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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADLs) receives the necessary services to maintain grooming, and personal hygiene for one (Resident#343) of eight residents reviewed for ADLs. Specifically, on 8/1/2023 Resident #343 was observed lying in bed in a hospital gown with a towel over their chest and abdomen. Coffee had spilled onto the towel, the resident's call bell was behind the resident on the head board and the resident's fingernails were observed to be long, untrimmed, and dirty on both hands. The finding is: The facility's policy titled Activities of Daily Living - General, dated 5/1/2021, documented to ensure residents receive all necessary care including activities of daily living. This policy aims to promote resident independence, dignity, and well-being while ensuring their safety and comfort. This policy applies to all residents in the nursing home who require assistance with Activities of Daily Living and to all nursing home staff responsible for providing ADL care services. ADLs are essential self-care tasks that individuals typically perform on a daily basis to maintain their personal hygiene, health, and well-being. These include, but are not limited to: bathing, dressing, toileting, transferring; eating and drinking, and grooming. Resident #343 was admitted with [DIAGNOSES REDACTED]. The 7/23/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The MDS documented that the resident required extensive assistance of one person for personal hygiene and required supervision and set-up for eating. A Comprehensive Care Plan (CCP) titled ADLs: Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, effective 9/23/2022 and last updated 5/2/2023, documented the resident will be clean, dry, and groomed daily and to keep nails trimmed and clean. On 8/1/2023 at 11:32 AM Resident #343 was observed lying in bed in a hospital gown with a towel over their chest and abdomen. An overbed table was observed over the resident's bed. Coffee had spilled onto the towel. Another liquid was observed spilled on the overbed table. The resident's call bell was behind the resident looped over the headboard, and the resident's fingernails were observed to be untrimmed, long, and dirty on both hands. The resident stated they (Resident #343) could not reach the call bell and the spill happened about two hours ago. The resident stated they (Resident #343) would like their fingernails trimmed. Resident #343 was observed by unit Registered Nurse (RN #1) on 8/1/2023 at 11:36 AM. RN #1 removed the coffee soiled towel and observed that the sheet under the towel and the hospital gown were also soiled with coffee. RN #1 stated they (RN #1) would send in a Certified Nursing Assistant (CNA) to clean and dress the resident. RN #1 placed the resident's call bell at the resident's right side and left the room. During an observation on 8/1/2023 at 12:35 PM, CNA #2 (the assigned CNA) and the resident's family member were at the resident's bedside. The resident was in bed and was dressed. The resident's nails were still untrimmed and dirty. CNA #2 was interviewed immediately after the observation on 8/1/2023 at 12:35 PM and stated sometimes the resident is combative and the resident's family member has to be present to keep the resident calm in order to trim and clean the nails. The resident's family member was interviewed immediately after CNA #2's interview on 8/1/2023 at approximately at 12:37 PM and stated they visit the resident every day, and the resident's nails should be cut. The family member stated there are times when the resident might refuse care, but no one ever said anything about the resident refusing to get their nails cut. The family member stated the resident could scratch themselves with the long nails. Resident #343 was observed in the day room with the family member present on 8/3/2023 at 11:57 AM. The resident's nails were trimmed and clean. RN #2, the Unit Supervisor, was interviewed on 8/3/2023 at 2:46 PM. RN #2 stated the CNA is supposed to keep the resident's fingernails trim and clean. RN #2 stated if the resident refused to have their nails trimmed and cleaned, the CNA should document on the CNA accountability record and let the nurse know. RN #2 stated the nurse can intervene and talk to the family and that the resident's family is at the facility most days. The Director of Nursing Services (DNS) was interviewed on 8/3/2023 at 3:20 PM and stated nail cutting is done on bath days and as needed. The DNS stated if the resident refused, the CNA should document that on the accountability record and let the nurse know. The nurse can talk to the resident and ask the family to assist. Review of the CNA accountability record for (MONTH) 2023 revealed that the resident refused showers on 7/8/2023 and 7/15/2023; however, received showers on 7/19/2023, 7/22/2023, 7/26/2023, and 7/29/2023. 10 NYCRR 415.12(a)(3) | Plan of Correction: ApprovedSeptember 18, 2023 In response to the deficiencies related to F677, where resident #343 was observed with spilled coffee on themselves and long untrimmed nails, we have developed a comprehensive plan of correction to address the issues, enhance resident care, and prevent similar occurrences in the future. For resident #343, found to have been affected by the deficient practice, corrective actions were taken with the CNA who was providing care for the resident. The CNA was given discipline along with receiving education on proper ADL care, dignity, and call bell accessibility on (MONTH) 29, 2023. Resident #343 underwent a thorough assessment by occupational therapy to determine the necessity of adaptive feeding equipment for both food and drink consumption. Following a comprehensive evaluation, it was determined that such equipment was unnecessary for their specific needs. Instead, resident #343 was provided with essential education on best practices for eating and drinking. They were informed about techniques to ensure safe and efficient consumption and were encouraged to promptly alert the staff in the event of any spills or concerns, thereby ensuring their overall well-being and comfort during meal times. To identify other residents who may have the potential to be affected by a similar deficiency, a comprehensive review of ADL (Activities of Daily Living) care practices was conducted for all residents on (MONTH) 1, 2023. This thorough examination aimed to ensure the highest standard of care for everyone residing in the facility. During this review, any residents found to have spills or untrimmed nails were promptly attended to, and their specific needs were addressed to maintain their comfort and well-being. Additionally, the facility conducted a visual inspection of all residents to ensure that the incident involving Resident #343 was an isolated occurrence. Fortunately, no other issues were noted during this inspection, reassuring the staff and residents that proper care and attention to detail remain paramount in maintaining the residents' quality of life. Furthermore, in collaboration with the F919 deficiency received, all call bells were meticulously inspected to ensure their proper functioning and accessibility to residents. To prevent the recurrence of this issue, systemic changes will be implemented to enhance ADL care and address resident needs comprehensively. All CNAs will receive re-education on proper ADL care, which includes maintaining cleanliness and hygiene, promptly addressing spills, and ensuring nails are properly trimmed. Additionally, CNAs will be reminded to promptly inform the nurse when residents refuse care, facilitating alternative approaches and necessary care plan updates. Furthermore, to promote resident well-being and overall personal care, administration will collaborate with the recreation and nursing departments to explore the implementation of spa days as a regular practice. In conjunction with F919 requirements, comprehensive staff education will be undertaken to ensure the optimal functioning of call bells. Moreover, a holistic approach to resident care will be employed by educating not only CNAs but also LPNs, RNs, PTs, OTs, Speech therapists, recreation staff, respiratory therapists, and administrative personnel on identifying and addressing spills and nail care for residents. This multi-disciplinary effort underscores our commitment to providing the highest quality of care to all residents and upholding the utmost standards of resident safety and comfort. To ensure ongoing compliance and maintain the highest standards of care, a quality assurance program will be initiated. Audits will be conducted to verify that residents' ADL needs are being met appropriately, the presence of any dignity concerns, and if call bells are accessible. The Assistant Directors of Nursing have designed an audit tool that will be conducted weekly for the first (1) month on ten (10) residents from each unit, followed by bi-weekly audits for two (2) months, and then monthly audits for the subsequent three (3) months then as directed by the QAPI committee. Any deficient findings will be addressed immediately. All audit outcomes will be reported to the QAPI committee. The target date for completing these corrective actions is (MONTH) 30, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain dedicated to improving resident care, enhancing hygiene practices, and ensuring a comfortable and dignified environment for all residents. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 1, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was not effectively administered to ensure sufficient staffing was provided to promote the highest practicable physical mental and psychosocial well-being of each resident. The Facility Assessment did not include the overall number of facility staff needed to ensure that each resident's needs were being met. Additionally, the Administrator did not monitor and enhance the quality of care and services by repeating the same deficiencies including: F656 Develop/Implement Comprehensive Care Plan, F658 Services Provided meet Professional Standards, F689 Free of Accident Hazards/Supervision/Devices and F840 Use of Outside Resources. Cross Reference: F697 Pain Management F725 Sufficient Nursing Staff F755 Pharmacy Services F838 Facility Assessment The finding is: Review of the Facility assessment dated [DATE], in its entirety, revealed that there was no overall number of facility staff needed included in the assessment to ensure that each resident's needs were being met. The Facility Assessment documented the following staffing plan: The facility does not take a census-based approach to staffing but looks at the acuity levels of the residents to provide the best staffing possible. The facility looks at various factors including the level of assistance needed, the clinical complexity, and treatment provided to each resident when examining appropriate staffing levels. The goal is to ensure all residents' needs are met in an appropriate and timely fashion. Staff assignments are based on the residents being treated. The Director of Nursing Services (DNS) and the Administrator were interviewed concurrently on 8/10/2023 at 10:31 AM. The Administrator stated that the Facility Assessment was last updated on 3/27/2023 and that the resident acuity section was updated on 8/1/2023. The Administrator stated that the facility assessment does not have the overall numbers or nursing par levels as part of the staffing plan. The Administrator stated that the nursing par levels that the Director of Payroll and Schedules provided were developed by the previous DNS. The Administrator was not involved with developing par levels for nurse staffing. The Facility Assessment was not updated to include par levels because the Administrator did not know that was something that needed to be included. The Administrator stated that they (Administrator) met with the DNS sometime in (MONTH) 2023 (could not recall the exact date) to develop par levels based on current census, Minimum Data Set assessments, and Electronic Medical Record data. The Administrator stated there were no meeting notes available to confirm that the Administrator met with the DNS regarding the facility assessment. The Administrator stated that the new par levels have not been developed as of today (8/10/2023). The Administrator stated that Resident Council brought concerns about staffing in (MONTH) 2023. The Administrator stated that there was one particular weekend that the residents complained about but was not sure of the details because the previous DNS addressed it with the Resident Council. The Administrator was not involved with addressing the Resident Council Concerns since the Director of Nursing was responsible for staffing. The Administrator was re-interviewed on 8/10/23 at 3:30 PM. The Administrator stated that they (Administrator) were not sure if there was sufficient staffing on 8/6/2023 on Sagamore 2 unit or in the other example dates provided regarding staffing shortages during the sufficient staffing task review. The Administrator stated that they (Administrator) would have to finalize the par levels in order to determine that. Currently, the Administrator and DNS speak with the Director of Payroll and Schedules on a daily basis to adjust staffing according to changes in census and needs. The 6/27/2022 par levels are used as a guide. The Administrator stated that some days the facility does have sufficient staff and some days they can do better. The Administrator stated that it fluctuates with the number of staff who are out for various reasons. The Administrator stated there have been issues that are brought to the Quality Assurance Performance Improvement (QAPI) meetings continually, like nosocomial wounds, weights, safety, and grievances. We address staffing at the quarterly QAPI meeting because staffing problems have come up. We discuss job fairs, how can we attract people, i.e. new hires, bonuses, and incentives. The Administrator stated there has been some progress. 10 NYCRR 415.26 | Plan of Correction: ApprovedSeptember 19, 2023 F-835 In response to the deficiencies identified under F835, we have developed a comprehensive plan of correction to address the concerns raised and to ensure that our nursing home is providing the highest quality care and services to our residents. We acknowledge the importance of adequate staffing, thorough facility assessments, and effective administrative oversight in promoting resident well-being. While the individual deficiencies are discussed at length in their appropriate sections, below are key items regarding those deficiencies as they relate to F835. To address the insufficient staffing concern, we are committed to continuous efforts in recruiting and hiring qualified staff for our facility. We are actively engaging with various staffing agencies and recruiters, as well as exploring partnerships with nursing schools, CNA schools, and technical schools to attract and retain skilled professionals. Our approach aligns with the previously discussed plan of correction for F725, which outlines our strategies for mitigating staffing challenges within the context of the broader industry and the impact of the ongoing COVID-19 pandemic. Furthermore, to rectify the deficiency related to the facility assessment (F838 below), we will revise and enhance our facility assessment process to include specific numerical benchmarks for staffing needs based on resident acuity and care requirements. This assessment will be a dynamic tool, reviewed and updated regularly to reflect changes in resident population and care demands. To address the concern regarding administrative oversight, the current administrator will undergo targeted education and training by the consultant utilized for these plans of correction to ensure that deficiencies are not repeated. This education will focus on enhancing the administrator's ability to effectively monitor and improve the quality of care and services provided within the facility. We recognize the importance of addressing deficiencies at their source and preventing their recurrence through informed and proactive leadership. In terms of corrective action for residents found to have been affected by deficient practices, assessments will be conducted as part of the associated deficiencies and all necessary actions taken based on those deficiencies. This also applies to prevention. The administrator and assistant administrators will participate in a dedicated education program specifically designed to enhance their comprehension of the deficiency F835, in conjunction with the associated deficiencies. This education program will also have a primary focus on equipping the administrators with the knowledge and skills required to effectively deliver high-quality, person-centered care within the facility. The consultant utilized for these plans of correction will conduct these education sessions. To ensure compliance, the administrator or their designated representative will assume the responsibility of regularly providing the consultant with updates regarding F835 and the cross-referenced deficiencies. This will be in addition to the administrator or designee monitoring the audits for the cross-referenced deficiencies. This measure is essential to maintain ongoing monitoring and to ensure that the administrator and assistant administrators are consistently aligned with the standards of high-quality, person-centered care. The target date for the completion of these corrective actions is (MONTH) 1, 2023, and the person responsible for correction is the consultant. We are dedicated to continuous improvement and the provision of the highest quality care for our residents, and this plan of correction represents our commitment to addressing the deficiencies identified under F835 and promoting resident well-being. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 15, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the Recertification Survey, initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was identified for one (Resident #91) of one resident reviewed for [MEDICAL TREATMENT]. Specifically, there was no [MEDICAL TREATMENT] or Renal care plan created for Resident #91, who received bedside [MEDICAL TREATMENT] in the facility. The finding is: The facility's policy titled Comprehensive Care Plan, dated 2/1/2021, documented residents of the facility will have a Comprehensive Care Plan (CCP) completed in accordance with Federal and State requirements. The CCP will include the resident's problems, strengths, and needs. An individual CCP will be developed for each problem, strength, or need, measurable objectives, and timetables in order to meet the resident's physical, mental and psychosocial needs that are identified from the Resident's Comprehensive Assessments. The development of the CCP is prepared with an interdisciplinary team approach. Resident #91 was admitted with [DIAGNOSES REDACTED]. The 7/8/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had severely impaired cognitive skills for daily decision making. The MDS documented the resident received [MEDICAL TREATMENT] while a resident. A physician's orders [REDACTED]. This type of catheter is used for short-term [MEDICAL TREATMENT] treatment). Resident #91 was observed lying in bed receiving bedside [MEDICAL TREATMENT] on 8/7/2023 at 1:46 PM. The [MEDICAL TREATMENT] nurse, who worked for an outside contractor, was present. Review of Resident #91's medical record revealed no comprehensive care plan for [MEDICAL TREATMENT] or End Stage [MEDICAL CONDITION]. Registered Nurse (RN) #7 was interviewed on 8/7/2023 at 1:59 PM. RN #7 reviewed Resident #91's medical record and stated there was no Comprehensive Care Plan (CCP) developed for [MEDICAL TREATMENT]. RN #7 stated there should be a CCP for [MEDICAL CONDITION] or [MEDICAL CONDITION]. RN #7 stated the care plan is usually done by the admission nurse or the MDS nurse or any RN can implement the care plan. RN #7 stated care plans were updated a lot better before. RN #7 stated for about a year registered nurses have been utilized a lot more like medication nurses and staff nurses and the situation is getting worse due to staffing. RN #7 stated [MEDICAL TREATMENT] is one of Resident #91's main [DIAGNOSES REDACTED]. The Director of Nursing Services (DNS) was interviewed on 8/8/2023 at 8:36 AM and stated there should have been a [MEDICAL TREATMENT] CCP. The DNS stated the MDS nurse, the admission nurse, or any RN can create a care plan. The DNS stated the [MEDICAL TREATMENT] company nurse has their own care plan, but the [MEDICAL TREATMENT] company is a separate contractor. The DNS stated our facility nurses do not have access to the [MEDICAL TREATMENT] company's care plan and our staff need their own care plan. 10 NYCRR 415.11(c)(1) | Plan of Correction: ApprovedSeptember 17, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In response to the deficiencies related to F656, where resident #91 did not have a [MEDICAL TREATMENT] or renal care plan despite being on bedside [MEDICAL TREATMENT], we have developed a comprehensive plan of correction to address the issue, ensure proper care planning, and prevent similar occurrences in the future. For resident #91 and any other residents found to have been affected by this deficiency, immediate corrective actions were taken. [MEDICAL TREATMENT] and renal care plans were promptly developed and updated upon notification to ensure that residents on bedside [MEDICAL TREATMENT] have appropriate and comprehensive care plans in place. The [MEDICAL TREATMENT] unit RNs were educated, and disciplines were given to address deficient practice. To identify other residents who may have the potential to be affected by a similar deficiency, an audit was conducted on all [MEDICAL TREATMENT] residents on (MONTH) 8, 2023, to ensure that care plans were in place and up to date. This audit confirmed that the deficiency was isolated to resident #91. However, to ensure ongoing compliance and resident safety, recurring audits will be conducted monthly for the next six (6) months by the unit managers or designee. All negative findings will be corrected when found. All audit outcomes will be reported to the QAPI committee. All nursing RN staff will be in-serviced on placing resident care plans timely to prevent recurrence of deficient practice. The policy and procedure for care planning was reviewed and no changes were made at this time. The target date for completing these corrective actions is (MONTH) 15, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain dedicated to ensuring the highest quality of care for our residents, particularly those requiring specialized [MEDICAL TREATMENT] and renal care. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 15, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure sufficient number of qualified staff required to meet each resident's needs. The facility assessment did not consider a review of individual staff assignment and systems for coordination and continuity of care for resident's within and across these staff assignments. Additionally, the facility assessment did not include the need for the respiratory care clinicians on the ventilator unit. The finding is: Review of the Facility assessment dated [DATE], in its entirety, revealed that there was no overall number of facility staff needed included in the assessment to ensure that each resident's needs were being met. The Facility Assessment documented the following staffing plan: The facility does not take a census-based approach to staffing but looks at the acuity levels of the residents to provide the best staffing possible. The facility looks at various factors including the level of assistance needed, the clinical complexity, and treatment provided to each resident when examining appropriate staffing levels. The goal is to ensure all residents' needs are met in an appropriate and timely fashion. Staff assignments are based on the residents being treated. An untitled document dated 6/27/2022 provided by the Director of Payroll and Schedule documented Nurse and Certified Nurse Aide (CNA) par levels on the 7AM-3PM shift, 3PM-11PM shift, and 11PM-7AM shift on all units. The document included, Please use this as a guideline to staffing, adjust pars as the census fluctuates. The Director of Payroll and Schedules was interviewed on 8/7/2023 at 12:30 PM. The Director of Payroll and Schedules stated that they began supervising the staffing coordinators on Monday, 7/31/2023. Prior to 7/31/2023, the Director of Payroll and Schedules provided assistance with staffing for short periods of time when the facility did not have a Scheduling supervisor available. The Director of Payroll and Schedules stated that the Director of Nursing Services (DNS) provided them with the Registered Nurse (RN), Licensed Practical Nurse (LPN) and CNA par levels based on the census and acuity on the units. The Director of Payroll and Schedules stated that staffing numbers are posted in the scheduling office for the staffing coordinators to follow. The Director of Payroll and Schedules stated that they are not involved in creating the Facility Assessment. The DNS and the Administrator was interviewed concurrently on 8/10/2023 at 10:31 AM. The Administrator stated that the facility assessment was last updated on 3/27/2023 and that the resident acuity section was updated on 8/1/2023. The Administrator stated that the facility assessment does not have the overall numbers or nursing par levels as part of the staffing plan. The Administrator stated that the nursing par levels that the Director of Payroll and Schedules provided was developed by the previous DNS. The Administrator was not involved with developing par levels for nurse staffing. The facility assessment was not updated to include par levels because the Administrator did not know that was something that needed to be included. The Administrator stated that they (Administrator) met with the DNS sometime in (MONTH) 2023 (could not recall the exact date) to develop par levels based on current census, Minimum Data Set assessments and Electronic Medical Record data. The Administrator stated there were no meeting notes available to confirm that the administrator met with the DNS regarding the facility assessment. The Administrator stated that the new par levels have not been developed as of today (8/10/2023). 10 NYCRR 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedSeptember 19, 2023 F-838 In response to the concerns raised regarding deficiencies related to F838, we have developed a comprehensive plan of correction to address the issues identified by ensuring accuracy in our facility assessment and rectifying any potential impact on resident care. First, we acknowledge the oversight in our facility assessment, where specific staffing numbers were missing, and respiratory clinicians were inadvertently excluded from the ventilator unit listing. To rectify this, a thorough revision of the facility assessment will be conducted. This revision will include precise numbers for staffing requirements and ensure the accurate inclusion of respiratory clinicians on the ventilator units. The facilityÆs administrator and assistant administrators will undergo re-education on the importance of the facility assessment along with the components necessary. This education will be conducted by the consultant utilized for these plans of correction. Further, the facility assessment policy was reviewed and no changes were needed. No residents were affected by this deficiency. To prevent the recurrence of the deficient practice, systemic changes will be implemented. The facility assessment will be reviewed and updated on a monthly basis for a minimum of one (1) year and shared with the QAPI committee. Regular audits and cross-checks will be conducted to ensure that the facility assessment accurately reflects staffing and clinician requirements. We will establish a continuous quality assurance program to monitor compliance. The corrective actions will be diligently monitored to ensure that the deficient practice does not recur. This will involve ongoing assessments, audits, and reviews of resident care plans, facility assessments, and staffing documentation. The responsible person for the correction of this deficiency is the Administrator, and the expected date for completion of these corrections is (MONTH) 15, 2023. This plan of correction signifies our commitment to addressing deficiencies promptly and comprehensively to maintain the highest standards of care within our nursing home. We will closely monitor the implementation of these measures and make any necessary adjustments to prevent the recurrence of similar issues and to ensure the safety and well-being of all our residents. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 4, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure the resident environment remained as free of accident hazards as is possible. This was identified for one (Resident #39) of four residents observed for medication administration. Specifically, during the medication pass observation conducted on 8/2/2023 Resident #39 was observed with a bottle of Tylenol PM (pain medication also used to assist with sleeping), antacid tablets, and a tube of Icy-Hot pain cream at the resident's bedside. There was no Physician's order for the Tylenol PM, antacid tablets, or tube of Icy-Hot pain cream and the resident was not assessed to self-medicate. The finding is: The facility's policy titled, Preventing Accidents, dated 6/24/2022, documented staff will provide appropriate supervision and monitoring of residents, especially those at higher risk of accidents due to cognitive impairment or mobility issues. Staff will closely observe residents during activities and assist as needed to prevent accidents. Resident #39 was admitted with [DIAGNOSES REDACTED]. The 4/30/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #39's current physician orders dated 7/29/2023 revealed that there was no order for Tylenol PM, the antacid chewable tablets, or the pain cream. During the medication pass observation on 8/2/2023 at 9:18 AM, performed by Registered Nurse (RN) #3, Resident #39 was observed to have a bottle of Tylenol PM (a medication containing 500 milligrams (mg) of [MEDICATION NAME] (a pain and fever reducer) and 25 mg of [MEDICATION NAME][MEDICATION NAME] (an [MEDICATION NAME] that can be used as a sleep aid) at their bedside. The resident stated they (Resident #39) self-medicate with Tylenol PM to help sleep and for pain. Resident #39 stated the family brought in the Tylenol PM last month. The resident also had a bottle of antacid tablets and a tube of Icy-Hot cream. RN #3 stated that the medications would have to be taken away and discussed with the physician; however, the resident was very adamant about keeping the medications. RN #4 was interviewed on 8/3/2023 at 2:04 PM. RN #4 stated they were the nursing supervisor on Resident #39's unit on 8/2/2023. RN #4 stated they (RN #4) took the Tylenol PM, antacid tablets, and pain cream away from the resident but did not call or notify the Physician. RN #4 stated they (RN #4) thought RN #3 (the medication nurse from 8/2/2023) called the Physician. Resident #39's physician, who is also the Medical Director, was interviewed on 8/3/2023 at 2:50 PM. The physician stated they were not aware Resident #39 was self-medicating with Tylenol PM and no one had called to inform them (physician). The physician stated the resident would need an order for [REDACTED]. The Director of Nursing Services (DNS) was interviewed on 8/3/2023 at 3:21 PM. The DNS stated the resident should not have their own medications at the bedside, and if they do, the staff should educate the resident that all medications have to be ordered. In addition, the Physician has to be informed if a resident is self-medicating, and the resident should be assessed to determine if the resident can safely administer their medications. 10 NYCRR 415.12(h)(1) | Plan of Correction: ApprovedSeptember 19, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-0689 In response to the recent incident involving resident #39 at our nursing home, where they were found with Tylenol PM, antacids, and Icy-Hot pain cream on their bedside table without a valid medical order or prescription, we have developed a comprehensive plan of correction to ensure the safety and well-being of our residents. Upon discovering the unauthorized medications in resident #39's possession, immediate action was taken. The medications were promptly removed, and our staff-initiated communication with the resident's attending physician to discuss the situation and seek guidance and whether any new medical orders were necessary to address the residentÆs needs appropriately. The NP saw the resident on (MONTH) 3, 2023 and discussed the situation with the resident. The resident will speak with the physician and obtain permission prior to utilizing her own medications. An assessment was completed by the ADON, NP, and charge nurse to ascertain if the resident can safely self-medicate. It was determined that the resident does not have the ability to safely self-medicate. The resident agreed with the findings of the assessment without concern. The residentÆs chart was updated accordingly. All resident rooms were checked for medication to assure, if present, they had the appropriate orders which indicate they were able to self-medicate. Any medications which were observed in residentsÆ rooms who did not have orders to self-medicate were removed and the physician was informed to assess residents for use and self-application. No findings of this nature were detected. We recognize the importance of educating our staff on proper protocols related to self-administration of medications and the prohibition of non-prescribed medications. Clinical staff, including RNs, LPNs, CNAs, MDS nurses, PTs, OTs, Speech therapists, recreation staff, respiratory therapists, and administrative personnel will be re-in serviced so they are well-informed about our policies and procedures regarding medication management, and they understand the potential risks associated with residents having unauthorized medications. We will add an informational document in our admission packet which provides the process on how the resident can request self-medicating if the resident desires. We have reviewed the policies regarding self-administration of medication and noted that no changes are needed at this time. However, we added to the policy that an informational document will be added to our admission packet which provides the process on how the resident can request self-medicating if desired. To prevent similar incidents in the future, we will conduct thorough audits throughout the facility to review and confirm that any medications found in a resident's possession are accompanied by a valid physician's orders [REDACTED]. This audit, utilizing the custom made audit tool, will be conducted by the unit manager or designee, twice a month for three (3) months then monthly for three (3) months and then as directed by the QAPI committee. Any negative findings will be corrected immediately then reported to the ADONs. All audit findings will be reported to the QAPI committee. The target date for completing these corrective actions is (MONTH) 4, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We are committed to protecting resident rights while ensuring a safe and appropriate environment for all residents. |
Scope: N/A
Severity: N/A
Citation date: August 10, 2023
Corrected date: September 1, 2023
Citation Details Based on record review and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that Legionella culture sampling was completed annually. Specifically, a water sampling for Legionella detection was not completed in 2022 for the entire facility. The facility provided documented evidence that Legionella testing was conducted on 10/14/2021 and then again on 3/10/2023 for four of the five buildings. There was no documented evidence that Legionella water sampling monitoring was completed one of five buildings, the Seacliff building which includes the Ventilator unit, since 9/30/2020. The finding is: The facility Legionella policy and procedure revised 5/12/2023 documented the nursing home will conduct Legionella testing on ten water samples across the facility, as required by New York State Department of Health (NYSDOH) regulations. The policy also documented that Legionella testing will be conducted at least annually or as directed by the NYSDOH, and more frequently if deemed necessary based on previous test results or identified risk factors. The Environmental Assessment of Water System in Healthcare Setting form dated 3/14/2022 and 3/13/2023 documented that annual testing for the surveillance of Legionnaires Disease and water sampling from sampling locations will be conducted annually for Legionella prevention. A Review of the Legionella Summary Report dated 3/20/2023 documented water sample for Legionella detection was collected from four consecutive buildings, however, there was no documented evidence that water sampling for Legionella detection was completed for the fifth stand-alone building (Seacliff) which houses the facility's ventilator dependent residents on the first-floor nursing unit. There was no documented evidence that water sampling for the detection of Legionella for the year 2022. A Review of the Legionella Summary Report dated on 10/25/2021 documented water sample for Legionella testing was collected from four consecutive building, however, there was no documented evidence that water sampling for Legionella detection was completed for the fifth stand-alone building (Seacliff) that houses the facility's ventilator dependent residents on the first-floor unit. And there was no documented evidence that water sampling was completed for the Seacliff building since 9/2020. The Assistant Director of Plant Operation was interviewed on 8/4/2023 at 4:00 PM and stated the Director of Plant Operation was responsible for ensuring all water testing was completed. The Assistant Director of Plant Operation stated that water testing for Legionella detection should have been completed in (MONTH) 2022, as per the annual Environmental Assessment of Water Systems. The Director of Plant Operation was interviewed on 8/7/2023 at 9:20 AM. The Director of Plant Operation stated that they were responsible for ensuring that Legionella testing was completed yearly. The Director of Plant Operation stated they were employed in (MONTH) 2022 and were unsure when the last time Legionella testing was completed for the Seacliff building. The Director of Plant Operation stated the Legionella testing was not completed in (MONTH) 2022 because they were in the process of switching companies. The Director of Plant Operation stated that testing should have been completed in 2022 as per the annual Environmental Assessment of Water Systems. The Director of Plant Operation stated that the Seacliff building has a separate water management system from the rest of the other buildings and that water sampling for Legionella detection should have been completed for the Seacliff building. The Administrator was interviewed on 8/7/2023 at 9:44 AM. The Administrator stated that they oversee the maintenance department and that the Maintenance Director was responsible for ensuring that water sampling for Legionella detection is completed for the facility. The Administrator stated that water samples should be collected from the entire facility and that there was an oversight with the Seacliff building. The Administrator stated that they have been employed in the facility a little over one year and could not say when the last time water sampling for Legionella testing was completed for the Seacliff building. The Administrator stated that on 8/9/2023 they have scheduled water sampling to be collected for the Seacliff building. The Administrator stated that water sampling for Legionella detection was completed late 2021 and that due to a change in Maintenance Director as well as the company that does water testing for the facility the water testing was not completed for the year 2022. | Plan of Correction: ApprovedSeptember 17, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I210 In response to the deficiency identified under I210, where Legionella water sampling was not completed for the entire facility in 2022, a comprehensive plan of correction has been established to address the issue, prevent its recurrence, and ensure ongoing compliance with Legionella testing requirements. To address the situation, re-education sessions on Legionella testing will be conducted for key personnel including the Director of Maintenance, Assistant Director of Maintenance, Maintenance Supervisors, the Administrator, and assistant administrators. These educational sessions will reinforce the importance of annual Legionella testing and the significance of comprehensive monitoring in all facility buildings. Although no residents were affected by this deficiency, we recognize the importance of identifying other residents who may have been potentially affected by the same deficient practice. As such, we will conduct a retrospective review to ensure that any missed testing in 2022 did not have any unintended consequences. Resident EMR charts have been reviewed to identify any residents that may have been showing signs and symptoms of [DIAGNOSES REDACTED] over the past year. If any resident was showing symptoms as notated in the chart, the medical director was consulted and discussion on the root cause was conducted. However, no residents were noted to have signs and symptoms of [DIAGNOSES REDACTED]. It's essential to note that in 2023, comprehensive Legionella testing was conducted for all five buildings within our facility. The results of these tests have indicated no signs of Legionella contamination, affirming the effectiveness of our preventive measures and the safety of our residents and staff. This reassuring outcome underscores our commitment to maintaining a secure and healthy environment within our facility. The next scheduled water testing for the five buildings is Spring 2024. To avoid the recurrence of this isolated, unintentional problem leading to a deficiency, several systemic changes will be implemented. These include setting up automatic reminders both with the Legionella testing company and within the facility itself to ensure that testing is completed annually for all five buildings. These reminders are calendar reminders that alert both the Director of Maintenance and the Administrator of the upcoming testing date at least 30-days before the testing date. Further, the Legionella testing company has stated that their system will send out an automated email reminding the facility to schedule the annual water testing for legionella. Further, the consultant who is overseeing these plans of correction will be monitoring the testing to ensure its completion. This will serve as an additional layer of assurance that the testing requirement is consistently met. Additionally, the infection control preventionist has been tasked with collaborating closely with the Director of Maintenance on the Legionella water safety plan. This collaborative effort aims to prevent any recurrence of this isolated incident and to enhance overall water safety within the facility. The target date for completing these corrective actions is immediate, and the Administrator will be responsible for overseeing the implementation of this plan of correction. We are committed to maintaining the highest standards of safety within our facility, and this plan reflects our dedication to continual improvement and resident well-being. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 1, 2023
Citation Details Based on observation and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each controlled-substance storage box was separately locked as per the state and federal guidelines. This was identified for one of two medication carts on Seacliff 1 unit on 8/8/2023. Specifically, on 8/8/2023, a controlled substance box in a medication cart on Seacliff 1 unit did not have a lock. The unlocked box was observed with narcotic controlled substances. The finding is: The facility's policy, titled Medication Storage, dated 5/1/2021, documented all controlled substances, as defined by federal and state regulations, will be stored in a double-locked area within the medication cart or cabinet. The double locking will include both a locked drawer or compartment and a lock securing the medication cart or cabinet itself. On 8/8/2023 at 2:07 PM on Seacliff 1 unit a medication cart was observed with Licensed Practical Nurse (LPN) #1. The narcotic box (controlled substance storage box) within the medication cart did not have a lock. There was a hole in the box and the key lock was missing. LPN #1 stated that the box was like that when they (LPN #1) came onto their shift in the morning, and they (LPN #1) had placed a maintenance request through the automated system. The medication cart on Sea(NAME)1 unit was observed on 8/9/2023 at 12:10 PM with LPN #5. The narcotic box within the medication cart was still missing the key lock. LPN #5 opened the narcotic box and there were multiple narcotic blister packs present in the box. LPN #5 stated that the blister packs contain narcotic medications, and they then removed the narcotics. LPN #5 further stated they (LPN #5) would place a maintenance work order to repair the narcotic storage box in the medication cart. The Director of Plant Operations was interviewed on 8/9/2023 at 1:53 PM and stated they were not aware of the missing lock on the narcotic box. The Director of Plant Operations was re-interviewed on 8/9/2023 at 2:01 PM and stated the work order was just received today and the lock was fixed about an hour ago. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 2:27 PM and stated when the nursing staff identifies a maintenance issue, they need to contact maintenance through the software system and let a supervisor know about the problem. The DNS stated narcotic medications should be stored in a double locked box. 10 NYCRR415.18(e)(1-4) | Plan of Correction: ApprovedSeptember 17, 2023 F - 0761 In response to the deficiency identified under F761, where a controlled substance box in a medication cart lacked a lock, we have established a comprehensive plan of correction to rectify the situation and prevent any similar incidents in the future. Immediate action was taken to address the issue by promptly fixing the missing lock on the controlled substance box on the date of discovery, (MONTH) 8, 2023. The unit nurse was educated on (MONTH) 9, 2023, regarding repair of the lock box and not to use the box until it is repaired along with the reminder of double lock use for storage of all narcotics. To ensure the safety and well-being of our residents, an audit of all medication carts was conducted, confirming that this was an isolated incident. This audit was conducted on (MONTH) 9, 2023. To prevent such occurrences moving forward, an educational in-service was conducted to inform all nurses (RNs and LPNs) about the importance of notifying a nursing supervisor and/or maintenance in the event of a broken lock on a controlled substance box. This education empowers staff to take swift action to address and rectify such situations. Further, a review of associated policies regarding narcotic boxes and notification of concerns has been reviewed and appropriate updates have been made to provide clearer instructions for staff. To ensure ongoing compliance, a rigorous auditing process will be implemented using a specialized audit tool. Weekly audits of all controlled substance boxes, both within medication carts and in medication rooms, will be conducted for the first (1) month. Subsequently, these audits will transition to a monthly schedule for the next five (5) months. The audits will be done by the unit managers or designee to prevent the recurrence of this deficient practice. Additional measures will be put in place to ensure the proper maintenance and functionality of controlled substance box locks. The DNS will be informed of the areas in need of repair after work requests have been sent to Maintenance. The corrective actions will be diligently monitored through a comprehensive quality assurance program. The Director of Nursing will oversee the implementation of the plan of correction in collaboration with the Director of Plant Operations. The date for correction is set immediately following the discovery of the deficient practice, with ongoing monitoring and audits conducted as specified. The Director of Nursing will take responsibility for the correction of this deficiency and for ensuring the effective implementation of the plan across the facility. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 9, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 476 and NY 550) initiated on [DATE] and completed on [DATE], the facility did not immediately consult with the resident's Physician and/or notify the resident's Designated Representative when there was a significant change in the resident's physical status. This was identified for two (Resident #738 and Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that 1A) Resident #738's Designated Representative was informed when the resident developed a Stage 3 pressure ulcer to their left shoulder on [DATE], 1B) Resident #738's Physician was not notified when the Licensed Practical Nurse (LPN) #7 identified a significant change in Resident #738's condition from [DATE] to [DATE], and 2) Resident #43's Designated Representative was informed when the resident became positive for COVID-19 infection on [DATE]. The findings are: The facility's policy titled Resident Change in Condition dated [DATE] documented to ensure timely communication with medical providers, families, and appropriate staff to facilitate appropriate care, including licensed nurses, certified nursing assistants (CNAs), and other healthcare professionals. When a significant change in a resident's condition is identified, the following notification procedure will be followed: The Licensed Nurse or staff member directly involved in providing care will immediately inform the Charge Nurse or Nursing Supervisor. The Charge Nurse or Nursing Supervisor will promptly assess the resident and initiate appropriate interventions as per the Nursing Home's (NH's) established protocols. The medical provider responsible for the resident's care will be notified promptly of the change in condition. Following the notification of the medical provider, the NH will promptly inform the resident's authorized representative or family member(s) about the change in the resident's condition, unless the resident has explicitly expressed their wish to not disclose such information. 1) Resident #738 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making and a Brief Interview for Mental Status (BIMS) could not be completed. The resident was totally dependent on the assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one stage IV pressure ulcer upon admission to the facility. 1A) The Wound Care Progress Note dated [DATE] written by the former Registered Nurse (RN) Wound Care Nurse (RN #15) documented that the resident was seen by the wound care team on [DATE]. The Stage 4 sacral wound 19 centimeters (cm) x 20 cm x 0.5 cm. A Stage 3 left shoulder pressure ulcer was identified on [DATE] measuring 3.5 cm x 3.5 cm x 0.2 cm with moderate drainage. A review of the EMR did not reveal documented evidence that the resident's Designated Representative was notified of the Stage 3 pressure ulcer to the left shoulder. The Director of Nursing Services was interviewed on [DATE] at 10:45 AM and stated that when the resident's left shoulder wound was first identified on [DATE], the resident's Designated Representative should have been made aware by the RN Wound Care Nurse. 1B) The Nursing Progress Note dated [DATE] at 2:54 PM documented that the resident's vital signs (V/S) were checked and documented as follows: blood pressure (B/P) ,[DATE] millimeters of Mercury (mmHg) (normal ,[DATE] mmHg), Temperature (T) 98.1 degrees Fahrenheit (F) (normal 98.6 F), pulse (P) 78 per minute (normal range ,[DATE]), Respiration (R) 16 breaths per minutes (normal range ,[DATE]), oxygen (O2) saturation level 98% (normal 92% and above). The resident was non-verbal, and no acute distress was noted. The comfort measures were maintained. The Nursing Progress Note dated [DATE] at 7:39 AM written by Licensed Practical Nurse (LPN #7) documented that the resident was first observed sweating but resting quietly. The resident's V/S were checked and documented as follows: blood pressure (B/P) ,[DATE] mmHg, T 100 degrees F, pulse rate 130 per minute, respiration (R) 15 breaths per minutes oxygen saturation level 90%. Tylenol (fever reducer) administered, no response, unchanged. At 1 AM V/S were B/P ,[DATE] mmHg, T 100.8 F, P 136 per minute, R 15 per minute, O2 saturation 88%. The V/S were checked again at 4 AM. Resident was notably sweating T 100.0 F, P 128 per minute, R 15 per minute, O2 saturation 89%. LPN #7 documented they were called to Resident #738's room by Respiratory services at 6 AM. V/S taken, none at this time. The resident was on Comfort Measures Only (CMO)/Do Not Resuscitate (DNR)/Do Not Intubate (DNI). The Supervisor was made aware. The Medical Director's service was called and a message was left. A note was placed in the Nurse Practitioner's (NP) communication book. LPN #7 was interviewed on [DATE] at 12:10 PM and stated that they (LPN #7) had taken the resident's V/S four times during their (LPN #7) shift which began on [DATE] at 11 PM and ended on [DATE] at 7 AM. LPN #7 stated that they took the resident's V/S once at the start of their (LPN #7) shift on [DATE], but was uncertain of the exact time, and then at 1 AM, 4 AM, and 6 AM on the morning on [DATE]. LPN #7 stated that now, looking at the Nursing Progress Note they (LPN #7) wrote back on [DATE], with the resident's elevated temperature and high pulse rate, they (LPN #7) should have called a Physician to make them aware so that maybe a Physician could have ordered a medication to help slow the resident's pulse rate down. LPN #7 stated that they (LPN #7) only contacted the Medical Director of the facility after the resident had expired. LPN #7 stated that they could have also called a Registered Nurse (RN) to ask them what they (LPN #7) should do for the resident since the resident had an elevated temperature and a high pulse rate. LPN #7 stated that they (LPN #7) had first worked on a long-term care unit in the facility and when they (LPN #7) were moved to the ventilator unit, the critical care unit of the facility, they (LPN #7) did not know how to handle it because the unit was made up of fragile people. The Medical Director was interviewed on [DATE] at 1:00 PM and stated that the resident was on comfort care which the medical team was aware of and not much could have been done differently for the resident except for end-of-life management. The Medical Director stated that the LPN should have alerted their RN Supervisor and documented that in their (LPN #7) Nursing Progress Note. The Medical Director stated that the resident was ventilator dependent who was on comfort care and would only have been treated to manage severe pain, severe anxiety, or shortness of breath. The Director of Nursing Services (DNS) was interviewed on [DATE] at 3:45 PM and stated that the LPN #7 should have made the RN Charge Nurse or the RN Supervisor aware that the resident had an elevated temperature, high pulse rate, and low BP so they could have assessed the resident and then called the Physician. 2) Resident #43 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated that the resident had severely impaired cognitive skills for daily decision making. The resident required extensive assistance of two persons for bed mobility, transfers, and toilet use; and extensive assistance of one person for walking in the corridor, locomotion off the unit, dressing, and bathing. The resident was frequently incontinent of bowel and bladder. The physician's orders [REDACTED]. The Nursing Progress Note dated [DATE] at 4:58 AM written by Registered Nurse (RN) #16 documented that the resident's COVID-19 Rapid Swab test was positive and that the Nurse Practitioner (NP) and the resident's family would be informed in the morning (AM). The Social Service Progress Note dated [DATE] written by Social Worker (SW) #5 documented that they (SW #5) spoke with the resident due to a change in condition secondary to testing positive for COVID-19 infection on [DATE]. SW #5 provided emotional support and an avenue to ventilate feelings for the resident to improve psychological well-being. Contact precautions remained in place. Resident has the opportunity to call loved ones, thereby maximizing ongoing connection with their designated supports. RN #16 was contacted on [DATE] at 2:00 PM and was unavailable for interview. The resident's Primary Physician (Physician #3) was interviewed on [DATE] at 3:00 PM and stated that they (Physician #3) would not notify the resident's Designated Representative if the resident became positive for COVID-19, the NP would do that. NP #2 was interviewed on [DATE] at 9:45 AM and stated that usually the nursing staff alerts the Designated Representative when a resident turns positive for COVID-19 infection. NP #2 stated that they (NP #2) reviewed the Progress Notes in the Electronic Medical Record (EMR) and did not see any documentation that an NP or Physician alerted the resident's Designated Representative that the resident was positive for COVID-19 infection. SW #5 was interviewed on [DATE] at 9:15 AM and stated that normally the nursing staff calls the resident's Designated Representative to inform them of a positive COVID-19 result. SW #5 stated that they did not call the resident's Health Care Proxy (HCP)/Designated Representative. The Director of Nursing Services (DNS) was interviewed on [DATE] at 10:05 AM and stated that RN #16 should have called the resident's Designated Representative and notified the NP at the time they (RN #16) wrote the Nurse's Note because it was a change in the resident's status. The DNS stated that RN #16 could have informed the RN Supervisor or the Nurse relieving them (RN #16) to contact the Designated Representative because it was early in the morning. 10 NYCRR 415.3(f)(2)(ii)(b) | Plan of Correction: ApprovedSeptember 18, 2023 In response to the identified deficiencies related to F580 concerning the failure to consult with residents #738 and #43's PCP or notify the resident's HCP/designated representative about significant changes in their physical status, we have developed a comprehensive plan of correction to rectify the issues, enhance communication, and prevent similar occurrences in the future. For resident #43, who is still under our care, a thorough assessment will be conducted to identify and address any ongoing needs arising from the missed notification. The resident's HCP or designated representative will be immediately contacted and informed about the current status of resident #43, ensuring that they are involved in the care planning process moving forward. Regarding resident #738, who has sadly passed away, while this did not directly lead to the residentÆs passing, we take this information seriously. No further action can be taken for the resident as they are deceased . However, we are committed to taking proactive steps to ensure that similar incidents do not occur for other residents in the future. To identify other residents who may have been affected by a similar deficiency, we have conducted an audit of the Electronic Medical Records (EMR) system to review residents' records for the past 30 days. No additional findings were identified during this audit. To prevent the recurrence of this issue, multiple measures will be implemented. Nursing staff, including Registered Nurses (RNs), and Licensed Practical Nurses (LPNs), will receive education regarding the requirement to notify the PCP and designated representatives for changes in residents' conditions, per facility policy. It should be noted that RN #15 who was directly involved in this deficiency is no longer employed at the facility. A review of the policy will also be conducted to ensure it aligns with current standards of practice and regulatory requirements. To ensure ongoing compliance, the Assistant Director of Nursing (ADON's) will conduct regular audits using an audit tool created specifically to review recent changes in residents' conditions. These audits will help monitor and verify that notifications are being made as required, and any deviations will be addressed promptly through corrective actions and additional education. The target date for completing these corrective actions is (MONTH) 10, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain dedicated to improving our communication practices and ensuring the highest quality of care for our residents. |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: August 10, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that pain management was provided to each resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #116) of two residents reviewed for Pain Management. Specifically, Resident #116 with [DIAGNOSES REDACTED]. Resident #116 did not receive the 6:00 PM dose of [MEDICATION NAME] on 7/22/2023. The resident reported their pain level was 9 out of 10 because the [MEDICATION NAME] was not administered. Additionally, the facility staff did not monitor or assess resident's pain level on 7/22/2023 during the 3:00 PM-11:00 PM shift. This resulted in actual harm to Resident #116 that is not Immediate Jeopardy. The finding is: The facility's policy, titled Pain Management, dated 8/26/2022, documented to ensure that residents receive appropriate pain management interventions, promoting their comfort, well-being, and overall quality of life. Medications will be prescribed and administered based on the resident's pain assessment and care plan. Accurate documentation of pain assessment, interventions, and resident responses will be maintained in the resident's record. Resident #116 was admitted with [DIAGNOSES REDACTED]. The 6/15/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident was receiving the pain medication regimen and had no pain in the last 5 days. During the Resident Council Meeting held on 8/2/2023 at 12:52 PM, Resident #116 stated that on 7/22/2023 they did not receive their pain medication, [MEDICATION NAME], during the evening shift and they were in a lot of pain. The Comprehensive Care Plan (CCP) for Pain: Alteration in Comfort related to MS dated 8/3/2017 and last reviewed on 6/29/2023 documented interventions including ongoing assessment of pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors; administer medications as ordered by the physician, encourage to report pain and discomfort as soon as possible, monitor for effectiveness of pain medication and revise pain management as needed; and obtain a pain scale before and after administration of pain medications. physician's orders [REDACTED]. -[MEDICATION NAME] 10 mg tablet, give two tablets (20 mg) by oral route every 12 hours (6:00 AM and 6:00 PM) for a [DIAGNOSES REDACTED]. -[MEDICATION NAME] 10 milligram (mg) tablet, give one tablet by oral route once daily at 1:00 PM for a [DIAGNOSES REDACTED]. -Monitor and record pain every shift. Review of the (MONTH) 2023 Medication Administration Record [REDACTED]. There were no comments on the MAR indicated [REDACTED]. The medical record including the nursing progress notes did not indicate why the [MEDICATION NAME] was not administered and why the pain assessment was not completed on 7/22/2023 during the 3:00 PM-11:00 PM shift Registered Nurse (RN) #5 was interviewed on 8/10/2023 at 9:29 AM and stated they (RN #5) were the only assigned medication nurse for Resident #116's unit on the 3:00 PM-11:00 PM shift on 7/22/2023. RN #5 stated they (RN #5) were responsible to administer medication to the entire unit; however, they were not able to complete the medication pass for the side of the unit that Resident #116 resides on. RN #5 stated they were not able to administer the evening medications for Resident #116 because they (RN #5) were working alone that night and they were just learning the medication pass process at the facility. Review of Resident #116's medical record revealed no documented evidence that RN #5 contacted the physician or a supervisor about not being able to administer the resident's evening medications as per the physician's orders [REDACTED]. Physician #1, who was Resident #116's Physician, was interviewed on 8/10/2023 at 9:35 AM and stated they were not aware that Resident #116 missed their evening medications on 7/22/2023. Physician #1 further stated that [MEDICATION NAME] helps with muscle spasms. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 10:44 AM and stated for missed medications, the doctors and the family member have to be informed. The DNS stated any negative outcomes should be determined; medication error investigations should be completed, and education is needed. The DNS stated RN #5 should have reached out for help from a supervisor if there was a staffing problem. Resident #116 was interviewed on 8/10/2023 at 11:33 AM and stated they have [MEDICAL CONDITION] and get muscle spasms. Resident #116 stated they were in a lot of pain and had a terrible night on 7/22/2023 because they missed the muscle relaxant. Resident #116 stated they have been on [MEDICATION NAME] for a long time and the pain is mainly in their legs and right arm. Resident #116 stated on the night of 7/22/2023 their pain level was 9 on a scale of 0-10 (zero being the least pain and 10 being the highest pain level). Resident #116 stated the [MEDICATION NAME] helps and most of the time the pain is tolerable, but if they miss the [MEDICATION NAME], the pain gets very uncomfortable. Resident #116 was re-interviewed on 8/10/2023 at 4:20 PM. Resident #116 stated they (Resident #116) told the 11:00 PM-7:00 AM Licensed Practical Nurse (LPN) #2 about their pain level on 7/22/2023. Resident #116 stated LPN #2 told the resident that they (Resident #116) had to wait until the next dose of the [MEDICATION NAME] was due at 6:00 AM on 7/23/2023. Physician #1 was re-interviewed on 8/10/2023 at 4:34 PM. Physician #1 stated if the resident reports they have pain level of 9 out of 10 you have to take their statement as valid. Physician #1 stated missing the [MEDICATION NAME] dose may have caused Resident #116 discomfort. The resident was not happy, and the resident wants to make sure that does not happen again. Physician #1 stated they were surprised that no one called them to let them know the resident was in pain. Physician #1 stated they would have told the nurse to administer the [MEDICATION NAME], even though the dose was missed at 6:00 PM. Physician #1 stated the nurse should have called them. 10 NYCRR 415.12 | Plan of Correction: ApprovedSeptember 19, 2023 F 0697 In response to the medication administration error incident involving resident #116 on (MONTH) 22, 2023, wherein they did not receive their 6 p.m. pain medication, resulting in a pain complaint level of 9/10 and no documentation or notification provided to the nursing supervisor or physician, we have developed a comprehensive plan of correction to rectify the situation and prevent similar incidents from occurring in the future. Immediate action was taken upon discovering the error. A medication error incident report was promptly completed to document the details of the incident and its consequences. The resident was assessed for pain management and guidance was sought from the PCP on any additional actions that need to be taken. No further steps are required at this time. Additionally, disciplinary action was undertaken involving RN #5, who was responsible for the medication administration oversight in this case. RN #5 has been thoroughly re-educated on the proper protocols for medication administration, emphasizing the necessity of immediate notification to the nursing supervisor and physician whenever a concern or problem arises with medication administration. Residents affected by the deficient practice, like resident #116, have been individually assessed and their pain management needs reevaluated. Any necessary interventions were put in place promptly to address their pain levels and ensure their comfort based on discussion with their individual PCP. To identify other residents potentially affected by the same deficient practice, a thorough review of medication administration records was conducted for a period of one month prior to the event through the end of (MONTH) 2023. This will allow us to pinpoint any potential discrepancies and take corrective actions as needed to ensure all residents are receiving their medications as prescribed. Any and all MAR indicated [REDACTED]. A root cause analysis is being conducted in conjunction with the QAPI committee to ascertain why the concerns arose and ways to prevent them in the future. To prevent a recurrence of this deficient practice, several measures will be implemented. First, we will establish an enhanced system for medication administration documentation and notification. This system, which incorporates alerts within the EMR system, reports for nursing leadership, and updates to the policies, incorporates clear guidelines outlining reporting and escalation procedures in the event of a medication administration error. We have been collaborating closely with the Medical Director and individual PCPs to modify medication administration times, ensuring that residents receive their medications in a timely manner as indicated in the Medication Administration Record [REDACTED]. The associated policies have been reviewed and updated accordingly to these new changes. Further, audits will be conducted by the ADONs or designees to assess the adherence to proper protocols for medication administration and notification. All licensed nurses will be re-in-serviced to reinforce the significance of accurate medication administration and the essential need for notification of missed doses or concerns regarding residentsÆ health. To monitor the effectiveness of these corrective actions, a robust quality assurance program will be initiated. This program will involve periodic audits, as described below, of medication administration practices, documentation, and notifications. Any deviations from the established protocols will be addressed promptly, and staff will receive ongoing training to reinforce proper practices. The ADONs or their designees will conduct an audit using a specific audit tool weekly for eight (8) weeks then monthly for ten (10) months then as directed by the QAPI committee. All negative findings will be corrected immediately and reported to the ADON. All audit findings will be reported to the QAPI committee. The targeted completion date for all corrective actions is (MONTH) 30, 2023. The Director of Nursing will be responsible for overseeing the implementation and effectiveness of these corrective measures, ensuring the safety and well-being of our residents and the prevention of similar incidents in the future. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that medications were administered within one hour of the ordered administration time. This was identified for 1) one of three units in the [MEDICATION NAME] building on 8/1/2023; 2) one of three units in the Sagamore building on 8/6/2023; and 3) the facility did not ensure that an account of controlled drugs was maintained on each unit for one of three units in the Woodcrest building. Specifically, 1) on 8/1/2023 on the Woodcrest 3 unit during the 7:00 AM-3:00 PM shift, 13 residents ( Resident #200, #358, #120, #341, #45, #639, #319, #210, #366, #241, #387, #303, #169) did not get there 9 AM medications within one hour of the physician-ordered administration time; 2) Five (Resident #4, #261, #379, #426, and #442) of 30 residents on Sagamore 2 unit received medications beyond one hour of the scheduled administration time on 8/6/2023 during the 7:00 AM-3:00 PM shift due to insufficient staffing; and 3) On Woodcrest 3 unit the narcotic sheets were not reconciled with the amount of narcotic medications present in the blister pack for Resident #205. The findings include but are not limited to: The facility's policy titled Medication Administration, dated 5/14/2020, documented to promote medication safety, prevent medication errors, and to ensure that residents receive their prescribed medications in a timely and appropriate manner. Medication administration times will be strictly adhered to, and medications will be administered at the prescribed intervals. If a medication must be administered exactly at the time specified, the physician's orders [REDACTED]. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. 1). An example of one of the thirteen resident's affected on the [MEDICATION NAME] building: Resident #303 was admitted with [DIAGNOSES REDACTED]. The 7/7/2023 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. During an observation on 8/1/2023 at 11:11 AM of the [MEDICATION NAME] 3-unit, Registered Nurse (RN) #12, the unit coordinator was observed passing medications. RN #12 was interviewed on 8/1/2023 immediately after the observation and stated they (RN #12) were administering 9:00 AM medications. RN #12 stated they (RN #12) still had 13 more residents to administer the 9:00 AM medications to (Resident #200, #358, #120, #341, #45, #639, #319, #210, #366, #241, #387, #303, #169). RN #12 stated they (RN #12) were the only nurse on the unit and usually there are at least two medication nurses assigned to the unit for medication pass. RN #12 stated being the unit coordinator they also are responsible to take care of any other issues on the unit. Review of Resident #303's medication orders as of 8/1/2023 revealed the following: -Aspirin (blood thinner) 81 milligrams (mg) delayed release every day at 9:00 AM ([MEDICATION NAME]) [MEDICATION NAME] (supplement) 1 mg tablet every day at 9:00 AM (for hair loss). [MEDICATION NAME] 5 mg tablet, three times a day at 9:00 AM, 1:00 PM, and 5:00 PM (for anxiety). [MEDICATION NAME] 100 mg capsule three times a day at 9:00 AM, 1:00 PM, and 5:00 PM (for neuralgia-nerve pain) Vitamin D3 50 micrograms capsule, every day at 9:00 AM (supplement) [MEDICATION NAME] 2.5 mcg-Olodaterol 2.5 mcg actuation mist, inhale 2 puffs once daily at 9:00 AM (for [MEDICAL CONDITION]). Review of the Administration Documentation History Detail Report (a report indicating medication administration time) for 8/1/2023 for Resident #303 revealed the above 9:00 AM medications were administered at 11:52 AM. In addition, the 1:00 PM doses of [MEDICATION NAME] and [MEDICATION NAME] were administered at 12:46 PM as per the Administration Documentation History Detail Report (within one hour of the previous dose). RN #12 was re-interviewed on 8/3/2023 at 11:41 AM and stated they (RN #12) were currently giving out 9:00 AM medications. RN #12 stated usually there are two nurses, but RN #12 was alone again today. RN #12 was asked by the surveyor about the 9:00 AM doses of Diazapam and [MEDICATION NAME] being administered within one hour of the 1 PM doses on 8/1/2023. RN #12 stated it could happen because things get very confusing; RN #12 stated it is hard when you are alone giving medications for the whole unit. Resident #303 was interviewed on 8/3/2023 at 1:04 PM. Resident #303 stated they get [MEDICATION NAME] for Anxiety. Resident #303 stated sometimes the medications are late, like today the medications are late because they only have one nurse. Resident #303 stated they feel increased Anxiety if they do not get the [MEDICATION NAME] on time. Physician #2 was interviewed on 8/4/2023 at 12:30 PM. Physician #2 stated they were not aware that the [MEDICATION NAME] doses were given that close together on 8/1/2023. Basically, the antianxiety medication was given less than an hour apart. Physician #2 stated they will have to change the order for [MEDICATION NAME] to every 8 hours for the resident's safety. Resident #303 has a high tolerance to the medication, there was no real risk of toxicity, and it does not exceed maximum daily dose, but they (Physician #2) did change the scheduled administration time for the resident's safety. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 12:53 PM about the medications being administered late. The DNS stated they were aware of the issue with the late medication administration and the [MEDICATION NAME] doses being given within an hour of each other. The DNS stated they were not sure what the staffing issues were on the unit. The DNS stated the accepted standard is medications are due one hour before or one hour after the ordered time. The DNS stated the facility will have to do a medication error in-service education for the nurse. 2). During the Sufficient Staffing Task review the facility provided nursing schedules including a schedule dated 8/6/2023 which documented one Licensed Practical Nurse (LPN) and two Certified Nursing Assistants (CNAs) were scheduled on Sagamore 2 unit during the 7:00 AM to 3:00 PM shift. The nursing schedule did not include the name of a Registered Nurse Supervisor assigned to the unit. The facility Historical Census Summary Report dated 8/6/2023 documented that there was a total of 30 residents on Sagamore 2 unit resulting in an occupancy rate of 86%. The facility Administration Documentation History Detail Report (a report indicating medication administration time) dated 8/6/2023 documented the following late medication administrations on Sagamore 2 unit: -Resident #4 received Humalog Kwikpen Insulin 100 unit/milliliters subcutaneous injection at 1:48 PM. The medication was scheduled to be administered at 12:00 PM. Resident #4's blood glucose level was 201 milligrams/deciliter at 1:48 PM. -Resident #261 received Ademelog [MEDICATION NAME] U-100 Insulin [MEDICATION NAME] 100 unit/milliliters subcutaneous pen injection at 1:47 PM. The medication was scheduled to be administered at 12:00 PM. Resident #261's blood glucose level was 239 milligrams/deciliter at 1:47 PM. -Resident #379 received Ademelog [MEDICATION NAME] U-100 Insulin [MEDICATION NAME] 100 unit/milliliters subcutaneous pen injection at 10:00 AM. The medication was scheduled to be administered at 8:00 AM. Resident #379's blood glucose level was 210 milligrams/deciliter at 10:00 AM. -Resident #426 received Ademelog [MEDICATION NAME] U-100 Insulin [MEDICATION NAME] 100 unit/milliliters subcutaneous pen injection at 9:54 AM. The medication was scheduled for 8:00 AM. The next dose was administered at 1:45 PM when the insulin was scheduled to be administered at 12:00 PM. Resident #426's blood glucose level was 237 milligrams/deciliter at 9:54 AM and 280 milligrams/deciliter at 1:45 PM. -Resident #442 received [MEDICATION NAME] (drug used in the treatment of [REDACTED]. The medication was scheduled to be administered at 12:00 PM. Licensed Practical Nurse (LPN) #6, the medication nurse, was interviewed on 8/7/2023 at 2:09 PM. LPN #6 stated they (LPN) were the only nurse on Sagamore 2 unit on 8/6/2023 during the 7:00 AM to 3:00 PM shift. LPN #6 stated that there needs to be two nurses on Sagamore 2 unit to care for the 30 residents on the unit. LPN #6 stated that there were just two CNAs on the unit of 30 residents until 1:00PM then from 1:00 PM to 3:00 PM, there was just one CNA working with LPN #6 because the other CNA had a personal emergency and had to leave. LPN #6 stated that it is difficult to work alone on the unit because they are responsible for medication administration, wound care treatments, and documentation. LPN #6 stated that they were late for the medication pass on 8/6/2023 and the 9:00 AM medication administration was done by 11 AM and the 1:00 PM medications were administered by 3:00 PM. LPN #6 stated there were eight wound care treatments to do, all of which have to be pre-medicated one hour before treatment. LPN #6 stated that for one of the eight residents it takes up to 25 minutes for one wound care treatment. LPN #6 stated that some of the wound care treatments are tied with brief changes, which further interrupts medication administration. LPN #6 stated that there 12 residents who require two-person assistance so that they may be pulled to assist the CNA with care. LPN #6 stated that the 7:00 AM to 3:00 PM shift was especially challenging because Resident #361 was actively passing away and required [MEDICATION NAME] to be administered every 2 hours. LPN #6 stated that they (LPN #6) provided emotional support for Resident #361 and the family throughout the shift on top of their normal duties. LPN #6 stated that the workload snowballs due to interruptions. LPN #6 stated all of the interruptions causes subsequent medication administrations to be late. LPN #6 stated that there is no way to get everything done on time. LPN #6 stated that they informed RN #5, who was their supervisor, when the CNA had to go home early and RN #5 told LPN #6 to prioritize toileting the residents since that is an emergency. RN #5 was interviewed on 8/10/23 at 10:11 AM. RN #5 stated that they (RN #5) were assisting in multiple units between the Sagamore and the Woodcrest buildings on 8/6/2023. RN #5 stated that they cannot recall if LPN #6 told RN #5 about the CNA going home early. RN #5 stated that if LPN #6 told that them there was just one CNA on Sagamore 2 unit, they would tell LPN #6 to prioritize toileting the residents and keeping the residents comfortable. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:39 PM. The DNS stated that if there are not enough staff available on a unit, it is expected that the supervisor for the unit is to assist with care and to pull other staff members from another unit to fill the needs. 3) Resident #205 was admitted with [DIAGNOSES REDACTED]. The 5/29/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. A physician's orders [REDACTED]. The medication cart on Woodcrest 3 unit was observed with LPN #4 on 8/8/2023 at 1:16 PM. Review of the narcotic log compared to the blister pack for the Resident #205's [MEDICATION NAME] revealed the blister pack had 8 tablets left, while the narcotic log listed 10 medications left. LPN #4 just signed off the narcotic log in front of the surveyor for the two tablets of [MEDICATION NAME] that were administered earlier in the day. LPN #4 stated they (LPN #4) gave the two tablets at 8:30 AM and 12:30 PM, respectively, and did not get a chance to sign for the medications in the narcotic log. LPN #4 stated they (LPN #4) were the only nurse on the unit. RN #2 (unit supervisor) was interviewed on 8/8/2023 at 2:53 PM. RN #2 stated they just heard about the incident within the hour and spoke to LPN #4 regarding the importance of signing the narcotic log. RN #2 stated being short-handed was no excuse and LPN #4 will be in-serviced. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 07:30 AM. The DNS stated when the medication was taken out of the blister pack, it should have been logged in the narcotic book (log). 10 NYCRR 415.18(a) | Plan of Correction: ApprovedSeptember 27, 2023 F - 0755 In response to the identified medication administration concerns related to F755, we are committed to implementing a robust plan of correction to prevent similar incidents and uphold the highest standards of medication management within our nursing home. 1. Immediate Corrective Actions For the residents found to have been affected by the deficient practice (residents #303, 4, 261, 379, 426, 442, 205) Medication Error Investigations were conducted, and the residentÆs primary care physician (PCP) was informed. The staff involved, (RN #2, 5, 12 - LPN #4, 6), received education on medication administration timeliness. Further, a re-education program for all licensed nurses (RNs and LPNs) was conducted, focusing on the importance of administering medications in a timely manner and narcotic logs. Further, LPN #4 has received discipline and re-education regarding narcotic signing and counting. Responsible parties: Director of Nursing, Attending Physicians, Administrator 2. Identification of other residents All residents are potentially affected by this practice. A comprehensive assessment of the eMAR was conducted across all units for the preceding month to determine whether medications were administered according to their designated schedules. In cases where the administration time was delayed, a thorough medication error report was documented. Furthermore, the PCP will be promptly informed of any such instances. A root cause analysis is being conducted in conjunction with the QAPI committee to ascertain why the concerns arose and ways to prevent them in the future. Responsible Parties: Director of Nursing, Consultant Pharmacist 3. Systemic Changes The existing policy was thoroughly reviewed by the Medical Director, Director of Nursing, Consultant Pharmacist, and Administrator and was determined to be in compliance with current guidance on appropriate medication administration times and safe medication practices. The Director of Nursing, working with nursing supervisors and educational materials provided by the consultant Pharmacist provided re-education to the registered nurses (RN) and licensed practical nurses (LPN) on medication pass procedures, and specifically the timeliness of medication administration. In addition, all licensed nursing staff have been provided with the current policy and procedure. Using information available from the facilityÆs Electronic Medical Record (EMR) System, the facility Nurse Managers will implement a report-based program to assess the timeliness of medication administration. This will be accomplished by generating reports from the EMR system either at the conclusion of the shift or during the next suitable period when a nursing manager is available to look at any unreviewed shifts' medication administration. The Facility Administrator and Director of Nursing will be informed of any variances. Additional staffing and staff re-education will be provided as necessary. Responsible parties: Medical Director, Director of Nursing, Consultant Pharmacist, Administrator 4. QA Monitoring: The facility plans to monitor its performance to make sure that solutions are sustained by taking the following actions. Nurse managers will conduct regular audits to oversee and address the identified deficiencies of medication administration times and narcotic books. These audits will be carried out by nurse managers, supervisors, or designated personnel on a 10% sample of residents from each unit. The audit tool they will use has been developed by the Director of Nursing to ensure all appropriate areas are addressed. The audit schedule will encompass weekly assessments across all shifts for a duration of four (4) weeks, followed by monthly audits for the subsequent five (5) months, and as directed by the QAPI committee. In cases where unfavorable outcomes are identified, immediate corrective actions will be implemented and subsequently reported to the Assistant Directors of Nursing. All audit findings will be communicated to the QAPI committee to ensure transparency and ongoing improvement efforts. Responsible parties: Director of Nursing We are committed to rectifying these deficiencies promptly and maintaining the highest quality of care for our residents. The target date for completion of this plan of correction is (MONTH) 30, 2023, and the Director of Nursing will be responsible for implementation of this plan. This plan of correction represents our dedication to continuous improvement and maintaining the highest standards of care within our nursing home. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 20, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for 1) one (Resident #318) of three residents reviewed for skin conditions and 2) for one (Resident #455) of one resident reviewed for Restraints. Specifically, 1) Resident #318 did not receive the physician ordered wound treatment to the resident's bilateral legs on 8/6/2023. 2) Resident #455 with [DIAGNOSES REDACTED].#455 was observed without wearing the helmet. Additionally, the physician's orders [REDACTED].#8 without notifying the resident's Physician. The resident was evaluated by the Nurse Practitioner (NP) #2 on 8/7/2023 who reordered the helmet to be worn at all times. The findings include: 1) The facility's policy titled Wound Interventions-Miscellaneous Wound Treatments, revised 2/18/2022, documented it is the policy of the facility to provide wound interventions to assist in the development of a care plan. These interventions will be selected based on the individual needs of the resident. Resident #318 was admitted with [DIAGNOSES REDACTED]. The 7/15/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had three Venous/Arterial ulcers. Treatments included application of non-surgical dressings and application of ointments and medications. physician's orders [REDACTED]. physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) titled Skin Integrity: Venous Left Lower Leg-Chronic Venous Ulcer, effective 10/5/2021 and last updated 7/31/2023 included a wound care note: Seen by wound care team for weekly follow up 7/31/2023- Left Lateral leg (venous) measures same: 18.0 centimeters (cm) x 12.0 cm x 0.3 cm with 90% yellow, 10% pink, large drainage. A CCP titled Skin Integrity: Right Posterior Lower Leg, effective 1/16/2023 and last updated 7/31/2023 included a wound care note: Seen by wound care team for weekly follow up 7/31/2023- Right posterior leg measures same 25.0 cm x 25.0 cm x 0.2 cm with 90% yellow and 10% pink, large drainage. A CCP titled Skin Integrity: Venous Right leg (Anterior) effective 11/8/2022 and last updated 7/31/2023 included a wound care note: Seen by wound care team for weekly follow up 7/31/2023- Right lower anterior leg measure same 6.0 x 4.5 x 0.2 with 90% yellow 10% Pink with large drainage. Resident #318 was observed in their room on 8/1/2023 at 11:02 AM. The resident had dressings to both lower extremities. Resident #318 stated the dressing changes are supposed to be done every day, but there have been days when the dressing changes were note done, especially on weekends because of staffing. Resident #318 stated the nurses tell them that they (nurses) do not have time to do their treatments. Registered Nurse (RN) #11 was interviewed on 8/10/2023 at 8:17 AM and stated on 8/6/2023 (Sunday) they (RN #11) were assigned as the medication and treatment nurse on Woodcrest 1 unit. RN #11 stated they were alone and did not get any assistance. RN #11 stated they explained to the Resident #318 that they could not do the ulcer treatments because they (RN #11) did not have time. RN #11 stated they thought someone was going to come in at 3:00 PM to help, but that did not happen. RN #11 stated they did not notify the doctor that the treatment was not done; however, they (RN #11) informed RN #10 (supervisor) that the treatments were not completed for Resident #318. Review of the (MONTH) 2023 Treatment Administration Record (TAR) revealed that the wound treatments for the bilateral lower leg ulcers and the monitoring of the dressings were not signed for on 8/6/2023. Review of the medical record revealed no progress notes addressing the missed treatments on 8/6/2023. Physician #1 was interviewed on 8/10/2023 at 9:40 AM and stated the resident has Chronic [MEDICAL CONDITION]. Physician #1 stated many people at home miss treatments. Physician #1 stated they (Physician #1) were not happy about the missed treatment, and they were not aware that the treatments were missed. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 10:44 AM and stated for missed treatments, the doctor has to be informed; the family has to be informed; we have to determine if there were any negative effects; there has to be a missed treatment investigation; and the staff has to be educated regarding the importance of following the physician's orders [REDACTED]. Resident #318 was observed on 8/10/2023 at 11:06 AM during the wound treatments to the bilateral lower extremities. The wound care nurse (RN #9) was performing the treatment and was assisted by Licensed Practical Nurse (LPN) #13. RN #9 was informed that there was a missed treatment on 8/6/2023 and RN #9 stated, I need the treatments done as ordered because there is a lot of drainage, and if it is missed on the day shift it should be done on the PM shift or brought to the supervisor's attention and be put on report. RN #10, the Nursing Supervisor, was interviewed on 8/10/2023 at 12:43 PM. RN #10 stated they were covering all of the buildings on Sunday, 8/6/2023. RN #10 stated that RN #11 did not notify them (RN #10) that they (RN #11) could not get to the treatment for [REDACTED]. RN #10 stated if RN #11 told them, they would have helped or got someone to help. 2) The facility's policy titled Use of Helmets for Resident Safety and dated 12/29/2022 documented to ensure the resident's protection, comfort, and well-being while adhering to the prescribed safety measures. Residents requiring the use of a helmet will have undergone a medical assessment, are prescribed based on the resident's medical condition, safety needs, and recommendations of the healthcare provider. A care plan will be developed and will include details about the helmet's usage, fit, maintenance, and monitoring. Residents will wear the prescribed helmet as directed by the healthcare provider and outlined in their care plan. Staff will monitor residents to ensure the helmet is worn as required and is properly secured. Staff will document the helmet's usage in the resident's record, including the times when the helmet is worn, removed and repositioned. Resident #455 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making and both short and long term memory problems. The resident was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toilet use. The resident was totally dependent on one person for eating and personal hygiene. The Comprehensive Care Plan (CCP) titled, Activity of Daily Living (ADL) Functional/Rehabilitation Potential initiated on 12/30/2022 and updated on 8/8/2023, documented selfcare deficit as evidenced by decreased mobility, ambulation and transfers. The intervention effective 1/6/2023 documented Helmet at all times. Remove every shift for skin check and hygiene. The CCP for Behavioral Symptoms/Dementia effective 12/31/2022 and last revised on 8/9/2023 documented the resident exhibited behaviors of kicking others, verbally threatening others, hitting and scratching self, disrobing in public, combative during care, pulling at feeding tube and crawling on the floor. A Physician's (MD) order dated 1/6/2023 documented Resident #455 was to wear a helmet at all times and to remove every shift for skin check and hygiene. The following observations of Resident #455 were made: -On 8/1/2023 at 10:50 AM Resident #455 was observed dressed in a hospital gown and not wearing a helmet. -On 8/3/2023 at 12:05 PM there was a strong odor of feces in the hallway which was emanating from Resident #455's room. Resident #455's room door was open, and the resident was observed in bed wearing a hospital gown and lying on their side with their buttock's exposed. Resident #455 was not wearing a helmet. A disposable incontinence pad was placed beneath their buttocks. Fecal material was present on the incontinence pad and was smeared on the bed sheet and the hospital gown. -On 8/3/2023 at 12:31 PM there was a strong odor of feces in the hallway which was emanating from Resident #455's room. Resident #455's room door was open, and the resident was observed in bed wearing a hospital gown and lying on their side with their buttock's exposed. Resident #455 was not wearing a helmet. A disposable incontinence pad was placed beneath their buttocks. Fecal material was present on the incontinence pad and was smeared on the bed sheet and the hospital gown. Certified Nursing Assistant (CNA) #15 was interviewed on 8/3/2023 at 12:31 PM and stated they were the assigned CNA for Resident #455. CNA #15 stated they were just about to provide incontinence care to the resident as they knew that the resident was soiled with feces; however, they were waiting to finish passing the lunch trays. On 8/3/2023 at 2:07 PM Resident #455 was dressed in a hospital gown and was not wearing a helmet. On 8/3/2023 at 2:22 PM Resident #455 was observed in bed wearing a hospital gown and was not wearing a helmet. On 8/4/2023 at 2:37 PM Resident #455 was observed in bed not wearing a helmet. The Physical and Occupational Therapy Evaluations and Plans of Treatment both dated 12/31/2022 documented the resident had the following medical precautions/contraindications: falls/safety, helmet. The Certified Nursing Assistant (CNA) Accountability Record from (MONTH) 30, 2022 through (MONTH) 6, 2023 were reviewed. The CNA Accountability Record did not include use of the helmet. MD order, written by the Licensed Practical Nurse (LPN) #8, dated 8/3/2023 documented to discontinue the use of helmet. The order was signed by Physician #3 on on 8/7/2023. The medical progress note dated 8/7/2023, written by Nurse Practitioner (NP) #2 documented Although patient is not compliant with helmet, I will continue order to keep helmet in place pending neurosurgery follow up. The MD order dated 8/7/2023 documented to use the helmet at all times and to remove every shift for skin check and hygiene. The order was signed by NP #2. CNA #15, the assigned 7:00 AM - 3:00 PM CNA, was interviewed on 8/4/2023 at 12:37 PM. CNA #15 stated they have worked with Resident #455 since they were admitted in (MONTH) of 2022. CNA #15 stated the resident wore a helmet when physical therapy transferred them (Resident #455) from the bed to a geriatric recliner and moved them (Resident #455) to the dining area. CNA #15 looked in the resident's room, but no helmet was found. Physician #3, the resident's Primary Care Physician, was interviewed on 8/7/2023 at 10:42 AM and stated that they did not write the order to discontinue the use of the helmet for Resident #455. Physician #3 stated that the helmet discontinuation order was entered by someone else, and they (Physician #3) just signed off on the order. Physician #3 stated they were not too familiar with Resident #455 and the Nurse Practitioner who saw the resident should be contacted for more detailed information. Licensed Practical Nurse (LPN) #8 was interviewed on 8/7/2023 at 11:17 AM and stated they were instructed by Registered Nurse (RN) #7 to review resident charts and to discontinue devices that were no longer being used. LPN #8 stated they discontinued the helmet order on 8/3/2023 and did not write a progress note with an explanation why the helmet was discontinued. LPN #8 stated they did not remember Resident #455 ever wearing a helmet and there was no helmet in their (Resident #455) room. LPN #8 stated they would not have discontinued the helmet order on their own. LPN #8 stated they do not specifically remember who they communicated with to obtain the helmet discontinuation order. LPN #8 stated they may have spoken to either NP #1 or NP #2. LPN #8 stated they wrote a note in the unit's green book, which is a book used by the nurses to communicate with the Doctors and the NPs. A review of the communication book on 8/7/2023 at 2:47 PM confirmed that LPN #8 wrote a note dated 8/3/2023 that documented Resident #455 no longer wears helmet, not getting out of bed, needs one to one in chair. NP #2 was interviewed on 8/7/2023 at 11:24 AM and stated they wrote the order for the helmet when the resident was admitted because it was probably an order from the Neurosurgeon. NP #2 stated they did not discontinue the order for the helmet on 8/3/2023. NP #2 then stated they were not contacted by anyone from the facility regarding Resident #455's helmet order. NP #2 stated that the resident should have been assessed before the helmet was discontinued and a corresponding progress note should have been written. NP #1 was interviewed on 8/7/2023 at 12:45 PM. NP #1 stated they were not contacted by anyone from the facility regarding the helmet order. RN #7 was interviewed on 8/7/2023 at 12:51 PM and stated that they gave a directive to LPN #8 to discontinue devices that were no longer necessary for all residents. RN #7 stated LPN #8 should have reached out to the resident's Physician or the NP to confirm if the helmet could be discontinued. RN #7 stated Resident #455 does not have fractures of the skull or soft spots that require a helmet, but the NP needed to do an evaluation before the helmet was discontinued. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:14 PM and stated for a new admission, the admitting nurse communicates the hospital discharge orders to the admitting doctor and the doctor will either agree or disagree with the orders. The admitting nurse is also responsible for initiating the CNA Accountability. The helmet orders were initiated on 1/6/22 not on the admission day. 10 NYCRR 415.12 | Plan of Correction: ApprovedSeptember 17, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** In response to the deficiencies related to F684, involving inadequate skin care for resident #318 and discontinuation of a medical helmet without physician's sign-off for resident #455, we have developed a comprehensive plan of correction to address the issues, enhance the quality of care, and prevent similar occurrences in the future. For resident #318, corrective actions were taken to provide proper skin care to address any issues resulting from the deficient practice. Resident #318 receives comprehensive wound care, including weekly treatment and assessment by the facility's dedicated wound care nurse. In addition to the care provided by the wound care nurse, the resident benefits from a multi-disciplinary approach to wound management. This includes regular evaluation and treatment by the consultant wound care doctor at the facility, as well as consultations with wound care specialists in the hospital for second opinions. The primary care physician was informed of the treatment not being done and the family was informed on (MONTH) 30, 2023. The staff responsible for the residentÆs treatment was educated and disciplined on (MONTH) 28, 2023, including RN#11, RN#10. Resident #455's medical helmet discontinuation was also addressed. The nurse who discontinued the helmet was educated and discipline imposed on (MONTH) 30, 2023, due to deficient practice. The NP overseeing the resident re-ordered the helmet to always be worn. The residentÆs CNA accountability record and the CCP were updated to include the current order. CNA # 15 was educated and disciplined due to deficient practice on (MONTH) 30, 2023. To identify other residents who may have the potential to be affected by similar deficient practices, a check of any resident who required immediate care was rendered. Residents who required devices were checked to ensure they were in place according to the residentsÆ orders. Any residents with inadequate skin care or treatments will have their care promptly addressed and documented in accordance with physician orders. To prevent the recurrence of these issues, systemic changes will be implemented. The associated policies have been reviewed and no changes are needed at this time. Nursing staff, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs), will receive re-education on quality-of-care practices, emphasizing the importance of adhering to physician orders, providing treatments, and following established protocols for treatment discontinuations. To ensure ongoing compliance and the provision of high-quality care, a quality assurance program will be initiated. Audits, utilizing a specially designed tool, will be conducted to verify that devices and treatments are being administered according to physician orders [REDACTED]. All negative findings will be corrected when found. All audit outcomes will be reported to the QAPI committee. The target date for completing these corrective actions is (MONTH) 20, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain committed to enhancing the quality of care provided to our residents and upholding the highest standards of resident safety and well-being. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 15, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that each resident could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside. This was identified 1) one (Resident #343) of eight residents reviewed for Activities of Daily Living (ADL) and 2) one (Resident #259) of three residents reviewed for the communication-sensory care area. Specifically, 1) On 8/1/2023, Resident #343's call light was wrapped over the head of the bed frame while the resident was in bed. The call bell was not in view or within reach of the resident. 2) Resident #259, with [DIAGNOSES REDACTED]. The findings are: The facility's policy, titled Call Light, dated 1/10/2023, documented every resident must have a call light attached from the wall unit to their bed at all times. When a resident is in bed or sitting at the bedside, the call light switch must be within their reach. Always place the call light within the resident's reach. If the call bell is defective, report immediately to maintenance and to the Charge Nurse. Provide resident with an alternate means of calling for assistance. 1). Resident #343 was admitted with [DIAGNOSES REDACTED]. The 7/23/2023 Annual Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The MDS documented that the resident required extensive assistance of one person for personal hygiene and required supervision and set-up for eating. The MDS documented the resident had no limitations in upper extremity range of motion. Resident #343 was observed lying in bed in a hospital gown with a towel over their chest/abdomen on 8/1/2023 at 11:32 AM. The overbed table was observed over the resident's bed. Coffee had spilled onto the towel. Another liquid was observed spilled on the overbed table. The resident's call bell was behind the resident on the headboard. The call bell was not within view of the resident nor within the resident's reach. The resident stated they (Resident #343) could not reach the call bell and the coffee spill happened about two hours ago. Resident #343 was observed by unit Registered Nurse (RN) #1 with the surveyor present on 8/1/2023 at 11:36 AM. RN #1 removed the coffee soiled towel and observed that the sheet under the towel and the hospital gown were also wet with coffee. RN #1 then placed the resident's call bell at the resident's right side and left the room. Resident #343's 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) #2 was interviewed on 8/4/2023 at 2:47 PM and stated they were assigned to Resident #343 on 8/1/2023. CNA #2 stated they (CNA #2) do not think Resident #343 can use the call bell, but they always place it within the resident's reach. Resident #343 was observed in bed on 8/7/2023 at 10:50 AM. The call light was observed near the resident's right hand. The resident was asked by the surveyor if they (resident) were able to activate the call light. The resident stated, sure, and then activated the call light. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:50 PM and stated call bells should be functional and within reach of the resident. 2) Resident #259 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The resident required extensive assistance of two persons with bed mobility, transfer, locomotion on and off the unit, dressing, and toilet use. The Comprehensive Care Plan (CCP) for visual function initiated on 6/13/2023 documented Resident #259 had a visual deficit related to [MEDICAL CONDITION] in the right eye. Interventions include ophthalmology and optometry consults as appropriate, leave furniture in their room in the same position, encourage to ask for assistance as needed, eyeglasses on when awake, eye drops as ordered, maintain eyeglasses (e.g., label, clean and repair) provide large print reading materials, provide talking books, audio tapes as per resident interests and provide assistive devices as needed. Resident #259 could be heard yelling in their room on 8/1/2023 at 11:43 AM. Resident #259 was observed in bed with their call bell clipped to the upper right side of their pillow. The resident stated they were unable to find their call bell and could not ring for assistance. Resident #259 was informed of the location of their call bell. Resident #259 stated they were blind in their right eye and were unable to see the call bell. The resident stated they needed to go to the bathroom because they had a bowel movement while in bed. There was a noticeable odor of feces present in the room. Resident #259's was heard yelling in their room on 8/3/2023 at 12:18 PM. Resident #259's call bell was observed on the floor next to their bed with a broken clip. Resident #259 stated they needed to use the bathroom. Certified Nursing Assistant (CNA) #27 entered Resident #259's room with the resident's lunch tray on 8/3/2023 at 12:18 PM. CNA #27 stated Resident #259 likes to keep the call bell near them, but the call bell clip was broken. CNA #27 picked up the call bell and placed the call bell in the resident's hand. On 8/4/2023 at 12:05 PM Resident #259's call bell was observed on the floor next to their bed with a broken clip. Licensed Practical Nurse (LPN) #8 was interviewed on 8/4/2023 at 12:07 PM. LPN #8 stated they were not aware that the clip for Resident #259's call bell was broken. LPN #8 stated they were not asked by CNA #27 to complete a maintenance order for the call bell clip. LPN # 8 picked up the call bell and placed the call bell in Resident #259's hand. LPN #8 stated when a CNA reports a maintenance problem, they (LPN #8) are responsible for submitting a maintenance work order. A maintenance work order dated of 8/4/2023 at 12:09 PM was reviewed and documented Resident #259 needed a new clip for their call bell. CNA #27 was re-interviewed on 8/8/2023 at 11:56 AM. CNA #27 stated they knew Resident #259's call bell clip was broken on 8/3/2023 and they (CNA #27) should have reported to the charge nurse right away. CNA #27 stated they forgot to report the broken call bell clip to the charge nurse. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:34 PM. The DNS stated that alert and oriented resident's call bells should be functioning and within reach of the resident at all times. 10 NYCRR 415.29 | Plan of Correction: ApprovedSeptember 17, 2023 F-0919 In response to the concerns raised regarding the positioning of call bell devices and their accessibility to residents #343 and #259, we have developed a comprehensive plan of correction to ensure that call bells are within reach and functioning properly for all residents, promoting their safety and well-being. For residents found to have been affected by the deficient practice, corrective actions will be taken to ensure their safety and comfort. Specifically, for residents #343 and #259, call bell devices were repositioned within their reach, and any concerns they may have had were promptly addressed. CNA #2 and CNA # 27 were educated and disciplined appropriately. To identify other residents who might potentially be affected by similar issues, we will extend our audit to all resident rooms to verify the positioning and functionality of their call bell devices. Any necessary adjustments will be made promptly to ensure that all residents can reach their call bells without difficulty. Education is a crucial component of our corrective action plan. All staff members will receive comprehensive training on call bell usage and best practices. This education will encompass responding promptly to call bells, ensuring that call bell devices are within reach of residents, and promptly reporting any malfunctioning or broken devices to the maintenance team for immediate resolution. To prevent the recurrence of this issue, systemic changes will be implemented including new protocols for positioning and maintaining call bell devices to ensure that they always remain within residentsÆ reach. Further, the policies for call bells have been reviewed and updates made to specify the steps that are needed to be taken should a call bell not be in an appropriate location or if damaged and needing a replacement. To address the issue, we will conduct a thorough facility-wide audit of all call bells. This audit will determine the functionality of each call bell and ensure that they are positioned within easy reach of the residents. For the initial month, weekly audits will be conducted to closely monitor the call bell systems and their positioning. Following this, monthly audits will be conducted for the next eleven (11) months, then as instructed by the QAPI committee to reinforce compliance and maintain effective call bell accessibility. These audits will be conducted by the unit manager or designee. All negative findings will be addressed immediately through counseling with the employee. All audit outcomes will be reported to the QAPI committee. The target date for completing these corrective actions is (MONTH) 15, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain committed to maintaining the highest standards of resident care and safety within our nursing home. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 1, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure that each resident is treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of their quality of life. This was identified for one (Resident #224) of one resident reviewed for resident rights. Specifically, during a lunch meal observation on 8/1/2023 at time 1:05 PM Registered Nurse (RN) #13 was observed standing over Resident #224 while feeding the resident. The finding is: The facility's policy titled Assisting with Feeding dated 10/26/2022 documented to provide assistance with feeding to residents who require it as part of their care plan in the nursing home. This policy aims to ensure that residents receive proper nutrition and hydration, maintain their overall health, and experience a comfortable dining experience. Staff will respect residents' preferences and dignity while assisting with feeding. Resident #224 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) was not performed because the resident was rarely/never understood. The resident required limited assistance of one person for eating. During the Dining Task observation conducted on 8/1/2023 at 1:05 PM Resident #224 was observed in the dining area, seated in a wheelchair at a dining table. RN #13 was observed standing over Resident #224 feeding the resident their lunch meal. Resident #224's head was tilted backwards with their neck extended. The resident's mouth was open and the eyes were gazing up at the ceiling. The Comprehensive Care Plan (CCP) for Nutritional Status initiated on 1/4/2022 and last reviewed on 7/6/2023 documented that the resident was at risk for altered nutritional status related to: Dementia, Depression, and Vitamin D/B12 Deficiency. The interventions included to allow the resident to make food preference(s) known, to assist the resident with feeding/fluids as needed and, to encourage intake of meals and fluids. The CCP for ADL Functional/Rehabilitation Potential initiated on 1/3/2022 and last reviewed on 7/23/2023 documented the resident is to be provided with limited assistance at mealtimes. RN #13 was interviewed on 8/1/2023 at 1:09 PM and stated Resident #224 usually eats by themselves but they (RN #13) wanted to assist the resident before the resident's food got cold. RN #13 stated they knew they should be seated when assisting a resident with eating. The Assistant Director of Nursing Services (ADNS), RN #12, was interviewed on 8/3/2023 at 3:04 PM. ADNS, RN #12 stated when a staff person is assisting a resident with eating the staff person should be seated next to the resident. RN #13 was re-interviewed on 8/10/2023 at 10:18 AM and stated they made a mistake by standing to feed the resident. RN #13 stated the proper way of assisting a resident at mealtime is to be seated next to the resident and allow the resident to do what they can while providing encouragement. Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:34 PM and stated when meal assistance is provided, the resident should be encouraged to feed themselves as much as possible, and provided with encouragement. The staff should be seated next to the resident and not standing while feeding the resident. 10 NYCRR 415.3(d)(1)(i) | Plan of Correction: ApprovedSeptember 15, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** General Information In response to the recent New York State Department of Health (NYSDOH) survey conducted from (MONTH) 1, 2023, through (MONTH) 10, 2023, our nursing home is committed to addressing the identified deficiencies promptly and effectively. To ensure the development and implementation of an acceptable plan of correction, we have enlisted the expertise of an external consultant. With more than [AGE] years of nursing experience, including a distinguished tenure as a director of nursing, the consultant brings valuable insights and knowledge to guide our corrective actions. She is affiliated with a group that is known for its commitment to quality healthcare consultation. Moreover, we are convening the facility's Quality Assurance (QA) Committee to comprehensively examine the deficiencies highlighted in the survey report. The QA Committee's focus will be on diligently addressing each deficiency and taking additional measures as needed to rectify any underlying issues. The committee's approach will encompass the following key areas: A. A thorough assessment of causative factors contributing to the identified deficiencies will be undertaken. This assessment will involve an in-depth analysis of processes, procedures, and potential gaps that may have led to the deficiencies. B. Specific interventions and steps will be identified to eliminate and correct the causative factors unearthed during the assessment phase. These interventions will be targeted and tailored to address the root causes of each deficiency. C. To proactively address evolving problems or deficient practice situations, the facility will establish routine triggers or parameters. These signals will alert all staff members to potential issues and prompt timely action. The system will be meticulously carried out through consistent monitoring, reporting mechanisms, and clear communication channels. D. The facility will implement a robust measurement system to evaluate the success or shortcomings of our efforts in maintaining compliance. This measurement will involve tracking relevant metrics, regularly assessing outcomes, and comparing our progress against established benchmarks. Adjustments to the plan of correction will be made based on these evaluations to ensure sustained compliance and improved practices. As we move forward, the combined expertise of the consultant and our dedicated QA Committee will guide us in implementing effective strategies to address the deficiencies identified in the NYSDOH survey. We are fully committed to providing the highest quality of care to our residents and maintaining a culture of continuous improvement. The targeted actions outlined above reflect our dedication to this commitment and our pursuit of excellence in resident care. F550 In response to the observed incident involving RN #13 standing over resident #224 while feeding, we have developed a comprehensive plan of correction to address the deficient practice, ensure resident dignity, and prevent similar incidents from occurring in the future. For residents found to have been affected by the incident, immediate corrective actions will be taken to address any potential discomfort or distress they may have experienced. Resident #224 will be provided with additional support and counseling, if needed, to address any emotional impact resulting from the incident. Employee # 13 was in-serviced on (MONTH) 28, 2023, regarding the deficient practice. To identify other residents who may potentially be affected by a similar deficiency, we will conduct a thorough review of feeding practices for all residents. All residents were observed during feeding on (MONTH) 29, 2023, by nursing supervision, no other staff were observed standing while assisting residents at mealtime. After a thorough review of the current policies regarding resident rights and assisting residents with feeding, it was determined that no changes were needed. Nevertheless, in an unwavering commitment to upholding resident rights and preserving their dignity, the facility has established a comprehensive employee policy that underscores the importance of respecting resident rights and ensuring their dignity at all times, with immediate corrective actions specified for any instances of noncompliance. In light of our renewed focus on resident dignity, particularly concerning the feeding process, the facility is dedicated to ensuring that all members of our healthcare team are well-equipped and informed. To this end, comprehensive re-education sessions will be scheduled for all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), as well as members of the Occupational Therapy and Speech Therapy departments. These educational initiatives will further reinforce our commitment to upholding resident rights and dignity, enhancing the quality of care provided to our residents, and fostering an environment of respect and empathy throughout the facility. In order to effectively monitor and enforce compliance with our established resident dignity policies, the facility has introduced a specialized audit tool. This tool will serve as a meticulous checklist to evaluate adherence to resident rights and dignity standards, particularly during feeding procedures. Audits will be conducted on a weekly basis for an initial period of eight (8) weeks, ensuring a thorough and consistent assessment of our practices. Subsequently, the auditing frequency will transition to a monthly schedule for the following four (4) months, maintaining a proactive approach to oversight. As the Quality Assurance and Performance Improvement (QAPI) committee guides our quality improvement efforts, any negative findings during these audits will be promptly addressed and corrected without delay. Furthermore, all audit results, whether positive or negative, will be diligently reported to the QAPI committee, fostering transparency and accountability in our ongoing commitment to resident dignity and care excellence. The target date for completing these corrective actions is (MONTH) 1, 2023. The Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain dedicated to maintaining the highest standards of resident dignity and care within our nursing home. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 15, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 549) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure each resident was free from any significant medication errors. This was identified for one (Resident #638) of one resident reviewed for significant medication errors. Specifically, on 7/18/2022 Resident #638 received two doses [MEDICATION NAME](hypnotic for sleep which is a controlled substance), 10 milligrams each, for a total of 20 mg. The physician order [REDACTED]. The finding is: The facility's policy, titled Medication Administration, dated 5/14/2020, documented to promote medication safety, prevent medication errors, and to ensure that residents receive their prescribed medications in a timely and appropriate manner. Medication administration will be conducted according to each resident's individualized care plan and physician's orders [REDACTED]. Nursing home staff will carefully review each medication order for accuracy, including the medication name, dosage, route of administration, and administration time. Medication Administration Records (MARs) will be accurately completed, signed, and dated by the administering staff member immediately after medication administration. Resident #638 was admitted with [DIAGNOSES REDACTED]. The 7/7/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident received antianxiety, antidepressant, and hypnotic medications. A physician's orders [REDACTED]. A nursing progress note dated 7/18/2022 at 2:12 AM, written by Registered Nurse (RN) #6, the 11:00 PM-7:00 AM medication nurse, documented the physician (Physician #2) was notified that Resident #638 was [MEDICATION NAME] mg twice tonight. The physician ordered to transfer the resident to the emergency room for evaluation. Resident #638 was alert with clear speech and appropriate responses; the resident left the unit at 2:00 AM in stable condition via stretcher with two attendants. A message was left for the family to call the unit. Review of the controlled substance disposition record for Resident #638's [MEDICATION NAME] 10 mg documented that on 7/18/2022 the midnight dose (12:00 AM) was first signed for by Licensed Practical Nurse (LPN) #3, the 3:00 PM-11:00 PM medication nurse indicating that LPN #3 took a tablet from the blister pack, bringing the count down to three tablets. RN #6 also signed the controlled substance disposition record on 7/18/2022 indicating that RN #6 also took a tablet from the blister pack, bringing the count down to two tablets. Review of the (MONTH) 2022 Medication Administration Record (MAR) revealed that the 7/18/2022 [MEDICATION NAME] 10 mg was signed for by RN #6, and not LPN #3. The medication error report dated 7/18/2022 concluded that the 3:00 PM-11:00 PM nurse (LPN #3) administered the 10 mg [MEDICATION NAME] and did not communicate to the 11:00 PM-7:00 AM nurse (RN #6) that the 12 AM medication was administered. The conclusion further documented that RN #6 failed to check the narcotic log, which would have shown that the medication was already given. The recommendations were that the nurses had to follow the rules of medication administration. Physician #2 was interviewed on 8/4/2023 at 12:30 PM and stated it was dangerous to give the double dose (20 mg) [MEDICATION NAME] a resident that age. Physician #2 stated that is why the resident was sent to hospital. Physician #2 stated there was a risk because 20 mg exceeds the maximum daily dose of 12.5 mg. Physician #2 stated everything was ok with the resident. RN #6 was interviewed on 8/5/2023 at 9:20 AM and stated they (RN #6) were the assigned medication nurse for Resident #638 on 11:00 PM-7:00 AM shift on 7/17/2022-7/18/2022. RN #6 stated they (RN #6) signed [MEDICATION NAME] the MAR and the narcotic log. RN #6 stated the nurse before them, LPN #3, gave [MEDICATION NAME] their shift and did not sign for administering the medication in the MAR. RN #6 stated the medication was not due on the 3 PM-11 PM shift. RN #6 stated the medication was to be given and ordered at midnight because the resident wanted it at midnight. RN #6 stated they do not know why LPN #3 gave the medication. RN #6 stated when they gave the medication, they checked the order, took it out of the narcotic box, signed the narcotic log, gave the medication, and then signed the MAR. RN #6 stated LPN #3 signed for the medication in the narcotic log and they saw LPN #3's initials, but did not think twice about it because they just assumed LPN #3's initials were from night before. RN #6 stated after they gave the medication, they were not sure what happened, they questioned LPN #3 and LPN #3 told them that they (LPN #3) gave [MEDICATION NAME]. LPN #3 was interviewed on 8/7/2023 at 10:12 AM and stated they were the 3:00 PM-11:00 PM medication nurse for Resident #638 on 7/17/2022. LPN #3 stated if the medication was due at midnight, they could give the medication at 11:00 PM. LPN #3 stated the resident requested [MEDICATION NAME] the resident said sometimes, they (resident) have to wait a long time to get [MEDICATION NAME] incoming staff because they are getting report and it takes a long time. LPN #3 stated they gave [MEDICATION NAME] 11:00 PM. LPN #3 stated they could not remember if they told the incoming 11:00 PM-7:00 AM nurse. LPN #3 stated they signed the narcotic log but may not have signed the MAR. The Director of Nursing Services (DNS) was interviewed on 8/7/2023 at 10:33 AM and stated the problem was communication. If LPN #3 was still on unit and gave the medication that was technically due on the next shift, LPN #3 should have communicated this to the other nurse. The DNS also stated LPN #3 should have signed for the medication in the MAR when it was given. The DNS stated there was a disciplinary action done for the nurses involved. 10 NYCRR 415.12(m)(2) | Plan of Correction: ApprovedSeptember 17, 2023 F - 0760 In response to the medication administration error involving resident #638 on (MONTH) 18, 2022, where they inadvertently received two doses of Ambien, we have undertaken a comprehensive plan of correction to ensure resident safety and prevent similar incidents from occurring in the future. The residentÆs Primary Care Physician (PCP) was notified about the medication error, and in accordance with the PCP's guidance, the decision was made to send the resident to the hospital for further evaluation. Consequently, the resident was transported to the hospital on (MONTH) 18, 2022, at 1:37 AM, and subsequently returned to the facility on the same day at 5:20 AM after undergoing evaluation. The PCP was updated regarding the resident's return, and on (MONTH) 18, 2022, the resident was assessed by the Nurse Practitioner (NP) who noted no adverse effects from the incident. Notably, the family had been informed about the situation before the decision to seek hospital evaluation was made. LPN #3 and RN #6 were interviewed to help identify the root cause and individualized education and disciplines were provided to each of them. A review of the facility's narcotic books was conducted on each unit on (MONTH) 26, 2023, to ensure compliance with the proper signage of narcotics when they are removed from blister packs. During this assessment, no instances of deficient practice were identified. To prevent any future recurrence, an in-service training session was conducted for licensed nurses (RNs and LPNs), emphasizing the importance of promptly signing for narcotics when they are taken out of blister packs, aiming to mitigate the risk of medication errors. The policy governing this practice has been thoroughly reviewed, and it has been determined that no changes are necessary at this time. Nurse managers and supervisors will conduct regular audits through the use of an audit tool to ensure the prevention of the identified deficient practice. These audits will be performed on all units and across all shifts weekly for a duration of two (2) months, followed by monthly audits for four (4) months. The frequency of audits will be determined by the Quality Assessment and Performance Improvement (QAPI) committee thereafter. Immediate corrective actions will be taken in response to any adverse findings, with subsequent reporting to the Assistant Directors of Nursing (ADON). All audit results will be communicated to the QAPI Committee. The responsibility for rectifying this deficiency lies with the DNS, with a target completion date for corrective actions set at (MONTH) 15, 2023. Our unwavering commitment to preventing medication errors and prioritizing resident safety underscores our dedication to continual enhancement and the maintenance of the highest standards of care within our nursing home. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 9, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that all residents were free from physical restraints imposed for the purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was identified for one (Resident #455) of one resident reviewed for restraints. Specifically, Resident #455 was observed in their bed with the right side of the bed placed against the wall. On the left side of the bed three pillows were observed folded in half and wedged between the mattress and bed frame which caused the mattress to curve upward and prevented the resident for exiting the bed. There was not a physician's orders [REDACTED]. The finding is: The facility's policy titled Restraints dated 1/25/2008 and last reviewed 4/2015 documented that the facility shall promote and encourage a restraint free environment. Residents have the right to be free from physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. A restraint is any physical or chemical means used to control or restrict freedom of movement. Additionally, the policy documented that restraints include practices that meet the definition of a restraint, such as: placing a chair or bed so close to a wall that the wall prevents the resident from rising out of the chair or voluntarily getting out bed. The policy stated a physician's orders [REDACTED]. The resident will be evaluated quarterly for the continued need for the restraint. Resident #455 was admitted with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated [DATE] documented the resident had severely impaired cognitive skills for daily decision making and long term and short-term memory problems. The resident was totally dependent on two persons for bed mobility, transfer, dressing, eating, and toilet use. The resident was totally dependent on one person for eating and personal hygiene. The resident used a wheelchair as a mobility device. The resident's CCP (Comprehensive Care Plan) for Behavioral Symptoms/Dementia effective 12/31/2022 and last revised on 8/9/2023 documented the resident exhibited behaviors of kicking others, verbally threatening others, hitting and scratching self, disrobing in public, combative during care, pulling at feeding tube and crawling on the floor. Resident #455 was observed sleeping in bed on 8/1/2023 at 10:50 AM. The right side of the bed was placed against the wall and on the left side of the bed three pillows were folded in half and wedged between the mattress and bed frame which caused the mattress to curve upward and prevented the resident from exiting the bed. The CCP (Comprehensive Care Plan) titled, Care Area: Falls, initiated on 12/30/2022 and last revised on 8/8/2023 documented that the resident is at risk for fall/injury/ fracture related to falls in the last month prior to admission, fracture related to a fall in the last six months prior to admission, impaired balance, gait disturbance, limited endurance, antipsychotic medication, antidepressant medication, laxatives, anti-[MEDICAL CONDITION] medication, communication deficits, agitation, restlessness, cognitive impairment, [MEDICAL CONDITION] and incontinence. Interventions included but were not limited to place the bed in the lowest position. The CCP did not include the use of pillows between the mattress and the bed frame as an intervention to prevent the resident from exiting the bed. The CNA (Certified Nursing Assistant) Accountability Record for (MONTH) 2023 and (MONTH) 2023 did not include the use of pillows between the mattress and the bed frame as an intervention to prevent the resident from exiting the bed. Resident #455's physician's orders [REDACTED]. Resident #455's Physical and Occupational Therapy assessments and notes from 12/31/2022 through 7/31/2023 were reviewed and there was no documentation regarding the use of pillows. CNA (Certified Nursing Assistant) #15, the assigned 7 AM-3 PM CNA, was interviewed on 8/3/23 at 12:31 PM and stated that the pillows were under the mattress because the resident crawled off the mattress and the resident was found by the door. CNA #15 stated the pillows helped prevent the resident from crawling out of bed. CNA #15 stated that the pillows were placed there recently and was not sure when it started. CNA #15 stated they are not sure who placed the pillows beneath the mattress, the pillows appeared under the mattress one morning, and they (CNA #15) continued the practice. CNA #15 stated they knew placing the pillows under the mattress may not be the right thing to do. On 8/3/2023 at 2:30 PM CNA #15 pointed out that they (CNA #15) removed the pillows and as a result the resident's legs were observed dangling over the side of the mattress. CNA #15 stated this is what happened before they started placing the pillows beneath the mattress. CNA #15 stated they could not recall how long the staff have been placing the pillows under the mattress, so the resident does not climb out of bed. RN (Registered Nurse) #11 was interviewed on 8/3/2023 at 2:44 PM and stated that they (RN #11) usually made rounds on each floor of the building, and they never saw pillows placed beneath the resident's mattress. RN #11 stated the pillows should not be there and that staff are not allowed to place pillows beneath the mattress because the resident would not be able to get out of bed. The ADNS (Assistant Director of Nursing Services) RN #10 was interviewed on 8/3/2023 at 3:04 PM and stated they were not aware of the pillows placed beneath the resident's mattress. RN #10 stated that is not something the facility practiced. RN #10 stated that they knew the resident had a history of [REDACTED]. The Director of Rehabilitation was interviewed on 8/7/2023 at 2:10 PM and stated if they saw a bed against a wall and pillows placed under the opposite side of the mattress, they would think it is a preventive measure for safety, but it is not the most efficient way. They would use a defined perimeter mattress because the goal is to maximize safety. The resident was evaluated and utilized a low bed and floor mats. The Director of Rehabilitation stated that crawling into the hallway is a behavioral issue and there would not be an intervention from Physical Therapy. The Director of Rehabilitation was re-interviewed on 8/10/2023 at 9:14 AM and stated that the resident had not had an assessment for restraints or siderails since being admitted to the facility in (MONTH) 2022. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:14 PM and stated they never observed the resident's bed against the wall and the pillows between the mattress and bedframe. DNS stated that placing pillows underneath the mattress would prevent the resident's ability to get out of bed. 10 NYCRR 415.4(a)(2-7) | Plan of Correction: ApprovedSeptember 18, 2023 In response to the deficiencies related to F604, where resident #455 was observed with pillows wedged between the mattress and bed frame, restricting the resident's ability to exit the bed, we have formulated a comprehensive plan of correction to address the issue, ensure resident safety, and prevent similar occurrences in the future. For residents found to have been affected by this practice, immediate corrective actions were taken to ensure their safety and well-being. For resident #455, the pillows were removed, and the resident was assessed by the nursing supervisor, with no concerns or harm noted. The staff responsible for the pillows by resident #455 (CNA #15) was educated and disciplinary action was completed on (MONTH) 30, 2023. To identify other residents who may have been affected by similar deficiencies, a full house audit was completed on (MONTH) 16, 2023, to ensure that no pillows or items are obstructing residents' ability to exit their beds unless prescribed and documented appropriately for the residentÆs health or safety. There were no observed devices noted that prevented residents from exiting their beds. To prevent the recurrence of this issue, a systemic change will be implemented to address the use of pillows or non-standard devices in residents' beds. The policies regarding restraints, bed exiting, and related matters have undergone a comprehensive review process, resulting in revisions aimed at enhancing accessibility and comprehension for our staff. Consequently, educational sessions are being conducted for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), Recreation, Rehabilitation, Respiratory, MDS, and Administrative personnel to ensure a thorough understanding of these updated policies. To ensure ongoing compliance and resident safety, a quality assurance program will be established to monitor bed configurations, the use of pillows, restraint practices, and the overall implementation of these policies. An audit tool has been created for this purpose. Audits will be conducted every two (2) weeks by the unit managers or their designated representatives for the initial three (3) months. Subsequently, the audit frequency will transition to monthly for the following three (3) months, with further adjustments as directed by the QAPI committee. Any negative findings identified during these audits will be promptly addressed through counseling with the responsible employee. The outcomes of all audits will be meticulously documented and reported to the QAPI committee for further evaluation and improvement. The target date for completing these corrective actions is (MONTH) 9, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain committed to maintaining the highest standards of resident safety and care within our nursing home. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 550) initiated on [DATE] and completed on [DATE], the facility did not ensure that residents and/or their Designated Representatives participated in the development and implementation of his or her person-centered plan of care. This was identified for one (Resident #43) of four residents reviewed for Notification of Change. Specifically, there was no documented evidence in the Electronic Medical Record (EMR) that Resident #43 had a Comprehensive Care Plan (CCP) meeting held since [DATE]. Additionally, there was no documented evidence that the resident's Health Care Proxy (HCP)/Designated Representative was invited to a CCP meeting since [DATE]. The finding is: The facility's policy titled, Care Plan Scheduling and Meeting dated [DATE] documented to provide each resident with an individualized interdisciplinary plan of care. Scheduling of the CCP Review and Meetings will be generated by the Minimum Data Set (MDS) Coordinator (Director). The MDS Coordinator will distribute MDS/CCP schedule monthly; The Social Worker (SW) notifies the resident, family, or Designated Representative of the CCP meetings as scheduled; Types of meetings or conferences are admission, quarterly, significant change in residents' condition and overall status, and specialized/ad-hoc meetings; The attendance will be documented in the resident's EMR under the Care Plan (CP) Meeting section. Resident #43 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated that the resident had severely impaired cognitive skills for daily decision making. The resident's current HCP/Designated Representative was interviewed on [DATE] at 5:05 PM and stated that they (the resident's current HCP) had never been invited to a CCP meeting for Resident #43 and did not even know what a CCP meeting was. The resident's current HCP stated that they became the resident's HCP and Designated Representative approximately a year and a half ago when the previous HCP expired. The resident's current HCP stated that the resident's prior HCP had never been invited to a CCP meeting either for the resident. The annual Care Plan Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (P(NAME)). The questions and concerns were addressed and the goals and interventions were reviewed. The participants of the meeting were Social Services, Dietary, and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that an annual review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (P(NAME)). The questions and concerns were addressed and the goals and interventions were reviewed. See SW Progress Note. The participants of the meeting were Social Services and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that a quarterly review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (P(NAME)). The questions and concerns were addressed and the goals and interventions reviewed. See SW Progress Note. The participants of the meeting were Social Services, Dietary, and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that a quarterly review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (P(NAME)). The questions and concerns were addressed and the goals and interventions reviewed. See SW Progress Note. The participants of the meeting were Social Services, Dietary, Registered Nurse (RN) MDS Coordinator, and Therapeutic Recreation staff members. The Social Services Progress Note dated [DATE], written by SW #5, documented that a quarterly review CCP Meeting was held today. There was no documented evidence that the resident's HCP was invited or present at the meeting. The quarterly CCP Meeting Report dated [DATE], written by SW #5, documented: Interdisciplinary Team (IDT) met on [DATE] to review the resident's Plan of Care (P(NAME)). The questions and concerns were addressed and the goals and interventions were reviewed. See SW Progress Note. The participants of the meeting were Social Services and Therapeutic Recreation staff members. A review of the resident's EMR revealed no Social Services Progress Note dated [DATE] documenting the quarterly CCP Meeting was held on this date. A review of all Social Services Progress Notes dated [DATE] to [DATE] in the resident's EMR revealed no documented evidence of a Care Plan Meeting held for this resident. The Director of Social Services was interviewed on [DATE] at 5:15 PM and stated that the MDS Office gives the Social Services Department a list of residents who are due to have a CCP Meeting. The Director of Social Services stated that each SW will then schedule a meeting with their residents' family/Designated Representative. The Director of Social Services stated that by looking at the Resident #43's CCP, there was no documented evidence that the resident had a CCP meeting since [DATE] and should have had one at least quarterly. The Director of Social Services stated that they (Director of Social Services) were not sure how that happened and would speak to the resident's SW to find out. SW #5 was interviewed on [DATE] at 5:30 PM and stated that they (SW #5) were not sure why there had not been a Care Plan Meeting held for the resident since [DATE] because all residents should have Care Plan Meetings quarterly. SW #5 stated that they (SW #5) have tried calling the resident's HCP/Designated Representative, but they (resident's HCP/Designated Representative) do not answer the phone. SW #5 stated that it was on error on their (SW #5) part for not documenting in the resident's EMR when they (SW #5) have tried contacting the resident's HCP/Designated Representative and getting no response. The RN MDS Director was interviewed on [DATE] at 5:35 PM and stated that the MDS Department sends out the schedule for the Care Plan Meetings for each unit. The SW then sets up the Care Plan Meeting with the family or Designated Representative based on the schedule. The RN MDS Director stated that they (MDS Director) did not see a documented Care Plan Meeting in either a Progress Note or in the resident's CCP since [DATE]. 10 NYCRR 415.11(c)(2)(i-iii) | Plan of Correction: ApprovedSeptember 18, 2023 In response to the deficiencies identified under F553, we have formulated a comprehensive plan of correction to rectify the issues related to resident #43's care plan and the failure to invite their Health Care Proxy (HCP) or designated representative to care plan meetings. For resident #43, a comprehensive care plan meeting will be immediately scheduled to address any care needs that may have been overlooked due to the lack of a meeting since (MONTH) 12, 2022. The resident's HCP or designated representative will be invited to the meeting to ensure their input and preferences are considered in the care planning process. Multiple attempts to reach the responsible party were unsuccessful. The responsible party responded on (MONTH) 28, 2023, and a CCP meeting will be held on (MONTH) 5, 2023. A focused CCP meeting was held on (MONTH) 16, 2023. Any care gaps or deficiencies that have arisen due to the lack of recent care plan meetings will be identified and addressed promptly. To identify other residents who may potentially be affected by a similar deficiency, we will conduct a review of all resident care plans to ensure that care plan meetings have been conducted as required. Any residents found to have missed care plan meetings will have these meetings promptly scheduled to address their care needs and ensure that their preferences are considered. Disciplinary action has been taken against Social Worker #5 on (MONTH) 17, 2023, who was responsible for organizing care plan meetings for this resident. This action serves as a reminder of the critical importance of adhering to care planning protocols. Re-education will be provided to the entire social work department and the MDS department on care plan meetings, including the scheduling and documentation processes, to prevent similar oversights. The Interdisciplinary Team (IDT) will examine and potentially modify the Comprehensive Care Plan (CCP) meeting approach to determine if a more effective and conducive method should be employed. The goal is to ensure that care plan meetings are conducted consistently and inclusively to meet the needs of our residents. Upon careful review, it was determined that our policies were comprehensive and in alignment with best practices, and no changes were deemed necessary at this time. As per the policy, the MDS nurse oversees the scheduling of comprehensive care plan meetings, while the social worker is tasked with notifying the resident and/or their representative of the scheduled meeting. To prevent the recurrence of this issue, the Director of Social Services will design an audit tool and conduct monthly audits to ensure that all CCP meetings are being held, the appropriate individuals are invited, and documentation is complete. This proactive measure will help us maintain compliance and identify any deviations from our care planning protocols. The Director of Social Services will be responsible for overseeing the implementation of this plan of correction with a date of correction of (MONTH) 30, 2023. We remain dedicated to improving our care planning processes and ensuring the highest quality of care for our residents. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 30, 2023
Citation Details Based on observations, record review, and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on two of three nursing units in the Woodcrest Building. Specifically, on 8/4/2023 on the Woodcrest 1 unit there was an upholstered couch used by residents in the common area that was soiled and stained; and on Woodcrest 3 unit there were two upholstered chairs used by residents in the common area that were soiled and stained. The finding is: The facility's policy titled, Cleaning Furnishings, dated 6/1/2022, documented to create a clean and hygienic environment for residents, staff, and visitors, promoting infection prevention and overall well-being. Nursing home staff will conduct routine cleaning of all furnishings in common areas, resident rooms, and other designated spaces, as per the established cleaning schedule. Routine cleaning will include dusting, vacuuming, and spot-cleaning of stains to maintain the cleanliness and appearance of the furnishings. On 8/4/2023 at 11:35 AM on Woodcrest 1 unit, there was a couch in the common area used by residents that was observed to be soiled and stained. On 8/4/2023 at 11:40 AM on Woodcrest 3 unit, there were two upholstered chairs used by residents in the common area that were observed to be soiled and stained. The Housekeeping Director was interviewed on 8/4/2023 at 11:50 AM and acknowledged the condition of the couch and chairs and stated they will be cleaned. The Housekeeping Director stated it is up to the assigned building housekeeper to make observations and alert the Housekeeping Director about dirty furnishings. The Housekeeping Director further stated the nursing staff can also make observations and put a request for cleaning through the automated maintenance and housekeeping request software system. Housekeeper #1 was interviewed on 8/7/2023 at 8:28 AM and stated they (Housekeeper #1) do the housekeeping services in the common areas of the Woodcrest building. Housekeeper #1 stated they (Housekeeper #1) brought the condition of the couch and upholstered chairs to the attention of the housekeeping supervisor. Housekeeper #1 could not remember the name of the supervisor or when this was brought to a supervisor's attention. Observations on Woodcrest 1 unit and Woodcrest 3 unit were made on 8/7/2023 between 8:35 AM and 8:40 AM respectively. The couch and upholstered chairs were no longer on the units. Registered Nurse (RN) #2, the Woodcrest Nursing Supervisor, was interviewed on 8/7/2023 at 10:59 AM. RN #2 stated if nursing staff notices housekeeping issues, nursing can report the problem to housekeeping through a computer program. RN #2 stated everyone can report housekeeping and maintenance issues, it is a dual effort between the nursing and housekeeping departments. 10 NYCRR415.5(h)(2) | Plan of Correction: ApprovedSeptember 17, 2023 In response to the deficiencies related to F584, which involve the presence of soiled and stained furnishings including a couch and two upholstered chairs, we have developed a comprehensive plan of correction to address the issues, ensure a clean and hygienic environment, and prevent similar occurrences in the future. For residents affected by the soiled and stained furnishings, immediate corrective actions will be taken. The soiled couch and upholstered chairs were removed immediately upon notification and are being evaluated by an outside cleaning consultant to ascertain whether they can be cleaned or if they need to be replaced. If possible, they will be thoroughly cleaned, sanitized, and restored to their optimal condition. If required, replacements will be provided to affected residents to ensure their comfort and well-being. To identify other residents who may have been affected by similar deficiencies, a full house assessment by the housekeeping department of all furnishings was conducted on (MONTH) 5, 2023. This assessment determined that no additional furnishings needed cleaning, potential external cleaning requirements, and/or the need for replacement. If any soiled items are noted in the future, immediate actions will be taken by the housekeeping department. The associated policies related to the cleanliness of furnishings throughout the facility have been reviewed and no modifications are needed. Environmental staff will be re-educated on the policies. To maintain ongoing compliance and ensure a clean environment, a quality assurance program will be established. An audit tool was created to allow for monthly audits for the period of twelve (12) months by the housekeeping supervisors or designee and then as directed by the QAPI committee. The audit will provide a consistent assessment of the state of furnishings and guide timely interventions. If any soiled items are noted immediate actions will be taken by the housekeeping department. These audits will ensure that the deficient practice does not recur and that residents' living spaces remain clean, comfortable, and conducive to their well-being. The target date for completing these corrective actions is (MONTH) 30, 2023. The Director of Environmental Services will be responsible for overseeing the implementation of this plan of correction. We are dedicated to maintaining a high standard of cleanliness and ensuring that our residents reside in a comfortable and hygienic environment. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023 the facility did not ensure that services were provided or arranged by the facility, as outlined by the comprehensive care plan, to meet professional standards of quality. This was identified for two (Resident #91 and #422) of 27 residents observed during the initial tour on Seacliff 1 unit. Specifically, Resident #91's and #422's tube feeding bottles were not labeled with the resident name, date, or start time. The findings are: 1) Resident #422 was admitted with [DIAGNOSES REDACTED]. The 7/2/2023 annual MDS assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had moderately impaired cognitive skills for daily decision making. The resident was also non-verbal and ventilator dependent. The physician's orders [REDACTED]. On 8/1/2023 at 10:08 AM Resident #422 was observed in bed. The resident was ventilator dependent. The resident's tube feeding was running. The bottle was [MEDICATION NAME] 1.5 and the pump was set at 65 ml/hour. There was no label on the bottle indicating the resident's name or the start time of the feeding. On 8/1/2023 at 10:10 AM Registered Nurse (RN) #17 observed the tube feeding with the surveyor and stated there should be label on the bottle with the resident's name and start time of the feeding. RN #17 was not sure who started the feeding. 2) Resident #91 was admitted with [DIAGNOSES REDACTED]. The 7/8/2023 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score, as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident had a feeding tube while a resident of the facility. The physician's orders [REDACTED]. On 8/1/2023 at 10:17 AM Resident #91 was observed in bed. The Nepro 1.8 tube feeding bottle was hung; however, the pump was not running indicating the feeding was complete. There was no resident label on the bottle, with the resident's name and start time of the feeding. On 8/1/2023 at 10:18 AM RN #17 observed the tube feeding with the surveyor and stated there should be label on the bottle with the resident's name and start time of the feeding. RN #17 was not sure who started the feeding. RN #18 was interviewed on 8/7/2023 at 4:00 PM and stated they (RN #18) started the tube feedings for Resident #91 and Resident #422 and hung the bottles on the evening of 7/31/2023 and that the feedings continued into 8/1/2023. RN #18 stated they were working on the unit by themselves. RN #18 stated the unit is a ventilator unit with 27 residents, and 24 of the 27 residents require tube feedings. There was no supervisor to help. RN #18 stated they did not have time to label the bottles. The Director of Nursing Services (DNS) was interviewed on 8/8/2023 at 8:34 AM and stated the evening nurse should have labeled the tube feeding bottles with the resident's name, date and start time. 10 NYCRR 415.11 (c)(3)(i) | Plan of Correction: ApprovedSeptember 17, 2023 In response to the deficiencies related to F658, where tube feeding bottles were not labeled for residents #91 and #422, we have developed a comprehensive plan of correction to address the issue, enhance safety protocols, and prevent similar occurrences in the future. For residents #91 and #422, corrective actions were immediately taken to label their tube-feeding bottles accurately. This ensured that they received the appropriate nutritional care. RN #17 and RN #18, noted to have deficient practice with the labeling of the bottles, were educated and disciplined on (MONTH) 24, 2023. To identify other residents who may have the potential to be affected by a similar deficiency, we conducted a thorough reviews on (MONTH) 1, 2023, of all tube feedings and no other bottles were found to be without appropriate labeling procedures and documentation. Any residents found to have unlabeled or inaccurately labeled tube feeding bottles will have the situation rectified immediately, and their care protocols will be updated accordingly. All licensed nursing staff will be re-in-serviced on how to properly label tube feeding bottles which are hung at the residentÆs bedside with the residents name, date, and start time to prevent deficient practice from recurring. The policy and procedure was reviewed and no changes are being made at this time. To ensure ongoing compliance and maintain resident safety, a quality assurance program will be put into practice. An audit tool was designed and the audits will be conducted by the 3 pm û 11 pm supervisors to verify that tube feeding bottles are accurately labeled for all residents receiving tube feeding. The audits will be done weekly for one (1) month, then monthly for five (5) months, then as directed by the QAPI committee. Any negative findings will be corrected immediately through counseling with the employee. All audit outcomes will be reported to the QAPI committee. The target date for completing these corrective actions is (MONTH) 30, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We remain committed to enhancing our protocols and ensuring the highest standards of care for our residents, particularly those with specialized dietary needs. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 9, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the Recertification and Abbreviated surveys (NY 799 and NY 391) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure nursing services are provided by sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity, and [DIAGNOSES REDACTED]. Additionally, the facility did not provide services by sufficient number of licensed nurses and nurse aides (assistants) on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Specifically, 1) 10 of 10 Residents in the Resident Council meeting held on 8/2/2023 reported chronic understaffing on weekends and some weekdays, 2) Review of weekend staffing and staffing during the recertification survey revealed numerous occasions of insufficient nursing staff to provide timely resident care, 3) On 8/6/2023 during the 7:00 AM-3:00 PM shift on Sagamore 2 unit, there was only one Certified Nursing Assistant (CNA) and one Licensed Practical Nurse (LPN) available to provide care for 30 residents, 4) on 7/30/2023, Resident #22 was not taken out of bed during the 7:00 AM-3:00 PM shift because there was only one LPN and 2 CNAs for 38 Residents on the Seacliff 2 unit. Cross References: F658 - Services Provided Meet Professional Standards F684 - Quality of Care F697 - Pain Management F755 - Pharmacy Services The findings include but were not limited to: 1) A Resident Council meeting was held on 8/2/2023 at 10:45 AM. All 10 residents in attendance reported that the facility is understaffed on weekends and some weekdays. The residents reported that the CNAs are often pulled to other floors to help staff on other units, the call bell response time varies from a half an hour to one hour, and they only receive one shower a week due to understaffing. The residents also reported that medications are not administered timely, and they were not taken out of bed timely because not enough staff are available to assist with the mechanical (Hoyer) lifts to transfer the residents out of bed. The Resident Council president was interviewed on 8/4/2023 at 2:36 PM and stated that they have been the president of the council since the fall of 2022. The Resident Council president stated that the council meets every month and at each meeting there are complaints related to short staffing. The Resident Council president stated they do not get a copy of the meeting minutes and do not get an opportunity to review the contents of the meeting minutes to validate the accuracy. The Resident Council president stated that even the residents who do not attend the meetings complain about staffing issues regularly when they (Resident Council president) meet with them prior to the scheduled Resident Council meetings. Review of the Resident Council meeting minutes dated (MONTH) 2023 documented residents reported that the [MEDICATION NAME] 3 unit is understaffed on weekends. The Resident Council meeting minutes for (MONTH) 23, 2023, (MONTH) 18 2023, and (MONTH) 14, 2023, were reviewed and lacked documented evidence of staffing issues. The meetings minutes were not signed by the Resident Council president, Administration nor the Director of Therapeutic Recreation. The Director of Therapeutic Recreation was interviewed on 8/8/2023 at 3:04 PM. The Director of Therapeutic Recreation stated that in (MONTH) 2023 the Resident Council reported that understaffing on weekends was a problem. The Director of Therapeutic Recreation stated that the Resident Council Meeting minutes were not given to the Resident Council president for review for accuracy because the Director of Therapeutic Recreation was not aware that they were required to provide the meeting minutes to the Resident Council president. The Administrator was interviewed on 8/10/2023 at 10:31 AM. The Administrator stated that the Resident Council brought concerns about staffing up during the Resident Council meeting in (MONTH) 2023. The Administrator stated that there was one weekend that the residents complained about. The Administrator stated that they were not sure of the details because the previous Director of Nursing Services (DNS) addressed the concerns with the Resident Council. The Administrator was not involved with addressing the Resident Council concerns since the DNS was responsible for staffing. 2) Review of the Facility assessment dated [DATE] in its entirety revealed that there was no overall number of facility staff needed included in the assessment to ensure the resident's needs were being met. The Facility Assessment documented the following staffing plan: The facility does not take a census-based approach to staffing but looks at the acuity levels of the residents to provide the best staffing possible. The facility looks at various factors including the level of assistance needed, the clinical complexity, and treatment provided to each resident when examining appropriate staffing levels. The goal is to ensure all residents' needs are met in an appropriate and timely fashion. Staff assignments are based on the residents being treated. An untitled document dated 6/27/2022 documented the following Nurse and Certified Nurse Aide/Assistant (CNA) par levels on the 7:00 AM-3:00 PM shift, 3:00 PM-11:00 PM shift, and 11:00 PM-7:00 AM shift on all units. This document was not included as part of the Facility Assessment. 7:00 AM - 3:00 PM Shift: Brookville 1 unit (Bed Capacity of 30): 1 LPN, 4 CNA Brookville 2 unit (Bed Capacity of 30): 1 Registered Nurse (RN), 4 CNA Brookville 3 unit (Bed Capacity of 30): 1 LPN, 4 CNA [MEDICATION NAME] 1 unit (Bed Capacity of 43): 1 RN, 2 LPN, 5 CNA [MEDICATION NAME] 2 unit (Bed Capacity of 43): 1 RN, 2 LPN, 5 CNA [MEDICATION NAME] 3 unit (Bed Capacity of 43): 1 RN, 2 LPN, 5 CNA Seacliff 1 unit (Bed Capacity of 39): 1 RN, 2 LPN, 6 CNA Seacliff 2 unit (Bed Capacity of 50): 1 RN, 2 LPN, 6 CNA Seacliff 3 unit (Bed Capacity of 54): 1 RN, 1 LPN, 6 CNA Sagamore 2 unit (Bed Capacity of 35): 1 RN, 1 LPN, 3 CNA Sagamore 3 unit (Bed Capacity of 31): 1 LPN, 4 CNA Woodcrest 1 unit (Bed Capacity of 43): 2 LPN, 4 CNA Woodcrest 2 unit (Bed Capacity of 43): 1 RN, 1 LPN, 5 CNA Woodcrest 3 unit (Bed Capacity of 43): 2 LPN, 4 CNA 3:00 PM -11:00 PM Shift: Brookville 1 unit (Bed Capacity of 30): 1 LPN, 4 CNA Brookville 2 unit (Bed Capacity of 30): 1 LPN, 4 CNA Brookville 3 unit (Bed Capacity of 30): 1 LPN, 4 CNA [MEDICATION NAME] 1 unit (Bed Capacity of 43): 1 RN, 1 LPN, 4 CNA [MEDICATION NAME] 2 unit (Bed Capacity of 43): 1 RN, 1 LPN, 4 CNA [MEDICATION NAME] 3 unit (Bed Capacity of 43): 1 RN, 1 LPN, 4 CNA Seacliff 1 unit (Bed Capacity of 39): 1 RN, 1 LPN, 5 CNA Seacliff 2 unit (Bed Capacity of 50): 1 RN, 1 LPN, 5 CNA Seacliff 3 unit (Bed Capacity of 54): 2 LPN, 5 CNA Sagamore 2 unit (Bed Capacity of 35): 1 RN, 3 CNA Sagamore 3 unit (Bed Capacity of 31): 1 LPN, 4 CNA Woodcrest 1 unit (Bed Capacity of 43): 1 LPN, 4 CNA Woodcrest 2 unit (Bed Capacity of 43): 1 LPN, 4 CNA Woodcrest 3 unit (Bed Capacity of 43): 1 LPN, 4 CNA 11: PM- 7:00 AM Shift: Brookville 1 unit (Bed Capacity of 30): 1 LPN, 3 CNA Brookville 2 unit (Bed Capacity of 30): 1 LPN, 3 CNA Brookville 3 unit (Bed Capacity of 30): 1 LPN, 3 CNA [MEDICATION NAME] 1 unit (Bed Capacity of 43): 1 RN, 3 CNA [MEDICATION NAME] 2 unit (Bed Capacity of 43): 1 RN, 3 CNA [MEDICATION NAME] 3 unit (Bed Capacity of 43): 1 RN, 3 CNA Seacliff 1 unit (Bed Capacity of 39): 1 RN, 1 LPN, 4 CNA Seacliff 2 unit (Bed Capacity of 50): 1 RN, 1 LPN, 4 CNA Seacliff 3 unit (Bed Capacity of 54): 1 LPN, 3 CNA Sagamore 2 unit (Bed Capacity of 35): 1 RN, 2 CNA Sagamore 3 unit (Bed Capacity of 31): 1 LPN, 3 CNA Woodcrest 1 unit (Bed Capacity of 43): 2 LPN, 4 CNA Woodcrest 2 unit (Bed Capacity of 43): 1 RN, 1 LPN, 5 CNA Woodcrest 3 unit (Bed Capacity of 43): 2 LPN, 4 CNA The Facility Census Detail Reports were reviewed and documented the following: Brookville 1 unit (Bed Capacity of 30) maintained a census of 29 from 5/13/23 to 8/6/23 Brookville 2 unit (Bed Capacity of 30) maintained a census of 29 to 30 from 5/13/23 to 8/6/23 Brookville 3 unit (Bed Capacity of 30) maintained a census of 30 from 5/13/23 to 8/6/23 [MEDICATION NAME] 1 unit (Bed Capacity of 43) maintained a census of 38 to 41 from 5/13/23 to 8/6/23 [MEDICATION NAME] 2 unit (Bed Capacity of 43) maintained a census of 31 to 39 from 5/13/23 to 8/6/23 [MEDICATION NAME] 3 unit (Bed Capacity of 43) maintained a census of 39 to 42 from 5/13/23 to 8/6/23 Seacliff 1 unit (Bed Capacity of 39) maintained a census of 24 to 29 from 5/13/23 to 8/6/23 Seacliff 2 unit (Bed Capacity of 50) maintained a census of 37 to 40 from 5/13/23 to 8/6/23 Seacliff 3 unit (Bed Capacity of 54) maintained a census of 42 to 43 from 5/13/23 to 8/6/23 Sagamore 2 unit (Bed Capacity of 35) maintained a census of 28 to 30 from 5/13/23 to 8/6/23 Sagamore 3 unit (Bed Capacity of 31) maintained a census of 27 to 31 from 5/13/23 to 8/6/23 Woodcrest 1 unit (Bed Capacity of 43) maintained a census of 42 to 43 from 5/13/23 to 8/6/23 Woodcrest 2 unit (Bed Capacity of 43) maintained a census of 43 from 5/13/23 to 8/6/23 Woodcrest 3 unit (Bed Capacity of 43) maintained a census of 41 to 42 from 5/13/23 to 8/6/23 (Sagamore 1 unit was closed from 5/13/23 to 8/6/23) The Facility Staffing Sheets for weekends from 5/13/23 to 8/6/23 were reviewed. Additionally, staffing sheets throughout the survey, 8/1/2023 to 8/10/2023, were reviewed. The staffing sheets revealed that the facility was understaffed on the following days: Brookville 1 unit, 7:00 AM-3:00 PM Shift, had a par level of 4 CNAs. The unit was understaffed by 2 CNAs on 5/14/23, 7/16/23, 8/6/23. Additionally, the unit was understaffed by 1 CNA on 6/18/23, 7/2/23, 7/15/23, and 8/7/23. Brookville 1 unit, 3:00 PM-11:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 7/15/23, 7/16/23, and 8/6/23. Brookville 2 unit, 7:00 AM-3:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 6/18/23, 7/2/23, 7/15/23, 8/3/23, 8/5/23, and 8/6/23. Additionally, the unit was understaffed by 2 CNAs on 7/16/23. Brookville 2 unit, 3:00 PM-11:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 7/15/23, 7/16/23, and 8/6/23. Brookville 3 unit, 7:00 AM-3:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 2 CNAs on 5/14/23 and 8/6/23. Additionally, the unit was understaffed by 1 CNA on 6/18/23, 7/2/23, 7/15/23, 7/16/23, 8/1/23, 8/3/23, 8/5/23, 8/7/23, and 8/8/23. Brookville 3 unit, 3:00 PM-11:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 1 CNA on 7/15/23, 8/5/23, and 8/6/23. Sagamore 2 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 1 LPN and 3 CNAs. The unit was understaffed by 1 CNA on 5/14/23 and understaffed by 1 RN and 1 CNA on 5/28/23, 6/4/23, 6/18/23, 7/2/23 and 8/6/23. Additionally, the unit was understaffed by 1 LPN and 1 CNA on 7/16/23, and 7/30/23. Sagamore 2 unit, 3:00 PM-11:00 PM Shift had a par level of 3 CNAs. The unit was understaffed by 1 CNA on 7/16/23. Sagamore 3 unit, 7:00 AM-3:00 PM Shift had a par level of 4 CNAs. The unit was understaffed by 2 CNAs on 6/4/23, 7/16/23, 7/30/23, 8/5/23, and 8/6/23. [MEDICATION NAME] 1 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 5 CNAs. The unit was understaffed by 1 LPN and 2 CNAs on 5/14/23 as well as1 RN and 2 CNAs on 7/2/23. Additionally, the unit was understaffed by 2 LPNs and 1 CNA on 8/6/23. Furthermore, the unit was understaffed by 1 LPN and 1 CNA on 8/7/23. [MEDICATION NAME] 1 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 7/15/23 as well as 1 LPN on 8/6/23. [MEDICATION NAME] 2 unit, 7:00 AM -3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 5 CNAs. The unit was understaffed by 2 LPN on 7/2/23. Additionally, the unit was understaffed by 1 RN, 1 LPN, and 2 CNAs on 7/16/23 and 8/6/23. [MEDICATION NAME] 3 unit, 7:00 AM-3:00 PM shift had a par level of 1 RN, 2 LPNs, and 5 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 7/2/23 and 7/16/23 and 1 RN, 1 LPN and 2 CNAs on 8/6/23. [MEDICATION NAME] 3 unit, 3:00 PM-11:00 PM Shift had a par level of 1 RN, 1 LPN, and 4 CNAs. The unit was understaffed by 1 RN and 1 CNA on 7/15/23 as well as 1 LPN on 8/6/23. Woodcrest 1 unit, 7:00 AM-3:00 PM Shift had a par level of 2 LPNs, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23, 6/18/23, and 7/16/23. Additionally, the unit was understaffed by 1 CNA on 6/4/23 and 2 LPNs on 8/5/23. Furthermore, the unit was understaffed by 1 LPN and 2 CNAs on 7/30/23 and 8/6/23. Woodcrest 1 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23 and 1 CNA on 7/15/23. Woodcrest 2 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 1 LPN, and 5 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 5/14/23 and 7/30/23. The unit was understaffed by 2 CNAs on 6/18/23 and 7/2/23, 3 CNAs on 7/16/23, as well as RN and 3 CNAs on 8/6/23. Woodcrest 2 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN, and 4 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 5/14/23, 7/2/23, and 7/15/23. The unit was understaffed by 1 CNA on 6/4/23. Additionally, the unit was understaffed by 1 RN and 1 CNA on 6/18/23. Woodcrest 3 unit, 7:00 AM-3:00 PM Shift had a par level of 2 LPNs, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23 and 7/2/23. The unit was understaffed by 1 LPN and 2 CNA on 7/16/23, 7/30/23 and 8/6/23. Additionally, the unit was understaffed by 2 LPNs and 1 CNA on 8/5/23. Woodcrest 3 unit, 3:00 PM-11:00 PM Shift had a par level of 1 LPN, and 4 CNAs. The unit was understaffed by 1 LPN and 1 CNA on 5/14/23 and 7/15/23. Seacliff 1 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 6 CNAs. The unit was understaffed by 1 LPN and 3 CNAs on 7/16/23 as well as 2 LPNs and 2 CNAs on 8/6/23. Seacliff 1 unit, 3:00 PM-11:00 PM Shift had a par level of 1 RN, 1 LPN, and 5 CNAs. The unit was understaffed by 1 CNA on 8/5/23. Seacliff 2 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 2 LPNs, and 6 CNAs. The unit was understaffed by 1 RN and 2 CNAs on 7/2/23, 7/16/23, and 8/7/23. Additionally, the unit was understaffed by 1 RN, 1 LPN and 3 CNAs on 7/30/23 as well as 1 RN, 1 LPN and 2 CNAs on 8/6/23. Seacliff 2 unit, 3:00 PM-11:00 PM Shift had a par level of 1 RN, 1 LPN, and 5 CNAs. The unit was understaffed by 1 RN and 1 CNA on 8/5/23. Seacliff 3 unit, 7:00 AM-3:00 PM Shift had a par level of 1 RN, 1 LPN, and 6 CNAs. The unit was understaffed by 3 CNAs on 6/18/23 and 7/30/23. The unit was understaffed by 1 RN and 2 CNAs on 8/5/23 as well as 1 RN and 3 CNAs on 8/6/23. The Director of Payroll and Schedules was interviewed on 8/7/2023 at 12:30 PM. The Director of Payroll and Schedules stated that they began supervising the staffing coordinators on Monday, 7/31/2023. Prior to 7/31/2023, the Director of Payroll and Schedules provided assistance with staffing for short periods of time when the facility did not have a Scheduling supervisor available. The Director of Payroll and Schedules stated that the Director of Nursing Services (DNS) provided them with the Registered Nurse (RN), Licensed Practical Nurse (LPN) and CNA par levels based on the census and acuity on the units. The Director of Payroll and Schedules stated that staffing numbers are posted in the scheduling office for the staffing coordinators to follow. The Director of Payroll and Schedules stated that the facility has a lot of staff out for various reasons including leave of absence, Family Medical Leave Act (FMLA), and sick leave. The Director of Payroll and Schedules stated that staffing agencies are unable to provide new licensed nurses. When staff call out for their shift, the staffing coordinators approach all staff currently working in the facility for coverage. The Director of Payroll and Schedules stated that the part time staff are working full time hours and that the facility has contract limitations and cannot hire per diem staff. The DNS and the Administrator was interviewed concurrently on 8/10/2023 at 10:31 AM. The Administrator stated that the facility assessment does not have the overall numbers or nursing par levels as part of the staffing plan. The Administrator stated that the nursing par levels that the Director of Payroll and Schedules provided was developed by the previous DNS. The Administrator was not involved with developing par levels for nurse staffing. The facility assessment was not updated to include par levels because the Administrator did not know that was something that needed to be included. The Administrator stated that they (Administrator) met with the DNS sometime in (MONTH) 2023 (could not recall the exact date) to develop par levels based on current census, Minimum Data Set assessments and Electronic Medical Record data. The Administrator stated there were no meeting notes available to confirm that the Administrator met with the DNS regarding the facility assessment. The Administrator stated that the new par levels have not been developed as of today (8/10/2023). The Administrator was re-interviewed on 8/10/2023 at 3:30 PM. The Administrator stated that the staffing coordinators use the par levels dated 6/27/2022 as a guide and adjust the staffing numbers based on daily conversations with the DNS regarding changes in census. The Administrator stated that some days the facility does have sufficient staff and some days they can do better. The Administrator stated that the staffing levels fluctuate with the number of staff who are out for various reasons. The DNS was re-interviewed on 8/10/2023 at 3:39 PM. The DNS stated that they staff the units according to the availability of staff and the needs of the residents. If there are not enough staff available on a unit, they will pull staff from another unit. The DNS stated that most days the facility does have sufficient staff but some days they do not because of call outs, leave of absence, etc. 3) Review of the final staffing sheet dated 8/6/2023 revealed that there was one Licensed Practical Nurse (LPN) #6 and two Certified Nursing Assistant (CNAs) CNA #8 and CNA #9 on the Sagamore 2 unit during the 7:00 AM-3:00 PM Shift. The facility Historical Census Summary Report dated 8/6/23 documented that there were 30 occupied beds on Sagamore 2 unit with an occupancy rate of 86%. An untitled document dated 6/27/2022 documented the following par level for Sagamore 2 unit during the 7:00 AM-3:00 PM shift based on a full census of 35 Residents: 1 RN, 1 LPN and 3 CNAs. Licensed Practical Nurse (LPN) #6, the medication nurse, was interviewed on 8/7/2023 at 2:09 PM. LPN #6 stated they (LPN#6) were the only nurse on Sagamore 2 unit on 8/6/2023 during the 7:00 AM to 3:00 PM shift. LPN #6 stated that there needs to be two nurses on Sagamore 2 unit to care for the 30 residents on the unit. LPN #6 stated that there was just two CNAs on the unit of 30 residents until 1:00 PM. LPN #6 stated that from 1:00 PM to 3:00 PM, there was just one CNA working with LPN #6 because the other CNA had a personal emergency and had to leave. LPN #6 stated that it is difficult to work alone on the unit. LPN #6 stated that they are responsible for medication administration, wound care treatments, and documentation. LPN #6 stated that they were running late with the medication pass on 8/6/2023 and the 9:00 AM medication administration was done by 11:00 AM. The 1:00 PM medications were administered by 3:00 PM. LPN #6 stated that if there were two nurses, it would take an hour and a half to complete the medication pass. LPN #6 stated there were eight wound care treatments to do, all of which have to be pre-medicated one hour before the treatment. LPN #6 stated that for one of the eight residents it takes up to 25 minutes for one wound care treatment. LPN #6 stated that some of the wound care treatments are tied with brief changes, which further interrupts medication administration. LPN #6 stated that there 12 residents who require two-person assistance so that they (LPN #6) may be pulled to assist the CNA with care. Also, LPN #6 stated lunch was served at 12:00 PM that they had to collect the lunch trays at 2:35 PM because the one CNA was so busy. LPN #6 stated that the 7:00 AM to 3:00 PM shift was especially challenging because Resident #361 was actively passing away and required [MEDICATION NAME] (pain medication) to be administered every 2 hours. LPN #6 stated that they (LPN #6) provided emotional support for Resident #361 and the family throughout the shift on top of their normal duties. LPN #6 stated that the workload snowballs due to interruptions. LPN #6 stated all of the interruptions cause subsequent medication administrations to be late. LPN #6 stated that there was no way to get everything done on time. LPN #6 stated that they informed Registered Nurse (RN) #5, who was their supervisor, when the CNA had to go home early. LPN #6 stated that RN #5 told LPN #6 to prioritize toileting the residents since it was an emergency. CNA #8 was interviewed on 8/9/2023 at 11:07 AM. CNA #8 stated that on 8/6/2023 at 1:00 PM, CNA #9 had a personal emergency and had to leave. CNA #8 was the only CNA on the unit from 1:00 PM to 3:00 PM. CNA #8 stated that they requested for another CNA to come to the unit to assist but no one came. CNA #8 stated that LPN #6 had to interrupt medication pass to provide assistance with two-person care and picking up meal trays. CNA #8 stated that a lot of residents were using the call bell for assistance and they (LPN #6 and CNA #8) could not be everywhere at once. CNA #8 stated that residents had to wait for care and that it could take up to 20 minutes to provide care for just one resident. CNA #8 further stated that even 2 CNAs for the unit was not enough because when they went on break, that leaves just one CNA for the whole unit. CNA #9 was interviewed on 8/9/2023 at 11:41 AM. CNA #9 stated that they had to leave at 1:00 PM on 8/6/2023. CNA #9 stated that they (CNA #9) started the shift at 7:00 AM with just 2 CNAs. CNA #9 stated that they normally have 3 CNAs, but 4 CNAs is needed. CNA #9 stated that every resident has care needs that require 30-45 minutes of the staff's time. CNA #9 stated that when there are just two CNAs for 30 residents, it is impossible to get to every resident. CNA #9 stated that several call bells were sounding on 8/6/2023 and that it is stressful and overwhelming to work with just two CNAs. CNA #9 stated that they cannot provide care to two-person assist residents timely because the other CNA is usually busy or no one else is available to assist and the residents have wait for care until the other CNA or the LPN is available. CNA #9 stated that when the CNAs go on break there is just one CNA on the unit because there is no one else to cover. RN #5 was interviewed on 8/10/2023 at 10:11 AM. RN #5 stated that they (RN #5) were assisting on multiple units between the Sagamore and Woodcrest buildings on 8/6/2023. RN #5 stated that they cannot recall if LPN #6 told them about CNA #9 leaving early. RN #5 stated that if LPN #6 told that them there was just one CNA on Sagamore 2 unit, they would instruct LPN #6 to prioritize toileting the residents and keeping the residents comfortable. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 3:39 PM. The DNS stated that if there are not enough staff available on a unit, it is expected that the supervisor for the unit is to assist with care and to pull other staff members from another unit. The DNS stated that they were not sure if two CNAs were sufficient for 30 residents on Sagamore 2 unit on 8/6/2023 during the 7:00 AM-3:00 PM shift. The DNS stated that they were not sure if one licensed nurse was sufficient on Sagamore 2 unit. The DNS stated that if the LPN needed assistance the RN Supervisor should have assisted the LPN. 4) Resident #22 was admitted with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #22 had a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident had moderately impaired cognition. Resident #22 required limited assistance of one-person for bed mobility and transfer. Resident #22 was not steady and only able to stabilize with staff assistance during surface-to-surface transfers and moving from a seated to a standing position. Resident #22 utilized a wheelchair as a mobility device. The At Risk for Falls Care plan dated 4/6/2023 documented that Resident #22 was at risk for falls/injury related to use of cardiovascular and diuretics medications. The care plan documented the intervention of transfers with supervision. The facility's final Staffing Schedule dated 7/30/2023 on the 7:00 AM- 3:00 PM shift documented one Registered Nurse (RN) and two Certified Nursing Assistants (CNAs) worked on Seacliff 2 unit. The facility's Census Detail Report dated 7/30/2023 documented 38 residents were residing on the Seacliff 2 unit. Resident #22 was interviewed on 8/1/2023 at 10:33 AM. Resident #22 stated that on Sunday, 7/30/2023, they were not transferred out of bed until 4:00 PM. Resident #22 stated that they (Resident #22) prefer to get out of bed after breakfast, between 8:00 AM and 9:00 AM. Resident #22 stated their legs hurt and feel wobbly and therefore they require assistance to get out of bed. Resident #22 stated they knew they did not get out of bed until 4:00 PM on Sunday, 7/30/2023 because they looked at the clock on the wall in their room. The CNA assigned to Resident #22 on 7/30/2023 during the 7:00 AM-3:00 PM shift was unavailable for interview during the recertification survey. Licensed Practical Nurse (LPN) #8 was interviewed on 8/10/2023 at 4:27 PM. LPN #8 stated that they recalled working on 7/30/2023 on the Seacliff 2 unit during the 7:00 AM-3:00 PM shift. LPN #8 stated that the unit was understaffed with just 2 CNAs on the unit during the 7:00 AM- 3:00 PM shift. LPN #8 stated that they knew that Resident #22 was not assisted to get out of bed because there were not enough CNAs available. Resident #22 was taken out of bed during the 3:00 PM-11:00 PM shift after 4:00 PM because there were three CNAs and two licensed nurses working on the 3:00 PM -11:00 PM shift. The Director of Nursing Services (DNS) was interviewed on 8/10/2023 at 4:37 PM. The DNS stated that if a resident asked to get out of bed, the CNAs could have alerted a Supervisor to assist with the request. The DNS stated that they were not sure if two CNAs were sufficient to provide care for 38 residents. The DNS stated that if they had more staff available from other units, they should have been directed to the Seacliff 2 unit. 10 NYCRR 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedSeptember 19, 2023 Plan of correction not approved or not required |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: August 10, 2023
Corrected date: October 9, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 476) initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #738) of four residents reviewed for Pressure Ulcers. Specifically, Resident #738 was admitted to the facility with an unstageable pressure ulcer to the sacral region which deteriorated to a Stage 4 pressure ulcer. The resident was identified as a high risk for pressure ulcer development. On 8/1/2022 Resident #738 was identified with a new Stage 3 pressure ulcer (pressure injuries that extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) to the left shoulder and on 8/29/2022 with a new Stage 4 pressure ulcer (pressure injuries that extend to muscle, tendon, or bone) to the right shoulder with no prior documented evidence of the resident's skin being compromised in these areas. This resulted in actual harm to Resident #738 that is not Immediate Jeopardy. The finding is: The facility's policy titled, Wound Interventions - Interdisciplinary dated 12/16/2020 and last revised 2/18/2022 documented that to provide interdisciplinary wound interventions to assist in the development of a care plan. These interventions will be selected based on the individual needs of the resident. Procedures included but were not limited to avoid repositioning resident on pressure ulcers; Establish a written repositioning/turning schedule using a turning clock; When the side-lying position is used, a 30-degree turning position should be used; Use devices such as pillows or foam wedges to prevent direct contact between bony prominences; Use a lifting sheet; Select appropriate support surface for the resident in bed and/or in a chair; and Use a dynamic surface such as air-loss mattresses, if indicated. The facility's policy titled, Turning and Positioning dated 5/23/2023 documented regular turning and repositioning of residents is essential to prevent the development of pressure ulcers. The residents who are immobile or have a higher risk of pressure ulcers may require more frequent turns. Nursing home staff will document the turning and positioning schedule, interventions performed, and the resident's responses in the resident's record. Documentation should include the date, time, and staff member responsible for each turn. Any changes in the resident's skin condition or the development of a pressure ulcers will be addressed promptly. The facility's policy titled, Pressure Ulcer Notification/Investigation Form dated 6/2014 documented that upon identification or decline of a pressure ulcer, the clinical Nurse Manager/Licensed Nurse will conduct an investigation and complete the pressure ulcer notification/investigation form. The pressure ulcer investigation form must be initiated by the end of the shift in which the new pressure ulcer was identified. The Nurse Manager/Licensed Nurse will complete all information on the form pertinent to the identification of a new pressure injury; Conduct an investigation to determine causative factors and document findings on the form; Once completed the form is to be placed in the Wound Care Nurse's mailbox; Inform the Nursing Supervisor/Assistant Director of Nursing (ADNS); Document (the pressure ulcer) in the Progress Notes and place the resident on the 24 hour report; Notify the Medical Doctor (MD)/Nurse Practitioner (NP) of the findings and obtain a treatment order and initiate the treatment as ordered. Nurse at time of the finding is to inform the resident's contact; Wound care will notify the interdisciplinary team; A separate care plan will be initiated upon discovery of the pressure injury; Plan of care to be reviewed and new interventions to be placed as needed. Resident #738 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making and a Brief Interview for Mental Status (BIMS) could not be completed. The resident was totally dependent on the assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The resident was always incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one Stage 4 pressure ulcer upon admission to the facility. The resident utilized pressure-reducing devices while in a chair and bed and was on a turning and repositioning program. The Comprehensive Care Plan (CCP) for Skin Integrity: At Risk for Skin Breakdown dated 1/9/2022 documented no reasons as to why the resident was at risk for skin breakdown. The interventions included for the Certified Nursing Assistant (CNA) to evaluate the resident's skin condition daily during care and report any skin abnormalities to the Nurse; Provide incontinent care; and to maintain turning and positioning schedule as recommended. The CCP for Skin Integrity: Sacrum dated 1/11/2022 documented that the resident had an Unstageable pressure ulcer upon admission which progressed to a Stage 4. The interventions included to monitor the ulcer site and dressing placement every shift; Maintain turning and positioning schedule every 2 hours as recommended; Monitor and report changes in ulcer's size, drainage, and color; Provide treatments as ordered by the Medical Doctor (MD); and monitor effectiveness of treatment(s) ordered. The CCP was updated on 1/12/2022 indicating the sacral pressure ulcer was now a Stage 3 measuring 3 centimeters (cm) x 2 cm x 0.1 cm. The CCP was updated on 3/24/2022 indicating the pressure ulcer to the sacrum was now assessed as a Stage 4 measuring 9 cm x 6 cm x 0.2 cm. The Wound Care Progress Note dated 1/11/2022 written by the former Registered Nurse (RN) Wound Care Nurse (RN #15) documented that the resident was seen status [REDACTED]. The plan of care (P(NAME)) included to continue with turning and repositioning every 2 hours and as needed and to continue to be seen and followed by the wound care team on a weekly basis. The Physician Order's dated 5/4/2022 documented Comfort Measures Only (CMO), Do Not Hospitalize (DNH), Do Not Resuscitate (DNR), No Antibiotics, No intravenous (IV) Fluids, No laboratory work-up, and No weights. A Nursing Assessment created on 7/23/2022 and completed on 8/1/2022 documented that the resident's Braden Scale (a tool used to identify the risk for developing pressure ulcer) score was 12 indicating that the resident was at high risk for developing pressure ulcers. The Wound Care assessment dated [DATE] written by the Wound Care Physician (WCP) documented that the resident had a Stage 4 pressure injury to the sacrum measuring 17.0 cm in length, 19 cm in width, and 0.5 cm in depth. The wound bed had 95% pink granulation (healthy tissue), 5% yellow slough (dead tissue), and 0% black eschar (dead tissue). The recommendations included to adhere to the facility repositioning and decubitus prevention protocol. The Wound Care Progress Note dated 7/25/2022 written by the former RN Wound Care Nurse (RN #15) documented that the resident was seen by the wound care team on 7/25/2022. The Stage 4 sacral wound measured 17 cm x 19 cm x 0.5 cm. Continue Santyl (enzymatic debridement agent)/Alginate (wound dressing). The CNA Documentation Record dated (MONTH) 2022 documented that the resident's skin was checked every day once on the 7:00 AM-3:00 PM shift, once on the 3:00 PM-11:00 PM shift, and once on the 11:00 PM-7:00 AM shift. The CNAs documented either an a which meant performed or a g which meant issue reported and documented under the Skin Check/Care task. The CNA Documentation Record dated (MONTH) 2022 also documented that the resident was turned and positioned every two hours under the Turn and Position task. The Wound Care assessment dated [DATE] written by the WCP documented that the resident's Stage 4 pressure injury to the sacrum now measured 19.0 centimeters (cm) in length, 20 cm in width, and 0.5 cm in depth. The Wound Care Assessment also documented for the first time that the resident now had a Stage 3 pressure injury to the left shoulder measuring 3.5 cm in length, 3.5 cm in width, and 0.2 cm in depth. The wound bed had 80% pink granulation and 20% yellow slough. The physician's orders [REDACTED]. Apply Santyl followed by Calcium Alginate. Cover with a dry protective dressing (DPD) daily and as needed. The Wound Care Progress Note dated 8/1/2022 written by the former RN Wound Care Nurse (RN #15) documented that the resident was seen by the wound care team on 8/1/2022. The Stage 3 left shoulder pressure ulcer measured 3.5 cm x 3.5 cm x 0.2 cm with moderate odorless drainage. Review of Nursing Progress Notes revealed no documentation related to a change in skin condition to the resident's left shoulder prior to 8/1/2022. The Comprehensive Care Plan (CCP) for Skin Integrity: Stage 3 Left Shoulder dated 8/2/2022 documented that the resident was seen by the wound care team on 8/1/2022. The wound was stable and to continue with the current plan of care (P(NAME)). The Wound Care assessment dated [DATE] written by the WCP documented that the resident had a Stage 4 pressure injury to the sacrum measuring 17.0 centimeters (cm) in length, 20 cm in width, and 0.5 cm in depth. The Wound Care Assessment also documented that the resident had a Stage 3 pressure injury to the left shoulder measuring 2.5 cm in length, 3.5 cm in width, and 0.3 cm in depth. The CNA Documentation Record dated (MONTH) 2022 documented that the resident's skin was checked every day, once on the 7:00 AM-3:00 PM shift, once on the 3:00 PM-11:00 PM shift, and once on the 11:00 PM-7:00 AM shift. The CNAs documented either an a which meant performed or a g which meant issue reported and documented under the Skin Check/Care task. The CNA Documentation Record dated (MONTH) 2022 also documented that the resident was turned and positioned every two hours under the Turn and Position task. The Wound Care assessment dated [DATE] written by the WCP documented that the resident had a Stage 4 pressure injury to the sacrum measured 18.0 centimeters (cm) in length, 20 cm in width, and 0.5 cm. The Stage 3 pressure injury to the left shoulder measured 2.0 cm in length, 3.0 cm in width, and 0.2 cm in depth. The Wound Care Assessment also documented for the first time that the resident now had a Stage 4 pressure injury to the right shoulder measuring 3.5 cm in length, 14.0 cm in width, and 0.2 cm in depth (Many measured as one). The wound bed had 90% pink granulation, 10% yellow slough. The physician's orders [REDACTED]. Review of Nursing Progress Notes revealed no documentation related to a change in skin condition to the resident's right shoulder prior to 8/29/2022. The CCP effective for Skin Integrity: Stage 4 Right Shoulder dated 8/29/2022 documented that the resident was seen by the wound care team on 8/29/2022. Right shoulder Stage 4 scattered (areas) measured 3.5 cm x 14.0 cm x 0.3 cm with 90% pink and 10% yellow wound bed. Moderate amount of drainage. Treatment continues with Santyl and Alginate. The Treatment Administration Record (TAR) for the month of (MONTH) 2022 and (MONTH) 2022 to monitor skin Integrity daily. The TAR was signed by nursing staff to indicate the skin was monitored daily as documented. The current RN Wound Care Nurse (RN #9) was interviewed on 8/8/2023 at 12:30 PM and stated that when they do weekly wound rounds with the WCP, they (RN #9 and WCP) do not have the time to do a full body check of the resident because there are a lot of residents to be seen. RN #9 stated that sometimes during weekly wound rounds, they (RN #9 and WCP) may spot something else, but most times they (RN #9 and the WCP) go straight to the wound that they (RN #9 and WCP) are there to evaluate. RN #9 could not explain how the right shoulder pressure ulcer was initially identified as a Stage 4 on 8/29/2022. The former RN Wound Care Nurse (RN #15) was interviewed on 8/08/2023 at 1:50 PM and stated that the first time they (RN #15) are made aware of a pressure ulcer, they (RN #15) write a Progress Note. RN #15 stated that they (RN #15) could not recall what happened and why the first time the resident's left shoulder was seen on wound rounds on 8/1/2023, it was already a Stage 3. RN #15 stated that when a pressure ulcer is first identified, an RN or a Licensed Practical Nurse (LPN) has to fill out a pressure ulcer communication form and send it to the Wound Care Office. RN #15 stated that then an investigation would be conducted to try and determine how the pressure ulcer occurred and these investigations were kept in a binder in the Wound Care Office. The Wound Investigation Reports for Resident #738's the left and right shoulder pressure ulcers were requested on 8/8/2023 from the Director of Nursing Services (DNS) and from the Administrator; however, the facility was not able to provide the Wound Investigation Reports related to the resident's left shoulder pressure ulcer identified on 8/1/2022 and the right shoulder pressure ulcers identified on 8/29/2022. On 8/9/2023, the DNS provided an Investigative Report Injury of Unknown Origin Skin dated 8/1/2022 for the resident's left shoulder wound and 8/29/2022 for the resident's right shoulder wound. Staff assigned to the resident on the preceding shifts for 48 hours, including RNs, Licensed Practical Nurses (LPNs), and CNAs were interviewed and all stated that they had no knowledge of either wound prior to wound care rounds. The root cause analysis of the pressure ulcer development was the resident had impaired mobility, incontinent of bowel and bladder, totally dependent for mobility for turning and positioning, with [MEDICAL CONDITION] on a ventilator and receiving Tube feedings (fed by a tube into the stomach), had a history of [REDACTED]. The resident's primary 3:00 PM-11:00 PM Certified Nursing Assistant (CNA) #11 was interviewed on 8/8/2023 at 2:45 PM and stated they were not the person who found either of the resident's shoulder pressure ulcers. CNA #11 stated that the resident was a two person assist for bathing, brief changing, and for turning and positioning. CNA #11 stated that the only time the resident came out of bed was when they were showered. CNA #11 stated that the resident was only able to be turned from side to side because the wound on the resident's sacrum was so big. CNA #11 stated that when they positioned the resident, they would put two pillows along the resident's front, one pillow between their knees, and two pillows along their back. CNA #11 stated that the procedure is to turn and position a resident every two hours, but they have other residents that also need to be dealt with so there really is no set time for turning and positioning and that the resident would be turned 2 to 3 times on their shift. CNA #11 stated that the resident would also sweat a lot and they would change Resident #738's gown when they repositioned the resident. The resident's primary 3:00 PM-11:00 PM LPN #7 was interviewed on 8/9/2023 at 10:00 AM and stated that they remembered the resident well due to the resident's large sacral wound. LPN #7 stated that the resident was laying on their back for most of the time with a pillow on each side of them underneath their hips to take pressure off the sacral area. LPN #7 stated that if a resident was comfortable and asleep, it was their right to not be disturbed and not turned and positioned during the night. LPN #7 stated that they never had a treatment to do for Resident #738 and therefore would never have a reason to turn them (Resident #738) over. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 10:45 AM and stated that Wound Investigation Reports are completed for nosocomial pressure ulcers (developed at the facility); however, the Wound Investigation Reports could not be found for the left and right shoulder wounds that the resident developed in the facility. The DNS stated that a Progress Note should have been written when each wound was first identified and by whom. The resident's primary 7:00 AM-3:00 PM CNA #12 was interviewed on 8/09/2023 at 11:50 AM and stated that if they see any redness on a resident, they would notify a Nurse and they did not notice any changes in the resident's skin. CNA #12 stated that they could not remember who first discovered the resident's shoulder wounds. CNA #12 stated that they try their best to turn and position a resident every 2 hours, especially a resident with wounds, but sometimes it is difficult when there are only 4 or 5 CNAs working a shift instead of the usual 6 CNAs. CNA #12 stated that the resident was never on their back due to the large sacral wound. CNA #12 stated that they would position the resident on their side with one pillow behind the back from the shoulder to their waist and one pillow between their legs. CNA #12 stated that the resident was showered on their shift twice a week and if it was not a shower day, they would clean the resident in bed and change the resident's gown because the resident would sweat a lot. The resident's primary 11:00 PM-7:00 AM shift CNA (CNA #13) was contacted on 8/9/2023 at 2:05 PM and was unavailable for interview. The Wound Care Physician (WCP) was interviewed on 8/9/2023 at 2:15 PM and stated that by definition a wound is a Stage 3 when it has slough at the base. The WCP stated residents on ventilators, such as Resident #738, are compromised patients with multiple issues and a wound could develop fairly quickly due to lack of mobility, nutritional factors, and overall multiple comorbidities. The WCP stated that despite seeing the resident on a weekly basis, a wound could have developed at any time during that week. The WCP stated that someone must have told them that the resident had something on their (Resident #738) shoulders for them to assess the resident's shoulders during wound rounds. The WCP stated that they would think that the resident's skin had to be compromised in some way before it developed to a Stage 3 or Stage 4. The WCP stated that they would assume that the resident's skin would have shown some redness first because the skin cannot go from nothing to something. The WCP stated that neither the CNAs nor the Nurses brought a change in the resident's skin condition to their attention. The WCP stated the first time they saw the resident's left shoulder pressure ulcer the wound was already a Stage 3 and the first time they saw the right shoulder pressure ulcer the wound was assessed as a Stage 4. The DNS was re-interviewed on 8/9/2023 at 3:50 PM and stated that the resident's skin could not have been intact and then gone to a Stage 3 or a Stage 4 pressure ulcer. The DNS stated that there had to have been some change in the resident's skin that should have been seen when showering the resident, turning and positioning the resident, and when changing the resident's clothes. The DNS stated that there was no documentation of the resident's left and right shoulder pressure ulcers prior to being seen on wound rounds and there should have been. The DNS also stated they would not expect a resident to be left on their back to sleep on during the 11:00 PM - 7:00 AM shift if the resident was on turning and positioning program. 10 NYCRR 415.12(c)(2) | Plan of Correction: ApprovedSeptember 18, 2023 In response to the deficiencies related to F686, involving resident #738 developing nosocomial pressure ulcers to their shoulders without prior documented evidence of compromised skin in these areas, we have developed a comprehensive plan of correction to address the issues, enhance wound care protocols, and prevent similar occurrences in the future. For resident #738, immediate corrective actions were taken to provide appropriate wound care for the pressure ulcers on their shoulders. These actions included specialized treatment interventions and close monitoring by the wound care provider, then current wound care nurse (RN# 15), and current wound care nurse (RN# 9) to promote the healing of these ulcers. Resident 738 passed away four months later, and it is important to note that this event was unrelated to the incidents previously discussed. Specialized education sessions were conducted for the RNs, LPNs, and CNAs who worked on SC1 between 8/1/2022 and 8/29/2022 to address the need for proper documentation of the resident's changing skin condition. Disciplinary actions will also be conducted on these select employees as needed to reinforce the importance of accurate and timely documentation. The wound care nurse (RN# 15) is no longer employed at the facility. Re-education on resident change in condition policies will be provided to all Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) emphasizing the importance of consistent monitoring, timely reporting, assessment, and documentation of any changes in residents' skin conditions. All policies related to skin checks and wound care have been reviewed, and no changes have been made as they continue to align with current best practices and standards. The EMR system has been thoroughly checked to identify any residents who may have experienced skin breakdown within the past 90 days. This information was cross-referenced with wound care incident reports to ensure that all wounds have been appropriately identified and addressed. For any residents with questionable skin conditions, in-person evaluations were conducted by the wound care nurse (RN #9) and the wound care provider to ensure accurate categorization and appropriate care. Following this comprehensive assessment, it was determined that no other wounds were found that match the deficiency cited. A quality assurance program will be initiated to monitor the effectiveness of these corrective actions. The wound care nurse or designee will conduct an audit of wound care incident reports to ensure that timely observation and notification of skin changes are addressed promptly. This audit will utilize an audit tool designed by the Director of Nursing. Each incident report will be reviewed and audited for twelve (12) months, then as directed by the QAPI committee, to assure compliance with deficient practice. Any negative findings will be corrected immediately through employee counseling. All audit outcomes will be reported to the QAPI committee. The target date for completing these corrective actions is (MONTH) 9, 2023, and the Director of Nursing will be responsible for overseeing the implementation of this plan of correction. We are committed to providing the highest quality of wound care and ensuring the well-being of our residents. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 10, 2023
Corrected date: October 9, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 8/1/2023 and completed on 8/10/2023, the facility did not ensure outside services were provided to resident timely as per their physician's orders [REDACTED].#97) of one resident reviewed for [MEDICAL CONDITION] Medication Side Effects. Specifically, Resident #97, with a medical [DIAGNOSES REDACTED]. The resident has not been seen by the Neurologist as of 8/10/2023. The finding is: The facility's policy titled, Consults dated 2/21/2021 documented to provide residents with consultation services in accordance with their plan of care and as ordered by a physician. The physician will order the consult. The nurse generates the Consultation Request form. If the facility has the consultant in-house, the consult request will be sent directly to the consultant for review and scheduling. Once completed, the consultant will document their notes, recommendations, and any additional information into the resident's medical chart. Resident #97 was admitted with [DIAGNOSES REDACTED]. The 3/31/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident had intact cognition. The MDS documented the resident was independent with one-person physical assistance with eating. The 6/28/2023 Quarterly Minimum Data Set (MDS) assessment documented that the resident required extensive assistance with one person physical assist for eating. A Comprehensive Care Plan (CCP) titled Multiple Medication Use: At Risk for Adverse Drug Interaction related to Use of Multiple Medications, effective 5/20/2019 documented Physician (MD) to review and evaluate medications monthly and as needed (PRN), to observe signs and symptoms of adverse drug reactions, and to review the Pharmacy Consultants' recommendations and follow-up. A Comprehensive Care Plan (CCP) titled Neurological Disease: [MEDICAL CONDITION], effective 5/20/2019 documented interventions including but not limited to assist resident in the Activities of Daily Living (ADL) tasks and to encourage rest periods as needed. Therapy evaluation as needed when changes are noted in ADLs and safety. A Comprehensive Care Plan (CCP) titled ADLs Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, effective 5/8/2019 documented interventions were updated on 6/15/2023 to provide a two-handled cup with a lid at all meals and to provide extensive assistance at mealtimes. A Medical Progress Note written by Nurse Practitioner (NP) #2 on 5/8/2023 documented that Resident # 97 has worsening tremors likely related to [MEDICAL CONDITION] medications. [MEDICATION NAME] was increased for outburst of aggressive behavior. NP #2 documented dosing believed to be too high. NP #2 documented discussion with the resident's Health Care Proxy to attempt a slow gradual drug reduction of [MEDICATION NAME]. A Medical Progress Note dated 5/12/2023 documented the resident was noted with increased tremors. Resident #97 has [MEDICAL CONDITION] and was on [MEDICATION NAME] 25mg/ [MEDICATION NAME] 100mg (medications used to treat [MEDICAL CONDITION] symptoms) twice a day. The progress note documented to obtain a Neurology consult to follow up. A physician's orders [REDACTED]. Resident #97 was observed in bed on 8/3/2023 at 8:43 AM. The resident was observed shaking. Resident #97 was unable to verbalize why they (resident) were shaking. Resident #97 was observed out of bed on 8/8/2023 at 10:24 AM. The resident was observed in their wheelchair in the hallway. Tremors persisted and Resident #97 stated that they did not recall being seen a specialist for their tremors. Certified Nurse Assistant (CNA) #18, who was Resident #97's assigned CNA, was interviewed on 8/9/2023 at 1:27 PM. CNA #18 stated that Resident #97 had [MEDICAL CONDITION] but was previously able to participate more actively during care. CNA #18 stated that there was a gradual but notable decrease in function since last year. CNA #18 stated that Resident #97 became more reliant on staff's assistance and began to request help for different ADLs. CNA #18 stated that they were aware of the resident's increased shakiness. CNA #18 stated that they did not know if tremors have affected the resident's ability to feed themselves or if the resident just preferred to be fed. CNA #18 stated that Resident #97 had recently started to use a cup with a lid to drink their beverages during meals. The Medical Services Coordinator was interviewed on 8/4/2023 at 9:58 AM and stated that they had started working in the facility five weeks ago. The Medical Services Coordinator stated that they run reports in the Electronic Medical Record (EMR) system regularly to update new residents with consult orders. The Medical Services Coordinator stated that they communicate with the respective in-house specialists when they visit the facility to ensure that residents who needed to be seen would be seen. The Medical Services Coordinator was re-interviewed on 8/9/2023 at 1:52 PM and stated that they (Medical Services Coordinator) had reviewed Resident #97's order and the medical record. The Medical Services Coordinator confirmed that Resident #97 had an MD order for Neurology consult on 5/12/2023 but was not able to find documented evidence that the resident was on the list to be seen by the Neurologist. The Medical Services Coordinator stated that there was no documented evidence that Resident #97 was seen by the Neurologist as per their MD order. The Medical Services Coordinator stated that they (Medical Services Coordinator) were not aware of how the previous Medical Services Coordinator ensured that physician's orders [REDACTED]. The Neurologist was interviewed on 8/9/2023 at 2:19PM and stated that they visited the facility about once a month. The Neurologist stated that the medical office would provide a list of residents that need to be seen and evaluated. The Neurologist would also be contacted by the resident's attending physician if there was an emergency that required immediate Neurology assessment. The Neurologist stated that they very likely did not receive a referral for Resident #97 and did not see the resident because they would have documented their assessment and findings in the resident's progress note after they visited the resident. NP #2 was interviewed on 8/9/2023 at 2:39 PM. NP#2 stated that Resident #97 had [DIAGNOSES REDACTED]. NP #2 stated that they were aware of Resident #97's increased tremors after a medication dosage change. NP #2 stated that Neurology consult was appropriate in order to address and re-assess Resident #97's [MEDICAL CONDITION] progress and treatment and to provide recommendations to determine the best medical management of the resident's overall health. NP #2 stated that they (NP #2) were not aware that Resident #97 was not followed by the Neurologist and stated that the consult should have been done, preferably within a month after the referral was made. NP #2 stated that Resident #97's tremors improved; however, would still expect the resident to be seen by the Neurologist. Resident #97's attending Physician (MD) #3 was interviewed on 8/9/2023 at 3:20 PM and stated that they (MD #3) expected the medical office staff to notify the specialist when a consultation request was made. MD #3 stated that they would expect that the resident would be seen within a couple of weeks after the referral was made. MD #3 stated that they were not aware that Resident #97 was still not seen by since (MONTH) of 2023 and they still expected the resident to be seen by the Neurologist now. The Director of Nursing Services (DNS) was interviewed on 8/9/2023 at 3:33 PM and stated that they expected the Neurologist to see the resident who had a physician's orders [REDACTED]. The DNS stated that they expected a consult to be completed within two months after the physician's orders [REDACTED]. 10 NYCRR 415.26(e)(1)(i-iv) | Plan of Correction: ApprovedSeptember 19, 2023 F - 0840 In response to the identified deficiency involving resident #97, where a neurology consult was ordered but not completed, we have devised a comprehensive plan of correction to address the issue and implement systematic improvements to prevent such occurrences in the future. Resident #97 who was found to have been affected by the deficient practice will have their pending neurology consults promptly addressed and scheduled. An in-house neurology consultation was ordered for the resident and Resident #97 was seen by the neurologist on (MONTH) 6, 2023. The medical suite coordinator, who managed the consults at that time, no longer works at the facility. We will work diligently to ensure that any pending consultations are promptly scheduled and that resident care needs are addressed without delay. A thorough review of all residents' medical records was conducted by the interdisciplinary team (IDT) to identify other residents who may potentially be affected by missed or delayed consultations. For those identified, prompt action was taken to assure the necessary consultations are addressed in a timely manner. The medical director, director of nursing, assistant directors of nursing, administrator, assistant administrators, medical suite coordinator, director of administrative operations, and nursing executive assistant have met to discuss the consultation process. The consultation process will be thoroughly revamped to ensure that consultations are not missed and are addressed in a timely manner. This includes the usage of fully electronic consults for both in-house consultants and external referrals to consultants. These electronic requests will be integrated with the EMR system to ensure continuity of care and ease of identifying the requested needs. Policies and procedures related to consultation services will be reviewed and updated to reflect the new process and to prevent similar occurrences. A regular review of consultants' services will be conducted by the DNS, Administrator, and Medical Director to ensure that services meet residents' needs, and changes will be made as necessary. Education of the medical suite coordinator will be conducted to reinforce the significance of timely consults and the necessity of effective communication with the medical director, director of nursing, and administrator regarding any concerns related to consultation appointments. Further, the medical suite coordinator, RNs, and LPNs will be in-serviced on the new consultation process once the final details are established. To ensure ongoing compliance, audits were designed and will be conducted every other week for the next six (6) months to verify that all consults are being addressed and attended to. Any noncompliance with a timely appointment will be addressed immediately and reported to the DNS. The nursing executive assistant will be responsible for these audits and providing them to the QAPI committee for review. All corrective actions will be implemented by (MONTH) 9, 2023. The Director of Nursing will oversee the correction process and monitor its implementation to prevent the recurrence of similar deficiencies. The Medical Suite Coordinator will be responsible for ensuring proper coordination and communication throughout the consultation process. This plan of correction underscores our dedication to continuous improvement and maintaining the highest standards of care within our nursing home. We will diligently monitor the implementation of these measures, making necessary adjustments to ensure the timely addressing of consults and the well-being of our residents. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source Based on observation and staff interview, alcohol-based hand-rub (ABHR) dispensers were installed above or below ignition sources in the corridors. This was noted on one of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, ABHR dispensers were observed installed above or below ignition sources including wall sconces or electrical outlets in corridors. Examples are: 1) [MEDICATION NAME] 2- adjacent to resident room [ROOM NUMBER] 2) [MEDICATION NAME] 2- between resident rooms 237 & 238 3) [MEDICATION NAME] 2- adjacent to resident room [ROOM NUMBER] In an interview on 8/8/23 at approximately 11:50am, the Director of Plant Operations stated that they will move the ABHR dispensers. 2012 NFPA 101: 19.3.2.6 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source Based on observation and staff interview, alcohol-based hand-rub (ABHR) dispensers were installed above or below ignition sources in the corridors. This was noted on one of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, ABHR dispensers were observed installed above or below ignition sources including wall sconces or electrical outlets in corridors. Examples are: 1) [MEDICATION NAME] 2- adjacent to resident room [ROOM NUMBER] 2) [MEDICATION NAME] 2- between resident rooms 237 & 238 3) [MEDICATION NAME] 2- adjacent to resident room [ROOM NUMBER] In an interview on 8/8/23 at approximately 11:50am, the Director of Plant Operations stated that they will move the ABHR dispensers. 2012 NFPA 101: 19.3.2.6 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source Based on observation and staff interview, alcohol-based hand-rub (ABHR) dispensers were installed above or below ignition sources in the corridors. This was noted on two of four floors. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, ABHR dispensers were observed installed above or below ignition sources including wall sconces or electrical outlets in corridors. Examples are: 1) Woodcrest 2- between resident rooms 234 & 233 2) Woodcrest 2- between resident rooms 106 & 105 3) Woodcrest 2- between resident rooms 111 & 112 In an interview on 8/9/23 at approximately 11:49am, the Supervisor of Plant Operations stated that they have already started removing the ABHR dispensers. 2012 NFPA 101: 19.3.2.6 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.2.6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source Based on observation and staff interview, alcohol-based hand-rub (ABHR) dispensers were installed above or below ignition sources in the corridors. This was noted on two of four floors. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, ABHR dispensers were observed installed above or below ignition sources including wall sconces or electrical outlets in corridors. Examples are: 1) Woodcrest 2- between resident rooms 234 & 233 2) Woodcrest 2- between resident rooms 106 & 105 3) Woodcrest 2- between resident rooms 111 & 112 In an interview on 8/9/23 at approximately 11:49am, the Supervisor of Plant Operations stated that they have already started removing the ABHR dispensers. 2012 NFPA 101: 19.3.2.6 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 K325 In response to the identified deficiency concerning alcohol-based hand-rub (ABHR) dispensers being installed above or below ignition sources in the corridors, we have developed a comprehensive plan of correction to promptly address this issue and ensure the safety of our nursing home facility. As an immediate action, we have relocated all ABHR dispensers that were identified during the survey to meet the necessary safety requirements, ensuring that they are not installed near ignition sources. Furthermore, the Director of Maintenance or their designated representative will conduct a thorough audit of all ABHR dispensers within our facility to ensure they are correctly positioned in compliance with safety regulations. If any dispensers are found to be in locations that do not meet the requirements, they will be promptly relocated to ensure compliance. To maintain compliance and vigilance, the Director of Maintenance or their designee will conduct monthly audits of all ABHR dispensers for a duration of six months. Further, any time a new ABHR dispenser is installed, the director of maintenance or their designee will verify that it is positioned appropriately. This systematic approach will help identify and address any issues with dispenser placement promptly, reducing the risk of non-compliance and enhancing the safety of our residents and staff. All findings resulting from these measures will be reported to our Quality Assurance and Performance Improvement (QAPI) committee for review and necessary action. This collaborative approach underscores our commitment to resident safety and adherence to regulatory requirements, ensuring that our facility maintains the highest standards of safety regarding the placement of ABHR dispensers. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety of our nursing home. Through prompt relocations, regular audits, and ongoing monitoring, we aim to prevent future deficiencies and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of safety in our facility. Responsible party: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2024
Corrected date: January 26, 2024
Citation Details 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within housekeeping closets, utility rooms, boiler room and in the corridors throughout the building on four of four floors. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors and the basement. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories with a basement and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within storage rooms and in the corridors throughout the building on four of four floors and the basement. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within shower rooms, soiled utility rooms, elevator machine room and in the corridors throughout the building on four of four floors. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on three of three floors and the basement. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be three stories with a basement and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within storage rooms, soiled utility rooms, boiler room and in the corridors throughout the building on three of three floors and the basement. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within housekeeping closets, utility rooms, boiler room and in the corridors throughout the building on four of four floors. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within housekeeping closets, utility rooms, boiler room and in the corridors throughout the building on four of four floors. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors and the basement. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories with a basement and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within storage rooms and in the corridors throughout the building on four of four floors and the basement. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors and the basement. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories with a basement and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within storage rooms and in the corridors throughout the building on four of four floors and the basement. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within shower rooms, soiled utility rooms, elevator machine room and in the corridors throughout the building on four of four floors. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be four stories and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within shower rooms, soiled utility rooms, elevator machine room and in the corridors throughout the building on four of four floors. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on three of three floors and the basement. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be three stories with a basement and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within storage rooms, soiled utility rooms, boiler room and in the corridors throughout the building on three of three floors and the basement. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the building was at least Type II (222) Fire Resistive, Noncombustible construction in accordance with NFPA 101. Specifically, the facility did not provide an approved hardship waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on three of three floors and the basement. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the building was observed to be three stories with a basement and Type II (000) construction. Unprotected steel beams were observed in areas including but not limited to within storage rooms, soiled utility rooms, boiler room and in the corridors throughout the building on three of three floors and the basement. In an interview on 8/9/23 at approximately 9:09am, the Administrator stated that they did a Fire Safety Evaluation System (FSES) in (MONTH) 2023 and that they are trying for an equivalency. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMarch 6, 2024 K161 The Facility is seeking a continuing waiver based on financial hardship. On (MONTH) 8, 2023, during the recertification survey, the building was observed as a Type II (000) construction with unprotected steel beams in areas including storage rooms and corridors. Existing Condition: The facility was constructed between 1960 and 1990 and classified as a Type II (000) building. However, due to economic constraints, the facility cannot afford the significant financial investment required to upgrade the building to meet the current LSC requirements for fire resistance. Reasons for Non-Compliance: 1. Resident Disruption: Making these repairs would substantially impact the lives and homes of the residents requiring them to be misplaced for 10+ weeks at a time while repairs are conducted which goes against their rights and regulation to a home-like environment. 2. Financial Hardship: Addressing the unprotected steel beams would require extensive renovations, incurring substantial costs that are not currently feasible within the facilityÆs budget. 3. Regulatory Challenges: In certain areas, implementing fireproofing measures would necessitate lowering ceilings, potentially violating other regulations such as minimum ceiling height requirements. Corrective Actions: While complete compliance is not achievable at this time, the facility is committed to ensuring the safety of residents and staff through the following: 1. Daily Communication with Central Monitoring Station: The facility will call the central monitoring station daily to confirm communication effectiveness and ensure immediate response to any fire alarms. 2. Increased Fire Drills: Fire drills will be conducted monthly on each shift to test and improve employee response preparedness. 3. Quarterly Exit Checks: The Director of Plant Operations or designee will conduct quarterly inspections of all exits to ensure unobstructed egress pathways. Additional Safety Features: The facility has implemented several fire protection and life safety features exceeding the LSC minimum requirements, including: 1. Quick Response Sprinklers: The entire building is equipped with quick response sprinkler systems, providing a rapid and effective response to potential fires. 2. Comprehensive Smoke Detection: Smoke detectors are installed throughout all spaces, ensuring early detection of fire and prompt notification to authorities. 3. Class A Interior Finishes: All interior finishes are Class A, minimizing the spread of flames and smoke in case of a fire. Responsible Party: The director of maintenance is responsible for this. Timeline: 1. Daily communication with the central monitoring station will begin immediately. 2. Increased fire drills will commence immediately. 3. Quarterly exit checks will begin immediately. Waiver Request: The facility requests a continuing waiver for financial hardship on the basis of the outlined circumstances. We believe that the implemented additional safety measures, coupled with the existing fire protection and life safety features, provide a sufficient level of protection for residents and staff. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: September 30, 2023
Citation Details 2012 NFPA 101: 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 96: 10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable: (1) NFPA 12 (2) NFPA 13 (3) NFPA 17 (4) NFPA 17A 2009 NFPA 17A: 7.2 Owner's Inspection. 2009 NFPA 17A: 7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. 2009 NFPA 17A: 7.2.2 At a minimum, this quick check or inspection shall include verification of the following: (1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) The tamper indicators and seals are intact. (4) The maintenance tag or certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range. (7) The nozzle blowoff caps, where provided, are intact and undamaged. (8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. 2009 NFPA 17A: 7.2.5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. Based on observation, staff interview and documentation review, the facility did not maintain the range hood fire extinguishing system (ANSUL) in the kitchen on the ground floor in accordance with NFPA 96, in that there was no documentation provided regarding the required monthly inspections. The findings are: On 8/7/23 at approximately 12:06pm during the recertification survey, the last documented ANSUL inspection in the kitchen on the ground floor was completed in (MONTH) 2023 as noted by tags on the pull station and containers. There was no documented monthly ANSUL inspections noted since the service date. In an interview on 8/7/23 at approximately 12:06pm, the Director of Plant Operations stated that they should be done at the same time as the fire extinguisher inspections. 2012 NFPA 101: 9.2.3 2011 NFPA 96: 10.2.6 2009 NFPA 17A: 7.2, 7.2.1, 7.2.2, 7.2.5 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 K324 In response to the identified deficiency regarding the maintenance of the range hood fire extinguishing system (ANSUL) in the kitchen on the ground floor, specifically the absence of documented monthly inspections in accordance with NFPA 96, we have developed a comprehensive plan of correction to address this issue and ensure the safety of our nursing home facility. To rectify the lack of documented monthly inspections, we will restart the ANSUL system inspections. These monthly inspections will begin in (MONTH) 2023. These inspections will be carried out with the utmost diligence to ensure that the system is in proper working order and compliant with NFPA 96 standards. Furthermore, to enhance accountability and ensure that the ANSUL system inspections are consistently performed, the Director of Maintenance will include the inspection of the ANSUL system as part of the monthly fire extinguisher audit. This integrated approach will ensure that both the fire extinguishers and the ANSUL system are inspected and documented monthly. To maintain continuous compliance and vigilance, the ANSUL system will be inspected monthly alongside the fire extinguishers, and the findings will be documented. These findings will be reported during our Quality Assurance and Performance Improvement (QAPI) meetings for review and necessary action. Re-education of all maintenance staff who perform fire extinguisher checks will be conducted on proper procedures for fire extinguisher and ANSUL system checks. In conclusion, our plan of correction underscores our commitment to addressing the identified deficiency and enhancing the safety of our nursing home. Through the resumption of ANSUL system inspections, integration into the fire extinguisher audit process, and regular documentation and reporting, we aim to prevent future deficiencies and create a safer environment for our residents and staff. We are dedicated to implementing these corrective measures with diligence and care to uphold the highest standards of fire safety in our facility. Responsible party: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: November 13, 2023
Citation Details Based on observation and staff interview, a soiled utility room was observed not positively latching. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:07am during the recertification survey, a soiled utility room on Brookville 3 was observed with tape over the latching mechanism. The door did not positively latch when tested . In an interview on 8/7/23 at approximately 11:07am, the Director of Plant Operations stated that he will remove the tape. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)Based on observation and staff interview, a soiled utility room was observed not positively latching. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:07am during the recertification survey, a soiled utility room on Brookville 3 was observed with tape over the latching mechanism. The door did not positively latch when tested . In an interview on 8/7/23 at approximately 11:07am, the Director of Plant Operations stated that he will remove the tape. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)Based on observation and staff interview, a soiled utility room was observed not positively latching. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:07am during the recertification survey, a soiled utility room on Brookville 3 was observed with tape over the latching mechanism. The door did not positively latch when tested . In an interview on 8/7/23 at approximately 11:07am, the Director of Plant Operations stated that he will remove the tape. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.6.3* Corridor Doors. 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors protecting corridor openings were not positively latching or hit the door frame when tested . This was noted on three of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) [MEDICATION NAME] 3- the clean linen room door was not positively latching. There was a glove in the latching mechanism of the door frame 2) [MEDICATION NAME] 3- the door to the staff lounge was not positively latching 3) [MEDICATION NAME] 2- the door to the clean utility room was not positively latching 4) [MEDICATION NAME] 1- the door to the soiled utility room hit the frame when tested 5) [MEDICATION NAME] 1- the door to the conference room was held open with two door chocks In an interview on 8/8/23 at 11:52am, the Director of Plant Operations stated that they will replace the strike plate on the clean utility room door and address the issues. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.6.3* Corridor Doors. 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors protecting corridor openings were not positively latching or hit the door frame when tested . This was noted on three of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) [MEDICATION NAME] 3- the clean linen room door was not positively latching. There was a glove in the latching mechanism of the door frame 2) [MEDICATION NAME] 3- the door to the staff lounge was not positively latching 3) [MEDICATION NAME] 2- the door to the clean utility room was not positively latching 4) [MEDICATION NAME] 1- the door to the soiled utility room hit the frame when tested 5) [MEDICATION NAME] 1- the door to the conference room was held open with two door chocks In an interview on 8/8/23 at 11:52am, the Director of Plant Operations stated that they will replace the strike plate on the clean utility room door and address the issues. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.6.3* Corridor Doors. 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors protecting corridor openings were not positively latching or hit the door frame when tested . This was noted on three of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) [MEDICATION NAME] 3- the clean linen room door was not positively latching. There was a glove in the latching mechanism of the door frame 2) [MEDICATION NAME] 3- the door to the staff lounge was not positively latching 3) [MEDICATION NAME] 2- the door to the clean utility room was not positively latching 4) [MEDICATION NAME] 1- the door to the soiled utility room hit the frame when tested 5) [MEDICATION NAME] 1- the door to the conference room was held open with two door chocks In an interview on 8/8/23 at 11:52am, the Director of Plant Operations stated that they will replace the strike plate on the clean utility room door and address the issues. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)Based on observation and staff interview, a resident room door was observed to stick in the frame when tested . This was noted on one of four floors. The findings are: On 8/8/23 at approximately 10:04am during the recertification survey, the door to resident room 301 on Sagamore 3 stuck in the frame when tested . In an interview on 8/8/23 at approximately 10:04am, the Director of Plant Operations stated that he will adjust the door. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)Based on observation and staff interview, a resident room door was observed to stick in the frame when tested . This was noted on one of four floors. The findings are: On 8/8/23 at approximately 10:04am during the recertification survey, the door to resident room 301 on Sagamore 3 stuck in the frame when tested . In an interview on 8/8/23 at approximately 10:04am, the Director of Plant Operations stated that he will adjust the door. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)Based on observation and staff interview, a resident room door was observed to stick in the frame when tested . This was noted on one of four floors. The findings are: On 8/8/23 at approximately 10:04am during the recertification survey, the door to resident room 301 on Sagamore 3 stuck in the frame when tested . In an interview on 8/8/23 at approximately 10:04am, the Director of Plant Operations stated that he will adjust the door. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.6.3* Corridor Doors. 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors protecting corridor openings were not positively latching when tested . This was noted on one of three floors. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Sea(NAME)3- the door to the doctor's lounge was not positively latching. There was paper in the latching mechanism of the door frame. When the paper was removed, the door was tested again and hit the frame 2) Sea(NAME)3- the door resident room 317 was not positively latching In an interview on 8/10/23 at approximately 10:30am, the Director of Plant Operations stated that they would adjust the door. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.6.3* Corridor Doors. 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors protecting corridor openings were not positively latching when tested . This was noted on one of three floors. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Sea(NAME)3- the door to the doctor's lounge was not positively latching. There was paper in the latching mechanism of the door frame. When the paper was removed, the door was tested again and hit the frame 2) Sea(NAME)3- the door resident room 317 was not positively latching In an interview on 8/10/23 at approximately 10:30am, the Director of Plant Operations stated that they would adjust the door. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.6.3* Corridor Doors. 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors protecting corridor openings were not positively latching when tested . This was noted on one of three floors. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Sea(NAME)3- the door to the doctor's lounge was not positively latching. There was paper in the latching mechanism of the door frame. When the paper was removed, the door was tested again and hit the frame 2) Sea(NAME)3- the door resident room 317 was not positively latching In an interview on 8/10/23 at approximately 10:30am, the Director of Plant Operations stated that they would adjust the door. 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 24, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 11, 2023
Corrected date: December 30, 2023
Citation Details Based on observation, staff interview and documentation review, the facility did not ensure that the emergency preparedness plan (EP plan) was reviewed and updated. The findings are: On 8/11/23 between 9:00am-3:00pm during the recertification survey, review of the facility's EP plan revealed the following: 1) An attestation page indicating that the EP plan was reviewed by the Administrator dated 1/1/2023 2) The provided NFPA 99 risk assessment completed by the facility indicated that Respiratory/Ventilator as Category 4 for Gas/Vacuum Systems and Electrical Systems instead of the required Category 1 3) Page 4 of the Fire Safety Manual indicated that the facility is a code compliant structure. Four of the five main buildings were cited with a non-compliant building construction type since approximately (YEAR) 4) Section E: Emergency Procedures for Specific Events page (E.51) for Sea(NAME)indicates: Floors (2-3): Emergency exits are located at the bottom of each stairwell (5) in building. The exit within the South stair is between the 1st and 2nd floors and the stairwell continues to the basement level 5) There was no list of items served by the generator as indicated in Section B page (B.30) In an interview on 8/11/23 at approximately 2:30pm, the Administrator stated that they are in the process of updating the emergency preparedness plan. | Plan of Correction: ApprovedOctober 13, 2023 E004 In response to the deficiency identified in our nursing home regarding the lack of regular review and updates to our Emergency Preparedness (EP) plan, we have developed a comprehensive plan of correction to address this issue promptly and ensure the safety and well-being of our residents and staff. The last review of our EP plan was conducted in (MONTH) 2023, as noted in the survey findings. We are committed to conducting a full review and update of the EP plan to incorporate all necessary changes as outlined in the Statement of Deficiency (SOD), specifically an attestation page indicating that the EP plan was reviewed by the Administrator, the NFPA 99 risk assessment indicated Respiratory/Ventilator as Category 1, the Fire Safety Manual to notate the buildings K161 findings and appropriate steps being taken, the Seacliff exit within the South stair being relabeled, and a list of items served by the generator. This comprehensive review will ensure that our EP plan is current and aligned with the latest regulatory requirements, industry best practices, and the specific needs of our facility. The EP plan will be reviewed and updated within the next 90 days to ensure it is up to date. In addition to the full review and update, we recognize the importance of ongoing monitoring and maintenance of our EP plan. To accomplish this, we will implement an annual review process to ensure that our EP plan remains responsive to the evolving needs of our facility. This annual review will involve a thorough assessment of the plan's effectiveness and relevance and any necessary adjustments will be made accordingly. Any changes and modifications will be relayed to the staff through in-service education sessions. Furthermore, to enhance accountability and regulatory compliance, we will establish quarterly audits through our Quality Assurance and Performance Improvement (QAPI) subcommittee, the safety committee. These audits will focus on verifying that our EP plan not only meets regulatory requirements but also aligns with the best practices in emergency preparedness. Any identified deficiencies or opportunities for improvement will be promptly addressed to ensure the highest level of safety for our residents and staff. In conclusion, our plan of correction demonstrates our commitment to maintaining an up-to-date and effective Emergency Preparedness plan in our nursing home. We will ensure that our EP plan is reviewed, updated, and responsive to the changing needs of our facility, and we will regularly audit and assess its compliance with regulatory requirements. The safety and well-being of our residents and staff remain paramount, and we are dedicated to implementing these corrective measures with diligence and care to ensure their protection during emergencies. Responsible party: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: January 10, 2024
Citation Details 2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Based on observation and staff interview, exit doors equipped with delayed-egress locking systems were not functional. This was noted on three of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, exit doors equipped with delayed-egress locking systems were tested and not functional. Examples are: 1) Brookville 3- South stair 2) Brookville 2- South stair 3) Brookville 1- North stair In an interview on 8/7/23 at approximately 11:02am, the Director of Plant Operations stated that they will adjust the delayed-egress locking mechanisms. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Based on observation and staff interview, exit doors equipped with delayed-egress locking systems were not functional. This was noted on three of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, exit doors equipped with delayed-egress locking systems were tested and not functional. Examples are: 1) Brookville 3- South stair 2) Brookville 2- South stair 3) Brookville 1- North stair In an interview on 8/7/23 at approximately 11:02am, the Director of Plant Operations stated that they will adjust the delayed-egress locking mechanisms. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Based on observation and staff interview, exit doors equipped with delayed-egress locking systems were not functional. This was noted on one of four floors. The findings are: On 8/8/23 at approximately 11:02am during the recertification survey, the emergency exit doors in the vicinity of the adult day care, equipped with a delayed-egress locking system, was tested and not functional. This was noted on the ground floor. In an interview on 8/7/23 at approximately 11:02am, the Director of Plant Operations stated that they will adjust the delayed-egress locking mechanisms. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Based on observation and staff interview, exit doors equipped with delayed-egress locking systems were not functional. This was noted on one of four floors. The findings are: On 8/8/23 at approximately 11:02am during the recertification survey, the emergency exit doors in the vicinity of the adult day care, equipped with a delayed-egress locking system, was tested and not functional. This was noted on the ground floor. In an interview on 8/7/23 at approximately 11:02am, the Director of Plant Operations stated that they will adjust the delayed-egress locking mechanisms. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)Based on observation and staff interview, the audible alarm on an exit door equipped with a delayed-egress locking system was not functional. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 11:51am during the recertification survey, the South stair door on Woodcrest 1, equipped with a delayed-egress locking system, was tested and the audible signal was not functional. This was noted on the first floor. In an interview on 8/9/23 at approximately 11:51am, the Director of Plant Operations stated that they will check the speaker on the magnetic lock. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)Based on observation and staff interview, the audible alarm on an exit door equipped with a delayed-egress locking system was not functional. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 11:51am during the recertification survey, the South stair door on Woodcrest 1, equipped with a delayed-egress locking system, was tested and the audible signal was not functional. This was noted on the first floor. In an interview on 8/9/23 at approximately 11:51am, the Director of Plant Operations stated that they will check the speaker on the magnetic lock. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Based on observation and staff interview, exit doors equipped with delayed-egress locking systems were not functional. This was noted on one of three floors. The findings are: On 8/10/23 at approximately 10:38am during the recertification survey, the East stair door on Sea(NAME)3, equipped with a delayed-egress locking system, was tested and not functional. This was noted on the third floor. In an interview on 8/10/23 at approximately 10:38am, the Director of Plant Operations stated that they will adjust the delayed-egress locking mechanism. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. Based on observation and staff interview, exit doors equipped with delayed-egress locking systems were not functional. This was noted on one of three floors. The findings are: On 8/10/23 at approximately 10:38am during the recertification survey, the East stair door on Sea(NAME)3, equipped with a delayed-egress locking system, was tested and not functional. This was noted on the third floor. In an interview on 8/10/23 at approximately 10:38am, the Director of Plant Operations stated that they will adjust the delayed-egress locking mechanism. 2012 NFPA 101: 19.2.2.2.4, 7.2.1.6.1, 7.2.1.6.1.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 23, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: August 11, 2023
Corrected date: N/A
Citation Details Based on observation and staff interview, an extension cord and a multi-tap outlet adapter were observed in use within the maintenance shop in the basement. The findings are: On 8/8/23 at approximately 12:44pm during the recertification survey, an extension cord and a multi-tap outlet adapter were observed in use within the maintenance shop. This was noted in the basement. In an interview on 8/8/23 at approximately 12:44pm, the Director of Plant Operations stated that he would replace them with a relocatable power tap. 2012 NFPA 99: 10.2.3.6 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 8, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: January 26, 2024
Citation Details 2012 NFPA 99: 6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning (2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following: (a) Low lubricating oil pressure (b) Low water temperature (below that required in 6.4.1.1.11) (c) Excessive water temperature (d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply (e) Overcrank (failed to start) (f) Overspeed Based on observation and staff interview, alarm conditions were observed on the remote alarm annunciator for the emergency generator while the generator was not running. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:12pm during the recertification survey, alarm conditions were observed on the remote alarm annunciator for the emergency generator. The remote alarm annunciator indicated Alarm Silenced and Communication Status. At the time of the observation, the emergency generator was not running. This was noted on Woodcrest 1. In an interview on 8/9/23 at approximately 12:12pm, the Director of Plant Operations stated that he would call the company to check it out. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 24, 2023 K916 In response to the identified deficiency related to alarm conditions on the remote alarm annunciator for the emergency generator while the generator was not running, we have developed a comprehensive plan of correction to address this issue and enhance the safety and reliability of our emergency generator system at our nursing home facility. To promptly address the issue, we have already contacted our emergency generator vendor to repair the remote annunciator. They are ordering the necessary parts and will make the repairs as soon as they arrive with an expected completion date of (MONTH) 10, 2023. This corrective measure ensures that the remote annunciator functions properly and accurately reflects the status of the emergency generator. Furthermore, as part of our commitment to ensuring the ongoing reliability of our emergency generator system, the Director of Maintenance or their designated representative will conduct a comprehensive check and testing of all remaining generator remote annunciators. This testing will confirm their proper operation and accuracy in reporting generator status. Any issues identified during these checks will be promptly reported to the emergency generator vendor for necessary repairs. To enhance accountability and ensure continuous monitoring, we will incorporate the inspection of the remote annunciator into our weekly generator exercise audit. This regular audit will include checking the remote annunciator panels to confirm their proper functionality during the weekly generator exercise test. Additionally, the Director of Maintenance or their designee will conduct weekly audits of the remote annunciator panels during the weekly generator exercise test. This systematic approach will help identify and address any emerging issues with the annunciators promptly, ensuring the accurate reporting of generator status. All findings resulting from these measures will be reported during our Quality Assurance and Performance Improvement (QAPI) meetings for review and necessary action. This collaborative approach underscores our commitment to resident safety and the proper functioning of our emergency generator system, especially during critical situations. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety and reliability of our nursing home facility's emergency generator system. Through immediate action, regular inspections, ongoing audits, and collaboration with our generator vendor, we aim to prevent future issues and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of emergency preparedness. Responsible party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2011 NFPA 70: 700.10 Wiring, Emergency System. (A) Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. Based on observation, staff interview and documentation review, the facility did not provide identification for all panels serving the emergency system. This was noted on one of three floors. The findings are: On 8/10/23 at approximately 12:00pm during the recertification survey, emergency circuits within panels in the electrical room on Sea(NAME)1 were not identified. Examples are: 1) Panel EPC-1A- the circuits are not labeled as to what areas they serve. For example, within resident room [ROOM NUMBER], the emergency outlet is identified as being served by circuit #68 in panel EPC-1A, but circuit #68 within panel EPC-1A in the electrical room is not labeled 2) The Life Safety panel lacks numbers to identify the circuits In an interview on 8/10/23 at approximately 12:00pm, the Director of Plant Operations stated that he will have the panels updated. 2011 NFPA 70: 700.10 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 In response to the identified deficiency related to the lack of identification for all panels serving the emergency system, we have developed a comprehensive plan of correction to address this issue and enhance the safety and clarity of our nursing home facility. To promptly address the issue, we will update the electrical panel directory in the areas identified during the survey. This update will accurately reflect which areas are being served by each individual circuit, ensuring that the emergency system is clearly identified and understood. Furthermore, as part of our commitment to ensuring the proper identification of all panels serving the emergency system, the Director of Maintenance or their designated representative will inspect all other circuit panels within the facility to confirm that they are labeled appropriately. To ensure ongoing compliance and the continuous accuracy of panel identification, the Director of Maintenance or their designee will conduct regular audits of the electrical panels. These audits will be conducted quarterly for a duration of one year and whenever the panels are updated to reflect changes in the electrical system. In addition to these measures, re-education will be provided to electricians and individuals who participate in electrical work within the facility. This educational reinforcement will emphasize the importance of clear panel identification and its role in maintaining the safety and functionality of the emergency system. All findings resulting from these measures will be reported during our Quality Assurance and Performance Improvement (QAPI) meetings for review and necessary action. This collaborative approach underscores our commitment to resident safety and the proper functioning of our electrical systems, especially during emergency situations. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety and clarity of our nursing home facility. Through immediate action, regular inspections, ongoing audits, and staff reeducation, we aim to prevent future issues and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of electrical safety and identification in our facility. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: December 28, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6.1* Applicability. 2012 NFPA 99: 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99: 3-5.2.2.1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3-5.2.2.2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA 101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, Gas and Vacuum Systems (d) * Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 footcandles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3-5.2.2.3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3-5.2.2.3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3-5.2.2.3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas - task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c) * Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a. *The outside design temperature is higher than +20?F (-6.7?C), or b. The outside design temperature is lower than +20?F (-6.7?C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3-4.1.1.1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3-5.2.2.2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. Based on observation, document review (i.e., posted electrical panel directories), and staff interview, the facility was not provided with an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System in that Emergency System- Life Safety (LS) Branch wiring was not separated from Critical System (CS) wiring. This was noted for panels on one of four floors and the basement. The findings are: On 8/8/23 at approximately 12:28pm during the recertification survey, Review of the POS [REDACTED]. Examples are: 1) [MEDICATION NAME] 1- Social work office- Panel LSP-C1 Aa (life safety panel) had (LS) circuits such as #2 exit signs and (CS) circuits such as #4 nurse call 2) Basement- boiler room- Panel EP-B (critical panel) had (LS) circuits such as #6 ground floor emergency lights and (CS) circuits such as #1-3 elevator In an interview on 8/8/23 at approximately 12:28pm, the Director of Plant Operations stated that they will address the issue. 2012 NFPA 99: 6.1, 6.1.1 1999 NFPA 99 Standard for Health Care Facilities: 3-5 10NYCRR 711.2(a)(1)2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6.1* Applicability. 2012 NFPA 99: 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99: 3-5.2.2.1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3-5.2.2.2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA 101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, Gas and Vacuum Systems (d) * Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 footcandles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3-5.2.2.3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3-5.2.2.3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3-5.2.2.3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas - task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c) * Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a. *The outside design temperature is higher than +20?F (-6.7?C), or b. The outside design temperature is lower than +20?F (-6.7?C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3-4.1.1.1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3-5.2.2.2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. Based on observation, document review (i.e., posted electrical panel directories), and staff interview, the facility was not provided with an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System in that Emergency System- Life Safety (LS) Branch wiring was not separated from Critical System (CS) wiring. This was noted for panels on one of four floors. The findings are: On 8/8/23 at approximately 11:01am during the recertification survey, Review of the POS [REDACTED]. Examples are: 1) Electrical room- Life Safety Panel LS-FA-1 had (LS) circuits such as #3 fire alarm and (CS) circuits such as #1 call bells 2) Electrical room- Panel ELVPP-B (critical panel) had (LS) circuits such as #1 elevator lights and (CS) circuits such as corridor outlets 3) Physical therapy gym- Panel LS PT- had (LS) circuits such as #1 fire alarm and (CS) circuits such as Heater circuit and Administration closet outlet In an interview on 8/8/23 at approximately 11:01am, the Director of Plant Operations stated that they will address the issue. 2012 NFPA 99: 6.1, 6.1.1 1999 NFPA 99 Standard for Health Care Facilities: 3-5 10NYCRR 711.2(a)(1)2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6.1* Applicability. 2012 NFPA 99: 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99: 3-5.2.2.1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3-5.2.2.2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA 101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, Gas and Vacuum Systems (d) * Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 footcandles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3-5.2.2.3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3-5.2.2.3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3-5.2.2.3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas - task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c) * Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a. *The outside design temperature is higher than +20?F (-6.7?C), or b. The outside design temperature is lower than +20?F (-6.7?C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3-4.1.1.1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3-5.2.2.2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. Based on observation, document review (i.e., posted electrical panel directories), and staff interview, the facility was not provided with an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System in that Emergency System- Life Safety (LS) Branch wiring was not separated from Critical System (CS) wiring. This was noted for panels on one of four floors and the basement. The findings are: On 8/9/23 at approximately 11:44am during the recertification survey, Review of the POS [REDACTED]. Examples are: 1) Woodcrest 2- electrical room- Panel ELVP2 (life safety panel) had a mix of (LS) circuits and (CS) circuits such as #1 exit signs/ time tracker In an interview on 8/9/23 at approximately 11:44am, the Director of Plant Operations stated that the time tracker circuit should not be on the life safety panel. 2012 NFPA 99: 6.1, 6.1.1 1999 NFPA 99 Standard for Health Care Facilities: 3-5 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 23, 2023 K915 In response to the identified deficiency related to the absence of an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System and the mixing of wiring between the Emergency System- Life Safety (LS) Branch and Critical System (CS) wiring, we have developed a comprehensive plan of correction to address this issue and enhance the safety of our nursing home facility. To rectify the issue, we will take immediate action by contacting a qualified electrician (or utilizing in-house resources if appropriate) to separate and relocate the mixed loads identified within the life safety electrical panel. This corrective measure ensures that the LS Branch wiring and CS wiring are properly separated, conforming to NFPA 99 standards for Essential Electrical Systems. Furthermore, to ensure ongoing compliance and the continued separation of loads, the Director of Maintenance or their designated representative will conduct a thorough audit of all life safety/critical panels. This audit will confirm that there are no mixed loads on any other panels within the facility. To maintain continuous compliance and vigilance, the Director of Maintenance or their designee will conduct audits of these panels monthly for one year and every time electrical work is performed on the premises to ensure that loads are consistently kept on their respective panels. Any negative findings will be brought to the QAPI committee for review. In addition to these measures, re-education will be provided to all electricians and individuals responsible for handling electrical materials within the facility. This educational reinforcement will emphasize the importance of maintaining the separation of LS Branch and CS wiring to ensure the safety of residents and compliance with regulatory standards. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety of our nursing home. Through immediate action, regular audits, ongoing compliance, and staff reeducation, we aim to prevent future issues and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of electrical safety in our facility. Responsible Party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not provide a battery powered lighting unit facing the automatic transfer switch in the boiler room. This was noted in the basement. The findings are: On 8/8/23 at approximately 12:30pm during the recertification survey, a battery powered lighting unit was not provided facing the automatic transfer switch in the boiler room. This was noted in the [MEDICATION NAME] basement. In an interview on 8/9/23 at approximately 12:40pm, the Director of Plant Operations stated that they will add the battery powered lights. 2012 NFPA 101: 19.2.9.1, 7.9.2.4 2010 NFPA 110: 7.3.1 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not provide a battery powered lighting unit facing the automatic transfer switch in the boiler room. This was noted in the basement. The findings are: On 8/8/23 at approximately 12:30pm during the recertification survey, a battery powered lighting unit was not provided facing the automatic transfer switch in the boiler room. This was noted in the [MEDICATION NAME] basement. In an interview on 8/9/23 at approximately 12:40pm, the Director of Plant Operations stated that they will add the battery powered lights. 2012 NFPA 101: 19.2.9.1, 7.9.2.4 2010 NFPA 110: 7.3.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 2012 NFPA 101: 7.9.2.3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities Based on observation and staff interview, emergency lighting was not provided in accordance with Section 7.9 in that emergency lights were operable with a switch. This was noted on two of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, emergency lights were observed operable with a switch in that the lights were in the off position at the time of observation. This was noted on Sagamore 3, 2 & 1 in the corridors adjacent to Stair 1. In an interview on 8/8/23 at approximately 10:10am, the Director of Plant Operations stated that the lights might be out. 2012 NFPA 101: 19.2.9.1, 7.9.2.3 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 2012 NFPA 101: 7.9.2.3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities Based on observation and staff interview, emergency lighting was not provided in accordance with Section 7.9 in that emergency lights were operable with a switch. This was noted on two of four floors. The findings are: On 8/8/23 between 9:00am-3:00pm during the recertification survey, emergency lights were observed operable with a switch in that the lights were in the off position at the time of observation. This was noted on Sagamore 3, 2 & 1 in the corridors adjacent to Stair 1. In an interview on 8/8/23 at approximately 10:10am, the Director of Plant Operations stated that the lights might be out. 2012 NFPA 101: 19.2.9.1, 7.9.2.3 10NYCRR 711.2(a)(1)Based on observation and staff interview, the facility did not provide a battery powered lighting unit facing two automatic transfer switches in the mechanical room. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:40pm during the recertification survey, a battery powered lighting unit was not provided facing two automatic transfer switches in the mechanical room. This was noted on Woodcrest ground floor. In an interview on 8/9/23 at approximately 12:40pm, the Director of Plant Operations stated that they will add the battery powered lights. 2012 NFPA 101: 19.2.9.1, 7.9.2.4 2010 NFPA 110: 7.3.1 10NYCRR 711.2(a)(1)Based on observation and staff interview, the facility did not provide a battery powered lighting unit facing two automatic transfer switches in the mechanical room. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:40pm during the recertification survey, a battery powered lighting unit was not provided facing two automatic transfer switches in the mechanical room. This was noted on Woodcrest ground floor. In an interview on 8/9/23 at approximately 12:40pm, the Director of Plant Operations stated that they will add the battery powered lights. 2012 NFPA 101: 19.2.9.1, 7.9.2.4 2010 NFPA 110: 7.3.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 2012 NFPA 101: 7.9.2.3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities Based on observation and staff interview, emergency lighting was not provided in accordance with Section 7.9 in that emergency lights were operable with a switch. This was noted on two of three floors. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, emergency lights in the dining rooms were observed operable with switches in the corridor. This was noted on Sea(NAME)3 & 2. In an interview on 8/10/23 at approximately 10:25am, the Director of Plant Operations stated that they would take the lights off of the switches. 2012 NFPA 101: 19.2.9.1, 7.9.2.3 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 2012 NFPA 101: 7.9.2.3* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting due to any of the following: (1) Failure of a public utility or other outside electrical power supply (2) Opening of a circuit breaker or fuse (3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities Based on observation and staff interview, emergency lighting was not provided in accordance with Section 7.9 in that emergency lights were operable with a switch. This was noted on two of three floors. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, emergency lights in the dining rooms were observed operable with switches in the corridor. This was noted on Sea(NAME)3 & 2. In an interview on 8/10/23 at approximately 10:25am, the Director of Plant Operations stated that they would take the lights off of the switches. 2012 NFPA 101: 19.2.9.1, 7.9.2.3 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: August 11, 2023
Corrected date: N/A
Citation Details Based on observation and staff interview, exit signs were not displayed in accordance with 7.10. This was noted on one of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, doors within stairs on the ground floor lacked a No Exit sign. Examples were: 1) North stair- door to the Mansion House 2) North stair- door to the corridor 3) South stair- door to the corridor In an interview on 8/7/23 at approximately 11:54am, the Director of Plant Operations stated that he would add the sign. 2012 NFPA 101: 7.10.8.3 10NYCRR 711.2(a)(1)Based on observation and staff interview, exit signs were not displayed in accordance with 7.10. This was noted on one of one floors. The findings are: On 8/10/23 at approximately 10:15am during the recertification survey, doors in the vicinity of the link building lacked signage in accordance with 7.10. Examples were: 1) Exiting from the courtyard to the link building lacked directional signage 2) Exiting from within the link, lacked an exit sign 3) Sliding double doors lacked a No Exit sign. In an interview on 8/10/23 at approximately 10:15am, the Director of Plant Operations stated that he would address the issue. 2012 NFPA 101: 7.10.8.3 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 8, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2024
Corrected date: January 26, 2024
Citation Details 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panels. This was noted on four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panels were observed throughout the survey. Audible trouble signal annunciation was observed at fire alarm control panels on the floors. This was noted on Brookville 3, 2, 1 & ground floors. Additionally, the fire alarm control panel at the Brookville 2 nursing station was not lit and not functional. In an interview on 8/7/23 at approximately 11:30am, the Director of Plant Operations stated that there is a problem with the wiring and network systems and that each building is not seeing the other buildings. He further stated that he called the fire alarm company for service. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panels. This was noted on four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panels were observed throughout the survey. Audible trouble signal annunciation was observed at fire alarm control panels on the floors. This was noted on Brookville 3, 2, 1 & ground floors. Additionally, the fire alarm control panel at the Brookville 2 nursing station was not lit and not functional. In an interview on 8/7/23 at approximately 11:30am, the Director of Plant Operations stated that there is a problem with the wiring and network systems and that each building is not seeing the other buildings. He further stated that he called the fire alarm company for service. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panels. This was noted on three of three floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panels were observed throughout the survey. Audible trouble signal annunciation was observed at fire alarm control panels on Sea(NAME)3, 2 & 1. In an interview on 8/7/23 at approximately 11:30am, the Director of Plant Operations stated that there is a problem with the wiring and network systems and that each building is not seeing the other buildings. He further stated that he called the fire alarm company for service. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panels. This was noted on three of three floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panels were observed throughout the survey. Audible trouble signal annunciation was observed at fire alarm control panels on Sea(NAME)3, 2 & 1. In an interview on 8/7/23 at approximately 11:30am, the Director of Plant Operations stated that there is a problem with the wiring and network systems and that each building is not seeing the other buildings. He further stated that he called the fire alarm company for service. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the fire alarm system was maintained in accordance with NFPA 72. Specifically, the facility did not provide an approved time limited waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panels. This was noted on four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panels were observed throughout the survey. Audible trouble signal annunciation was observed at fire alarm control panels on the floors. This was noted on Brookville 3, 2, 1 & ground floors. Additionally, the fire alarm control panel at the Brookville 2 nursing station was not lit and not functional. In an interview on 8/7/23 at approximately 11:30am, the Director of Plant Operations stated that there is a problem with the wiring and network systems and that each building is not seeing the other buildings. He further stated that he called the fire alarm company for service. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the fire alarm system was maintained in accordance with NFPA 72. Specifically, the facility did not provide an approved time limited waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the fire alarm system was maintained in accordance with NFPA 72. Specifically, the facility did not provide an approved time limited waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the fire alarm system was maintained in accordance with NFPA 72. Specifically, the facility did not provide an approved time limited waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panel. This was noted on one of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panel were observed throughout the survey. Audible trouble signal annunciation was observed at the fire alarm control panel on the ground floor. In an interview on 8/8/23 at approximately 10:44am, the Director of Plant Operations stated that he is waiting for a call back from the fire alarm company. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1)Based on record review conducted during a Life Safety Code (LSC) offsite Post Survey Revisit (PSR) on 2/8/2024, the facility did not ensure that the fire alarm system was maintained in accordance with NFPA 72. Specifically, the facility did not provide an approved time limited waiver from CMS. ---- The facility was cited for the following during the 8/11/2023 recertification survey: 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.5.4 All apparatus requiring rewinding or resetting to maintain normal operation shall be rewound or reset as promptly as possible after each test and alarm. Based on observation and staff interview, the fire alarm system was not maintained in accordance with NFPA 72 in that multiple trouble signals were observed on the fire alarm control panels. This was noted on three of three floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, multiple observations of multiple trouble signals on the fire alarm control panels were observed throughout the survey. Audible trouble signal annunciation was observed at fire alarm control panels on Sea(NAME)3, 2 & 1. In an interview on 8/7/23 at approximately 11:30am, the Director of Plant Operations stated that there is a problem with the wiring and network systems and that each building is not seeing the other buildings. He further stated that he called the fire alarm company for service. 2012 NFPA 101: 9.6.1.3, 9.6.1.5 2010 NFPA 72: 14.5.4 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMarch 6, 2024 The facility is seeking a time-limited waiver. On (MONTH) 7-11, 2023, during the recertification survey, multiple trouble signals were observed on the fire alarm control panel. Audible trouble signal annunciation was observed at the fire alarm control panel. Corrective Actions Taken: 1. Contacted the fire alarm vendor to address the trouble signals. 2. Vendor confirmed that the system is fully operational without any issues impacting fire safety. 3. The identified trouble signals are related to non-essential system components and do not affect the core functionality of the fire alarm system. Additional Actions: 1. The facility will re-educate maintenance staff on the operation of the fire alarm panels. 2. Training will emphasize the significance of understanding the meaning of alarms and how to respond effectively. 3. Maintenance staff will be instructed to document all system issues and actions taken. 4. Daily calls to the monitoring station will be conducted to ensure communication between the system and facility are still intact. Timeline for Completion: October 2023: Identify and hire a qualified vendor to address the non-essential system components. November 2023: Work with the vendor to obtain all necessary permits and materials. Order necessary materials and equipment. Mid-March 2024: Begin repair and replacement of system components. December 31, 2024: Completion of all repairs and system optimization. Responsible Party: The Director of Maintenance is responsible for the completion. Documentation: Maintain documentation of all corrective actions taken, including copies of all relevant documentation (e.g., invoices, permits, test results). Waiver Request: A time-limited waiver is requested to allow for the completion of the planned repairs and system optimization. The waiver will be in effect until (MONTH) 31, 2024. Justification for Waiver: 1. The fire alarm vendor confirms that the system is currently fully operational and does not pose any immediate safety concerns. 2. Addressing the non-essential system components requires specialized equipment and coordination with the vendor, which necessitates additional time. 3. The facility has implemented additional measures to ensure continued system vigilance and staff preparedness. |
Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: August 11, 2023
Corrected date: N/A
Citation Details Based on observation and staff interview, oxygen cylinders were not kept segregated in the physical therapy oxygen storage area. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 11:10am during the recertification survey, a rack of six full oxygen cylinders was observed in the section for empty oxygen cylinders in the physical therapy oxygen storage area. This was noted in the physical therapy gym on the ground floor. In an interview on 8/9/23 at approximately 11:10am, the Director of Plant Operations stated that he would let rehabilitation staff know. 2012 NFPA 99: 11.6.5.2, 11.6.5.3 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 8, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details 2012 NFPA 101: 19.1.1.4.1 Additions. Additions shall be separated from any existing structure not conforming to the provisions within Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. (See 4.6.7 and 4.6.11.) 2012 NFPA 101: 19.1.1.4.1.1 Communicating openings in dividing fire barriers required by 19.1.1.4.1 shall be permitted only in corridors and shall be protected by approved self-closing fire door assemblies. (See also Section 8.3.) Based on observation, staff interview and documentation review, doors connecting the link building to other buildings were not provided with a 2-hour fire resistance rating. This was noted on the ground floor. The findings are: On 8/7/23 and 8/9/23 between 9:00am-3:00pm during the recertification survey, doors between the link building and Brookville and between the link building and Woodcrest were observed to be 45 minute fire resistance rated doors. Review of the provided life safety drawings indicated that these doors were part of a 2-hour fire resistance rated barrier. In an interview on 8/7/23 at approximately 3:05pm, the Director of Plant Operations stated that they will replace the doors for a 2 hour barrier. 2012 NFPA 101: 19.1.1.4.1, 19.1.1.4.1.1 10NYCR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 K100 In response to the identified deficiency in our nursing home, which revealed that the ground floor doors connecting the link building to other structures were not provided with the required 2-hour fire resistance rating, we have developed a comprehensive plan of correction to address this issue promptly and effectively. Firstly, we will prioritize the replacement of all doors separating the link building from other structures that were identified during the recent survey. These doors will be replaced with 2-hour fire-rated doors as mandated by regulatory standards. The Director of Maintenance or their designated personnel will oversee this process to ensure that the replacement is carried out in accordance with fire safety guidelines and within the appropriate timeframes. To ensure the ongoing compliance of all fire-rated doors throughout the facility, we will conduct a one-time extensive audit of all doors that are designated as fire-rated. This audit will be conducted by a qualified team and will encompass a thorough assessment of each door's fire resistance rating, structural integrity, and functionality. The results of this audit will be compiled into a report and submitted to our Quality Assurance and Performance Improvement (QAPI) committee for review. To enhance accountability and transparency in managing fire-rated doors, we will establish a master list of all such doors within our facility. This master list will be stored electronically and accessible to key personnel, including the Maintenance Director, Assistant Director, Supervisors, and Administration Department. Anytime a door is replaced or undergoes maintenance that may impact its fire rating, it will be updated promptly on this master list. This systematic approach will ensure that the status of all fire-rated doors remains up-to-date, reducing the risk of non-compliance and enhancing resident safety. In conclusion, our plan of correction is designed to rectify the deficiency in fire resistance ratings for doors connecting buildings within our nursing home. Through the replacement of non-compliant doors, regular audits, and the establishment of a comprehensive master list, we are committed to enhancing the fire safety of our facility and ensuring compliance with all relevant regulations. Our residents' safety and well-being remain our utmost priority, and we are dedicated to implementing these corrective measures with diligence and care. Responsible party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details 2012 NFPA 101: 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101: 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. Based on observation and staff interview, doors to hazardous areas hit the door frame when tested , thus preventing smoke-tight enclosures. This was noted on two of four floors. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Woodcrest 3- the door to the clean linen room hit the frame when tested 2) Woodcrest 1- the door to the medication room hit the frame when tested In an interview on 8/9/23 at 12:14pm, the Director of Plant Operations stated that they will adjust the doors. 2012 NFPA 101: 19.3.2.1, 19.3.2.1.2 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 24, 2023 K321 In response to the identified deficiency concerning doors to hazardous areas that did not properly latch and prevented the creation of smoke-tight enclosures, we have developed a comprehensive plan of correction to address this issue and enhance the safety of our nursing home facility. As a priority, we have taken immediate action to address the specific doors that were identified during the survey as not latching properly. These doors have been promptly repaired to ensure that they now effectively latch and provide the necessary smoke-tight enclosure. Additionally, the Director of Maintenance or their designated representative will conduct a thorough inspection of all self-closing doors leading to hazardous areas within our facility. This assessment will confirm that these doors are positively latching as required for safety compliance. To maintain compliance and vigilance in this regard, the Director of Maintenance or their designee will monitor these doors on a weekly basis for a duration of one month. Subsequently, these doors will be monitored on a monthly basis for an additional three months. Thereafter, doors will be monitored as part of the daily walkthrough conducted by the maintenance supervisors. This systematic approach will help identify and address any emerging issues with door latching promptly, reducing the risk of non-compliance and enhancing resident safety. All findings resulting from these measures will be reported to our Quality Assurance and Performance Improvement (QAPI) committee for review and necessary action. This collaborative approach underscores our commitment to resident safety and adherence to regulatory requirements, ensuring that our facility maintains the highest standards of safety in regards to doors in hazardous areas. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety of our nursing home. Through prompt repairs, regular inspections, and ongoing monitoring, we aim to prevent future deficiencies and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of safety in our facility. Responsible party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: August 11, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, interior movable partitions were not provided with a Class C interior wall finish material. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:00pm during the recertification survey, a shower room across from resident room [ROOM NUMBER] was noted under construction. The shower stall was sectioned off with movable partitions. There was no documentation provided that the partitions were Class C rated. In an interview on 8/9/23 at approximately 12:00pm, the Director of Plant Operations stated that they would replace the partitions with a rated material. 2012 NFPA 101: 19.3.3.2, 10.2.8.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 8, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: January 9, 2024
Citation Details 2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 Based on observation and staff interview, the facility did not ensure that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This was noted in one of two stairs. The findings are: On 8/7/23 at approximately 11:56am during the recertification survey, an electrical transformer and conduit were observed not enclosed or separated from the egress stairwell. This was observed within the north stair at the ground level. In an interview on 8/7/23 at approximately 11:56am, the Director of Plant Operations stated that they will verify the wires and pipes and enclose everything that needs to be enclosed. 2012 NFPA 101: 19.2.1, 7.1.3.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 Based on observation and staff interview, the facility did not ensure that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This was noted in one of two stairs. The findings are: On 8/7/23 at approximately 11:56am during the recertification survey, an electrical transformer and conduit were observed not enclosed or separated from the egress stairwell. This was observed within the north stair at the ground level. In an interview on 8/7/23 at approximately 11:56am, the Director of Plant Operations stated that they will verify the wires and pipes and enclose everything that needs to be enclosed. 2012 NFPA 101: 19.2.1, 7.1.3.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 Based on observation and staff interview, the facility did not ensure that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This was noted in one of two stairs. The findings are: On 8/7/23 at approximately 11:56am during the recertification survey, an electrical transformer and conduit were observed not enclosed or separated from the egress stairwell. This was observed within the north stair at the ground level. In an interview on 8/7/23 at approximately 11:56am, the Director of Plant Operations stated that they will verify the wires and pipes and enclose everything that needs to be enclosed. 2012 NFPA 101: 19.2.1, 7.1.3.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.6.3 Level. Walking surfaces shall comply with all of the following: (1) Walking surfaces shall be nominally level. (2) The slope of a walking surface in the direction of travel shall not exceed 1 in 20, unless the ramp requirements of 7.2.5 are met. (3) The slope perpendicular to the direction of travel shall not exceed 1 in 48. 2012 NFPA 101: 7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel. Based on observation and staff interview, the exit discharge from the South stair was not nominally level and uniformly slip resistant along the natural path of travel. This was noted for one of two stairs in the building. The findings are: On 8/9/23 at approximately 12:18pm during the recertification survey, sections of paved path were missing along the exit discharge from the South stair. The ground was uneven with areas of dirt and grass along the natural path of travel. In an interview on 8/9/23 at approximately 12:18pm, the Director of Plant Operations stated that there was a water main break, and they were getting proposals to repair the paved path. 2012 NFPA 101: 19.2.1, 7.1.6.3, 7.1.6.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.6.3 Level. Walking surfaces shall comply with all of the following: (1) Walking surfaces shall be nominally level. (2) The slope of a walking surface in the direction of travel shall not exceed 1 in 20, unless the ramp requirements of 7.2.5 are met. (3) The slope perpendicular to the direction of travel shall not exceed 1 in 48. 2012 NFPA 101: 7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel. Based on observation and staff interview, the exit discharge from the South stair was not nominally level and uniformly slip resistant along the natural path of travel. This was noted for one of two stairs in the building. The findings are: On 8/9/23 at approximately 12:18pm during the recertification survey, sections of paved path were missing along the exit discharge from the South stair. The ground was uneven with areas of dirt and grass along the natural path of travel. In an interview on 8/9/23 at approximately 12:18pm, the Director of Plant Operations stated that there was a water main break, and they were getting proposals to repair the paved path. 2012 NFPA 101: 19.2.1, 7.1.6.3, 7.1.6.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.6.3 Level. Walking surfaces shall comply with all of the following: (1) Walking surfaces shall be nominally level. (2) The slope of a walking surface in the direction of travel shall not exceed 1 in 20, unless the ramp requirements of 7.2.5 are met. (3) The slope perpendicular to the direction of travel shall not exceed 1 in 48. 2012 NFPA 101: 7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel. Based on observation and staff interview, the exit discharge from the South stair was not nominally level and uniformly slip resistant along the natural path of travel. This was noted for one of two stairs in the building. The findings are: On 8/9/23 at approximately 12:18pm during the recertification survey, sections of paved path were missing along the exit discharge from the South stair. The ground was uneven with areas of dirt and grass along the natural path of travel. In an interview on 8/9/23 at approximately 12:18pm, the Director of Plant Operations stated that there was a water main break, and they were getting proposals to repair the paved path. 2012 NFPA 101: 19.2.1, 7.1.6.3, 7.1.6.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 2012 NFPA 101: 7.7.3.4* Stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation. Based on observation and staff interview, the facility did not ensure that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This was noted in one of five stairs. The findings are: On 8/10/23 between 10:00am-11:30am during the recertification survey, the following was noted: 1) A bx conduit was observed above the ceiling and penetrated through the wall within the South stair on Sea(NAME)3. The conduit was not enclosed or separated from the egress stairwell In an interview on 8/10/23 at approximately 10:37am, the Director of Plant Operations stated that the conduit did not serve the stairwell. 2) The level of exit discharge within the South stair is between the 2nd and 1st floors. The stair continues more than one-half story down to the basement without any means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation In an interview on 8/10/23 at approximately 11:17am, the Director of Plant Operations stated that they will address the issue. 2012 NFPA 101: 19.2.1, 7.1.3.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 2012 NFPA 101: 7.7.3.4* Stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation. Based on observation and staff interview, the facility did not ensure that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This was noted in one of five stairs. The findings are: On 8/10/23 between 10:00am-11:30am during the recertification survey, the following was noted: 1) A bx conduit was observed above the ceiling and penetrated through the wall within the South stair on Sea(NAME)3. The conduit was not enclosed or separated from the egress stairwell In an interview on 8/10/23 at approximately 10:37am, the Director of Plant Operations stated that the conduit did not serve the stairwell. 2) The level of exit discharge within the South stair is between the 2nd and 1st floors. The stair continues more than one-half story down to the basement without any means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation In an interview on 8/10/23 at approximately 11:17am, the Director of Plant Operations stated that they will address the issue. 2012 NFPA 101: 19.2.1, 7.1.3.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection-rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. c) Existing openings to mechanical equipment spaces protected by approved existing fire protection-rated door assemblies shall be permitted, provided that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment. ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes (h) Existing penetrations protected in accordance with 8.3.5 (i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 2012 NFPA 101: 7.7.3.4* Stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation. Based on observation and staff interview, the facility did not ensure that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. This was noted in one of five stairs. The findings are: On 8/10/23 between 10:00am-11:30am during the recertification survey, the following was noted: 1) A bx conduit was observed above the ceiling and penetrated through the wall within the South stair on Sea(NAME)3. The conduit was not enclosed or separated from the egress stairwell In an interview on 8/10/23 at approximately 10:37am, the Director of Plant Operations stated that the conduit did not serve the stairwell. 2) The level of exit discharge within the South stair is between the 2nd and 1st floors. The stair continues more than one-half story down to the basement without any means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation In an interview on 8/10/23 at approximately 11:17am, the Director of Plant Operations stated that they will address the issue. 2012 NFPA 101: 19.2.1, 7.1.3.2.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 24, 2023 K211 In response to the identified concerns regarding means of egress at our nursing home, specifically referencing issues related to the presence of electrical transformers, conduits, and other items that are not serving the stairwell within the fire-rated compartment, we have developed a comprehensive plan of correction to address these issues and enhance the safety of our facility. As a priority, we will take the necessary steps to either remove or enclose in fire-rated material all items within the stairwell fire-rated compartment that do not serve a direct purpose for the stairwell. Anything that can be removed is being removed. Anything that is required will be encased in fireproofing materials. The Director of Maintenance or their designated representative will conduct a thorough audit of all means of egress throughout the facility to identify any additional items not serving the stairwell that require removal or enclosure in fire-rated material. To maintain ongoing compliance and vigilance, the Director of Maintenance or their designee will conduct monthly audits of each stairwell for a duration of six months. Furthermore, any time work is performed within the staircases or in proximity to the egress path, an audit will be conducted to prevent the recurrence of these issues. Findings from these audits will be brought to our Quality Assurance and Performance Improvement (QAPI) committee for review and necessary action. In conclusion, our plan of correction demonstrates our unwavering commitment to resident safety and well-being. Through the removal or enclosure of non-essential items and regular audits, we aim to prevent future deficiencies and create a safer environment for our residents and staff. We are dedicated to implementing these corrective measures with diligence and care to uphold the highest standards of safety in our nursing home. Responsible party: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. Additionally, the life safety drawings for Brookville 1 indicated that the smoke barrier wall ran between the shared bathroom in resident room [ROOM NUMBER], but the bathroom door was not fire-rated or provided with a self-closing device. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. Additionally, the life safety drawings for Brookville 1 indicated that the smoke barrier wall ran between the shared bathroom in resident room [ROOM NUMBER], but the bathroom door was not fire-rated or provided with a self-closing device. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for four of four floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on four of four floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for three of three floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on three of three floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. Based on observation, staff interview and documentation review, the facility did not provide for an effective response of health care personnel. This was noted for three of three floors. The findings are: On 8/7/23 to 8/11/23 between 9:00am-3:00pm during the recertification survey, the facility did not provide for an effective response of health care personnel in that the building life safety drawings were not accurate. The life safety drawings provided by the facility indicated that corridors were part of a 30 minute fire-resistant barrier, including corridor doors. Corridor doors, including but not limited to resident room doors, on three of three floors were not provided with self-closing devices as required in fire barriers. In an interview on 8/9/23 at approximately 10:58am, the Administrator stated that he contacted the consultant regarding the life safety drawings. 2012 NFPA 101: 19.7.2.1.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 24, 2023 K700 In response to the identified deficiency related to inaccurate building life safety drawings and the absence of self-closing devices on corridor doors as required in fire barriers, we have developed a comprehensive plan of correction to address this issue and enhance the safety of our nursing home facility. To rectify the issue of inaccurate building life safety drawings, we have taken immediate action by contacting the company that last completed the drawings. We have requested that they revisit our facility to redraw the building layout in compliance with all applicable regulations and standards. This corrective measure ensures that our life safety drawings accurately reflect the current state of our facility and its compliance with fire safety requirements. Once updated, the maintenance department will be educated on the updated fire safety drawings. Furthermore, in parallel with the correction of the drawings, we will address the deficiency related to corridor doors not having self-closing devices as required in fire barriers. This will involve assessing the affected doors and ensuring that they are equipped with the necessary self-closing devices to comply with fire safety regulations, as needed. Our commitment to safety extends to regularly reviewing/auditing and updating our building life safety drawings as needed to reflect any changes in our facility's layout or systems. We will audit these drawings on an annual basis unless there are modifications that would require exploring the fire safety plan. Any negative findings will be brought to the QAPI committee for review. This proactive approach will help us maintain accurate documentation and ensure that we are always in compliance with regulatory standards. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety of our nursing home. Through the revision of building life safety drawings and the installation of self-closing devices where required, we aim to prevent future issues and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of fire safety in our facility. Responsible Party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: September 30, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:00am during the recertification survey, a fire extinguisher was noted missing from its hanger in the corridor in the vicinity of resident room [ROOM NUMBER] on Brookville 3. In an interview on 8/7/23 at approximately 11:00am, the Director of Plant Operations stated that he would replace it. 2012 NFPA 101: 19.3.5.12 2010 NFPA 10 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:00am during the recertification survey, a fire extinguisher was noted missing from its hanger in the corridor in the vicinity of resident room [ROOM NUMBER] on Brookville 3. In an interview on 8/7/23 at approximately 11:00am, the Director of Plant Operations stated that he would replace it. 2012 NFPA 101: 19.3.5.12 2010 NFPA 10 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. 2012 NFPA 101: 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2010 NFPA 10: 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. Based on observation and staff interview, portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was noted in the basement. The findings are: On 8/8/23 at approximately 12:48pm during the recertification survey, approximately 10 fire extinguishers were observed in the plant operations office in the basement. The last documented inspection as noted on the tags on the fire extinguishers was 4/10/23. In an interview on 8/8/23 at approximately 12:48pm, the Director of Plant Operations stated that the fire extinguishers should have been inspected. 2012 NFPA 101: 19.3.5.12, 9.7.4.1 2010 NFPA 10: 7.2.1.2 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. 2012 NFPA 101: 9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 2010 NFPA 10: 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. Based on observation and staff interview, portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. This was noted in the basement. The findings are: On 8/8/23 at approximately 12:48pm during the recertification survey, approximately 10 fire extinguishers were observed in the plant operations office in the basement. The last documented inspection as noted on the tags on the fire extinguishers was 4/10/23. In an interview on 8/8/23 at approximately 12:48pm, the Director of Plant Operations stated that the fire extinguishers should have been inspected. 2012 NFPA 101: 19.3.5.12, 9.7.4.1 2010 NFPA 10: 7.2.1.2 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 16, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: December 27, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25: 5.3.1.1.1.6* Dry sprinklers that have been in service for [AGE] years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. Based on observation, documentation review and staff interview, automatic sprinkler and standpipe systems were not inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that: 1) sprinklers in the building were observed dusty; and 2) there was no documentation provided that dry sprinklers that have been in service for [AGE] years were replaced or that a representative sample was tested . This was noted in the kitchen on the ground floor. The findings are: On 8/7/23 at approximately 12:10pm during the recertification survey, the following was noted in the kitchen: 1) Multiple sprinkler heads throughout the kitchen were observed laden with dust 2) There was no documentation provided that dry sprinklers that have been in service for [AGE] years were replaced or that a representative sample was tested . This was noted for sprinklers in the walk-in refrigerators and freezers with manufactured dates of 2009 In an interview on 8/7/23 at approximately 12:10pm, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.2.1.1.1, 5.3.1.1.1.6**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25: 5.3.1.1.1.6* Dry sprinklers that have been in service for [AGE] years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. Based on observation, documentation review and staff interview, automatic sprinkler and standpipe systems were not inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that: 1) sprinklers in the building were observed dusty; and 2) there was no documentation provided that dry sprinklers that have been in service for [AGE] years were replaced or that a representative sample was tested . This was noted in the kitchen on the ground floor. The findings are: On 8/7/23 at approximately 12:10pm during the recertification survey, the following was noted in the kitchen: 1) Multiple sprinkler heads throughout the kitchen were observed laden with dust 2) There was no documentation provided that dry sprinklers that have been in service for [AGE] years were replaced or that a representative sample was tested . This was noted for sprinklers in the walk-in refrigerators and freezers with manufactured dates of 2009 In an interview on 8/7/23 at approximately 12:10pm, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.2.1.1.1, 5.3.1.1.1.6Based on observation, documentation review and staff interview, the facility did not ensure that automatic sprinkler systems are inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that there was no documentation to indicate that the pressure gauges on the fire pump was being tested or replaced every 5 years. The findings are: On 8/8/23 at approximately 10:46am during the recertification survey, there was no documentation to indicate that the pressure gauges on the fire pump was being tested or replaced every 5 years. The manufactured date on the pressure gauge was (YEAR). In an interview on 8/8/23 at approximately 10:46am, the Director of Plant Operations stated that the sprinkler company did the other buildings and must have missed these gauges. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.2.1Based on observation, documentation review and staff interview, the facility did not ensure that automatic sprinkler systems are inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that there was no documentation to indicate that the pressure gauges on the fire pump was being tested or replaced every 5 years. The findings are: On 8/8/23 at approximately 10:46am during the recertification survey, there was no documentation to indicate that the pressure gauges on the fire pump was being tested or replaced every 5 years. The manufactured date on the pressure gauge was (YEAR). In an interview on 8/8/23 at approximately 10:46am, the Director of Plant Operations stated that the sprinkler company did the other buildings and must have missed these gauges. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.2.1 | Plan of Correction: ApprovedOctober 16, 2023 A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details 2012 NFPA 101: 7.2 Means of Egress Components. 2012 NFPA 101: 7.2.1 Door Openings. 2012 NFPA 101: 7.2.1.1 General. 2012 NFPA 101: 7.2.1.1.1 A door assembly in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.1 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. 2012 NFPA 101: 7.2.2.5.1.1 All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. 2012 NFPA 101: 7.1.3.2 Exits. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. Based on observation and staff interview, the facility did not ensure that means of egress were protected as per 7.1 & 7.2. This was noted for one of two stairs in the building. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Fire-rated doors were not provided with a legible fire-rated label. Examples are: a. Brookville 3- North stair- not legible fire-rated label b. Brookville Ground- North stair- painted fire-rated label 2) A hole in the wall with exposed wires was observed on the 1st floor landing within the North stair In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 7.2, 7.2.1, 7.2.1.1, 7.2.1.1.1, 7.2.1.15.2, 7.2.2.5.1.1, 7.1.3.2, 7.1.3.2.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 7.2 Means of Egress Components. 2012 NFPA 101: 7.2.1 Door Openings. 2012 NFPA 101: 7.2.1.1 General. 2012 NFPA 101: 7.2.1.1.1 A door assembly in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.1 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. 2012 NFPA 101: 7.2.2.5.1.1 All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. 2012 NFPA 101: 7.1.3.2 Exits. 2012 NFPA 101: 7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. Based on observation and staff interview, the facility did not ensure that means of egress were protected as per 7.1 & 7.2. This was noted for one of two stairs in the building. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Fire-rated doors were not provided with a legible fire-rated label. Examples are: a. Brookville 3- North stair- not legible fire-rated label b. Brookville Ground- North stair- painted fire-rated label 2) A hole in the wall with exposed wires was observed on the 1st floor landing within the North stair In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 7.2, 7.2.1, 7.2.1.1, 7.2.1.1.1, 7.2.1.15.2, 7.2.2.5.1.1, 7.1.3.2, 7.1.3.2.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 7.2 Means of Egress Components. 2012 NFPA 101: 7.2.1 Door Openings. 2012 NFPA 101: 7.2.1.1 General. 2012 NFPA 101: 7.2.1.1.1 A door assembly in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.1 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted for two of two stairs in the building. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Woodcrest 3 (3rd floor)- North and South stairs- painted fire-rated labels 2) Woodcrest 2- North and South stairs- painted fire-rated labels 3) Woodcrest 1- North and South stairs- painted fire-rated labels In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 7.2, 7.2.1, 7.2.1.1, 7.2.1.1.1, 7.2.1.15.2 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 7.2 Means of Egress Components. 2012 NFPA 101: 7.2.1 Door Openings. 2012 NFPA 101: 7.2.1.1 General. 2012 NFPA 101: 7.2.1.1.1 A door assembly in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.1 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted for two of two stairs in the building. The findings are: On 8/9/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Woodcrest 3 (3rd floor)- North and South stairs- painted fire-rated labels 2) Woodcrest 2- North and South stairs- painted fire-rated labels 3) Woodcrest 1- North and South stairs- painted fire-rated labels In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 7.2, 7.2.1, 7.2.1.1, 7.2.1.1.1, 7.2.1.15.2 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 K225 In response to the identified deficiency concerning the failure to ensure that means of egress were adequately protected in accordance with the 2012 NFPA 101 standards (specifically, 7.1 & 7.2), we have developed a comprehensive plan of correction to address this issue and enhance the safety and compliance of our facility. To rectify the problem of painted fire rating labels on doors, we will take immediate action. Firstly, all doors found with painted fire rating labels will be cleaned as thoroughly as possible to make the fire rating legible. If, after cleaning, the labels remain illegible, replacements will be promptly ordered and installed to ensure full compliance with fire safety standards and an engineer will be hired to validate the fire rating on the doors. The painting staff will be in-serviced on the importance of not painting over fire ratings on doors. Furthermore, the Director of Maintenance or their designated representative will undertake a comprehensive assessment of all fire-rated doors located within fire-rated enclosures throughout the facility. This assessment will focus on verifying the legibility of fire rating labels on these doors. For any doors found with illegible labels, work orders will be generated to facilitate their cleaning or replacement. This meticulous approach will ensure that all fire-rated doors are appropriately identified and compliant. To maintain continuous compliance and vigilance in this regard, the Director of Maintenance or their designee will conduct monthly audits of all fire-rated doors within fire-rated enclosures for a period of three months. Subsequently, these audits will continue on a quarterly basis for three quarters and then transition to an annual schedule thereafter. These regular audits will help identify and address any issues with fire rating labels promptly, reducing the risk of non-compliance and enhancing resident safety. Additionally, the Director of Maintenance or their designee will do a one-time audit of the facility to ensure any holes in the wall are sealed properly and no wires are exposed. Any holes will be patched and sealed promptly and any wires sealed off appropriately to prevent safety concerns. All findings resulting from these measures will be reported to our Quality Assurance and Performance Improvement (QAPI) committee for review and necessary action. This collaborative approach underscores our commitment to resident safety and adherence to regulatory requirements, ensuring that our facility maintains the highest standards of fire safety. Responsible party: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: September 26, 2023
Citation Details 713-1.3 Nursing units. Each nursing unit shall include the following service areas and shall meet the following minimum requirements: (b) A nurses' call system that can register a call from each resident's bedside, toilet and bathing facilities to the nurses' station. The call system shall also register a visual signal at each resident's doorway, the clean room, soiled workroom and nourishment station on the nursing unit. 713-1.8 Details and finishes. Details and finishes shall comply with the requirements set forth in section 712.-1.26 of this Title and with the following: (a) Corridors used by residents shall be equipped with firmly secured handrails on both sides. Based on observation and staff interview, 1) a nurse call station was not provided in the shower room and nurse call annunciation was not provided in the medication room on the 3rd floor; and 2) a section of handrail was missing on the 1st floor. This was noted for two of four floors. The findings are: On 8/7/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) A nurse call station and nurse call annunciation were not provided. Examples are: a. Brookville 3- a nurse call station was observed missing in the shower room b. Brookville 3- nurse call annunciation was observed missing in the medication room In an interview on 8/7/23 at approximately 11:06am, the Director of Plant Operations stated that they would have the nurse call stations fixed. 2) An approximately 16 foot section of handrail was not provided on Brookville 1 across from the staff lounge In an interview on 8/7/23 at approximately 11:42am, the Director of Plant Operations stated that they would install the handrail. | Plan of Correction: ApprovedOctober 24, 2023 I560 In response to the concerns raised during the recent survey at our nursing home, specifically regarding the absence of a call bell annunciator in one shower room, one medication room, and a missing section of handrail, we have developed a comprehensive plan of correction to address these issues and ensure the safety and well-being of our residents. To address the missing call bell annunciators, we will promptly contact the nurse call system vendor to replace the missing annunciators in the BV3 shower room and BV3 medication room. This replacement will ensure that residents have a reliable means of calling for assistance in these critical areas, promoting their safety and timely access to care. The vendor will be contacted immediately and the facility will work diligently with them to ensure all items are repaired or replaced timely but no later than 10/1/2023. In addition to addressing the call bell annunciator issue, we are committed to rectifying the missing 16-foot section of handrail promptly. This replacement will be carried out to ensure that our facility's corridors are equipped with the necessary safety features to prevent accidents and provide support for our residents. This will be completed by 10/1/2023. To prevent such oversights in the future and to enhance accountability, the Director of Maintenance or their designated representative will conduct a thorough check of all duty stations/annunciators for the nurse call system throughout our facility. This assessment will ensure that they are not only installed but also functioning properly to meet resident needs. Furthermore, they will inspect and confirm that all corridor handrails are not only installed but also securely fixed in place to provide maximum support and safety. To maintain a consistent focus on these important safety measures, the Director of Maintenance or their designee will conduct monthly audits of these items for a duration of six months. The findings from these audits will be systematically documented and presented to our Quality Assurance and Performance Improvement (QAPI) committee for review, ensuring that any issues are addressed promptly and comprehensively. After the completion of the six-month audits, the facility will continue to monitor these items on an annual basis or as needed. If there is an issue or concern noted, staff members will be instructed to put the concern into the maintenance work order system so that it can be reviewed and addressed promptly. In conclusion, our plan of correction underscores our unwavering commitment to resident safety and well-being. By addressing the missing call bell annunciators, replacing the handrail, conducting regular inspections, and implementing a robust auditing process, we aim to prevent future deficiencies and create a safer environment for our residents. We are dedicated to implementing these corrective measures with diligence and care to uphold the highest standards of care and safety in our nursing home. Responsible party: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: November 13, 2023
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Based on observation and staff interview, a door incorporated as part of the smoke barrier was not provided with a self-closing device and a hold open device tied into the fire alarm system. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:28am, the smoke barrier was noted to run across the corridor door to resident room [ROOM NUMBER] on Brookville 1. The door lacked a self-closing device and a hold open device tied into the fire alarm system. In an interview on 8/7/23 at approximately 11:28am, the Director of Plant Operations stated that they would address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Based on observation and staff interview, a door incorporated as part of the smoke barrier was not provided with a self-closing device and a hold open device tied into the fire alarm system. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:28am, the smoke barrier was noted to run across the corridor door to resident room [ROOM NUMBER] on Brookville 1. The door lacked a self-closing device and a hold open device tied into the fire alarm system. In an interview on 8/7/23 at approximately 11:28am, the Director of Plant Operations stated that they would address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Based on observation and staff interview, a door incorporated as part of the smoke barrier was not provided with a self-closing device and a hold open device tied into the fire alarm system. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:28am, the smoke barrier was noted to run across the corridor door to resident room [ROOM NUMBER] on Brookville 1. The door lacked a self-closing device and a hold open device tied into the fire alarm system. In an interview on 8/7/23 at approximately 11:28am, the Director of Plant Operations stated that they would address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on four of four floors. The findings are: On 8/7/23 & 8/8/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) [MEDICATION NAME] 3 (3rd floor)- smoke barrier doors in the South and East corridor- fire-rated labels were worn and not legible 2) [MEDICATION NAME] 2- smoke barrier doors in the South corridor- painted fire-rated label; and smoke barrier doors in the East corridor- fire-rated labels were worn and not legible 3) [MEDICATION NAME] 1- smoke barrier doors in the Center corridor- fire-rated labels were worn and not legible 4) [MEDICATION NAME] ground floor- painted fire-rated labels on fire-barrier doors between the Brookville and [MEDICATION NAME] buildings In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on four of four floors. The findings are: On 8/7/23 & 8/8/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) [MEDICATION NAME] 3 (3rd floor)- smoke barrier doors in the South and East corridor- fire-rated labels were worn and not legible 2) [MEDICATION NAME] 2- smoke barrier doors in the South corridor- painted fire-rated label; and smoke barrier doors in the East corridor- fire-rated labels were worn and not legible 3) [MEDICATION NAME] 1- smoke barrier doors in the Center corridor- fire-rated labels were worn and not legible 4) [MEDICATION NAME] ground floor- painted fire-rated labels on fire-barrier doors between the Brookville and [MEDICATION NAME] buildings In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on four of four floors. The findings are: On 8/7/23 & 8/8/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) [MEDICATION NAME] 3 (3rd floor)- smoke barrier doors in the South and East corridor- fire-rated labels were worn and not legible 2) [MEDICATION NAME] 2- smoke barrier doors in the South corridor- painted fire-rated label; and smoke barrier doors in the East corridor- fire-rated labels were worn and not legible 3) [MEDICATION NAME] 1- smoke barrier doors in the Center corridor- fire-rated labels were worn and not legible 4) [MEDICATION NAME] ground floor- painted fire-rated labels on fire-barrier doors between the Brookville and [MEDICATION NAME] buildings In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Based on observation, staff interview and document review, a door incorporated as part of the smoke barrier was not provided with a self-closing device and a hold open device tied into the fire alarm system. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:30pm, the provided life safety drawings indicated that the smoke barrier ran across the door within the staff development office on Woodcrest ground floor. The door lacked a self-closing device and a hold open device tied into the fire alarm system. In an interview on 8/9/23 at approximately 12:30pm, the Director of Plant Operations stated that they would address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Based on observation, staff interview and document review, a door incorporated as part of the smoke barrier was not provided with a self-closing device and a hold open device tied into the fire alarm system. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:30pm, the provided life safety drawings indicated that the smoke barrier ran across the door within the staff development office on Woodcrest ground floor. The door lacked a self-closing device and a hold open device tied into the fire alarm system. In an interview on 8/9/23 at approximately 12:30pm, the Director of Plant Operations stated that they would address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Based on observation, staff interview and document review, a door incorporated as part of the smoke barrier was not provided with a self-closing device and a hold open device tied into the fire alarm system. This was noted on one of four floors. The findings are: On 8/9/23 at approximately 12:30pm, the provided life safety drawings indicated that the smoke barrier ran across the door within the staff development office on Woodcrest ground floor. The door lacked a self-closing device and a hold open device tied into the fire alarm system. In an interview on 8/9/23 at approximately 12:30pm, the Director of Plant Operations stated that they would address the issue. 2012 NFPA 101: 19.3.7.8, 8.5.4.4 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on three of three floors and the basement. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Sea(NAME)3 (3rd floor)- North, East, West, South and Center stairs- painted fire-rated labels 2) Sea(NAME)3- East and North smoke barrier doors- fire-rated labels were worn and not legible 3) Sea(NAME)2- North, West, East and Center stairs- painted fire-rated labels 4) Sea(NAME)2- North smoke barrier doors- fire-rated labels were worn and not legible 5) Sea(NAME)1- North, East and South stairs- painted fire-rated labels 6) Sea(NAME)Basement- West stair- painted fire-rated label In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on three of three floors and the basement. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Sea(NAME)3 (3rd floor)- North, East, West, South and Center stairs- painted fire-rated labels 2) Sea(NAME)3- East and North smoke barrier doors- fire-rated labels were worn and not legible 3) Sea(NAME)2- North, West, East and Center stairs- painted fire-rated labels 4) Sea(NAME)2- North smoke barrier doors- fire-rated labels were worn and not legible 5) Sea(NAME)1- North, East and South stairs- painted fire-rated labels 6) Sea(NAME)Basement- West stair- painted fire-rated label In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on three of three floors and the basement. The findings are: On 8/10/23 between 9:00am-3:00pm during the recertification survey, the following was noted: 1) Sea(NAME)3 (3rd floor)- North, East, West, South and Center stairs- painted fire-rated labels 2) Sea(NAME)3- East and North smoke barrier doors- fire-rated labels were worn and not legible 3) Sea(NAME)2- North, West, East and Center stairs- painted fire-rated labels 4) Sea(NAME)2- North smoke barrier doors- fire-rated labels were worn and not legible 5) Sea(NAME)1- North, East and South stairs- painted fire-rated labels 6) Sea(NAME)Basement- West stair- painted fire-rated label In an interview on 8/7/23 at approximately 11:57am, the Director of Plant Operations stated that they would address the issues. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedJanuary 16, 2024 In response to the identified deficiency related to fire-rated doors lacking legible fire rating labels, we have developed a comprehensive plan of correction to address this issue and enhance the safety of our nursing home facility. To rectify the issue, we will begin by cleaning the doors that were found with painted fire rating labels to the best of our ability to make the fire rating legible. If, after cleaning, the labels remain illegible, replacements will be promptly ordered and installed to ensure full compliance with fire safety standards and an engineer will be hired to validate the fire rating on the doors. The painting staff will also be in-serviced on the importance of not painting over fire ratings on doors. This immediate action ensures that the fire rating information on these doors is clearly visible and compliant with safety standards. Additionally, the Director of Maintenance or their designated representative will conduct a thorough inspection of all fire-rated doors located within fire-rated enclosures. This inspection will verify that all labels on these doors are legible and meet the necessary requirements for compliance. Work orders will be generated for any doors where labels are found to be illegible, ensuring that they are promptly cleaned and made legible. As with K225, the Director of Maintenance or their designee will conduct monthly audits of all fire-rated doors within fire-rated enclosures for a period of three months. Subsequently, these audits will continue on a quarterly basis for three quarters and then transition to an annual schedule thereafter. This systematic approach will help identify and address any emerging issues with fire rating labels promptly, reducing the risk of non-compliance and enhancing resident safety. All findings resulting from these measures will be reported during our Quality Assurance and Performance Improvement (QAPI) meetings for review and necessary action. This collaborative approach underscores our commitment to resident safety and adherence to regulatory requirements, ensuring that our facility maintains the highest standards of fire-rated door labeling. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing the safety of our nursing home. Through immediate action, regular inspections, ongoing audits, and compliance with labeling requirements, we aim to prevent future issues and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of fire safety in our facility. Responsible Party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 11, 2023
Corrected date: October 10, 2023
Citation Details 2012 NFPA 101: 19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. 2012 NFPA 101: 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. Based on observation and staff interview, a supply duct in a corridor was not protected as per 19.3.1. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:39am during the recertification survey, a supply duct in the corridor in the vicinity of the North stair was observed with a pipe holding the metal curtain open within the duct. There was no fusible link provided. As a result of this configuration, the metal curtain would not close automatically in the case of a fire in the duct. In an interview on 8/7/23 at approximately 11:39am, the Director of Plant Operations stated that he will have the duct fixed. 2012 NFPA 101: 19.3.1, 19.3.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. 2012 NFPA 101: 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. Based on observation and staff interview, a supply duct in a corridor was not protected as per 19.3.1. This was noted on one of four floors. The findings are: On 8/7/23 at approximately 11:39am during the recertification survey, a supply duct in the corridor in the vicinity of the North stair was observed with a pipe holding the metal curtain open within the duct. There was no fusible link provided. As a result of this configuration, the metal curtain would not close automatically in the case of a fire in the duct. In an interview on 8/7/23 at approximately 11:39am, the Director of Plant Operations stated that he will have the duct fixed. 2012 NFPA 101: 19.3.1, 19.3.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. 2012 NFPA 101: 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. Based on observation and staff interview, a supply duct was not protected as per 19.3.1. This was noted on one of three floors. The findings are: On 8/10/23 at approximately 10:50am during the recertification survey, a supply duct within the staff lounge on Sea(NAME)3 was observed not enclosed with 1-hour fire resistance construction. The door to the corridor hit the frame when tested and lacked a fire-rated label. In an interview on 8/10/23 at approximately 10:50am, the Supervisor of Plant Operations stated that they will either enclose the duct or address the door. 2012 NFPA 101: 19.3.1, 19.3.1.1 10NYCRR 711.2(a)(1)2012 NFPA 101: 19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8. 2012 NFPA 101: 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. Based on observation and staff interview, a supply duct was not protected as per 19.3.1. This was noted on one of three floors. The findings are: On 8/10/23 at approximately 10:50am during the recertification survey, a supply duct within the staff lounge on Sea(NAME)3 was observed not enclosed with 1-hour fire resistance construction. The door to the corridor hit the frame when tested and lacked a fire-rated label. In an interview on 8/10/23 at approximately 10:50am, the Supervisor of Plant Operations stated that they will either enclose the duct or address the door. 2012 NFPA 101: 19.3.1, 19.3.1.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 13, 2023 K311 û 02 In response to the identified deficiency related to the supply duct in the corridor near the north stair, specifically the absence of a fusible link on a pipe holding a metal curtain open within the duct, we have developed a comprehensive plan of correction to address this issue and enhance the safety of our facility. To address the missing fusible link and ensure proper functionality of the metal curtain vent, we will promptly replace the fusible link on the metal curtain vent and remove the pipe that was holding it open. This corrective action will ensure that in the event of a fire within the duct, the metal curtain will close automatically, as required by safety standards. The Director of Maintenance or their designated representative will conduct a thorough inspection of all fire dampers within the facility to confirm that they are properly held open by a fusible link, in compliance with safety regulations. To maintain continuous compliance and vigilance, the Director of Maintenance or their designee will conduct quarterly audits of all fire dampers for a period of four quarters. These audits will help identify and address any issues promptly, reducing the risk of non-compliance and enhancing resident safety. All findings resulting from these measures will be reported to our Quality Assurance and Performance Improvement (QAPI) committee for review and necessary action. This collaborative approach underscores our commitment to resident safety and adherence to regulatory requirements, ensuring that our facility maintains the highest standards of fire safety. In conclusion, our plan of correction demonstrates our dedication to addressing the identified deficiency and enhancing overall fire safety in our nursing home. Through fusible link replacement, pipe removal, duct enclosure, regular inspections, and ongoing audits, we aim to prevent future deficiencies and create a safer environment for our residents and staff. We are committed to implementing these corrective measures with diligence and care to uphold the highest standards of fire safety. Responsible party: Director of Maintenance |