Putnam Ridge

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 adequate supervision and assistance to prevent accidents for two residents, resulting in actual harm to one. One resident, with a history of cerebral infarction, pulmonary embolism, and severe cognitive impairment, required total assistance for activities of daily living and specifically needed two staff members for bed mobility and transfers. Despite this, a certified nurse aide provided care alone during incontinence care, which led to the resident falling from bed. The resident was later found with multiple injuries, including a contusion to the right face, right elbow, a forehead laceration, and was subsequently diagnosed at the hospital with an acute intertrochanteric right femur fracture. The investigation confirmed that the fall occurred when only one staff member assisted the resident, contrary to the care plan and documented requirements. Another resident, diagnosed with Alzheimer's disease, diabetes, and dementia, was identified as being at high risk for falls and had a care plan requiring one-hour safety checks and supervision. On the day of the incident, there was no documented evidence that hourly safety checks were performed during a specific shift, and the resident was found on the floor after an unwitnessed fall from their wheelchair. Observations also revealed that the resident was left unsupervised in the day room, sliding forward in their wheelchair with the chair alarm activated, while no staff were present to supervise due to other duties or absences. Interviews with staff confirmed lapses in following the care plans, including failure to perform and document required safety checks and lack of clarity regarding supervision responsibilities in the day room. Staff acknowledged awareness of the residents' high fall risk but did not consistently implement or document the required interventions. The Director of Nursing was unaware of the incomplete safety check log at the time of the incident, and staff involved in the incidents either failed to follow established protocols or did not ensure proper documentation and supervision.

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 develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for several residents, as required by policy. For one resident with a history of cerebral infarction and severe cognitive impairment, the care plan and aide Kardex specified the need for two-person assistance with bed mobility and transfers. However, a certified nurse aide provided care alone, resulting in the resident falling from bed and sustaining injuries, including bruising and a laceration. The incident was documented by the Director of Nursing, and it was confirmed that the required two-person assist was not provided. Another resident with dementia, a femur fracture, and repeated falls had a physician order for a velcro alarm seatbelt in the wheelchair, with instructions for scheduled release and monitoring of the resident's ability to self-release. There was no evidence in the care plan addressing the use or release schedule of the lap/seat belt, and staff were unaware of the order or procedures related to the restraint. Observations showed the resident wearing the seatbelt for extended periods and being unable to remove it on command, with staff confirming the lack of guidance in the care plan or Kardex. A third resident with Alzheimer's disease, contractures, and muscle weakness had physician orders for a knee abductor roll and rolled gauze hand protectors. The care plan did not address these devices, and observations revealed the resident without the prescribed supports. Staff interviews indicated that therapy recommendations were not incorporated into the care plan, and the nurse manager could not locate documentation for these interventions, attributing the omission to a transition between electronic medical records. Additionally, care plans for activities and safety checks were missing or not implemented for other residents reviewed.

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

A deficiency occurred when a resident's right to choose their health care provider was not honored. The resident, who had diagnoses including dementia, anxiety, and major depressive disorder, was dependent on staff for all activities of daily living and had severely impaired cognition. The resident's representative had formally requested that a specific Certified Nurse Aide (CNA) not be assigned to provide care for the resident. Despite this request, the CNA continued to provide care to the resident, as observed by the resident's son. Interviews with facility staff confirmed that the request was communicated to the appropriate personnel, including the Director of Nursing, Staffing Coordinator, floor nurses, and the CNA in question. However, the CNA was still assigned to and provided care for the resident after the request was made. Staff members interviewed were unable to explain why the CNA continued to provide care despite the documented preference and communication, indicating a failure in the facility's process to ensure resident choice regarding care providers.

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 all alleged violations of abuse, specifically injuries of unknown origin, were reported to the state survey agency within the required two-hour timeframe. On the morning of 08/26/2025, a resident with severe cognitive impairment and total dependence for activities of daily living was observed with a bruise to the right eye and right arm. The initial observation was made by an LPN, who notified another LPN and the Nurse Practitioner. The Nurse Practitioner assessed the resident, noted additional swelling and bruising, and determined the injuries were consistent with a fall. The Assistant Director of Nursing was informed and began an investigation into the cause of the injuries. Despite the facility's policy requiring immediate reporting of suspected abuse or injuries of unknown origin, the incident was not reported to the state agency until 11:05 PM, well beyond the two-hour requirement. Interviews with the DON, Administrator, and Assistant DON confirmed awareness of the policy and the event, but the report was delayed until after a CNA provided a statement late in the evening. The deficiency was cited for failure to report the incident in a timely manner as required by regulation.

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 activities were available and designed to meet the interests and support the well-being of all residents, specifically for two residents with cognitive impairments and behavioral needs. One resident with diagnoses including dementia, schizophrenia, and depression was observed multiple times wandering the hallways and not participating in activities, despite documented preferences for music and religious activities. There was no documented activity care plan for this resident in the current electronic medical record, and staff relied on verbal communication to share preferences. Observations showed the resident was often not engaged by staff and did not participate in ongoing activities, even when redirected. Another resident with Alzheimer's disease, anxiety, and depression missed an off-unit activity because the activities staff were unable to transfer the resident from an enclosed frame walker to a wheelchair, and nursing staff were not available to assist with the transfer. This resident's care plan indicated a need for transport assistance to attend off-unit events, but the lack of coordination between activities and nursing staff resulted in the resident remaining on the unit and not participating in the scheduled activity. Interviews with staff confirmed that the transition to a new electronic medical record system led to missing care plans and that activities staff could not perform necessary transfers without nursing assistance.

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 sufficient staff with the necessary competencies and skills to meet the behavioral health needs of a resident with a history of dementia, schizophrenia, and depression. The resident exhibited behaviors such as wandering, entering other residents' rooms, and urinating or defecating in inappropriate places. The individualized care plan required ongoing monitoring, redirection, and thirty-minute safety checks, but these interventions were not consistently implemented. Documentation revealed that thirty-minute checks were missing for entire shifts on most days within a one-month period, and staff interviews confirmed that these checks were not always completed or signed for as required. Multiple observations showed the resident wandering unsupervised in hallways and other residents' rooms, including entering a room under contact precautions and defecating in a public area. Staff were not consistently present to redirect or supervise the resident, and on several occasions, the resident was only redirected after being observed by staff who were exiting other rooms. Family members and other residents' visitors reported witnessing the resident engaging in inappropriate toileting behaviors and wandering without supervision, sometimes having to call for staff assistance themselves. Interviews with staff and management indicated that while there were expectations for regular monitoring and redirection, staffing levels and the availability of unit assistants were inconsistent. Staff acknowledged that the required thirty-minute checks were not always performed, and that unit assistants, who provided additional supervision and engagement, were not present every day. The lack of consistent supervision and incomplete documentation of required checks contributed to the facility's failure to maintain the resident's highest practicable physical, mental, and psychosocial well-being as outlined in the care plan.

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 comfortable and safe temperature levels were maintained in all resident rooms during a heat emergency when the air conditioning unit on one unit (Dogwood) was not functional. During the breakdown of the air-conditioning system, the facility did not check or document resident room temperatures, as the policy only required monitoring hallway temperatures. Although hallway temperatures were within regulatory limits, there was no evidence that resident rooms were checked for adequate or comfortable temperatures during the period the air-conditioning was out of service. The facility's policy required the Maintenance Department to monitor and document temperatures in all occupied areas, including resident rooms, and for the Administrator to review these logs during periods of high heat, but this was not done. A resident's spouse reported discomfort with the temperature on the affected unit, but a grievance report was not completed, and the issue was considered resolved after an air-conditioning unit was installed in the dining area. Nursing staff and the DON did not check resident room temperatures, and the Director of Maintenance confirmed that only hallway temperatures were monitored. The air-conditioning was restored to the affected unit the following day, but there was no documentation or evidence that resident rooms were checked for temperature compliance during the outage.

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 sufficient nursing staff to meet the needs of all residents, as evidenced by multiple occasions where staffing levels fell below the facility's own minimum guidelines across several shifts and units. Record reviews of staffing schedules for February, March, and April 2025 revealed repeated instances where the number of Certified Nurse Aides (CNAs) on duty was less than required for both day, evening, and night shifts. The facility's staffing plan outlined specific minimums, but these were not consistently met, resulting in periods where only two CNAs were present on units that required three, and similar shortfalls on other shifts. Interviews with CNAs and nursing staff confirmed that these staffing shortages led to delays in resident care, such as longer wait times for toileting, feeding, and showers. Staff reported being unable to complete all scheduled showers and having to postpone care tasks to later shifts or days. CNAs described increased workloads, with some responsible for up to 20 residents each, and noted that residents and their families frequently complained about the delays in care. Staff also reported that the lack of adequate staffing contributed to issues such as increased urinary tract infections and skin breakdowns due to delayed incontinence care. The staffing coordinator and DON acknowledged the ongoing challenges in maintaining adequate staffing, despite efforts to use agency staff and incentive programs. Staff interviews indicated that the use of agency staff did not always resolve the issue, and regular staff were often asked to work extra shifts, leading to physical exhaustion. The administrator, newly in position, stated they were working to improve staffing numbers. The deficiency was cited under 10NYCRR 415.13(a)(1)(i-iii) for failing to ensure sufficient nursing staff to meet resident needs.

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 maintain residents' dignity and provide timely assistance with eating during meal services on the Apple unit. Due to an outbreak of respiratory syncytial virus, the unit dining room was closed, and residents were served meals in the hallways. Observations revealed that residents waited extended periods for assistance with eating because of a shortage of tray tables and insufficient staff. For example, one resident who was dependent for eating waited approximately 25 minutes before being assisted, while another resident with severe cognitive impairment and requiring supervision or assistance was left with an uneaten tray for over an hour before receiving minimal help. Another resident requiring setup assistance had their tray delivered but not set up for nearly an hour. Staff interviews confirmed that the dining room closure led to meals being served in hallways for supervision purposes, not infection control. The unit was short-staffed, with only two CNAs present instead of the minimum three, resulting in residents waiting a long time for assistance. Staff, including activities and rehabilitation personnel, were required to help during meals due to the high number of residents needing eating assistance. The unit manager acknowledged that the administration and DON were aware of the staffing challenges and the heavy assistance needs on the unit. Additionally, staff members referred to residents requiring eating assistance as "feeders" in the presence of other residents and a family member. Both the activities leader and a CNA admitted they were unaware that using the term "feeder" was inappropriate. These actions and language choices failed to uphold the residents' right to dignity and respect as outlined in the facility's Resident Rights policy.

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 residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good nutrition and personal hygiene. For one resident with diagnoses including non-Alzheimer's dementia, arthritis, and depression, documentation showed they required substantial to maximal assistance for toileting and transfers. On a specific date, there was no documented evidence that this resident was toileted during the day or evening shifts, with only night shift documentation present. Interviews with staff revealed that residents sometimes waited up to 45 minutes for toileting assistance, especially when staffing levels were low, and that the resident's family had complained about long wait times for care. Staff also indicated that the resident required a two-person assist for transfers and that delays occurred when a second staff member was not immediately available. Another resident, who was dependent on staff for all ADLs due to conditions such as seizures, diabetes, dysphagia, and a deep tissue injury, experienced a significant delay in receiving assistance with eating. Observations showed that the resident's lunch tray was delivered and left at the bedside, but the resident was not fed for over an hour. Documentation of meal intake was also incomplete for this resident, with many days left blank. Staff interviews confirmed that feeding could be delayed when there were only two aides on the unit, as showers and other care tasks took priority, and that documentation sometimes lapsed due to insufficient staffing.

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

A resident with a history of seizure disorder, Lennox-Gastaut syndrome, and intellectual disabilities was admitted to the facility with a hospital discharge summary that included an order for Diazepam nasal spray as an immediate-use medication for active seizures. Upon admission, the medication reconciliation process conducted by a registered nurse and a nurse practitioner failed to transcribe the Diazepam nasal spray order into the resident's electronic medical record. As a result, the medication was not available in the facility. Subsequently, the resident experienced a prolonged seizure episode during which staff were unable to administer any oral medications due to the resident's condition. Emergency services were called, and the resident was transferred to the hospital for treatment. Interviews with the admitting nurse and nurse practitioner revealed uncertainty and lack of recall regarding the omission of the Diazepam nasal spray order during the admission process. The facility's policy required two nurses to review all medication entries, but this process did not ensure the inclusion of the necessary seizure medication.

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

Two residents experienced significant medication errors due to failures in medication administration and order management. One resident with Alzheimer's disease, dementia, and depression, who was severely cognitively impaired and dependent on staff, received a double dose of Baclofen for three consecutive days. This occurred after duplicate physician orders for Baclofen 2.5 mg once daily were entered on consecutive days, resulting in the medication being administered twice daily instead of once. The error was not identified or questioned by the LPN administering the medication, who assumed the dosage had been increased and did not seek clarification, leading to the resident receiving 5 mg daily instead of the prescribed 2.5 mg. Another resident with Alzheimer's disease, ataxia, and hypertension, who also had severe cognitive impairment and required supervision for meals, was administered Nifedipine ER 30 mg in a crushed form, despite a clear warning on the medication packaging not to crush the extended-release tablet. The nurse did not have a physician order to crush the medication and was unaware of the warning. Additionally, the same nurse failed to administer a prescribed dose of guaifenesin cough syrup but documented in the Medication Administration Record that it had been given. Interviews with nursing staff and management confirmed that proper procedures were not followed in both cases. Duplicate orders were not clarified or discontinued, and medications were administered and documented incorrectly. The facility's policy required physician orders for crushing medications and proper administration techniques, which were not adhered to in these instances.

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

A deficiency was identified when a resident with Alzheimer's disease, dementia, and abnormal weight loss, who was dependent on staff for all activities of daily living including eating, was fed by a Unit Assistant who had not completed a State-approved feeding assistant training course. The resident required a mechanically altered diet with aspiration precautions, and the care plan specified that staff should feed and assist the resident to complete meals. During observation, the Unit Assistant was seen feeding the resident puree food, and both the Unit Assistant and facility leadership confirmed that the assistant had only received in-house training and was unaware of the requirement for State-approved training. Interviews with the Director of Human Resources and the Director of Nursing revealed that Unit Assistants routinely feed residents after receiving facility-based training, but none had completed the required State-approved eight-hour course. Documentation supporting completion of State-approved training for feeding assistants was not available, and facility leadership was not aware of the regulatory requirement for such training. This resulted in the resident being fed by unqualified staff, contrary to regulatory 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

Surveyors observed multiple failures in infection prevention and control practices within the facility. Staff members, including an activities leader, dietary aide, certified nurse aide, and nurse practitioner, entered and exited a room under contact and droplet isolation precautions for a resident with respiratory syncytial virus (RSV) without donning or doffing personal protective equipment (PPE) or performing hand hygiene. These staff members also failed to change masks, wear required face shields or goggles, and did not close the door as required. Some staff stated they did not notice the precaution signs or were unaware of the PPE requirements, despite the presence of posted signage and facility policy outlining these protocols. Additional deficiencies were observed during meal service, where staff, including an activities leader and an LPN, were seen placing their thumbs inside milk cartons while assisting residents, without wearing gloves or performing hand hygiene. The staff involved acknowledged that this was not appropriate practice, though one LPN claimed to have performed hand hygiene prior to the observation. These actions occurred during direct resident care and food handling, increasing the risk of contamination. A resident who tested positive for RSV was observed walking unmasked in the hallway and sitting in close proximity to other residents during meal times, with no staff intervention to encourage mask use or redirect the resident. The unit manager confirmed the resident's positive status and stated that attempts to have the resident wear a mask were unsuccessful. The facility's infection preventionist confirmed that all staff should use PPE when entering rooms under contact and droplet precautions, including when interacting with non-infected roommates.

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 residents received treatment and care in accordance with professional standards of practice, as evidenced by the absence of identification bands on 12 out of 39 residents observed on the Apple unit. The facility's Medication Administration policy requires nurses to verify a resident's identification by checking their identification band before administering medication. However, during an observation, it was noted that these residents did not have identification bands in place, which is a critical step in ensuring the correct administration of medications. Interviews with staff revealed that Licensed Practical Nurse #1 had to rely on other staff members or the electronic medical record system to identify residents during medication administration due to the lack of identification bands. Registered Nurse #1 acknowledged the issue and stated that they conduct audits to replace missing bands, but residents on the Apple unit, which is a dementia unit, frequently remove their bands. The Director of Nursing confirmed the ongoing issue and emphasized the need for regular checks to ensure identification bands are in place, particularly on the dementia unit where residents are prone to removing them.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 Plan for Affected Resident: All 12 Residents affected were given new wrist bands. Plan to identify other potentially affected residents: All residents’ wrist bands were checked on each unit. All residents had wristbands in place. Plan for system changes and measures to prevent occurrence: The facility medication administration policy was reviewed. The policy was updated. All nursing staff were educated with emphasis on verification of residents by checking the residents’ name and medical record number on their wrist bands. If a resident does not have a wristband, they can verify via EMAR picture and continue their medication administration. The LPN is to create a wristband for any resident without a wristband by the end of the shift. All LPNs including nurse 1, were re-educated on the facility medication administration policy with emphasis on resident identification bands. Plan for monitoring correction action: Weekly audits will occur for one month on 15 residents per unit by the ADON/Unit Managers/Designee to ensure that all residents are wearing an identification band. After one month the wristbands will be audited biweekly for an additional two months. After two additional months wristband audits will be conducted monthly. All results will be reported at the quarterly quality measure meeting.

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 sufficient nursing staffing to meet the needs of residents on Unit A, as determined by their own nursing coverage plan. The facility's policy outlined a staffing plan to provide necessary services, but the actual staffing levels fell short of these guidelines. The staffing schedules for May, June, and July 2024 revealed that the number of Certified Nursing Assistants (CNAs) on various shifts was consistently below the required levels. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the facility often operated with fewer CNAs than needed, leading to inadequate care for residents who required total care. Interviews with CNAs highlighted the challenges faced due to insufficient staffing. CNAs reported that they were often required to care for more residents than the staffing plan allowed, with some shifts having only two CNAs for a unit of 41 residents. This situation was exacerbated on weekends when staffing levels were particularly low. CNAs expressed frustration that despite raising concerns with administration, no effective measures were taken to address the staffing shortages. The facility's reluctance to use agency staff further compounded the issue, as agency staff were sometimes turned away despite the need for additional help. The Director of Nursing acknowledged the staffing issues and stated that efforts were being made to hire more staff and reduce reliance on agency workers. However, the staffing coordinator indicated that the facility was expected to use ideal staffing levels rather than minimal ones, which were not being met. Despite claims of improvement, the facility's staffing levels remained inadequate, impacting the quality of care provided to residents on Unit A.

Plan Of Correction

Plan of Correction: Approved January 14, 2025 The Staffing Coordinator/designees will schedule sufficient staffing on all units and all shifts. The facility assessment was reviewed and updated to show current staffing resources. Plan for Monitoring Corrective Action: The facility has implemented a bi-weekly staffing meeting to go over new hires, retention, recruitment, incentives, and all other related staffing issues. The final staffing schedule will be reviewed on a weekly basis by the staffing coordinator/DON, and findings presented to the bi-weekly staffing meeting. The facility will seek additional contracts from staffing agencies as a staffing contingency plan. We will increase the frequency of our orientation to facilitate a quicker onboarding process, thereby increasing our staffing resources. Our facility assessment will be reviewed and updated annually or as needed to show current staffing resources. All findings from the bi-weekly staffing meeting will be monitored by the QAPI monthly x 6 by the staffing coordinator/designee.

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 medications were administered in accordance with the prescriber's order or professional standards for three residents. Resident #1, who has a seizure disorder, was administered Depakote Sprinkles outside the regulated time frame on multiple occasions in October and November 2024. There was no documented evidence that the physician was informed of these late administrations. Licensed Practical Nurses involved admitted to errors in documentation and timing but did not notify the physician as required. Resident #2, diagnosed with Parkinson's disease, received Carbidopa-Levodopa outside the regulated time frame on several occasions in August and September 2024. The medication administration record showed discrepancies in the timing of doses, and the involved LPNs did not notify the physician of the late administrations. Some LPNs claimed to have administered the medication on time but signed the records late due to system glitches or being short-staffed. Resident #3, who suffers from insomnia, refused Trazodone and Melatonin on multiple occasions in January 2024, and there was no evidence that the physician was informed of these refusals. Additionally, there was a lack of documentation for the administration of these medications on one occasion. The Director of Nursing acknowledged the need for proper documentation and physician notification when medications are administered late or refused.

Plan Of Correction

Plan of Correction: Approved January 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F760- Plan for affected Residents: Residents #1 & #2 will have their medication given within the regulated time frame. Resident #3 MD/NP will be made aware when the resident refuses medication. Resident #1 [MEDICATION NAME] and [MEDICATION NAME] levels were drawn, and the levels were in normal limits with no adverse effects. Plan to identify other potentially affected residents: Each Nurse Manager will do a weekly audit on 10 residents on their unit to ensure the medication is being administered timely. In addition, the Nurse Manager will conduct weekly chart audits on medication administration documentation to ensure that MD was made aware if a resident refused medication. Plan for system changes and measures to prevent occurrences: The policy was reviewed. Nurse Educator/ADON will re-educate LPN/RN’s on medication administration policy highlighting medication administration time. MD/NP to be notified when a resident refuses medication and this should be documented in the progress note as well as the medication administration record. Weekly medication administration competency will be done on 10% of the licensed nurses by Nurse educator/designee. Plan for Monitoring Corrective action: Nurse managers will conduct weekly audits on 10% of the residents on their unit to ensure that medications are given at the time prescriber ordered or in accordance with professional standards. Additionally, weekly chart audits will be done by each nurse manager on 10% of residents on their unit to ensure that for those residents that refused medication the NP/MD was notified, and it’s documented in the medical record. The facility plans to monitor its performance to ensure solutions are sustained by nurse educator/designee conducting weekly medication administration competency on 10% of the licensed nurses. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2).

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 a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. Resident #2, with a history of falls and requiring moderate assistance for transfers, experienced multiple falls from their wheelchair over a two-month period. Despite these incidents, there was no documented evidence of new interventions being implemented to prevent further falls, and the resident's care plan was not updated accordingly. Resident #3, who was cognitively intact but had poor safety awareness, also experienced several unwitnessed falls, some resulting in minor injuries. The resident's care plan included interventions such as anti-skid socks and a well-lit environment, but there was no documentation of new interventions following each fall. The Director of Nursing acknowledged the resident's poor safety awareness and confusion but did not provide evidence of additional measures taken to prevent further falls. Interviews with the Director of Nursing and the Administrator revealed that while the facility held regular meetings to discuss fall risks and safety interventions, there was a lack of documented follow-up actions or new interventions for the residents involved. The facility's failure to update care plans and implement effective fall prevention strategies contributed to the ongoing risk of accidents for these residents.

Plan Of Correction

Plan of Correction: Approved January 29, 2025 Plan for affected Resident: Resident #2 continues wheelchair pad alarm and remains in supervised area for safety. All fall interventions will be documented on updated care plan at the time of fall and reviewed at the risk meeting weekly. Resident has not had any recent falls. Resident #3 is no longer at the facility. Plan to identify other potentially affected residents: All admissions and readmission fall risk assessments will be reviewed upon admission and each quarter to ensure the appropriate interventions are in place to aid in the prevention of falls based upon the resident risk category. Resident charts were audited from (MONTH) 1st 2024 to current for residents that are at risk for falls to ensure that appropriate interventions are in place. Plan for system changes and measures to prevent recurrence: The fall policy was reviewed and updated. The facility will take the following measures to ensure the problem does not reoccur: Nurse educator/designee will re-educate all licensed nursing staff on Fall Risk assessment and Fall Prevention. All CNA’s will be in-serviced on fall prevention by Staff Educator/designee. All new admissions/readmissions and any incident or accident that took place the day before will be reviewed at the morning IDT meeting to ensure that interventions are in place and properly documented. All new admission & re-admission resident charts will be audited weekly by ADON/Designee. Additionally, those residents who are at risk of falls will be in a supervised area for safety. Daily Environmental rounds will be conducted by nurse managers/supervisor and nurse educator to ensure the unit is free from accident hazards as is possible. Nursing staff will rotate supervised areas to ensure adequate supervision is being provided for residents that are at risk, as documented on the CNA assignment. Plan for monitoring corrective action: The facility plans to monitor its performance to make sure that solutions are substantiated by doing weekly audits that will be conducted by the nurse managers/designee to ensure all residents discussed at the at-risk meeting/admission and readmission have fall interventions with date in place. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2) thereafter.

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 with urinary and bowel incontinence received appropriate treatment and services to prevent urinary tract infections. This deficiency was identified during an abbreviated survey, where it was found that a resident, who was always incontinent and dependent on direct care staff, was diagnosed with urinary tract infections on two separate occasions. The facility's incontinence policy requires residents to be kept dry, clean, and comfortable, with checks and changes every two to four hours. However, documentation revealed numerous instances where direct care staff did not record providing necessary incontinence care over several months. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living. Despite having a care plan that included specific interventions to prevent urinary tract infections, such as applying barrier ointment and monitoring for symptoms, the facility's records showed significant lapses in documented care. Interviews with staff indicated a lack of awareness of these documentation omissions, and the Director of Nursing acknowledged that missing documentation could either be an omission or indicate that care was not provided. The deficiency was noted under 10 NYCRR 415.12(d)(1).

