to the provider for review. They stated that the drug regimen review dated 4/26/2024 was reviewed by them when they signed it on 9/9/2024. They stated they did not discontinue the medication because it had been previously discontinued. They stated they never intended to discontinue the medication because the patient is bed bound and needs the medication. The Medical Provider stated they also review the orders. They stated they agreed to continue with Enoxaparin 40 mg injection and never wanted it to be discontinued. The Nurse Practitioner acknowledged that they should start writing a note in the patient's chart after they review it and make changes. They stated, that it is not easy to write a note because of the large volume. They stated that after the provider reviews the recommendations, they will document on the form for the Director of Nursing or Unit Managers to enter the changes in the electronical medical record. They stated that the unit manager would be responsible for ensuring the change in medication is reflected on the Medication Administration Record. They stated that the facility also has a group chat to discontinue or add new orders. They stated the expectation is that orders are picked up daily.
10 NYCRR 415.12 (I)(1)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, it was determined that the facility did not ensure residen...
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Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (NY00340278) from 9/5/24 to 9/13/24, it was determined that the facility did not ensure residents were free from significant medication errors for 3 (Residents #38, #104, #89) of 23 residents reviewed for medication administration. Specifically, 3 residents did not receive medications in accordance with the prescriber's orders and accepted health standards established by national boards and councils. This included but was not limited to antibiotic, antidiabetic pill, vitamin, supplement, antihypertensives, inhaler for chronic obstructive pulmonary disease, and antipsychotic which were not administered at the prescribed time on 9/5/24.
The findings include
The facility policy, 'Administration of Medications' last reviewed January 2024 documented that a licensed nurse will be responsible for passing medications to residents in accordance with techniques approved for use in the facility and compliance with New York State codes rules and regulations and with other applicable federal and state laws. Medications will be administered using the six rights of medication administration: right resident, right medication, right dose, right time, right route, right documentation. If a medication is missing or unavailable in the emergency box, the cubex should be checked to see if it is present. If it is not present, the nurse should call the physician or nurse practitioner for a hold order and document and call the pharmacy on the whereabouts and when the delivery will be. Any medication operational concerns such as errors in labels, medication not available, shortages/ low supply of medication, discrepancies in controlled drug counts, med cart problems, etc. are reported to the unit manager or charge nurse or supervisor and corrected as appropriate and as per policy as acceptable. All medication administration problems are noted and reported to the unit manager or charge nurse or supervisor before the shift ends. Daily oversight of administration documentation is performed by the director of nursing or designee.
The facility policy, 'Storage of Drugs' last revised August 2023 included documentation that the drugs for each resident shall be kept and stored in their original containers as received from the pharmacy and there shall be no transferring between containers.
According to the Physician Desk Reference, the 6 rights of safe medication administration include the right patient, right drug, right dosage, right route, right time, and the right documentation.
1. Resident #38 was admitted to the facility with diagnoses which included urinary tract infection, retention of urine, and type 2 diabetes mellitus.
The Physician's Orders for Resident #38 included Methenamine Hippurate (antibiotic) 1 gram tablet, give by oral route 2 times every day at 9:00 AM and 5:00 PM for diagnosis of personal history of urinary tract infections, and Metformin (diabetes oral medication) 1,000 mg, give 1 tablet by oral route 2 times per day at 6:00 AM and 5:00 PM for diagnosis of type 2 diabetes mellitus with hyperglycemia.
2. Resident #104 was admitted to the facility with diagnoses which included hypertensive heart with heart failure, chronic diastolic heart failure, and chronic obstructive pulmonary disease.
The Physician's Orders for Resident #104 included Carvedilol (heart medication) 6.25 mg, give 1 tablet by oral route 2 times per day with food at 6:00 AM and 5:00 PM for diagnosis of hypertension, Advair Diskus (inhaler) 250 mcg-50 mcg/dose powder for inhalation, inhale 1 puff 2 times per day at 9:00 AM and 5:00 PM for chronic obstructive pulmonary disease, Entresto (heart medication) 24 mg-26 mg tablet give 1 tablet by oral route 2 times per day at 9:00 AM and 5:00 PM for heart failure, and Vitamin C 500 mg tablet, give by oral route 2 times per day for 10 days at 9:00 AM and 5:00 PM for diagnosis of COVID-19.
3. Resident #89 had diagnoses which included schizophrenia, generalized anxiety disorder, and dementia with agitation.
The Physician's Orders for Resident #89 included Olanzapine (antipsychotic medication) 10 mg tablet, give 1 tablet by oral route 2 times per day at 9:00 AM and 5:00 PM for diagnosis of schizoaffective disorder, bipolar type.
Review of Licensed Practical Nurse #3's timecard documented Licensed Practical Nurse #3 clocked out at 3:31 PM on 9/5/24.
Review of Medication Administration Records History Details of 23 residents dated 9/5/24 on Licensed Practical Nurse #3's assignment documented that 3 residents for whom some medications were due at 5:00 PM, received some of those medications between 2:23 PM and 2:31 PM.
1. For Resident #38, Methenamine Hippurate (antibiotic) 1 gram tablet and Metformin (diabetes oral medication) 1,000 mg tablet which were due at 5 PM were signed as administered on 9/5/24 at 2:23 PM by Licensed Practical Nurse #3.
2. For Resident #104, Carvedilol (heart medication) 6.25 mg, give 1 tablet by oral route 2 times per day with food at 6:00 AM and 5:00 PM for diagnosis of hypertension, Advair Diskus (inhaler) 250 mcg-50 mcg/dose powder for inhalation, inhale 1 puff 2 times per day at 9:00 AM and 5:00 PM for chronic obstructive pulmonary disease, Entresto (heart medication) 24 mg-26 mg tablet give 1 tablet by oral route 2 times per day at 9:00 AM and 5:00 PM for heart failure, and Vitamin C 500 mg tablet, give by oral route 2 times per day for 10 days at 9:00 AM and 5:00 PM for diagnosis of COVID-19, were signed as administered on 9/5/24 at 2:26 PM by Licensed Practical Nurse #3.
3. For Resident #89, Olanzapine (antipsychotic medication) 10 mg tablet, give 1 tablet by oral route 2 times per day at 9:00 AM and 5:00 PM for diagnosis of schizoaffective disorder, bipolar type was signed as administered on 9/05/24 at 2:31 PM by Licensed Practical Nurse #3.
On 9/9/24 at 11:24 AM during an interview, Licensed Practical Nurse #3 stated they gave the 5 PM medications on 9/5/24 between 2:23 PM and 2:31 PM because they needed to leave at 3:30 PM and there was no nurse to relieve them. They stated they were asked to do so by the Director of Nursing. They stated they did not notify the physician and were not aware if the physician was aware of the situation. They stated they endorsed and gave the medication cart keys to Registered Nurse Unit Manager #1.
On 9/9/24 at 11:37 AM, during an interview, the Registered Nurse Unit Manager #1 stated their hours were 7:00 AM-3:30 PM, but they were willing until 5 PM and stated they did give 5 PM medications if needed and often did so. They stated they did not know why Licensed Practical Nurse #3 gave the 5 PM medications listed above too early, and stated that Licensed Practical Nurse #3 should not have done that. They stated that Licensed Practical Nurse #3 should have left those medications for them to administer. Registered Nurse Unit Manager #1 stated that when they administered the 5 PM medications on 9/5/24, they did not notice that some medications had been given too early by Licensed Practical Nurse #3. They stated they looked at the 'due' medications and administered them. They stated they were not aware of this situation.
On 9/9/24 at 11:47 AM, during an interview, the Nurse Practitioner stated they did not give orders to any nurses to administer any resident's medications early. They stated they were not made aware that medications were administered early. They stated if they had been asked, they would have reviewed each of the residents and their medication orders and made their determination.
On 9/9/24 at 12:13 PM, during an interview and record review with the Director of Nursing, the medication administration times of the above resident's medications were reviewed. The Director of Nursing stated the medications should not be given more than one hour prior to or one hour after the ordered time. They stated the medication nurse was responsible for notifying the Nurse Practitioner or the physician of the situation and ask for a new order for a time change. The Director of Nursing stated the medications were administered too early and therefore they were considered medication errors.
10 NYRCC 415.12(m)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the recertification survey from [DATE] to [DATE], the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the recertification survey from [DATE] to [DATE], the facility did not ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standard of practice. Specifically, the 2nd floor unit south side medication cart
was observed with expired 22-gauge insyte autogaurd needles which are used to administer intravenous medications.
Findings include:
The facility policy, 'Storage of Drugs' last revised [DATE] did not document the facility policy regarding the storage of medical supplies such as intravenous needles.
On [DATE] at 4:34 PM, the 2nd floor unit south side medication cart was observed with three 22-gauge insyte autogaurd needles with expiration dates of [DATE].
On [DATE] at 4:39 PM, Licensed Practical Nurse #4 stated the insyte autogaurd needles should not be on the medication cart. They stated the nurse who starts an intravenous line is responsible for checking that the insyte autogaurd needle is within range, and the nurse who holds the keys to the medication cart is responsible for assuring that everything in the medication cart is within range. They stated the insyte autogaurd needles should have been discarded.
10NYCRR 483.45 (g)(h)
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 F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that Certified Nurse Aides were provided the required 12 hours of t...
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Based on record reviews and interviews conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that Certified Nurse Aides were provided the required 12 hours of training and/or annual in-services on dementia care management and resident abuse prevention, to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 5 of 5 Certified Nurse Aides ( #9, #19, #20, #21, and #22), reviewed for Nurse Aide training, were provided 12 hours of mandatory training.
The Facility Assessment Tool Report, dated 7/1/24, documented: In accordance with New York State Department of Health requirements, in-service training is provided for Certified Nurse Aides sufficient to ensure their continuing competence. Training is at least 12 hours per year and includes dementia management and resident abuse prevention training. All staff receive annual training related to safety, emergency code and plans, and specific training required for their position.
The findings are:
During an interview on 09/09/24 at 03:45 PM, the Director of Nursing/Staff Educator stated they were responsible for documentation of the Certified Nurse Aide mandatory in-services. The Director of Nursing/Staff Educator was provided with a random sample of five Certified Nurse Aides and proof of the required 12 hours of annual in-service training was requested. The Director of Nursing/Nurse Educator provided the following documentation:
For Certified Nurse Aide #8: The Director of Nursing provided documentation for 30 minutes of annual in-service training (Kiosk Training) and a sign in-sheet for Annual Mandatory Education for 2024 without the education hours listed for Certified Nurse Aide #8. The Director of Nursing stated the time needed to complete Annual Mandatory In-service packet would be 1-2 hours. The Director of Nursing stated Certified Nurse Aide #8 did not complete the required 12 hours of annual mandatory in-service and they were not able to provide further proof of in-services for 2023 or 2024.
For Certified Nurse Aide #19: The Director of Nursing provided documentation for 1 hour of annual in-service training (Elopement and Customer Service Training) and a sign in-sheet for Annual Mandatory Education for 2024 without the education hours listed. The Director of Nursing stated the time needed to complete Annual Mandatory In-service packet would be 1-2 hours. The Director of Nursing stated Certified Nurse Aide #19 did not complete the required 12 hours of annual mandatory in-service and was not able to produce further proof of in-services for 2023 or 2024.
For Certified Nurse Aide #20: The Director of Nursing provided documentation for 1 hour of annual in-service training (Elopement and Customer Service Training). The Director of Nursing stated Certified Nurse Aide #20 did not complete the required 12 hours of annual mandatory in-service and was not able to produce further proof of in-services for 2023 or 2024.
For Certified Nurse Aide #21: The Director of Nursing provided documentation for 30 minutes of annual in-service training (Customer Service Training). The Director of Nursing stated Certified Nurse Aide #21 did not complete the required 12 hours of annual mandatory in-service and was not able to produce further proof of in-services for 2023 or 2024.
For Certified Nurse Aide #22: The Director of Nursing provided documentation for 1 hour of annual in-service training (Elopement and Customer Service Training). The Director of Nursing stated Certified Nurse Aide #22 did not complete the required 12 hours of annual mandatory in-service and was not able to produce further proof of in-services for 2023 or 2024.
During an interview on 09/10/24 at 11:08 AM with Certified Nurse Aide #18, they stated they received in-services in the last year, but not recently. They stated that in-services were usually in-person with Director of Nursing or Unit Manager.
During an interview on 09/13/24 at 12:00 PM, the Administrator stated the facility was currently attempting to hire an Assistant Director of Nursing which would enable the Director of Nursing to spend more time providing annual in-services.
10 NYCRR 415.26 (c)(1)(iv)
CONCERN
(E)
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, interview, and record review conducted during the recertification survey from 9/5/2024 to 9/13/24, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from 9/5/2024 to 9/13/24, the facility did not ensure residents' right to a safe, clean, comfortable and homelike environment. This was evident during environmental observations of resident Units 1 and 2. Specifically, on Unit 2, resident rooms were observed with sticky floors, garbage receptacles overflowing, garbage was strewn the floor, and soiled adult briefs were observed lying on floor; and on Unit 1, the floor near the nursing station and in front of the elevator was littered with garbage, and appeared stained and the Unit 1 dining room floor was observed with dried spills of coffee, and breakfast trays were still on tables at 12:35 PM.
The findings are:
During observations on 09/05/24 on Unit 1, at 10:12 AM debris was on floors by the Unit 1 nursing station with straws, paper, caps to bottles, and other particles of dust or dirt. The floor by nursing station in front of elevator appeared stained and dirty. At 12:35 PM, the Unit 1 dining room floor was observed with dried spills of coffee, and breakfast trays left on tables after residents had completed their meals.
During observations on 09/05/24 of resident room [ROOM NUMBER]:
- at 10:07 AM, a soiled adult brief was observed lying on the floor to the left side of the resident bed and the floor had garbage thrown on it and was sticky.
- at 11:08 AM, the resident was sitting on the side of the bed and a soiled adult brief and garbage were still present on the floor.
- at 12:22 PM, a strong smell of urine was noticed and the resident was sitting at bedside eating lunch; a soiled adult brief remained on the floor.
During observations on 09/05/24 of resident room [ROOM NUMBER]:
- at 10:20 AM, the floor was littered with garbage, and the garbage receptacle was overflowing. The sink area was soiled with tan stains and littered with resident clothing and debris.
- at 12:27 PM, garbage was strewn on the floor, empty cans, empty food containers, the garbage receptacle was full and overflowing, and the floor was sticky.
During an interview on 09/05/24 at 12:08 PM, Certified Nurse Aide #16 stated that morning care had not been completed for all residents on their assignment due to them being overwhelmed with 30 residents to provide morning care for, as well as feed and assist with housekeeping. Certified Nurse Aide #16 stated facility was chronically understaffed and they did as much as possible during their shift but had difficulty completing all tasks.
During an interview on 09/13/24 12:00 PM with Administrator, they stated facility had sufficient housekeeping staff but felt they could benefit from additional training and oversight. They stated that they were in the process of hiring a new Maintenance Director. They stated that housekeeping staff was available 7:00 AM-3:00 PM shift and 3:00 PM-11:00 PM shift.
10 NYCRR 415.29
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 surveys (NY00346428), conducted 9/...
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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 (NY00346428), conducted 9/5/24 to 9/13/24, the facility did not ensure each resident remained as free of accident hazards as possible for 4 of 5 residents (#35, #161, #18, and #87) reviewed for accidents. Specifically, 1) Resident #161 had falls on 6/29/24 and 7/4/24, was on an anticoagulant (blood thinner) medication and there was no documented evidence of neuro-checks following falls on 6/29/24 and 7/4/24 and the resident was not sent to the hospital for evaluation, 2) Resident #35's shepherd's hook/enabler rail was loose and not functionable for over one month, 3)Resident #18 had a fall on 8/2/2024 and sustained a hip fracture and the fall care plan was not updated with new interventions to prevent recurrence of falls, and 4) Resident #87 had falls with major injuries on 2/8/24, 2/29/24 and 5/8/24 and the fall care plan was not updated with new interventions to prevent recurrence of falls.
Findings include:
The policy and procedure titled Resident Falls last revised September 2023 documented each resident fall will be managed in a manner that maximizes well being and safety including assessment for injury with appropriate follow up. The follow up procedure determines the causative/contributive factors, root cause, interventions to prevent recurrence, or in the event that recurrence is highly likely means to prevent major injury from falls.
The undated facility Accident/Incident Prevention and Management policy documented it is the policy of Renaissance Rehabilitation and Nursing Care Center to promote and maintain a safe environment and develop corrective measures to prevent reoccurrence.
1. Resident #35 had diagnoses which included personal history of transient ischemic attack, flaccid hemiplegia affecting left non-dominant side, and obesity due to excess calories.
The 8/13/2024 Minimum Data Set Assessment documented the resident had intact cognition, and was dependent for bed mobility (rolling left to right).
The comprehensive care plan titled: Activities of Daily Living: transfer, bed mobility, ambulation (last updated 5/23/23) documented the Resident required assistance with activities of daily living tasks secondary to cerebrovascular accident with left hemiplegia. Resident is dependent with transfers requiring assistance of 2 staff via mechanical hoyer lift. Resident required extensive assist of 1 for mobility and was non-ambulatory. Interventions included to Assist with transfers and bed mobility as recommended. Bilateral shepherd hooks to bed, encourage participation in activities of daily living care.
On 9/05/24 at 10:20 AM, 9/06/24 at 10:20 AM, 09/09/24 at 10:14 AM, and 9/10/24 at 10:38AM, Resident #35's shepherd's hook/enabler rail on the right side of the bed was observed to be loose and not functionable.
On 09/05/24 at 10:20 AM during an observation and brief interview with Resident #35, the shepherd's hook/enabler rail on resident's right side was observed to be loose. Resident #35 stated that the shepherd's hook/enable rail had been loose for over a month, and they were not able to utilize side rail to turn and reposition or push themselves up in bed. Resident #35 stated they had informed numerous unit staff members of the defective shepherd's hook/enabler rail and that the facility maintenance checked it over a month earlier but did not complete a repair. Resident #35 stated the broken shepherd's hook/enable rail affected their daily bed mobility by making it difficult to turn and reposition, reach for items on side table, and move up in bed and during cares. Resident #35 stated the Certified Nurse Aides observed the broken shepherd's hook/enable rail device daily during cares daily.
On 09/10/24 at 11:27 AM during an interview, Licensed Practical Nurse #4 stated that Resident #35 had not discussed a loose shepherd's hook/enable with them and that Resident #35 had only reported television issues in the past. Licensed Practical Nurse #4 stated that right sided shepherd's hook/enabler rail was functional to their knowledge, and they were not aware of device being loose. They stated that the last time they assisted with cares with the resident was over a month ago and that the Certified Nurse Aide provided care to Resident #35.
On 09/10/24 at 03:15 PM during an interview, the Regional Director of Maintenance and Life Safety stated they just became aware of Resident #35 broken shepherd's hook/enabler today (9/10/24). Regional Director of Maintenance stated about a month ago (no official date), a member of maintenance team was verbally informed of loose rail by staff on the second floor and they assessed rail. Regional Director of Maintenance stated that the plan to repair side rail required the resident to be taken out of bed so full repair could take place. They stated at the time of assessment, the maintenance staff tightened rails as much as possible with Resident #35 in the bed. Regional Director of Maintenance stated the staff on the second floor were made aware that full repair could only take place if Resident #35 was not present in the bed. Regional Director of Maintenance was not aware why follow up and permanent repair was not made and stated it could be related to recent staff changes in Maintenance Department and communication deficit between Maintenance staff and Second Floor Unit nursing staff.
On 09/11/24 at 10:54 AM during an interview Certified Nurse Aide #17 stated they verbally reported to a member of the Maintenance team (name unknown) over a month ago that Resident #35's shepherd's hook/enabler was loose and not functionable. They stated that a member of the Maintenance Department observed shepherd's hook/enabler rail in resident room the same day, tightened bolts but it was never fully repaired. Certified Nurse Aide #17 reported that the member of the Maintenance team verbally reported that Resident #35 would need to be out of bed for the full repair and that Unit Manager was aware of this information.
On 09/12/24 at 05:04 PM a review was conducted of the second floor Maintenance Binder there was no record of maintenance request for shepherd's hook/enabler rail repair request from 1/2024 to present date.
2. Resident #161 was admitted with diagnoses which included status post left above knee amputation, osteomyelitis, and rheumatoid arthritis.
The fall assessment dated [DATE] documented a score of 12 that indicated that Resident #161 was at high risk for falls.
The 5/18/24 physician orders documented that Resident #161 was to receive Eliquis (blood thinner medication) 2.5 mg twice a day.
The 5/21/24 Fall Care Plan documented Resident #161 is at increased risk for falls related to: 6/18/24 status post fall no apparent injuries, complained of neck pain at 2:05 AM, neck x-ray result showed no compression deformities, mild degree of osteopenia, mild degree of spondylosis. Noted old bruise on forehead fading away, 6/29/24 s/p fall, no apparent injuries, 7/4/24, s/p fall redness to right side of forehead. The following were documented as interventions: 6/18/24 s/p fall provide positioning wedge cushion; 6/29/24 keep bed in lowest position, neuro checks q shift, fall monitoring x 3 days, bilateral floor mats, scoop mattress overlay provided; 7/4/24 s/p fall hourly check x 24 hour.
The 6/14/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #161 had intact cognition. The assessment further documented lower extremity impairment on one side. Resident #161 received dependent assistance with chair and bed transfers. The assessment documented Resident #161 had no falls since admission or prior assessment and did not receive rehab services.
The 6/29/24 Accident/Incident Report documented resident unable to describe incident. Resident observed laying on her left side on floor in room beside bed. No apparent injuries on assessment. No mental status change, range of motion within normal limits. The following were documented as interventions: Keep bed in lowest position, floor mats for both sides of bed. Neuro checks each shift and fall monitoring for 3 days post fall.
The 7/4/24 Accident/Incident Report documented resident stated she fell out of bed. Resident found lying on floor mat next to bed, resident hoyered back unto bed after assessment, no injuries, no bleeding. The following were documented as interventions: Call bell within reach, safety matts, bed in lowest position, hourly check x 24 hours.
There was no documented evidence of neuro checks being done following the falls on 6/29/24 and 7/4/24.
Additionally, there was no documented evidence in the electronic medical record to indicate hourly checks were put in place for 24 hours as per care plan after the fall on 7/4/24.
On 09/10/24 at 11:31 AM, Certified Nurse Aide #10 stated after the falls, Resident #161 was put in a geri chair and they used floor mats. Certified Nurse Aide #10 stated Resident #161 was always climbing out of bed saying they were going home.
On 9/12/24 at 11:46 AM, Registered Nurse Unit Manager #2 stated after a fall they immediately assess resident, get their vitals and call the physician and family. Registered Nurse Unit Manager #2 stated if there was no Registered Nurse overnight, the Licensed Practical Nurse would assess resident. Registered Nurse Unit Manager #2 stated if the resident hit their head from a fall there was nothing different they would do. If there were no injuries, the resident would not be sent out to the hospital. Registered Nurse Unit Manager #2 stated if a resident was on anticoagulant they would notify doctor and doctor would determine if the anticoagulant should be held. Registered Nurse Unit Manager #2 stated it was the same protocol as any other fall. The doctor would order neuro-checks for 3 days and the nurses should write a progress note. Registered Nurse Unit Manager #2 stated the physician was called and they did not order to send Resident #161 to hospital, stated the physician knew the medications Resident #161 was on. When asked, Registered Nurse Unit Manager #2 stated they did not remind the physician that Resident #161 was on an anticoagulant medication. Registered Nurse Unit Manager #2 stated they usually did hourly checks which would be listed on the Medication Administration Record and they would have to check it every hour. Registered Nurse Unit Manager #2 stated they did hourly checks for 24 hours for the fall on 7/4/24, but was never given a paper log to document the hourly checks, and acknowledged it was not documented in the Medication Administration Record or Treatment Administration Record for June and July of 2024. Registered Nurse Unit Manager #2 stated they trie to remind the doctors but sometimes their suggestions were not welcomed.
On 09/12/24 at 1:04 PM, the Director of Nursing stated when a resident had a fall and was on an anticoagulant medication, they did not necessarily send the resident to the hospital; it depended on the severity of injury. The Director of Nursing stated they would evaluate the resident. Director of Nursing stated if there was a change in mentation or vitals signs they might send the resident out. The Director of Nursing stated the resident had no change in mentation and the final decision was made by the physician or nurse practitioner whether or not to send the resident to the hospital. The Director of Nursing stated the neuro checks was the way they monitor mentation and acknowledged there was no documented evidence of neuro checks or hourly checks for monitoring in Resident #161's electronic medical record. The Director of Nursing stated if the nurse practitioner did not put in the order for neuro checks or monitoring then it would not populate in the either the Treatment Administration Record or the Medication Administration Record for the nurses to do. The Director of Nursing stated the nurses should remind the Nurse Practitioner if the resident is on an anticoagulant medication after a fall, so the order gets put in for neuro checks.
3. Resident #18 was admitted to the facility with diagnoses which included vascular dementia, chronic obstructive pulmonary disease, and muscle weakness.
The 5/7/24 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #18 had a moderately impaired cognition. The assessment further documented no impairments on the upper or lower extremities. Resident #18 received supervision with chair and bed transfers. The assessment documented Resident #18 was continent of bowel and bladder.
A fall risk assessment dated [DATE] documented a score of 11 documenting a high fall risk.
A review of the Accident/ Incident Report dated 8/2/2024 documented Resident # 18 was found on their back close to the bathroom door. Urine was on the floor. The resident stated they slid in their own urine on the way to the bathroom. Abrasion to face, 8/10 pain to the right hip. New intervention put in place at the time of the event included encourage resident to call for assistance.
A Nursing progress Note dated 8/3/24 at 11:36 AM documented Resident #18 complained on nausea and right hip pain, Nurse Practitioner ordered to give Zofran 4 mg tablet for nausea and transfer to the hospital.
A review of the nursing progress note dated 8/4/2024 at 12:37 am documented writer spoke with nurse at the hospital, per nurse, Resident # 18 was diagnosed with a right hip fracture and will have intramedullary nail femur surgery in the morning.
A fall risk assessment dated [DATE] documented a score of 12 that is a high fall risk.
The Fall Risk Care Plan had no documented evidence of any new interventions added to the care plan after the fall on 8/2/24. The last two interventions were dated 5/24/24. The interventions included to place the bed in the lowest position and resident to be toileted at night.
On 09/05/24 at 02:30 PM during an observation and brief interview, Resident #18's room was cluttered with trash on the floor (cups, empty med cup, paper). Nasal cannula tubing was observed on the floor at the bedside. The call bell was not in reach. Resident #18 stated they had a recent fall while trying to go to the bathroom and after the fall they had to go to the hospital.
On 09/10/24 at 11:31 AM Resident #18 was observed in the bed with head of bed elevated. Resident's right leg was resting on the wheelchair located near the foot of the right side of the bed and their left leg was on the bed. The call bell was not in reach. Surveyor handed Resident# 18 the call bell and staff from OT assisted the resident to the middle of the bed.
On 09/10/24 at 11:38 AM during an interview, Resident #18 stated they are aware that they need assistance to get back in bed. They attempted to transfer themself back to bed because they were uncomfortable in the chair. They stated when they ring their call bell it takes a time for someone to come. Resident #18 stated the day of their fall they attempted to go to the bathroom independently. They stated they made it near the bathroom when they fell and hit the right side of their head and had pain in the right side of their hip. Resident #18 stated they do not use the call bell because it takes so long that they give up and do what they need to do for themself. They stated that sometimes there is only one person on for the whole unit.
On 09/12/24 at 11:50 AM during an interview, Licensed Practical Nurse #4 stated they worked in the facility for 7 years. They stated they are not familiar with the care plan for Resident #18. They stated in the past, Resident #18 attempted to get out of bed without help. Licensed Practical Nurse #4 stated that during a medication pass and at various times throughout the day they will monitor Resident #18 for safety per their nursing judgment, although there were no current orders to do so. Surveyor asked Licensed Practical Nurse #4 if Resident #18 had any recent falls. Licensed Practical Nurse #4 stated they are not aware of Resident #18 having recent falls, but after reviewing Resident #18 medical record, Licensed Practical Nurse #4 stated the resident had a fall and fractured the right hip in August. Licensed Practical Nurse # 4 stated they can not recall any new interventions put in place to prevent Resident # 18 after the fall in August from falling again.
On 09/12/24 at 12:06 PM during an interview, Certified Nurse Aide #17 stated that in the electronic medical record (Sigma Care) the system identified how to care for Resident #18. Certified Nurse Aide #17 stated the resident had hip surgery and they need to be careful with the transfer of the resident. Surveyor asked Certified Nurse Aide #17 about new interventions put in place for Resident #18 afetr the fall in August. They stated they transfer with the assist of 2 staff, they need to do safety checks on them every 1-2 hours which is documented in the Certified Nurse Aide instructions.
10 NYCRR 415.12(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
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 09/05/24 to 9/13/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the actual staffing from April 1, 2024 through June 30, 2024 and August 9, 2024 through September 9, 2024 on all three shifts for each unit, the facility did not provide adequate nurse staffing to meet the needs of the residents on multiple occasions during each of the months reviewed, based on the Facility-Wide Assessment.
The findings are:
The Facility-Wide assessment dated [DATE] and reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 8/22/24, stated the below facility resources were needed to provide competent resident support and care daily and during emergencies:
Facility-Wide Assessment Staffing Plan:
Licensed Nurses providing administrative direction, supervision and direct care: Director of Nursing: 1 Registered Nurse full time days. Assistant Director of Nursing 1 Full time equivalent.
Registered Nurse Manager: 2 full time equivalents.
RN Supervisors: evenings and weekends: 3 full time equivalents.
Licensed Practical Nurse Medication Nurses 7:00 AM-7:00 PM and 7:00 PM to 7 AM: 4-6 Full time equivalents daily.
Direct care Staff: Certified Nurse Aides: 6-8 for days, 6-8 for evenings, 4-6 for nights.
The facility actual staffing sheets from April 1st through June 30, 2024, August 9, 2024 through September 9, 2024 and the Facility Assessment for residents to direct care nursing staff ratios, documented the facility was understaffed 18 out of 30 days in April, 2024, 24 out of 30 days in May, 2024, and 22 out of 30 days in June, 2024 in nursing staff.
During a Resident Council meeting on 09/09/24 at 11:15 PM, one resident stated they waited 4 hours for a response to their call bell and another resident stated that there was no staff to be found at 11:30 PM. Another resident stated the facility was short staffed.
During an observation and brief interview on 09/05/24 at 9:55 AM, Resident #81 was observed in bed with trash on right side of bed and wheelchair positioned at the left side of the foot of the bed. Resident #81 stated they had been waiting to get out of bed since 7:30 AM. They rang the call bell and a staff came and shut the call bell off.
During an observation on 09/05/24 at 10:07 AM, Resident #66 had a soiled adult brief lying on floor at left side of their bed. The Resident's floor was soiled and sticky.
During an interview with Resident #62's family member on 09/05/24 at 11:03 AM, they stated they were informed by nursing staff that when they were short staffed, they could not get residents out of bed. The family member stated Resident #62 was in bed for an entire week.
During an interview on 09/05/24 at 11:33 AM, Resident #32 stated they need assistance with shaving, but sometimes the facility was too short staffed.
During an observation on 09/05/24 at 11:34 AM with Director of Nursing present, Resident #78 was observed with feces on their hands, on the tray table, and on the floor along with a torn adult brief. The Resident's room smelled of urine and feces.
During an observation on 09/05/24 at 11:49 AM, Resident #4 was observed sitting on the side of their bed wearing a pajama top and had soiled diaper. A soiled pajama bottom was observed on the floor.
During an observation on 09/05/24 at 12:22 PM, Resident #66's room had a strong smell of odor while eating the Resident was eating lunch. A soiled adult brief was observed on the floor.
During an observation and brief interview on 09/05/24 at 12:37 PM, Resident #38 was in bed, wearing a gown, eating lunch. Resident stated they liked to get out of bed but staff frequently told them there was not enough staff to assist them to get out of bed because they required 2 staff assist and a Hoyer lift for transfers. Resident #38 stated they thought they had not gotten out of bed in about a week.
During an observation and brief interview on 9/06/24 at 09:58 AM, Resident #38 was lying in bed wearing a gown. Resident #38 stated they wanted to get out of bed but there was not enough staff to assist them.
During an interview on 09/06/24 at 10:53 AM, Resident #35 stated they often waited extended periods of time to get changed.
During an observation and interview 09/10/24 at 11:38 AM, Resident #18 stated they need assistance to get back in bed. They stated they attempted to self-transfer back to bed because they were uncomfortable in the chair. Resident #18 stated when they ring their call bell it takes a while for someone to come.
During a brief interview on 09/05/24 at 12:08 PM with Certified Nurse Aide #16, they stated morning cares were not completed for Resident #45 and Resident #66 before 11:45 AM due to the Certified Nurse Aide being overwhelmed with 30 residents to provide morning cares for and assist residents with breakfast and lunch. Certified Nurse Aide #16 stated they were also requested to assist with housekeeping on the floor during their shift. They stated reason for cares being delayed and assignment of 30 residents was due to a call-out which was not re-staffed by the facility. They stated this occurred at least a few times a month and that staffing shortage had been a chronic concern within the facility. They stated they had difficulty completing their assigned resident care tasks when the facility was short staffed and that some tasks were not completed. They stated overtime was requested frequently.
During an interview 09/06/24 at 03:35 PM, Resident #106 complained that staff took a long time to respond to call bells, especially at night. Resident #106 also reported that they recently fell when self-transferring after no staff responded to call bell.
During an interview on 9/9/24 at 12:13 PM, the Director of Nursing stated that due to difficulties with nursing staffing between 3 PM to 7 PM, most of the Resident's medications were ordered to be administered at 7 PM.
During an interview on 09/10/24 at 11:08 AM, Certified Nurse Aide #18 stated that there were frequently shifts where the facility was understaffed. They stated there were usually 3-4 aides assigned to second floor unit during 7:00 AM-3:00 PM shift, but that sometimes staffing could be as low as two Certified Nurse Aides covering second floor with a resident census of about 50 residents. Certified Nurse Aide #18 stated when staffing was low they had approximately 30 residents assigned to them. They stated resident cares were completed when staffing was low, but were delayed, including assisting residents with meals and answering call bells. They stated overtime was requested frequently.
During an interview on 09/10/24 at 11:43 AM, Licensed Practical Nurse #4 stated the facility was frequently not staffed sufficiently. They stated they were requested to work overtime frequently.
During an interview on 09/13/24 at 10:30 AM, Registered Nurse Unit Manager #2 stated four Certified Nurse Aides were the optimal amount needed for the unit but there were frequently shifts where there were only 2 to 3 Certified Nurse Aides assigned. They stated that in addition to their role and duties as Unit Manager, they were also responsible for medication administration, providing treatments to residents, assisting with cares when licensed practical nurses and certified nurse aides staffing was low. They stated they had difficulty entering or updating resident care plans as a result of low staffing. They stated that some weeks they were not able to work on resident care plans at all. They stated their assigned hours at hire were to 8:30 AM to 4:00 PM however, they usually were required to work from 7:30 AM-approximately 6:00 PM due to call outs or to have a Registered Nurse in building. They frequently had to cover other floor units to provide medication administration due to short staffing, often resulting in late medication administration. Registered Nurse Unit Manager #2 stated they were frequently contacted when not on duty via phone or text with questions or requested to work overtime by the Director of Nursing. They stated staffing at weekends was especially difficult and the facility was short-staffed frequently on Saturdays or Sundays, especially for Registered Nurses.
During an interview on 09/13/24 at 10:52 AM, the Staffing, Human Resources and Payroll Coordinator stated staffing minimums were based on recommendations from facility report and New York State requirements and based on resident census. They stated nursing staffing has been a challenge for the facility over recent years. The facility does not utilize staffing agencies. They did in past and did not feel it benefited facility. They stated from Monday to Friday, there is always a Registered Nurse in the building and weekends usually have a Registered Nurse during the 7:00 PM to 7:30 AM shift. The Staffing Coordinator stated that callouts are handled by contacting all staff who are not working to offer extra shifts and that bonuses/incentives are offered to staff who agree to cover shifts. They will also offer bonuses/incentives to a staff member who is currently working to stay for an additional shift. The Staffing Coordinator stated they have had concerns from staff bought to their attention in the past about staffing shortages. They stated they have not had staffing concerns from families or residents. The Staffing Coordinator stated they are continuously trying to recruit new hires in nursing and dietary and that the main barrier to hiring is related to competition in area. The Staffing Coordinator stated the facility offers incentives and bonuses to entice new hires. Exit interviews are held when a staff member resigns and efforts are made to retain staff. Coordinator stated they have made recent progress with hiring in nursing and dietary aide staff.
During an interview on 09/13/24 at 11:25 AM, the Director of Nursing stated staffing schedules are reviewed with the Staffing Coordinator daily. They stated that staffing can be challenging, and they are aware of areas of concern on Payroll Based Journal reports. They stated a Registered Nurse is present in building Monday to Friday and most weekends during 7:00 PM to 7:30 AM shift. The Director of Nursing acknowledged there have been shifts in which there was no Registered Nurse in building after review of staffing logs. They stated that any emergency that occurs when a Registered Nurse is not in the building would be called into facility Nurse Practitioner who is on call 24 hours, 7 days a week, the Director of Nursing and the Medical Director. All falls with major injury would be sent to hospital. They stated that Registered Nurses serving as Unit Managers are often also responsible for medication administration and treatments due to short staffing. The Director of Nursing stated they are aware that resident cares are often completed late or not completed when Certified Nurse Aide staffing is low. They stated the Licensed Practical Nurses and Registered Nurses would assist with cares during low staffing and that due to this, updates to care plans can sometimes be delayed. The Director of Nursing stated that they assist with entering/updating resident care plans when this occurs, which is frequently. The Director of Nursing stated that there are challenges with recruiting Certified Nursing Aides, nursing and dietary staff. They stated housekeeping is adequately staffed. The Director of Nursing stated that the facility hired two Assistant Directors of Nursing over the last year and the facility was not able to retain these hires. Exit interviews were completed and they stated that workload was a presenting factor in deciding not to continue employment. They stated that the facility does not have a staffing waiver and does not utilize staffing agencies. They stated efforts are in place in increase hiring of all nursing staff and dietary employees with bonuses and incentives offered. Overtime is used frequently, and incentives are used to encourage staff members to accept overtime.
During an interview on 09/13/24 at 12:00 PM, the Administrator stated that staffing was challenging. The Administrator stated they were not sure if there was a Registered Nurse in the building at least 8 hours, 7 days a week. They stated that there was a Registered Nurse in building Monday through Friday days and most nights and weekends. They stated that emergencies that occurred when a Registered Nurse was not in building would be called in to the facility Nurse Practitioner who is on call 24 hours a day, 7 days a week and / or Director of Nursing who will assess emergency verbally and provide instructions. They stated that the facility continues to recruit for all levels of nursing staff. The Administrator stated call outs are attempted to be restaffed by the Staffing Coordinator or Director of Nursing and by offering overtime with incentives or reassigning staff from another floor to cover. The Administrator stated they believe facility is adequately staffed but would always want more employees. They stated that the facility does not use agency staff and that the facility could benefit from using agencies, however the decision not to utilize agency was made by Facility Corporate leadership prior to the Administrator's hire. The Administrator stated facility has sufficient housekeeping staff but feels they could benefit from additional training and oversight. They stated the facility is in process of hiring a new maintenance director. The Administrator stated Dietary Department is short-staffed as well and stated that the Staffing Coordinator continues to try to recruit through Indeed and friends and family. Administrator stated they feel that staffing shortages may affect resident care in terms of wait time and that the employees work hard to cover deficits.
415.13(a)(1)(i-iii)
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 F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, it was determined that the facility did not use the services of a Registered Nurse for at leas...
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Based on record review and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, it was determined that the facility did not use the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week per the regulations. Specifically, the facility was unable to provide documented evidence that a Registered Nurse had worked 4/12/24, 4/13/24, 4/27/24, and 5/18/24.
Findings include:
Review of the nurse staffing reports (report posted to inform residents and visitors of the number and hours of nursing staff working) for dates 4/1/24 through 6/30/24 and 8/9/24 through 9/9/24 provided by the facility Staffing, Human Resources and Payroll Coordinator, the facility did not have a Registered Nurse assigned to staffing for the facility's three shifts on 4/12/24, 4/13/24, 4/27/24, and 5/18/24.
During an interview on 09/13/24 at 10:52 AM with the Staffing, Human Resources and Payroll Coordinator, they stated staffing minimums were based on recommendations from the Facility Report and New York State requirements and based on resident census. They stated nursing staffing has been a challenge for the facility over recent years. The facility does not utilize staffing agencies. Staffing agencies were utilized in the past and the facility did not feel agency use was beneficial. The Staffing Coordinator stated that from Monday to Friday, there is always a Registered Nurse in the building. Weekends usually have a Registered Nurse during the 7:00PM to 7:30AM shift. The Staffing Coordinator stated that callouts are handled by contacting all staff who are not working to offer extra shifts and that bonuses/incentives are offered to staff who agree to cover shifts.
During an interview on 09/13/24 at 11:25 AM with the Director of Nursing, they stated staffing schedules are reviewed with the Staffing Coordinator daily. They stated that staffing can be challenging. They stated a Registered Nurse is present in building Monday to Friday and most weekends during 7:00PM to 7:30AM shift. The Director of Nursing acknowledged there have been shifts in which there was no Registered Nurse in building after review of staffing log during interview. They stated that any emergency that occurs when a Registered Nurse is not in building would be called in to the facility Nurse Practitioner who is on-call 24 hours,7 days a week, Director of Nursing and Medical Director. All falls with major injury would be sent to hospital.
During an interview on 09/13/24 at 12:00 PM with the Administrator, they stated that staffing is challenging. The Administrator stated they were not sure if there was a Registered Nurse in the building at least 8 hours, 7 days a week. They stated that there is a Registered Nurse in building Monday through Friday days and most nights and weekends. They stated that emergencies that occur when a Registered Nurse is not in building would be called in to the facility Nurse Practitioner who is on call 24 hours a day, 7 days a week and / or Director of Nursing who will assess emergency verbally and provide instructions. They stated that facility continues to recruit for all levels of nursing staff.
10NYCRR 415.13(b)(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
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure certified nursing aide performance reviews were completed at least ...
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Based on record review and interview conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure certified nursing aide performance reviews were completed at least once every 12 months for 5 of 5 Certified Nurse Aides ( #8, #19, #20, #21, #22) reviewed.
The findings are:
During an interview on 09/09/24 03:45 PM with Director of Nursing/Staff Educator, they stated they are responsible for documentation of the Certified Nurse Aide annual performance reviews. The Director of Nursing/Staff Educator, was provided with a random sample of five Certified Nurse Aides, and documentation of their annual performance appraisals was requested. Review of Certified Nurse Aides (#8, #19, #20, #21 and #22) dates of hire provided by the facility, revealed all five of the Certified Nurse Aides had been working at the facility for more than one year.
The Director of Nursing stated they have not completed annual performance appraisals for the Certified Nursing Aides since they started employment in November 2022. The Director of Nursing was not able to provide documentation of annual performance appraisals for the five randomly sampled Certified Nurse Aides.
During an interview on 09/10/24 11:08 AM with Certified Nurse Aide #18, they stated they have been employed since 2019 and do not recall annual performance appraisals being completed in recent years.
During an interview on 09/13/24 12:00 PM, the Administrator stated the facility is currently recruiting to hire an Assistant Director of Nursing which will enable the Director of Nursing to ensure the completion of annual performance reviews.
10NYCRR 415.26 (c)(2)(iii)
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordan...
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Based on observations and interviews conducted during the recertification survey from 9/5/24 to 9/13/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, meat, mashed potatoes, milk, and super shake were not maintained within the acceptable temperature range for food safety during a dinner observation on 9/5/24. Additionally, perishable foods were not labeled and dated and nonperishable foods were expired during observations in the kitchen.
The undated facility policy, Dietary Department -Food Temperatures documented it is the policy of the dietary department to take temperatures of all food items served to residents before the tray line begins. All parts of potentially hazardous foods requiring cooking will be heated to at least 170°F with the exception of poultry, pork, and roast beef. All poultry, poultry stuffing, stuffed meats, and stuffing containing meat will be heated so all parts are at least 165°F with no interruption of the cooking process. Pork and food containing pork is to be heated so all parts of the food are at least 150°F. Rare roast beef and/or rare beef steaks are to be heated to an internal temperature of 130°F.
Proper labeling and dating of each item. left over foods will be used within 3 days.
The entire mass of all precooked, refrigerated, potentially hazardous food that is to be reheated is to be heated rapidly to 165°F or above and held above 140°F until served. Potentially hazardous foods requiring refrigeration will be stored and served at a temperature not exceeding 45°F. It is the responsibility of the cook preparing the meal to take temperatures of all the food items served to residents. The temperatures will be recorded before each meal is served on a form designed for this purpose. A chart of correct serving and cooking temperatures is attached to the recording form to guide the cook in ensuring the food is at the proper temperature.
The in-service, 'Modified elevator usage' signed by staff on April 26, 2024 included documentation that test tray temperatures are to be taken on unit each meal this is repeated until each unit is served.
On 9/5/24 at 9:15 AM during the initial tour of the kitchen in the walk-in refrigerator, a 2-liter container of liquid eggs was open with no date of when it was opened, a one-liter plastic container half filled with a white- yellow substance was observed with no label, and was undated, and two loaves of sliced white bread were observed on the counter undated.
On 9/5/24 at 9:30 AM during an interview, the Food Service Director stated the egg salad should have a preparation date and a discard date, the liquid eggs should have an open date. The Food Service Director stated that consuming expired food can lead to food poisoning.
On 9/5/24 at 4:42 PM, 2 large linen carts were observed near the elevator. Activity Aide #6 stated, 'We use those to bring meal trays onto the unit because the big meal truck does not fit into the small elevator'.
On 9/5/24 at 4:45 PM, Activity Aide #7 was observed on the lobby level near the elevators, removing resident meal trays from the large, insulated meal truck and loading them onto linen carts. When asked, Activity Aide #7 stated, 'We do that because the big meal truck does not fit in the small elevator'.
On 9/5/24 at 5:20 PM, the surveyor requested food temperatures to be checked on a dinner meal. Registered Nurse Unit Manager #1 checked temperatures on meal tray. The temperature of the meat was 109 degrees, the temperature of mashed potatoes was 116 degrees, the temperature of reduced fat milk and super- shake was 48 degrees. Registered Nurse Unit Manager #1 stated they did not know why the cold foods were not cold enough and the hot foods were not hot enough.
On 9/5/24 at 5:30 PM during an interview, the [NAME] Supervisor #1 reviewed the temperatures taken from the meal tray and stated those temperatures were within the danger zone.
On 9/5/24 at 5:36 PM during an interview, the Food Service Director agreed that the food temperatures reviewed taken from the meal tray were in the danger zone.
On 9/5/24 at 5:46 PM during an interview, the Administrator stated they were not aware that food was being served in the danger zone. They stated they were not aware if staff had been checking food temperatures on the units.
On 9/10/2024 at 10:00 AM during the follow up tour of the emergency supply area, ten twelve-ounce bags of gravy mix were observed with an expiration date of 8/4/24.
On 9/10/2024 at 10:00 AM, during an interview the Food Service Director stated the gravy mix was expired.
10 NYCRR 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
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the Quality Assurance...
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Based on record review and interviews conducted during the recertification and abbreviated surveys (NY00352254 and NY00331775) from 9/5/24 to 9/13/24, the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service. Specifically, the large elevator was not working consistently since the spring of 2024 and was shut down in mid July 2024, and the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service which included but was not limited to food not being maintained at safe temperatures when served on the units, residents were eating on disposable plastic plates, approximately 10 residents who had previously been eating lunch in the main dining room on the main floor before the large elevator was shut down could no longer do so, and live music performances did not occur for approximately 2 months. The facility did not provide documentation for any meetings held to address the ongoing problem of the large elevator being shut down.
The findings are:
The facility policy, 'Quality Assurance Performance Improvement' last reviewed February 2024 documented the purpose of the Quality Assurance Performance Improvement policy is to ensure that the facility complies with state and federal regulations regarding the quality of care provided to residents. This policy outlines the framework for ongoing assessment, monitoring, and improvement of the quality of services delivered within the facility. This policy applies to all staff including management, healthcare professionals, and support personnel involved in the provision of care and services within the facility. It is the responsibility of the administrator of the facility for the implementation and oversight of the Quality Assurance Performance Improvement program. The quality assurance committee composed of representatives from various departments will be responsible for the development implementation and evaluation of the Quality Assurance Performance Improvement program. All staff members are responsible for actively participating in Quality Assurance Performance Improvement activities including reporting incidents identifying opportunities for improvement and implementing changes as necessary. Regular assessments of the quality of care and services provided to residents will be conducted to identify areas for improvement. Performance improvement projects will be initiated based on the findings of assessments or as identified through incident reports, resident/ family feedback, or regulatory requirements. Ongoing monitoring of key performance indicators related to resident care safety and satisfaction will be conducted to ensure adherence to established standards. Staff members will receive education and training on Quality Assurance Performance Improvement principals quality improvement methodologies and relevant regulations to enhance their ability to contribute to the program. Transparent communication channels will be established to facilitate the exchange of information among staff members, residents, families, and external stakeholders regarding quality improvement initiatives and outcomes. Mechanisms for soliciting feedback from residents, families, and staff regarding their experiences and suggestions for improvement will be implemented and regularly evaluated. Relevant data related to resident care safety incidents, infection control, medication management and other quality indicators will be collected, analyzed, and trended to identify patterns and areas for improvement. Data will be collected using validated tools and methodologies to ensure accuracy and reliability. Continuous improvement will be emphasized as an integral part of the organizational culture with a commitment to addressing identified issues promptly and effectively. Regular review meetings will be held to assess the progress of performance improvement projects, share best practices, and make adjustments to the Quality Assurance Performance Improvement program as needed. Findings and outcomes of Quality Assurance Performance Improvement activities will be documented and actions taken will be communicated to relevant stakeholders. This policy complies with all applicable federal state and local regulations governing nursing home operations and quality of care any identified noncompliance with regulatory requirements will be promptly addressed through corrective actions and included in the Quality Assurance Performance Improvement for ongoing monitoring. This policy shall be implemented immediately upon approval by the administrator of the facility. All staff members shall be provided with training on the contents of this policy and their roles and responsibilities and supporting the Quality Assurance Performance Improvement program.
The facility provided the survey team with an in-service titled 'Modified elevator usage' with an in-service sign-in sheet dated April 26th which documented that dietary services will prepare food for food service tray line and bring trays to elevator in meal carts, activities, housekeeping, and any other available staff members will assist with loading trays onto linen carts and bring to units to be distributed, empty linen carts returned to lobby to restock with trays on meal cart, linen carts are sanitized by kitchen staff before and after meals, test tray temperatures to be taken on unit each meal, this is repeated until each unit is served, all staff are instructed not to take breaks nor use the elevator during meal times, medically cleared staff members allowed to use elevator. Rehabilitation services, activity services, admissions, linen and housekeeping, and nursing were included in the in service. For activity services, smokers should continue to be taken out to smoke according to smoking schedule, visitation continues to resume as normal, and families and residents are given priority elevator use to take residents to and from unit. There was no documented evidence of providing activities as usual and including live music programming.
The facility provided an in-service dated 5/1/24 which documented the topic, 'All hands-on deck' which did not have a documented lesson plan and was non-specific as to each staff person's role.
There was no documented evidence that additional in-services or trainings were conducted after April 26th 2024.
On 9/11/24 at 6:02 PM during an interview, the Director of Activities stated that approximately ten (10) residents had been eating lunch in the main dining room on the main floor before the large elevator was shut down, and now they do not do so because the large elevator has been shut down.
On 9/11/24 at 6:30 PM during an interview with the Director of Maintenance and the Administrator, the question was asked if the broken large elevator had been discussed in Quality Assurance Performance Improvement meetings. The Administrator stated they discussed the subject, but they did not document the discussions in the Quality Assurance Performance Improvement minutes or create a Quality Assurance Performance Improvement Plan for the large elevator outage. When asked if anything was put in place to assure that all residents could be transported safely, the Director of Maintenance said that Medsleds were put in place on 4/27/24. The Director of Maintenance and the Administrator added that some staff education was put in place, and they would look for the documentation. The Director of Maintenance said that they attended some of the morning meetings and the elevator was discussed but they did not think that would have been documented.
On 9/12/24 at 11:23 AM during an interview, the Director of Admissions stated the facility restricted admissions to the facility during the period of time while the large elevator was shut down, of residents who would be difficult to get in and out of the elevator during an emergency situation such as bariatric residents, residents with spinal injuries, residents who cannot sit up, but they did not have any documentation of this.
On 9/12/24 at 11:30 AM during an interview the Regional Director of Nursing, they stated the facility restricted admissions during the period of time while the large elevator was shut down. They restricted admissions of residents who would be difficult to get in and out of the small elevator during an emergency situation such as bariatric residents, residents with spinal injuries, and residents who could not sit up, but there had been no documentation of the admissions restrictions.
On 9/12/24 at 12:46 PM during a follow-up interview with the Director of Activities, they stated that live music performances did not occur for approximately 2 months because the 2-man band which had usually performed weekly on a large keyboard and used amplifiers and a drum set could not fit on the small elevator. When asked if the facility made any attempts to purchase a smaller keyboard or assist the musicians with transporting their equipment to the units, the Director of Activities stated, no. When asked if the facility made any attempts to bring in other live music, they stated that a family member volunteered to play the ukulele twice during the 2 month time period, but no other musicians played live music during the 2 month time period.
On 09/12/24 at 06:16 PM, during the QAPI/QAA task during a group interview which included the Administrator, Director of Nursing, Director of Maintenance, Director of Social Work, and Director of Activities, and others, they stated the broken large elevator was not a topic in Quality Assurance Performance Improvement meetings. They stated that there was no documentation of the plan for transporting meal trays to units, for staff to use the steps, or that they had educated staff on how to transport residents in gerichair on the small elevator. They stated that a timeline of getting the elevator fixed was originally 3-4 weeks but was not documented in a Quality Assurance Performance Improvement plan. They stated they had not addressed the issue of providing alternative live music to replace the usual live music 2-man band performances which had been playing a large electric keyboard which could not fit into the small elevator. They stated a plan was not created to address food temperatures, food temperatures were not being checked on the units, test trays were not being brought to the units, heated china plates were eliminated, and residents were eating on disposable plastic plates. They stated that screening residents for new admissions was discussed, but it was not documented.
On 9/13/24 at 9:10 AM during an interview, the facility owner/ operator stated they were aware of the broken large elevator. The facility owner/ operator stated they believed the broken large elevator was a topic in Quality Assurance Performance Improvement meetings because in Quality Assurance Performance Improvement meetings, they discussed the issues in the facility, but they were not sure if that occurred. They stated they did not go to any Quality Assurance Performance Improvement meetings. In reference to having created a plan during the shut-down of the large elevator, the facility owner/operator stated they have people that work for them that do that. The facility owner operator stated they believed the staff were maintaining the food temperatures for the residents during the period that the large elevator has been shut down. The facility owner operator stated they were not aware that live music did not occur. They stated they had alternative activities in the building. They stated they did not think the broken elevator negatively impacted the residents. The facility owner/operator stated the large elevator had issues for last couple of months but did not get shut down totally until the summertime. They stated the technician came in several times, but parts were not readily available. They stated the elevator technician company was having staffing problems, and they kept extending the dates the job would be completed. They stated they were originally told the elevator would be fixed by mid-August. They stated they were not sure how many weeks it was shut down. They stated the small elevator was working, and the fire department was made aware of the situation. The facility owner operator stated that emergency transports and evacuation transports were addressed. They stated they did not think they jeopardized the safety or health of the residents due to the broken large elevator.
On September 13th 2024 at 1:35 PM during an interview, the Food Service Director stated they were responsible for implementing the plan for meal delivery and assuring that test tray temperatures were taken on units at each meal, but when the large elevator was shut down, bringing test trays onto the units was slowing the process of meal tray delivery and they were more concerned with getting the trays to the residents as quickly as possible. They stated they believe the food temperatures were within the safety zone, but they were not checking food temperatures after the large elevator was shut down and there was no documentation of food temperatures on the units. They stated they checked the food temperatures on the tray line, 3 times during each meal service in the kitchen.
On September 13th 2024 at 4:09 PM during an interview, [NAME] Supervisor #3 stated that from April until the large elevator was shut down, they were aware to bring test trays to the units and check temperatures of food to assure foods were in the safety zone but when the elevator was shut down they stopped doing so because they were more concerned with getting the food quickly to the residents. They stated that bringing the test trays to the units was holding up the elevators and slowing down the process of the meal tray delivery.
On September 13th 2024 at 4:12 PM during an interview, [NAME] Supervisor #2 stated that from April until the large elevator was shut down, they were aware to bring test trays to the units and check temperatures of food to assure foods were in the safety zone but when the elevator was shut down they stopped doing so because bringing the test trays to the units was holding up the elevators and slowing down the process of the meal tray delivery, and they were concerned with getting the food quickly to the residents.
10 NYCRR 483.75 (a)(2)(h)(i)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure and/or maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, 1) The facility did not have a current Water Management Plan in place that defined potential areas of Legionella risk that was updated yearly, 2) infection control precautions were not properly implemented for residents with Covid-19 infection, 3) during administration of medication there was a breach in infection control practices with a glucometer, and 4) the facility was not implementing Enhanced Barrier Precautions.
The findings are:
1. The undated policy on Legionella documented, It is the policy of Renaissance Rehabilitation and Nursing Center to comply with the New York State regulations on Legionella culture sampling and analysis.
A request was made to the Director of Maintenance on 9/9/2024 at 8:45 AM to see the facility's Water Management Plan and Facility Risk Assessment.
On 9/9/2024 at 11:22 AM a binder was handed to surveyors with a Facility Risk assessment dated [DATE]. There was no Water Management Plan inside the binder.
The facility did not provide a Water Management Plan which detailed the water management team, flow diagrams, control measures based on the environmental assessment until 9/11/2024.
2. The facility's Covid-19 Infection Prevention & Control Policy, last reviewed/revised 7/12/2024, documented that the facility will follow guidance recommended by CMS/CDC/ State and local health agencies related to core principles and infection prevention and control practices, provide for clear and prominent signage that notifies staff, residents and others of entry restrictions to specific areas of the facility that are designated for infection control, ensure that personnel are designated to be responsible for ensuring the staff utilize PPE appropriately; these personnel include the Director of Nursing, Infection Preventionist, Unit Managers and the Administrator, as well as Department heads while staff are working within their specific departments.
On 9/5/24 at 9:50 AM, during observation and interview in Resident #76's room, Resident #76 stated were positive for COVID-19. There were no signs posted on the Resident #76's door indicating any precautions.
On 9/5/24 at 9:53 AM, during an interview with the Director of Nursing they stated that Resident # 76 tested positive for COVID-19 on Tuesday morning 9/3/24 at approximately 9:00 AM and they would post a sign at the door. They stated signs indicating respiratory and contact precautions should be posted on the resident's door by the floor nurse as soon as a positive COVID-19 result was received.
3. The facility's Policy and Procedure on Administration of Medication, last reviewed 1/2024, documented that all items used for medication administration/pass that are shared between residents are to be cleaned/sanitized and air-dried between resident use and upon conclusion of medication administration/ pass per policy and prevailing CDC/CMS/DOH requirement.
During a medication administration observation on 9/9/24 at 3:44 PM, Licensed Practical Nurse #5 took a finger stick blood sugar using the glucometer on Resident #39.
During medication administration on 9/9/24 at 3:56 PM, Licensed Practical Nurse #5 was observed about to proceed to take finger stick blood sugar for Resident #63 using the same glucometer as the one they used for Resident # 39 without sanitizing the glucometer. The surveyor stopped Licensed Practical Nurse #5 and asked if they should sanitize the glucometer and they stated, Yes the glucometer should be sanitized between uses on different residents. Licensed Practical Nurse #5 sanitized the glucometer, then took the fingerstick blood sugar.
On 9/9/24 at 5:45 during an interview, Registered Nurse Unit Manager # 1 stated the nurse who was using the glucometer was responsible for sanitizing it between residents, and the nurses should know this.
4. The Infection Control Policies and Procedures, last reviewed/revised 7/12/24, documented the facility will implement infection control based on federal and state public health advisories, guidelines and rules.
On 09/05/24 at 12:24 PM, Resident #38 was observed with a urinary catheter. No observation of signage to indicate Enhanced Barrier Precautions.
On 09/06/24 at 09:58 AM, Resident #38 was observed with a urinary catheter. No observation of signage to indicate Enhanced Barrier Precautions.
On 09/09/24 at 11:01 AM during an interview, Certified Nurse Aide # 8 stated when they perform urinary catheter care on Resident #38, they wear eyeglasses to protect themselves from urine splashes in their eyes. They stated that for residents with a urinary catheter, they wear gloves when they perform catheter care but they do not use any other personal protective equipment.
On 09/09/24 at 11:57 AM during an interview, Licensed Practical Nurse #4 stated they are a regular staff nurse at the facility, and they are not aware of any residents on Enhanced Barrier Precautions, stated they never heard of it. They stated that for urinary catheter care, they were instructed to wear gloves to protect them from contact with urine and they like to wear goggles to protect themselves from urine splashes, but they were never instructed to wear any additional personal protective equipment to protect the resident from infection. They stated that for wound care for a large wound, they were not instructed to wear a gown and not educated on Enhanced Barrier precautions.
On 9/11/24 at 11:57 AM during an interview with the Director of Nursing they stated that staff are not yet aware of Enhanced Barrier Precautions. They stated the Department Heads are aware that Enhanced Barrier Precautions should be followed at the facility, but they are not sure of how much knowledge the Department Heads have about Enhanced Barrier Precautions. The Director of Nursing acknowledged that staff in the facility still need to be trained on Enhanced Barrier Precautions at this time. They have plans to train the staff as soon as possible on Enhanced Barrier Precautions and will meet with the regional directors to make plan to train staff.
10 NYCRR 415.19(a)(1-3) (b) (4)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on record review and interviews conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not implement an antibiotic stewardship program that included antibiotic use pr...
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Based on record review and interviews conducted during a recertification survey from 9/5/24 to 9/13/24, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility could not provide documentation of tracking antibiotic use which included appropriate use of antibiotics and duration of antibiotic treatment.
The findings are:
The undated Antibiotic Stewardship Policy documented it is the policy of the facility to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to track infections and reduce possible adverse events associated with antibiotic use.
During an interview on 9/12/2024 at 10 AM, Registered Nurse Unit Manager #2 stated there were residents on antibiotics in July and August 2024. Registered Nurse Unit Manager #2 further stated they did not track the antibiotic use or report it. They stated they were not familiar with the term 'antibiotic stewardship'.
During an interview on 9/11/24 at 3:00 PM, the Director of Nursing/Infection Preventionist stated it was their responsibility to track antibiotic use which included appropriate use of antibiotics and duration of antibiotic treatment. They stated they did not have a list of infections and the use of antibiotics which included appropriate use of antibiotics and duration of antibiotic treatment. They stated infections and antibiotic use should be tracked and monitored by the Registered Nurse Unit Managers, but it was not being completed.
During an interview on 9/12/24 at 9:00 AM, the Administrator stated the Nursing Department was responsible for monitoring the use of antibiotics in the facility.
10 NYCRR 415.19
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure the Infection Preventionist completed specialized training in infection co...
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Based on record review and interviews during a recertification survey from 9/5/2024 to 9/13/2024, the facility did not ensure the Infection Preventionist completed specialized training in infection control prior to starting their role. Specifically, the facility designated Infection Preventionist was the Director of Nursing, and did not have documented evidence of completed specialized training in infection prevention and control.
The findings are:
On 9/6/24 a request was made to see documentation of the Infection Preventionist's specialized training in infection prevention and control.
A review of the training certificate provided, documented the Director of Nursing completed 4 hours New York State Infection Control Mandatory Training Certificate on 10/15/2023.
On 9/09/24 at 3:25 PM during an interview, the Director of Nursing stated they did not have any other specialized training in infection control.
10NYCRR 415.19
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 F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on record review, and interviews during the recertification and abbreviated surveys (NY00340278, NY346428) from 9/5/24 to 9/13/24, the facility could not provide evidence that training was provi...
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Based on record review, and interviews during the recertification and abbreviated surveys (NY00340278, NY346428) from 9/5/24 to 9/13/24, the facility could not provide evidence that training was provided annually to their staff on resident abuse prevention.
The findings are:
The undated facility policy titled abuse, neglect, mistreatment, and misappropriation of resident property included that the policy of the facility includes training employees, through orientation and ongoing sessions on issues related to abuse and prohibition practices. It documented that staff and volunteers will receive education about abuse upon first employment and annually after that.
On 9/9/24 at 3:45 PM, during the staffing task, the surveyor requested from the Director of Nursing, the training logs of five sampled certified nurse aides. The Director of Nursing provided training logs for only for two of the five certified nurse aides.
On 9/10/24 at 11:15 AM the Director of Nursing was asked to provide documentation of staff abuse prohibition and prevention training which had been completed in the past 12 months. The Director of Nursing, they stated they could not find any documentation of the requested trainings and stated that it had probably not been completed in the past 12 months.
On 9/10/24 at 12:30 PM during an interview with Licensed Practical Nurse #4, they stated they had been in-serviced on the facility abuse protocol but they did not remember when.
On 9/10/24 at 12:34 PM during an interview with Certified Nurse Aide #8, they stated they had been in-serviced on the facility abuse protocol but they were not sure when.
On 9/12/24 at 11:56 AM during an interview with Licensed Practical Nurse #3, they stated they did an abuse in-service but did not remember when.
10NYCRR 483.95
CONCERN
(F)
📢 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 F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 9/5/24 to 9/13/24, it was determined the governing body ...
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Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254 and NY00340278) from 9/5/24 to 9/13/24, it was determined the governing body did not establish and implement policies regarding the management and operation of the facility to ensure regulatory compliance. Specifically, the large elevator was not working consistently since the spring of 2024 and the facility did not ensure the Quality Assurance Performance Improvement committee developed and implemented an appropriate plan of action to address identified issues related to the large elevator being out of service.
Findings include:
The facility policy, 'Elevator Breakdown-Single Car Operation' last review April 2024 documented during downtime of one elevator car, the facility will continue to operate with as little impact as possible to resident convenience, quality of life, and provision of services. The Administrator and Maintenance Director/designee must be notified immediately upon awareness of elevator outage event with identification of specific elevator car that is not operational. Downtime of larger elevator car will potentially impact meal delivery, evacuation processes, and movement of larger items that exceed the capacity of the smaller elevator car. The fire department will be made aware of the single car operation situation to manage emergency response in the event of a fire call and to plan for any necessary non fire evacuation of the upper level of the building during which the elevator would be used. If the larger elevator car is non-operational dietary services will modify delivery of meals by use of transport cards that can fit on the smaller elevator stairwell modifications are in place to accommodate safe transport of bariatric residents by stretcher between levels admission criteria during large elevator car downtime will be adjusted to defer bariatric admissions.
Facility staff members were aware that the large elevator was shut down, but no quality assurance measures were put in place to identify or address the issue and ensure clinical staff and residents were educated on interventions/plan to address the problem. The facility could not provide any documentation of interventions/plans that were put in place to address the issue
No evidence of a Quality Assurance Performance Improvement plan action to address identified issues related to the large elevator being out of service was documented. (See F865)
On 9/13/24 at 9:10 AM during an interview, the facility owner/ operator stated they were aware of the broken large elevator. The facility owner/ operator stated they believed the broken large elevator was a topic in Quality Assurance Performance Improvement meetings because in Quality Assurance Performance Improvement meetings, they discussed the issues in the facility, but they were not sure if that occurred. They stated they did not go to any Quality Assurance Performance Improvement meetings. In reference to having created a plan during the shut-down of the large elevator, the facility owner/operator stated they have people that work for them that do that. The facility owner operator stated they believed the staff were maintaining the food temperatures for the residents during the period that the large elevator has been shut down. The facility owner operator stated they were not aware that live music did not occur. They stated they had alternative activities in the building. They stated they did not think the broken elevator negatively impacted the residents. The facility owner/operator stated the large elevator had issues for last couple of months but did not get shut down totally until the summertime. They stated the technician came in several times, but parts were not readily available. They stated the elevator technician company was having staffing problems, and they kept extending the dates the job would be completed. They stated they were originally told the elevator would be fixed by mid-August. They stated they were not sure how many weeks it was shut down. They stated the small elevator was working, and the fire department was made aware of the situation. The facility owner operator stated that emergency transports and evacuation transports were addressed. They stated they did not think they jeopardized the safety or health of the residents due to the broken large elevator.
10 NYCRR 415.26
CONCERN
(F)
📢 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 F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254, NY00...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY00352254, NY00345799 and NY00340278) from 9/5/24 to 9/13/24, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was evident for the entire facility. Specifically, the large elevator was out of order since the spring of 2024.
The findings are:
The facility policy, 'Elevator Breakdown-Single Car Operation' last review April 2024 documented during downtime of one elevator car, the facility will continue to operate with as little impact as possible to resident convenience, quality of life, and provision of services. The Administrator and Maintenance Director/designee must be notified immediately upon awareness of elevator outage event with identification of specific elevator car that is not operational. Downtime of larger elevator car will potentially impact meal delivery, evacuation processes, and movement of larger items that exceed the capacity of the smaller elevator car. The fire department will be made aware of the single car operation situation to manage emergency response in the event of a fire call and to plan for any necessary non fire evacuation of the upper level of the building during which the elevator would be used. If the larger elevator car is non-operational dietary services will modify delivery of meals by use of transport cards that can fit on the smaller elevator stairwell modifications are in place to accommodate safe transport of bariatric residents by stretcher between levels admission criteria during large elevator car downtime will be adjusted to defer bariatric admissions.
The Resident Council Meeting notes dated 3/12/24 documented the residents would like to have outdoor activities when the weather gets warmer.
The Resident Council Meeting notes dated 5/7/24 documented the parts of the elevator have been ordered.
On 9/5/24 at 9:15 AM, the large elevator was observed with a sign posted, 'Out of Order'.
On 9/5/24 at 4:42 PM, 2 large linen carts were observed near the elevator. Activity Aide #6 stated, 'We use those to bring meal trays onto the unit because the big meal truck does not fit into the small elevator'.
On 9/5/24 at 4:45 PM, Activity Aide #7 was observed on the lobby level near the elevators, removing resident meal trays from the large, insulated meal truck and loading them onto linen carts. When asked, Activity Aide #7 stated, 'We do that because the big meal truck does not fit in the small elevator'.
On 9/5/24 at 5:30 PM during an interview, [NAME] Supervisor #1 reviewed the temperatures taken from a meal tray and stated those temperatures were within the danger zone. They stated it is a transportation issue. They stated foods are checked for safe temperatures in the kitchen 3 times during dinner tray service at 4:45 PM, 5:15 PM, and 5:45 PM. They stated the facility has a large food truck which can withstand the heavy weight of china plates which can be heated to retain food temperatures, and the food truck is also insulated, but the large food truck is not being used to bring meal trays upstairs because it does not fit into the small elevator. They stated that because the large elevator is broken, trays are currently being brought to the units on un-insulated linen carts which cannot withstand the heavy weight of the china plates which can be heated to keep food hot. They stated they have not been checking food temperatures on the units since the large elevator was shut down because they did not have time and wanted to get the resident's trays to the residents as fast as possible.
On 9/5/24 at 5:36 PM during an interview, the Food Service Director agreed that the food temperatures reviewed taken from the meal tray were in the danger zone. The Food Service Director stated they agreed with [NAME] Supervisor #1's statements regarding foods being served in the danger zone. The Food Service Director stated that the large elevator has been out of service for some time. The Food Service Director stated they are not sure who is responsible for the problem of serving foods within safe temperatures, stated it is probably a combination of the broken large elevator and not having enough staff on the unit to pass the trays timely. They stated they have not been checking food temperatures on the units since the large elevator was shut down because they did not have time. They stated they had wanted to get the resident's trays to the residents as fast as possible.
On 9/5/24 at 5:46 PM during an interview, the Administrator stated they were not aware that food is being served in the danger zone. They stated they were not aware of any dietary staff taking food temperatures on the units. They stated the elevator has been broken since April. They stated that the technician came last week but they are waiting for parts. They stated that is the only company that works on this type of elevator.
On 9/6/24 at 1:00 PM during an interview, the Director of Maintenance stated the large elevator was jamming a dozen times a day starting in April, the elevator technician came out but did not have the parts available to repair the problem. The Director of Maintenance stated the large elevator was out of order since mid-July. They stated they called other elevator repair companies, but they would not have been able to do the repair any faster than [NAME] Inc. so the facility chose [NAME] Inc. for the repair. They stated the parts have been very difficult to obtain because the elevator parts became obsolete in 1969, and now the parts need to be retrofitted.
On 9/11/24 at 5:35 PM the survey team observed two Emergency Medical Technicians bringing a stretcher into the small elevator. The Emergency Medical Technicians were observed lifting the head of the stretcher to approximately 45° in order to fit the stretcher into the small elevator. The Emergency Medical Technician lowered the head of the stretcher as much as possible and the head of the stretcher remained at approximately a 45° angle.
On 9/11/24 at 5:35 during an interview, the Emergency Medical Technician stated the stretcher could not go flat inside the small elevator and demonstrated at such.
On 9/11/24 at 6:02 PM during an interview, the Director of Activities stated that approximately 10 residents were eating lunch in the main dining room on the main floor before the large elevator was shut down.
On 9/12/24 at 8:35 AM during an interview with the Director of Maintenance and a review of documentation of communication between the Director of Maintenance and the elevator installation and repair company, the Director of Maintenance stated that at beginning of April, the large elevator door was not closing properly 2-3 times daily and if the door did not close, the elevator would not move, and the Director of Maintenance further stated that the technician determined the problem was the speed reducer, but it would take a long time to receive the part, the Director of Maintenance stated they found the part on E-Bay but the elevator repair company did not approve installation of a used part. The Director of Maintenance provided:
-Text messages dated May 13 and May 21 from the Director of Maintenance to elevator repair company asking for follow-up.
The Director of Maintenance stated that some phone calls ensued to try to establish a plan for repair, which were undocumented.
-An invoice dated June 21st to elevator repair company and a check dated July 3rd.
-A text message dated July 12 requesting follow-up shipping date of part.
-A letter dated July 15th notifying the families of the broken main elevator.
-A text message dated July 29th requesting follow-up shipping date of part. The elevator repair company replied they were unsure of part arrival date and would not have a technician until 3rd week of August.
-An email from elevator repair company dated August 12th documented elevator repair company came to facility to begin demolition of large elevator door.
-A text message dated August 14 asking elevator repair company why the technician was not at the facility today. Reply from elevator repair company unsure of when technician will be back.
-A text message dated August 15th askingelevator repair company for follow-up.
-A text message dated August 22nd asking elevator repair company for follow-up.
-A text message dated August 23rd from elevator repair company stating they will come after hours to complete the work due to lack of technicians.
-A text messages dated August 29th and 30th from the Director of Maintenance asking elevator repair company for follow-up with possible completion date.
-A text message dated August 30th from elevator repair company documenting the need for additional parts which are on order.
-A text message dated September 4th asking elevator repair company for follow-up. Reply from elevator repair company documented they did not have the correct wiring diagram.
-A text message dated September 5th asking elevator repair company for follow-up.
-A text message dated September 11th from elevator repair company documented need a new transformer.
On 9/12/24 at 7:04 PM, during a record review with the Director of Activities of the April, May, June, July, August, and September activity schedules documented that the concert activity was cancelled on April 25, May 9, May 16, May 23rd, June 6th, June 13th, June 20th in 2024. The Director of Activities stated that concert activities were cancelled in April, May, and June and concert activities were not scheduled for July 18th and 25th because the large elevator was shut down.
On 9/13/24 at 9:10 AM during an interview, the facility owner /operator stated they were aware that the large elevator was out or order. They stated the large elevator had issues for last couple of months but did not get shut down totally until the summertime. They stated they had the technician come in several times, but parts are not readily available. They stated elevator repair company dominates the region and was having staffing problems, and they keep extending the dates the job will be completed. They stated they were originally told the elevator would be fixed by mid-August. They stated they were not sure how many weeks it was shut down.
10 NYCRR 415.29(f)(1-7)
Jun 2023
4 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interviews during an abbreviated survey (NY00316997), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are repo...
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Based on record review and interviews during an abbreviated survey (NY00316997), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 39 out of 56 residents reviewed for incident reporting. Specifically, the facility failed to report in a timely manner an incident of 39 resident's not receiving their scheduled physician ordered evening medications on 05/20/2023 when the reportable incident was discovered. The facility reported the incident only after surveyor intervention. The facility reported the incident on 05/24/2023 at 2:06 PM.
The findings are:
The policy and procedure titled Incident/Accident/Reporting Policy last revised 04/2022 documented that it is the policy of the facility to promote and maintain a safe environment, and to maintain reports and surveillance of all resident's accidents and incidents. An incident is defined as an unusual event that has the potential to cause injury. Submit incident report via the Health Commerce System (HCS) immediately, once the reasonable cause threshold is met for abuse, neglect, and mistreatment.
Report all other incidents via the HCS within 24 hours.
During an interview conducted with the Director of Nursing (DON) on 05/25/2023 at 9:30 AM, the DON stated that they became aware of the incident of the Registered Nurse Supervisor's (RNS) refusal to administer medication to the residents after the police arrived at the facility. The DON was notified of the situation by the police officer on 05/20/2023 at 10:50 PM. The DON stated that this should have been an immediate reportable incident.
During an interview conducted with the Administrator on 05/25/2023 at 9:30 AM, the Administrator stated the DOH is aware, they are still conducting their investigation and they have 5 or 10 days to report it to the DOH. The Administrator stated this should have been an immediate reportable incident.
415.4(b)(2)
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an abbreviated survey (NY00316997), the facility failed to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an abbreviated survey (NY00316997), the facility failed to ensure residents were aware of the grievance process. Specifically, (1) the required grievance process was not posted in prominent areas on the units where residents reside; (2) grievance forms were not readily available to residents; and (3) residents did not have the option to file a grievance anonymously.
The findings are:
The undated facility policy and procedure titled Grievance/Complaint Procedure documented that any resident, his or her representative (sponsor), interested family member, or advocate may file a grievance or complaint concerning his or her treatment, medical care, behavior of other residents, staff members, theft of property, etc., without the fear of threat or reprisal in any form.
During an observation conducted in Unit 1 on 05/23/2023 at 12:05 PM revealed that there were no postings of the grievance process, grievance forms, or an area to file a grievance anonymously.
During an observation conducted in Unit 2 on 05/23/2023 at 12:50 PM revealed that there were no postings of the grievance process, grievance forms, or an area to file a grievance anonymously.
During an interview conducted with the Administrator on 05/23/2023 at 315PM, the Administrator stated they did not have any filed grievances for the last two months. They stated grievances are immediately handled so it does not pile up and [NAME]. They stated their grievance process is through the local ombudsman and the anonymous grievances are also handled through the ombudsman. The Administrator stated that residents access grievance forms through him, the social worker or anyone on the units.
During an in an interview conducted with the Social Services Director (SSD) on 05/24/2023 at 11 AM, the SSD stated they are not aware if residents know how to file a grievance but residents can come to them for complaints. They stated it is their understanding that they fill out the grievance forms with the resident. They stated the grievance forms are in their office and no other location. They stated anonymous grievances are filed through the ombudsman and the facility does not have anything set up for residents or families to file anonymously. In addition, SSD stated there are no grievance process instructions posted on the units where residents reside. They stated that their expectations were for residents to have access to the grievance forms without asking and capable of filing a grievance anonymously should they choose to.
§483.10(j)(4)
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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00316997), the facility did not provide or arrange for services or care that adhered to accepted standards...
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Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00316997), the facility did not provide or arrange for services or care that adhered to accepted standards of quality that were in accordance with acceptable standards of practice for 39 of 56 residents. Specifically, a Registered Nurse Supervisor (RNS #1) did not follow the Physician Orders to administer scheduled medications (4pm-9pm) to 39 residents on Unit 1 on 05/20/2023. This was evident for, but not limited to, Residents #1, #4, #10, #18, and #21.
The Findings are:
Review of facility Policy and Procedure on Administration of Medications dated April 2022 documented that a licensed nurse will be responsible for passing medications to residents according to techniques approved for use at this facility in compliance with the New York State Codes, rules and regulations and other applicable state and federal laws.
Review of Medication Administration Documentation Audit Detail Report revealed that the scheduled medication on Unit 1 on 05/20/2023 from 8:00pm and 9:00pm involved a total of 39 residents and a total of 185 medications/treatments that RNS #1 failed to administer as ordered. The 39 residents affected included the following residents:
Resident #1 had diagnoses that included dementia, aphasia, and cerebrovascular disease. Review of the physician order initiated/renewed on 03/16/2023 and Medication Administration Record (MAR) dated 05/01/2023 revealed that the resident's 8:00pm medications magnesium oxide 400mg (241.3 mg magnesium) tablet and tamsulosin 0.4mg capsule were not administered on 05/20/2023. The review also revealed that the resident's 9:00pm medications artificial tears (polyvinyl eye drops), colace 10 mg capsule, compression socks-medium, donepezil 5mg tablet, memantine 10mg tablet, potassium chloride ER 20mg were not administered on 05/20/2023.
Resident #4 had diagnoses that included Hypertensive chronic kidney disease, Unspecified sequelae of cerebral infarction, and Hemiplegia and hemiparesis. Review of the physician order renewed on 02/21/2023 and MAR dated 05/01/2023 revealed that the resident's 9:00pm medications atorvastatin 40mg tablet, docusate sodium 100mg capsule, famotidine 20mg tablet, metoprolol tartrate 25mg tablet, mirtazapine 15gm tablet, senna 8.6mg tablet, tamsulosin 0.4mg capsule, and tramadol 37.5mg acetaminophen 325mg tablet were not administered on 05/20/2023.
Resident #10 had diagnoses that included Alzheimer's disease, Dementia in other
diseases classified elsewhere, unspecified severity, with anxiety, and Aphasia following other cerebrovascular disease. Review of the physician order renewed on 05/18/2023 and MAR dated 05/01/2023 revealed that the resident's 9:00pm medications acetaminophen 325mg tablet, cetirizine 10mg tablet, gabapentin 100mg capsule, pantoprazole 40mg tablet - delayed release, and trazodone 50mg were not administered on 05/20/2023.
Resident #18 had diagnoses that included Alzheimer's disease, chronic kidney disease, and Nonrheumatic aortic (valve) stenosis. Review of the physician order renewed on 04/24/2023 and MAR dated 05/01/2023 revealed that the resident's 8:00pm medications diltiazem CD 120mg capsule extended release 24 hr, eliquis 2.5mg tablet, and finasteride 5mg tablet were not administered on 05/20/2023. The review also revealed that the resident's 9:00pm medications lipitor 10mg tablet, metoprolol succinate ER 100mg tablet, refresh tears 0.5% eye drops, risperidone 0.25mg tablet, and tamsulosin 0.4mg capsule were not administered 05/20/2023.
Resident #21 had diagnoses that included Type 2 diabetes mellitus, Peripheral vascular disease, and acute osteomyelitis. Review of the physician order renewed on 04/28/2023 and MAR dated 05/01/2023 revealed that the resident's 9:00pm medications acetazolamide 500mg extended release, crestor 5mg tablet, docusate sodium 100mg capsule, famotidine 20mg tablet, humalog kwikpen (u-100) insulin 100 unit/ml subcutaneous, melatonin 3mg tablet, timoptic 0.5% eyedrops, and trazodone 50mg tablet were not administered 05/20/2023.
Review of Medication Error Report dated 5/24/2023 revealed that on 5/20/2023 the RNS #1 did not administer residents' medications on Unit 1 as ordered. Residents were assessed by the physician and noted with no negative outcomes. In order to avert similar errors in the future, the facility conducted an in-service for nurses on medication administration.
During an interview conducted with RNS #1 on 5/25/2023 at 12:13pm, RNS #1 stated they were not informed until they arrived to work at approximately 2:00pm on 5/20/2023 that the Unit 1 nurse was approved leave from 7:00pm to 11:00pm and that they (RNS #1) would be responsible for the 8:00pm and 9:00pm medication administration. RNS#1 revealed that at the 7:00pm shift change the narcotic count was not completed on Unit 1 because the other nurse was in a hurry to leave. RNS #1 stated that they became overwhelmed with the task of administering the medications to the residents. RNS #1 stated they prioritized the 8pm and 9pm med pass by administering medications to the residents who were hanging around the med cart and screaming the loudest. RNS #1 stated they did not know what else to do. RNS #1 stated that they did not reach out to the Director of Nursing, or the Administrator, or the Physician, or the 3 Regional Nurses for assistance when they felt overwhelmed with the assignment. RNS #1 stated that the diabetic residents were informed that their blood sugars would be checked in the morning. RNS #1 confirmed that police officers were called to the facility by Unit 1 residents who reported that they had not received their medications. RNS #1 confirmed knowledge of Standards of Practice of Care and stated that as a nurse that is to hand medications out to your residents timely. RNS #1 stated I've been giving meds since 1975; residents were pissed off and anxious because they did not get their meds, they wanted narcs. And there was nothing I could do about it. At 11:00pm I was done, I was pooped. RNS #1 also stated that administering medications to residents is not part of my supervisory responsibilities.
During an interview conducted with the Administrator and the Director of Nursing (DON) on 5/25/2023 at 9:30am they stated that a chain of command exists regardless of shift or day of the week. Staff in the facility are to first call the DON with any concerns or issues. If the DON is on vacation or otherwise not in the facility, they still need to be contacted first. The Administrator is available after business hours except for Saturdays when he is only available after 8pm. The Regional Nurse Consultant #1 is available via phone since she is works remotely out of state. Two (2) other Regional Nurse Consultants are available locally and can come to the facility as soon as possible if needed. When questioned if RNS#1 who worked the 7pm to 7:30am shift on 5/20/2023 was aware of the chain of command and availability of assistance, they both confirmed that RNS #1 was aware and had in the past called on administrative staff to assist. Both the Administrator and the DON first became aware of the RNS #1's refusal to administer medication to the residents after the police arrived at the facility. The DON was notified of the situation by the police officer on 5/20/2023 at 10:50pm. The Administrator confirmed that they were notified by the Director of Nursing of the situation on 5/20/2023 at 11:02pm.
Interview was attempted and unsuccessful with the Primary Care Physician on 5/25/2023 at 1:00pm and 6/22/2023 at 10:50am. Telephone calls were forwarded straight to voice mail and was unable to leave a message as mailbox was full.
415.11(c)(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
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during an abbreviated survey (NY00316997), the facility did not ensure that residents wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during an abbreviated survey (NY00316997), the facility did not ensure that residents were free of significant medication errors for 39 out of 56 residents reviewed for Medication Administration. Specifically, residents did not receive significant medications including insulin, anti-coagulant, anti-seizure (epilepsy), cardiac, and pain medications during the evening medication pass on 05/20/2023. This was evident but not limited to Residents #7, #17, #22, #28, and #38. This resulted in potemtial for more than minimal harm that is not immediate jeopardy.
The findings are:
Review of facility Policy and Procedure on Administration of Medications dated April 2022 documented that a licensed nurse will be responsible for passing medications to residents according to techniques approved for use at this facility in compliance with the New York State Codes, rules and regulations and other applicable state and federal laws.
Review of facility Policy and Procedure on Medication Errors dated April 2022 documented to ensure resident safety and compliance with regulatory requirements are maintained. It is the facility policy to report all medication and treatment discrepancies, errors, and occurrences timely. Medication error is noted as any event that may cause or lead to inappropriate medication use or resident harm. A nurse is to notify primary physician of medication error occurrence.
Review of Medication Administration Documentation Audit Detail Report revealed that the scheduled medication on Unit 1 on 05/20/2023 from 8:00pm and 9:00pm involved a total of 39 residents and a total of 185 medications and treatments that Registered Nurse Supervisor #1 (RNS #1) failed to administer as ordered.
Review of the physician orders and electronic Medication Administration Records (eMARs) dated 05/20/2023 revealed omissions for multiple medications for residents #1 through resident #39. Omissions were noted when information was not documented as medication administered. RNS #1 was on duty and failed to administer per physician order medications to 39 residents scheduled for 8:00pm and 9:00pm. The 39 residents affected included the following 5 residents.
Resident #7 had diagnoses that included coronary artery disease, heart failure, and diabetes. Review of the eMAR dated 5/20/2023 revealed the following medications were not administer per physician orders at 9:00pm: bumetanide 1mg tablet, carvedilol 6.25 mg tablet, eliquis 5mg tablet, entresto 24mg-26mg tablet, topiramate 100mg tablet, and morphine ER 30mg tablet extended release.
Resident #17 had diagnoses that included respiratory failure, coronary artery disease, diabetes, asthma, and seizure disorder. Review of the eMAR dated 05/20/2023 revealed the following medications were not administer per physician orders for 9:00pm: baclofen 10mg tablet; celexa 10mg tablet, depakote 500mg tablet delayed release, lantus solostar u-100 insulin 100unit/ml (3ml) subcutaneous pen, novolog flexpen u-100 insulin aspart 100 unit/ml (3ml) subcutaneous, quetiapine 100mg tablet, and quetiapine 25mg tablet.
Resident #22 had diagnoses that included diabetes, cerebral vascular accident, and hypertension. Review of the eMAR dated 05/20/2023 revealed the following medications were not administer per physician orders at 9:00pm: humalog KwikPen (U-100) Insulin 100 unit/mL subcutaneous, and Levemir FlexTouch U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen.
Resident #28 had diagnoses that included heart failure, diabetes, and cerebral vascular accident. Review of the eMAR dated 05/20/2023 revealed the following medications were not administer per physician orders at 8:00pm: tresiba flextouch U-100 insulin 100 unit/mL (3 mL) subcutaneous pen
Resident #38 had diagnoses that included septicemia in the last 30 days, hypertension, and anemia. Review of Resident #38's eMAR dated 05/20/2023 revealed the following medications were not administer per physician orders at 9:00pm: depakote 500mg tablet delayed release, lorazepam 0.5mg tablet, and lorazepam 1mg tablet.
Review of Medication Error Report dated 05/24/2023 revealed that on 05/20/2023 RNS #1 did not administer residents' medications on Unit 1 as ordered. Residents were assessed by the physician and noted with no negative outcomes.
Review of Town of [NAME] Park Police Case Report Summary Case Number 2023-00005028 reported occurrence from 05/20/2023 at 7:56pm through 05/20/2023 at 8:59pm. RNS #1 named as subject of the occurrence. Incident Report Nature of Call noted as no nurse to hand out meds/facility is in panic. Two (2) police units with three (3) officers responded. The narrative of report revealed officers responded to a report of a nurse not handing out medication and locked in their office. Upon arrival patrol officers encountered several residents in the first-floor lobby of the facility stating that they have not received their medication. Patrol officers spoke with the RNS #1. RNS #1 stated that they were not going to administer medication unless it was life or death. RNS #1 stated it was not her job to administer medication that was not life or death. RNS #1 continued to show frustration.
Review of RNS #1's State of New York License Number 276590-01 revealed they are registered to practice through 10/31/2024. Clear and active license with no disciplinary action noted.
Review of Record of Employee Disciplinary Procedure dated 05/22/2023 revealed RNS #1 was suspended as a result of the Department of Health complaint regarding ordered medications that were not administered to residents. Suspension is to be unpaid and was given per verbal phone conversation until investigation is final.
Review of Orientation Checklist for RN and LPN and New Hire Checklist dated 03/31/2021 revealed RNS #1 had received In-Service that included overview of incidents and accidents and notifying nursing administration. RNS #1 acknowledged in writing on 03/31/2021 that they had been instructed in the procedures of medication administration and reporting of problems and difficulties according to the policies of the facility.
Review of facility in-service on the topic of Medication Administration Policy dated 04/08/2022 revealed 31 employees attended. The in-service sheet includes RNS #1's signature which serves as proof of attendance and of their pledge to administer medication safely and effectively.
During an interview conducted with the Administrator and the Director of Nursing (DON) on 05/25/2023 at 9:30am revealed that a chain of command exists regardless of shift or day of the week. Staff in the facility are to first call the DON with any concerns or issues. The Administrator is available after business hours except on Saturdays, such as on 05/20/2023, when, due to religious observance, they are not available until after 8pm. The Regional Nurse Consultant #1 is available via phone since they are working remotely due to a family illness. Two (2) other Regional Nurse Consultants are available locally and can come to the facility as soon as possible as needed. When questioned if the RNS #1 who was working the 7pm to 7:30pm shift on 05/20/2023 was aware of the chain of command and availability of assistance, they both confirmed that the RNS #1 was aware and had in the past called on administrative staff to assist. When questioned if the RNS #1 called any administrative staff to report any of their concerns on 05/20/2023 during the 7pm to 7:30pm shift, they both confirmed that RNS #1 did not call anyone for assistance or to report any concerns. Both the Administrator and the DON first became aware of RNS #1's refusal to administer medication to the residents after the police arrived at the facility. The DON was notified of the situation by the police officer on 05/20/2023 at 10:50pm. The Administrator confirmed that they were notified by the DON of the situation on 05/20/2023 at 11:02pm.
During an interview conducted with Resident #40 on 05/23/2023 at 1:00pm, Resident #40 stated they contacted the New York State because there were not enough staff to pass out meds on 05/20/2023. Resident #40 stated they received their meds on time because they screamed at RNS #1. Resident #40 stated that they felt RNS #1 does not have to give out meds because of their position. Resident #40 stated Resident #41 called the police. Resident #40 also stated that the facility was short staffed yesterday and the DON was passing out meds.
During a telephone interview conducted with the RNS #1 on 05/25/2023 at 12:13pm, the RNS #1 stated they were not informed until they arrived to work at approximately 2:00pm on 05/20/2023 that the Unit 1 nurse had an approved leave from 7:00pm to 11:00pm and that they (RNS #1) would be responsible for the 8:00pm and 9:00pm medication administration. The RNS stated that they did not attempt to call the DON, Administrator, Physician, and/or any of the 3 Regional Nurses since they did not think to call for help. RNS #1 stated they prioritized the 8pm and 9pm med pass by administering medications to the residents who were 'hanging on the med cart and screaming the loudest'. RNS #1 stated they did not know what else to do and stated that they told the diabetic residents that their blood sugars were to be checked in the morning. RNS #1 revealed that at the 7:00pm shift change they did not conduct the narcotic count on Unit 1 because the other nurse was in a hurry to leave. RNS #1 confirmed that police officers arrived at the facility after being called by Unit 1 residents that reported they were not receiving their medications. RNS #1 confirmed knowledge of Standards of Practice of Care and stated that is if a nurse is there you hand meds out to your residents. RNS #1 stated I've been giving meds since 1975; residents were (upset) and anxious because they did not get meds, they wanted narcs, and there was nothing I could do about it, and at 11:00pm I was done, I was pooped. The RNS stated that it could be a med error .sure, because I did not meet the timeframe. The RNS also stated that administering medications to residents is not in my supervisor responsibilities.
415.12(m)(2)
Oct 2022
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure that a Comprehensive Care Plan was deve...
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Based on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure that a Comprehensive Care Plan was developed to ensure treatment and services were provided to maintain the resident's highest practicable physical well-being for 1 of 3 residents (Resident #101) reviewed for pain management. Specifically, a pain management care plan was not developed for Resident #101 who was prescribed Neurontin and Tramadol for chronic pain syndrome.
The Findings Are:
The facility Policy and Procedure titled Comprehensive Care Plan (CCP) undated documented the CCP will include measurable goals to meet the resident's medical, nursing, psychosocial needs. Problems, strengths, or needs identified by members of the Comprehensive Care Plan team will be included in the CCP as appropriate. The policy further documented nursing will evaluate goal achievement within the expected date of goal achievement.
Resident #101 had diagnoses including Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication; Right Leg, Chronic Obstructive Pulmonary Disease, and Type II Diabetes Mellitus with Diabetic Neuropathy.
The Minimum Data Set (MDS, a resident assessment tool) dated 8/29/22 documented resident had Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #101 was independent for all activities of daily living.
Review of Physician orders revealed Resident #101 was prescribed Neurontin 300 mg and Tramadol 50 mg for chronic pain syndrome.
Review of Pharmacist Drug Regimen Review dated 9/12/22 documented ensure treatment plan within the medical record includes goals for pain management and functional improvement with a discussion of tapering doses or discontinuing if benefits do not outweigh risks.
Review of the medical record revealed there were no care plans in place to address pain management.
During an interview on 10/12/22 at 11:59 AM, the Director of Nursing (DON) stated unit managers are responsible for ensuring care plans are created and implemented accordingly. The DON stated all medications should have a diagnosis with listed medication use on the care plan and confirmed there was no care plan for pain management. The DON stated If the pharmacy consultant makes a recommendation, this should be addressed immediately by nursing staff. The DON stated care plans are an extension of the physician orders.
During an interview on 10/12/22 at 03:01 PM, the Registered Nurse Unit Manager (RNUM #2) stated they were not aware there was no care plan in place for pain management for resident #101. RNUM #2 stated the DON will provide a copy of the pharmacy regimen review if it is something nursing needs to address. RNUM #2 stated they did not recall being told about the care plan issue. The RNUM #2 stated every medication should have a care plan associated with it.
415.12
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during a Recertification Survey between 10/3/2022-10/12/2022 it was determined ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during a Recertification Survey between 10/3/2022-10/12/2022 it was determined that the facility did not ensure that each resident and/or resident representative was offered the opportunity to be involved in the their care plan for one of four residents reviewed for care planning, Specifically, Resident #95 was not invited to participate in the care plan meeting with the interdisciplinary team.
The Finding Is:
The Policy and Procedure titled Comprehensive Care Plan undated documented Responsibility of the Social Worker she will schedule initial quarterly annual significant change and Medicare Comprehensive Care Plan Meeting for each resident as appropriate. The Social Worker chairs and lead the meeting to ensure that all medical records for the resident being discussed are present at the meeting.
Resident # 95 was admitted to the facility on [DATE] with a diagnosis of Atherosclerosis of Aorta, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus.
The Quarterly Minimum Data Set (MDS a resident assessment and screening tool) with reference date 8/29/2022 documented the resident had intact cognition.
A Comprehensive Care Plan (CCP) titled long term placement initiated 11/1/2017 documented interventions resident placement status is to remain long term within the facility. Resident and or resident representative will be invited to attend Interdisciplinary team care plan meeting.
Review of the Care Plan meeting minutes documentation dated revealed there was no documentation that an Interdisciplinary team care plan meeting occurred during 2022.
During an interview with the Resident on 10/3/2022 at 10am Resident # 95 stated they did not know what a care plan meeting was.
During an interview on 10/12/2022 at 11:00am with the brother of Resident #95 they stated they have not had a care plan meeting in a while, over a year. They stated the meetings keep getting cancelled because the social worker left.
During an interview on 10/6/2022 at 9:46am with the Social Worker they stated they started working at the facility on 9/1/2022. They stated they reached out to the former Social Worker to determine where care plan attendance was recorded for 2022, and they were told if it is not in the medical record it did not happen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for Residents # 60 and #89 who were reviewed for ADL's. Specifically, 1. Resident #60 did not receive twice a week showers as per the care plan and unit shower schedule and 2. Resident #89 was observed wearing the same attire for multiple days, and a Comprehensive Care Plan (CCP)was not revised timely to address the resident's refusals with ADL cares.
The findings are:
The facility Policy and Procedure (P&P) titled ADL Support undated documented OBRA requires that nursing facilities care for residents in a dignified manner that promotes self-worth and physical, psychological, and emotional well-being. It is important to promote quality of life.
1. Resident #60 had diagnoses including Secondary Parkinsonism Unspecified, Tremor, and personal history of Transient Ischemic Attack (TIA).
The Minimum Data Set (MDS, a resident assessment tool) dated 8/1/22 documented the resident had a Brief Interview of Mental Status) BIMS core of 15, indicating no cognitive impairment and required one person limited physical assist for transfers, walking, dressing, and toileting, no assistance with eating and personal hygiene.
Review of the ADL Comprehensive Care Plan dated 2/24/20 documented resident required limited assist of 1 for bathing. Interventions included assist resident with bathing, dressing, grooming needs, provide privacy. In addition, shower twice per week as per resident's preference.
Review of the CNA Documentatation Detail for Bathing for the months of August and September 2022 revealed no evidence of resident #60 being bathed on 8/1/22,8/4/22, 8/8/22, 8/11/22, 8/15/22, 8/18/22, 8/22/22, 8/25/22, 8/29/22, 9/1/22, 9/5/22, 9/12/22, 9/22/22, 9/26/22 and 9/29/22.
During an interview on 10/3/22 at 10:41 AM, Resident # 60 stated they were not showered regularly. Resident #60 stated they would like to be showered at least once a week although they are entitled to twice a week showers. Resident #60 stated they recognize there is a staffing issue at the facility.
During an Interview on 10/11/22 at 11:35 AM, Certified Nursing Assistant (CNA #4) stated Resident #60 is independent and requires supervision during showers and someone must always be present with the resident in the shower room for fall monitoring. CNA #4 stated Resident #60 should be showered twice a week. CNA #4 stated Resident #60 shower days are Mondays and Thursdays during the 7 AM to 3 PM shift. CNA #4 stated resident #60 does not refuse ADL cares. CNA #4 stated all cares should be documented in the Electronic Medical record ( EMR) and electronically signed. CNA #4 stated if there are no initials, this means the care was not provided.
During an Interview on 10/11/22 at 11:46 AM, Registered Nurse Unit Manager (RNUM #2) stated there are times when Resident #60 is approached for bathing and may decline because they would like to be bathed at another time, and that all refusals should be documented in the EMR. RNUM #2 stated they rely on staff honesty when asked if they completed assigned tasks. RNUM #2 stated they will also assess the resident for cleanliness to confirm if they have been bathed or showered. RUNM #2 stated there were missing CNA signatures in the EMR. RNUM #2 stated they were not aware of missing documentation in the EMR.
During an Interview on 10/11/22 at 11:56 AM, Licensed Practical Nurse (LPN #5) stated Resident #60 does not refuse cares and should be showered twice a week.
2. Resident #89 had a diagnosis including Spinal Stenosis, Obstructive Pulmonary Disease, and Psychotic Disorder with Delusions due to know physiological condition.
The admissions MDS assessment dated [DATE] documented the resident had a BIMS score of 14, indicating no cognitive impairment and required two-person extensive physical assist for bed mobility, transfers, and toileting, one-person physical extensive assist for locomotion on/off unit, and personal hygiene.
Review of the Behavior Symptoms (resists care) dated 9/23/22 documented resident care refusals related to their oxygen tubing. The care plan was not thoroughly developed to include behaviors and interventions to address ADL care refusals.
During intermittent observations on 10/3/22 at 10:31 AM and 12:04 PM, 10/4/22 at 9:34 AM, and 10/5/22 at 9:48 AM Resident #89 was observed wearing the same dirty stained white socks, a red t-shirt, and green underwear. Resident #89's hair was disheveled and greasy.
During an interview on 10/5/22 at 02:28 PM, Certfied Nursing Assistant (CNA #1) stated if the resident refuses cares, CNAs should inform the nurse and the nurse will intervene. Socks should be changed if the condition is poor. CNA #1 stated resident #89 doesn't typically refuse clothing changes.
During an interview on 10/5/22 at 2:30 PM, CNA #2 stated they noted dirty socks on the resident that morning
During an interview on 10/6/22 at 10:25 AM, Registered Nurse Unit Manager (RNUM #2) stated the resident's clothing should be changed daily, when dirty/soiled, and in between meals when necessary. RNUM #2 further stated CNAs should be changing resident clothing in the morning when providing cares and all nursing staff should change resident clothing if they see clothing in unclean or poor condition throughout the day.
415.12 (a)(3)
CONCERN
(D)
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 interview and record review during the recertification survey conducted 10/3/22-10/12/22, it could not be ensured that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review during the recertification survey conducted 10/3/22-10/12/22, it could not be ensured that the facility maintained acceptable parameters of nutritional status for 2 of 5 residents (Residents #51 and #42) reviewed for Nutrition. Specifically, Resident #51 received nutrition via G-Tube, had a significant weight loss, and was not reassessed by clinical nutrition staff until10/05/22 and Resident #42 was assessed for 19.69% significant weight loss in one month on 8/30/22 and orders for supplements were not added until 10/3/22.
The findings include:
Review of the facility's policy and procedure revised 9/2022 titled, Height and Weight Monitoring documented that if a weight change of (+) or (-) 5 lbs or more from the previous weight is evident, the Dietician will review the weights, ensure there is documentation on the resident's diet, assess and summarize their consumption and update the Physician/NP as needed, the purpose being to implement corrective actions and prevent the weight change from progressing to a 5% weight change, evaluate and update the resident's plan of care, make recommendations as needed and document the review in the resident's chart.
1.Resident #51 was admitted to the facility on [DATE] with diagnoses including Dysphagia and Intellectual Disabilities.
Review of the 7/25/22 Annual Minimum Data Set (MDS; a resident assessment tool) showed that Resident #51 was cognitively impaired, was dependent on staff for all ADLs including feeding via G-Tube, and had no weight loss.
Review of the 10/05/22 Physician's Orders indicated that resident was to receive Jevity 1.5 75cc /hour up at 5am down at 9pm, 1200cc/24hr 1800cal 77gm pro 2112cccc TFW 2400cc.
Resident #51's Monitoring-Weights documented 7/07/22: 101 pounds, 8/25/22: 92.4 pounds (- 8.6 lbs, 8.5% loss from previous), 9/09/22: 92.2 pounds (-0.2 loss from previous) and 10/04/22: 92.0 pounds (-0.2 loss from previous).
Review of the 2/7/2018 Nutritional Status Care Plan effective 7/20/22 documented the resident is at risk due to NPO (nothing by mouth), on GT (gastrostomy tube) feeding. Interventions included TF (tube feeding)dependent, provide tube feed as ordered, During a review of the care plan interventions, a change was not made to the interventions until 10/05/22 to document a change in the feeding schedule to start feedings at 5AM during the daytime hours.
Medical note dated 8/09/22 written by the Physician documents the resident was seen for monthly review, frail, thin, on Jevity via PEG. There is no documentation of the resident's weight.
Nurse's note dated 8/25/22 documented the resident is to be sent out to the hospital for G-Tube replacement and the resident returned from hospital with a new G-Tube.
Dietary note dated 8/30/22 written by Diet Tech documented the resident was triggered by significant weight change. Resident's diet Jevity 1.5 at 75 cc/hr TID, on at 4am, 1 pm, 10 pm. 1200 cc/24 hrs. 1800 Kcal. Weight change shows 8.6 # 8.5% loss in one month. Etiology suggests recent tear in G Tube, hospital visit to replace defective G-Tube. Interventions listed. RD notified and will re-evaluate as soon as possible (ASAP).
Review of the Weight Trend Meeting dated 8/30/22 and 9/28/22 documents that the residents weight loss was to be discussed in the meeting.
Medical note dated 9/13/22 written by the Physician documents the resident was seen for monthly review, weight 92.2, frail, thin, nonverbal, makes eye contact, abdominal peg site healthy, soft, non-tender, positive bowel sounds. No distress, resident totally dependent for ADLs continue Jevity via PEG, optimize nutrition and hydration. There is no documentation regarding weight loss or the torn G-Tube.
Medical note dated 9/26/22 written by the Nurse Practitioner (NP) documents a lab review. CBC WNL. Physical exam: examined in bed, abdomen with positive bowel sounds soft, PEG, anemic, stable, continue to monitor. There is no documentation of weights or weight loss.
On 10/11/22 at 9:10 AM, an interview was conducted with the Certified Nursing Assistant (C.N.A. # 1) who stated they are familiar with the resident and stated when checking th eresident in the morning at start of the shift they noticed the resident vomited frequently during the summer, and they reported it to the nurse. The CNA stated that CNAs should report any issues with tube feeding to the nurse.
On 10/11/22 at 9:20 AM, an interview was conducted with the Licensed Practical Nurse (L.P.N. # 4) who stated they are familiar with the resident and noticed the resident looked thinner in August and was experiencing difficulties tolerating the tube feeding (vomiting in the mornings in the summer), and they reported it to the nurse manager.
On 10/11/22 at 9:30 AM, an interview was conducted with the Registered Nurse Unit Manager (RNUM # 2) who stated they are familiar with the resident but was not aware that the resident was vomiting in the mornings, and was not aware of the resident's weight loss in August. The RNUM stated that the CNAs and LPNs should report any issues with tube feeding to the RNUM. RNUM #2 stated they did not speak with the Registered Dietician (RD) in September after the resident had a noted weight loss.
On 10/11/22 at 9:40, an interview was conducted with the Diet Tech who stated they were aware of the resident's weight loss on 8/30/22. The Diet Tech stated they reported the weight loss concern on 8/30/22 during Weight Trend Meeting.
On 10/11/22 at 10:00 AM, an interview was conducted with the Registered Dietician (RD) who stated they became aware of the resident's weight loss on 9/10/22 when they reviewed the weight taken on 9/9/22 and they spoke with the nurses on 9/10/22 who told them that the resident's tube had been torn and needed to be replaced on 8/25/22, and therefore they didn't make any changes to the tube feeding at that time because the current diet was sufficient to meet the residents needs, and they thought the resident would gain the weight back. The RD stated that on 10/5/22 they reviewed the 10/4/22 weight and noticed that the resident was not gaining weight on the current diet, and they changed the tube feeding time to be administered during the day so the nurses could monitor the feeding more effectively in case there were issues with the resident's positioning at night. The RD stated they don't usually report weight concerns to the Nurse Practitioner (NP) or Medical Doctor (MD), rather they report to nursing. The RD stated they didn't document any notes on the resident until 10/5/22.
On 10/11/22 at 9:52 AM, an interview was conducted with the Primary Physician (MD) who stated they were not aware of the resident's weight loss until 10/7/22. The Physician stated if they had known sooner, they would have reviewed the resident's medications and made adjustments to the feeding orders and medications to address the issues of weight loss.
On 10/11/22 at 11:45 AM, an interview was conducted with the Nurse Practitioner (NP) who stated they were not aware of the resident's weight loss until 10/5/22. The NP stated they would have contacted the RD to see if the resident could tolerate any supplements or increase the resident's calorie intake by changing the tube feeding formula, and they would have reviewed the medications to check if any medications could be causing clogs in the tube. The NP stated they don't think that a clogged tube would have caused such a great weight loss.
2. Resident #42 had diagnoses including other Cerebral Infraction due to occlusion or Stenosis of Small Artery and Type 2 Diabetes Mellitus with unspecified complications.
The annual Minimum Data Set (MDS, a resident assessment tool) dated 7/18/22 documented resident had a BIMS score of 3, indicating a severe cognitive impairment and required one-person extensive physical assist for bed mobility, transfers, locomotion on/off unit, one-person limited assist for dressing and toileting, and supervision for eating.
Review of Physician's Orders documented 8/31/22 Diet: NAS, puree, thin liquids, and revealed no supplement orders.10/3/22 Supplement: Super Shake QD with lunch.
Review of the nutritional status care plan dated 9/8/22 documented the resident was at risk for weight loss/gain and altered nutrition and hydration. Interventions included monitor weights, intakes, and labs as available, and supplements provided per MD order.
Review of the Monitoring-Weights documented the resident's weight on 7/7/22 was 131 lbs and on 8/25/22 the weight was 105.2 lbs.
Review of dietary progress note dated 7/26/22 1:41 pm documented resident weighed131 lbs. Weight was stable over the last 6 months. Resident continued to self-feed, food/fluid intakes are good, tolerating regular texture. No dietary changes noted.
Review of dietary progress note dated 8/30/22 12:22 PM documented resident triggered by significant weight change. Weight change shows 25.8 lbs.; 19.69% in 1 month. No Supplements were provided at this time.
Review of dietary progress note dated 9/28/22 10:59 AM documented weight loss change shows 27.8 lbs.; 21% loss in 1 month. Supplements provided per MD order, super shake daily with lunch.
Review of the Weight Trend Meeting document dated 8/30/22 and 9/28/22 documented the resident's weight loss was discussed in the meeting.
Review of the CNA Documentation Detail for Eating from 8/1/22 to 9/1/22, average meal intake ranged from 25% to 100%. Only 28 meal intakes were documented out of a total of 93 meals.
Interview with Certified Nursing Assistant (CNA #1) on 10/12/22 at 11:11 AM, the CNA stated any care provided to resident will be entered in the CNA accountability, but many times there was no staff available and the CNA stated they were the only CNA on the floor or there would be one other CNA and 50 residents to care for. CNA #1 stated there is not time to document, therefore there would be a lot of missing documentation.
During an interview on 10/7/22 at 12:02 PM, the Dietary Tech (DT) stated once a significant weight change is noted, a weight meeting is held to discuss the resident and/or concerns. Resident #42 did not like the texture of the puree food and refused to eat. The DT believed this may have contributed to the significant weight loss. The DT stated they reviewed the resident's meal intake in the CNA Documentation Detail and based the findings on the documented intake but did not address the omisssions and was not made aware by nursing staff that there was a decline in meal intake.
During an interview on 10/7/22 at 12:34 PM, the Director of Nursing (DON) confirmed in the Electronic Medical Record (EMR) that an order for supplements was not implemented until 10/3/22. DON stated the dietician usually reports to DON or someone from nursing if an order for supplements is needed. The nursing staff will reach out to the Medical Doctor (MD) for a supplement order.
During an interview on 10/7/22 at 2:02 PM, the Registered Nurse Manager (RNUM #2) stated they were unaware that there were omissions in meal intake documentation. The RNUM #2 stated that usually obtaining supplement orders is a quick process if there is a weight loss. Dietary will give the recommendation and nursing will get an order from the doctor right away. The entire process is done on the same day.
During a follow up interview on 10/11/22 at 12:24 PM, the DON stated resident weight concerns are discussed during morning report and nutrition concerns are brought up during this meeting. The DON stated the expectation is for the dietician (RD) to follow up with nursing regarding nutritional concerns and the nurse should contact the MD for orders. The DON stated there is a lag time issue with communication and was unable to identify the cause for the breakdown of communication amongst the interdisciplinary team.
483.21 (b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
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 conducted during a Recertification Survey conducted from 10/03/22-10/12/22, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a Recertification Survey conducted from 10/03/22-10/12/22, the facility did not ensure that medical supervision was provided for 1 of 5 residents (#51) reviewed for nutrition. Specifically, the Physician and/or the Nurse Practitioner did not address the resident's significant unplanned weight loss between 7/7/22 and 8/25/22 of 8.6 pounds through the review date of 10/11/22.
The finding is:
Review of the facility's policy and procedure revised 9/2022 titled, Height and Weight Monitoring documented that if a weight change of (+) or (-) 5 lbs. or more from the previous weight is evident, the Dietician will review the weights, ensure there is documentation on the resident's diet, assess and summarize their consumption and update the Physician/NP as needed, the purpose being to implement corrective actions and prevent the weight change from progressing to a 5% weight change, evaluate and update the residents plan of care, make recommendations as needed and document the review in the resident's chart.
Review of the facility's policy and procedure revised 10/26/2021 titled, Required Documentation Regarding Resident Weight Fluctuation documented that any resident with an unplanned weight loss or gain of 5% in one month, 7.5% in three months, or 10% in six months is considered to be a significant change. This significant weight loss or gain must be addressed by the Physician in his/her progress notes and by nursing and the RD/DTR in their progress notes, MDS and the Comprehensive Care Plan. The Care plan must be updated and adjusted accordingly addressing the weight fluctuation problem.
Resident #51 was admitted to the facility on [DATE] with diagnoses including Dysphagia and Intellectual Disabilities.
Review of the 7/25/22 Annual Minimum Data Set (MDS; a resident assessment tool) showed that Resident #51 was cognitively impaired, was dependent on staff for all activities of daily living (ADLs) including feeding via G-Tube, and had no weight loss.
Review of the 10/26/2021 Physician's Orders indicated that the resident was to receive 400cc of Jevity 1.5 at 75cc/hr TID via pump. On at 4am, 1pm, 10pm. 1200cc/ 24hr, 1800cal 77gm pro 2112cc TFW 2400cc, discontinued on 10/05/22, Check residual prior to each tube feeding using syringe kit. Hold feeding and notify physician if residual is >_150 cc's, and Food Consistency: NPO.
Review of Resident #51's weight records documented 7/07/22: 101 pounds, 8/25/22: 92.4 pounds (- 8.6 lbs, 8.5% loss from previous).
Review of the 2/7/2018 Nutritional Status Care Plan effective 7/20/22 documented the resident is at risk due to NPO, on GT feeding. Interventions included TF dependent, provide tube feed as ordered, Certified Nursing Assistmat (C.N.A), Nursing, Dietary, and medical to monitor weights and lab data, follow Speech language Pathology (SLP) guidelines, and monitor for signs/symptoms (s/s) of dehydration. During review of the care plan notes, the most recent monitoring/evaluation note was documented on 8/11/22, which documented stable weight.
Review of the Physician Medical note dated 8/09/22 documented the resident was seen for monthly review, frail, thin, on Jevity via PEG. There is no documentation of the resident's weight.
Review of the nurses note dated 8/25/22 at 4:10 AM documented the resident's G-Tube is torn and was replaced in house. A nurse's note dated 8/25/22 at 12:33 PM documented the resident is to be sent out to the hospital for G-Tube replacement, and a nurse's note dated 8/25/22 at 5:40 PM, documented the resident returned from hospital with a new G-Tube.
Review of the 8/30/22 Dietary Technician note documented the resident was triggered by significant weight change. Resident's diet Jevity 1.5 at 75 cc/hr TID, on at 4am, 1 pm, 10 pm. 1200 cc/24 hrs. 1800 Kcal. Weight change shows 8.6 # 8.5% loss in one month. Etiology suggests recent tear in G Tube, hospital visit to replace defective G-Tube. Interventions listed. Registered Dietician notified and will re-evaluate as soon as possible (ASAP).
Review of the Weight Trend Meeting document dated 8/30/22 and 9/28/22 documented the resident's weight loss was discussed in the meeting.
A Physician note dated 9/13/22 documented the resident was seen for monthly review, weight 92.2, frail, thin, nonverbal, makes eye contact, abdominal peg site healthy, soft, non-tender, positive bowel sounds. No distress, resident totally dependent for ADLs continue Jevity via PEG, optimize nutrition and hydration. There was no documentation addressing the residents recent weight loss.
A Nurse Practitioner (NP) note dated 9/26/22 documented a lab review. CBC within normal limits (WNL). Physical exam: examined in bed, abdomen with positive bowel sounds soft, PEG, anemic, stable, continue to monitor. There is no documentation of weights or the residents recent weight loss.
Review of the Dietary notes revealed the Registered Dietician (RD) did not address the residents weight loss prior to 10/5/22.
On 10/13/22 and 10/14/22, observations revealed Resident #51 in bed, the feeding pump running, Jevity bottle in place, no leakage or spills observed.
On 10/11/22 at 9:10 AM, an interview was conducted with the Certified Nursing Assistant (C.N.A. # 1) who stated they they familiar with the resident and stated the resident vomited frequently in the morning, which was reported to the nurse.
On 10/11/22 at 9:20 AM, an interview was conducted with the Licensed Practical Nurse (L.P.N. # 4) who stated they are familiar with the resident and noticed the resident looked thinner in August and was experiencing difficulties tolerating the tube feeding, and reported it to the nurse manager.
On 10/11/22 at 9:30 AM, an interview was conducted with the Registered Nurse Unit Manager (RNUM # 2) who stated they were familiar with the resident but were not aware of the resident's weight loss in August. RNUM #2 stated they did not speak with the Registered Dietician (RD) until October regarding the residents weight loss.
On 10/11/22 at 9:40, an interview was conducted with the Diet Tech who stated they were aware of the resident's weight loss on 8/30/22 by checking the weight logs in SigmaCare, saw the weight loss, wrote the note, reported it to the Registered Dietician and reported the concern on 8/30/22 during Weight Trend Meeting which was attended by the Director of Nursing (DON), both Unit Managers, Infection Control Nurse, Admissions Nurse, MDS coordinator, and the Director of Rehab.
On 10/11/22 at 10:00 AM, an interview was conducted with the Registered Dietician (RD) who stated they became aware of the resident's weight loss on 9/10/22 when they reviewed the 9/9/22 weight and had spoken with the nurses on 9/10/22. RD stated they were told that the resident's tube had been torn and needed to be replaced on 8/25/22, and therefore they didn't make any changes to the tube feeding at that time because the current diet was sufficient to meet the residents needs, and they thought the resident would gain the weight back. The RD stated they don't usually report weight concerns to the NP or MD, rather they report to nursing. The RD stated they didn't document the residents weight loss until 10/5/22.
On 10/11/22 at 9:52 AM, an interview was conducted with the Primary Physician (MD) who stated they were not aware of the resident's weight loss until 10/7/22. The Physician stated if they had known sooner, they would have reviewed the resident's medications and made adjustments to the feeding orders and medications to address the issues of weight loss.
On 10/11/22 at 11:45 AM, an interview was conducted with the Nurse Practitioner (NP) who stated s/he was not aware of the resident's weight loss until 10/05/22. The NP stated they would have contacted the RD to see if the resident could tolerate any supplements or increase the resident's calorie intake by changing the tube feeding formula, and they would have reviewed the medications to check if any medications could be causing clogs in the tube. The NP stated they do not think that a clogged tube would have caused such a great weight loss.
On 10/11/22 at 12:10 PM an interview was conducted with the Director of Nursing (DON) who stated that during monthly weight meetings concerns are discussed amongst the MDS Coordinator, RD, Diet Tech, DON, and unit managers. The DON stated that a discussion is had to address the weight issue. The DON stated that the RD should follow up and coordinate with the RNUM, give their recommendations to any nurse working the floor, and the nurse should call the NP or MD to place the orders. The DON stated they did not know the reason for the lag time from when the resident's weight loss concern was first discussed on 8/30/22 up until 10/5/22.
415.15(b)(1)(i)(ii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification and Complaint Survey (NY00302051) conducted from 10/3/22-10/12/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification and Complaint Survey (NY00302051) conducted from 10/3/22-10/12/22, the facility did not provide pharmaceutical services to assure the administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 residents (#70) reviewed for drugs and medications. Specifically, the facility did not ensure that an anxiety medication, was administered as ordered. Subsequently, the Resident did not receive Xanax on 9/23/22 and the resident's Medication Administration Record had Xanax documentation omissions on 8/21/22, 8/29/22, 9/23/22, and 9/28/22.
The finding is:
The Resident was admitted to the facility on [DATE] with diagnoses including but not limited to Anxiety Disorder, Depression, and Acute & Chronic Respiratory Failure.
The Minimum Data Set (MDS; an assessment tool) dated 7/25/22 documented that resident has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15 associated with intact cognition. The resident received antianxiety medication 5 days and antidepressant 6 days in the lookback period and was on Oxygen therapy.
A review of Care Plan titled, Mood State dated 7/31/22 documented interventions including administer medications as ordered.
A review of the Physician's orders dated 8/9/22 documented Alprazolam 0.25 mg once daily at bedtime for Generalized Anxiety Disorder.
Review of the resident's Medication Administration Record (MAR) dated August 2022 documented: Alprazolam 0.25 mg was not documented as administrated on 8/21/22 and 8/29/22.
Review of the resident's MAR dated September 2022 documents: Alprazolam 0.25 mg was not documented as administrated on 9/23/22 and 9/28/22.
On 10/03/22 at 11:27 AM, an interview was conducted with the resident who stated they were not getting Xanax at bedtime. The resident stated they felt anxious when they didn't get the Xanax.
On 10/6/22 at 6:50 PM, an interview was conducted with Licensed Practical Nurse (LPN #1) who stated they gave the Alprazolam on 8/21/22 and 8/29/22 but sometimes they forget to go back into the MAR to sign off. #1 LPN stated they work 12-hour shifts (7PM to 7AM), and they were working both sides of the unit alone.
On 10/7/22 at 3:45 PM, an interview was conducted with Registered Nurse (RN #1). RN #1 stated that on 9/23/22 there was no medication nurse on the first floor, so they began to administer medications on both the north and south sides of the unit until LPN #3 came in, at which time they gave report to LPN #3, and LPN #3 took over the medication administration on the floor.
On 10/7/22 at 12:15 PM an interview was conducted with LPN#2 who stated that on 9/28/22 they worked 7 AM to 7:30 PM and stayed until 8:30 PM to help. LPN #2 stated that the resident asked for the Alprazolam after 8:00 PM and they gave it, but they forgot to go into the resident's MAR to sign the administration.
On 10/7/22 at 4:20 PM, an interview was conducted with LPN #3 who stated they came in to work on 9/23/22 at approximately 9:15 PM and administered medications on the first-floor unit. LPN #3 stated that when they came into work, RN #1 reported they had completed the medication pass on the north side of the unit. LPN #3 stated that the resident did not call for Xanax, so they had no concerns that the resident's medications might not have been administered, especially since RN #1 had told them that they had already completed medication pass on the north side. LPN #3 stated that the reason that they didn't check the MAR for missed medications on the north side is that RN#1 had reported administering all the medications on the north side.
On 10/7/22 at 4:45 PM, an interview was conducted with the Director of Nursing who stated that Medication Administration Records (MARs) are monitored by them and the unit managers if a resident or resident's representative complains or if there are any administration concerns. The DON stated it is possible to see medications highlighted in red to indicate that they are overdue and medications highlighted in green to indicate that they are due now, in the Sigmacare Dashboard. The DON stated any nurse can see all the overdue medications in the MAR for the shift that they are working, and they should be checking to ensure all medications are administered and signed off. The DON stated that the consulting pharmacist reviews resident's MARs for medication omissions and emails them to the facility staff.
On 10/7/22 at 5:00 PM an interview was conducted with the consultant pharmacist. The pharmacist stated the resident's August Medication Administration Record (MAR) was reviewed by the pharmacist on 8/12/22 and no omissions were noted, and the September MAR was reviewed by the pharmacist on 9/23/22 and no omissions were noted. The pharmacist stated they did not notice the omissions in August because they reviewed the resident's MAR prior to the omissions, and they did not notice the omissions in September because they reviewed the September MAR prior to the omissions on 9/23/22 and 9/28/22. The pharmacist stated they only review the MAR for the month they are reviewing, and do not review back to the date on which they ended the previous review.
415.18
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
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 conducted during the Recertification Survey and Abbreviated Survey ( NY 003018...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Recertification Survey and Abbreviated Survey ( NY 00301827, 00294084 and NY00302051) conducted from 10/3/2022- 10/12/2022, the facility did not ensure that medical records were complete and accurately documented for 2 of 2 residents (Residents # 119 and #120) reviewed for Pressure Ulcers and 1 of 6 residents (Resident #70) reviewed for Medication Administration. Specifically, the Certified Nursing Assistant (CNA) documentation for turning and positioning task for (Residents #119 and #120) was incompete, and the Medication Administration Record documentation for Xanax administration for Resident #70 was incomplete.
The Findings are:
The facility Policy and Procedure (P&P) titled Pressure Ulcer Protocol: Prediction, Prevention and Treatment undated documented prevention strategies maybe implemented regardless of risk/score based on nursing judgement and [NAME]. The policy further documented pressure relief interventions will be instituted for at risk residents assessing the need for use of prophylactic equipment in bed, prophylactic equipment in OOB, and repositioning/ambulation of resident as per care plan. Obtain physicians' order (for treatment/use of pressure ulcer products).
1. Resident # 119, a [AGE] year-old who was admitted to the facility on [DATE] with a diagnosis of Anoxic Brain Damage, Aphasia and Adult Failure to Thrive.
The admission Minimum Data Set, dated [DATE] (MDS a resident assessment and screening tool) documented the resident was severely impaired never rarely made decisions. The resident was totally dependent for bed mobility, toileting and transfers.
The care plan for at risk for impaired skin integrity related to immobility and incontinence initiated on 6/21/2022 documented the resident will not develop new pressure ulcer throughout the review period. Interventions Maintain turning and positioning schedule as recommended every two hours and as needed to maintain comfort and positioning. Apply cream as needed to the skin and monitor skin condition daily during care and report changes.
Review of the C.N.A. Documentation Detail revealed no documented evidence that turning and postioning was performed on June 24, 25, 26, 27, 28, 29, 30, July 3, 4, 5, and August 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,18, 19, 20, 21 and 22.
During an observation on 10/3/2022 at 10AM resident was in bed with GT feeding in progress no turning and positioning observed.
During an interview on 10/11/2022 at 10AM with Certified Nursing Assistant (CNA #1) they stated they did turn the resident when the resident was in bed.
2. Resident #120 had diagnoses including Local Infection of the Skin and Subcutaneous Tissue, Unspecified, Chronic Venous Hypertension w/Ulcer of Bilateral Lower Extremities, and Acute Kidney Failure.
The admission MDS dated [DATE] documented resident #120 had a BIMS score of 15, indicating no cognitive impairment. Resident required two-person extensive physical assist for bed mobility, transfers, dressing, and toileting and one-person extensive physical assist for locomotion on/off unit. Resident #120 was at risk for developing pressure ulcers. No pressure ulcers were identified on the assessment.
Review of wound care plan dated 12/16/21 documented resident had impaired skin integrity as evidenced by cellulitis and coccyx wound. Interventions included wound treatment as ordered and turn and reposition every 2 hrs. and as needed.
The admission nursing progress note dated 12/1/22 8:45 PM documented noted redness to resident #120 coccyx and buttocks.
Review of the CNA Documentation Detail for December 2021, January 2022, and February 2022 for turning and positioning revealed turning and positioning documentation omissions on December 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 31, and January 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 20, 23, 24, 27, 28, 30, 31, and February 1, 2, 4, 7, 8, 9, 10, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24. In addition, there was no evidence of refusals for turning and positioning.
During an interview with on 10/12/22 at 10:20 AM, the Registered Nurse Unit Manager (RNUM #1) stated if there is redness on a resident's skin, they will receive barrier cream and an order for turn and position every 2 hours would be ordered. RNUM #1 further stated if a resident is admitted with redness or rash, they should be considered high risk and CNAs are supposed to be documenting in sigma each time the resident was turned and positioned, and s/he was not aware of documentation omissions.
During an interview on 10/12/22 at 10:52 AM, Certified Nursing Assistance (CNA #5) stated there were times they would attempt to turn resident but the resident would refuse; would complain about foot and leg wounds hurting. CNA #5 stated they did not document the refusals in the electronic medical record (EMR).
3. The Resident was admitted to the facility on [DATE] with diagnoses including but not limited to Anxiety Disorder, Depression, and Acute & Chronic Respiratory Failure.
The Minimum Data Set (MDS; an assessment tool) dated 7/25/22 documented that resident has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15 associated with intact cognition. The resident received antianxiety medication 5 days and antidepressant 6 days in the lookback period, and was on Oxygen therapy.
A review of the facility policy titled, Administration of Medications dated June 2016 and revised April 2022 documented that medication administration must be charted on the Medication Administration Record (MAR) immediately before going onto the next resident as follows: Initials indicating medication was given as ordered. If a medication is not given for any reason, the nurse must document the reason the medication was not given in the MAR. Controlled medication administration is to be recorded after administration, and if there is any reason to withhold the medication, documentation in the MAR as to the reason why the medication was not given is to be documented.
A review of the Physician's orders dated 8/9/22 documented Alprazolam 0.25 mg once daily at bedtime for Generalized Anxiety Disorder.
A review of Care Plan titled, Mood State dated 7/31/22 documented interventions including administer medications as ordered, and monitor for additional signs and symptoms of depression such as change in sleep pattern, angry outbursts, encourage family visits, loss of appetite.
Review of the resident's Medication Administration Record (MAR) dated August 2022 documented: Alprazolam 0.25 mg 1 tablet daily at bedtime for Generalized Anxiety Disorder ordered 8/10/22 was not documented as administrated on 8/21/22 and 8/29/22.
Review of the resident's MAR dated September 2022 documents: Alprazolam 0.25 mg 1 tablet daily at bedtime for Generalized Anxiety Disorder ordered 8/10/22 was not documented as administrated on 9/23/22 and 9/28/22.
On 10/03/22 at 11:27 AM, an interview was conducted with the resident who stated they were not getting Xanax at bedtime and they called the nurse to complain. The resident stated they felt anxious when they didn't get the Xanax.
On 10/6/22 at 6:50 PM, an interview was conducted with Licensed Practical Nurse (LPN #1) who stated they gave the Alprazolam on 8/21/22 and 8/29/22 but sometimes they forget to sign off administrations in the MAR. LPN #1 stated they work 12-hour shifts (7PM to 7AM), and they were working both sides of the unit alone.
On 10/7/22 at 12:15 PM an interview was conducted with LPN#2 who stated that on 9/28/22 they worked 7 AM to 7:30 PM and stayed until 8:30 PM to help. LPN #2 stated that the resident asked for the Alprazolam after 8:00 PM and they gave it, but they forgot to sign the administration in the resident's MAR.
On 10/7/22 at 4:20 PM, an interview was conducted with LPN #3 who stated they came in to work on 9/23/22 at approximately 9:15 PM and administered medications on the first-floor unit. LPN #3 stated that when they came into work, RN #1 reported they had completed the medication pass on the north side of the unit. LPN #3 stated that the resident did not ask for Xanax, so the LPN had no concerns that the resident's medications might not have been administered, especially since RN #1 had told them that they had already completed medication pass on the north side. LPN #3 stated that the reason that they didn't check the MAR for missed medications on the north side is that RN#1 had reported administering all the medications on the north side.
On 10/7/22 at 4:45 PM, an interview was conducted with the Director of Nursing who stated that Medication Administration Records (MARs) are monitored by them and the unit managers if a resident or resident's representative complains or if there are any administration concerns. The DON stated it is possible to see medications highlighted in red to indicate that they are overdue, and medications highlighted in green to indicate that they are due now, in the Sigmacare Dashboard. The DON stated any nurse can see all the overdue medications in the MAR for the shift that they are working, and they should be checking to ensure all medications are administered and signed off. The DON stated that the consulting pharmacist reviews resident's MARs for medication omissions and emails them
415.12(a)(1-4)
CONCERN
(E)
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 and interviews conducted during the recertification survey and abbreviated survey (301827) conducted from 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during the recertification survey and abbreviated survey (301827) conducted from 10/3/2022-10/12/2022 the facility did not maintain a safe, clean, comfortable, and home-like environment for 2 of 2 units (Units 1 and 2). Specifically,(1) the facility did not ensure that adequate housekeeping services were provided to maintain floors, bathrooms, and resident sinks on unit 2. the facility did not maintain an appropriate hot water temperature for the residents.
The Findings are:
The Policy and Procedure titled Housekeeping undated documented in order to prevent and control the spread of disease it is the objective of the housekeeping departments to present as far as possible aesthetic clean and contamination free surroundings for patients' visitors and personnel.
An initial tour of the facility was conducted on 10/3/2022 between 9:30am and 12.00pm and the following was observed. The elevator on the second floor had strong smell of urine, room [ROOM NUMBER]-1 had garbage on the floor consising of empty juice containors, napkins, crumbled paper and the floors were dirty. room [ROOM NUMBER]-2 had a strong odor of urine and the floor was dirty. The sink in room [ROOM NUMBER]-1 was rusty. room [ROOM NUMBER]-1 had a strong smell of urine.
1. On 10/5/22 at 9:39 AM during a tour of Unit 2, a strong odor of feces and urine was noted immediately upon entering the unit via elevator.
On 10/6/22 at 10:31 AM during a tour on unit 2, a strong odor of feces and urine was noted in the dining room during an activity.
During an interview on 10/322 at 10:47 PM, Resident #101 reported their bathroom is not cleaned consistently. Resident #101 stated their neighbor is constantly smearing feces on the toilet, and if housekeeping has gone home for the day, the toilet will stay in an unsanitary condition until housekeeping returns the next morning. Resident #101 stated that whenever the bathroom is in this condition, they go downstairs to use the bathroom.
During an interview on 10/422 at 9:17 AM, Resident #88 complained about their bathroom not being operational. Resident #88 complained of their neighbor smearing feces everywhere. Resident #88 stated they complained to the night aides and medication nurse last night and nothing was done to address it. Residents #88 stated they use another bathroom when their bathroom is in this condition. At the time of interview the room bathroom was observed with used paper towels and smeared feces on the floor and bathroom walls.
During an interview on 10/12/2022 at 4:00PM with the Director of Housekeeping/Maintenance (DOH/M) they stated on Monday the units are always messy because it is after the weekend when the facility does not have enough staff. There is no Lobby person just one housekeeper on the first and second floors. During the week there is a Lobby person and one housekeeper on the first and second floors. The DOH/M stated things are not up to PAR, the guy that buffs the floor quit.
During an interview on 10/12/2022 at 4:10PM with housekeeping staff #1 they stated the facility is short staffed and they are the only one buffing and stripping the floors. They further stated when the facility hires staff they do not stay.
During an interview on 10/6/22 at 10:40 AM, housekeeping staff #2 they stated there are times when they come in at the start of their shift and must clean messes that were left from the night before such as urine, feces, and vomit on resident floors.
2.During an Interview with Resident #30 on 10/04/22 at 9:20 AM Resident #30 complained about the water being cold.
During an observation on 10/04/22 at 9:20 AM this surveyor ran water in the room of Resident #30 for about 2 minutes and water never got warm or hot.
During a Resident Council Meeting on 10/04/22 at 1:36 PM 10 of 10 residents stated the water at the facility is always cold and takes 45minutes to 1 hour to warm up.
During an observation on 10/05/22 at 10:02 AM of room [ROOM NUMBER] and room [ROOM NUMBER], the hot water knob was turned on and ran for 2-3 minutes without getting warm.
During an observation on 10/6/22 at 2:15 PM, water temperatures were taken in four resident rooms at the end of the corridor (rooms 101, 114, 127 and 129) using the facility thermometer. The water temps ranged from 87 to 98 degrees Fahrenheit.
During an interview with the resident in room [ROOM NUMBER] at 2:15 PM, the resident stated that in the morning it takes the water 15 -20 minutes to warm up.
During an interview on 10/6/22 at 2:20PM with the Director of Maintenance, the Director of Maintenance stated that the circulating pump must have a check valve installed.
During an interview with Director of Maintenance on 10/7/22 at approximately 2:00 PM, the Director of Maintenance stated that a mixing valve was installed, but the mixing valve installed is not the correct fit for the recirculating pump and the correct mixing valve to install on the recirculating pump would be ordered.
10 NYCRR 415.29(j)(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on observation, resident and staff interviews and record review conducted during a Recertification Survey and Abbreviated Survey (294084) the facility did not ensure that sufficient nursing staf...
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Based on observation, resident and staff interviews and record review conducted during a Recertification Survey and Abbreviated Survey (294084) the facility did not ensure that sufficient nursing staff was consistently provided for 2 of 20 residents interviewed and 7 of 10 residents who attended a group meeting (Resident Council) who expressed complaints regarding lack of sufficient staffing, delay in and not receiving care in a timely manner. Additionally, according to the Facility Assessment resident to staff ratios, Nurse and Certified Nurse Aide (CNA) levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents.
The findings are:
During individual interviews conducted at various times during the initial phase of the survey from 10/03/22 through 10/12/22, 2 of 20 residents interviewed confidentially stated that the facility did not have sufficient staff and 7 of 10 residents who attended a group meeting (Resident Council) also complained of staffing concerns specifically at night or on the weekends.
During a resident council meeting on 10/04/22 at 01:36 PM, 7-10 residents reported the call lights blink all night and nobody to comes to help residents.
During a resident council meeting on 10/04/22 at 01:36 PM, 7-10 residents reported 3 days in a row medication was not given timely, specifically Friday (9/30/22), Saturday (10/1/22) and Sunday (10/2/22), this also occurred on the night shifts. The residents stated they: don't get medications timely especially on evenings and night shifts, at times, only one CNA (Certified Nurse Aide) on duty at night on each unit resulting in slow response time, must wait a long time for assistance, timely toileting is an issue and it takes as long as an hour after ringing the call bell to get help which occurs mostly on the 3-11 PM shift and 11-7 shift and that it is worse on a weekend.
Review of August and September Nurse staffing revealed 9/30/22 Unit L 7PM-7:30AM 1 Registered Nurse (RN) who was also listed as the facility Supervisor, Unit II 1 Licensed Practical Nurse (LPN). 10/1/22 Unit L 7AM-7:30PM 1 LPN and a second LPN was also listed as the facility Supervisor, Unit II 7PM-7:30AM 1 LPN.
10/2/22 Unit L 7AM-7:30PM 1 LPN and a second LPN was also listed as the facility Supervisor and 7PM-7:30AM 1 LPN, Unit II 7AM-7:30PM 1 LPN and 7PM-7:30AM 1 LPN
Review of August and September CNA staffing revealed 8/18 Unit L 3PM-11PM 1 CNA and 11PM-7:00AM 1 CNA on 8/14, 8/15, 8/17, 8/19, 8/20, 8/21, 8/23 and 8/25. Unit II 11PM-7AM 1 CNA on 8/15, 8/16, 8/19, 8/20, 8/21, 9/17, 9/25, 9/26 and 9/28.
Review of the August and September Medication Administration Record for Resident #70 revealed Xanax was not signed out as being administered on 8/21/22, 8/29/22 and 9/28/22.
Review of August and September Nurse staffing sheets for the above dates revealed 8/21/22 7PM-7:30AM Unit L 1 LPN and Unit II 1 LPN and 8/29/22 Unit L 7PM-7:30AM 1 LPN, Unit II 7PM-7:30AM 1 LPN and 1 RN who was also listed as the facility Supervisor and 9/28/22 Unit L 7PM-7:30AM 1 LPN and 1 RN who was listed as working 3PM-11PM as well as the facility supervisor, Unit II 7:00PM-7:30AM 1 LPN.
On 10/6/22 at 6:50 PM, an interview was conducted with Licensed Practical Nurse (LPN #1) who stated they gave Xanax on 8/21/22 and 8/29/22 but sometimes they forget to go back into the MAR to sign off that the medication was administered. LPN #1 stated they work 12-hour shifts (7PM to 7:30AM), and they were working both sides of the unit alone, but there should be 2 nurses on the unit, one for each side of the unit.
Review of the September Medication Administration Record for Resident #70 revealed Xanax was not administered on 9/23/22 as per physician order
Review of September Nurse staffing sheets for the above dates revealed 9/23/22 Unit L 7PM-7:30AM 1 RN who was also listed as the facility Supervisor and Unit II 1 LPN.
On 10/7/22 at 3:45 PM, an interview was conducted with Registered Nurse (RN #1). RN #1 stated that on 9/23/22 there was no medication nurse on the first floor, so they began to administer medications on both the north and south sides of the unit until LPN #3 came in, at which time they gave report to LPN #3, and LPN #3 took over the medication administration on the floor.
On 10/7/22 at 4:20 PM, an interview was conducted with LPN #3 who stated they came in to work on 9/23/22 at approximately 9:15 PM and administered medications on the first-floor unit. LPN #3 stated that when they came into work, RN #1 reported they had completed the medication pass on the north side of the unit. LPN #3 stated that the reason that they didn't check the MAR for missed medications on the north side is that RN#1 had reported administering all the medications on the north side.
On 10/12/22 at 03:40 PM, an interview was conducted with the Administrator regarding staffing efforts and staffing minimums. During a review of Facility Assessment with the Administrator, the Facility Assessment documented 2 -4 nurses and 2 -10 Certified Nursing Assistant (C.N.A.s) per shift. The Administrator clarified that the minimum number of nurses is 2 per unit per shift (a total of 4 per shift) and the minimum amount of C.N.A.s is 2 per unit per shift (a total of 4 per shift), but they usually have only one nurse per unit on night shift (7PM to 7AM). The Administrator stated they provide bonuses to cover call outs to meet the minimum of three CNAs per unit on days and evening shifts, and to meet the minimum of 2 CNAs per unit on night shift, and they use agency staff as needed, and have contracts.
During an interview with Staffing Coordinator (SC) on 10/12/22 at 3:49 PM, SC stated that Nursing has taken a big hit from the pandemic, they would like to have more staff of course. SC stated they felt they could manage with the current staff available for nursing. SC stated the minimum amount of CNA's required for day shift would be 3, the minimum amount of CNA's required for night shift would be 2, the minimum number of nurses required for night shift would be 1. SC stated they tried to make sure there are 2 CNAs and 2 Nurses on a any shift during the day. SC and nursing supervisors are authorized to offer bonuses to fill vacancies if there are less than 2 nurses per floor on the day shift and less than 3 CNAs per floor on the day/evening shift and less than 1 nurse per floor on the night shift and less than 2 CNA's per floor on the night shift.
415.(a)(1)(i-iii)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review conducted during the Recertification Survey the facility did not ensure that 3 of 10 randomly reviewed Certified Nursing Assistants (CNAs), CNAs #5, #6 and #7, com...
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Based on interview and record review conducted during the Recertification Survey the facility did not ensure that 3 of 10 randomly reviewed Certified Nursing Assistants (CNAs), CNAs #5, #6 and #7, completed the required 12 hours of annual in-service training. In addition, 2 of 10 randomly reviewed CNAs, CNA #6 and CNA #7 recently hired, did not receive a facility orientation
The findings are:
Three of ten CNA training records reviewed lacked evidence that they were provided 12 hours of training annually to include abuse prevention as evidenced by the following:
In an undated list provided on 10/12/22 CNA #5 was hired on 09/12/1994, CNA #6 was hired on 06/6/22 and CNA #7 was hired 8/12/22.
Review of in-service sign-in sheets revealed there were no sign in sheets for CNA #5, #6 and #7. There was no evidence that CNA #5, #6, and #7 attended an in-service on abuse prevention during this year.
During an interview with Staff Developer (SD) on 10/12/22 at 3:30 PM, SD stated that they did not have the required 12-hour mandatory trainings for CNA#5, #6, and #7. SD stated CNA #5 was hired 9/12/1994 and has not completed any trainings for 2022 as of yet. SD stated they have not been able to catch up with CNA #5 to provide any mandatory education. SD stated CNA#6 was hired 6/6/22 and has not completed any trainings for 2022 as of yet. SD stated S. CNA #7 was hired 8/12/22 and has not completed any trainings for 2022 as of yet.
During an interview with Director of Nursing (DON) on 10/12/22 at 3:40 PM, DON stated that CNA #6 and CNA #7 were given unit orientation but did not receive a facility orientation which would include trainings from the 12 hours mandatories. DON stated the reason the mandatory trainings were not provided during orientation was a result of not having a staff developer hired for nursing. DON stated the unit orientation provided included shadowing of other CNA's showers, feeding, and a review of fire drills, codes etc.
The staff developer and DON stated they were unable to provide documentation that CNAs #5, #6 and #7 had the mandatory in-services.
415.26(c)(1)(iv)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review conducted during a Recertification Survey conducted from 10//22-10/12/22 the facility did not ensure that residents were consistently offered and prov...
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Based on observation, interview and record review conducted during a Recertification Survey conducted from 10//22-10/12/22 the facility did not ensure that residents were consistently offered and provided with evening snacks. Specifically, 7 out of 10 alert and oriented residents from 2 out of 2 units, that attended the resident council meeting stated that they were not offered a snack, or if they asked for a snack, they were not provided with an evening snack.
The findings are:
A resident council meeting was conducted on 10/04/22 01:36 PM 7 out of 10 residents in attendance stated they were not provided or offered evening snacks and if they asked for an evening snack, they were told by the staff that, no snacks were available, or that the pantry was closed for the night. The Residents stated snacks-were not offered between 6 PM and 8AM and they were told after dinner the pantry is locked and residents are not allowed to enter the pantry.
Observations on 10/06/22 at 06:54 PM revealed the 1st floor pantry had 5 cookies and 5 puddings.
Observation on 10/06/22 at 07:14 PM revealed the 2nd floor pantry had 4 puddings, 2 applesauce and 10 cookies.
During an observation on 10/6/22 at 7:07PM, Dietary Aide #3 removed the dinner/food trucks from the first floor and second floors, and no evening snacks were brought to the 1st or 2nd floors.
During an observation on 10/06/22 at 7:19 PM Licensed Practical Nurse (LPN#1) stated sandwiches and cookies are kept in the pantry for people that want something in between meals. At that time LPN#1 checked the pantry and stated there were small amounts of snacks left in the pantry. LPN#1 stated the supervisor has a key to the kitchen if anything is needed after kitchen staff leave for the night. LPN #1 stated kitchen staff will usually bring snacks to the floor in evening. LPN#1 stated if resident's request any snacks or nourishments they will go get the snacks from the pantry and if there is nothing in the pantry the supervisor will go down to kitchen and get something.
During an interview with Food Service Director (FSD) on 10/07/22 at 8:54 AM, FSD stated the pantries on the 1st and 2nd floor units were stocked twice a day, after lunch at 1PM and again around 3PM. FSD stated the unit pantry refrigerators are stocked with sandwiches, puddings, and cookies. Nursing will call down throughout the day and food service staff will bring anything to the floors that is requested and the supervisor has a key to go to kitchen and get anything that is requested. The supervisor can go down and get sandwiches and cookies and or whatever they need. They leave sandwiches in the walk-in cooler, and supervisor goes to kitchen and constantly bring things up.
During an interview with the Registered Dietician on 10/11/22 at 10:48 AM, RD stated that FSD wanted to keep the same systems in place. RD stated they spoke to the FSD and the FSD told them they prefer to send up snacks and nourishments with the dinner tray. RD stated nourishments or snacks are cheese and crackers or sandwiches. These items will be sent with dinner meal, and residents are told to save it for later. RD stated the residents know it is their night snack. RD stated if there is nothing sent with the dinner tray there will be sandwiches, pudding, and crackers with cheese in the unit pantries for those residents who are hungry at night. RD acknowledged currently there is no system to track it.
During an interview with Dietary Aide #3 (DA#3) on 10/12/22 at 3:36 PM, DA#3 stated they leave around 7:30 PM-8PM. DA#3 stated the dietary aides provide snacks to the 1st and 2nd floor unit pantries and only bring up snacks to the unit at 3PM. When asked if they bring snacks up after dinner DA#3 stated no, only if the residents ask. DA#3 stated at night they are sometimes alone because of staffing but there might be 2 people on shift at night. DA#3 stated the chef leaves between 6:30PM-7PM.
415.14(f)(1)(2)(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, interview conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure proper maintenance of the unit pantry refrigerator accordi...
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Based on observation, interview conducted during the Recertification Survey conducted from 10/3/2022 -10/12/2022, the facility did not ensure proper maintenance of the unit pantry refrigerator according to professional standards for food safety. Specifically, a pantry refrigerator was not maintained in a sanitary condition in accordance with standards for food service safety. This was evident for 1 of 2-unit pantries (Unit 2).
The findings are:
The facility Policy and Procedure (P&P) titled Between Meal Feeding undated documented rotation of stock and sanitation of the nursing pantry areas is the responsibility of the respective nursing units and Nutritional Services. The policy further documented procedures for cleaning and care of the nursing pantry area have been developed by Nutritional Services and are posted in each pantry.
On 10/5/22 at 9:39 AM, a tour of the Unit 2 pantry with the RNC (Regional Nurse clinical) present revealed an unclean refrigerator with a few cans of ginger ale, a few cups of apple sauce and puddings for the residents. The freezer was observed with old food spillage. Dirt stains were noted on the door inside of the refrigerator. Dirt stains were also noted underneath the refrigerator drawers and shelves. There was no evidence of a cleaning schedule or procedures for cleaning the unit pantry posted in the pantry area.
During a second tour of Unit 2 pantry on 10/5/22 at 2:37 PM, the Director of Nursing (DON) stated uppon opening the refrigerator door, that the condition of the refrigerator was filthy. The DON stated the Night shift aides are responsible for cleaning the refrigerator. The DON was not certain if there was a cleaning schedule implemented for cleaning of the refrigerator.
During a third tour of the Unit 2 pantry on 10/06/22 at 10:22 AM, revealed the refrigeratpr remained unclean with old food spillage in the freezer and refrigerator.
During an interview on 10/5/22 at 02:38 PM, Licensed Practical Nurse ( LPN #5) stated night shift aides are responsible for cleaning the refrigerator but that they were not sure who specifically is responsible for overseeing CNAs are cleaning the refrigerator.
During an interview on 10/6/22 at 10:18 AM, Registered Nurse Unit Manager (RNUM #2) stated the night supervisor would oversee ensuring the aides are completeling their assigned tasks during the night shift.
415.14(h)
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most New York facilities.
- • 20% annual turnover. Excellent stability, 28 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Renaissance Rehabilitation And Nursing's CMS Rating?
CMS assigns RENAISSANCE REHABILITATION AND NURSING CARE CENTER 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 Renaissance Rehabilitation And Nursing Staffed?
CMS rates RENAISSANCE REHABILITATION AND NURSING CARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 20%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Renaissance Rehabilitation And Nursing?
State health inspectors documented 48 deficiencies at RENAISSANCE REHABILITATION AND NURSING CARE CENTER during 2022 to 2024. These included: 48 with potential for harm.
Who Owns and Operates Renaissance Rehabilitation And Nursing?
RENAISSANCE REHABILITATION AND NURSING CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 104 residents (about 87% occupancy), it is a mid-sized facility located in STAATSBURG, New York.
How Does Renaissance Rehabilitation And Nursing Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, RENAISSANCE REHABILITATION AND NURSING CARE CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (20%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Renaissance Rehabilitation And Nursing?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Renaissance Rehabilitation And Nursing Safe?
Based on CMS inspection data, RENAISSANCE REHABILITATION AND NURSING CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 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 Renaissance Rehabilitation And Nursing Stick Around?
Staff at RENAISSANCE REHABILITATION AND NURSING CARE CENTER tend to stick around. With a turnover rate of 20%, the facility is 26 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 29%, meaning experienced RNs are available to handle complex medical needs.
Was Renaissance Rehabilitation And Nursing Ever Fined?
RENAISSANCE REHABILITATION AND NURSING CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Renaissance Rehabilitation And Nursing on Any Federal Watch List?
RENAISSANCE REHABILITATION AND NURSING CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.