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NYS Health Profiles
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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 483. 90 The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. (d) Space and equipment. The facility must (2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. 415. 29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. (b) Equipment. The nursing home shall maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. (j) Housekeeping. (1) The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be clean. The facility shall be maintained in good repair including, but limited to buildings, utilities, fixed equipment, resident care equipment and furnishings. Based on observations, interviews, and record review conducted during the Abbreviated Survey (Complaint NY 340), the facility failed to maintain their heating system in proper working conditions and to adequately maintain the residents' rooms windows to provide a healthy, functional, and comfortable environment for residents, personnel and the public in accordance with 42 CFR Part 483 and 10 NYCRR: 415. 29. Specifically: 1. Hot water coil heating system in several resident rooms and a shower room were not delivering heat. 2. Portable heating units were observed in use in some resident rooms. 3. Three out of four resident's shower rooms were not provided with any type of heating system. 4. Residents rooms' windows were not properly maintained to prevent air drafts. 5. There was no maintenance system in place to ensure that the building and utilities were maintained in good repair and safe operating condition to protect the health and safety of residents, personnel and the public. This resulted in causing temperatures in residents' rooms, shower rooms and common areas in three of three nursing units to fall below the required range. The findings are: On 01/16/2025, from approximately 10:00 AM to 12:30 PM, and again from 3:45 PM to 4:30 PM temperatures observed in resident rooms, shower rooms, corridors, and staff and visitor restrooms were below State and Federal required ranges. Temperatures at resident rooms in the East and North units were observed between 63 - 69 degrees Fahrenheit. Temperatures in the shower rooms in East, West and North units were 64 - 65 degrees Fahrenheit. Temperature in the rehabilitation gym was at 67. 1 degrees Fahrenheit, dining/activities room was 66 degrees Fahrenheit. Corridors in the North unit at 65 degrees Fahrenheit. In addition, some residents' rooms were observed with air drafts coming from windows and heating coil units not working at all or not working properly to maintain the temperature at required levels. Observations included, but not limited to the following: East unit: -room [ROOM NUMBER]: Temperature 69 -70 F. observed with bottom window frame covered with a towel and a portable heater in use. -room [ROOM NUMBER]: Temperature range 63 - 65 F. Residents' window observed covered with plastic and blue tape around the edges. Air draft felt coming from the window opening. A portable heater observed in use. -room [ROOM NUMBER]: observed with plastic cover outside the window and a portable heater in use. -room [ROOM NUMBER]: temperature 68 F. The Director of Maintenance(DOM), who was present at the time of observation stated that the unit needs the motor changed, they don't remember the last time the motor was changed and that everything is done in house. -room [ROOM NUMBER]: window covered with towels. -room [ROOM NUMBER]: 67. 4 F. -room [ROOM NUMBER]: 66 F, heat not blowing off from the unit. -room [ROOM NUMBER]: 68. 2 F. -room [ROOM NUMBER]: temperature 70 F - 71. 4 F and 70. 3 - 69. 8 F towels observed in the windows, draft coming from the windows gaskets. -room [ROOM NUMBER]: 70 F, windows covered with plastic. -Shower room: 64. 9 F. There is no heating system installed. North unit: -room [ROOM NUMBER]: Room at 70. 9 F. Toilet observed at 53 F. -room [ROOM NUMBER]: 63. 5 F. Air draft coming from the window. A portable heater observed in use. The heating coil unit observed covered with resident's clothes, and the other unit observed shut off. -room [ROOM NUMBER]: A portable heater observed in use in 44A, the temperature registered at 74 F, and in 44B the temperature registered at 69 F, the resident on side 44 B stated that they like the room to be cold. -room [ROOM NUMBER]: 69 - 70 F, window covered with plastic. -room [ROOM NUMBER]: 67 F. Unit not working properly. The DOM stated that the unit needs motor replacement. -room [ROOM NUMBER]: 67F. Heating coil unit observed to be off. -room [ROOM NUMBER]: 66 F. Heating coil unit's motor in disrepair. - Shower room: 64 F. Heating coil unit not working. The DOM stated that they will replace the motor of the unit. -Corridor 64. 9 F - 67. 1. West Unit -Shower room [ROOM NUMBER] - 65. 9 F. -Shower room [ROOM NUMBER] - 61. 7 F The DOM stated that there is no heat system in the above shower rooms. Common Areas: -Rehab gym: 67. 1 F - Activities room/dining room: 66 - 67 F. Air draft coming from the bottom of the heating coil units. The DOM stated that they can close the bottom of the heating coil units. -The staff restroom located by the lobby: 44 F. -The visitors' restroom: 42F. On 01/16/25 at approximately 12:15 PM, the Director of Maintenance (DOM) was interviewed and stated the following: -They were not aware that the resident rooms and common areas were below regulatory temperature ranges. -They have not received any complaints from residents or staff. -They do not take air temperatures every day. -The heating system for the East and North units comes from the boiler to the heating coil units in resident rooms, and in corridors is through air handlers. -The heating system at the facility in the East and North units has not been changed since they began working at the facility in 2013. -They changed the motor of the unit that provides heat to the corridor in the North Unit about a year ago. Further stating that the motor usually last 3 - 4 years. -Residents can shut on / off the heating coil units by themselves. -Residents can open the windows by themselves. -They do not do frequent windows checks; they check the windows on as needed basis and check to see if the windows are cracked or broken. -There is no heating system in the showers rooms of the West and North units. -They do not have a regular maintenance schedule, and everything is done on as a needed basis. -Environmental rounds are done once per month, and they are done to check what is wrong or not working, but they do not document it. -They have put plastic covers on some resident room's windows to prevent the air drafts, and that they have replaced the motor in some of the coil heating units. On, 01/16/25 at approximately 12:53 PM, the Administrator stated that they did provide portable space heaters to residents that request it to make them more comfortable, not because there were any issues with the heating system, and did not know that there was a problem with the heating system, The Administrator further stated that they have not received any complaints from residents; some residents like to have the heat off and some other residents open the windows; that are residents that like to have their rooms colder and others warmer. On 01/16/25 at approximately 4:30 PM, the Director of Maintenance (DOM) stated that they will check the windows for air drafts and will cover them with plastic from the outside, will continue to replace the motors in the malfunctioning coil heating units, and will take a look at the options to install heat in residents' shower rooms. Further stating that all repairs will be done in house as they do have available parts for the heating coil units in the basement. On 01/16/25 at approximately 5:45 PM, document review of the temperature logs, revealed that air temperatures were only taken in two separate instances, both related to heating complaints made to the Department of Health. First instance, intake NY 610, temperatures taken only on 12/01/2024 | Plan of Correction: ApprovedFebruary 17, 2025 i. Residents rooms that were below 70 were immediately offered a room change. i.a The Administrator and Director of Maintenance in consultation with plumber/boiler vendor did a complete assessment of the heating system and identified multiple issues. 1. Hallway thermostat schedule wasn't set properly. 2. Visitor Bathroom heater was defective. 3. One boiler would go into standby mode 4. Some windows needed to be resealed 5. Some rooms were missing insulation above the windows 6. Some of the vents on the room units were in the open position 7. Some units fan blower motors need to be replaced 8. East Shower room, one West shower room didn't have heating units 9. One west shower room, North shower room heating unit weren't working. i.b 1. Hallway thermostat was reprogramed, a lock box was replaced with access restricted to maintenance 2. Visitor Bathroom heater was replaced, staff bathroom repaired 3. Computer control board on the boiler was replaced 4. Windows were resealed 5. Insulation above the windows was replaced 6. All vents were checked and closed 7. All blower motors were checked and those that were broken were replaced 8. A ductless unit was installed in the East Shower room, A ductless unit was installed in the West shower room 9. West shower room heating unit was repaired, A ductless unit was installed in the North shower room ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is function properly and a daily room temperature log will be added to the daily room check log. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for F908 tag |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Abbreviated Survey case #NY 340 and initiated on 1/15/2025, the facility did not ensure that residents have the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely, including that the physical layout of the facility maximizes resident independence and does not create a safety risk. This was identified for 8 of 18 residents reviewed for Quality of Care. Specifically, a complaint was received reporting that the East unit of the facility was freezing cold affecting all the residents on that unit. The finding is: The facility's policy titled; 'Cold Weather Emergency' updated 1/16/2025 documented under Plan A Residents are to be checked and temperatures are to be taken immediately on all residents. All rooms are to have adequate supply of blankets. If temperatures are below 70 degrees Fahrenheit resident's temperatures will be taken every four hours. An observation tour was conducted on 1/15/2025 at 10:45 AM on the East and West unit. Multiple residents were observed in their beds, some residents were covering with four blankets. Electrical space heaters were noted in 5 resident's room. Residents were sitting in the hallway wearing thick robes, sweatshirts with hoods on their heads. During an interview with Resident #8 on 1/15/2025 at 2:39 PM they stated they have Arthritis, and they are always cold. Resident #8 stated their legs stiffens up and makes it difficult for them to go to Physical Therapy. During an interview with Resident #2 on 1/15/2025 at 10:48 AM, they stated staff will not turn up the heat when they complain about being cold. The resident also stated they believe the heat goes off at nights because it gets so much colder. Resident #2 stated they do not eat in the main dining area because it's too cold and they would rather eat in their room, which is also cold but not as cold of the dining room. During an interview with Resident #10 on 1/15/2025 at 3:01 PM they stated they shiver until they fall asleep at night. They also stated that they put boxes in front of their bedroom window to prevent the draft at night when they are in bed. Resident #10 stated that it is cold all day but worse at night. During an interview with Resident #11 on 1/15/2025 at 3:10 PM they stated they spoke to the Administrator, (does not recall their name), about being cold. The Resident stated they have [MEDICAL CONDITION] and Arthritis, and the cold affects their legs and makes it difficult in Physical Therapy. The resident stated that the Administrator brought a space heater in their room. Resident #11 stated even with the space heater they are still cold. The facility did not have documented evidence they had identified that resident's room temperatures were at a safe and comfortable range. The facility could not provide any documentation that room temperatures were monitored to ensure comfortability. During an interview on 1/16/25 at 1:54 PM the Director of Maintenance stated that the windows in some of the rooms caused drafts in the winter. The Director of Maintenance further stated that plastics are placed over the windows to seal and prevent draft. The Director of Maintenance acknowledged that residents still complained of lack of heat and those residents were provided with space heaters. The Director of Maintenance also stated that the East and North Units have an older heating system and need repairs. The repairs are expensive and will take a long time. During an interview with the Administrator on 1/16/2025 at 4:48 PM and 5:42 PM they stated that they were not aware that there were room temperatures below 70 degrees. They stated that when residents complained that they were cold they were offered space heaters and room changes. The Administrator stated that they were not aware that the heating units in some rooms were not radiating heat. During an interview with Registered Nurse #2 on 1/15/2025 at 5:05 PM they stated some of the residents complained of being cold at night. Registered Nurse #2 stated that sometimes they would set up a space heater at the nursing station and have the residents gather around the heater and close the double doors to the unit to try to keep the unit warm. Registered Nurse #2 stated they told Maintenance regarding the issues with the heat. 10 NYCRR 483. 10 (i)(1) | Plan of Correction: ApprovedFebruary 20, 2025 i. Residents rooms that were below 70 were immediately offered a room change. i.a The Administrator and Director of Maintenance in consultation with plumber/boiler vendor did a complete assessment of the heating system and identified multiple issues. 1. Hallway thermostat schedule wasn't set properly. 2. Visitor Bathroom heater was defective. 3. One boiler would go into standby mode 4. Some windows needed to be resealed 5. Some rooms were missing insulation above the windows 6. Some of the vents on the room units were in the open position 7. Some units fan blower motors need to be replaced 8. East Shower room, one West shower room didn't have heating units 9. One west shower room, North shower room heating unit weren't working. i.b 1. Hallway thermostat was reprogramed, a lock box was replaced with access restricted to maintenance 2. Visitor Bathroom heater was replaced, staff bathroom repaired 3. Computer control board on the boiler was replaced 4. Windows were resealed 5. Insulation above the windows was replaced 6. All vents were checked and closed 7. All blower motors were checked and those that were broken were replaced 8. A ductless unit was installed in the East Shower room, A ductless unit was installed in the West shower room 9. West shower room heating unit was repaired, A ductless unit was installed in the North shower room ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is function properly and a daily room temperature log will be added to the daily room check log. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for F584 tag |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 3, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |