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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
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 821) initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's need was developed and implemented for each resident. This was identified for one (Resident #55) of five residents reviewed for Unnecessary Medications. Specifically, on 9/24/2024 Resident #55 was transferred to the hospital due to unresponsiveness. The resident was readmitted on [DATE] with a [DIAGNOSES REDACTED]. There was no documented evidence that a comprehensive care plan with appropriate interventions was developed to prevent further potential Opioid Overdose. The finding is: The facility's Opioid Overdose Management/Use of [MEDICATION NAME] policy and procedure dated 12/2024 documented the facility will have [MEDICATION NAME] (a medicine that reverses Opiod overdose) available on each nursing unit for use in the event of an apparent or suspected Opioid overdose is identified. The Medical Director shall approve standing orders for the facility to allow the administration of [MEDICATION NAME] by any licensed nurse to any resident upon reasonable suspicion of Opioid overdose, without having to first obtain a verbal or written order to prevent delay in treatment that may result in resident harm. Such reasonable suspicion shall be based on the presentation of symptoms of Opioid overdose. The facility's Comprehensive Interdisciplinary Care Plan Completion of Minimum Data Set 3.0 policy and procedure reviewed 12/2024 documented that the interdisciplinary team will assess the resident holistically to develop a plan that will promote quality of care and quality of life to assist the resident in achieving goals. Resident #55 was admitted with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15, which indicated intact cognition. The resident's Mood Interview score was 10, which indicated mood symptoms were present. The resident had no behavioral symptoms present and was receiving Anti-Anxiety, anti-depressants, Opioid, and hypnotic medications; indicators were present for the use of the medications. A Nurse Practitioner's note dated 9/24/2024 documented the resident was re-examined and found non-responsive to verbal as well as tactile (touch) stimuli. The resident was responsive to deep and painful stimuli. [MEDICATION NAME] ([MEDICATION NAME]) Spray 4 milligram Nasal time one dose was given and within seconds the resident had opened their eyes, became slowly responsive to their name, and was moaning. 911 was activated to transfer the resident to the hospital for further treatmentfor [DIAGNOSES REDACTED]. A Health Status Note dated 9/24/2024 at 4:39 PM documented the resident was transferred to the hospital for severe lethargy. A Patient Review Instrument dated 9/30/2024 documented primary [DIAGNOSES REDACTED]. During an interview on 2/7/2025 at 4:05 PM, the Minimum Data Set Coordinator stated they or the admission nurse could have initiated a care plan that addressed the drug overdose to prevent further occurrences. The Minimum Data Set Coordinator stated they usually initiated the original care plans, and the unit nurses were responsible for updating and initiating the interim care plans. The Minimum Data Set Coordinator further stated a care plan with interventions specifically addressing the Opioid overdose should have been developed. During an interview on 2/7/25 at 4:15 PM, the Director of Nursing Services stated that a care plan addressing the Opioid overdose should be developed and implemented. The Minimum Data Set Coordinator was responsible for initiating the care plans. The Director of Nursing Services stated that the Minimum Data Set Coordinator should have initiated a care plan with appropriate interventions that addressed the Opioid overdose to prevent further occurrences and if the Minimum Data Set Coordinator was not available, the Registered Nurse Supervisors could have initiated the care plan. 10 NYCRR 415.11(c)(1) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center for Rehabilitation and Healthcare provides this Plan of Correction Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F656. Resident #55 care plan was updated on 2/10/2025 by MDS Coordinator to include [DIAGNOSES REDACTED]. All residents on opioids and/or have a history of opioid overdose have the potential to be affected by this alleged deficient practice A full house audit was conducted on all residents by MDS Coordinator/DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that addresses their risk for opioid overdose and have appropriate goals and interventions to prevent potential opioid overdose. Any negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. ?Çó Policy and Procedure for Comprehensive Care Plan was reviewed by MDS Coordinator/ DON/ Social Worker, Coordinator/DON/social worker The DON/MDS Coordinator educated the nursing staff and IDT on 2/25/2025 about ?Ç£Comprehensive Care Plans?Ç¥ with emphasis on developing a person-centered care plan for those residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression, with appropriate goals and interventions to prevent further potential opioid overdose. Care plans were immediately updated to reflect an accurate, person-centered plan of care for the residents based upon the residents assessed condition and needs, if required. . Staff were reminded of the potential consequences to both the residents and staff if the policy is not followed. Any staff found responsible for the deficient practice will be referred to the DON for counseling. An audit was conducted on all residents by MDS Coordinator /DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that accurately reflects their physical and mental health needs and assures their needs are addressed and met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. ?Çó The MDS Coordinator /DON/Designee will audit 5 resident care plans x 4 weeks, then 5 resident care plans monthly x 3 months to ensure that residents with moderate to high risk index for opioid overdose or serious opioid-induced respiratory depression have a person- centered care plan addressing potential for opioid overdose with appropriate goals and interventions to prevent further potential opioid overdose. Any adverse findings will be immediately corrected. ?Çó Audit findings will be presented to the QA Committee monthly meetings x 6 months. The results of these audits will be reviewed in the monthly QA Committee monthly meetings for 6 months or until 100% compliance is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5. The date for correction and the title of the person responsible for correction of each deficiency: ?Çó DON is responsible for the compliance by 03/10/2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details Based on observation, interviews, and record review conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task. Specifically, 1) several food items were stored in the walk-in refrigerator and walk-in freezer without proper labeling and dating; multiple frozen item bags were observed with ice and frost inside their packaging; Additionally, a plastic container and milk crates in the dry storage area were observed to be dirty. 2) Cold food items including yogurt, milk, chicken salad sandwich, and egg salad temperatures were observed above 41 degrees Fahrenheit. The findings are: A facility policy and procedure titled Food Storage effective 10/2024, documented food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. A date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. Plastic containers with tight-fitting covers must be used for storing broken lots of bulk foods. All containers must be legible, accurately labeled, and dated. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Refrigerated food storage: all foods should be covered, labeled, and dated. A facility policy and procedure titled Cleaning and Sanitation of Dining and Food Service Areas, effective 10/2024, documented the food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Tasks shall be designated to be the responsibility of specific positions in the department. All staff will be trained on the frequency of cleaning necessary. During an initial tour of the kitchen on 2/3/2025 at 9:26 AM, the walk-in refrigerator was observed with multiple food items (tapioca pudding, and beet salad) not properly labeled and dated. The walk-in freezer was observed with multiple food items (corn, French toast, chicken nuggets, French fries, turkey burger, beef burger, pork chops, and frankfurters) not properly labeled and dated. The bags of turkey burgers, beef burgers, pork chops, and frankfurters were observed to have ice/frost build up on the inside of the packaging. There were also two packages of Perogies and a corned beef outside of their original delivery pack without a delivery date. A plastic container of jelly was not dated in the reach-in refrigerator; the edges and the lid of the container had remnants of peanut butter on it. The Food Service Director was immediately interviewed and stated the cooks are responsible for labeling and dating food returned to the freezer. The Food Service Director stated the cooks should ensure that the food packages are sealed to prevent freezer burn. The container of jelly should have been dated and the edges should have been cleaned. During an interview on 2/3/2025 at 9:35 AM, Cook #1 stated the cooks are responsible for labeling and dating food packages when returning to the freezer. Cook #1 stated food with freezer burn cannot be served and should be discarded. During a tour of the dry storage area on 2/3/2025 at 9:40 AM, a plastic tub of beef soup base was observed with black dust on the lid. The plastic tub was stored on top of milk crates which were observed with a buildup of the soup base powder along the top and edges. The Food Service Director stated that the container and the milk crates should have been cleaned. During an interview on 2/6/2025 at 3:21 PM, the Administrator stated that stored food should be labeled and dated. The Administrator stated they were not aware the kitchen was not following the food storage procedure. 2) A facility policy and procedure titled Food Temperatures effective 3/2022 last reviewed 1/2025, documented it is the policy to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Food temperatures will be checked on all items prepared in the dietary department. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. No food will be served that does not meet the food code standard temperatures. Place cold menu items such as ham salad or egg salad over an ice bath in a pan and not beside a heated steam table. The Cook's Temperature Log Sheet maintained by the facility did not include evidence of cold food temperature monitoring. During an interview on 2/6/2025 at 12:25 PM, Cook #2 stated they only measure the temperature of cold entr??es but do not take the temperature of the other cold food items that are placed on the individual resident tray such as milk, yogurt, sandwiches, etc. During the Kitchen observation on 2/6/2025 at 12:32 PM, two trays of sandwiches were not kept in an ice bath. During an observation and interview on 2/6/2025 at 12:33 PM, Cook #3 stated they did not keep the sandwiches (such as American cheese, egg salad, tuna salad) on ice during preparation, nor did they take the temperatures of the sandwiches. Cook #3 measured the temperatures of the sandwiches. The American cheese sandwich temperature was measured at 60 degrees Fahrenheit, and the chicken salad sandwich temperature was measured at 50 degrees Fahrenheit. Cook #3 stated the temperature of the sandwiches should be below 40 degrees Fahrenheit. During an interview on 2/6/2025 at 12:40 PM, the Food Service Director stated the proper serving temperature for cold food should be 41 degrees Fahrenheit or below. The Food Service Director stated they do not routinely measure the temperature of cold food items such as sandwiches, milk, and yogurt. During an interview and observation on 2/6/2025 at 12:45 PM, Dietary Aide #1 stated that they do not measure the temperature of the cold food items before they place the food items on the individual resident trays. Dietary Aide #1 stated they usually kept cold items in a cooler, but the cooler was broken and was never replaced. Dietary Aide #1 measured the temperature of cold food items, finding yogurt at 50 degrees Fahrenheit, milk at 50 degrees Fahrenheit, and a cup of egg salad at 60 degrees Fahrenheit. Dietary Aide #1 stated the temperature of the cold food should be less than 41 degrees Fahrenheit. During an interview on 2/6/2025 at 3:21 PM, the Administrator stated they were aware of the food temperature standards and cold food should be maintained at a temperature of 41 degrees Fahrenheit or below. The Administrator stated they did not know the Food Service Director was not monitoring the temperature of the cold food items served to the residents. 10 NYCRR 415.14(h) | Plan of Correction: ApprovedMarch 3, 2025 Pine(NAME)Center For Rehabilitation and Healthcare provides the Following Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F812. The Food Service Director ensured that all improper labeled and dated food items were discarded immediately. The Food service Director gave in-services to the cooks on 2/4/2025 on properly labeling and dating food items The Food service Director cleaned the edge of the lid immediately upon recognition. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this alleged deficient practice. Food Service Director did a kitchen-wide tour on 2/03/2025 to ensure that the facility is in compliance with food storage procedure. All negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Administrator and Food Service Director reviewed the policy on Food Storage. No changes were made. They also reviewed the policy on Cleaning and Sanitation of Dining and Food Service Areas and the policy on Food Temperatures and no changes were made. Kitchen staff were in serviced on 2/04/2024 on the policies with specific focus on proper labeling of food packages, disposing of freezer burned food, and on the cleanliness of the food storage areas. They were also in-service on Cold Food temperatures, with specific focus on keeping all cold food items on ice during preparation to adhere to the regulations. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Facility has implemented tray line temperature audits to ensure the facility is in cold food temperature compliance. Audits will be done weekly for the 1st 4 weeks and then monthly for the following 5 months. The facility has implemented audits on proper labeling/dating as well as cleanliness to ensure staff are adhering to state and federal regulations and will be done weekly for the 1st 4 weeks and then monthly for the following 5 months following. Audits will be discussed at the QA meeting to monitor for compliance 5. The date for correction and the title of the person responsible for correction of each deficiency ?Çó The Administrator will be responsible for implementation and compliance by 03/10/2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 821), the facility did not ensure that an investigation of alleged abuse was thoroughly and timely investigated to prevent further potential abuse, neglect, exploitation, or mistreatment. This was identified for one (Resident #55) of two residents reviewed for Abuse. Specifically, on 12/28/2024 Resident #55 verbalized that a Certified Nursing Assistant scratched them during the morning care. There was no documented evidence that an investigation to rule out abuse, neglect, or mistreatment was initiated until 12/30/2024. The finding is: The facility Accident/Incident Report reviewed 1/2025 documented all accidents/incidents involving residents must be reported to the Director of Nursing Services and or Assistant Director of Nursing. An Accident/Incident Report must be completed on the shift in which the accident/incident occurred. A copy of this report is to be provided to the Assistant Director of Nursing/designee within 24 hours of such incident. Resident #55 was readmitted to the facility with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score as 12, which indicated the resident had moderately impaired cognition. The resident required partial to moderate assistance for toileting, bathing, dressing, rolling left to right, and personal hygiene. There was no functional limitation in the range of motion to the upper and lower extremities. The resident's Mood Interview score was 10, which indicated mood symptoms were present. The resident had no behavioral symptoms. A Late entry note dated 1/15/2025 for 12/30/2024, entered by the Director of Nursing Services, documented that on 12/30/2024, Resident #55's representative reported that the resident had a scratch on their buttocks. A complete body check was done, and the resident's skin was found to be intact, without scratches or redness. Resident #55 then informed the Director of Nursing Services that on 12/28/2024 at approximately 7:30 AM, during care, Certified Nursing Assistant #5 squeezed the resident's fingers. The assigned Certified Nursing Assistant #4 was also present in the room. The Accident and Incident Report dated 12/30/2024 documented the resident alleged they were scratched by a Certified Nursing Assistant during care on 12/28/2024 at approximately 7:30 AM. The resident's statement on the Accident/Incident Report documented the Certified Nursing Assistant scratched me on purpose. A Summary of Investigation dated 12/30/2024 documented Resident #55 had initially reported their buttock injury, which was caused by a Certified Nursing Assistant during morning care, to the nurse on Saturday 12/28/2024. The report documented that the nurse initially examined the area and had no findings; however, Resident #55 was upset and continued to insist that they were scratched on the right buttocks. During a skin assessment, the nurse noted visible lines of indented skin on the resident's right upper thigh caused by the brief. There was no documented evidence that an investigation was initiated on 12/28/2025 including statements from the involved Certified Nursing Assistant #4 and Certified Nursing Assistant #5 to rule out abuse, neglect, or mistreatment. There was no documented evidence of a nursing progress note related to the allegations made by the resident regarding staff intentionally scratching the resident's buttock area or squeezing their finger during care. A Typed statement signed by Resident #55 dated 12/30/2024 documented that on 12/28/2024 around 7:30 AM Certified Nursing Assistant #4 and Certified Nursing Assistant #5 came to their room to change them. Certified Nursing Assistant #4 proceeded to change them while Certified Nursing Assistant #5 was standing on the left side of the room. Certified Nursing Assistant #4 closed the left side of the brief and then asked Certified Nursing Assistant #5 to assist. Certified Nursing Assistant #5 came to the right of the bed. Resident #55 told Certified Nursing Assistant #5 not to touch them as they usually have only one Aide helping them and did not want Certified Nursing Assistant #5 to assist. Resident #55 grabbed the strap of the brief with both hands to stop Certified Nursing Assistant #5. While Resident #55 was turning to their left side for Certified Nursing Assistant #4 to close the right side of the brief, Certified Nursing Assistant #5 grabbed the resident's right hand and squeezed the resident's hand hard, and with their (Certified Nursing Assistant #5) other hand they scratched the resident's right buttock. A Comprehensive Care Plan dated 1/14/2025 documented the resident has accusatory, attention-seeking, and fabrication behaviors towards staff and peers. Interventions included a two-person approach during care and to observe for changes in the resident's behavior. During an interview on 2/6/2025 at 12:26 PM, Certified Nursing Assistant #4 stated they were assigned to Resident #55 on 12/28/2024. Certified Nursing Assistant #4 stated that on 12/28/2024 the resident asked to be changed, and they informed the resident that they would get a second Certified Nursing Assistant to assist with their care. Certified Nursing Assistant #4 stated that during the brief change Certified Nursing Assistant #5 assisted with applying the brief on one side. Certified Nursing Assistant #4 stated after they had fastened the tape on the left side of the brief, Certified Nursing Assistant #5 was about to fasten the tape on the other side when the resident screamed Don't touch me, at that time Certified Nursing Assistant #5 left the room to get Licensed Practical Nurse #1. Certified Nursing Assistant #4 stated Licensed Practical Nurse #1 came and stayed in the resident's room until the care was completed. Certified Nursing Assistant #4 stated during care Resident #55 did not complain Certified Nursing Assistant #5 scratched them or squeezed their hand. During an interview on 2/6/2025 at 12:45 PM, Certified Nursing Assistant #5 stated on 12/28/2024 they had assisted Certified Nursing Assistant #4 with the care of Resident #55. Certified Nursing Assistant #5 stated the resident was a two-person approach and was upset because the resident did not want them in the room. Certified Nursing Assistant #5 stated as they were about to fasten the brief, Resident #55 grabbed the brief and said, Don't touch me. Certified Nursing Assistant #5 stated they did not touch the resident and left the room right away to get Licensed Practical Nurse #1. Certified Nursing Assistant #5 stated shortly after the incident, Registered Nurse #2 Supervisor interviewed them regarding the resident's complaint of being scratched. Certified Nursing Assistant #5 stated they had short nails and were wearing gloves during care. Certified Nursing Assistant #5 stated they did not touch the resident and did not squeeze the resident's hand. During an interview on 2/6/2025 at 1:42 PM, Registered Nurse #2, the 7:00 AM-3:00 PM shift supervisor, stated on 12/28/2024 between 9:00 AM -10:00 AM the resident called the receptionist to speak with the Supervisor. Registered Nurse #2 stated the resident reported that someone scratched them on their leg; however, the resident did not want to be touched. Registered Nurse #2 stated they observed two lines on the resident's right upper thigh that were red and looked like the lines of indented skin caused by the brief. Registered Nurse #2 stated when they assessed the resident on 12/28/24 that they did not document their assessment in the medical record. Registered Nurse #2 stated that they had forgotten to document their assessment in the chart and did not start an investigation. During an interview on 2/7/2024 at 12:00 PM, Resident #55 stated while the staff was applying their brief, they asked Certified Nursing Assistant #5 not to touch them. Resident #55 stated they held onto their brief and Certified Nursing Assistant #5 held on to their (the resident's) right hand to remove their (the resident) hand from the brief and Certified Nursing Assistant #5 squeezed their hand. The resident stated their hand was hurting for four days after the incident. Certified Nursing Assistant #5 also scratched them when they tried to remove their hand from the brief. The resident stated that the Certified Nursing Assistant #5 should have stopped when they asked them not to touch them. The Resident further stated that both Certified Nursing Assistant #4 and Certified Nursing Assistant #5 were wearing gloves during the care. During an interview on 2/7/2025 at 1:58 PM, Licensed Practical Nurse #1 stated they worked on the morning shift 7:00 AM-3:00 PM on 12/28/2024. Licensed Practical Nurse #1 stated Certified Nursing Assistant #5 reported to them that the resident did not want two persons in their room during care. Licensed Practical Nurse #1 Licensed Practical Nurse #1 stated that the resident permitted them to stay in the room until Certified Nursing Assistant #4 had completed the care. Licensed Practical Nurse #1 stated the resident did not complain to them that a Certified Nursing Assistant scratched them or squeezed their hand. During an interview on 2/7/2025 at 2:30 PM, the Director of Nursing Services stated they were made aware of the allegation by the resident's representative called them on 12/30/2024. The Director of Nursing Services stated Registered Nurse #2 did not notify or complete a report of the allegation made by the resident on 12/28/24. The Director of Nursing Services stated an investigation should have been initiated by Registered Nurse #2 who was first notified of the allegation of abuse and should have documented their assessment in the progress note. The Director of Nursing Services and the Nurse Practitioner assessed the resident on 12/30/2024 and initiated an investigation. 10 NYCRR 415.4(b)(3) | Plan of Correction: ApprovedMarch 5, 2025 Pine(NAME)Center for Rehabilitation and Healthcare Provides this Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F610. SW met with resident #55 on 2/28/2025 and offered psychological and psychiatric services. Resident declined the services, and resident denied any emotional distress. RN #2 was re-educated on 3/01/2025 on the policy and procedure on initiating abuse/mistreatment/neglect investigation and reporting guidelines and on proper documentation. Certified Nurses Assistant #4 and #5 was re-educated on 2/26/2025 on the policy and procedure of abuse/mistreatment/neglect and exploitation Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the alleged deficient practice. Facility did an audit/review on 2/25/2025 on investigations of allegations, and no potential reportable allegations of abuse were found. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Abuse Reporting and Investigating was reviewed by DNS, Admin, and Social Worker and no updates were made. All RN Supervisors were re-educated on 3/01/2025 on the Policy and Procedure for Abuse Reporting and Investigation Policy by the DON/designee. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure allegations of abuse, neglect or mistreatment are investigated immediately as required. Any adverse findings will be immediately corrected accordingly. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
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 2/3/2025 and completed on 2/7/2025, the facility did not ensure pharmaceutical services met the needs of each resident including appropriately administering all drugs and biologicals in accordance with the professional standards of practice. This was identified for one (Resident # 21) of five residents reviewed for unnecessary medications. Specifically, Resident #21 was prescribed [MEDICATION NAME] Sodium ([MEDICATION NAME]) Injection Solution 5000 units per milliliter and the nursing staff administered the injection without rotating the subcutaneous injection sites. Cross Reference: F658- Services Provided Meet Professional Standards The finding is: The Policy and Procedure for Injection Site Rotation dated (MONTH) 2023 documents that rotation of the injection site is required. The pdr.net/drug summary/ [MEDICATION NAME] Sodium injection website for [MEDICATION NAME] subcutaneous injection administration documented to rotate the injection site frequently. The National Library of Medicine; National Center for Biotechnology Information: Nursing Skills 2nd edition 2023 documented it is important to rotate [MEDICATION NAME] sites to avoid bruising in one location. Resident # 20 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period. The current physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no documented evidence that the injection site was rotated to other sites on these dates. During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections. During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated [MEDICATION NAME] injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of [MEDICATION NAME] administration should be documented accurately and the injection site should be rotated. If the [MEDICATION NAME] injection site is not rotated, it can cause tissue damage and discomfort for the resident. During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of [MEDICATION NAME] is not rotated bleeding, pain, and tissue damage can occur. 10 NYCRR 415.11(c)(3)(i) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center for Rehabilitation and Healthcare provides this Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F755. Resident #20 was reassessed by the RN Supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated on 2/26/2025 to include rotating sites with each administration. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON/Designee and no updates were made. All Nurses were re-educated on 3/01/2025 by the DON on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The consultant pharmacist will monitor externally for appropriate site rotation based on administration records and will report negative findings to DON. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
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 2/3/2025 and completed on 2/7/2025, the facility did not ensure services provided by the facility as outlined in the comprehensive care plan (CCP) must meet professional standards of quality. This was identified for one (Resident # 20) of five residents reviewed for unnecessary medications. Specifically, Resident #20 had a physician's orders [REDACTED]. The nursing staff were not rotating the injection sites when administering [MEDICATION NAME]. Cross Reference: F755- Pharmacy Svcs/Procedures The finding is: The Policy and Procedure for Injection Site Rotation dated (MONTH) 2023 documented that rotation of the injection site is required. Resident # 20 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period. The current physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no documented evidence that the injection site was rotated to other sites on these dates. During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections. During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated [MEDICATION NAME] injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of [MEDICATION NAME] administration should be documented accurately and the injection site should be rotated. If the [MEDICATION NAME] injection site is not rotated, it can cause tissue damage and discomfort for the resident. During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of [MEDICATION NAME] is not rotated bleeding, pain, and tissue damage can occur. 10 NYCRR 415.11(c)(3)(i) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center for Rehabilitation and Healthcare provides this Plan of Correction Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F658. Resident #20 was reassessed by RN supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated ON 2/26/2025 to include rotating sites with each administration. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON and no updates were made. All Nurses were re-educated on 3/01/2025 by DON/Designee on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months on all residents on [MEDICATION NAME] to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency ?Çó DON will be responsible for implementation and compliance by 03/10/2025. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
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, record review and staff interview during the Life Safety Code recertification survey, the facility did not ensure that the West building was constructed to be at least an NFPA 101 Type V (111) construction. A CMS Time Limited Waiver (TLW) to correct this issue is set to expire on July,01, 2025. The findings are: During the Life Safety Code survey, on (MONTH) 04, 2025, between 10:30 AM - 3:00 PM, it was noted that the Old Building (West Bldg.) is a two story fully sprinklered Type V (000) construction building. On (MONTH) 04, 2025, at approximately 2:30 PM, the Owner stated that the architect is currently drawing plans, that additional smoke detectors were already installed, and they have not yet obtained permits from the local jurisdiction; further stating that the work will be most definitely done before the TLW expires on (MONTH) 01, 2025. On (MONTH) 06, 2025, at approximately 9:50 AM, the Administrator provided the CMS Time Limited Waiver letter. CMS letter dated 07/26/2024 states that a temporary waiver is for additional time to allow the facility to come into compliance with the prescriptive requirements for K271, which will allow the facility to pass an FSES and meet an equivalent level of safety as required by K161. The time limited waiver is set to expire on (MONTH) 01, 2025. On (MONTH) 06, 2025, at approximately 12:21 PM, documents provided for review included the Fire Alarm vendor contract dated 03/26/2024, with scope of work: to replace existing smoke detectors with new smoke detectors. 41 - 2W smoke detectors and one photo smoke detector. On (MONTH) 10, 2024, at approximately 11:30 AM, post survey document review of NYSDOH records, an architect letter submitted to the NYSDOH and dated 08/02/2022, states that the nursing home was stated to be comprised of two separate buildings of different construction types connected by a short corridor link and separated by a 2-hour fire barrier. The original building referred to as the Old Building is a wood frame structure with exterior masonry bearing walls that has 2-stories above grade and 1-story below grade (a Basement). The construction type of the Old Building is Type V (000). The Old Wing is fully sprinklered and has a fire alarm and smoke detection system with smoke detectors in corridors and habitable spaces. The New Wing is of Type II (222) construction with a concrete plank and bearing wall structural system. It is also 2-stories above grade and 1-story below grade (a Basement). Due to the site's sloping topography, it is possible to exit at grade at a portion of the Basement level. The New Wing is fully sprinklered and has smoke detection in corridors and habitable spaces. On (MONTH) 10, 2024, at approximately 2:30 PM, post survey document review of The facility's Plan of Correction for tag K161 cited during the 01/23/2024 Life Safety Code survey included: -In order to achieve a passing FSES score it has been determined that the facility will need to reconfigure the existing second floor corridor ramp in zone 2-C to achieve a code compliant slope of 1:12 or less. It was determined that to create an accessible ramp the facility will need to construct an addition to the facility to accommodate the level change via a ramp. A limited time waiver until 07/15/2025 is required in order to complete the work. The Architect prepared schematic drawings as part of a Limited Review Application (LRA) to the NYSDOH. The LRA ( 5) was approved on (MONTH) 22, 2023. The approved schematic plan had subsequently submitted to the local Building Department for review. The filing representative has been actively communicating with the Town and providing supplemental information is requested. Upon approval from the Town for such an extension of the facility final construction drawings will be produced. It's anticipated that: Town approval will occur by 6/1/2024. Final construction drawings will be prepared between 6/1/2024 and 8/1/2024. Permits will be obtained by 11/1/2024. Construction will take place between 11/1/2024 and 7/1/2025 in zones 2-C and 1-C. FSES will take place after construction between 7/1/2025 and 07/15/2025. The Facility is contracted with an architectural/engineering firm to conduct an FSES after installation. At time of survey, there was no evidence that any of the above milestones had been completed, neither that the construction phase was currently in progress. NFPA [PHONE NUMBER]: 19.1.6.2 NYCRR711.2(a)(1) 10 NYCRR 415.29 | Plan of Correction: ApprovedMarch 17, 2025 Pine(NAME)Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3.Pine(NAME)Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025 3a. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. fire watches 2. additional fire drills 3. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. provide additional extinguishers 7. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required.?Ç¥ 8. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11.The Administrator is responsible for the correction of this deficiency by 4/1/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details 415.14 Dietary Services (h) Sanitary conditions. The facility shall store, prepare, distribute and serve food under sanitary conditions; and in accordance with the sanitary requirements of Part 14 (Service Food Establishments) of Chapter 1 (State Sanitary Code) of this Title. 14-1.31 Food; Definitions of contamination and potentially hazardous food; food sources; hermetically sealed foods. (a) Food is to be free from adulteration, spoilage, filth or other contamination, and suitable for human consumption. (b) Contamination means exposing food to filth, toxic substances, manual contact during service or preparation if such food will not be subsequently cooked prior to service, rodent or insect contact or infestation, or any condition which permits introduction of pathogenic microorganisms or foreign matter. 14-1.40 Food protection, potentially hazardous food, temperature and refrigeration requirements. (a) Food is to be protected from contamination during storage, preparation, display, service and transportation. 14-1.95 Equipment acceptable. Equipment installed in existing food service establishments is acceptable in that establishment provided that it is in good repair, maintained in a sanitary condition, the food-contact surfaces are nontoxic and it performs its intended function in a satisfactory manner without contaminating food by normal use. 14-1.110 Cleaning frequency. (d) Non-food-contact surfaces of equipment are to be cleaned as often as necessary to keep the equipment free of accumulations of dust, dirt, food particles and other debris. 14-1.140 Plumbing. (a) Plumbing is to be sized, installed and maintained to carry adequate quantities of potable hot and cold water at satisfactory pressure to all parts of the food service establishment where needed for satisfactory operation. Sewage and liquid wastes are to be carried to the sewer or sewage disposal facility in a manner which protects the premises, personnel and contents within the establishment and surroundings from contamination. All plumbing is to be constructed and maintained to prevent contamination of the potable water supply, food, equipment, utensils, the premises, contents, employees and patrons. There is to be no direct connection between the sewage system and any drains originating from fixtures and equipment used for storage, preparation or processing of food or drink. Waste lines from equipment requiring indirect drains are to be installed so as to prevent backflow from sewers and drains from other fixtures. 14-1.170 Floors. Floors and floor coverings of food storage, food preparation equipment, utensil washing areas, and floors of walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules, are to be maintained clean and in good repair and are to be smooth, durable, and non-absorbent. The use of anti-skid floor covering is acceptable when necessary for safety reasons. Based on observation, document review, and staff interviews, the facility did not ensure that food for resident consumption was protected from contamination during storage; that equipment installed in the kitchen were kept clean and in good repair; and that floors of walk-in refrigerators were maintained clean in accordance with the sanitary requirements of Part 14 (Service Food Establishments) of Chapter 1 (State Sanitary Code) of this Title. This was observed in the only kitchen that serves the facility. The findings are: On (MONTH) 04, 2025, at approximately 2:20 PM, during a tour of the kitchen in the basement, the following was observed in the presence of the Director of Maintenance and the Administrator: -The compressor above the chest freezers used to store food for resident consumption was observed heavily dusted. -In the walk in refrigerator, the mesh cover of the compressor was observed dusty and in disrepair, in addition, the compressor was observed to be leaking directly onto the walk in refrigerator's floor. Uncovered crates storing 40z milk cartons used for resident consumption were observed stored directly under said compressor; and a puddle of standing water was observed on the floor by the corner close to the compressor. -In the walk in refrigerator, food debris were observed on the floor under the racks storing food for resident consumption. The Administrator, who was present at the time of observation, stated that they are looking to replace the fan cover in the walk in refrigerators. On (MONTH) 06, 2025, at approximately 10:05 AM, the Director of Food Services stated that the walk in boxes are cleaned every day in the afternoon, and that there are no cleaning logs that record the cleaning, further stating that the cleaning of walk in boxes is under the job description for kitchen's staff. On (MONTH) 06, 2025, at approximately 10:15 AM, the Director of Maintenance stated that they are responsible for the maintenance of the compressor fans in the kitchen, and that they will get them repaired and cleaned. On (MONTH) 10, 2025, at approximately 12:44 PM, the Administrator stated via email, that the vendor will be going to resolve the issue with the fridge. On (MONTH) 10, 2025, at approximately 3:53 PM, review of the following policies provided to surveyors at time of survey: A.Policy and Procedure titled Food Storage, effective date 10/2024, states that Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods to prevent contamination or cross contamination. Food is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). Refrigerated food storage: All refrigerator units are kept clean and in good working condition at all times. B. Policy and procedure titled Cleaning and Sanitation of Dining and Food Service Areas, effective date 10/2024, states that the food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. 415.14(h) 14-1.31(a)(b), 40(a), 95, 110, 140, 170 | Plan of Correction: ApprovedMarch 10, 2025 Pine(NAME)Center For Rehabilitation and Healthcare Provides the following Plan Of Correction 1. No Residents were affected by the deficient practice 2. All residents have the potential to be affected by this deficient practice. 3. The food service director immediately moved the milk crates to a different location in the fridge. 4. The Compressor above the chest freezer has been cleaned and will be checked weekly to ensure no dust build-up 5. The walk in fridge has been swept and cleaned. 5. The food service director inserviced all staff on filling out the cleaning logs 6. The EVS Director reached out to the vendor who will be replacing the fan mesh cover and fixing the leak, the vendor came on site and the facility received and approved the quote and the vendor will be onsite 3/12/2025 to complete the work. 7. The Food service director will conduct daily checks of the walk in fridge until it is repaired and report all findings to the administrator/EVS Director. 7. The Food service director will conduct daily checks of the walk in fridge to ensure it has been swept and cleaned. 7. The EVS Director/designee will present any findings at the quarterly QA/QAPI meetings. 8. The EVS Director/designee will be responsible to correct this deficiency. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19.2.7 Discharge from Exits. Discharge from exits shall be arranged in accordance with Section 7.7 2012 NFPA 101: 7.7.4 Components of Exit Discharge. Doors, stairs, ramps, corridors, exit passageways, bridges, balconies, escalators, moving walks, and other components of an exit discharge shall comply with the detailed requirements of this chapter for such components. 2012 NFPA 101: 7.2.5 Ramps. 2012 NFPA 101: 7.2.5.1 General. Every ramp used as a component in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.5. 2012 NFPA 101: 7.2.5.2 Dimensional Criteria. The following dimensional criteria shall apply to ramps: (2) Existing ramps shall be permitted to remain in use or be rebuilt, provided that they meet the requirements shown in Table 7.2.5.2(b), unless otherwise permitted by any of the following: (a) The requirements of Table 7.2.5.2(b) shall not apply to industrial equipment access areas as provided in 40.2.5.2. (b) The maximum slope or maximum height between landings for a single ramp run shall not apply to ramps providing access to vehicles, vessels, mobile structures, and aircraft. (c) Approved existing ramps with slopes not steeper than 1 in 6 shall be permitted to remain in use. (d) Existing ramps with slopes not steeper than 1 in 10 shall not be required to be provided with landings. Table 7.2.5.2(b) Existing Ramps Dimensional Criteria Feature ft/in. mm Minimum width 30 in. 760 Maximum slope 1 in 8 Maximum height between landings 12 ft 3660 2012 NFPA 101: 7.3.4 Minimum Width. 2012 NFPA 101: 7.3.4.1 The width of any means of egress, unless otherwise provided in 7.3.4.1.1 through 7.3.4.1.3, shall be as follows: (1) Not less than that required for a given egress component in this chapter or Chapters 11 through 43 (2) Not less than 36 in. (915 mm) where another part of this chapter and Chapters 11 through 43 do not specify a minimum width 2012 NFPA 101: 19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms. 2012 NFPA 101: 19.2.3.5 The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers. 2012 NFPA 101: 7.4.1.1 The number of means of egress from any balcony, mezzanine, story, or portion thereof shall be not less than two, except under one of the following conditions: 2012 NFPA 101: 7.5.1.1.2 Exit access corridors shall provide access to not less than two approved exits. 2012 NFPA 101: 19.2.4.1 The number of means of egress shall be in accordance with 7.4.1.1 and 7.4.1.3 through 7.4.1.6. 2012 NFPA 101: 19.2.4.2 Not less than two exits shall be provided on every story. 2012 NFPA 101: 19.2.4.3 Not less than two separate exits shall be accessible from every part of every story. 2012 NFPA 101: 7.5.1.3.1 Where more than one exit, exit access, or exit discharge is required from a building or portion thereof, such exits, exit accesses, or exit discharges shall be remotely located from each other and be arranged to minimize the possibility that more than one has the potential to be blocked by any one fire or other emergency condition. 2012 NFPA 101: 7.5.1.3.7 The balance of the exits, exit accesses, or exit discharges specified in 7.5.1.3.6 shall be located so that, if one becomes blocked, the others are available. Based on observations, record review and staff interviews, the facility did not ensure that mean of egress components were in accordance with the requirements of NFPA 101 Life Safety Code, 2012 Edition. Specifically: 1.A ramp located on the second floor did not comply with the dimensional criteria set forth in 2012 NFPA 101: 7.2.5.2. 2.A corridor located on the first floor, was not at least four-foot wide in accordance with 2012 NFPA 101: 19.2.3.4*. A CMS Time Limited Waiver to correct this issue is set to expire on July,01, 2025. At the time of survey, the facility did not demonstrate substantial progress in addressing the deficiencies and conditions for which the time limited waiver was granted. The findings are: On (MONTH) 04, 2025, at approximately 11:10 AM, during the Life Safety Code recertification survey, it was noted that the ramp located on the second floor between the Old Building and the New Wing contains a slope of 15 inches (height) in 10.3 feet (length). Per 2012 NFPA 101: 7.2.5.2 existing ramps are only permitted to be 1 inch in 8 feet. There was no work observed to be completed or in progress to address this issue, and for which a time limited waiver, set to expire on (MONTH) 01, 2025, was granted. On (MONTH) 04, 2025, at approximately 2:15 PM, on the first floor resident's West Wing, it was observed that the corridor (adjacent to Administrator's office) serving as exit access for five occupied resident sleeping rooms and one nurse office, was reduced to 40 inches in clear width. In addition, it was noted that at the other end of said corridor, there are two emergency exits located opposite one to the other, and with an approximately 28 ft distance between each other. This arrangement would not meet the following sections of the Life Safety Code: 2012 NFPA 101: 7.5.1.3.1 exits, exit accesses, or exit discharges shall be arranged to minimize the possibility that more than one has the potential to be blocked by any one fire or other emergency condition. 2012 NFPA 101: 7.5.1.3.7, the balance of exits, exit accesses, or exit discharges shall be located so that, if one becomes blocked, the others are available. In the case that a fire or other emergency situation that would potentially block the access to said emergency exits occurs (e.g. at the middle of the corridor), residents and staff would need to use as means of egress the corridor where the width is reduced to 40 inches. On (MONTH) 04, 2025, at approximately 2:30 PM, the Owner stated that the architect is currently drawing plans, and they have not yet obtained permits from the local jurisdiction; further stating that the work will be most definitely done before the TLW expires on (MONTH) 01, 2025. On (MONTH) 05, 2025, at approximately 3:00 PM, the Owner stated that in order to modify the corridor width, they plan to adjust the lobby and remove a part of the wall, further stating that this will be done at the same time as the work in the ramp on the second floor is completed. On (MONTH) 06, 2025, at approximately 9:50 AM, the Administrator provided the CMS Time Limited Waiver letter. CMS letter dated 07/26/2024 states that a temporary waiver is for additional time to allow the facility to come into compliance with the prescriptive requirements for K271, which will allow the facility to pass an FSES and meet an equivalent level of safety as required by K161. The time limited waiver is set to expire on (MONTH) 01, 2025. The facility did not demonstrate substantial progress in addressing the deficiencies and conditions for which the time limited waiver was granted. On (MONTH) 10, 2024, at approximately 2:40 PM, post survey document review of The facility's Plan of Correction for tag K271 cited during the 01/23/2024 Life Safety Code survey included: -The cited deficiency relates to an existing second floor corridor ramp with an excessive ramp slope (greater than 1:12). The facility's operator contracted with an architectural firm to determine how to best reconfigure the existing ramp to achieve a code compliant slope of 1:12 or less. It was determined that to create an accessible ramp the facility will need to construct an addition to the facility to accommodate the level change via a ramp. A new time limited until 7/1/2025 is required to obtain local approval and construct the ramp addition. - It's anticipated that: Town approval will occur by 6/1/2024. Final construction drawings will be prepared between 6/1/2024 and 8/1/2024. Permits will be obtained by 11/1/2024. Construction will take place between 11/1/2024 and 7/1/2025. At time of survey, there was no evidence that any of the above milestones had been completed, neither that the construction phase was currently in progress. NFPA [PHONE NUMBER] NYCRR711.2(a)(1) 10 NYCRR 415.29In a post survey review conducted on (MONTH) 17, 2025, at approximately 3:00PM, it was determined that the facility did not provided evidence that the corridor adjacent to the Administrator's office which serves as means of egress and observed to be reduced to 40 inches in clear width; was widen to the 48 inches minimum, as required by 2012 NFPA 101: 19.2.3.4*. Specifically, the facility did not provide an approved CMS Time Limited Waiver. The facility was cited for the following during the 02/07/2025 recertification survey: 2012 NFPA 101: 19.2.7 Discharge from Exits. Discharge from exits shall be arranged in accordance with Section 7.7 2012 NFPA 101: 7.7.4 Components of Exit Discharge. Doors, stairs, ramps, corridors, exit passageways, bridges, balconies, escalators, moving walks, and other components of an exit discharge shall comply with the detailed requirements of this chapter for such components. 2012 NFPA 101: 7.2.5 Ramps. 2012 NFPA 101: 7.2.5.1 General. Every ramp used as a component in a means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.5. 2012 NFPA 101: 7.2.5.2 Dimensional Criteria. The following dimensional criteria shall apply to ramps: (2) Existing ramps shall be permitted to remain in use or be rebuilt, provided that they meet the requirements shown in Table 7.2.5.2(b), unless otherwise permitted by any of the following: (a) The requirements of Table 7.2.5.2(b) shall not apply to industrial equipment access areas as provided in 40.2.5.2. (b) The maximum slope or maximum height between landings for a single ramp run shall not apply to ramps providing access to vehicles, vessels, mobile structures, and aircraft. (c) Approved existing ramps with slopes not steeper than 1 in 6 shall be permitted to remain in use. (d) Existing ramps with slopes not steeper than 1 in 10 shall not be required to be provided with landings. Table 7.2.5.2(b) Existing Ramps Dimensional Criteria Feature ft/in. mm Minimum width 30 in. 760 Maximum slope 1 in 8 Maximum height between landings 12 ft 3660 2012 NFPA 101: 7.3.4 Minimum Width. 2012 NFPA 101: 7.3.4.1 The width of any means of egress, unless otherwise provided in 7.3.4.1.1 through 7.3.4.1.3, shall be as follows: (1) Not less than that required for a given egress component in this chapter or Chapters 11 through 43 (2) Not less than 36 in. (915 mm) where another part of this chapter and Chapters 11 through 43 do not specify a minimum width 2012 NFPA 101: 19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms. 2012 NFPA 101: 19.2.3.5 The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers. 2012 NFPA 101: 7.4.1.1 The number of means of egress from any balcony, mezzanine, story, or portion thereof shall be not less than two, except under one of the following conditions: 2012 NFPA 101: 7.5.1.1.2 Exit access corridors shall provide access to not less than two approved exits. 2012 NFPA 101: 19.2.4.1 The number of means of egress shall be in accordance with 7.4.1.1 and 7.4.1.3 through 7.4.1.6. 2012 NFPA 101: 19.2.4.2 Not less than two exits shall be provided on every story. 2012 NFPA 101: 19.2.4.3 Not less than two separate exits shall be accessible from every part of every story. 2012 NFPA 101: 7.5.1.3.1 Where more than one exit, exit access, or exit discharge is required from a building or portion thereof, such exits, exit accesses, or exit discharges shall be remotely located from each other and be arranged to minimize the possibility that more than one has the potential to be blocked by any one fire or other emergency condition. 2012 NFPA 101: 7.5.1.3.7 The balance of the exits, exit accesses, or exit discharges specified in 7.5.1.3.6 shall be located so that, if one becomes blocked, the others are available. Based on observations, record review and staff interviews, the facility did not ensure that mean of egress components were in accordance with the requirements of NFPA 101 Life Safety Code, 2012 Edition. Specifically: 1.A ramp located on the second floor did not comply with the dimensional criteria set forth in 2012 NFPA 101: 7.2.5.2. 2.A corridor located on the first floor, was not at least four-foot wide in accordance with 2012 NFPA 101: 19.2.3.4*. A CMS Time Limited Waiver to correct this issue is set to expire on July,01, 2025. At the time of survey, the facility did not demonstrate substantial progress in addressing the deficiencies and conditions for which the time limited waiver was granted. The findings are: On (MONTH) 04, 2025, at approximately 11:10 AM, during the Life Safety Code recertification survey, it was noted that the ramp located on the second floor between the Old Building and the New Wing contains a slope of 15 inches (height) in 10.3 feet (length). Per 2012 NFPA 101: 7.2.5.2 existing ramps are only permitted to be 1 inch in 8 feet. There was no work observed to be completed or in progress to address this issue, and for which a time limited waiver, set to expire on (MONTH) 01, 2025, was granted. On (MONTH) 04, 2025, at approximately 2:15 PM, on the first floor resident's West Wing, it was observed that the corridor (adjacent to Administrator's office) serving as exit access for five occupied resident sleeping rooms and one nurse office, was reduced to 40 inches in clear width. In addition, it was noted that at the other end of said corridor, there are two emergency exits located opposite one to the other, and with an approximately 28 ft distance between each other. This arrangement would not meet the following sections of the Life Safety Code: 2012 NFPA 101: 7.5.1.3.1 exits, exit accesses, or exit discharges shall be arranged to minimize the possibility that more than one has the potential to be blocked by any one fire or other emergency condition. 2012 NFPA 101: 7.5.1.3.7, the balance of exits, exit accesses, or exit discharges shall be located so that, if one becomes blocked, the others are available. In the case that a fire or other emergency situation that would potentially block the access to said emergency exits occurs (e.g. at the middle of the corridor), residents and staff would need to use as means of egress the corridor where the width is reduced to 40 inches. On (MONTH) 04, 2025, at approximately 2:30 PM, the Owner stated that the architect is currently drawing plans, and they have not yet obtained permits from the local jurisdiction; further stating that the work will be most definitely done before the TLW expires on (MONTH) 01, 2025. On (MONTH) 05, 2025, at approximately 3:00 PM, the Owner stated that in order to modify the corridor width, they plan to adjust the lobby and remove a part of the wall, further stating that this will be done at the same time as the work in the ramp on the second floor is completed. On (MONTH) 06, 2025, at approximately 9:50 AM, the Administrator provided the CMS Time Limited Waiver letter. CMS letter dated 07/26/2024 states that a temporary waiver is for additional time to allow the facility to come into compliance with the prescriptive requirements for K271, which will allow the facility to pass an FSES and meet an equivalent level of safety as required by K161. The time limited waiver is set to expire on (MONTH) 01, 2025. The facility did not demonstrate substantial progress in addressing the deficiencies and conditions for which the time limited waiver was granted. On (MONTH) 10, 2024, at approximately 2:40 PM, post survey document review of The facility's Plan of Correction for tag K271 cited during the 01/23/2024 Life Safety Code survey included: -The cited deficiency relates to an existing second floor corridor ramp with an excessive ramp slope (greater than 1:12). The facility's operator contracted with an architectural firm to determine how to best reconfigure the existing ramp to achieve a code compliant slope of 1:12 or less. It was determined that to create an accessible ramp the facility will need to construct an addition to the facility to accommodate the level change via a ramp. A new time limited until 7/1/2025 is required to obtain local approval and construct the ramp addition. - It's anticipated that: Town approval will occur by 6/1/2024. Final construction drawings will be prepared between 6/1/2024 and 8/1/2024. Permits will be obtained by 11/1/2024. Construction will take place between 11/1/2024 and 7/1/2025. At time of survey, there was no evidence that any of the above milestones had been completed, neither that the construction phase was currently in progress. NFPA [PHONE NUMBER] NYCRR711.2(a)(1) 10 NYCRR 415.29 | Plan of Correction: ApprovedApril 22, 2025 Pine(NAME)Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3.Pine(NAME)Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025 3a. The facility will require a time limited waiver for three years, ending 2/7/2028, to complete construction to widen the corridor to 48 inches minimum. The facility is currently investigating means to widen the existing first floor corridor as it is located between a masonry chimney and apparent bearing wall. The existing LRA shall be updated accordingly to include this work. It?ÇÖs anticipated that the LRA will be updated by 8/7/2025. Following LRA modification approval, construction drawings will be prepared by 2/7/2026. Local approvals are expected to be obtained by 8/7/2026. Construction is anticipated to be complete by 10/7/2027. Signoffs are anticipated to be complete by 2/7/2028. 3b. While the facility has a time limited waiver in place, upon further review of the existing conditions during production of construction drawings the Architect determined that the existing ramp slope is compliant. An existing ramp is permitted to have a maximum slope of 1:8, or 12.5%. The existing ramp was recorded to measure 15 inches in height and 10.3 feet in length. The existing ramp slope is calculated to be 12.14%, which is less than 12.5% maximum permitted. 3c. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. fire watches 2. additional fire drills 3. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. provide additional extinguishers 7. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required.?Ç¥ 8. During construction, facility will perform frequent observations of the work areas to monitor resident safety. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11. The Administrator is responsible for the correction of this deficiency by 4/1/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99: 6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. 2011 NFPA 70: 720.11 110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. 2011 NFPA 70: 110.27 Guarding of Live Parts. (A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. Based on observation and interviews, the facility did not ensure that live parts of electrical equipment were guarded against accidental contact, and electrical cables were kept in workmanlike manner in accordance with NFPA 70: National Electrical Code. The findings are: On (MONTH) 04, 2025, between 10:30 AM - 3:00 PM, during the Life Safety Code recertification survey the following was observed: -Electrical cables hanging by the wall, close to the ramp, in resident occupied area on the second floor. -Live electrical cables observed stored into a plastic bucket and out in the open in the former rehabilitation room in the basement, -Electrical cables hanging from the ceiling in the former rehabilitation room in the basement, On (MONTH) 05, 2025, at approximately 1:00 PM, the Director of Maintenance stated that the electrician will go to the facility the same week to fix the observed issues. 2012 NFPA 99: 6.3.2.1 2011 NFPA 70: 110.12, 110.27. 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMarch 6, 2025 Pine(NAME)Center for Rehabilitation and Healthcare Provides this Plan Of Correction. 1. No Residents were affected by this deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The electrical cables by the ramp have been covered and the facility will have the vendor onsite to discuss removing the cables. 4. They cables in the former Rehabilitation room have all been removed or covered up. 5. The EVS Director/designee will conduct an audit around the facility to identify any additional wiring that needs to be covered up. 6. The EVS Director will audit the facility every week for the first 4 weeks and then monthly for 3 months and then quarterly for up to a year to ensure all live electrical cables are covered. 7. The EVS Director/designee will present any findings in the quarterly QA/QAPI meetings. 8. The EVS Director/designee will be responsible to correct this deficiency |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101: 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 2012 NFPA 101: 4.7.4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 2012 NFPA 101: 4.7.6* A written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner. Based on document review and staff interview, the facility did not ensure that fire drills were held at unexpected times, and that written records included which emergency fire conditions were simulated during each fire drill in accordance with NFPA 101: Life Safety Code. Specifically, in six of 12 fire drills the condition that caused the simulated fire drill and fire alarm activation was not documented; and fire drills were conducted at similar times in two of three shifts. The findings are: On (MONTH) 05, 2025, at approximately 1:10 PM, during the document review part of the Life Safety Code Survey, record revision of the facility fire drill logs for the past 12 months revealed the following: 1. Three of four drills conducted in the morning shift, 7 AM - 3 PM, were performed at similar times. Two were held at 10:00 AM and the other one at 10:10 AM. 2. Four of four drills conducted in the night shift, 11 PM - 7 AM, were performed at similar times. Two were held between 6:00 AM - 6:15 AM; and the other two held between 11:00 PM - 11:30 PM respectively. 3. The drills conducted from (MONTH) 2024 to (MONTH) 2025, did not include the scenario simulated during the fire drill, as a result it could not be determined that the fire drills were conducted under varying conditions. On (MONTH) 06, 2025, at approximately 3:45 PM, during the exit interview, the Administrator and the owner acknowledged the findings. 2012 NFPA 101: 19.7.1.4*, 19.7.1.6, 4.7.4*, 4.7.6* 42CFR 483.90(a)(i) | Plan of Correction: ApprovedMarch 10, 2025 Pine(NAME)Center for Rehabilitation and Healthcare provides the following Plan Of Correction 1.No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. - The EVS Director will conduct fire drills along with scenarios for each fire drill on all three shifts and alternate the times within the shifts, as well as the dates within the month 4. The Administrator will review with the EVS Director the proposed times and dates of the fire drill to ensure the randomization of the dates and times that the fire drills are being conducted. 5.The Administrator will review the fire drill log book on a quarterly basis to ensure fire drills have been scheduled/conducted on random times/dates. 6.The Administrator will report the findings of his quarterly fire drill audit at the quarterly QA/QAPI meeting. 7.The Administrator and EVS Director will be responsible for the correction of this deficiency. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details 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: 4.3.1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. 2011 NFPA 25: 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. 2011 NFPA 25: 5.3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. 2011 NFPA 25: 5.3.4.3.2 If the test results indicate an incorrect freeze point at any point in the system, the system shall be drained, the solution adjusted, and the systems refilled. Based on document interview and staff interviews, the facility did not ensure that the sprinkler system was maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Specifically, sprinkler system components not tested or replaced at required time intervals, or corrective actions not provided when required. This was observed for the Sprinkler System serving the whole facility. The findings are: On (MONTH) 05, 2025, at approximately 2:30 PM, during the document review part of the Life Safety Code recertification survey, the following was noted for the Sprinkler System annual inspection records dated 06/17/2024: -Under Gauges Section: Gauge Date: 12/23/2019. -Under Easy Riser or Shotgun Systems Section and Wet System Section: Date of Gauge Replacement: 12/23/2019. There was no evidence that the gauges were replaced or tested every five years. In addition, the documentation provided for review did not include the anti-freeze test. On (MONTH) 06, 2025, at approximately 3:45 PM, during the exit interview, the Administrator acknowledged the findings and stated that they will call the sprinkler service company and request the test results. On (MONTH) 10, 2025, at approximately 12:44 PM, the Administrator submitted via email the antifreeze annual test results. The test dated 02/29/2024 included under work performed/resolution code the following: The emergency stairwell system did not test well with the freeze point of 29??. It is recommended that the stairwell system be drained and replenished. No additional document was provided for review to verify that a corrective action following the recommendations suggested by the vendor, and in accordance with 2011 NFPA 25: 5.3.4.3.2 for the antifreeze test results was performed; and that the gauges were tested or replaced every five years. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 4.3.1*, 5.3.2.1, 5.3.4*,5.3.4.3.2 42CFR 483.90(a)(i) | Plan of Correction: ApprovedMarch 11, 2025 Pine(NAME)Center for Rehabilitation and Healthcare provides the following Plan of correction. 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The facility has a signed quote for the gauge testing/replacement the vendor will be onsite to preform the 5 year/gauge inspection/replacement. 4. The Administrator will coordinate with the EVS Director/vendor to conduct retesting of the emergency stairwell freeze point and drain and replenish if needed. 5. The vendor will be onsite 3/20/2025 to conduct all necessary testing/replacements 6. The facility has created an alert in our maintenance portal to alert when the facility is due for testing. 7. The EVS Director/designee will coordinate with vendor to schedule/conduct any further required testing. director of Maintenance. 8. The EVS Director/designee will call the vendor and have them come down to and inspect the emergency stairwell system and they will preform any necessary work and rested once the work is completed. 9. The EVS Director/designee will report any findings at the quarterly QA/QAPI meetings. 10. The EVS Director/designee are responsible to correct this deficiency |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 7, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 713-1.9 Mechanical requirements. (e) Toilet rooms and physical therapy rooms shall have mechanical exhaust or window exhaust fan with back-draft louvers or, if approved by the department, operable windows which can be used for ventilation. 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. (c) All floor, ceiling and wall surfaces shall be easily cleanable, and designed for the maintenance of a comfortable, sanitary environment for each resident. This shall not apply to ceilings in boiler rooms, mechanical and building equipment rooms, administration and similar spaces that are not typically occupied by residents. Based on observations, staff interviews, and record reviews, the facility did not ensure that the facility was constructed and maintained to provide a comfortable, sanitary environment for each resident. Specifically, exhaust fans, wall surfaces observed in disrepair, and corridors not equipped with firmly secured handrails. This was observed in two of four nurse units within the facility. The findings are: On (MONTH) 04, 2025, at approximately 10:40 AM, the Director of Maintenance, stated that housekeeping staff clean the residents' rooms, toilets and floors every day in the morning starting at 8:30AM, and in the afternoon; and additional cleaning is done as needed, further stating that housekeeping rounds are done daily but not recorded. On (MONTH) 04, 2025, between 10:30 AM - 3:00 PM, the following was observed: -In the South Wing on the second floor, peeling paint was observed on corridor walls along the corridor, and in the corners of door frames of residents' rooms, and by the elevator. - In the South Wing on the second floor, the exhaust fan in nurse station's toilet and in resident's room [ROOM NUMBER] were not working. -In the West Unit on the second floor, the handrail by the ramp was observed not firmly secured. -On the first floor, resident room [ROOM NUMBER] observed with peeling paint around window frame and stained ceiling tiles. The Administrator, who was present at time of observations, stated that they are planning to repaint the peeling paint across the corridor, and in resident rooms in a couple of weeks. On (MONTH) 06, 2025, at approximately 10:15 AM, the Director of Maintenance stated that they do walk throughs the facility every day and look for issues that need to be fixed like windows' shades, peeling paint on walls. Further stating that is in the process of implement a form with list of duties, and that environmental staff is trained every three months in their duties and how to do them. On (MONTH) 06, 2025, at approximately 11:00 AM, document review of task list included as duties: Clean, sweep, mop all rooms, restrooms with time Start and End of shift. Cleans up/sanitizes any messes that occur during shift 12-4:On unit & 4-8: Entire Facility. On (MONTH) 06, 2025, at approximately 3:45 PM, during the exit interview, the Administrator and the Owner acknowledged the findings, and stated that they are planning in renovate the second floor in a couple of months, including painting the walls, but no definitive date is still set for the project. 713-1.9 (e) 713-1.8 (a) (c) | Plan of Correction: ApprovedMarch 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME)Center For rehabilitation and Healthcare Provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. The toilet in room [ROOM NUMBER] has been repaired by the maintenance team. 4. The maintenance team has started plastering/repainting/repairing the entire second floor 5. The handrail by the ramp has been readjusted and tightened to ensure it is firmly secured. 6. room [ROOM NUMBER] has been plastered and repainted and stained ceiling tiles have been replaced. 7. Exhaust fan for the second floor bathroom was purchased and was installed by the maintenance team 8. The EVS Director inserviced all his staff on the facilities policy on high dusting 9. Audits will be conducted every week for the first 4 weeks and monthly for the next 3 months to ensure high dusting is completed 10. The EVS Director/designee will ensure any items put into the facilities maintenance system are immediately addressed. 11. The EVS Director will report any findings at the quarterly QA/QAPI Meetings. 12. The EVS Director will be responsible of the correction of this deficiency. |