Latta Road Nursing Home East
January 17, 2025 Complaint Survey

Standard Health Citations

FF15 483.35(d)(4)-(6):NURSE AIDE REGISTRY VERIFICATION, RETRAINING

REGULATION: § 483. 35(d)(4) Registry verification. Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless- (i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or (ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered. § 483. 35(d)(5) Multi-State registry verification. Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual. § 483. 35(d)(6) Required retraining. If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: March 16, 2025

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, during an abbreviated Life Safety Code survey, it was noted that the healthcare facility was not in compliance with the building construction type requirements. The existing health care facility was observed to be a Type II (000) construction for a building that is greater than two stories in height. The facility did not demonstrate substantial progress in addressing this issue in accordance with the conditions for which a time limited waiver was previously granted. A Time Limited Waiver for this issue expired on ,[DATE]/ 2023. The findings are: 1. In an interview on [DATE] the Director of Environmental Services stated that the facility did not conduct any physical alteration of the building to come into compliance with the prescriptive requirements nor achieving a passing score on the 2013 FSES. 2. The Director of Environmental Services further stated that the facility's Architect and Contractor would be installing a fire rated ceiling assembly to come into compliance with the prescriptive requirements moving forward. 3. The facility's Plan of correction from the [DATE] recertification in part stated that The facility will engage an architect to determine the rating of the current ceiling assembly, complete a FSES and/or provide the facility with a permanent solution to meet the requirements of the Life Safety Code. The facility submitted a time limited waiver to the NYSDOH . on[DATE] to provide time for the architect to complete the assessment, provide a permanent solution to meet the requirements and implement the solution. 4. A review of the NYSDOH records revealed that the facility was granted a time limited waiver in effect until [DATE] to remedy this issue via the prescriptive requirement or by achieving a passing score on the 2013 FSES. 5. The facility was cited for the following during the [DATE] Life Safety Code recertification survey: Based on observation, staff interview, and record review, during the Life Safety Code recertification survey, the existing health care facility was observed to be a Type II (000) construction for a building that is greater than two stories in height. The nursing home building is noted to be three stories with a basement. The findings are: During the Life Safety Code inspections on [DATE], [DATE], and [DATE] between 8:30am and 4:45pm, multiple observations made during the survey of the three-story building revealed that a fire-resistant rated ceiling assembly had not been maintained or could not be verified. For example, unprotected lighting fixtures assemblies were incorporated in the drop ceilings in the basement and on the 3rd, 2nd, and 1st floors. The steel structural members (i.e., joists) in the building were not provided with fire proofing. The lack of adequate fire proofing on steel structural members or not having a fire resistance rated ceiling assembly would mean that this building would be considered a Type II (000) Unprotected, Non-combustible structure. The Life Safety Code prohibits existing health care occupancies from utilizing buildings of Type II (000) construction that are more than two stories in height. At the Life Safety Code exit conference on [DATE] at 4:15pm, the Administrator and Director of Maintenance were both made aware of the building construction type issue. 10 NYCRR 415. 29 10 NYCRR 711. 2(a)(1) 2012 NFPA 101: 19. 1. 6. 1. 8. 2. 1, 8. 2. 1. 2 2012 NFPA 220: 4. 1. 6

Plan of Correction: ApprovedFebruary 7, 2025

1. CNA #4 was terminated from the facility effective 10/15/ 2024. 2. An audit of all CNAs certification at the facility was completed and reviewed. The were no other CNAs that did not have an active C.N.A certificate. Completed: 1/2/2025 3. The facility has reviewed the facility policy on C.N.A renewal and there has been no changes. A spreadsheet is sent to this Director of Nursing and the Administrator that automatically populates notification 45 day prior to the expiration date. 4. All renewed C.N.As will be reported to the Quality assurance team for 3 months then quarterly thereafter to ensure that all Certification renewals are completed timely Responsible party: Business office