Plan Of Correction

Plan of Correction: Approved January 14, 2025 Plan for affected Resident: Resident #1 is being changed every 2-3 hours. Resident is on a UTI prevention protocol. Resident currently has no UTI. Incontinent care documentation is being done following incontinent care for bowel and bladder. Resident currently does not have a foley catheter. Plan to identify other potentially affected residents: Nurse Managers to do daily audits of CNA documentation for incontinent care bowel and bladder of each resident on their unit. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the charting has been done or is in progress for all incontinent residents. Plan for system changes and measures to prevent occurrences: The facility will take the following measure to ensure that the problem does not reoccur: The incontinent policy was reviewed and updated. Nursing Educator to re-educate CNA's and LPN's on peri care, Urinary tract infections and the incontinent policy. All incontinent residents are to be placed on a toileting schedule or changing schedule every 2-4 hours and PRN. Nurse Manager/Supervisor/designee to check that incontinent care is rendered to all incontinent residents on each unit per protocol every 2-4 hours. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the documentation has been done or is in progress after care is rendered for all incontinent residents. Residents readmitted with new foley catheter will be assessed by the RN for appropriateness of the foley and follow up with NP/MD for clinical necessity or foley will be removed if not indicated. Plan for Monitoring Corrective action: Nurse Manager/designee to do weekly audits on 10% of the residents per unit and patient resident observation to ensure that incontinent care is being provided timely and documentation is being done when incontinent care is provided. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2).

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 a comprehensive facility-wide assessment was conducted and documented to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, last completed in August 2024 and reviewed in September 2023, lacked a detailed staffing plan that specified the number of staff required per unit or shift. During a survey conducted in November 2024, it was found that the assessment did not include individual staff assignments or systems for coordination and continuity of care. The Administrator, who had been working at the facility since mid-August 2024, acknowledged the omission and stated that completing the facility assessment was a new task for them.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 The facility assessment was updated to include an updated staffing plan, the requirements of number of staff allotted for each unit or per shift. Plan for system changes and measures to prevent recurrence: The facility assessment’s staffing plan will be reviewed on a quarterly basis to review what changes need to be made to the staffing plan. Any updates/changes and initiatives will be reviewed. Additional input will be requested from the team to see what other suggestions and ideas they might have. Plan for monitoring corrective action: Facility assessment will be reviewed on a quarterly basis and any changes/updates will be discussed at the QA meeting.

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 did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food safety. During an initial tour of the kitchen, surveyors observed multiple food items in the walk-in refrigerator and the cook's refrigerator that were unlabeled and undated. Specifically, a rack of bread with ten loaves had no receive date, a package of approximately ten slices of cheese was not labeled or dated, a small pan of applesauce was not labeled, and a small pan of yogurt was dated but not labeled. Additionally, the cook's refrigerator contained 16.9 ounces of red wine vinegar, approximately fifty slices of cheese, a 120-milliliter bottle of hot sauce, yellow liquid in small cups, cakes in a baking pan, and cookies in a baking pan, all of which were unlabeled and undated. Furthermore, a rack designated for dry pans contained wet pans. During interviews, the Assistant Food Service Director (AFSD) and the Food Service Director (FSD) confirmed that all food items were supposed to be labeled and dated according to the facility's policy. The AFSD stated that without proper labeling and dating, staff would not know when the food items expired or what the food items were, potentially leading to residents getting sick from expired food. The FSD reiterated that any food item older than three days should have been discarded and that the rack designated for dry pans should only contain dry pans.

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 did not ensure that individuals working as nurse aides for more than 4 months were competent and certified to provide nursing and nursing-related services. Specifically, seven Training Nurse Aides (TNAs) were employed and functioned in the role of nurse aides for more than 4 months without receiving nurse aide certification. This was in violation of the Centers for Medicare and Medicaid Services (CMS) memorandum, which required facilities to ensure that anyone functioning as a nurse aide completed a state-approved nurse aide training program and passed an oral/written examination within 4 months of hire. The TNAs in question were hired on various dates and continued to work without certification beyond the allowed period. During interviews, the Director of Human Resources and the Director of Nursing (DON) acknowledged the issue. The Director of Human Resources stated that they believed the TNAs were permitted to work until a certain date and had been giving verbal reminders to the TNAs to complete their certification. The DON stated that they expected nurse aides to be competent and certified before performing care on residents and admitted to being aware of the non-certified nurse aides working due to staffing problems at the facility.

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 did not ensure that each certified nurse aide (CNA) received the required twelve hours of in-service education per year based on their individual performance review. Specifically, CNA #8 lacked 6 hours of training, CNA #9 lacked 10 hours of training, CNA #10 lacked 8.5 hours of training, and CNA #11 lacked 7 hours of training. Additionally, all four CNAs did not receive an annual performance evaluation. The last performance evaluations for CNA #8, #9, #10, and #11 were completed on 12/12/20, 9/7/22, 2/12/20, and 7/2/21, respectively. The Infection Control Nurse/Educator (IP) confirmed that no additional documented in-services were provided for these CNAs, attributing the lack of training to the pandemic, which prevented in-person meetings at that time. Interviews with the CNAs and the Director of Nursing (DON) revealed that the facility was behind on conducting evaluations and providing in-service education. CNA #8 mentioned that their last evaluation was about 2-3 years ago, despite the requirement for annual evaluations. The DON acknowledged inheriting incomplete evaluations and stated that Nurse Managers were responsible for conducting them but were behind schedule. The DON also mentioned that efforts were being made to catch up on the in-service education and evaluations.

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 did not ensure drugs and biologicals were stored in accordance with currently accepted professional principles for two of four medication carts on the Cedar and Apple units. Specifically, during a medication storage observation, multiple undated and expired medications were found on the Cedar Unit medication cart, including tobramycin eye drops, olopatadine eye drops, bacitracin ophthalmic ointment, Latanoprost eye drops, a daily probiotic supplement, Geri-Lanta, Chlorohexidine Gluconate oral rinse solution, ferrous gluconate, and carbamazepine. Additionally, the cart contained excessive debris, including medication wrappers, mouth swabs, used medication packaging, multiple unpackaged and unlabeled pills, and sticky residue. RN #2 confirmed that nurses should be cleaning the medication carts weekly and that the facility's pharmacy consultant should have identified the expired and undated medications during their monthly visits. On the Apple Unit medication cart, an unidentifiable pill in an unlabeled pill-crusher sleeve, expired NUTRI-Stat bottles, opened and undated bottles of Chlorahexidine Gluconate oral rinse solution, polyvinyl alcohol lubricating eye drops, and artificial tears were found. The cart also had multiple unidentifiable sticky residues and debris. LPN #3 stated that nurses were responsible for cleaning the medication carts and removing expired and undated medications. The Director of Nursing (DON) confirmed that staff should be dating bottles when opened and cleaning the medication carts routinely, and that medications should be discarded 30 days after opening.

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 did not ensure that a resident's representative was informed about an orthopedic appointment, resulting in the resident missing the appointment due to the lack of an escort. Resident #299, who had diagnoses including a fracture of the thoracic spine, diabetes, and congestive heart failure, was scheduled for an orthopedic consult. The Out of House Appointment and Transportation Worksheet indicated that the resident was not seen because a nurse aide was required but not provided, and the family was not notified to accompany the resident. The form's checkboxes for family notification and the need for a CNA escort were left blank. Interviews revealed that the Unit Secretary was unaware that a nurse aide was needed for the appointment and did not complete the worksheet fully. The Director of Nursing stated that the Unit Secretary was responsible for obtaining and documenting all necessary information for outside appointments, including whether an escort was needed. The DON was not aware that the resident missed the appointment due to the lack of staff in attendance. The incomplete documentation and lack of communication led to the resident missing the scheduled orthopedic consult.

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 did not implement a person-centered care plan with measurable objectives, time frames, and appropriate interventions for a resident who was non-compliant with wearing a TLSO back brace. The resident, who had a history of a T9-T10 vertebra fracture, diabetes, and congestive heart failure, was admitted with a physician's order to wear the TLSO brace when out of bed. However, the care plan created for the resident's non-compliance with the brace lacked documented goals, interventions, and updates, despite the resident's refusal to wear the brace and the spouse's concerns. Interviews with the facility's staff revealed that the care plan was initiated by the MDS coordinator due to the unit being busy with admissions. The registered nurses involved were aware of the resident's non-compliance but did not ensure that appropriate interventions were documented. The Unit Manager, who was new to the position, was supposed to add the interventions but failed to do so. This lack of proper documentation and follow-through led to the deficiency noted in the survey.

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 did not ensure that care was provided in a manner to maintain the dignity of a resident with a urinary (Foley) catheter. Specifically, the catheter bag for a resident was not concealed, allowing it to be visible to other residents, staff, and visitors from the public hallway. This was observed on multiple occasions, and the facility's policy on urinary catheter care, which mandates privacy, was not followed. The resident in question had diagnoses including cerebral infarction, chronic kidney disease, and atrial fibrillation, and required extensive assistance for personal hygiene and toilet use. During interviews, a CNA expressed uncertainty about why the catheter bag was uncovered, and an RN indicated they would request dignity bags from the supply room. The Director of Nursing acknowledged that staff had been previously instructed on this issue, but it remained a recurring problem. The deficiency was noted during a recertification survey, highlighting a failure to maintain the resident's dignity as per the facility's policy and regulatory 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 facility did not ensure that the call bell system was accessible for seven residents reviewed for the environment. Observations revealed that the call bells for these residents were not within their reach, despite care plans specifying that call bells should be accessible. For instance, Resident #115, who has severe cognitive impairment and requires supervision with bed mobility and transfers, was observed with the call bell hanging on the wall out of reach. Similarly, Resident #60, who has severe dementia, was also found with the call bell not within reach while in bed. Other residents, including those with diagnoses such as vascular dementia, epilepsy, and Alzheimer's disease, were similarly observed with call bells placed on the wall and not within their reach. Interviews with staff, including CNAs and an LPN, confirmed that call bells should be within reach of all residents and that this requirement is documented in the CNA care guide. The Director of Nursing also stated that all staff should follow the care plans, which include ensuring call bells are accessible. Despite these guidelines, multiple residents were found without accessible call bells, indicating a failure to adhere to the care plans and ensure resident safety and communication needs.

