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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: May 8, 2025
Citation Details None | Plan of Correction: ApprovedMay 9, 2025 Step 1: Staff assigned to resident # 96 received disciplinary memo issued by the DON regarding ADL care including removal of facial hair as indicated. Resident # 96's facial hair was removed on 4/24/ 25. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to resident ADL care. A full house review of all residents ADL care was conducted by the Administrative Nursing team. Issues noted were immediately addressed. Step 3: All Nursing staff will be re-educated by the RN Educator regarding ADL care. Education will include the need to remove facial hair (including female residents) .Licensed Nurses will complete a post test R/T ADL care to ensure understanding of information presented. CNAs were not required to complete a post test; participation by CNAs in discussion regarding ADL care was encouraged. ADL policy was reviewed by the Director of Clinical Operations with no revisions required. When possible, a hygiene aide will be assigned to specific units; this aide will be responsible for shaves, nails and other hygiene measures as assigned. Step 4: The DON/Admin/designee will conduct daily ADL rounds of each Unit x 6 weeks. These rounds will be conducted with two members of leadership; rounds will ensure that hygiene measures including removal of facial hair is completed. Issues noted will be immediately addressed. The Unit Managers/designees will perform 7 resident ADL audits Q week x 8 Weeks Audits will ensure that ADL care including removal of facial hair is completed. Issues noted will be immediately addressed. Results of daily and weekly audits will be reviewed with the QAPI Committee for input. The Director of Nursing is responsible for this plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: May 8, 2025
Citation Details None | Plan of Correction: ApprovedMay 9, 2025 Step 1: Staff assigned to resident # 96 received disciplinary memo issued by the DON regarding ADL care including removal of facial hair as indicated. Resident # 96's facial hair was removed on 4/24/ 25. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to resident ADL care. A full house review of all residents ADL care was conducted by the Administrative Nursing team. Issues noted were immediately addressed. Step 3: All Nursing staff will be re-educated by the RN Educator regarding ADL care. Education will include the need to remove facial hair (including female residents) .Licensed Nurses will complete a post test R/T ADL care to ensure understanding of information presented. CNAs were not required to complete a post test; participation by CNAs in discussion regarding ADL care was encouraged. ADL policy was reviewed by the Director of Clinical Operations with no revisions required. When possible, a hygiene aide will be assigned to specific units; this aide will be responsible for shaves, nails and other hygiene measures as assigned. Step 4: The DON/Admin/designee will conduct daily ADL rounds of each Unit x 6 weeks. These rounds will be conducted with two members of leadership; rounds will ensure that hygiene measures including removal of facial hair is completed. Issues noted will be immediately addressed. The Unit Managers/designees will perform 7 resident ADL audits Q week x 8 Weeks Audits will ensure that ADL care including removal of facial hair is completed. Issues noted will be immediately addressed. Results of daily and weekly audits will be reviewed with the QAPI Committee for input. The Director of Nursing is responsible for this plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Onsite Post Survey Revisit #1, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (1) (Resident #96) of three (3) reviewed. Specifically, the resident did not have facial hair removed as planned. This is a continuing deficiency from the standard survey with an exit date of 2/13/ 25. The policy and procedure titled Activities of Daily Living (ADL) Care and Support dated 2/28/2025 documented that the facility shall provide residents with Activities of Daily Living (ADL) care and support in accordance with current standards of practice, State and Federal regulations and are based on the resident's assessed needs, personal preference, and goals of care. Resident #96 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 2/8/2025 documented Resident was cognitively intact, understood by others, understands others, and required supervision or touch assistance for personal hygiene including shaving. The comprehensive care plan dated 2/20/2024 documented Resident #96 required assistance with self-care. The care plan documented the resident preferred to have their facial hair shaven. Observation on 4/24/2025 at 8:44 AM, Resident #96 had several one inch long, white hairs on the right side of their chin. Further observation noted other white hairs of various lengths on Resident #96's on their chin. During this observation, Resident #96 stated it bothered them to have long