Professional Documents
Culture Documents
F 580 483.10(g)(14)(i)-(iv)(15) Notify of Changes F 580 I. The following actions were accomplished 06/11/2019
SS=J (Injury/Decline/Room, etc.) for the residents identified in the sample:
Resident #402
§483.10(g)(14) Notification of Changes. • Resident is no longer at the facility
(i) A facility must immediately inform the • A medical record review has been
resident; consult with the resident's physician; completed to ensure all improvement
and notify, consistent with his or her authority, opportunities related to the change of
the resident representative(s) when there is- condition that was identified without
(A) An accident involving the resident which physician notification have been identified
results in injury and has the potential for and addressed in this plan of correction.
requiring physician intervention; • LPN #5 is no longer employed by the
(B) A significant change in the resident's facility
physical, mental, or psychosocial status (that is, • LPN #4 is no longer employed by the
a deterioration in health, mental, or psychosocial facility
status in either life-threatening conditions or • LPN #4 investigation into incident with
clinical complications); resident #402 has been completed
(C) A need to alter treatment significantly (that II. The following corrective actions will be
is, a need to discontinue an existing form of implemented to identify other residents
treatment due to adverse consequences, or to who may be affected by the same practice:
commence a new form of treatment); or All residents have the potential to be
(D) A decision to transfer or discharge the affected by this practice:
resident from the facility as specified in • Progress notes for all residents over the
§483.15(c)(1)(ii). past thirty (30) days have been reviewed to
(ii) When making notification under paragraph ensure any resident with an identified
(g)(14)(i) of this section, the facility must ensure change in condition, that the Physician/PA
that all pertinent information specified in has been notified.
§483.15(c)(2) is available and provided upon • Progress notes for all residents over the
request to the physician. past thirty (30) days have been reviewed to
(iii) The facility must also promptly notify the ensure Licensed Practical Nurses are
resident and the resident representative, if any, practicing within their scope of practice,
when there is- specifically as it relates to assessing
(A) A change in room or roommate assignment residents
as specified in §483.10(e)(6); or III. The following system changes will be
(B) A change in resident rights under Federal or implemented to assure continuing
State law or regulations as specified in compliance with regulations:
paragraph (e)(10) of this section. As per the Directed Plan of Correction, the
(iv) The facility must record and periodically Consultant has developed and
update the address (mailing and email) and implemented an In-service Program to
phone number of the resident address:
representative(s). • The Abuse Reporting and Prevention
policy has been newly adopted
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 05/10/2019
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 1 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 2 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 3 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 4 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 5 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 6 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 7 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 8 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
10NYCRR 415.3(e)(2)(ii)(d)
F 684 483.25 Quality of Care F 684 I. The following actions were accomplished 06/11/2019
SS=J for the residents identified in the sample:
§ 483.25 Quality of care Resident #401
Quality of care is a fundamental principle that • Resident is no longer at the facility
applies to all treatment and care provided to • A medical record review has been
facility residents. Based on the comprehensive completed to ensure all improvement
assessment of a resident, the facility must opportunities related to the change in
ensure that residents receive treatment and care condition that was identified without
in accordance with professional standards of physician notification or timely treatment or
practice, the comprehensive person-centered intervention have been identified and
care plan, and the residents' choices. addressed in this plan of correction.
Resident #402
This REQUIREMENT is not met as evidenced • Resident is no longer at the facility
by: • A medical record review has been
completed to ensure all improvement
Based on record review and interview during the opportunities related to the change of
abbreviated survey (NY00231469), the facility condition that was identified without
did not ensure residents received treatment and physician notification, not addressed timely
care in accordance with professional standards have been identified and addressed in this
of quality for 2 of 6 residents (Residents #401 plan of correction.
and 402) reviewed for quality of care. • LPN #5 is no longer employed by the
Specifically, Resident #402 had a change in facility.
condition that was not addressed timely. • LPN #4 investigation into incident with
Resident #401 had an emergent decline in resident #402 has been completed
condition and there was no documented • LPN #4 is no longer employed by the
evidence of appropriate and timely facility
treatment/interventions. Both residents required
Emergency Medical Service response and II. The following corrective actions will be
expired in the hospital. This resulted in implemented to identify other residents
Immediate Jeopardy and Substandard Quality of who may be affected by the same practice:
Care for Resident #402 and actual harm to All residents have the potential to be
Resident #401 that was not Immediate affected by this practice:
Jeopardy. • Progress notes for all residents over the
Findings include: past thirty (30) days have been reviewed to
ensure any resident with an identified
The facility policy Notification of Changes for change in condition, that the Physician/PA
Residents updated 12/1/17 documented the has been notified.
facility shall promptly notify the resident and/or • All Licensed Practical Nurses have had
the resident representative and his or her their employee file reviewed to determine if
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 9 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 10 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 11 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 12 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 13 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 14 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 15 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 16 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 17 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 18 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 19 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 20 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 21 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 22 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
10 NYCRR 415.12
F 689 483.25(d)(1)(2) Free of Accident F 689 I. The following actions were accomplished 06/11/2019
SS=D Hazards/Supervision/Devices for the residents identified in the sample:
Resident #402
§483.25(d) Accidents. • Resident is no longer at the facility
The facility must ensure that - • A medical record review has been
§483.25(d)(1) The resident environment remains completed to ensure all improvement
as free of accident hazards as is possible; and opportunities related to the fall on
12/15/2018 have been identified and
§483.25(d)(2)Each resident receives adequate addressed in this plan of correction
supervision and assistance devices to prevent • LP #4 is no longer employed by the
accidents. facility
• LPN #11 is no longer employed by the
This REQUIREMENT is not met as evidenced facility
by: Resident #404
• Resident is no longer at the facility
Based on record review and interview during the • A medical record review has been
recertification and abbreviated surveys completed to ensure all improvement
(NY00231469 and NY00233843), the facility did opportunities related to the fall on
not ensure adequate supervision was provided 1/29/2018 have been identified and
for 2 of 6 residents (Resident #402 and #404) addressed in this plan of correction
reviewed for falls. Specifically, for Residents • LPN #4 is no longer employed by the
#402 and 404, licensed practical nurses (LPNs) facility
were independently evaluating the resident's • LPN #11 is no longer employed by the
after falls without adequate supervision and facility
direction.
Findings include: II. The following corrective actions will be
implemented to identify other residents
The facility Post Fall Follow-Up policy revised who may be affected by the same practice:
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 23 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 24 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 25 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 26 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 27 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 28 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 29 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
10NYCRR 415.12(h)(1)
F 760 483.45(f)(2) Residents are Free of Significant F 760 I. The following actions were accomplished 06/11/2019
SS=D Med Errors for the residents identified in the sample:
Resident #403
The facility must ensure that its- • Resident is no longer at the facility
§483.45(f)(2) Residents are free of any • A medical record review has been
significant medication errors. completed to ensure all improvement
opportunities related to the significant
This REQUIREMENT is not met as evidenced medication error in which resident did not
by: receive ordered anticoagulant therapy for
21 consecutive days have been identified
Based on record review and interview during the and addressed in this plan of correction.
abbreviated survey (NY00231469), the facility • LPN #4 is no longer employed by the
did not ensure residents were free of significant facility
medication errors for 1 of 6 residents (Resident
#403) reviewed for medication regimens. II. The following corrective actions will be
Specifically, Resident #403 was found to have a implemented to identify other residents
blood clot and his medication orders were not who may be affected by the same practice:
followed. In addition, the facility did not have a All residents have the potential to be
process in place to identify transcription errors in affected by this practice:
physician orders. • All medication orders written in the past
Findings include: thirty (30) days will be reviewed to ensure
that any suspected medication errors have
Resident #403 was admitted to the facility on been investigated and reported
2/21/18 and had diagnoses including dementia • All medication orders written in the past
and atrial fibrillation (irregular heart rhythm). The thirty (30) days will be reviewed to ensure
12/5/18 Minimum Data Set (MDS) assessment that orders were transcribed accurately
documented the resident's cognition was • All residents receiving anticoagulation
severely impaired and he required extensive therapy will have anticoagulant therapy
assistance for most activities of daily living orders reviewed with physician/PA to
(ADLs). The MDS documented the resident ensure orders are appropriate and
received an anticoagulant (blood thinner) accurate
medication daily.
III. The following system changes will be
The comprehensive care plan (CCP) dated implemented to assure continuing
12/19/18 documented the resident was on compliance with regulations:
anticoagulant therapy related to atrial fibrillation As per the Directed Plan of Correction, the
and was on Xarelto (anticoagulant medication). Consultant has developed and
Interventions included to observe for signs of implemented an In-service Program to
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 30 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 31 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 32 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 33 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 34 of 35
PRINTED: 06/10/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335590 04/19/2019
10NYCRR 415.12(m)(2)
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HI2111 Facility ID: 0732
If continuation sheet Page 35 of 35