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 did not ensure adequate supervision to prevent accidents for a resident assessed at high risk for falls. The resident, who had diagnoses including lack of coordination, a non-displaced fracture of the seventh cervical vertebra, and dementia without behavioral disturbance, was observed multiple times attempting to stand up from their wheelchair without staff assistance or redirection. Despite being in a supervised area as per their fall care plan, the resident was seen trying to stand up from their wheelchair in the TV room and dining room without staff intervention. On one occasion, the resident was seated at the edge of their wheelchair seat, and two staff members present did not redirect the resident. On another occasion, the resident was observed sleeping in their wheelchair with their feet positioned between the foot pedals and their body slid down in the wheelchair. Interviews with staff revealed that the Unit Assistant, who was present during one of the incidents, did not assist the resident because they did not understand English well and were not responsible for resident care. The training nurse aide stated that they would assist the resident if they saw them trying to get up from their wheelchair and that the Unit Assistant could not assist with cares. The resident was later provided with a seatbelt as a fall prevention measure. The facility's failure to provide adequate supervision and timely intervention for a high-risk resident led to the deficiency noted in the report.

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 did not ensure all injuries of unknown origin were thoroughly investigated and reported to the New York State Department of Health (NYSDOH) for one resident reviewed for abuse. Specifically, Resident #449, who had a history of stroke, non-traumatic brain dysfunction, Parkinson's, and dementia, reported an unwitnessed fall and a broken arm that was not thoroughly investigated to rule out abuse. The resident was found with a skin tear below the left knee and a bruise/hematoma to the right arm, and upper arm and elbow pain. Despite the resident's report of falling out of bed during the night, the investigation did not determine if there was reasonable cause to believe that abuse, mistreatment, or neglect had occurred. The facility's Accident/Incident (A/I) Report and subsequent investigation were incomplete. The Director of Nursing (DON) acknowledged that the injuries were not further investigated based on the resident's and staff's statements. The investigation did not include an assessment of environmental factors that could have contributed to the fall or interviews with other staff or residents. Additionally, the determination on the A/I report regarding whether the incident could be considered abuse or neglect was not checked off, which the DON stated was an oversight. As a result, the incident was not reported to the NYSDOH.

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 Resident #64, who was unable to carry out activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene. Resident #64, who had diagnoses including vascular dementia, hypothyroidism, muscle weakness, and orthostatic hypotension, was observed on multiple occasions with urine-soaked pants. Specifically, on 10/18/23, the resident was seen at 9:28 AM, 10:42 AM, and 10:55 AM in the hallway sitting in a Merri walker with urine-soaked pants. Interviews with staff revealed that the resident had not been changed since the start of the 7 AM shift and was scheduled to be provided care only after lunch. Additionally, the resident was supposed to be toileted every two hours and as needed, but this was not adhered to by the staff on duty. Further observations on 10/25/23 showed that Resident #64 was still in bed at 10:08 AM, contrary to the care plan that required the resident to be out of bed by the 11 PM-7 AM shift. Interviews with various CNAs and LPNs indicated a lack of awareness and adherence to the resident's care plan, with staff members unable to explain why the resident was not out of bed as required. The Director of Nursing confirmed that the night shift was aware of the care plan but failed to follow it. This lack of compliance with the care plan resulted in the resident not receiving timely toileting and personal hygiene care, as mandated by the facility's protocols.

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 did not ensure that residents received treatment and care in accordance with professional standards of practice for three residents. Resident #23, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and major depressive disorder, received an incorrect dose of Clonazepam. The prescribed dose was 0.25 mg, but the resident was administered 0.50 mg, which was the previous dosage before it was reduced due to lethargy. This error was acknowledged by the involved LPN and the Director of Nursing (DON), and a medication discipline warning notice was issued to the responsible nurse. Resident #299, admitted for short-term rehabilitation with diagnoses including vertebral fracture and congestive heart failure, was sent to an orthopedic consult appointment without an aide. The consultant physician refused to see the resident without an aide, and the Unit Secretary admitted to not completing the Out of House Appointment and Transportation Worksheet fully, which included failing to document the need for a CNA escort. The DON confirmed that the Unit Secretary was responsible for ensuring all necessary information and arrangements were made for outside appointments. Resident #105, with diagnoses including vascular dementia and generalized anxiety disorder, was administered crushed medications without a physician's order. The LPN responsible for administering the medications stated that the resident was given crushed medications due to a cough, but there were no orders to crush the medications. Both the LPN and the LPN unit manager acknowledged that a physician's order was required to crush medications, and the medical doctor confirmed that it was unacceptable to crush medications without such an order.

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 did not ensure a medication error rate of no more than 5% during a medication administration observation, resulting in a 12% error rate. Specifically, Resident #132 was administered Metoprolol Extended Release Tablet crushed instead of whole, contrary to the physician's order and FDA guidelines. The LPN responsible for this error stated that they crush all pills for residents with dementia, regardless of their ability to swallow or the physician's order. This action was not in compliance with the facility's medication administration policy, which requires nurses to double-check and ensure all medications are administered as per the physician's order. Additionally, Resident #136 was administered medication through a feeding tube without flushing between two medications, as observed during a medication administration. The LPN involved could not provide a reason for not flushing the feeding tube between medications. The Director of Nursing confirmed that medications should be given according to professional standards and physician orders, which include not crushing extended-release medications and flushing feeding tubes between different medications.