hairs on their chin and they wanted someone to shave them. During an interview on 4/24/2025 at 8:55 AM, Certified Nurse Aide #1 stated that if a resident had on their care plan they were to be shaved, then staff should be following the care plan. Certified Nurse Aide #1 observed Resident #96 and stated their chin hairs needed to be shaved. During an interview on 4/24/2025 at 9:05 AM, the Director of Nursing stated staff should honor residents' preferences. At this time, the Director of Nursing observed Resident #96 and stated the resident needed to be shaved. During an interview on 4/24/2025 at 1:36 PM, the Administrator stated that they were doing care audits, and this should have been caught. They stated the resident's preference to be shaved should have been honored. A Quality Assurance and Performance Improvement (QAA) committee interview was conducted on 4/24/25 at 2:40 PM with the Administrator, Director of Nursing, Regional Registered Nurse and the Director of Clinical Services present. The Director of Nursing stated the team thought the plan of corrections for F677 was effective and they do not know why the residents were not asking to be shaved. The Administrator added the facility staff should also be offering the resident the choice to be shaved. 10 NYCRR 415. 12(a)(3) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details Based on observation and interview during an Onsite Life Safety Code Post Survey Revisit #1 completed on 4/24/25, structural components of the facility were not properly protected from fire. The structural support web truss system and steel beams located above the lay-in style ceiling assembly were not protected to meet minimum acceptable fire rated building construction classification. This affected three (first, second, and third floors) of three resident use floors in the front building. This is a continuing deficiency from the standard survey with an exit date of 2/13/ 25. The finding is: The minimum acceptable construction types for the three-story front building are type II(222) or type II(111) per the 2012 edition of the National Fire Protection Association (NFPA) 101: Life Safety Code and the 2012 edition of NFPA 220: Standard on Types of Building Construction. Construction type II(111) requires that the building be protected by a complete automatic sprinkler system and that structural components are protected by a one-hour fire rated barrier. Construction type II(222) requires that building structural components are protected by a two-hour fire rated barrier. Observations in the front building on 4/23/25 from 8:45 AM to 1:30 PM revealed it was protected by a complete automatic sprinkler system. Observations above the ceiling tiles in the front building on 4/23/25 from 1:11 PM to 1:29 PM revealed the ceiling tiles on the first, second, and third floors were comprised of an unrated lay-in ceiling assembly. Additional observations at this time revealed there were unprotected structural steel beams and steel web truss assemblies on the first, second, and third floors. During an interview on 4/23/25 at 1:16 PM, the Maintenance Director stated there had been no changes to the beams, trusses, or the ceiling tile assembly since the facility's last Life Safety Code survey. During an interview on 4/23/25 at 2:16 PM, the Administrator stated there had been no changes to the beams, trusses, or the ceiling tile assembly since the facility's last Life Safety Code survey. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 1. 6. 1. 8. 2. 1, 8. 2. 1. 2 2012 NFPA 220: 4. 1 2013 NFPA 101A: Guide on Alternative Approaches to Life Safety | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 4/24/25, the facility did not ensure that in accordance with accepted professional standards and practices, they maintained medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized for three (3) (Resident #2, #16 and #127) of eleven residents reviewed. Specifically, treatment orders for PICC line (peripherally inserted central catheter) dressing changes and measurements of their arm circumference were not documented as completed and the orders did not include external migration (displacement) measurements (#2). Additionally, Resident #16 and Resident #127 did not have physician orders [REDACTED]. The findings are: The policy and procedure titled Documentation and Charting dated 1/20 documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications, services performed, etc., must be documented in the clinical records. The facility utilizes an electronic health record for clinical documentation. The policy and procedure titled [MEDICAL TREATMENT] Management dated 5/19 documented the nurse will obtain orders for monitoring of site and interventions as appropriated. Orders are to include [MEDICAL TREATMENT] center, location, contact number and scheduled days. 1. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date 2/13/25 revealed the facility was cited for the lack of physician orders [REDACTED]. Per the facilities plan of corrections all residents were reviewed to ensure there was physician orders [REDACTED]. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 3/27/25 documented Resident #2 was cognitively intact, understands, and was understood. The assessment tool documented Resident #2 was on intravenous (IV) medications. Review of the medical providers orders active orders dated 3/27/25 to measure arm circumference (X) inches above insertion on admission and weekly and apply an [MEDICATION NAME] intravenous (IV) dressing weekly on the day shift with a start date 3/26/ 25. Additionally, the orders with last review date of 4/3/25 did not include an order to measure their peripherally inserted central catheter length measured from insertion site to tip of hub (migration/displacement measurement) as per the plan of correction. The treatment administration record dated 4/1/25 - 4/30/25 documented Resident #2's arm circumference was to be measured above insertion site weekly on 4/3/25, 4/10/25 and 4/17/ 25. There was no documented evidence the resident's arm circumference measurement was completed, and the record was blank. The arm circumference did not indicate the inches above the insertion site to measure the arm circumference and an x was documented. In addition, the PICC line dressing ([MEDICATION NAME] intravenous dressing) was to be changed weekly on 4/3/25, 4/10/25 and 4/17/ 25. There was no documented evidence the dressing change was completed, and the record was blank. During an observation on 4/23/25 at 11:01 AM, Resident #2 was in bed and had a PICC line (peripherally inserted central catheter) inserted in their right upper arm. The peripherally inserted central catheter dressing was intact but was not dated. During an interview at the time of the observation Resident #2 stated they had received (IV) intravenous medication but they thought the medication was completed. They stated staff had been changing the dressing to the intravenous (IV) site. During an interview on 4/24/25 at 1:40 PM, Registered Nurse Educator #1 stated for the past couple weeks they had been doing the weekly PICC line dressing changes, measuring arm circumferences, and measuring the lengths on all of the intravenously (IV) lines in the facility. They stated they were not necessarily responsible for completing those treatments but since they have been the Registered Nurse in the building, they had been doing them. Registered Nurse Educator #1 stated they had measured Resident #2's arm circumference weekly and changed the resident's PICC (peripherally inserted central catheter) line dressing weekly but had not signed off them off as completed in the electronic treatment record. They stated they had been multitasking and did not go back into the treatment record to sign them off as completed but they should have. Registered Nurse Educator #1 stated Resident #2's order for arm circumference just had an x to indicate the centimeters of Resident #2 arm circumference but there should have been the actual number in centimeters documented. During an interview on 4/24/25 at 2:00 PM, the Director of Nursing stated treatments should be documented as completed in the treatment record. They stated Resident #2 had an incomplete treatment administration record. The Director of Nursing stated they did not see an order for [REDACTED]. They stated they were responsible for the initial peripherally inserted central catheter orders for Resident #2 and must have omitted or unclicked the batch order for it. They stated that every resident should have had an order to measure the peripherally inserted central catheter length from insertion site to tip of hub per the facilities plan of corrections. During an interview on 4/24/25 at 2:56 PM, the Administrator stated their expectation would be that all treatments were completed as ordered and were signed off as given in the resident's medical record. If the treatments were not documented as completed it would be an incomplete record. 2a. Resident #16 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #16 was cognitively intact and received [MEDICAL TREATMENT] treatments The Comprehensive Care Plan initiated 11/20/24, documented Resident #16 had impaired renal function related to end stage renal (kidney) disease. The care plan did not include goals and interventions for [MEDICAL TREATMENT]. Review of the Visual/Bedside Kardex Report (guide used by staff to provide care) dated 4/24/25 revealed there was no documented evidence that Resident #16 received [MEDICAL TREATMENT] treatments. The Treatment Administration Record dated 4/1/25 - 4/30/25 documented the nurses monitored a Permacath/Central Catheter (flexible tube inserted into a large vein in the neck or chest) for signs of bleeding and placement every shift for [MEDICAL TREATMENT]. There was no documented evidence on the Treatment Administration Record that included the frequency and scheduled days of [MEDICAL TREATMENT] treatments. Review of the Order Listing Report (physician's orders [REDACTED].#16 to receive [MEDICAL TREATMENT] treatments. During an interview on 4/23/25 at 11:52 PM, Licensed Practical Nurse #6 stated residents who received [MEDICAL TREATMENT] should have a physician's orders [REDACTED]. They stated Resident #16 went to [MEDICAL TREATMENT] two times a week. During an interview on 4/24/25 at 1:52 PM, Licensed Practical Nurse Manager #3 stated that all residents who received [MEDICAL TREATMENT] should have a physician's orders [REDACTED]. Licensed Practical Nurse Manager #3 reviewed Resident #16's physician orders [REDACTED]. They stated Resident #16 had an order for [REDACTED]. b. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date 2/13/25 revealed the facility was cited lack of ongoing monitoring upon leaving the facility and returning from [MEDICAL TREATMENT]. Per the facilities plan of correction Resident #16's communication book was updated with current medication list and a full house review of all the residents receiving [MEDICAL TREATMENT] communication binders were to be reviewed. Review of Resident #16's [MEDICAL TREATMENT] communication binder on 4/24/25 at 12:29 PM revealed the Order Summary Report in Resident #16's binder reflected active orders as of 1/28/25 and did not include their correct type of [MEDICAL TREATMENT] site (Permacath -a flexible tube inserted into a large vein in the neck or chest), or current [MEDICAL TREATMENT] days. During an interview on 4/24/25 at 1:36 PM, Licensed Practical Nurse Manger #3 stated every resident would have their own [MEDICAL TREATMENT] binder that include a copy of their face sheet, physician orders, and [MEDICAL TREATMENT] communication forms. They stated the [MEDICAL TREATMENT] binders should be updated anytime there was a change to the resident' s physician orders. Licensed Practical Nurse Manager #3 stated they were responsible to update orders in the binders, this was important for the [MEDICAL TREATMENT] center to be aware of the resident's current physician orders. 3a. Resident #127 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that Resident #127 was cognitively intact and received [MEDICAL TREATMENT] treatments. The Comprehensive Care Plan initiated 8/1/24 documented Resident #127 needed [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION] three times a week. Interventions included (but not limited to) monitor/document any signs of infection to access site; monitor Permacath site for bleeding and placement; and to encourage Resident #1 to go to their scheduled [MEDICAL TREATMENT] appointments. Review of the Visual/Bedside Kardex Report dated 4/24/25 revealed there was no documented evidence that Resident #127 received [MEDICAL TREATMENT] treatments. Review of the Treatment Administration Record dated 4/1/25 - 4/30/25 revealed nurses documented they monitored Resident #127's Permacath/Central Catheter for signs of bleeding and placement every shift for [MEDICAL TREATMENT]. There was no documented evidence on the Treatment Administration Record that included the frequency and scheduled days of [MEDICAL TREATMENT] treatments. The Order Listing Report (physicians orders) that included active, completed, and discontinued physician orders, revealed there was no active order in place from 3/18/25 - 4/24/25 for Resident #127 to receive [MEDICAL TREATMENT] treatments three times a week. During an interview on 4/24/25 at 12:05 PM, Licensed Practical Nurse #7 stated there should be an order in the electronic medical record documenting what days residents went to [MEDICAL TREATMENT]. Licensed Practical Nurse #7 stated Resident #127 received [MEDICAL TREATMENT] three times a week. During an interview on 4/24/25 at 1:53 PM, the Director of Nursing stated they would expect all residents who received [MEDICAL TREATMENT] to have a physician's orders [REDACTED]. The Director of Nursing reviewed Resident #16 and Resident #127's physician's orders [REDACTED]. They stated Resident #16 and Resident #127's order for [MEDICAL TREATMENT] had not been re-activated upon readmission to the facility and should have been. During an interview on 4/24/25 at 1:55 PM, the Director of Clinical Operations stated [MEDICAL TREATMENT] orders were expected to be obtained on admission/re-admission specifying treatment and frequency. They stated both Resident #16 and Resident #127 should have had a physician's orders [REDACTED]. b. Review of Resident #127's [MEDICAL TREATMENT] communication binder on 4/24/25 at 9:14 AM revealed the Order Summary Report in Resident #127's binder reflected active orders as 1/28/ 25. During an interview on 4/24/25 at 1:53 PM, the Director of Nursing stated the [MEDICAL TREATMENT] binders would need to be updated if there was a change to the resident's schedule or when mediation changes occurred. The Director of Nursing stated the Order Summary Report dated 1/28/25 for Resident #16 and Resident #127 was not current had would have expected the Unit Managers to have updated both residents' [MEDICAL TREATMENT] binders with a current medication list. Further interview at 3:19 PM, the Director of Nursing stated all Unit Managers were educated regarding the plan of correction and were aware of what information needed to be included in each [MEDICAL TREATMENT] binder. They stated the Unit Managers were responsible to update each [MEDICAL TREATMENT] binder and that they were responsible to ensure the plan of correction was completed. The Director of Nursing stated a new medication list should have been printed and added to Resident #16 and Resident 127's [MEDICAL TREATMENT] binders on re-admission. NYCRR 10 415. 22(a) (1-4) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: April 24, 2025
Corrected date: May 8, 2025
Citation Details None | Plan of Correction: ApprovedMay 9, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Step 1: No adverse effect was noted to resident # 2 related to lack of documented PICC line dressing change and PICC line measurements. Resident # 2 was seen by provider on 4/26/25 and PICC line was removed at that time. The RN Educator was issued a medication error form by the DON on 4/23/25 for failure to document PICC line dressing change and measurements. MD orders for specific [MEDICAL TREATMENT] days, times and location for residents # 16 and 127 and were obtained and entered in to the record on 4/28/ 25. Updated MD orders for residents # 16 and 127 were added to the [MEDICAL TREATMENT] binders on 5/1/ 25. Administrative Nursing staff including DON and RN Educator were counseled by the Director of Clinical Operations regarding [MEDICAL TREATMENT] Policy & procedures and PICC line monitoring including arm circumference and PICC line catheter length. Step 2: A QAPI meeting was held on 4/28/25 to discuss ongoing non-compliance related to resident PICC line monitoring documentation and [MEDICAL TREATMENT] protocols. There are currently no residents with PICC lines in facility. A full house review of all residents receiving [MEDICAL TREATMENT] was completed to ensure that all [MEDICAL TREATMENT] residents have updated MD orders in [MEDICAL TREATMENT] binder, and that all have MD order for [MEDICAL TREATMENT] location, dates and times. Any issues noted were addressed. Step 3: An IV binder will be initiated for residents that have PICC lines and or receive IV antibiotics and or IV flushes. This binder will act as a quick reference guide for facility RNs. Binder will include copy of MAR/TAR to ensure that RNs are aware of days/times for PICC line medications, dressing changes and PICC line measurements. IV Binder will be updated as needed. All licensed Nurses will be re-educated on PICC line policy/protocol by the RN Educator/DON/Consultant including the need to ensure MD orders for PICC line monitoring and dressing changes are accurate and completions are documented. PICC line post test will be completed by all licensed nurses to ensure understanding of information. The [MEDICAL TREATMENT] and PICC line policies were reviewed by the Regional Director of Clinical Services with no revisions required. All licensed nurses will be re-educated by the RN Educator regarding [MEDICAL TREATMENT] policy and procedures including having updated MD orders in the [MEDICAL TREATMENT] binders and obtaining MD orders for resident [MEDICAL TREATMENT] location, days and times. All licensed nurses will complete a post test to ensure understanding of information presented. Newly hired nurses will be educated on [MEDICAL TREATMENT] and PICC length polices and will be required to complete the post test. Step 4: All residents with PICC lines will be reviewed at morning meeting x4; review will confirm that all orders for PICC lines are transcribed correctly and include arm circumference, catheter length and dressing changes. Any issues will be immediately addressed. The DON will audit all resident PIC lines weekly x 8 weeks. Audits will ensure that MD order for site monitoring includes catheter length and arm circumference and that dressing changes are documented as ordered. Any issues noted will be immediately addressed. Resident [MEDICAL TREATMENT] binders will be brought to morning meeting for IDT team review x 4 weeks. This review will ensure that all [MEDICAL TREATMENT] binders have accurate and updated information. Issues noted will be immediately addressed. The DON/designee will complete a [MEDICAL TREATMENT] audit of 5 residents weekly x 8 weeks. Audit will ensure that residents receiving [MEDICAL TREATMENT] have MD order for location, days and times for [MEDICAL TREATMENT] and current MD orders in individual [MEDICAL TREATMENT] binders. Issues identified will be immediately addressed The results of the reviews/audits will be shared with the QAPI Committee for review and input. The Consultant will attend the Monthly QAPI Commitee meetings x 3 months to ensure ongoing compliance. |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: March 31, 2025
Citation Details None | Plan of Correction: ApprovedMay 20, 2025 The facility had an FSES completed prior which indicated that the facility was in compliance with NFPA [PHONE NUMBER] 19 1. 6. 1 equivalency. However, due to the passage of time the facility will be conducting a new FSES to be performed in accordance with CMS survey and certification memo 17-15-LSC. The FSES was conducted on 3/10/ 25. All residents had the potential to be affected. No other life safety functions were affected. The facility will in-service the maintenance director on fire safety maintenance such as identification of any potential fire safety concerns or potential for unsafe or hazardous conditions. The Maintenance Director will be educated on the results of the FSES and on the requirement to ensure the facility is in compliance with NFPA [PHONE NUMBER] 19 1. 6. 1 Facility also intends to maintain compliance by utilizing an FSES for equivalency as necessary for future recertification's as applicable. An audit tool was created to ensure all items listed in the upcoming FSES are in place. Audits will be conducted monthly x 4. The results of the FSES, the requirement for a passing FSES and the results of the audits will be discussed at QAPI. The Administrator/Designee is responsible for this plan |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 7/15/24, the facility did not comply with emergency preparedness requirements. Specifically, the written emergency preparedness plan was not reviewed and updated at least annually. This had the potential to affect all staff and residents on four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1a. Review of the facility's red binder titled EOP revealed it contained a New York State Department of Health Comprehensive Emergency Management Plan Template and other various facility documents related to emergency preparedness. The Comprehensive Emergency Management Plan Template was approved for implementation by the former Administrator, former Director of Nursing, and the Maintenance Director, as indicated by their signatures dated 11/7/22 and 11/8/ 22. During an interview on 7/11/24 at 1:15 PM, the Administrator stated they had worked at this facility for three and a half months. They stated they had not reviewed the emergency preparedness binder since becoming the Administrator and their predecessor likely did review it in the last year, but they could not locate any proof or signatures. 1b. Review of the facility documents in the red binder titled EOP revealed it contained a sheet titled Disasters Other Than Fire, which appeared to be a table of contents for Chapter 6 pages that ranged from Agents of Terrorism on page 6. 3 to Carbon Monoxide Emergency on page 6. 144. Further review revealed no Chapter 6 pages were present. During an interview on 7/11/24 at 1:43 PM, the Administrator stated they did not know where any of the documents from the Chapter 6 table of contents were located. 1c. Further review of the red binder revealed it contained a document titled Procedures to be Followed in the Event of Interruption of Utility Services which stated the facility's generator was located outside of the building near the Director of Nursing office and it powered hall lights, hall plugs, nurse call system, fire exit signs, fire and smoke detection system, refrigeration, and boiler. During an interview on 7/11/24 at 1:45 PM, the Administrator stated the facility's generator was located inside the Mechanical Room, and if the location listed was wrong, they could not be certain that the list of what the generator covered was accurate. 1d. Further review of the red binder revealed it contained a document titled Severe Weather Policy from a sister facility. During an interview on 7/11/24 at 1:46 PM, the Administrator reviewed the document at this time and stated the sister facility's Severe Weather Policy was consistent with this facility's policy, but the name must be changed. 1e. Further review of the red binder revealed it contained a sheet titled Emergency Lists Contents, which appeared to be a table of contents for Chapter 7 pages that ranged from Disaster Kit Contents on page 7. 2 to Transportation Resources on page 7. 30. Some of these documents were present in the binder, and some were not. 1f. Further review of the red binder revealed it contained a sheet titled Emergency Preparedness, which stated a copy of the Emergency Preparedness Plan Summary will be placed in the admission packet for residents and/or their family/representative to sign and a copy will also be laminated and posted by the entrance at each facility. During an interview on 7/11/24 at 1:40 PM, the Administrator looked in the admission packet and stated they could not locate the document. Additionally, observation on 7/11/24 revealed a copy was not located at the entrance to the facility. 1g. Further review of the red binder revealed it contained a document titled Equipment served by Natural Gas which referred to the south building. During an interview on 7/11/24 at 1:57 PM, the Administrator stated they were not sure what the south building was referring to. During an interview on 7/11/24 at 1:58 PM, the Administrator stated the binder needed some updates. 42 CFR 483. 73-Emergency Preparedness 42 CFR: 483. 73(a) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: N/A
Corrected date: April 2, 2025
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 24, 2025
Corrected date: April 2, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |