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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 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 3/26/2025-4/1/2025, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 (Residents #90) of 5 residents reviewed for Activities of a Daily Living. Specifically, Resident #90, who required supervision with Activities of Daily Living, was observed during multiple observations with long, greasy hair, an unshaven face, and long, ungroomed fingernails. The findings include: The Policy and Procedure titled Activities of Daily Living was last reviewed on 10/1/2024 and documented. This center's policy is to provide activities of daily living care to all residents based on an assessment of their needs. Resident #90 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (a resident assessment tool) dated 3/13/2025 documented Resident #90 had severely impaired cognition and needed supervision or touching assistance (assistance is provided throughout the activity) with toileting, dressing, and personal hygiene. A resident care plan dated 3/21/2024 titled Activities of Daily Living documented the resident required supervision for personal hygiene. A physician order [REDACTED]. During an observation on 3/26/2025 at 10:30 AM, Resident # 90 was lying in bed with long, greasy hair, an unshaven face, and dirty, jagged fingernails. During an interview on 03/27/25 at 9:02 AM, the resident's family member stated on their last visit, the resident needed a haircut, shave, and nails trimmed. During an observation on 3/28/2025 at 10:48 AM, the resident was lying in bed with long, greasy hair and dirty, jagged fingernails. During an observation on 3/31/25 10 00 AM, the resident is in bed with long, jagged fingernails and greasy hair. During an interview on 04/01/25 at 1:05 PM, Certified Nurse Aide #17 stated they provided activities of daily living care to residents on the unit. They stated personal hygiene was provided daily and they were responsible for cutting and grooming residents' nails. They stated there was not always enough time to perform all the tasks. During an interview on 04/01/25 at 01:06 PM, the Licensed Practical Nurse # 18 stated the certified nurse aide was responsible for the resident's hygiene. They stated the Licensed Practical Nurse supervised and should ensure the hygiene was done. They stated the resident needed their nails trimmed and cleaned, face shaved, and a shower. During an interview on 04/01/25 at 1:10 PM, Registered Nurse Unit Manager #11 stated that the expectation was that Certified Nurse Aides provided all residents with nail care (cutting and grooming). They stated that Nurses and Nurse Managers on the unit were responsible for supervision to ensure tasks were completed. They stated that residents should not have long and ungroomed nails or unshaven and greasy hair. 10 NYCRR 415. 12(a)(2) | Plan of Correction: ApprovedApril 23, 2025 Corrective Actions for Residents Identified ADL care Provided for Dependent Residents. Resident #90 did not suffer ill effect from deficient practice. Residents who are dependent will be provided with ADL care every shift as evidenced by appearance will be well groomed. Nails will be trimmed and clean. Hair will be washed and without odor. Facial hair will be shaved to residents liking. Upon notification of this deficiency Resident #90 was immediately provided nail care, shaved and had his hair washed and groomed. Resident 90 was assessed and appeared to suffer no ill effects as a result of this deficient practice. Nurse Aide #17 was immediately reeducated regarding providing all ADL and grooming care to residents daily as ordered. Nurse Aide #17 was also provided guidance on time management to assist with completion of all tasks. LPN #18 and Nurse Manager #11 were both provided education regarding supervising Nurse Aides care to ensure all ordered cares were provided. Resident at Risk Dependent residents can be affected by this deficient practice The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficiency. All other residents appeared to be appropriately groomed. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Change All nursing staff (CNAs and Nurses) will be provided in-service education in regard to expected care of residents by Nurse Staff Educator/Designee. Specifically, residents who require total assistance with care. ADL level of care is listed on Resident Care profile card in EMR. The Administrator reviewed the facilitys policy on Activities of Daily Living and found it to be incompliance with all State and Federal Regulations. Education regarding the provision of daily ADL care, and grooming was provided to all nursing staff. Education regarding supervising CNAs to ensure daily grooming is provided to all residents, was provided to all nurses. Monitoring of Corrective Actions The DON has created an audit to ensure that daily grooming and ADL care is provided to all residents on a daily basis. Audits will be conducted on resident hygiene and Grooming on all units daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS The DNS/Designee will be responsible for completion of this plan of correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey on 03/26/2025-04/01/2025, the facility did not ensure each staff was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with for 2 of 10 staff reviewed for COVID-19 vaccines. Specifically, there was no documented evidence of immunization records for Covid-19 vaccination for Certified Nurse Aide #1, and Certified Nurse Aide # 2. Findings include: The facility policy titled COVID-19 revised 11/20/2024, documented it is the policy of the facility to follow the regulatory guidelines for COVID- 19. In addition, providing all staff and residents who declined to be vaccinated a written affirmation of their signature, which indicates they were offered the opportunity for COVID-19 vaccination but declined. The New Hire Report dated 3/26/25, documented Certified Nurse Aide #1 was hired 3/19/25 and Certified Nurse Aide #2 was hired 3/5/ 25. The facility's immunization records for staff revealed Certified Nurse Aide #1 and #2 had no record of Covid-19 immunization, education, or declination documented. During an interview on 03/31/2025 at 5:08 PM, the Infection Control Preventionist/ Assistant Director of Nursing stated the facility offered immunization to staff and residents for Covid-19, Influenza, and pneumococcal vaccination. In addition, [MEDICAL CONDITION] vaccination was offered to the staff. During a follow-up interview on 03/31/2025 at 5:19 PM, the Infection Control Preventionist/Assistant Director of Nursing stated the two certified nurse aides were newly hired and had been given a verbal consent or education. They stated there was no documentation the education was provided, and they did not find declinations in their records. During an interview on 03/31/2025 at 5:23 PM, the Director of Nursing stated they were not aware that the two certified nurse aides did not have any documentation of Covid-19 vaccination, education or declination on their records. 10NYCRR 415. 19 (a) (1-3) | Plan of Correction: ApprovedApril 23, 2025 Corrective Actions for Residents Identified CNA #1 and CNA #2 was offered COVID-19 vaccine Residents at Risk No resident at risk by deficient practice No resident at risk by deficient practice. An audit of new hires was conducted to ensure all new hires have either received the covid-19 vaccine or have a declination signed on file. Systemic Changes The facility reviewed Policy and Procedure COVID-19 no revision needed. Education to Assistant Director of Nursing on the Policy and Procedure COVID-19 All new hires will be offered the covid vaccination upon start of employment if they have not received. The facility reviewed Policy and Procedure COVID-19 no revision needed. Education to Assistant Director of Nursing on the Policy and Procedure COVID-19 All new hires will be offered the covid vaccination upon start of employment if they have not received. The facility reviewed Policy and Procedure COVID-19 no revision needed. Education to Assistant Director of Nursing on the Policy and Procedure COVID-19 All new hires will be offered the covid vaccination upon start of employment if they have not received. Audit tool created to ensure declination is received if staff does not have covid vaccine. Monitoring of Corrective Actions The Director of Nursing or Designee will review all new hires to ensure the facility has a declination on file should the staff choose not to be vaccinated. Bi-weekly x 8 weeks, then monthly x 3 months. Any issues noted will be addressed immediately and reported to the administrator. On a monthly basis the Director of Nursing will report the findings to the Administrator On a monthly basis the Director of Nursing or Designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey from 3/26/2025- 4/1/2025, the facility did not ensure that needed services, care, and equipment were provided to ensure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for 1 of 6 residents (Resident #40) reviewed for position and mobility. Specifically, Resident #40 was observed three times without a left palm guard in place, as ordered by the physician, to prevent further contractures. Findings include: The Policy and Procedure titled Issues of Splints, Orthoses, and Prostheses, last reviewed 8/17/2024, documented that the Nursing department will take responsibility for daily applications and removal of devices, and the Nurse Manager will be responsible for ensuring that the information is entered in the Certified Nurse Aide Accountability Record. Resident #40 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (resident assessment tool) dated 2/2/2025 documented the resident had severely impaired cognition, an impairment to the upper extremity on one side, and was dependent on staff with activities of daily living. The Comprehensive Care Plan for Activity of Daily Living, last updated 3/21/2022, documented that the resident will maintain optimal function range of motion to joints. Interventions included applying the left palm guard to the left hand daily. The physician's orders [REDACTED]. An occupational therapy evaluation & treatment plan for the certification period 4/26/2024- 5/25/2024 documented the application of left-hand roll 80% of the time to prevent contractures. During observations on 3/26/2025 at 12:26 PM, 3/29/2025 at 2:19 PM, and 3/31/2025 at 4:46 PM, Resident #40 was sitting in their wheelchair in the 2nd-floor dayroom. Both of the resident's hands were contracted, and no palm guard was noted. During an interview on 04/01/25 at 1:16 PM, Certified Nurse Aide #8 stated they did not apply the resident's device to her left hand. They further stated they were responsible for placing the palm guard, and knew they were supposed to but they did not do it. During an interview, 04/01/25 at 1:19 PM, Registered Nurse Manager #10 stated they were unaware that Resident #40 was not wearing their left palm guard. During an interview on 04/01/25 at 9:40 AM, the Director of Rehabilitation stated that the left palm guard was to prevent the contracture from worsening and also to prevent the resident from fingernails digging into her hand. They stated nurses were responsible for applying the device. 10NYCRR: 415. 12(e)(2) | Plan of Correction: ApprovedApril 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Upon notification of this deficiency, resident #40 was reassessed and noted to have no new injuries nor ill effects as a result of this deficient practice. Resident 40 left palm guard was immediately placed Palm guard placed in treatment orders to be signed off by nurse Nurse manager #10 and CAN #8 were both provided education on ensuring that resident devices were placed daily as per order. Residents at Risk The Director of Nursing conducted and audit to identify any other resident that may have been affected by this deficiency, and no other resident was identified. While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes The facility reviewed Policy and Procedure titled Issues of Splints, Orthoses, and Prostheses and no revision is needed. All nursing staff will be educated on policy listed above and the importance of placing adaptive equipment per physician order. An audit tool was created by the DON to ensure compliance with adaptive equipment for individuals with limited position and mobility. Monitoring of Corrective Actions The Director of Nursing or Designee will randomly observe 3-5 residents who has limited position and mobility to ensure their equipment are being used and physician orders [REDACTED]. Any issues noted will be addressed immediately and reported to the administrator. On a monthly basis the Director of Nursing will report the findings to the Administrator On a monthly basis the Director of Nursing or Designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey from 3/26/25 to 4/1/25, the facility did not ensure an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection was maintained for 2 of 3 residents (Residents #129 and #118) reviewed for Infection Control. Specifically, 1) Licensed Practical Nurse #21 and Certified Nurse #21 were observed providing cares to Resident #129, on enhanced barrier precautions, without donning a gown. 2) Resident #118 had an indwelling urinary catheter and the drainage bag and a portion of the drainage tube were lying on the floor. The findings are: The Policy titled Enhanced Barrier Precautions, last reviewed 1/6/25, documented: It is the policy of this facility to follow Center for Disease Control guidelines by utilizing Enhanced Barrier precautions in the care of patient susceptible to multiple drug-resistant organisms and to reduce the spread and prevalence of multiple drug-resistant organism related infections. The use of gown and gloves for high-contact resident care activities as indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of multiple drug-resistant colonization as well as for residents with multiple drug-resistant organism infection or colonization. 1) Resident #129 had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (a resident assessment tool) dated 1/14/25 documented Resident #129 had severe cognitive impairment, was at risk for pressure ulcer and had application of non-surgical dressings other than to feet. A physician's orders [REDACTED]. A resident care plan titled Impaired Skin Integrity, updated 3/5/25, documented the resident had a Stage 3 pressure ulcer to sacral region. Interventions (updated 1/8/25) included to treat / change dressing as per physician orders. During an observation on 03/31/25 at 3:58 PM Certified Nurse Aide #20 and Licensed Practical Nurse #21 were providing incontinence cares for Resident #129 and neither were wearing a gown. Certified Nurse Aide #20 was interviewed and stated it was an oversight and they should have worn a gown while providing cares. They stated that Resident #129 had a wound and they should have checked the resident's door for precaution information before providing cares. During an interview on 03/31/25 at 4:48 PM with Licensed Practical Nurse #21, they stated Resident #129 was on enhanced barrier precautions and they forgot to gown when prepping and assisting Certified Nurse #20 with cares prior to wound care. 2) Resident #118 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severely impaired cognition, and was dependent on staff with toileting hygiene, rolling left to right, and chair to bed transfer. The Comprehensive Care Plan titled Foley Catheter- Suprapubic Tube dated 9/30/22 documented enhanced barrier precautions, follow infection control practices for catheter care. The physician order [REDACTED]. During observations on 3/26/25 at 12:53 PM and on 3/27/25 at 10:50 AM Resident #118 was in bed; the indwelling urinary catheter drainage bag was in the privacy bag and attached to the bed frame. The drainage bag and portion of the drainage tube were lying on the floor. During an interview and observation on 3/27/25 at 10:53 AM, Licensed Practical Nurse #15 stated the urine collection bag and drainage tube were on the floor and should always be off the floor. This was infection control issue and should be corrected immediately. They stated that the privacy bag straps should be shorter to prevent the privacy bag and drainage tube from touching the floor. Licensed Practical Nurse #15 stated that they would talk to the Certified Nurse Aide who provided care for this drainage bag. During an interview on 03/28/25 at 11:22 AM, Certified Nurse Aide #14 stated that they provided care for Resident's #118 drainage bag. They stated that they needed to make sure the indwelling urinary catheter drainage bag and drainage tube had to be off the floor at all times. They stated that they were busy and missed observing when the drainage bag and tube were on the floor. 10NYCRR 415. 19(a)(2) | Plan of Correction: ApprovedApril 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Infection Prevention & Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Resident #129 and #118 did not suffer ill effect from this deficient practice. Staff will follow Infection prevention and control guidelines in regards to EBP as well as other transmission- based precautions. Residents medical devices, such as indwelling catheter/ tubing will placed in proper position and avoid touching the floor to prevent contamination. Resident #118 foley drainage tube, foley bag and privacy bag were immediately changed upon notification of this deficiency. This resident was assessed and found to have not [MEDICATION NAME] negative effects as a result of this deficiency. License Practical Nurse #15 and Certified Nurse Aide #14 were both re-educated on the facilitys infection control Policy and the need to ensure that residents foley drainage bags or tubes do not touch the floor. Resident #129 was assessed and found to have no signs of infection, no other signs of negative effects as a result of this deficiency. License Practical Nurse 21 and Certified Nurse Aide 20 were both re-educated on the facilitys Enhanced Barrier Precaution Policy and Procedure and the need to wear the recommended PPE. Monitoring for any signs of infection will be ongoing for this resident. Residents at Risk Any resident can be affected by this deficient practice The Director of Nursing Conducted and audit to identify any other resident that may have been affected by this deficient practice and no other resident was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes All staff will be provided in-service education in regards to EBP/Transmission based precautions by Infection Preventionist/ Nurse Staff Educator/Designee. All nursing staff (Nurses and CNAs) will receive in-service education in regards to proper placement of indwelling catheter tubing when residents are in and up out of bed to prevent tubing touching the floor. The Administrator reviewed the facilitys infection control and Enhanced Barrier Precaution Policies and found them to be in compliance with all local, state and federal regulations. The Director of Nursing will initiate Infection Control and Enhanced Barrier Precaution re-education for all staff Monitoring of Corrective Actions The DON has created and Audit to monitor foley drainage bags and tubes nut touching the floor. The DON has also created an audit to monitor compliance with PPE usage for all resident s on EBP. Audits will be conducted on indwelling catheter placement in/out of bed for those residents that are applicable. Audits will be performed every shift x 1week, daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee Audits will be conducted on all units in regards to staff use of EBP. To include signage outside of applicable rooms/Donning & Doffing of PPE. Audits will be performed every shift x 1week, then daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/ Designee The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during a recertification survey from 03/26/2025 to 04/01/2025, the facility did not ensure Certified Nurse Aides were provided the required hours of training and/or annual in-services on dementia care management to ensure safe delivery of care. Specifically, the facility was unable to provide documentation that 3 of 5 Certified Nurse Aides (#23, #24, and #25), had the required hours of the mandatory training. Findings include: The facility policy titled: Employees' Annual Mandatory Education, revised 11/28/2024, documented all staff must complete a series of mandatory annual education modules to comply with regulations and ensure high-quality resident care. The policy further states that completion records will be maintained by the Education Coordinator. A review of the facility's Certified Nurse Aide annual in-service training records revealed that the following Certified Nurse Aides did not meet the 12-hour annual training requirement and lacked documentation of mandatory dementia care management education: - Certified Nurse Aide #23 was hired on 07/19/ 2023. Completed in-service education record with a last training dated 11/25/2024 did not include documentation that dementia care management education was provided. - Certified Nurse Aide #24 was hired on 03/01/ 2019. The most recent documented in-service training was completed on 11/20/2024, but no documented evidence of dementia care management education was provided. - Certified Nurse Aide #25 was hired on 5/18/ 2023. No documentation was available confirming completion of dementia care management education. During an interview on 03/28/2025 at 11:45 AM, the Assistant Director of Nursing stated the documentation for dementia care for Certified Nurse Aides #23, #24 and #25 could not be located. 10 NYCRR 415. 26 (c)(1)(iv) | Plan of Correction: ApprovedApril 23, 2025 Corrective Actions for Residents Identified Required In-service training for Nurse Aides In-service training must ÔÇ£ Include dementia management training and resident abuse prevention training. Certified Nurse Aides #23, #24, and #25 did not have the required hours of the mandatory training in regards to Dementia training. No residents suffered ill effects. Upon notification of this deficiency, Certified Nurses Aides #23, #24, and #25 were all contacted and provided with Dementia in-service and all now meet the standard for the 12 hours of annual in-service. Audits of the employees assigned residents and units revealed no ill effects to those or any other resident as a result of this deficiency Residents at Risk Any resident can be affected by this deficient practice Any resident can be affected by this deficient practice Inservice coordinator/educator conducted an audit of all CNAs to determine if any other CNA was out of compliance with Dementia education or the annual 12 hour education, and none were noted out of compliance. The facility respectfully states that while all staff and therefore residents could have been affected, no other staff or resident was affected. Systemic Changes All CNAs will receive mandatory training on an annual basis by Nurse Staff Educator/Designee The Administrator has reviewed the facilitys policy on Employees Annual Mandatory Education and found it to be in compliance with all local, state and federal regulations. Monitoring of Corrective Actions Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/ Designee The DNS/Designee will be responsible for completion of this plan of correction. Audits will be completed in regards to Dementia training/Annual Mandatory for certified aides biweekly x 4 then monthly x 3 months. Audits to be completed by Human Resource Director/Nurse Staff Educator/Designee. Audits will be presented at QAPI meetings monthly by the Human Resource Director/ DNS to determine continued need The DNS/Designee will be responsible for completion of this plan of correction. The Administrator has created and audit tool to monitor compliance with CNA annual mandatory education including Dementia education. Responsible:The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 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 3/26/2025 through 4/1/2025, the facility did not ensure residents had the right to a dignified dining experience for 2 of 35 residents (Residents #2 and #113) reviewed for dignity while dining. Specifically, Certified Nurse Aides were observed standing over Resident #2 and Resident #113 while assisting with their meals. The findings include: The facility policy titled Quality of Life-Dignity dated 9/1/17 documented: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Comprehensive Care Plan for Activities of Daily Living- Range of Motion dated 11/29/19 documented Resident #2 required extensive assistance of one person for eating. The 2/22/25 Quarterly Minimum Data Set Assessment (a resident assessment tool) documented Resident #2 had severely impaired cognition and was dependent on staff with all activities of daily living. During an observation on 3/26/25 at 1:27 PM, Resident #2 was in the bed and Certified Nurse Aide #13 was standing over the resident while assisting them with eating their lunch meal. During an interview on 03/26/25 at 1:30 PM, Certified Nurse Aide #13 stated that they often assisted Resident #2 with eating. They stated that they knew they had to sit next to residents while assisting them to eat, rather than standing over them. Certified Nurse Aide #13 stated that they chose to stand over the resident because it was comfortable position to assist the resident with eating. 2. Resident #113 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) dated 2/27/25 documented Resident #113 had severe cognitive decline and was dependent on staff for eating. The Resident Care plan titled Activities of Daily Living/Range of Motion dated 5/30/24, documented Resident #113 was totally dependent on staff for eating. During an observation on 03/27/25 at 12:26 PM, Certified Nurse Aide #5 was observed standing over Resident #113 while assisting with feeding the lunch meal. During an interview on 03/27/25 at 12:40 PM with Certified Nurse Aide #5, they stated there were no chairs available while feeding Resident #113 lunch. They stated they were aware they should not stand over residents when assisting with eating. During an interview on 04/01/25 at 2:28 PM with Licensed Professional Nurse #6, they stated that Certified Nurse Aides should always be sitting at eye level when assisting residents with eating to maintain dignity. 10 NYCRR 415. 5 (d) (1)(i) | Plan of Correction: ApprovedApril 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Residents #2 and #13 Resident Rights The resident has a right to a dignified existence and respect. Residents #2 and #13 suffered no ill effects related to deficient practice. Residents will be provided with dignity and respect as evidenced by staff will be seated next to residents at eye level that require assist with meals. Resident Rights Following notification of this deficiency, resident #2 was assess on 4/1/25 and found to have no [MEDICATION NAME] ill effects related to this deficient practice. Resident #113 was assessed on 4/1/25and found to have no [MEDICATION NAME] ill effects as a result of this deficient practice. Aide #13 and Aide #5 were re-educated on 4/1/2025 residents rights and the procedure for providing feeding assistance, the need to sit beside residents while providing assistance with feeding. Resident at Risk Any resident can be affected by this deficient practice The Director of Nursing conducted and Audit to identify any other resident who was affected by this deficient practice and none was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. The Administrator/Designee has conducted and audit of chairs within the facility, available for use by staff providing feeding assistance, and found that there are sufficient numbers of available chairs. Dependent residents can be affected by this deficient practice Systemic Changes All nursing staff (CNAs and Nurses) will be educated by Nurse Staff Educator/ADON/Designee on procedure with assisting residents with eating during meals. Specifically, staff should be seated next to resident at eye level while assisting with meal. The Administrator has reviewed the facilitys Policy on Quality of life-Dignity, and found it to be in compliance with all state and federal regulations. Education will be provided to all Nurses and CNAs on the procedure for providing feeding assistance, specifically, staff should be seated next to the resident and at eye level while assisting with meals. Monitoring for Corrective Action The DON has created a meal time audit to monitor for staff sitting while providing feeding assistance. Meal time audits will be conducted for lunch & dinner daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 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 3/26/2025 to 4/1/25, the facility did not ensure that 1 of 1 Resident (Resident #129) reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice. Specifically, Resident #129, had a physician's orders [REDACTED]. The findings include: The facility policy titled OxygenTherapy - Face Mask and Cannula (undated) documented: Oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Oxygen is administered by licensed staff. Oxygen administration requires physician order. Resident #129 had [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (a resident assessment tool) dated 1/14/25, documented Resident #129 was severely cognitively impaired, aphasic, was dependent for toileting and transfers. A resident care plan titled Respiratory/Pulmonary care plan dated 2/9/24 documented to administer Oxygen as needed for wheezing/shortness of breath. Interventions included oxygen 2 liters via nasal cannula as needed. A physician order [REDACTED]. During an observation on 03/27/25 at 10:24 AM, Resident #129 was observed lying in bed, nasal cannula in place and the oxygen concentrator running at 3 liters/minute. During an observation on 03/28/25 at 9:42 AM, Resident #129 was observed lying in bed, nasal cannula in place and the oxygen concentrator running at 1. 5 liters/minute. During an interview on 4/1/25 at 2:20 PM with Licensed Practical Nurse #6, they stated oxygen levels were set by Licensed Practical Nurse or Registered Nurse as per physician order. They stated Resident #129's medical order was for oxygen to be administered at 2 Liters/minute via nasal cannula as needed. They stated they complete rounds of residents at start of every shift and oxygen concentration levels were checked at this time. They were not aware why the concentrator would have been observed running at 3 liters/minute or 1. 5 liters/minute. They stated that possibly a Certified Nurse Aide may have accidentally touched the dial on concentrator during cares. They stated that as far as they were aware, oxygen at 2 liters/minute had been set on oxygen concentrator daily. 10 NYCRR 415. 12 | Plan of Correction: ApprovedApril 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Upon notification of this deficiency resident #29 Oxygen was immediately adjusted to the prescribed 2L/min. An assessment revealed that resident #29 suffered no ill effects as a result of the deficient practice. Resident #29 will be seen by the MD/NP for possible discontinuation of his Oxygen therapy. LPN #6 was provided re-education on the importance of ensuring that residents Oxygen devices were set to the recommendations ordered by the MD/NP. Nurses to review and sign the flow of oxygen each shift. Residents at Risk An Audit of all residents with Oxygen therapy was conducted to identify any other resident that may have been affected by this deficiency and none were identified. While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes The facility reviewed Policy and Procedure Oxygen Therapy- Face Mask and Canula no revision was needed. Nursing staff to be in-service on the policy and procedure Oxygen Therapy- Face Mask and Canula. DON developed an audit tool to ensure the oxygen flow matched the doctors order the audit will include the resident who are on oxygen, Whether nurses sign off that the correct flow is being given, if there is a physician order [REDACTED]. Monitoring of Corrective Actions The Director of Nursing or Designee will conduct audits daily x2 weeks, then weekly x 4 week, then monthly x 3 months. Any issues with be addressed immediately and reported to the administrator. On a monthly basis the Director of Nursing will report the findings to the Administrator On a monthly basis the Director of Nursing or Designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Recertification survey from 3/26/25 to 4/1/25, the facility did not ensure the Residents right to a safe, clean, comfortable, and homelike environment. This was evident for 1 of 35 resident rooms (Resident #10) and the hallways of 2 West Unit during observation of the environment. Specifically, Resident #10's room was observed with a strong odor of urine on multiple occasions and there was a strong odor of urine in hallways of 2 West unit. The findings included: The facility policy titled Homelike Environment reviewed 10/18/24 documented: It is the policy of facility to ensure that all Residents live in an environment that is clean and neat, with appropriate furnishings in a state of good repair. Resident #10 had [DIAGNOSES REDACTED]. A significant change Minimum (MDS) data set [DATE] documented Resident #10 had moderately impaired cognition, was dependent for toileting hygiene, and incontinent of bladder and bowel. A resident care plan titled Activities of Daily Living/Range of Motion dated 7/25/24 documented Resident #10 had a self-care deficit related to toileting and interventions included extensive assistance. During an observation on 03/26/25 at 9:35 AM, there was a strong smell of urine upon entering unit 2 West from the elevator, near the nurse station/day room and in hallways. During an observation on 03/26/25 at 09:59 AM, Resident #10's room had a strong smell of urine. During an observation on 03/27/25 at 12:24 PM, there was a strong smell of urine upon entering unit 2 West from elevator, near the nurse station/day room and in hallways. During an observation on 03/27/25 at 12:46 PM, Resident #10's room had a strong smell of urine. During an observation on 03/28/25 at 12:14 PM, Resident #10's room and laundry hamper had a strong smell of urine. The laundry hamper was approximately 1/3 full of soiled clothing and the soiled clothing was not double bagged and sealed to contain odors. During an observation on 04/01/25 at 11:35 AM, Resident #10's room had a strong smell of urine in room and clothing in laundry hamper was not doubled bagged and sealed to contain odors. During an interview on 04/01/25 at 12:15 PM with Housekeeping staff #19, they stated laundry and housekeeping services were provided daily for 2 West Unit. Resident #10's laundry was picked up every morning abut 5:30 AM. When the laundry was picked up, resident clothing should be covered with a sheet for transport downstairs or if heavily soiled with feces or urine, transported in plastic bag. Housekeeping staff changed the plastic liners in resident laundry baskets during complete room cleaning daily. They stated rooms/hallways could smell like urine if clothing with urine odors were placed in laundry hampers without being bagged and tied to contain odors. They stated that linens were laundered outside of the facility and heavily soiled/wet linens should also be placed in plastic bags and tied before transporting to the soiled linen room on the units. They stated that soiled linens were removed from units each shift by housekeeping staff and transported to basement. During an interview and observation on 04/01/25 at 2:08 PM with Certified Nurse Aide #12, they stated Resident #10's urine had a very strong odor. They stated that Resident #10 was mostly incontinent and would use the toilet intermittently with assistance. They stated the 11 PM-7 AM shift changed the resident's adult brief at end of their shift and the day shift changed the resident again at about 7:45 AM while providing cares. They stated they did not usually find Resident #10 soaked but sometimes their clothing was wet. They stated soiled clothes were placed in laundry hamper and if the clothing was wet or smelled strongly of urine, they wrapped it in a plastic bag. The laundry bin was observed during the interview with Certified Nurse Aide # 12. A strong odor of urine was detected from laundry hamper; the plastic laundry hamper liner was in place and soiled, and urine smelling clothes were not bagged and tied. During an interview on 04/01/25 at 2:15 PM with Licensed Practical Nurse #6, they stated that Resident #10 was incontinent and used pull-up style disposable briefs at family request. They stated that the pull-up style briefs leaked more than facility adult briefs and the resident had been found wet at times. They stated that all soiled clothing, whether wet or with urine smell should be placed in a plastic bag and tied before placing in resident laundry hamper to avoid resident rooms and hallways from urine odors. If there was a particularly bad urine smell from a resident laundry hamper or clothing, the Certified Nurse Aides should remove the odorous clothing from hamper and transport to the Housekeeping/Laundry department located in the facility basement to avoid odors in resident rooms and unit hallways. They stated there should not be urine odors in resident rooms or unit hallways. 10 NYCRR 415. 5(h-i)(1-3) | Plan of Correction: ApprovedApril 23, 2025 Corrective Actions for Residents Identified Upon notification of this deficiency, resident #10 was removed from his room to all ow for terminal cleaning. Assessment revealed that this resident suffered no ill effects as a result of the deficient practice. Resident #10 room was terminally cleaned on Soiled laundry bagged and removed from room down to laundry on Hallways were mopped and cleaned to eliminate odor on 4/2/2025 and continues to be cleaned daily. LPN #6, and CNA #12 were all reeducated on the facilitys homelike environment policy with an emphasis on how soiled clothing should be managed to ensure odor control. Residents at Risk A facility wide audit will be conducted to ensure a safe, clean, and homelike environment is maintained and no other issues were identified. Although all residents had the potential to be affected by this deficient practice, no other resident was found to be affected Systemic Changes The Administrator reviewed policy on Homelike Environment and no revision is needed. All staff will be in-service on Policy and Procedure Homelike environment. The facility utilizes a complete room schedule to do a thorough cleaning. An audit tool was developed to ensure safe, clean, and homelike environment is maintained Monitoring of Corrective Actions The Housekeeping Supervisor or designee will conduct environmental Room and hallway audits for urine odors. The audit will be conducted weekly x3 months, then monthly x3 months. Any outstanding issues will be addressed immediately and reported to the administrator. On a monthly basis the Housekeeping Supervisor will report findings to the administrator. On a monthly basis the Housekeeping Supervisor or designee will report audit finding to Qapi Committee. Qapi committee to determine if further action is required based on report. Responsible: Director of Plant Operation/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation, documentation review and staff interview, the facility did not ensure the that the Patient care related Equipment (PCREE) was inspected and tested in accordance with NFPA 99. Specifically, the facility's electrical policy for inspecting the PCREE and non patient care related equipment (non -PCREE) was missing and not provided at time of survey. The findings are: During the Life Safety recertification survey conducted 4/1/25 and 4/2/25 between the hours of 9:30 AM to 3:30 PM, the following issues were noted a review of the facility's policy and procedure for inspecting the patient care related electrical equipment (PCREE) and the non - PCREE (patient care related electrical equipment) was missing and not provided at time of survey. In an interview with the Director of Plant Operations at approximately 2:40 PM, the Director of Plant Operations stated the policy will be located. 2012 NFPA 101 2012 NFPA 99: 10. 4. 2. 1, 10. 5. 2. 1 10 NYCRR: 711. 2 (a) | Plan of Correction: ApprovedMay 8, 2025 Corrective Actions for Residents Identified All residents, visitors and staff have the potential to be affected by the deficient practice Patient Care Related Electrical Equipment PCREE Policy located Any resident or other electrical devices will be inspected prior to being brought to any of the units Annual inspection will be conducted for patient care related equipment and non patient care related electrical equipment. Residents at Risk All residents, visitors and staff have the potential to be affected by the deficient practice Systemic Changes Review of the Electrical Device and Equipment Policy and Procedure no changes need. Maintenance, Social Services, Nursing administration, and Administrator to be educated on the importance of tracking and maintaining logs of all patient and non-patient care electrical equipment. Monitoring of Corrective Actions Director of Plant Operations or Designee will maintain a log of all non-patient care related equipment items that were logged weekly x4 weeks then monthly x3 months. If non-compliance if found this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues presented All finding will be submitted to monthly QAPI. QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 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. Based on observation, documentation 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, documentation of the 4-hour load bank test was missing and not provided at time of survey. The findings are: During the life safety recertification survey conducted on 4/1/25 at 12:10 PM, a review of the facility generator logs revealed that a 2 hour load bank test was conducted instead of the required 4-hour load bank test and documentation for the 4 hour load bank test was missing and not provided at time of survey. In an interview with the Director of Plant Operations at 11:00 AM the same day, the Director of Plant Operations stated that the vendor will be contacted. 2012 NFPA 101: 19. 5. 1. 1, 9. 1. 3. 1 2010 NFPA 110: 8. 4. 9 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMay 1, 2025 Corrective Actions for Residents Identified All residents, visitors and staff have the potential to be affected by the deficient practice. Facility contacted the Generator company to conduct the 4-hour load test Visit is scheduled to be completed on (MONTH) 7th, 2025. Residents at Risk All residents, visitors and staff have the potential to be affected by the deficient practice Systemic Changes Re-education to the Director of Plant Operation on the importance of running the 4-hour load test once every 36 months Ensure facility is maintaining a schedule for when test comes due with an audit. If not in compliance vendor will be contacted immediately. Monitoring of Corrective Active The Director of Plant Operations or Designee will complete audit to ensure each testing is within compliance with the NFPA 101 Electrical system monthly x3 month or until 100% compliance. If non-compliance if found this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues presented All findings and results will be submitted to the monthly QAPI meeting. QAPI committee will determine if further information is required Responsible :Director of Plant Operations or Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 9. 2 Heating, Ventilating, and Air-Conditioning. 9. 2. 1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A, Standard for the Installation of Air-Conditioning and Ventilating Systems. 2012 NFPA 90 A, Standard for the Installation of Air-Conditioning and Ventilating Systems. 5. 4. 8 Maintenance. 5. 4. 8. 1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: Standard for Fire Doors and Other Opening Protectives Chapter 19 Installation, Testing, and Maintenance of Fire Dampers 19. 4* Periodic Inspection and Testing. 19. 4. 1 Each damper shall be tested and inspected 1 year after installation. 19. 4. 1. 1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 19. 4. 2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment. 19. 4. 3 Full unobstructed access to the fire or combination fire/ smoke damper shall be verified and corrected as required. 19. 4. 4 If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. 19. 4. 9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire / smoke damper, date of inspection, name of inspector, and deficiencies discovered. 19. 4. 9. 1 The documentation shall have a space to indicate when and how the deficiencies were corrected. 19. 4. 10 All documentation shall be maintained and made available for review by the AHJ. Based on documentation review and staff interview, the facility did not ensure that the heating, ventilation, and air conditioning (HVAC) system was maintained in accordance with NFPA 101, 90 A and NFPA 80. Specifically, a follow - up report indicating repairs was missing and not provided at time of survey. The findings are: Documentation review of the facility's damper logs was conducted during the Life Safety recertification survey on 4/1/25 at 12:00 PM. It was noted that the fire / smoke dampers in the facility were inspected, tested and cleaned by a vendor (MONTH) 4 - 6, 2025 and several dampers failed (2 FD - 008 failed 12/4/24, and 2 FD 124 room [ROOM NUMBER] failed 12/6/24) and a follow -up report of repairs was missing and not provided at time of survey. In an interview with the Director of Plant Operations the same day, the Director of Plant Operations stated that the vendor will be contacted. On 4/2/25 at 4:05 PM, a statement was provided that the damper 2 FD - 008 was corrected 6/16/2023 and did not indicate how the deficiency was corrected. In an interview with the Director of Plant Operations at the time of the finding, the Director of Plant Operations stated that the date was a typo. 2012 NFPA 101: 19. 5. 2. 1, 9. 2, 9. 2. 1 2010 NFPA 80: 19. 4. 1, 19. 4. 1. 1, 19. 4. 2, 19. 4. 3, 19. 4. 4, 19. 4. 9 2012 NFPA 90 A: 5. 4. 8 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMay 5, 2025 Corrective Actions for Residents Identified All residents, visitors and staff have the potential to be affected by the deficient practice. Fire damper vendor was contacted 5/1/2025 and will be on sight to inspect fire dampers. Resident at Risk All residents, visitors and staff have the potential to be affected by the deficient practice Systemic Changes Education to Director of Plant Operations to ensure that if there are issues with inspection that needs to be repaired is to be completed in a timely manner to remain in compliance. Audit will be created to ensure that all reports received are dated correctly and no damper failure reported. If damper failure is noted the Vendor will be contacted to repair the dampers. Monitoring of Corrective Actions The Director of Plant Operations or Designee will ensure all reports are dated appropriately when receiving report from fire damper vendor and that any damper failure is addressed. Weekly x4,monthly x3 or until 100% compliance. If non-compliance if found this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues present. All finding will be submitted to monthly QAPI. QAPI Committee will determine if further action is needed. responsible: Director of Plant Operations or Designee |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on documentation review and staff interview, the facility did not ensure that the communication plan included a means for providing information to the incident command center, the authority having jurisdiction, or designee, about the facility's occupancy, needs, and the ability to provide assistance during an emergency. The findings are: Documentation review of the facility's emergency preparedness binder was conducted during the life safety recertification survey on 4/2/25 at 2:40 PM and it was noted that the policy and procedure for sharing information regarding its occupancy, needs and the ability to provide assistance was missing and not available at time of the survey. In an interview with the Administrator at approximately the same day, the Administrator stated that the information will be included in the emergency preparedness binder. 483. 73 (c)(7) | Plan of Correction: ApprovedMay 1, 2025 Corrective Actions for Residents Identified All residents, visitors and staff have the potential to be affected by the deficient practice Policy for sharing information regarding occupancy, needs and the ability to provide assistance was located. Resident at Risk All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes Policy reviewed and no revision needed. Education to the Director of Plant Operation on the importance of having policy readily available. Policy added to the emergency preparedness binder Monitoring of Corrective Actions The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information regarding occupancy is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance If non-compliance is found this will be reported to the administrator and the Director of Plant Operations All finding will be submitted to monthly QAPI. QAPI Committee will determine if further action is needed Responsible: The Director of Plant operations or designee |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation, documentation review and staff interview, the facility did not ensure that there was a method for sharing information from the emergency preparedness plan with residents and their families or representatives in accordance with Section 483. 73. Specifically, a policy and procedure for sharing components of the emergency preparedness plan with residents, family members and or representatives was missing and not provided at time of the survey. The findings are: During the Life Safety recertification survey on 4/2/25 , a review of the facility's Emergency Preparedness plan was conducted and it was noted that a policy and procedure for a method of sharing information from the emergency plan with residents, their families or representatives in the event of an emergency was missing and not provided at time of survey. In an interview with the Administrator the same day, the Administrator stated that the policy and procedure for sharing information will be added to the Emergency Preparedness plan. 483. 73 (c) (8) | Plan of Correction: ApprovedMay 1, 2025 All residents, visitors and staff have the potential to be affected by the deficient practice Policy for sharing components of the emergency preparedness plan with residents, families, and representative was located. Resident at Risk All residents, visitors and staff have the potential to be affected by the deficient practice Systemic Changes Policy reviewed and no revision needed. Education to the Director of Plant Operation on the importance of having policy readily available. Policy added to emergency preparedness binder. Monitoring of Corrective Actions The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information is in the Emergency Preparedness plan for each location weekly x4 monthly x3,or until 100% compliance If non-compliance is found this will be reported to the administrator and the Director of Plant Operations All finding will be submitted to monthly QAPI. QAPI Committee will determine if further action is needed responsible: Director of Plant Operations or Designee |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation, staff interview, and record review, the facility did not ensure that the sprinkler system was maintained in accordance with NFPA 101. Specifically, 1. Sprinklers in shower rooms exhibited signs of corrosion, 2. Water pressure gauge on the fire pump controller outdated, and 3. A follow - up report of repairs for the fire pump was missing and not provided at time of survey. These issues were noted on 2 of 2 resident floors and in the basement. The findings are: During the Life Safety recertification survey and Extended survey conducted on 4/1/25 and 4/2/25, between the hours of 9:30 AM and 3:30 PM, the following issues were observed: On 4/1/25 at 9:50 AM, a tour of the fire pump room was conducted and it was noted that the water pressure gauge on the fire pump controller was outdated. An examination of the water pressure gauge revealed that there was no evidence on the water pressure gauge on the front, sides or back that the water pressure gauge was replaced. During documentation review, documentation was missing indicating the date the water pressure gauges were replaced or re-calibrated and documentation was not provided at time of survey. In an interview with the Director of Plant Operations at the time of the finding, Director of Plant Operations stated that the vendor will be contacted. At approximately 10:35 AM, a tour of the shower room on the second floor was conducted and it was observed that 3 of 3 of the sprinklers in the shower room exhibited signs of corrosion. This same situation was observed in the shower room on the first floor. At 11:50 PM, the same day, documentation review of the facility sprinkler logs was conducted and it was noted that the fire pump failed during the annual service of the fire pump and a follow -up report indicating repairs was missing and not provided at time of survey. In an interview with the Director of Plant Operations the same day, Director of Plant Operations stated that the vendor will be contacted. 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 6 2011 NFPA 25: 5. 2. 1. 1. 1*, 6. 3. 4, 8. 3. 3. 1* 10 NYCRR: 711. 2 (a) | Plan of Correction: ApprovedMay 8, 2025 Corrective Actions for Residents Identified All residents, visitors and staff have the potential to be affected by the deficient practice. Sprinkler/Water Pressure vendor was contacted and scheduled to be on site on 4/21/ 2025. Sprinkler in shower room was replaced 4/21/ 2025. Water pressure gauge on the fire pump controller was replaced on 4/21/ 2025. a new inspection is scheduled to be completed on 5/29/2025 and will address any repairs for the fire pump. Residents at Risk All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes Maintenance staff will be re-in-service on compliance of inspection of the sprinkler system, pressure gauge being in compliance with dates and reports being done timely. Maintenance to create audit for monitoring sprinkler for corrosion, ensuring that the fire pump gauge date is in compliance Monitoring of Corrective Actions The Director of Plant Operation or Designee will monitor sprinkler for corrosion, water pressure gauge on the fire pump is within date, ensure if follow up report is needed that it is being obtained Weekly x 4 weeks, then monthly x 3 months or until 100% compliance. If non-compliance is found this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues presented. All finding will be submitted to monthly QAPI. QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee |
Scope: N/A
Severity: N/A
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |