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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 19, 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 from 03/12/2025 to 03/19/2025, the facility did not ensure that each resident was offered the COVID-19 immunization. This was observed in 5 of 5 residents (Residents #11, #23, #57, #84, #93) sampled for Immunizations out of a total of 26 sampled residents. Specifically, there was no documentation related to the screening, administration or declination, and education on the COVID-19 immunizations for Residents #11, #23, #57, #84, and # 93. The findings include: The facility policy titled COVID-19 Vaccination Administration for Residents last reviewed 10/14/2024 documented that the facility will provide all residents and representatives with education regarding the COVID-19 vaccination. The resident/representative decision to accept or decline the COVID-19 vaccination will be documented in the COVID Vaccination Care Plan. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #11 had severe cognitive impairments. It also documented that Resident #11's COVID-19 immunization status was up to date. The facility was unable to provide documented evidence that Resident #11's COVID-19 immunization status was up to date, or that they were offered and educated on the COVID-19 immunization. Resident #23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #23 had moderate cognitive impairments. It also documented that Resident #23's COVID-19 immunization status was up to date. The facility was unable to provide documented evidence that Resident #23's COVID-19 immunization status was up to date, or that they were offered and educated on the COVID-19 immunization. Resident #57 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #57 had moderate cognitive impairments. It also documented that Resident #57's COVID-19 immunization status was up to date. The facility was unable to provide documented evidence that Resident #57's COVID-19 immunization status was up to date, or that they were offered and educated on the COVID-19 immunization. Resident #84 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #84 had severe cognitive impairments. It also documented that Resident #84's COVID-19 immunization status was up to date. The facility was unable to provide documented evidence that Resident #84's COVID-19 immunization status was up to date, or that they were offered and educated on the COVID-19 immunization. Resident #93 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #93 had severe cognitive impairments. It also documented that Resident #93's COVID-19 immunization status was up to date. The facility was unable to provide documented evidence that Resident #93's COVID-19 immunization status was up to date, or that they were offered and educated on the COVID-19 immunization. On 03/17/2025 at 11:19 AM, the Infection Preventionist was interviewed and stated that the Director of Nursing is responsible for monitoring resident immunization statuses within the facility. On 03/17/2025 at 11:24 AM, the Director of Nursing was interviewed and stated that the facility offers residents immunizations for COVID-19, Influenza, Pneumococcal, and Respiratory [MEDICAL CONDITION]. The Director of Nursing stated that a nurse who was no longer employed by the facility had previously been responsible for monitoring resident immunization statuses and after that employee left the facility, it became the Director of Nursing's responsibility. The Director of Nursing stated that due to the personnel transition, they fell behind on maintaining their immunization program and that was why the sampled residents were not up to date on their immunizations. 10NYCRR 483. 80(d)(3) | Plan of Correction: ApprovedApril 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 and will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). The MDS Coordinator responsible for coding MDS comprehensive assessment on covid immunization was educated on improperly coding MDS (3/31/25). All Licensed nurses responsible for offering and educating residents the Covid vaccine were educated and re in serviced on failure to offer, screen educate and document in the COVID Vaccination Care Plan.3/31/25). II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered COVID-19 vaccine upon admission with documentation in EMR related to the screening, administration or declination, and education on the COVID-19 immunizations. An audit was completed by the DNS on the COVID-19 Vaccination to ensure that all current residents in house were offered the COVID-19 Vaccination with signed consent/declination and education on file. Any identified issues will be addressed (3/25/25) III. Systemic Changes: The Policy and Procedure for COVID-19 Vaccination Administration for Residents was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received a re in-service/education on ensuring that all residents are offered the COVID-19 vaccine upon admission. A matrix tracker was created to monitor the COVID-19 Vaccination status of all residents. Newly appointed Infection Control nurse was in serviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring and following up on all residents vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Covid vaccine, if appropriate, and vaccine status documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the COVID-19 vaccine upon admission. The DNS will conduct this audit weekly 3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person responsible: DNS Date:4/25/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the recertification survey from 03/12/2025 to 03/19/2025, the facility did not ensure that comprehensive care plans were developed. This was evident for 3 residents (Resident #28, #79, and #93) out of 26 sampled residents. Specifically, a diuretic care plan was not developed for Resident #28, a [MEDICAL TREATMENT] care plan was not developed for Resident #79, and a hospice care plan was not developed for Resident # 93. The findings are: The facility policy titled Comprehensive Care Planning with effective date 1/26/2023 and last review date 10/16/2023 documented the facility utilizes an interdisciplinary team to provide an individualized comprehensive resident assessment and care planning process in order to maximize and maintain every resident's functional potential and quality of life. It also documented the interdisciplinary team is responsible for the overall supervision, training, consultation, and evaluation of the individual resident's care plan. 1) Resident # 28 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident # 28 was moderately cognitive impairment, had [DIAGNOSES REDACTED]. Medical Doctor Order started on 7/5/2024 and last renewed 3/1/2025 documented Resident #28 was ordered to receive 1 tablet of medication [MEDICATION NAME] 50mg tablet by oral route daily for essential hypertension. Comprehensive Care Plan related to Cardiac Status was initiated on 7/5/ 2024. The cardiac care plan had no focus, no goals, and no interventions entered. There was no documented evidence that a comprehensive care plan related to the diuretic use was developed and implemented in the medical record of Resident # 28. On 03/18/2025 at 03:16 PM, Registered Nurse #3 was interviewed and stated, they developed, reviewed, and updated the comprehensive care plans at least every 3 months for the residents on the floor. Registered Nurse #3 also stated the electronic medical record system gave them an alert when the care plans were due for review. Registered Nurse #3 reviewed Resident #28's medical record and was unable to locate a comprehensive care plan that was developed for Resident #28 about cardiac care or to take the diuretic medication [MEDICATION NAME]. Registered Nurse #28 stated there should be a comprehensive care plan to address Resident #28's need for cardiac care and/or taking the diuretic. 2) Resident # 79 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident # 79 was cognitively intact and received [MEDICAL TREATMENT] care. Medical Doctor Order started on 1/23/2025 and last renewed 2/20/2025 documented Resident #79 was ordered to receive [MEDICAL TREATMENT] 3 times a week on Tuesday, Thursday, and Saturday. Comprehensive Care Plan related to [MEDICAL TREATMENT] was initiated on 9/20/ 2024. The [MEDICAL TREATMENT] care plan had no interventions entered. There was no documented evidence that a comprehensive care plan related to [MEDICAL TREATMENT] was developed and implemented in the medical record of Resident # 79. On 03/18/2025 at 03:07 PM, Registered Nurse # 4 was interviewed and stated Resident #79 was on [MEDICAL TREATMENT] 3 times a week and they developed the [MEDICAL TREATMENT] care plan for Resident #79 on 9/20/ 2024. Registered Nurse # 4 reviewed the [MEDICAL TREATMENT] care plan for Resident # 79. Registered Nurse # 4 stated no interventions were entered into the [MEDICAL TREATMENT] care plan. Registered Nurse # 4 also stated the [MEDICAL TREATMENT] care plan was not considered developed as it missed the interventions. 3) Resident # 93 had [DIAGNOSES REDACTED]. The Significant Minimum Data Set 3. 0 ((MDS) dated [DATE] documented Resident # 93 was severely cognitive impairment and received Hospice care. Medical Doctor Order started on 1/31/2025 documented Resident #93 received Hospice care. There was no documented evidence that a comprehensive care plan related to Hospice care was developed and implemented for Resident # 93 in their medical record. On 03/18/2025 at 03:00 PM, Registered Nurse # 4 was interviewed and stated Resident #93 was on Hospice care since January 2025. Registered Nurse # 4 also stated they did not develop a care plan related to Hospice for residents at the facility. Registered Nurse # 4 further stated they communicated with other staff for Hospice care through the progress notes. On 03/18/2025 at 03:24 PM, Director of Nursing was interviewed and stated the day shift registered nurses on the unit were responsible to develop, review, and update the comprehensive care plan at least every 3 months. Director of Nursing also stated every physician order [REDACTED]. Director of Nursing stated a comprehensive care plan is required for Hospice care. Director of Nursing also stated the care plans were not considered developed if the care plan missed goals or interventions. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedApril 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Correction: 1) Resident #28 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for the use of diuretics. 2) Resident #79 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for [MEDICAL TREATMENT] care. 3) Resident #93 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for hospice care. 4) The RN Supervisor #3 who was responsible for initiating comprehensive care plans for resident #28 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. 4) The RN Supervisor #4 who was responsible for initiating comprehensive care plans for resident #79 and #93 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that for all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status and initiated and updated as needed. An audit was completed by the DNS on all outstanding comprehensive care plans on all residents on our current census to ensure that all diagnosis, services, plan of care and medications have an active complete comprehensive care plan including goals. Any identified issues will be addressed(4/25/25). III. Systemic Changes: The Policy and Procedure for Comprehensive Care Plan was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received in-service/education on initiating and updating comprehensive care plans upon admission/re-admission or change in status on all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status is initiated and updated as needed. All new and re admissions will be reviewed within 24 hours of admission. All charts will be reviewed by IDT to ensure that a comprehensive care plans were developed for each residents diagnosis, services, plan of care and medications. All in house residents charts will be reviewed by IDT prior to quarterly, annual and significant change care plan meetings to ensure compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have a complete comprehensive care plan with a focus, goal and interventions initiated that will address all active diagnosis, service, plan of care and medications. The DNS will conduct an audit weekly x3 months. Any identified issues related to a delay in care planning results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date : 4/25/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 19, 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 conducted from 03/12/2025 to 03/19/2025, the facility did not ensure that each resident was offered the Pneumococcal and Influenza immunizations. This was observed in 5 of 5 residents (Residents #11, #23, #57, #84, #93) sampled for Immunizations out of a total of 26 sampled residents. Specifically, there was no documented evidence that Resident #23 was offered or educated on the Influenza immunization, and there was no documented evidence that residents #11, #23, #57, #84, and #93 were offered or educated on the Pneumococcal immunization. The facility policy titled Conducting the Influenza Vaccination Program for Residents, last reviewed 08/25/2023, documented that all residents/representatives will be provided with education on the influenza vaccine at the start of the influenza season. The facility policy titled Pneumococcal Vaccinations for Residents, last reviewed 11/05/2024, documented that to prevent pneumonia infections and to decrease the morbidity and mortality associated with pneumonia, the facility will offer Pneumococcal vaccines as recommended by the Centers for Disease Control and Prevention to all eligible residents. Residents [AGE] years of age and older that have no prior history of receiving the Pneumococcal vaccination will be offered the PCV20 Pneumococcal vaccine. The findings include: Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #11 had severe cognitive impairments. It also documented that Resident #11's Pneumococcal immunization status was not up to date because the resident declined the vaccination. The facility was unable to provide documented evidence that Resident #11 was offered and educated on the Pneumococcal immunization. Resident #23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #23 had moderate cognitive impairments. It also documented that Resident #23's Pneumococcal immunization status was not up to date because the resident declined the vaccination. The facility was unable to provide documented evidence that Resident #23 was offered and educated on the Pneumococcal immunization. The facility was also unable to provide documented evidence that Resident #23 was offered and educated on the Influenza immunization. Resident #57 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #57 had moderate cognitive impairments. It also documented that Resident #57's Pneumococcal immunization status was up to date. The facility was unable to provide documented evidence that Resident #57's Pneumococcal immunization status was up to date, or that they were offered and educated on the Pneumococcal immunization. Resident #84 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #84 had severe cognitive impairments. It also documented that Resident #84's Pneumococcal immunization status was up to date. The facility was unable to provide documented evidence that Resident #84's Pneumococcal immunization status was up to date, or that they were offered and educated on the Pneumococcal immunization. Resident #93 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Comprehensive assessment dated [DATE] documented that Resident #93 had severe cognitive impairments. It also documented that Resident #93's Pneumococcal immunization status was not up to date due to a medical contraindication. The facility was unable to provide documented evidence that Resident #93 had a medical contraindication that prevented them from being eligible for the immunization. On 03/17/2025 at 11:19 AM, the Infection Preventionist was interviewed and stated that the Director of Nursing is responsible for monitoring resident immunization statuses within the facility. On 03/17/2025 at 11:24 AM, the Director of Nursing was interviewed and stated that the facility offers residents immunizations for COVID-19, Influenza, Pneumococcal, and Respiratory [MEDICAL CONDITION]. The Director of Nursing stated that a nurse who was no longer employed by the facility had previously been responsible for monitoring resident immunization statuses and after that employee left the facility, it became the Director of Nursing's responsibility. The Director of Nursing stated that due to the personnel transition, they fell behind on maintaining their immunization program and that was why the sampled residents were not up to date on their immunizations. 10NYCRR 415. 19 (a) (1-3) | Plan of Correction: ApprovedApril 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the Influenza vaccine. Education on benefits and potential risk was provided. Consent was received. Influenza vaccine was administered on (MONTH) 17th, 2025. Family and MD were informed. 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Declination was received secondary to residents hospice status. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered the Influenza and Pneumococcal vaccine upon admission and annually and provided with educational material for review. An audit of the entire house was completed by the DNS on the Influenza and Pneumococcal Vaccination to ensure that all new admission and readmissions were offered the Influenza vaccine for the 2024-2025 flu season and Pneumococcal Vaccination with signed consent/declination and education on file. All identified issues were addressed.(3/26/25). The facility will ensure that each resident that was offered the Pneumococcal and Influenza immunizations will be followed with documented evidence in EMR to validate compliance. III. Systemic Changes: The Policy and Procedure for Conducting the Influenza Vaccination Program for Residents was reviewed by the DNS and found to be in compliance. The Policy and Procedure for Pneumococcal Vaccination for Residents was reviewed by the DNS and found to be in compliance. On 3/31/2025 all RNs and LPNs received in-service/education on ensuring that all residents are offered the influenza vaccine during the flu season and offered the pneumococcal vaccine upon admission if they meet the criteria and documented in EMR. A matrix tracker was created to monitor the Influenza and Pneumococcal vaccination status of all residents. Newly appointed Infection Control nurse was in serviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring, documenting and following up on all residents vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Flu and Pneumococcal vaccine, if appropriate, and documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the Influenza and Pneumococcal vaccine upon admission and annually. The DNS will conduct this audit weekly x3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19. 3. 2. 6* Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8. 7. 3. 1, unless all of the following conditions are met: (8) Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source Based on observation and staff interview during the recertification survey, the facility did not ensure that alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources. The findings are: During the Life Safety Code survey on 3/13/25 between 9:00am and 12:00pm, alcohol-based hand rub dispensers were noted installed directly above an ignition source (electrical outlet) in the following locations: - In the corridors on floors 2-4, near room [ROOM NUMBER], 309 and 409. - On the 1st floor, in the corridor outside of the kitchen. During the exit conference on 3/14/25 at approximately 2:15pm, the Administrator stated that the dispensers would be relocated 2012 NFPA101 10NYCRR 711. 2(a)(1) 10 NYCRR 415. 29 | Plan of Correction: ApprovedMarch 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action The alcohol-based hand rub dispensers on first floor near kitchen, on second floor near room [ROOM NUMBER], on third floor near 309, on fourth floor near 409 were removed and placed away from ignition sources (3/14/25). Identification of others All residents have the potential to be affected by this deficient practice. A complete audit of the entire building was completed to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources (3/14/25). No other issues were identified. All Maintenance Staff will be in serviced on the importance of ensuring that all Alcohol Based Dispensers shall not be installed above an ignition source within a 1 in. radius from an ignition source (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on placement of Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8. 7. 3. 1. All Maintenance staff will be in serviced on the importance of ensuring that appropriate placement of the Alcohol Based Hand-Rub Dispensers. All Alcohol Based Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources complying with requirements of 2012 NFOA 101. There will a visual check of all alcohol-based hand rub (ABHR) dispensers weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person Maintenance Director is responsible. 4/25/25- date of correction. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 19, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 2 Means of Egress Requirements. 19. 2. 1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19. 2. 2 through 19. 2. 11. 7. 2. 2. 1 General. 7. 2. 2. 1. 1 Stairs used as a component in the means of egress shall conform to the general requirements of Section 7. 1 and to the special requirements of 7. 2. 2, unless otherwise specified in 7. 2. 2. 1. 2. 7. 2. 2. 5. 5. 3 Exit Stair Handrails. All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements: (1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. Based on observation and staff interview, the facility did not ensure that all egress stairs were maintained in accordance with 2012 NFPA 101. This occurred in both of the facility's stairwells. The findings include: During the life safety survey of 3/13/25, between 9:00 am and 12:00 pm, it was noted that the handrails in the East and West stairs lacked the required contrasting colored marking stripe for the length of the stairwells. At the time of these findings, the Director of Environmental Services and Director of Maintenance stated that the rails would be painted. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 29, 2025 Immediate Corrective Action All handrails and handrail extensions were marked with a solid and continuous marking in egress stairs in both of the facility's stairwells (3/17/25). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all egress staircases was audited to ensure that it was maintained in accordance with 2012 NFPA 101 and that the handrails are painted with the required contrasting colored marking with a 1-inch width horizontal stripe for the length of the stairwell (3/17/25). All stairwell handrails have been painted with a 1-inch horizontal stripe to meet NFPA101 egress requirements. (3/17/25). All Maintenance staff will be in serviced on the importance of ensuring that all handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. Systematic Changes The Maintenance Director and Administrator reviewed the 2012 NFPA 101 manual and created a policy on Means of Egress Requirements. All Maintenance staff will be in serviced on the Means of Egress Requirements policy of Exit Stair Handrails (3/31/25). All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements:(1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. QA The Maintenance Director and Administrator developed an audit tool to ensure that all exit stair handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. There will a visual check of all exit stairwell handrails weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25- date of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 19, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 5. 1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9. 7, unless otherwise permitted by 19. 3. 5. 5. 2012 NFPA 101: 9. 7. 1. 1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: 2010 (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13 8. 15. 3. 2. 2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and interview, the facility did not ensure that sprinkler heads were located in all required areas of the building. This occurred on the first floor. The findings include: During the life safety survey on 3/13/2025 at approximately 10:15 am, it was noted that the East stair was interrupted by a door to the basement on the 1st floor landing. There was no sprinkler head located on the basement side of the door. This finding was acknowledged by the Maintenance Director, Administrator and Environmental Services Director. 2012 NFPA 101 2010 NFPA 13 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 29, 2025 Immediate Corrective Action A sprinkler head was installed on the basement side of the door ( ). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all areas of the building was completed to ensure that where noncombustible stair shafts are divided by walls or doors, sprinklers are provided on each side of the separation. (3/27/25) No other issues were found. All Maintenance staff will be in serviced on the importance of ensuring that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on the installation of Sprinkler Systems in residential occupancies up to and including four stories in height. All Maintenance staff will be in serviced on the policy which states that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation in accordance with 2010 NFPA 13 8. 15. 3. 2. 2 (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that Sprinkler Systems in residential occupancies where noncombustible stair shafts are divided by walls or doors, that sprinklers are provided on each side of the separation. There will be a visual check of all noncombustible stair shafts that are divided by walls or doors and ensure that sprinklers are provided on each side of the separation weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25- Date of Correction. |