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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: February 26, 2025
Citation Details None | 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: February 26, 2025
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 - 12/03/2024 - 12/04/24- 12/05/24 records temperatures range at 71. 2 -78 F. And, second instance, intake NY 340, the DOM provided the logs for temperatures taken on 01/10/25 -1/13/25 - 1/14/25 records temperatures range at 72. 2 - 77. 1 F. The DOM stated that they don't have a temperature policy, and that is something that they are going to incorporate, in addition to take daily air temperatures and create an air temperature log. On, 01/17/25 at approximately 10:05 AM, the Director of Maintenance stated that the plumbing company was scheduled to be at the facility that day in the afternoon to check on the heating system; residents from some of the affected rooms were moved to another rooms, and for the residents that stayed in their rooms extra blankets were provided, the windows were covered with plastic on both sides , further stating that they will check for air draft in windows, will caulk them and strip from outside; they will try to do the repairs in house, and if not possible will outsourced. And that they will install split units or electric ceiling panel heaters in the shower rooms. Further stating that the motor in the heating coil unit in room [ROOM NUMBER] was already replaced. On 01/17/25 at approximately 2:30 PM, the Administrator stated that they are doing repairs to the heating coil units, insulating windows, replacing motors, making sure there is no obstructions on the heating coil unit; they reached out to a boiler vendor to look at the heating system to see why this particular rooms are not working. He stated that believes the HVAC system is checked quarterly for the whole facility, and that there has to be a log on maintenance, and that there are no maintenance logs for the windows. He stated that they can call on the same day to install duct less heat units on the residents' showers. On 01/17/25, at approximately 2:50 PM, the DOM, provided a HVAC service log dated 10/05, 10/06, 1/23, and 6/3,the logs did not include the year, the DOM stated that it was from last year. The logs indicate locations on the West unit, but did not record anything on the East and North units. No other maintenance records were provided to indicate regular inspection and maintenance of the facility's heating system for all three nursing units. On 01/17/25, at approximately 5:07 PM, document review of the facility's work orders provided from 10/02/24 to 01/13/25, specifies that the heat was put on 11/8/24, no additional information contained within the document specifies the check and maintenance of heating coil units in resident rooms or residents' rooms' windows checks. On 01/31/25, at approximately 10:45 AM, document review of the facility's policy named Cold Weather Emergency, with an updated date 01/16/ 25. The policy states that a Plan A will be established for any room where the temperature drops below 70 F. And a Plan B if the temperature drops below 60 F. Plan A states the following actions for Housekeeping staff: The department will check all windows for drafts. Curtains or drapes will be drawn to minimize drafts and air flow. Sealing of air leaks will be called to the attention of the Maintenance Department. And, for Maintenance staff: The department staff will check all heating units for maximum productivity on notification of air leaks in or around windows or doors, sealant will be used by the maintenance department of effectuate stoppage. The room will be temperature-checked on a one-hour basis. Under Departmental Responsibilities Under Both Plans: Housekeeping must go to each room to check all windows and drapers are closed tightly and drafts sealed. Maintenance Department is to check units to ascertain that all systems are functioning adequately, each heating unit is to be checked individually throughout the building. The policy did not indicate how temperatures should be taken and documented. On 01/31/25, at approximately 11:25 AM, document review of the Plumbing, Heating and Cooling vendors invoice dated 01/20/25 detailed a service call, but no scope of the work provided and or needed to the heating system was included. In addition, no manufacture specifications for the coil heating units were provided for review. ??? 483. 90(d) (2) 415. 29(b), (j) (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: February 11, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |