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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure each Resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 2 (Residents #52 and #57) of 3 Residents reviewed for Activities of a Daily Living. Specifically, Resident #52 and #57 who required dependent assistance with Activities of Daily Living, were observed during multiple observations with fingernails that were long and ungroomed. The findings include: The facility policy titled Activities of Daily Living, reviewed 7/28/24, documented: It is the policy of this center to provide activity of daily living care to all Residents based on assessment of needs. 1) Resident #52 was admitted ,[DATE]/ 18. [DIAGNOSES REDACTED]. The Annual Minimum Data Set (a resident assessment tool) dated 1/2/25 documented Resident #52 was cognitively intact, was dependent on staff for toileting, bathing and lower body dressing, and required substantial/maximal assistance for personal hygiene. A Resident care plan dated 10/20/20 titled Activities of Daily Living Functional/Rehabilitation Potential documented they required a one-person physical assist for hygiene. A physician order [REDACTED]. During an observation and interview on 3/5/25 at 11:05 AM, Resident #52 was in bed with bilateral hand contractures and fingernails that were long and ungroomed. Resident #52 stated their fingernails were rarely cut and the last time was a while ago. During an observation on 03/06/25 at 08:43 AM, bilateral fingernails were observed long and ungroomed. During an observation on 03/10/25 at 01:25 PM, Resident was observed in wheelchair. Bilateral fingernails were long and ungroomed. During a follow-up interview on 3/12/25 at 12:26 PM, Resident #52 stated they had reported long nails to Certified Nurse Aides in the past. Resident #52 stated sometimes they would be cut but they frequently had to wait. 2) Resident #57 was admitted on ,[DATE]/ 25. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (a Resident assessment tool) dated 1/27/25 documented Resident #57 had moderately impaired cognition. The resident's care plan dated 1/14/25 titled Nursing Activities of Daily Living documented the resident required one person assistance for bathing and partial/moderate assistance for hygiene. A physician order [REDACTED]. During an observation on 03/07/25 at 10:20 AM, Resident #57 was resting in bed with bilateral long, ungroomed fingernails. During an observation on 03/10/25 at 11:55 AM, Resident #57 was in main dining room with bilateral long, ungroomed fingernails. During an observation on 03/11/25 at 9:06 AM, Resident #57 was in bed with bilateral long, ungroomed fingernails. During an interview on 03/10/25 at 11:37 AM, Certified Nurse Aide #10 stated they provided activities of daily living cares to residents on the unit. They stated personal hygiene was provided daily. They stated Certified Nurse Aides were responsible for cutting and grooming nails for non-diabetic residents. During an interview on 03/11/25 at 11:06 AM, Registered Nurse Unit Manager #11 stated that the expectation was that Certified Nurse Aides provided nail care (cutting and grooming) for all non-diabetic residents. They stated that Nurses and Nurse Managers on the unit were responsible for supervision to ensure tasks were completed. They stated residents should not have long and ungroomed nails. During an interview on 03/11/25 at 11:24 AM, the Director of Nursing stated that residents' nails should be kept short and well-groomed with no sharp edges. Nail care should be completed as needed during cares. On shower days, a full skin assessment including nail care should be conducted. They stated Certified Nurse Aides were responsible for resident hand nail care except for diabetics. 10 NYCRR 415. 12(a)(2) | Plan of Correction: ApprovedApril 4, 2025 P(NAME) F677: I. Immediate Corrective Actions: Resident # 52 1. The licensed nurse provided nail care for Resident# 52. 2. OT reassessed residents right hand contracture to determine if Resident # 52 would benefit from any devices for bilat hand contractures. 3. The resident verbalized satisfaction with nail care provided 4. The ADL CCP and CNAAR for Resident # 52 was updated by the RN regarding bilat hand contractures and provision of nail care. Resident # 57 1) The assigned CNA provided nail care for Resident # 57. 2) The resident verbalized satisfaction with nail care provided 3) The ADL CCP and CNAAR for Resident # 57 was updated by the RN regarding the provision of nail care. II. Identification of Others: 1. The DON, in conjunction with the RNS, conducted Facility rounds to ascertain if any other residents were not provided with nail care. There were no additional issues found. III. Systemic Changes: 1. The DON /Administrator reviewed the PP for the provision of nail care for residents and it was determined to be in compliance. This PP will be in serviced to all licensed nurses and CNAs by the Designee. The lesson plan will focus on: Reviewing the regulatory requirement (F677) 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; and The responsibility of Nursing staff to ensure nail care is provided to all residents as needed. The specific responsibility of the licensed nurse to provide nail care to residents with hand contractures. of the CNA to communicate to the Unit Nurse and/or RNS when nail care cannot be provided to a resident. IV. Quality Assurance: 1. The DON developed an audit tool to ensure residents are provided with nail care as needed. This audit will be completed by the RNS for 4 residents weekly x 4 weeks followed by 4 residents monthly for 11months. 2. Findings from the audit requiring immediate corrective action will be rectified immediately. 3. Results from the audit will be brought to the quarterly QA meeting. V. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during recertification and abbreviated survey (NY 960) from 03/05/2025 to 03/12/2025, the facility did not ensure that the resident's care plan was reviewed and revised timely for 1 of 2 residents (Resident #164) reviewed for falls. Specifically, Resident #164's care plan was not reviewed or updated to reflect new interventions after a medical assessment on 11/29/24 and a fall on 12/2/ 24. The findings include: Resident #164 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission assessment dated [DATE] documented Resident #164 had three or more falls in the last three months and had balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, and jerking or unstable when making turns resulting in a Fall Risk Assessment score of 21 (High Risk for falls). The 11/26/24 Care Plan Report documented risk for falls, orient to surroundings and routine on unit, introduce to roommate and staff. The Medical Progress Note dated 11/29/2024 documented deficits in mobility and activities of daily living due to weakness, balance impairment and debility. Continue with physical therapy/occupational therapy focusing on improving balance, increasing endurance and tolerance to exercise. Continue reviewing blood pressures and discuss with therapy to monitor of orthostatic [MEDICAL CONDITION] limiting functional therapy progress and falls. High risk of falls if [MEDICAL CONDITION] develops. This could result in injuries requiring readmission to the hospital and possible surgical intervention. The Incident Report dated 12/02/2024 documented that the resident had an unwitnessed fall in their room with complaints of pelvic pain. The resident was sent to a hospital emergency room for examination. The facility physician ordered x-rays of bilateral hips and pelvis. The x-rays were negative for fractures. There was no documented evidence in the electronic medical record that care plan interventions were updated after the 12/2/24 fall. The Incident Report dated 12/08/2024 documented the resident had an unwitnessed fall in their room resulting in injuries. The resident had a laceration to their head and bruises on both knees. The resident was sent to a hospital emergency room for examination. The facility physician ordered x-rays of the residents' knees. The x-rays were negative for fractures. During an interview on 03/12/25 at 11:25 AM, the Director of Nursing stated the Care Plan Report had two fall interventions dated 11/26/ 2024. The Director of Nursing stated the Care Plan Report should have been reviewed and updated with new interventions after the 12/2/24 fall but, that had not been done. During an interview on 03/12/2025 at 1:43 PM, Licensed Practical Nurse #1 stated care plan interventions are added over the course of a residents stay. All care plans are supposed to be reviewed after a fall or change of condition and new interventions are added if necessary. 10 NYCRR 415. 11 (c)(2)(i-iii) | Plan of Correction: ApprovedApril 4, 2025 P(NAME) F657 I. Immediate Corrective Action: 1)Resident #164 is no longer in the facility and was discharged with no outward or obvious issues. II. Identification of Others: 1) All residents could potentially be affected . 2) A list of residents who are potential for fall risk will be generated from the medical record, the comprehensive care plan was reviewed to ensure that all residents who are at risk was updated to reflect current status and contained new interventions to enhance communication. Any identified issues were addressed. 3) All residents who have had falls in the past 30 days will have their CCPs reviewed and updated to include any necessary safety , supervision and resident specific precautions and interventions. 3) Education was provided to all RNs tasked with updating Care Plans with respect to updating the plan of care for residents every time there is a fall; specifically that a new intervention must be in place post each fall and or after a change in condition. III. Systemic Changes: 1)The DNS and Administrator reviewed the Policy and Procedure for CCP and found same to be in compliance. 3) All Registered Nurses responsible for care planning will receive Inservice Education given by the Inservice Educator/DON /ADON on updating the CCP with quarterly MDS assessments and when any episodic event happens including falls , other incidents or change in conditions. Highlights of the lesson Plan include: The care planning process to include Assessment Planning, Goals/Interventions, Monitoring /Evaluation The responsibility of the RNS to review the CCP after each MDS assessment, fall , incident , and or change in condition and revise, based on changing goals, preferences, needs of the resident. The Responsibility of the RNS to revise and update the plan of care when an episodic event occurs. IV. Quality Assurance: 1 . The DNS developed an audit tool to monitor the facilitys compliance with updating the Fall CCP with interventions after each fall any resident experiences. 2) All residents that have had falls or change in conditions within the last 30 days or who are on the list of ?£potential to fall ?£ will reviewed by the DON/ADNS to ensure that the CCP has been updated to reflect any new interventions if need be. This audit will start as weekly x 4 weeks and monthly x 11months. 3) Any findings that require interventions will be addressed immediately and discussed in the next QA. V. Person Responsible for F Tag: DNS |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification and abbreviated survey (NY 646) from 3/5/24 to 3/12/24, it was determined the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #165) reviewed for accidents. Specifically, a two (2) person assist was not provided as per care plan resulting in Resident #165 rolling to the floor from the bed and sustaining a laceration/abrasion to their forehead, bridge of nose, and left hip. The findings include: Resident #165 was admitted to the facility with [DIAGNOSES REDACTED]. The (MONTH) 2024 Certified Nurse Aide Instructions documented resident required one- person physical assistance for bed mobility and bathing. The Activities of Daily Living Care Plan with a revision date of 11/28/24 documented dependent for bathing and required 2-person physical assist for bathing and bed mobility, half side rails to be used as enablers for bed mobility. The (MONTH) 2024 Certified Nurse Aide Instructions documented the resident was changed (undated) from a one-person physical assist to a 2-person physical assist for bathing and bed mobility. The 12/5/24 Admission 5-day Minimum Data Set Resident #165 was cognitively intact was dependent for bed mobility and transfers, used a wheelchair and was dependent for propelling wheelchair and further documented the resident was on the rehabilitation program and received occupational therapy and physical therapy for 120 minutes each. The 12/18/24 Accident/Incident Report documented in the conclusion, Resident #165 was receiving care by Certified Nurse Aide #8 at bedside, when they turned to get a fresh wash cloth from the bedside table to clean the body, the resident was rolling off the bed. Certified Nurse Aide #8 attempted to hold the resident, but the resident was already on the floor. The fall was witnessed, caused by resident intent or behavior. The resident was sent to hospital for Cat Scan and returned in stable condition. No treatment necessary to areas. Will observe for signs and symptoms of infection. Referred to rehabilitation. Resident's care was changed to 2 -person assistance with care. No evidence of abuse, neglect or mistreatment. The 12/19/24 Fall Assessment documented resident was unable to recall details of the incident. Resident was extensive assist of 1 person and uses a wheelchair for mobility, unable to lock and unlock wheelchair. Resident was alert but confused and able to follow simple directions. Recommend close supervision. Resident screened status [REDACTED]. 24. Resident noted with small laceration to anterior forehead on the bridge of nose; small, closed abrasion to left hip/pelvic and left trochanter. Resident hospitalized and returned on the same day. CAT scan of the brain is negative for any acute bleeding. The CAT of the bones does not show any fractures. Resident will be reassessed for possible side rails. Resident recommended to have low bed and floor mats for fall prevention. Resident requires frequent supervision due to fall decreased safety awareness. Resident will continue occupational therapy program in order to facilitate participation in functional activities and decrease caregiver burden. During interview on 3/11/25 at 1:37 PM Certified Nurse Aide #8 stated when they were providing care, they turned to get the towel to wash the resident, and the resident rolled onto floor. Certified Nurse Aide #8 stated the resident was able to move around in bed and was able to move onto their side when asked. Certified Nurse Aide #8 stated Resident #165 was a 1- person assist for bed mobility and bathing and stated they never saw any Certified Nurse Aides providing a 2- person assist for care of Resident #165 before or after the falls. Certified Nurse Aide #8 stated the only time they asked for assistance from another aide was to help move the resident up toward the head of the bed. Certified Nurse Aide #8 stated the nursing staff are not good with communication, and they don't tell the Certified Nurse Aides of changes with the resident's care. During interview on 3/12/25 at 5:54 PM during an interview, Physical Therapist #9 stated Resident #165 required 2-person extensive assist on 11/26/24 status [REDACTED]. 10 NYCRR 415. 12(h)(2) | Plan of Correction: ApprovedApril 4, 2025 689 P(NAME) Description: I. Immediate Corrective Action: Resident#165 is no longer at the facility. II. Identification of others: All residents will be reviewed to ensure the following : (1): Supervision status is accurately reflected in the CCP and CNAAR . (2) If care plan or CNAAR is not updated appropriately it will be immediately rectified. All resident charts were reviewed to ensure the appropriate supervision status. None others were identified. III. Systemic Changes: a. The Director of Nursing and Administrator reviewed the policy and procedure regarding Supervision. It was found to be in compliance. b. The Director of Nursing and Administrator reviewed the policy and procedure for accidents and incidents and found to be in compliance. c. All Nursing staff will be inserviced by ADNS , DON on the about the importance of checking the CNAAR for the final determinant of a residents supervision status. All C.N.As will receive education on checking the CNAAR for appropriate supervision status. IV. QA monitoring: a. An audit tool was created to monitor all residents supervision status to ensure its accuracy. c. Audits will be conducted weekly for 4 weeks for all residents then monthly for 11 months. d. All negative findings will be reported to the Director Nursing and the administrator and will be corrected immediately. e. All results of the audits will be brought to the QAPI committee quarterly for a year. V. Person Responsible: Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 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 03/05/25-03/12/25, the facility did not ensure each resident was offered pneumococcal immunizations and education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #1, #24) reviewed. Specifically, there was no documented evidence that Resident's #1 and #24 were offered, declined, or received education regarding the pneumococcal immunization. The findings include: The facility policy titled Pneumococcal vaccinations (last reviewed 7/3/24) documented: In order to prevent the spread of infectious disease and to mitigate the risk of morbidity and mortality associated with pneumococcal pneumonia, the facility will offer pneumococcal vaccinations to all residents and staff. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) dated 1/2/25 documented Resident #1 had intact cognition. There was no documented evidence that the resident/resident representative received education, was offered the pneumococcal vaccinations, or declined the vaccinations. Resident #1's previous pneumococcal vaccination was documented as last received 10/21/ 2001. Resident #24 was admitted [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] did not include documented evidence the resident/resident representative received education, was offered the vaccination, or declined the pneumococcal vaccine since their last documented pneumococcal vaccination on 8/23/ 2012. During an interview on 3/11/25 at 12:06 PM, the Administrator stated they did not have any documentation for Resident #1 and Resident #24 being offered and receiving education for the pneumococcal vaccination. They stated the facility has had nursing staffing shortages and turnover which could be the reason resident vaccinations were not completed or kept up to date. During an interview on 3/12/25 at 1:48 PM, the Director of Nursing stated if a resident refused a vaccination, a declination form would be signed and uploaded to the electronic medical record system. They stated that the pneumococcal vaccination should have been offered to all eligible Residents at admission and/or every five years. 10NYCRR 415. 19 (a) (1-3) | Plan of Correction: ApprovedApril 4, 2025 F883 P(NAME) Description: I. Immediate Corrective Action Resident # 1 and resident #24 were immediately offered education regarding the risks and benefits of the pneumococcal vaccine as well as offered the vaccine itself. II. Identification of others All residents have the potential to be affected by the deficient practice. All Resident Charts will be audited to determine if they received their pneumococcal vaccine, declined , and received education. All negative findings were rectified immediately. III. Systematic Changes The Policy and procedure regarding pneumococcal vaccines was reviewed and determined to be in compliance. An in-service will be provided to all LPNs and RNs to educate them that the resident and or representative has a right to receive education , receive or decline the pneumo vaccine as well as documented in the resident CCP. All consents and or declinations will also be uploaded to the document section of Sigma. IV. QA monitoring a. An audit tool was developed to ensure that all residents resident and or representative receive education , receive or decline the pneumo vaccine. Audits will be conducted weekly for 4 weeks and monthly for 11 months. Any negative findings from the audits will be corrected immediately. d. Audits will be brought to QA meeting. V. Title Responsible a. Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details Based on interview and record review during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that 5 of 5 randomly selected Certified Nurse Aides (Certified Nurse Aides #17, 18, 19, 20 and 21) received at least 12 hours per year of in-service education. Specifically, Certified Nurse Aides #17, 18, 19, 20, and 21 received only 10 of the 12-hours mandatory in-service training. The findings include: During an interview on 3/11/25 at 3:33 PM, the Director of Nursing was requested to provide the training records of 5 Certified Nurse Aides. Certified Nurse Aide #17 was hired 3/15/23 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #18 was hired 8/5/14 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #19 was hired 3/17/09 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #20 was hired 10/24/23 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. Certified Nurse Aide #21 was hired 5/14/19 and received 10 of the 12 hours of required annual in servicing, that did not include abuse or resident's rights. During an interview on 3/12/25 at 5:26 PM, the Administrator stated they were aware that that the five sampled Certified Nurse Aides did not meet the 12-hour in-service requirement, and only received 10 hours. The Administrator stated it is the Assistant Director of Nursing's responsibility to monitor the 12-hour annual in-service requirement for the Certified Nurse Aides. During the past year, they had two Assistant Directors of Nursing who did not remain employed at the facility, therefore the Certified Nurse Aide in-service monitoring had lapsed. They stated they were now aware that the Certified Nurse Aides only had 10 hours of in-service education and did not complete the mandatory topics such as abuse and resident rights. During an interview on 3/12/25 at 5:33 PM, the Director of Nursing stated they were now aware that the facility only provided 10 of 12 hours annual in-service required for the Certified Nurse Aides, and that the mandatory topics such as abuse, and residents' rights were not included in the annual in services provided to the 5 sampled Certified Nurse Aides. 10 NYCRR 415. 26(c)(2)(iii) | Plan of Correction: ApprovedApril 4, 2025 F730 P(NAME) Description: I. Immediate Corrective Action All C.N.As will be educated via in-service on resident abuse and resident rights All 5 CNAs reviewed have been provided with additional inservices to equal the required 12 hours/annually. II. Identification of others A. All residents have the potential to be affected .The DNS/designee will review all CNA records to ensure that all CNAs have received the mandatory in-services within the past year as well as 12 hours of in-service/year. Those found not to have these in-services will immediately be scheduled for in-services which will be provided by the DNS/designee. III. Systematic Changes The DNS/administrator reviewed the policy and procedure on C.N.A. yearly in-service and found it to be in compliance. IV. QA monitoring a. An audit tool was developed by the DON to ensure that all C.N.As are receiving the 12 hours of in-service annually specifically abuse and resident rights . b. Audits will be conducted weekly for 4 weeks on randomly selected CNAs and then monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. d. Audits shall be brought to QA meeting. V. Title Responsible a. Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure appropriate care was provided in accordance with professional standards of practice for 1 of 1 residents (Resident #10) reviewed for Skin Conditions. Specifically, on 2/18/25 the registered nurse was not made aware, and there was no documented evidence that a registered nurse assessment was conducted after Resident #10 was hit in the face with the bed control while cares were being provided by Certified Nurse Aide # 7. The findings include: Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. The 2/18/25 Accident/Incident Report documented Resident #10 was being given care by the Certified Nurse Aide when the resident was playing/fidgeting with the bed controls, and it suddenly swung into the resident's face. It further documented a nurse was notified and no injury was noted. Resident #10 received blood thinners. The documented plan was to detangle the bed control cord as needed. Abuse was ruled out. There was no documented evidence in the 2/18/25 progress notes after Resident #10 was hit in the face with the bed control while receiving cares. There was no documented evidence that Resident #10 was assessed by a Registered Nurse after they were hit in the face with the bed control on 2/18/ 25. The Quarterly Minimum (MDS) data set [DATE] documented Resident #10 had severely impaired cognition, and required partial to moderate assistance with bed mobility and transfers. During interview on 3/12/25 at 12:16 PM during an interview, the Director of Nursing stated on 2/18/25 Certified Nurse Aide #7 told Licensed Practical Nurse #5 that while they were providing care the bed remote swung and hit Resident #10 in the face. Licensed Practical Nurse # 5 went to see the resident and stated they did not see anything and endorsed it to oncoming Licensed Practical Nurse # 6. The Director of Nursing stated both Licensed Practical Nurse #5 and Licensed Practical Nurse #6 did not report the incident to the nursing supervisor and did not document the incident in the electronic medical record. The Director of Nursing stated a Registered Nurse should have assessed Resident # 10. During interview on 3/12/25 at 12:25 PM Licensed Practical Nurse #5 stated on 2/18/25 Certified Nurse Aide #7 was taking care of resident and while providing care, they stated the bed remote hit the resident in the face. Licensed Practical Nurse #5 stated they looked at Resident #10 and did not see any bruising. Licensed Practical Nurse #5 stated they should have reported it to the nursing supervisor but did not and instead told the oncoming nurse (Licensed Practical Nurse #6) at change of shift. Licensed Practical Nurse #5 stated they usually documented in progress notes regarding resident incident/s but did not write a note. On 3/12/25 at 12:37 PM during an interview, Licensed Practical Nurse #6 stated they were informed by Licensed Practical Nurse #5 that Certified Nurse Aide #7 was providing care and the bed remote hit the resident in the face. Licensed Practical Nurse #6 stated when they went to see Resident #10, they did not have any marks on their face. They further stated at some time during the next couple of weeks, there was some bruising showing. Licensed Practical Nurse #6 stated they did not document anything in the progress notes about the bruise on the resident's face. Licensed Practical Nurse #6 stated they normally would have documented but the bruising did not appear right away. Licensed Practical Nurse #6 stated they did not report it to anybody. Licensed Practical Nurse #6 stated they should have reported it to nursing supervisor so the resident could be assessed. On 3/12/25 at 2:42 PM, Certified Nurse Aide #7 stated while they were providing care, Resident #10 had the bed control in their hand and was struggling to unravel the cord and pulled it and it snapped back and accidentally hit the resident in the face. Certified Nurse Aide #7 stated they notified Licensed Practical Nurse #5 and stated that nobody asked them about the incident until now. Certified Nurse Aide #7 stated after the incident there was no redness or bruising on Resident #10's face. 10NYCRR 415. 4(b)(3) | Plan of Correction: ApprovedApril 4, 2025 F684 I. Immediate Corrective Action: 1) Resident # 10 was assessed by the MD and no untoward persisting effects of the bruise on the residents face were noted. 2) A full body assessment was done for Resident # 10 by the RN Supervisor to assess for any unknown bruises. None were found. 3) Resident # 10 was assessed by the SWD and no signs of psychosocial distress were noted. 3) The IDT Team reviewed Resident # 10 CCP and CNAAR for specific interventions. The Resident is determined to have all interventions in place needed. II. Identification of Others 1)The Facility respectfully states that all residents were potentially affected. 2)The DON will review all accidents/incidents for the past 30 days to ascertain if there were any injuries of unknown origin that required further investigation.: No issues were identified. III. Systemic Changes 1)The DON in conjunction with the Administrator reviewed the facilitys policy titled Accident/Incident Reporting and Investigation and found same to be compliant. 2)The policy and procedure will be re-in serviced to all registered nurses, licensed practical nurses, and certified nurse assistants by the Designee. The lesson plan will focus on: The responsibility of all direct care staff to report any incident involving or during resident care to the Unit Charge Nurse and/or RNS The responsibility of all direct care staff to report any injuries of unknown origin including bruising, redness, or skin changes The chain of command for reporting events involving residents includesÔÇ£ the CNA will report to the unit LPN, then the unit LPN will report to the unit change nurse and/or RN Supervisor. Immediate assessment of the resident by the RN Supervisor and initiation of A/I report. RN Supervisor to inform the physician and carry out any orders. MD/NP will also assess resident and document any findings. RN Supervisor to inform the designated health care representative of incident/change in condition and plan of care. Licensed nurse to document in the residents medical record as well as the 24-hour report. The responsibility of the DON and Administrator to investigate and report to NYSDOH any injuries of unknown origin. IV. Quality Assurance: 1)The DON developed an audit tool to monitor the facilitys compliance with ensuring an RN assessment and investigation is conducted for all incidents/accidents involving residents. 2) 4 Randomly selected incidents will be audited weekly 4 for weeks and monthly for 11 months. 3)All findings will be brought up at the QA Meeting for input and correction as needed. V.Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during a recertification survey from 3/5/25 to 3/12/25 it was determined that for 1 of 1 residents (Resident #10) reviewed for skin conditions the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, the state department was not notified after the 3/4/25 Accident/Incident Report documented Resident #10 was observed with discoloration that suddenly appeared on the right side of the resident's face. The findings include: Resident #10 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had severely impaired cognition, required partial to moderate assist for bed mobility and transfer; it further documented and had no falls. The 2/18/25 Accident/Incident report documented the resident was being given care by the certified nurse aide when the resident was playing/fidgeting with bed controls, and it suddenly swung into the resident's face. It further documented a nurse was notified and no injury noted. Abuse ruled out. There was no documented evidence of right eye/face bruising in the electronic medical record between 2/18/25 and 3/4/ 25. The 3/4/25 Accident/Incident documented Resident #10 was observed with discoloration that suddenly appeared on the right side of the resident's face. Resident alert and at baseline. Statements were taken from of all the staff on the unit. There were no recent falls or [MEDICAL CONDITION] activity. Resident was noted with movements that are somewhat erratic with control. Resident noted with recent incident with the bed controls swung towards their face per review of records causing injury at the time however it's reasonable to presume that this is the cause of the old nature of the bruise. Certified Nurse Aide #7 stated they were providing care, and resident was fidgeting with bed controls and the remote accidentally hit the resident in the face. The physician was made aware and had no new orders. The documented recommendation was for the bed remote cord to be stretched out as needed. The 3/4/25 medical progress note documented the resident was seen for what appeared to be an old right eye bruise.The area is showing signs of healing different stages of bruising. There were no signs of vision impairment. No further injury observed. Continue to monitor. On 3/05/25 at 2:15 PM, Resident #10 was observed with a yellowish bruise on the right cheek. During interview on 3/12/25 at 12:16 PM the Director of Nursing stated they were not aware Resident #10 had bruising until the 3/4/25 incident report was initiated. They stated they did not feel it was an injury of unknown origin as they attributed the bruising to the incident on 2/18/ 24. The Director of Nursing stated time had passed from the previous incident and should have considered the 3/4/25 reported bruising to be an injury of unknown origin. During interview on 3/12/25 at 12:25 PM, Licensed Practical Nurse #5 stated they were surprised when they received a call from the facility on 3/4/25 inquiring about the bruise on Resident #10's face. They stated they told the caller they did not see a bruise on the residents face from 2/18/25-3/4/25 and were not sure the bruise on Resident #10 right cheek was from the 2/18/25 incident. During interview on 3/12/25 at 12:46 PM, the Nurse Practitioner stated on 3/4/25 when they assessed the resident and wrote their note, it was the first time bruising was reported to them. They further stated prior to that date they had no knowledge of Resident #10 having a bruise. The Nurse Practitioner stated the bruise on Resident #10's right cheek was of unknown origin. The Nurse Practitioner stated staff were unable to explain what happened to Resident # 10. During interview on 3/12/25 at 12:47 PM, the Director of Nursing stated prior to the nurse practitioner conducting an assessment of Resident #10, they did not know where the bruising came from. The Director of Nursing stated when they started collecting statements for the 3/4/25 incident report staff told them the bruise was already there. The Director of Nursing stated an injury of unknown origin should have been reported within 2 hours and further stated Incident Reporting In-Service had not been done. NYCRR 415. 4(b)(2) . | Plan of Correction: ApprovedApril 4, 2025 F609 I. Immediate Correction: 1) Resident # 10 was assessed by the MD and no untoward persisting effects of the bruise on the residents face were noted. 2) Resident # 10 was assessed by the SWD and no signs of psychosocial distress were noted. 3)The IDT Team reviewed and updated Resident # 10 CCP and CNAAR for specific interventions- The Placement of the bed , TV remote are all secure and dont pose a risk to the resident or environmental hazard. II. Identification of Others: 1)The facility respectfully states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days will be reviewed to ensure that any incidents of unknown origin were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the DON and is in compliance. 2) Inservice education will be provided for all nursing staff on reporting requirements related to reporting violations involving abuse to the NYS DOH. 4)Highlights of the Lesson Plan include: The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/ DNS. Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH As per CMS 42CRF 483. 12(c) the reporting definition ?ôimmediately is defined as: 1) 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2) 24 hours if the alleged violation does not involve abuse and does not result in serious injury. As per Federal regulation 483. 12(b)(5) all reasonable suspicions of crimes and/or suspicious Incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/ designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facilitys compliance with ensuring that all incidents and accidents are investigated, and injuries of unknown origin are reported timely as per NYS DOH and Federal reporting guidelines. 2) 5 Random Accident and Incidents will be audited by DON/Designee weekly for 4 weeks and monthly for 11 months. Any identified issues will be immediately corrected. 3) Findings will be reviewed at QA Meeting to monitor sustainability. Responsible for this FTag: DON |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during a recertification survey from 03/05/2025 to 03/12/2025, the facility did not ensure that the residents' advance directives were accurate for 1 (Resident # 82) of 24 residents reviewed. Specifically, Resident #82's Medical Orders for Life Sustaining Treatment form was changed from Do Not Resuscitate (allow a natural death if the heart stops beating or resident stops breathing) to Full Code (perform Cardio-Pulmonary Resuscitation) and the physician orders [REDACTED]. The findings include: The facility policy, Advanced Directives, with a 12/13/2024 review date, documented the individual's wishes on advance directives will be identified and honored by the facility. All Do Not Resuscitate orders must align with the corresponding Medical Orders for Life Sustaining Treatment documentation to maintain accuracy in the resident's care preferences. A Do Not Resuscitate alert will be placed in the resident's Electronic Medical Record for immediate visibility to all relevant staff. A red sticker will be placed as a visual indicator on the resident's armband or next to the resident's name on the door. Resident's Advance Directives will reviewed upon admission, and re-admission from the hospital, quarterly, and annually. Resident # 82 had [DIAGNOSES REDACTED]. The Medical Orders for Life Sustaining Treatment form dated 9/05/2023 documented a Do Not Resuscitate Order (allow natural death). The quarterly Minimum Data Set (an assessment tool) dated 12/05/2024 documented the resident was cognitively intact. The social services note dated 12/19/2024 documented that during the 12/19/2024 quarterly care plan meeting, Resident #82 was present and updated the Medical Orders for Life Sustaining Treatment form to a Cardio-Pulmonary Resuscitation order (full code). The 12/19/2024 Medical Order for Life Sustaining Treatment was signed by the physician on 12/26/ 2024. The physician orders [REDACTED]. During a review of Resident #82's electronic medical record on 3/6/2025 at 11:20 AM, a Do Not Resuscitate alert was visible. During an observation on 3/06/2025 at 3:26 PM, a red sticker was seen on Resident #82's door name plate. During an observation on 3/06/2025 at 3:29 PM, a facility binder, containing Medical Orders Life Sustaining Treatment forms for all the residents on the unit, had the 09/05/2023 Medical Order for Life Sustaining treatment for [REDACTED]. 82. During an interview on 03/06/2025 at 3:36 PM, the facility Social Work Director stated when an advanced directive change was known, a new Medical Orders for Life Sustaining Treatment form was started and given to the Nurse Practitioner or Physician to sign. Then it was updated in the electronic medical record and the updated copy was placed in the binder in the unit. They stated usually the Nurse Practitioner or Physician put the orders in or would ask the nurses to put the changed orders in. During the quarterly care meeting on 12/19/2024, Resident #82 changed their Medical Orders for Life Sustaining Treatment from Do Not Resuscitate to Full Code. The Social Worker Director stated they did not know why Residents #82's physician orders [REDACTED]. During an interview on 03/10/2025 at 11:25 AM, Licensed Practical Nurse #1 stated staff identified residents who had advanced directives by the red dot on the door, red dot in computer and red dot on the wrist band. When a resident had to leave the facility to go to the hospital, the nurse made a copy of Medical Orders for Life Sustaining Treatment, resident's face sheet, and medication list to send with the emergency medical system team. They stated nurses checked for new orders in the computer when coming on duty. Licensed Practical Nurse #1 stated there was no formal reporting if advance directives changed unless a new order was put in place. Licensed Practical Nurse #1 stated they thought Resident #82's Medical Orders for Life Sustaining Treatment was Do Not Resuscitate and was not aware of the change from Do Not Resuscitate to Full Code. During an interview on 03/10/2025 at 4:10 PM, the Director of Nursing stated social workers made changes to the advance directives after being told by resident or family. The social worker was supposed to notify nursing after a new Medical Orders for Life Sustaining Treatment form was signed by the physician. The nurse was responsible for updating orders in the computer. The Director of Nursing did not know why Residents #82's orders were not updated. 10 NYCRR 415. 3(e)(1)(ii) | Plan of Correction: ApprovedApril 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F578: I. Immediate Corrective Actions: Resident # 82 1) The Primary Physician reviewed the Medical Orders for Life Sustaining Treatment (MOLST) and ensured it was revoked and the physician DNR order in the medical record was discontinued. 2) The RNS with the SW ensured DNR identifiers were removed for Resident # 82 3) The IDT Team met with Resident # 82 and updated the Care Plan updating to Full Code status and documented in the Medical Record. II.Identification of Others: 1) The facility respectfully states that all residents had the potential to be affected. 2) The DON and Director of Social Work obtained a list of all Advanced Directives. This list will be utilized by SW and RNS to review all residents orders for Advanced Directives including MOLST forms to ensure all Advanced Directives are accurate and current. No issues were noted. III. Systemic Changes: 1) The Administrator, Medical Director, DON, and Director of SW reviewed the Facility PP for Advanced Directives and found same to be compliant. All Physicians, NPs, Licensed nurses, Social workers, and IDT Team members will be in serviced by the Designee: Topic of Inservice is as follows: On admission the SW or admission RN will provide information on Advanced Directives and document the education in the medical record The admitting RN will ascertain if the resident has an existing Advanced Directive and inform physician for follow up orders as needed. If the resident is unable to discuss advanced directives on admission the SW in conjunction with the physician and IDT Team will discuss advanced directives with the resident representative/surrogate and/or Health Care Proxy (HCP) as indicated. All established Advanced Directives will be documented on the Medical Orders for Life Sustaining Treatment (MOLST) form signed by the physician/NP. The SW will be responsible for ensuring all accurate Facility identifiers for DNR are in place. The Advanced directives will also be documented in the physician order [REDACTED]. In cases where advanced directives are changed by the resident or HCP the SW will immediately inform the physician and document in Medical Record. Any prior MOLST form will be revoked and a new MOLST form signed by the physician will be completed as needed. The RN will be informed and ensure physician orders [REDACTED]. IV. Quality Assurance: 1) The Administrator developed an audit tool to monitor the Facility compliance with ensuring all residents Advanced Directives are accurate. This audit will be done by the Director of SW for 4randomly selected residents weekly x 4 weeks followed by 4 residents monthly x 11 months. 2) All audit findings will be discussed at Morning Meeting and presented at the Quarterly QA meeting for input and follow up as needed. V. Person Responsible: Director of Social Work |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure residents had the right to a dignified experience for 1 of 4 residents (Resident #24) reviewed for dignity. Specifically, Resident #24 was observed multiple times after meals with food/crumbs on their chin and their gown. The findings include: Resident #24 had [DIAGNOSES REDACTED]. A Resident Care Plan dated 3/30/21 titled Activities of Daily Living documented the resident required a one person assist with bathing, partial/moderate assistance for upper body dressing, and supervision or touching assistance for eating and personal /general hygiene. The Quarterly Minimum Data Set (an assessment tool) dated 12/26/24 documented Resident #24 had moderate cognitive impairment, upper and lower extremity impairment on one side and required supervision/touching assistance with eating and hygiene. During an observation on 3/05/25 at 10:35 AM, Resident #24 was observed in bed with dried food/crumbs on their chin and on their gown. During an observation on 03/05/25 at 11:48 AM , Resident #24 was observed in bed with dried food /crumbs on chin and on their gown. During an observation on 3/07/25 at 10:04 AM, Resident #24 was observed in bed with food/cereal on their gown. During an observation on 03/07/25 at 01:30 PM, Resident #24 was observed in the day room after lunch with food residue on their face. During an interview on 03/11/25 at 10:51 AM, Certified Nurse Aide #3 stated Resident #24 was independent when eating but. They stated when their meal was finished, the tray would be removed and activities of daily living, including bathing and change of clothes was usually done a little later. They stated the expectation was the residents face and hands were to be cleaned after meals if needed. They stated when working with Resident #24, they cleaned the resident's face, hands, clothing as needed after meals. During an interview on 03/11/25 at 11:27 AM, the Director of Nursing stated when resident meals were completed, tray/food and clothing protector/napkins should be removed and the resident should have their hands and face cleaned as needed. The Director of Nursing stated residents should not have food remains on their clothing or face/hands after meals. 10 NYCRR 415. 3 (d)(i)(i) | Plan of Correction: ApprovedApril 4, 2025 P(NAME) F 550 I. Immediate Corrective Action: 1) Resident # 24 has been provided with assistance during all meals. The residents CCP was revised to reflect her preferences. Nursing Instructions related to this were carried over to the CNAAR. 2) Resident # 24 CCP and CNAAR were reviewed to ensure the correct ADL care was being provided. 3) The SW interviewed resident #24 to identify the presence of any negative psychosocial outcomes related to the incident and none were noted or reported. II. Identification of Others: 1) The facility maintains the position that all residents were potentially affected 3) All residents CCPS and CNAARs will be reviewed by the Nursing Department to determine if assistance was needed during meals. All residents who have been determined to need assistance with ADLs during meals will be placed on the CNAs assignment sheets moving forward. III. Systemic Changes: 1)The DNS reviewed the Policy and Procedure for Residents Rights and found same to be in compliance. 2) All Nursing Staff received Inservice on the Resident Rights specific to residents right to respect and dignity. Highlights of the lesson plan include: Residents have the right to a dignified experience. Ensuring a resident has an Apron or is given the appropriate assistance in line with the CNAAR. The Responsibility of the Nursing Aides to routinely check if residents on their assignments are well maintained and free of an undignified experience. The Responsibility of the Nursing Aides to ensure that all residents including independent residents are cleaned up after meals. IV. Quality Assurance: 1) An audit tool to monitor compliance ensuring that residents are well maintained and free of an undignified experience. 2) Residents will be audited by the RN Managers weekly x 4 weeks followed by monthly x 11months. 3) Any findings will be corrected by the auditor immediately and brought the quarterly QAPI meeting. V. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during the Recertification survey from 3/5/2025 to 3/12/25, the facility did not ensure that 1 of 2 residents (Resident #34) reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice. Specifically, Resident #34, had a physician's order for oxygen to be administered via nasal cannula at 3 liters per minute, and was observed multiple times with the oxygen rate not consistent with the physicians' order. Additionally, there was no signage present indicating oxygen was being utilized in Resident #34's room. The findings include: The facility policy titled Oxygen Administration last revised on 10/29/24 documented to verify that there is a physician's order; place an oxygen in use sign on the outside of the room entrance door; and turn on the oxygen on at the prescribed rate. Resident #34 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) dated 12/19/24 documented Resident #34 had moderately impaired cognition, required supervision for toileting, dressing and transfers and set up assistance for eating. A physician order dated 9/27/24, documented oxygen at 3 liters/minute continuous via nasal cannula. A resident care plan, updated 12/2/24, documented to administer of oxygen per physician order. During observations on 3/05/25 at 12:03 PM, 3/06/25 at 8:51 AM, and 3/07/25 at 1:34 PM, Resident #34 was receiving oxygen via nasal cannula and the concentrator was observed running at 2. 5 liters/minute. There was no oxygen use signage observed on door/entrance to the resident's room. During an interview and observation on 3/07/25 at 2:10 PM, the oxygen concentrator was at 2. 5 liters/minute. Licensed Practical Nurse #1, observed the concentrator and stated the oxygen concentrator was running between 2. 5 and 3 Liters. They stated that Resident #34's oxygen administration rate could fluctuate between 2 and 3 liters and that they were aware the physician order was for the resident to receive 3 Liters continuously. They also stated that the facility did not require a physician order for [REDACTED]. During an interview and observation on 03/07/25 at 2:18 PM, Registered Nurse Supervisor #2, stated that oxygen use signage should have been posted on / near the doorway of Resident #34's room. They also stated that all residents in the building needed an order for [REDACTED]. During an interview on 3/10/25 at 2:21 PM, the Director of Nursing stated physician orders were required for all oxygen use except in an emergency and then the order would be obtained. Signage should be in place by door of a resident's room when using oxygen. Physician orders for liter administration rate were expected to be followed as written. Correct oxygen level settings should be monitored by the Nursing Supervisor on the unit and/or the Director of Nursing. 10 NYCRR 415. 12 | Plan of Correction: ApprovedApril 4, 2025 695 P(NAME) Description: I. Immediate Corrective Action Resident#34 was assessed by MD ensure there were no negative effects. Resident #34 was provided with a new concentrator; one that has the liter flow consistently matching the doctors order. II. Resident #34 now has a sign outside the room with the appropriate oxygen signage. II. Identification of others a. All residents on o2 were evaluated to ensure that oxygen delivery was consistent with MD order. No other residents were noted with this deficiency. b. All Rooms with Residents receiving oxygen were audited to ensure they have the proper signage. No other resident rooms were found to be lacking proper signage. III. Systematic Changes a. Policy and procedure regarding obtaining a MD order for oxygen usage was reviewed and found to be in compliance. An Inservice was provided to all -RNs and LPNs on ensuring that oxygen delivery is in accordance with doctors orders. IV. QA monitoring a. An audit tool was developed to ensure that all residents on oxygen have are being given the prescribed setting. b. Audit will be conducted By RNS on residents receiving oxygen weekly for 4 weeks and monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. d. Audits shall be brought to QA meeting to review with team. V. Title Responsible a. Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details Based on observation and interview conducted during the recertification survey conducted from 3/5/25 to 3/12/25, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, room C-19-B had broken window clips, room C-9-B had a broken radiator cover, a window shade that was stained, and black scuff marks on the wall between the window and resident dresser, room A-17 had a faulty window unit and faulty sealed Packaged Terminal Air Conditioner unit which allowed cold outside air to enter the room. The findings include: The facility policy titled Maintenance/Engineering policy dated 7/24/24 documented provide a safe, functional and effective environment for residents, staff and all individuals who provide care to residents and all individuals who visit the facility. During an observation on 03/06/25 at 12:08 PM of room C-19-B, a hand-written sign was observed on the lower left side of the window stating Do not open this window. A piece of the broken window opening latch was observed on the windowsill. During an observation on 03/06/25 at 12:12 PM of room C-9-B, the radiator cover was observed hanging/broken on the right side below the vents. The window shade was observed stained on the left and right lower sides. The wall between the resident's dresser and radiator/window area was observed with black scuff marks. During an interview on 03/12/25 at 12:23 PM the Director of Maintenance stated they were not aware of the sign posted on room C-19-B window and was not aware who wrote the sign. They stated the broken latches on the top of the window allowed for windows to be opened for cleaning purposes. They stated they have not received a work order request for repairs. The Director of Maintenance stated radiator cover bases frequently fall out if hit with a wheelchair or mechanical lift and can be snapped or drilled back in place. They stated window shades that are dirty or broken will need to be replaced. They stated they were not aware of concerns in room C-9-B and had not received a work order for repairs. They stated the facility currently has an order pending (document observed) for replacement shades for building. The Director of Maintenance stated staff members should report all environment concerns to their unit manager who should enter a work order into facility maintenance software program for repairs to be completed or call/page/e-mail environmental staff with concerns. During an interview on 03/11/25 at 11:35 AM, the Director of Maintenance stated the facility had three windows that were installed incorrectly which allows outside air to enter rooms and room A-17 was one of the three rooms with the faulty windows. They stated it is known that the Packaged Terminal Air Conditioner unit requires a correct seal to not allow outside air into the room. They stated the facility did receive a complaint on 12/10/25 from the resident in room A-17 that cold air was coming in through the Packaged Terminal Air Conditioner unit. The Director of Maintenance stated the facility was working with the window manufacture to determine if the repairs will be covered by the warranty. In addition, the facility is waiting for warmer weather to complete the repairs to the Packaged Terminal Air Conditioner unit. During an observation on 03/11/25 at 11:50 AM, room A-17 window panes could be moved back and forth allowing outside air to enter the room. 10 NYCRR 415. 5(h)(2) | Plan of Correction: ApprovedApril 4, 2025 I. Immediate Corrective Action: 1. Room C-19-B: On 3/6/25, Maintenance staff inspected the window in Room C-19-B. The broken window latch was repaired, and the Do not open sign was removed. 2. Room C-9-B: On 3/6/25, Maintenance repaired the broken radiator cover and secured it properly. On 3/6/25, Housekeeping cleaned the stained window shade and replaced it. On 3/6/25, Maintenance cleaned the black scuff marks on the wall between the dresser and window/radiator area. 3. Room A-17: On 3/11/25, Maintenance identified the faulty PTAC. Temporary sealing was applied to prevent outside air from entering. Maintenance placed a temporary seal on the Packaged Terminal Air Conditioner (PTAC) unit to minimize the cold air entering the room. The facility will complete permanent repair of the window and PTAC unit as soon as the weather permits, with a target completion date of 4/30/ 25. II. Identification of Others: All residents in the facility could potentially be affected by similar environmental issues. The Director of Maintenance conducted a thorough environmental round in all resident rooms to identify any additional issues like those found in Rooms C-19-B, C-9-B, and A- 17. All identified concerns will be fixed. III. Systemic Changes: 1. The Director of Maintenance reviewed the Maintenance/Engineering policy and incorporated a procedure for Sequra (Maintenance Tracking Software) emphasizing staff responsibility for reporting environmental concerns via the work order system. Maintenance staff now follow up daily to ensure timely resolution. 2. All Management staff were educated on the updated policy and how to effectively use Sequra to track maintenance requests. IV. Quality Assurance: An audit tool was created by the Director of Maintenance to track environmental concerns. Weekly audits of all rooms will be conducted for 4 weeks by the Maintenance Director and findings will be discussed at daily meetings. A monthly audit will continue Monthly for 11 months. The results of audits and any corrective actions will be reported to QA. V. Person Responsible: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details Based on interview, and record review conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that sufficient staff was available to meet the needs of all residents on 30 days reviewed. Specifically, actual staffing levels were below minimum levels on the following dates (2/2/2/25, 2/3/25, 2/4/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, 2/16/25, 2/17/25, 2/24/25, 2/25/25, 3/1/25, and 3/3/25). The findings include: The Minimum Par Levels for Nursing Sheets documented the 7AM -3PM shift for unit A should have at least 4 Certified Nurse Aides, Unit B should have at least 3 Certified Nurse Aides, and unit C should have at least 3 Certified Nurse Aides, the 3PM-11PM shift for unit A should have at least 3 Certified Nurse Aides, unit B should have at 3 Certified Nurse Aides, and unit C should have at least 2 Certified Nurse Aides, and the 11PM-7AM shift for unit A, unit B and unit C should have at least 2 Certified Nurse Aides. The (MONTH) 2025 daily staffing sheets documented 2/2/25 11AM - 7PM 1 Certified Nurse Aides on Unit B when the minimum requirement for the night shift was 2 Certified Nurse Aides. 2/3/25 7AM-3 PM 2 Certified Nurse Aides for Unit B and 2 Certified Nurse Aides for Unit C, when the minimum requirement for Unit B and Unit C was 3 Certified Nurse Aides.2/4/25 7 AM -3PM 3 Certified Nurse Aides on Unit A when the minimum requirement was 4 Certified Nurse Aides. 2/8/25 3 PM-11PM 1 Certified Nurse Aide on Unit A when the minimum requirement was 3 Certified Nurse Aides. 2/9/25 11PM-7AM 1 Certified Nurse Aide for Unit C when the minimum requirement was 2 Certified Nurse Aides. 2/10/25 11PM -7AM 1 Certified Nurse Aide for unit B when the minimum requirement was 2 Certified Nurse Aides. 2/12/25 11PM-7AM 1 Certified Nurse Aide for unit B when the minimum requirement was 2 Certified Nurse Aides. 2/16/25 11PM -7AM 1 Certified Nurse Aide for unit B and 1 Certified Nurse Aide for unit C when the minimum requirement was 2 Certified Nurse Aides. 2/17/25 11PM-7AM 1 Certified Nurse Aide for unit B and 1 Certified Nurse Aide for unit C when the minimum requirement was 2 Certified Nurse Aides. 2/24/25 7AM- 3PM 2 Certified Nurse Aides on unit B and when the minimum requirement was 3 Certified Nurse Aides. 2/24/25 11PM- 7AM 1 Certified Nurse Aides for Unit B when the minimum requirement was 2 Certified Nurse Aides. 2/25/25 11PM-7AM 1 Certified Nurse Aide for Unit C when the minimum requirement was 2 Certified Nurse Aides. The (MONTH) 2025 daily staffing documented 3/1/25 11PM-7AM 1 Certified Nurse Aide for Unit C when the minimum requirement was 2 Certified Nurse Aides. 3/3/25 11PM-7AM 1 Certified Nurse Aide for Unit B when the minimum requirement was 2 Certified Nurse Aides. During an interview on 3/12/25 at 5:12 PM, the Director of Human Resources and Staffing stated they received the minimum staffing requirement from the regional administration. The Director of Human Resources and Staffing stated sometimes they do not have enough Certified Nurse Aides. The Director of Human Resources and Staffing stated the weekends can be tougher to fill, they have a pool or contact list for the call outs, or they ask night shift to stay on for the next shift. The Director of Human Resources and Staffing stated overtime is offered and they do have incentives and bonuses to encourage new hires and stated that the overall staffing is getting better. The Director of Human Resources and Staffing stated they had a high turnover rate for the Certified Nurse Aides but feels it has improved. The Director of Human Resources and Staffing stated when they are short staffed, they will take a Certified Nurse Aide from another unit with a lower census to replace if they cannot get a Certified Nurse Aides to come in. The Director of Human Resources and Staffing stated the staffing was short on the following dates (2/2/25, 2/3/25, 2/4/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, 2/16/25, 2/17/25, 2/24/25, 2/25/25 3/1/25, and 3/3/25) but could not say if staffing shortages directly affected resident care. NYCRR 415. 13(a)(1)(i-iii) | Plan of Correction: ApprovedApril 4, 2025 P(NAME) Tag-F725 I. Immediate Corrective Action: The Administrator, DON and HR Coordinator furthered Facility recruitment efforts including: 1) contacted CNA Training program(s) LIST 2) contacted 1199 SEIU Hiring division 3) contacted additional Staffing agencies. 4) The facility posted ads for recruitment for all open positions in the facility with Apploy and Indeed. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The Social Service Department conducted an audit with randomly selected alert residents on each unit to identify any issues related to staffing concerns and resident care issues. There were no identified issues. III. Systemic Changes: 1) The DNS and Administrator reviewed and revised the Facility Assessment to document sufficient staffing needs for each unit based on: Acuity level and Census including special care needs of residents on individual units, and any other pertinent information about the resident needs. 2) An evaluation of diseases, conditions, physical, functional, or cognitive limitations of the resident population Specific skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. The number of Nursing staff to provide services to residents and assist and monitor aides. 3). The DNS provided all Nurse manager staff with education on measures to be taken when staffing is below par levels. Highlights of the Inservice include: The responsibility of the RNS to check staff at the beginning of each shift. The need to have a contact list of available staff and agencies to be called in as needed. The responsibility of the Charge Nurse on each unit to complete an assignment sheet and update as needed for any staffing changes The responsibility of all Nursing Staff to report to Charge Nurse/RNS when any care or services cannot be provided to residents during the shift. The responsibility of the RNS to ensure resident medications, treatments and care are provided in accordance with resident plan of care. The need for ancillary staff to assist with responding to call bells and informing direct caregivers of resident needs/requests. The responsibility of the DON/Designee to contact the NYSDOH Surge and Flex if the facility implements crisis staffing plan. IV. Quality Assurance: 1) The Administrator, in conjunction with the DNS developed an audit tool to ensure that staffing levels are monitored, and all residents receive required services in accordance with resident plan of care. This audit will be done for each unit weekly x 4 weeks and monthly for 11 months. 2) The HR designee will audit the Staffing to identify date, shift and unit that that had less than sufficient staffing weekly x 4 weeks followed by monthly x 11 months 3) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Person Responsible: DON |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 2. 3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 NFPA 96 10. 10 Portable Fire Extinguishers. 10. 10. 4 Portable fire extinguishers shall be maintained in accordance with NFPA 10. 2010 NFPA 10 Standard for Portable Fire Extinguishers 7. 2. 2. 2 Where required by 7. 2. 2. 1, the following inspection procedures shall be in addition to those addressed in 7. 2. 2: (1) Verifying that operating instructions on nameplates are legible and face outward (2) Checking for broken or missing safety seals and tamper indicators (3) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle. 7. 2. 3 Corrective Action. When an inspection of any fire extinguisher reveals a deficiency in any of the conditions listed in 7. 2. 2, immediate corrective action shall be taken. 2009 17 A Standard for Wet Chemical Extinguishing Systems Chapter 7 Inspection, Maintenance, and Recharging 7. 2. 5 At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. Based on observation, documentation review and staff interview, the facility did not ensure that the Ansul system (fire suppression system) was inspected and maintained in accordance to NFPA 101, NFPA 10 and NFPA 17 A. Specifically, the inspection tag for the fire-extinguishing system (Ansul) was not signed monthly and the K extinguisher revealed the pressure gauge needle in the recharge zone and not in the full zone. The findings are: During the Life Safety recertification survey conducted on 3/20/25 at 11:40 AM, a tour of the kitchen was conducted and it was noted that the monthly inspection tag for the Ansul system (fire suppression) was blank and not signed monthly as evidence of inspections. In addition, an examination of the K extinguisher adjacent to the stove revealed that the pressure gauge needle was in the recharge zone (red) and not in the full zone (green) and the service tag on the extinguisher indicated that the extinguisher was recharged in 2024. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the tag will be signed and the vendor will be contacted. 2012 NFPA 101: 9. 2. 3 2009 NFPA 17 A: 7. 1. 4. *, 7. 2. 1 2010 NFPA 10: 6. 6. 1, NFPA 96: 10. 10 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 11, 2025 K324 I. Immediate Corrective Action: 1. Ansul System Inspection Tag: On 3/20/25, the Director of Maintenance immediately addressed the issue with the Ansul system inspection tag and signed for the current month. 2. K Extinguisher Pressure Gauge: The K extinguisher was immediately removed from service and replaced with a fully charged extinguisher, ensuring it was in the full zone (green). The service company was contacted to inspect and recharge the K extinguisher. The fire extinguisher has been replaced and recharged. II. Identification of Others: All residents have the potential to be affected. The Director of Maintenance conducted a review of all fire suppression systems and extinguishers in the facility to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's fire safety and inspection procedures. The policy was updated and reviewed to ensure that all fire suppression system inspection tags are completed and signed monthly. Maintenance staff were in serviced to consistently monitor and document inspections monthly. A?é?áchecklist was?é?áupdated?é?áfor fire extinguishers, including monthly checks of pressure gauges to ensure that all extinguishers are within the full zone. This checklist will be used by staff during routine inspections. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of monthly fire suppression system inspections and extinguisher checks. 2. Monthly audits will be performed for six months of all ansul systems and fire extinguishers to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details 2011 NFPA 70 National Electrical Code Article 400. 8 Uses not Permitted. Unless specifically permitted in 400. 7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure. Based on observation and staff interview the facility did not ensure that power strips were used in accordance with NFPA 70. Specifically, refrigerators were noted plugged into power strips instead of directly into the wall outlet and a power strip was daisy - chained to a multiple adapter in a resident room. This was noted on 1 of 2 resident floors and in the basement. The findings are: During the Life Safety recertification survey conducted on 3/19/25 at 11:50 AM, a tour of recreation office revealed a refrigerator plugged into power strip instead of the wall outlet. This same situation was noted in the Director of Nursing office on the first floor. At 1:10 PM, a tour of resident room B 27 revealed that a power strip was daisy - chained to a multiple adapter and the multiple adapter was plugged into the wall outlet. The resident's personal equipment was plugged into the power strip. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the refrigerator will be plugged directly into the wall. 2012 NFPA 70: 400. 8 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 11, 2025 K920 I. Immediate Corrective Action: 1. Refrigerators Plugged into Power Strips: On 3/19/25, the Director of Maintenance immediately disconnected the refrigerators in the Recreation Office and the Director of Nursing Office from the power strips. The refrigerators were plugged directly into wall outlets to comply with NFPA 70 standards. 2. Daisy-Chained Power Strips in Resident Room: On 3/19/25, the Director of Maintenance immediately addressed the issue in Resident Room B-27 by disconnecting the daisy-chained power strip and multiple adapters. The equipment was properly reconfigured with a single, correctly rated power strip, plugged directly into a wall outlet. The resident's personal equipment was safely reconnected. II. Identification of Others: All residents have the potential to be affected. A facility-wide audit of all power strips and adapters in resident rooms, offices, and common areas was conducted on 3/19/ 25. The audit identified no additional instances of daisy-chaining or refrigerators plugged into power strips. NO further issues were noted. III. Systemic Changes: 1. The Director of Maintenance updated the facility's Electrical Safety Policy to ensure all electrical devices, including refrigerators and personal equipment, are directly connected to wall outlets unless explicitly approved by an electrical engineer or licensed contractor. The policy now includes strict guidelines on the proper use of power strips and prohibits daisy-chaining of power strips or adapters. 2. All staff, including maintenance and housekeeping, received an in- service on NFPA 70 electrical safety standards, focusing on proper usage of power strips, avoiding daisy-chaining, and ensuring that appliances are plugged directly into outlets where applicable. 3. The facility will ensure that all residents and or family members will be informed of the proper use of power strips in the facility by the following methods: Maintenance Director will hang up signage around the facility and discuss by monthly resident council the appropriate methods to use power strips. Additionally, the Maintenance Director will draft a policy/notice that will be placed at the front desk for all families to see as well as mailing/emailing to all family members this notice on the appropriate usage of power strips. IV. Quality Assurance: 1. The Director of Maintenance created an audit tool to track compliance with NFPA 70 regarding power strips, adapters, and appliance connections. The facility will conduct monthly audits for six months of all areas to ensure that no power strips are used inappropriately or daisy chained. The results of these audits will be reported to QAPI quarterly. V. Person Responsible: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 1. 3. 1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA 110: 8. 4. 1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. The findings are: Based on observation, record review and staff interview, the facility did not ensure that the generator was maintained, and all required tests were conducted in accordance with NFPA 101 and NFPA 110. Specifically, weekly and monthly load tests for (MONTH) and (MONTH) 2024 were missing and not provided at time of survey. During the life safety recertification survey on 3/19/25 at 10:50 AM, a review of the facility's generator logs was conducted and it was noted that the weekly visual for the week of (MONTH) 29th and the first week of (MONTH) 5, 2024 was missing and the monthly load tests for (MONTH) and (MONTH) was missing and not provided at time of survey. In an interview with the Director of Maintenance on 3/20/25, the Director of Maintenance confirmed that the documentation was missing. 2012 NFPA 101: 9. 1. 3. 1 2010 NFPA 110: 8. 3. 4, 8. 4. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 K918 I. Immediate Corrective Action: 1. Missing Generator Test Records: The Administrator educated the Maintenance Director on proper Generator testing as stated in NFPA 110. To address the missed load and run tests, a load bank test was performed to simulate the expected load on the generator for (MONTH) and August 2024. The generator was started and operated under load for the appropriate duration, as specified by NFPA 110. 2. Review and Verification: There were no other discrepancies or missing records. The documentation was updated to reflect accurate and complete test results. II. Identification of Others: All residents have the potential to be affected. A full audit of the generator maintenance logs was conducted to verify that no other load tests or maintenance records were missing or incomplete. No additional missing records were identified. III. Systemic Changes: 1. The Director of Maintenance in-serviced all maintenance staff on the updated procedures for documenting generator testing and inspections, emphasizing the importance of timely and complete record-keeping. IV. Quality Assurance: 1. An audit tool was updated to track the completion and documentation of weekly visual inspections and monthly load tests for the generator. Audits will be conducted monthly for six months to ensure compliance with NFPA 101 and NFPA 110 and verify that all test logs are completed and properly documented. 3. The results of the audits will be reported to QAPI quarterly. V. Person Responsible: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 4. 1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9. 6. 2012 NFPA 101: 9. 6. 1. 3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. Table 14. 4. 5 Testing Frequencies Component Annually Table 14. 4. 2. 2 Reference 13. Retransmission Equipment (The requirements of 14. 4. 10 shall apply.) X - - - - - 14. Remote Annunciators X - - - X 11 15. Initiating Devices* 14 (a) Duct detectors X - - - X - (b) Electromechanical releasing device X - - - X - 2010 NFPA 72: 14. 6. 3. 2 Upon request, a hard copy record shall be provided to the authority having jurisdiction. Based on observation, staff interview and record review, the facility did not ensure that all devices associated with the fire alarm system were tested annually. Specifically, service reports did not include the inspection and testing of the magnetic door hold open devices and the delayed egress devices and the report for the testing of these devices was not provided at time of survey. The findings are: Documentation review of the facility's fire alarm service report was conducted on 3/20/25 at 12:30 PM and it was observed that the fire alarm system was last serviced 7/10/24 and 1/6/25 and did not include the inspection and testing of the magnetic door hold open devices and the delayed egress devices. In an interview with the Director of Maintenance the same day, the Director of Maintenance stated that the vendor will be contacted. 2012 NFPA 101 2010 NFPA 72 10 NYCRR 415. 29 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 K345 I. Immediate Corrective Action: 1. Magnetic Door Hold Open Devices & Delayed Egress Devices Testing: On 3/20/25, the Director of Maintenance immediately contacted the fire alarm service company to schedule an inspection and testing of the magnetic door hold open devices and the delayed egress devices. The testing was conducted, and a report of the inspection and testing results of these devices has been obtained and placed in the facilitys records. II. Identification of Others: The Director of Maintenance conducted a full review of all fire alarm service reports from the past 12 months to ensure that all devices, including magnetic door hold open and delayed egress devices, were properly tested and documented. Any gaps in documentation were corrected, and the necessary reports were obtained. All residents have the potential to be affected. III. Systemic Changes: 1. The Director of Maintenance updated and reviewed the facilitys fire alarm maintenance policy to ensure that all components, including magnetic door hold open devices and delayed egress devices, are tested semiannually in accordance with NFPA 101. 2. The Director of Maintenance in-serviced the maintenance staff on the updated protocols for fire alarm system testing and documentation, emphasizing the importance of comprehensive record-keeping and compliance with NFPA 101. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of fire alarm system testing, ensuring that all devices are tested annually, and reports are properly documented. 2. Monthly audits for six months will begin to ensure that all devices are properly tested and documented in the annual service reports. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the fire drills were conducted under varied conditions in accordance with NFPA 101. Specifically, attendance sheets for the fire drills conducted in the fourth quarter of 2024 was missing and not provided at time of survey. The findings are: During the Life Safety recertification survey on 3/19/25 at 10:30 AM, the fire drill log was reviewed, and it was noted that the quarterly fire drill reports conducted in the fourth quarter of 2024 for the Day, Evening and Night shifts did not include attendance sheets and it could not be determined if staff participated in the drills. In an interview with the Director of Maintenance on 3/20/25, the Director of Maintenance stated that the fire drills are conducted by an outside vendor and confirmed the missing attendance sheets. 2012 NFPA 101: 19. 7. 1. 6, 19. 7. 2. 1*, 19. 7. 2. 3. 1 10 NYCRR: 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 K712 Completion Date: (No later than 60 days from exit date 03/20/2025) (05/19/2025). I. Immediate Corrective Action: 1. Fire Drill Attendance Sheets for Fourth Quarter of 2024: ?é?À On 3/20/25, the Director of Maintenance contacted the outside vendor responsible for conducting the fire drills to request the missing attendance sheets for the Day, Evening, and Night shifts from the fourth quarter of 2024. ?é?À The vendor provided the missing attendance sheets on 3/20/25, which were then added to the facility's fire drill records for the appropriate quarter. 2. Fire Drill Documentation Review: ?é?À The Director of Maintenance immediately reviewed the fire drill documentation for all prior quarters to ensure that attendance sheets for all shifts were present and complete. II. Identification of Others: ?é?À All residents have the potential to be affected. ?é?À The Director of Maintenance conducted a review of the fire drill logs for the entire year 2024 to ensure that all attendance sheets were accounted for. III. Systemic Changes: 1. An in-service was conducted by the Director of Maintenance for all maintenance staff on the importance of verifying and maintaining complete fire drill records, including attendance sheets. ?é?À A reminder was also issued to the outside vendor to ensure that all necessary documentation is submitted following each drill. IV. Quality Assurance: 1. The Director of Maintenance established a monthly internal audit to ensure that fire drill logs, including attendance sheets, are complete and accurate. ?é?À The audit will be conducted monthly for six months, and findings will be reviewed to ensure full compliance with NFPA 101. 2. The results of the audits will be reported to QAPI quarterly. V. Person Responsible: ?é?À Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the illumination in the means of egress was continuous in accordance with NFPA 101. Specifically, the wall mounted light switches in the Rehab corridor turned off all the lights leading to the emergency stairwell exit at the end of the corridor. This was noted on 1 of 2 resident floors. The findings are: During the Life Safety recertification survey conducted on 3/19/25 at approximately 12:50 PM, a tour of the Rehab corridor revealed that the wall mounted light switches, when turned to the off position, turned off all the lights in the corridor and an emergency stairwell exit was located at the end of the corridor. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the lights in the corridor will be continuous. 2012 NFPA 101: 7. 8, 7. 8. 1, 7. 8. 1. 1, 7. 8. 1. 2, 7. 8. 1. 3*, 7. 9. 2. 3* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 K281 I. Immediate Corrective Action: 1. Rehab Corridor Lighting: The Maintenance director immediately contacted an electrician to address the lighting issue in the Rehab corridor, powering every other light for clear illumination of egress. The wall-mounted light switches that were controlling the lights leading to the emergency stairwell exit have been re-wired to ensure that the illumination in the means of egress is continuous, even when the light switches are turned off. II. Identification of Others: All residents have the potential to be affected. However, none were. All other egress routes were found to be compliant. The Director of Maintenance conducted a review of all light switches and emergency exit routes on both residents floors to ensure compliance with NFPA 101, identifying and addressing any similar concerns. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's Life Safety procedures, ensuring maintenance staff are trained in NFPA 101 requirements for the illumination of means of egress. The training included instructions on how to ensure continuous illumination for safe exits. Maintenance staff were re-educated on the importance of maintaining proper lighting on all exit routes, with an emphasis on the emergency stairwell. 2. Regular checks on all emergency lighting systems during routine inspection were added to the routine maintenance checklist ensuring all corridors and exits are properly illuminated and compliant with NFPA 101. IV. Quality Assurance: 1. A tracking tool was developed by the Director of Maintenance to ensure ongoing compliance with lighting and means of egress standards. 2. Monthly audits of all exit routes will begin to ensure that lighting remains compliant with NFPA 101, and any identified issues will be corrected promptly. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 20, 2025
Corrected date: N/A
Citation Details Based on observation, documentation review and staff interview, the facility did not ensure that the fire doors were maintained in accordance with NFPA 101 and NFPA 80. Specifically, the fire rated labels on the fire doors were observed covered with paint and or illegible. This was noted in the basement and on 1 of 2 resident floors. The findings are: During the Life Safety survey on 3/19/24 at 11:35 AM, a tour of the basement revealed that the fire rated label on the center stairwell door was observed covered with paint. This same situation was noted on the fire door to the soiled utility room, storage room in corridor D, the stairwell door in Corridor 3 and the fire rated label on the door to the clean linen room on B even side was illegible. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the paint will be removed. 2012 NFPA 101: 19. 2. 1, 7. 2. 1. 15. 3 2010 NFPA 80: 4. 4. 5 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 11, 2025 K761 I. Immediate Corrective Action: 1. Fire Door Labels Covered with Paint/Illegible: On 3/19/25, the Director of Maintenance conducted an immediate inspection of all fire doors with illegible or covered fire-rated labels. The paint was removed from the labels on the center stairwell door, soiled utility room door, storage room door in corridor D, stairwell door in corridor 3, and the clean linen room door on the B even side by 3/20/ 25. All of the above referenced fire rated labels are now legible. II. Identification of Others: All residents have the potential to be affected. A thorough inspection of all fire doors within the facility was conducted to ensure no other fire-rated labels were covered or illegible. No other issues were found, but the Director of Maintenance has implemented a regular inspection schedule for fire doors to prevent the recurrence of this issue. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's policy on fire door maintenance to ensure that all fire-rated labels are always clearly visible and legible. 2. The Director of Maintenance in- serviced for all maintenance staff on the importance of maintaining clear and legible fire-rated labels and ensuring fire doors remain in compliance with NFPA 101 and NFPA 80. IV. Quality Assurance: 1. The Director of Maintenance created an audit tool to track the status of fire door label visibility. Monthly audits will be conducted for six months with findings reviewed to ensure that all fire door labels are visible and legible. 2. The results of monthly audits will be reported to QAPI quarterly. V. Person Responsible: Director of Maintenance |
Scope: N/A
Severity: N/A
Citation date: March 20, 2025
Corrected date: N/A
Citation Details Details not available | 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: March 20, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 Life Safety Code 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 2010 NFPA 13 8. 15. 3. 2. 1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. Based on observation and staff interview, the facility did not ensure that sprinklers were installed throughout the premises in accordance with NFPA 101 and NFPA 13. Specifically, 1. Sprinkler coverage was not observed in the alcove area in the soiled utility discharge linen chute room. 2. Dry Sprinkler coverage was missing in the walk - in box used for storage, and 3. Sprinkler coverage was not observed under the first accessible landing in a stairwell. This was noted in 1 of 3 emergency exit stairwells on 2 of 2 resident floors and in the basement. The findings are: During the life safety recertification survey on 3/19/25 between the hour of 9:30 AM and 3:30 PM, the following issues were noted: At approximately 11:40 AM, a tour of the soiled utility discharge room revealed sprinkler coverage was missing in the alcove area adjacent to the discharge chute. At approximately 12:00 PM, a tour of the storage room on corridor D revealed that the walk- in box in the room was used for dry storage and sprinkler coverage was not provided in the walk- in box. At approximately 12:50 PM, a tour of stairwell located in corridor 4 in the basement accessible from Old Rehab was conducted, and it was noted that sprinkler coverage was not provided under the first accessible landing. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the vendor will be contacted. 2012 NFPA 101: 19. 3. 5. 1 2010 NFPA 13: 8. 15. 3. 2. 1, 8. 15. 3. 3* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 K351 I. Immediate Corrective Action: 1. Soiled Utility Discharge Linen Chute Room (Alcove Area): On 3/19/25, the Director of Maintenance immediately arranged for an inspection and installation of sprinkler coverage in the alcove area adjacent to the discharge chute in the soiled utility room. Sprinkler coverage was installed and tested by a certified sprinkler contractor on 3/19/25, ensuring compliance with NFPA 101 and NFPA 13 standards. 2. Walk-In Storage Box: On 3/19/25, the Director of Maintenance contacted a certified contractor to install the missing dry sprinkler coverage in the walk-in box used for storage in the storage room on corridor D. Sprinkler coverage was installed and tested by the contractor on 3/19/25, ensuring full compliance with NFPA 101 and NFPA 13. 3. Stairwell Landing (Basement): A sprinkler contractor was contacted to install sprinkler coverage under the first accessible landing in the emergency exit stairwell located in corridor 4 in the basement. The missing sprinkler coverage was installed and tested ensuring compliance with NFPA 101 and NFPA 13. II. Identification of Others: All residents have the potential to be affected. The Director of Maintenance conducted a thorough inspection of all other stairwells, utility rooms, and storage areas on the premises to ensure there are no further gaps in sprinkler coverage. Additional checks were made to verify compliance in all areas, and no further issues were found. III. Systemic Changes: 1. The Director of Maintenance reviewed the facilitys sprinkler system installation policy to ensure that all areas, including utility rooms, storage spaces, and stairwells, are covered in accordance with NFPA 101 and NFPA 13. A new protocol was implemented for regular, detailed inspections of sprinkler coverage during routine maintenance rounds to ensure no areas are missed in the future. 2. A review of all floor plans was conducted to verify that sprinkler coverage is properly indicated and confirmed for all spaces. 3. The Director of Maintenance in-serviced to understand the importance of compliance with sprinkler installation standards and the process for identifying and addressing gaps in coverage. IV. Quality Assurance: 1. A new audit tool was created by the Director of Maintenance to track the status of sprinkler system coverage throughout the facility, ensuring ongoing compliance with NFPA 101 and NFPA 13. Monthly inspections and audits of all sprinkler systems, including utility rooms, storage areas, and stairwells, will be conducted with findings documented for review. 2. The results of the audits and any corrective actions will be reported to QAPI quarterly. V. Person Responsible: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 20, 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: 5. 2. 1. 1. 1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 5. 2. 1. 1. 2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (6) Painting unless painted by the sprinkler manufacturer 5. 2. 1. 1. 3* Any sprinkler that has been installed in the incorrect orientation shall be replaced. 5. 2. 1. 1. 4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation Based on observation and staff interview the facility did not ensure that sprinklers were maintained in accordance with NFPA 101 and NFPA 25. Specifically, 1. Quarterly sprinkler sprinkler missing for the year 2024 2. Sprinklers in the laundry room, dishwashing room and the family lounge area, exhibited signs of corrosion and or missing escutcheon plates, and 3. Water pressure gauges were observed outdated. These issues were noted in the basement and on 1 of 2 resident floors. The findings are: During the life safety recertification survey on 3/19/25 and 3/20/25 between the hours of 9:30 and 3:00 PM, the following issues were observed: On 3/19/25 at approximately 10:30 AM, documentation review of the facility sprinkler service reports revealed that the quarterly sprinkler report for the third quarter, for the year 2024 was missing and not provide at time of survey. At approximately 11:40 AM, a tour of the housekeeping closet in the laundry room revealed the sprinkler exhibited signs of corrosion (green color) and missing an escutcheon plate. At 12:05 PM the same day, a tour of the storage / sprinkler room was conducted and it was observed that 2 of 2 water pressure gauges on the sprinkler system indicated the year (YEAR) and documentation that the water pressure gauges were re-calibrated or replaced was not provided at time of survey. At 12:35 PM, a tour of the Beauty Salon revealed a unknown substance on the sprinklers in the room. In an interview with the Director of Maintenance at the time of the finding, the Director of Maintenance stated that the vendor will assess the sprinklers. At 1:40 PM, a tour of the family lounge area revealed 3 of 4 sprinklers exhibiting signs of corrosion. On 3/20/25 at 11:40 AM, a tour of the kitchen was conducted and it was noted that 3 of 3 sprinklers in the dishwashing room exhibited signs of corrosion (green color) and 1 of 3 of the sprinklers was missing an escutcheon plate. In an interview with the Director of Maintenance at the time of the finding on 3/19/25, the Director of Maintenance stated that the vendor will be contacted. 2012 NFPA 101: 9. 7. 5, 8. 5. 6 2011 NFPA 25: 5. 2. 1. 1. 1*, 5. 2. 1. 1. 2, 5. 3. 2. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 10, 2025 K353 I. Immediate Corrective Action: 1. Quarterly Sprinkler Report for 2024: On 3/19/25, the Director of Maintenance contacted the sprinkler service vendor to request the missing third-quarter report for 2024. The report was obtained on 3/20/25 and placed in the facilitys records to ensure compliance with NFPA 101 and NFPA 25. 2. Sprinkler Corrosion and Missing Escutcheon Plates: On 3/19/25, the Director of Maintenance immediately contacted a certified sprinkler contractor to assess and address the corrosion and missing escutcheon plates on sprinklers in the laundry room, dishwashing room, family lounge area, and Beauty Salon. The vendor inspected and replaced corroded sprinklers and installed missing escutcheon plates on 3/20/ 25. 3. Water Pressure Gauges: On 3/19/25, the Director of Maintenance arranged for the recalibration or replacement of outdated water pressure gauges. The water pressure gauges have been replaced by a certified vendor. 4. Substance on Sprinklers (Beauty Salon): On 3/19/25, the Director of Maintenance immediately arranged for the cleaning and inspection of the sprinklers in the Beauty Salon, where an unknown substance was found. The sprinklers were replaced on 3/20/ 25. II. Identification of Others: The Director of Maintenance conducted a full inspection of all sprinkler systems in the facility, including those in other common areas, to ensure no additional sprinklers were corroded or missing escutcheon plates. All residents have the potential to be affected. No additional issues were found, but ongoing checks will be implemented to prevent future occurrences. III. Systemic Changes: 1. The Director of Maintenance reviewed the facilitys sprinkler maintenance policy to ensure all quarterly sprinkler inspections are properly documented and provided in a timely manner. Maintenance staff will now inspect all sprinklers monthly for six months to ensure no corrosion or damage is present. IV. Quality Assurance: 1. A new audit tool was created by the Director of Maintenance to track the status of sprinkler system maintenance, including quarterly inspections and repairs. 2. The results of monthly audits will be reported to QAPI quarterly, with any corrective actions taken promptly. V. Person Responsible: Director of Maintenance |
Scope: N/A
Severity: N/A
Citation date: March 20, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |