Kings Harbor Multicare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a resident was free from physical restraints that were not required to treat a medical symptom, specifically related to the use of bed side rails. The facility’s own policies on Side Rails and Physical Restraints require individualized assessment, identification of a medical symptom necessitating the device, a specific and accurate physician order, informed consent, and ongoing reassessment at admission, readmission, quarterly, and with condition changes. For the resident in question, who had a history of stroke with right-sided paralysis and non-Alzheimer’s dementia and was severely cognitively impaired, the Quarterly MDS documented that bed rails were not in use, yet subsequent observations and records showed two upper side rails raised on multiple occasions while the resident was in bed. Surveyors observed the resident in bed on several dates with two upper side rails raised, and during one observation, staff instructed the resident to hold the rails while being turned, which the resident could do, but the resident was unable to lower the rails when asked. Multiple Siderail Use Assessments over several months documented that the resident could follow commands, required assistance with bed mobility, and used side rails for positioning and support, with the side rail location consistently documented as bilateral. However, several assessments were incomplete, particularly in the sections for side rail recommendations and documentation of resident/family consent and awareness of risks. Earlier assessments also documented that the resident/family did not consent to the use of side rails as enablers. Despite this, the care plan documented the provision of two half side rails as enablers, while the physician order only authorized one half side rail as an enabler, and there was no documentation of a medical symptom requiring the use of bed rails or an order for two upper side rails. The resident had a history of unwitnessed falls from bed both before and after side rail use, with documented injuries including swelling to the forehead, bleeding from the mouth, and hip pain requiring hospital evaluation. Staff interviews revealed that CNAs and nurses used the side rails to assist with turning, positioning, and transfers by having the resident hold onto the rails, and some staff believed the rails might help prevent falls, although they acknowledged that the resident had fallen out of bed with the rails in place. Nursing staff, including an RN and the Assistant DON, acknowledged that the resident could not put the side rails down independently, that there were risks of the resident’s fingers, face, or head getting caught or injured in the rails, and that side rails could be considered a restraint and pose entrapment risks when the resident could move in bed but could not operate the rails. The DON stated that residents should be assessed quarterly for side rail appropriateness and that documentation and physician orders should have been complete and correct, but in this case, there was no documented medical symptom justifying the bed rails, incomplete assessments, lack of documented consent, and a mismatch between the physician order and the actual use of two upper side rails, resulting in the resident being restrained contrary to regulatory and facility policy requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to report an incident of unknown origin that resulted in a serious injury to a resident to the New York State Department of Health (NYSDOH) as required by regulation and facility policy. The facility’s abuse reporting policy, reviewed in May 2025, states that incidents suspected of abuse, neglect, exploitation, misappropriation, or serious injury of unknown origin that is suspicious in nature must be reported within two hours after forming the suspicion to NYSDOH, and all other incidents must be reported within 24 hours. Despite this policy, the incident involving Resident #273, which resulted in a nasal fracture and lacerations, was not reported to the state agency. Resident #273 had diagnoses including cerebrovascular accident, seizure disorder, and Parkinson’s disease, and a quarterly MDS documented severely impaired cognition and dependence for toileting and rolling in bed. On 01/07/2026 at approximately 5:30 PM, an LPN conducting rounds found the resident lying on the bedroom floor between two beds, with uncontrolled tremors, a small laceration on the bridge of the nose with active bleeding, and a small laceration on the mid-forehead. The resident was unable to provide details of the event. The RN supervisor was notified, the areas were cleaned, pressure and an ice pack were applied, and the physician and family were notified. The resident was transferred to the hospital for further evaluation, and the hospital discharge summary documented fractures of the bilateral nasal bones and nasal septum, as well as resting tremors. Facility documentation, including the Fall/Occurrence Report and Summary of Investigation initiated on 01/07/2026, described the event as an unwitnessed fall with the resident found on the floor, severely cognitively impaired, and unable to state what happened. The investigation concluded that the resident, who had Parkinson’s disease and tremors, may have rolled out of bed onto the floor, and that there was no evidence to support abuse, neglect, or mistreatment; therefore, the incident was deemed not reportable to NYSDOH. Interviews with the Assistant DON, DON, and Administrator confirmed that they did not suspect abuse or neglect and decided the incident was not reportable, and there was no documented evidence that the incident resulting in the nasal fracture and lacerations was reported to the state agency, in violation of 10 NYCRR 415.4(b).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a resident with a change in condition received timely diagnostic testing and that refusals and collection difficulties were communicated and documented in accordance with professional standards and facility policy. The resident had hypertension, diabetes mellitus, and chronic kidney disease, with moderately impaired cognition, dependence for toileting, and continuous urinary incontinence. On 02/09/2026, the resident was found to have a fever of 101.9°F during wound rounds, and the MD ordered a one-time urinalysis/urine PCR along with other tests to rule out respiratory viruses and a urinary tract infection. The care plans in place included monitoring labs as scheduled, assessing the source of fever, and obtaining lab tests per physician order. Following the MD’s order for urine testing on 02/09/2026, staff made multiple attempts to obtain a urine specimen but were unsuccessful due to the resident’s inability to void and refusals. Nursing notes documented that no urine was obtained on 02/10/2026 at 4:22 PM, that the resident was uncooperative with urine collection on 02/10/2026 at 10:30 PM, and that urine could not be obtained on 02/11/2026 at 6:51 AM and again on 02/12/2026 at 3:55 PM. However, there was no documented evidence that the MD was notified when the ordered specimen was not collected, nor that the resident’s representative was notified of the refusals. There were also gaps where no attempts or outcomes were documented on multiple shifts between 02/09/2026 and 02/12/2026, despite staff interviews indicating that attempts and refusals occurred and that a supervisor had been verbally informed. A urine sample was eventually documented as collected and refrigerated on the night of 02/12/2026, and laboratory staff later reported that a sample was picked up on 02/13/2026, but the lab was unable to perform the test and needed a repeat specimen. The lab indicated that they likely attempted to notify the facility about the problem with the sample around 02/15/2026 but were not able to reach staff until 02/17/2026, when a call was documented requesting another urine sample. A new specimen was collected and refrigerated on 02/17/2026, and lab staff collected urine on 02/18/2026, with results electronically available on 02/19/2026 showing a positive urine PCR for Streptococcus group B and Candida. During this period, nursing progress notes from 02/14/2026 to 02/17/2026 lacked ongoing monitoring and assessment of the resident’s condition, and there was no documentation that the MD was informed of the delayed urine test results. On 02/19/2026, the resident again had an elevated temperature and later was noted by the MD to have altered mental status, low blood pressure, fever, and hypoxemia, leading to transfer to the hospital to rule out sepsis. The facility’s own policies required standardized processes for early recognition, timely notification, and efficient communication of lab values, but the record showed delays in specimen collection, lack of documentation of attempts and refusals, and failure to notify the MD and the resident’s representative when the ordered urine testing was not completed as intended.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and facility policy when a resident experienced vomiting after dinner. The resident had significant neurological diagnoses, including subdural hematoma, hydrocephalus, and dementia, and was documented as having severely impaired cognition and requiring extensive assistance with eating and bed mobility. On the evening in question, the resident ate dinner in their room with assistance and later vomited a small amount of undigested food, with vomitus observed on clothing and bed linens. Staff interviews and documentation show that the resident was described as alert, talking, and not in distress at that time. According to the facility’s policies on Notification of Changes and Falls/Occurrences, any accident, incident, or significant change in condition requires immediate notification of the physician and, as appropriate, the resident’s representative, as well as supportive documentation including vital signs, full physical assessment, and therapeutic interventions. The LPN reported in an investigative statement that vital signs were taken after being informed of the vomiting and that the resident was stable, but there was no documented evidence in the medical record that vital signs were recorded. There was also no documented evidence that the RN supervisor or the physician were notified of the vomiting episode, despite the facility’s policy and the RN supervisor’s later statement that such a change in condition should have been reported. Later that same evening, during bed linen changes, the resident was turned in bed and accidentally hit their head on the closet, resulting in a laceration and hematoma to the forehead. The LPN then notified the RN supervisor, who assessed the resident, noted changes in communication and mental status, obtained vital signs showing hypotension and bradycardia, and initiated emergency measures when the resident became unresponsive and pulseless. Subsequent interviews with the RN supervisor, DON, and Medical Director confirmed that the LPN did not notify the supervisor at the time of the vomiting and did not document the vital signs taken after the vomiting episode. The deficiency centers on the lack of timely notification and incomplete documentation following the resident’s vomiting, contrary to professional standards and the facility’s own policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the events surrounding a resident with severe impaired cognition and a history of osteopenia and prior falls. On the morning of the incident, the resident reported pain and an inability to stand to a Certified Nursing Assistant (CNA). Despite this, the resident was transferred by a Licensed Practical Nurse (LPN) and the CNA before being assessed by a Registered Nurse Supervisor or receiving any pain medication. This transfer occurred prior to any documented pain assessment or administration of pain relief, which was contrary to the facility's policy requiring pain assessment by a Registered Nurse using a Pain Assessment Tool. The resident was later transferred to the hospital, where they were diagnosed with an acute pelvic fracture. The facility's investigation revealed that the resident had a history of osteopenia and previous fractures, which increased their risk for further fractures. However, there was no documented evidence of a pain assessment or administration of pain medication before the hospital transfer. The LPN claimed to have administered pain medication but failed to document it, and the Registered Nurse Supervisor only assessed the resident after they had been moved to a chair. Interviews with the staff involved revealed a lack of adherence to the facility's pain management policy. The CNA and LPN transferred the resident without a prior assessment, and the LPN did not check the resident's hip due to the resident wearing pants. The Director of Nursing acknowledged that the resident's pain was new and should have been assessed before any movement. The facility's investigation concluded that there was no evidence of abuse, neglect, or mistreatment, but the deficiency in pain management was evident.

Plan Of Correction

Plan of Correction: Approved January 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was identified as being directly affected by the alleged gap in practice. The facility did not ensure that pain management is provided to resident who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. - An investigation was conducted and concluded that there was no evidence to support that abuse, neglect or mistreatment may have occurred. - Resident #1 was transferred to the hospital on [DATE] and readmitted to Kings Harbor on 2/15/24. - Upon resident #1 readmission from the hospital: - A Pain Assessment was completed - Resident #1 was evaluated by PMD and Tylenol 325mg q 6 hours for 14 days was ordered for pain management. - Care Plan #131A Pain Management was updated. - Resident #1 was monitored for pain and the effectiveness of pain management. - LPN #1 was educated on medication administration and documentation. - RN #1 was educated on pain assessment, pain management and updating Care Plan when change in resident condition is noted. - CNAs, LPNs and RNs of the Manor service were educated on reporting new onset of pain and deferring transfer/movement of resident prior to assessment by RN. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All residents with new onset of pain in the last 30 days will be reviewed by the RNM/RNS to ensure that a pain assessment is conducted, PMD was notified, appropriate pain management was implemented, and pain care plan was updated. In the event that non-compliance was identified, it will be immediately corrected to comply with F697. Responsible Party: RNM/RNS 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? An Ad Hoc QA/PI Meeting with the Administrator, DON, Medical Director, Director of QA/PI, and Staff Development was held to discuss the systemic changes that will be made to ensure that the deficient practice does not occur. 1. The Policy and Procedure for Pain Assessment, Education and Management was reviewed to assure compliance with F697 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and revised accordingly. The change in policy includes: - Pain assessment and Pain Management care plan update shall be performed: a. On admission/re-admission b. Quarterly and Annually for CCP Meeting c. Upon significant change in residents’ condition d. Upon any incident or accident as part of the assessment of the resident e. For any new complaint of pain identified by resident or staff f. Prior to initiation of a pain medication regime or change in pain medication regime g. Upon a change in the resident’s pain medication h. At any other time based on nursing or physician assessment Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all RNs and LPNs on pain assessment, management and care plan update. Highlights of the lesson plan include: - It is the policy of Kings Harbor to assess and manage resident’s pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. - When and how to perform pain assessment - Communicating with the medical provider when pain is identified - Documentation of pain assessment and management - Updating pain care plan as indicated in the Pain policy Responsible Party: Inservice Coordinator/Designee 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility’s compliance with ensuring that all residents with new onset of pain are assessed and managed and that all appropriate documentations are completed. Responsible Party: QA/PI 2. All residents with new onset of pain will be reviewed to ensure that they are assessed, and appropriate management is implemented weekly x 4 weeks and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Nursing Team Leaders/ADON 3. The results of the pain audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the pain audit will be presented and discussed at the facility monthly by QA/PI. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 21, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure compliance with the National Electric Code NFPA 70, 2011 edition, by not installing ground-fault circuit interrupter (GFCI) type outlet receptacles within six feet of sinks, which could potentially create an electrical hazard. This deficiency was observed during a facility tour conducted over several days, where outlet receptacles not of the GFCI type were found in resident rooms P436, M409, M401, and throughout all five resident floors. These observations were made in the presence of the Director of Maintenance, who acknowledged the issue.

Plan Of Correction

Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2011 NFPA 101, the observed electrical outlets in rooms P346, M409, M401, and other identified resident floors will be converted to approved GFCI outlets by the Engineering Staff. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by the deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that all electrical outlets are located within 6 feet of any water source. All identified outlets that are not compliant will be converted to approved GFCI outlets. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering reviewed and revised the facility policy on Electrical Outlet Testing to include, “GFCI to be used within 6 feet of water source.” b. All Engineering staff will be informed and educated regarding the revised policy on Electrical Outlet Testing. The education will include proper installation, usage, and testing of GFCIs. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: a. The Director of Engineering will include in the Environment of Care audit tool to inspect and test all GFCI receptacles. b. Audits will be performed monthly by the Engineering staff to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper installation and coverage of the automatic sprinkler system as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a recertification survey, it was observed that the sprinkler coverage was inadequate at the bottom landing of Stairwell D near a discharge door and in the emergency laundry storage room located in the basement. Additionally, a pendent sprinkler in the Soiled Utility Room was installed closer than four inches from the wall, which does not comply with the minimum distance requirements. Further deficiencies were noted during a tour of the kitchen, where a sidewall sprinkler was improperly installed on the ceiling of the dessert refrigerator. On the 3rd Floor of the Manor building, a sidewall sprinkler was also incorrectly installed on the ceiling of the Staff Restroom, and a pendent sprinkler was positioned closer than four inches from the wall in the resident's Shower Room. These observations indicate a failure to adhere to the specified guidelines for sprinkler installation, potentially compromising the effectiveness of the fire protection system.

Plan Of Correction

Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2010 NFPA 13, the Director of Engineering contacted the Fire Safety Sprinkler Company to: 1. Install the lacking fire sprinklers at the bottom landing of stairwell D and the emergency laundry storage room. 2. Appropriate sprinkler will be installed in the soiled utility room, 3rd floor Manor building staff restroom and the residents shower room. 3. The facility has signed a contract for installation and work has commenced. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility states that all residents have the potential to be affected by deficient practice. b. The contracted company reviewed sprinkler coverage throughout the facility and no additional areas were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. All Engineering staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as overview of requirements for sprinkler coverage as per K351. b. The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put into practice: a. The Director of Engineering has reviewed and revised the Environment Care Audit tool to ensure proper sprinkler coverage. b. Audits will be performed monthly by the Engineering Director/designee x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected by the Engineering Department or our contracted sprinkler company as needed. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an alleged incident of resident-to-resident physical abuse to the New York State Department of Health within the required 2-hour timeframe. The incident involved two residents, one of whom hit the other on the shoulder with a grabber. The incident occurred at approximately 1:40 PM, and the facility's Administrator was made aware of it by 1:55 PM. However, the report was not submitted to the Department of Health until the following day at 12:31 PM. Resident #193, who was hit, was admitted with diagnoses including end-stage renal disease, cerebral infarction, and polyneuropathy, and was cognitively impaired. Resident #325, who committed the act, was admitted with diagnoses including Alzheimer's disease, unspecified dementia, and major depressive disorder, and was severely impaired in cognition. The incident was witnessed by a Certified Nursing Assistant who reported it to a Registered Nurse, who then informed the Assistant Director of Nursing and the Director of Nursing. Despite the facility's policy requiring immediate reporting of abuse allegations, the Assistant Director of Nursing did not receive instructions from the Director of Nursing to report the incident until the next day. Both the Director of Nursing and the Administrator acknowledged the requirement to report such incidents within 2 hours but could not recall why the report was delayed. This failure to report in a timely manner constitutes a deficiency in the facility's compliance with state regulations.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #193 and resident #325 were identified as being directly affected by the alleged gap in practice. The facility did not ensure that an alleged violation involving resident-to-resident physical abuse was reported immediately, but no later than 2 hours after allegations were made to the State Survey Agency. - An investigation was conducted and concluded that the altercation was sudden in nature and was not premeditated. - Resident #193 and #325 were separated. Resident #325 was transferred to another unit. - Resident #193 and #325 were assessed and monitored. - Resident #193 and #325 medical provider and family were notified of the incident. - Resident #193 and #325 were seen and evaluated by the psychologist. - Resident #325 was seen and evaluated by the psychiatrist. - Social Services provided emotional support to residents #193 and #325. - The incident was reported to the NYS-DOH on 7/29/24. - RN #4 was re-educated on actual/alleged abuse reporting to ensure that the NYS-DOH is notified within 2 hours after the incident/allegation. - CNA #7 was re-educated on abuse prevention and reporting. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All incidents and accidents for the preceding 30 days were reviewed by the Assistant Directors of Nursing to ensure that any incidents of alleged or actual abuse or incidents involving serious injury were reported timely to the DON and Administrator, as required, to the state agency and all other required agencies (i.e. law enforcement when applicable). In the event that non-compliance was identified, the incident will be immediately reported to all required entities and staff involved re-inserviced on the required timeframes to report. Responsible Party: Assistant Directors of Nursing 3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not occur? 1. The Policy and Procedure for Abuse- Prohibition Protocol, Types of Abuse, Response/Reporting Prevention/Response/Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI, and Medical Director and revised accordingly. The change in policy includes: - Any alleged violations involving mistreatment, neglect, or abuse, including serious injuries of an unknown source must be reported to the Administrator/Designee, or department director immediately. An immediate investigation must be made and the findings of such investigation must be reported to the NYSDOH via Electronic Incident Reporting form within 2 hours of occurrence/discovery. Responsible Party: Administrator, DON, Medical Director, QA/PI 2. The Policy and Procedure for Abuse Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI, and Medical Director and found to be in compliance. Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 3. Inservice education will be provided by the Inservice Coordinator/designee to all staff on abuse, neglect, and mistreatment including injuries of unknown origin regarding reporting requirements related to violations involving abuse to the NYSDOH and NYPD, immediately. Education on Abuse Prohibition Protocol will continue to be provided to staff upon hire and annually thereafter. Highlights of the lesson plan include: - The facility staff must immediately report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property to the RNM/RNS/ADON. An investigation is to immediately follow. - The RNM/RNS/ADON will immediately notify the DON who will notify the Administrator. - Upon notification, the Assistant Director of Nursing/Designee must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYSDOH and as appropriate to other required agencies (i.e., NYPD). Responsible Party: Inservice Coordinator/Designee 4. The Residents Occurrence Log-In form (SAFETY-967) was reviewed and revised to ensure that actual/allegation of abuse is reported to the NY-DOH within 2 hours of the incident/allegation. Revision of form included adding: - Reportable (Y/N) - Date/Time Reported to DOH - Date/Time Reported to Other Agency Responsible Party: QA/PI 4. How will the corrective action(s) be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility’s compliance with ensuring that all accidents and incidents are investigated, and abuse is reported timely as per NYSDOH and Federal reporting guidelines. Responsible Party: QA/PI 2. All accidents/incidents and grievances involving alleged abuse or serious injuries will be audited daily by the Assistant Director of Nursing/designee for 30 days and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Assistant Director of Nursing/Designee 3. The results of the accidents and incidents audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the accidents and incidents audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely submission of resident assessments to the Centers for Medicare and Medicaid Services (CMS) system, as required by their policy. During a recertification survey, it was found that nine resident assessments were not submitted within the mandated 14 days of completion. The assessments for these residents had completion dates ranging from October 24, 2024, to November 1, 2024, but were not submitted until December 6, 2024. This delay was contrary to the facility's policy, which mandates timely submission of all Minimum Data Sets to CMS via the Internet Quality Improvement and Evaluation System. The issue arose due to an error in the submission process. The Assistant Director of Nursing, responsible for resident assessments, stated that a batch scheduled for submission on November 6, 2024, was accidentally missed. The Information Technology Support person confirmed that they had mistakenly submitted the same file twice, leading to one batch being overlooked. This error was not identified until the surveyor pointed it out during the survey. The Administrator acknowledged the mistake, noting it was the first occurrence of such an issue at the facility.

Plan Of Correction

Plan of Correction: Approved December 19, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 were identified as being affected by the alleged gap in practice. The facility did not ensure that residents MDS were submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 MDS assessments were submitted immediately to Centers for Medicaid and Medicare Services system and accepted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. The MDS Coordinators reviewed all resident comprehensive, discharge and significant change assessment for the last 3 months for timely completion and submission. All MDS were completed, submitted and accepted. Responsible Party: MDS Coordinators 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? 1. The Policy and Procedure titled MDS 3.0 Submission was reviewed to assure compliance with F640 by the Administrator in conjunction with the Assistant Director of RA, Chief Information Officer and Director of QA/PI and revised accordingly. The changes in policy include “It is the Policy of Kings Harbor Multicare Center to ensure that all MDSs are submitted to CMS via IQIES within 14 days of completion” and “RA Coordinator will ensure receipt of the IQIES validation report from MIS on a daily basis.” Responsible Party: Administrator, Assistant Director of RA, Chief Information Officer, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all MDS Coordinators and Information Technology support personnel on the policy titled “MDS 3.0 Submission” revised 12/2024. Responsible Party: Inservice Coordinator/Designee 3. An Audit tool will be created to ensure that all batch MDS assessments are submitted within the 14 day requirement. Responsible Party: Director of QA/PI 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. All MDS batches will be audited to ensure submission within 14 days of completion, weekly x 4 weeks and then bi-weekly x 5 months. Responsible Party: Assistant Director of RA 2. The results of the MDS submission audit will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 3. Results of the MDS submission audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During the Life Safety Recertification survey conducted from (MONTH) 4, 2024, through (MONTH) 10, 2024, the facility was found to be non-compliant with NFPA 70 standards regarding the use of extension cords and power strips. Specifically, surveyors observed unmounted power strips in use within the IT Room, Accounting Office, and other administrative areas. Additionally, in the Nursing Office located in 2West, a green extension cord was found under a desk, powering equipment. These observations indicate that the facility did not ensure that electrical systems were used in accordance with the National Electrical Code, as required by NFPA 101:9.1.2 and NFPA 70:400.8. At the time of the survey findings, the Director of Maintenance acknowledged the use of the extension cord, stating it was a temporary measure, and assured that all power strips would be mounted. However, the report does not provide any further details on corrective actions or the impact of these deficiencies on residents or staff. The deficiency highlights a failure to adhere to established electrical safety standards, which are critical for ensuring the safety and functionality of electrical systems within the facility.

Plan Of Correction

Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2012 NFPA 101 and 2011 NFPA 70, the Director of Engineering immediately instructed the Engineering staff to: 1. Mount the unmounted power strip in use in the IT room, Accounting office and other administrative areas. 2. Remove the extension cord in the 2 West Nursing office. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that extension cords in use are appropriate and power strips in use are mounted in accordance with the 2011 National Electric Code. All findings were deemed to be in compliance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering, Administrator and QA Director created a policy on use of extension cords and power strips. b. All staff will be informed and educated regarding this new policy, use of extension cords and power strips. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice: a. The Director of Engineering will develop an audit tool to monitor use of extension cords and power strips. b. Audits will be performed monthly by the Engineering staff x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse by a staff member, as observed during an abbreviated survey. The incident involved a Certified Nursing Assistant (CNA) who allegedly slapped a resident in the face after the resident, who was known to be combative and cognitively impaired, held onto the CNA's hand tightly. The facility's policy requires that any physical or verbal outburst from residents be reported immediately to a nurse or supervisor, which was not done in this case. The resident involved had a history of dementia, alcohol abuse, and delirium, and was assessed as cognitively impaired, requiring supervision or assistance with mobility and toileting. The care plan for the resident included interventions for managing aggressive behavior, but it was noted that instructions to notify a nurse and seek assistance if the resident became combative were omitted from the resident's care instructions. This omission contributed to the incident, as the CNA did not follow the appropriate protocol when the resident became aggressive. Interviews with staff revealed that the CNA involved in the incident did not report the resident's combative behavior to a nurse, as required by the facility's policy. Another CNA witnessed the incident and reported it later in the day. The facility's investigation concluded that abuse may have occurred, and the CNA was terminated. The incident was reported to law enforcement, but no arrest was made.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of insulin to the wrong resident. On the night of the incident, a Registered Nurse (RN) was asked by a Licensed Practical Nurse (LPN) to administer insulin to a specific resident. However, the RN, who was preoccupied and under pressure, did not verify the resident's identity by checking the wristband or the Electronic Medical Administration Record. Instead, the RN administered 24 units of Lantus insulin to a different resident who was not on insulin therapy. The resident who received the incorrect insulin dose had a diagnosis of Type 2 Diabetes Mellitus but was not prescribed insulin. Following the administration, the resident was alert and responsive, with vital signs within normal limits. The resident reported feeling unwell the following day, which could have been related to the insulin dose. The error was discovered when the resident informed the RN that they were not supposed to receive insulin, prompting the RN to notify the LPN, Nursing Supervisor, and Medical Doctor. The facility's policy on insulin administration requires nurses to review medication orders, identify residents, and follow the rights of medication administration. The RN involved in the incident did not adhere to these protocols, leading to the medication error. The RN's employment was subsequently terminated following the incident. The Medical Doctor confirmed that the resident did not sustain any harm from the insulin dose, and the resident was monitored with intravenous dextrose administered as a precaution.