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Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 a Complaint investigation (Complaint #NY 317) completed on an Extended Recertification survey with an exit date of 1/8/2025, the facility failed to protect the residents rights to be free from verbal and physical abuse by a Companion Aide for one (Resident #22) of six residents reviewed for abuse. Specifically, a Companion Aide was witnessed by facility staff being verbally and physically abusive towards Resident # 22. The facility did not review/revise abuse processes/protocols since 2016. In addition, the facility did not consistently implement their protocols regarding Companion Aides. They did not have an effective system to ensure background checks were verified as completed for all Companion Aides prior to starting at the nursing home; lacked an effective system to communicate with the residents/families, and Companion Aides the nursing home policy included Companion Aides were not to provide hands on care; lacked a system to monitor Companion Aides to ensure their specific policies were followed to ensure resident safety. This resulted in no actual harm with the potential for more than minimal harm with the likelihood to affect all residents and is substandard quality of care. The finding is: The policy and procedure titled, Abuse Prevention Program dated 11/28/16 documented the residents have the right to be free from abuse, neglect, mistreatment, corporal punishment. The facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, companion aides, legal guardians surrogates, friends, visitors, or any other individual. The policy and procedure titled Companion Aide with a revision date of 10/01/2020 documented the facility recognizes a resident's right to hire or engage the services of a Companion Aide. The Social Worker was listed as responsible for the implementation of this policy and the facility established guidelines. To ensure resident safety and security, Companion Aides must provide certain background information to the facility prior to beginning service, permit the facility to conduct a criminal background check and complete an Authorization for Release Information form. Companion Aides are subject to all the policies, guidelines, rules, and regulations in effect at the facility. Companion Aides providing services to residents residing in the Assisted Living & Skilled Nursing settings are not permitted to perform hands on care, this includes assisting residents with personal care or activities of daily living. An undated Private Hire Agreement provided by Social Worker #1, documented that all Companion Aides were to complete the agreement prior to their hire date. In consideration for access to the community for the purpose of performing personal care services to resident(s) they were to sign they understand and agree to the following: a criminal background check, validate any certifications or licenses as may apply or perform reference checks if deems necessary to ensure the safety of its residents. The form documents by signing they agree to assume all risks associated with or resulting from the performance of my services to residents. Additionally, by signing they agree to abide by all policies, procedures, rules, guidelines, and regulation of the community. Understands that our facility assumes no responsibility for supervising or monitoring the work of the companion aide engaged or employed by the resident. The Private Hire Agreement did not include the nursing home's specific policy which documented that Companion Aides were not to provide hands on care and they were subject to all to all the policies, guidelines, rules, and regulations in effect at the nursing home. 1. Resident #22 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 11/15/24 documented Resident #22 had severe cognitive impairments. Resident #22 required substantial/maximal assistance for toileting, toileting transfer, upper body dressing, lower body dressing, and for personal hygiene. The Comprehensive Care Plan dated 11/25/24 documented Resident #22 had severe dementia, was alert and oriented to person only. Interventions included to provide comfort and reassurance when resident was confused. Resident #22 had behavioral problems related to dementia which included resistive to hands on care, hitting/slapping/kicking staff members, verbally aggressive, and yelling at staff. Interventions included to give positive feedback and reinforcement for resident's compliance, reapproach resident as needed in a calm manner. The care plan did not address Resident #22 had a Companion Aide. The Accident and Incident Report signed by the Administrator and the Assistant Administrator documented on 11/26/24 between the hours of 8:00 AM and 9:00 AM Activities Aide #1 reported to the Licensed Practical Nurse Supervisors they heard screaming and thumping sounds coming from Resident #22's room. The Licensed Practical Nurse Supervisors went to Residents #22's room and the resident was receiving care at the bedside from CNA (Certified Nurse Aide #1) and a private companion aide. The report also documented the resident was restrained by Companion Aide#1, their arms were grabbed, crossed, and held to the resident's chest. The Accident and Incident Report included a Management Investigation Report that documented the event occurred because Resident #22 did not want to get out of bed and the hired Companion Aide #1 did not respect the resident's wishes. The Accident and Incident Report/ Management Investigation Report had four employee written statements, but did not include a written statement from Companion Aide #1 and Activities Aide # 1. Review of Certified Nurse Aide #1's statement dated 11/26/24 revealed Resident #22 did not want to get up, so they stated to the resident they would come back later. The Companion Aide was in the room at the time and said they were going to get the resident dressed. The Companion Aide moved the resident's blanket and the resident hit the Companion Aide with their legs. The Companion Aide grabbed both of Resident #22's hands, crossed them and pushed their arms towards the resident's chest. The Companion Aide told Resident #22 to stop, and they were going to get dressed. Certified Nurse Aide #1 documented they told the Companion Aide to stop, that we don't do that. Certified Nurse Aide #1 also documented the resident was scared. Review of Licensed Practical Nurse Supervisor #1's statement dated 11/26/24 revealed they responded to the reported situation, upon entering Certified Nurse Aide #1 was providing care and Companion Aide #1 was attempting to clean the resident. The resident was agitated but calmed after the Companion Aide walked away. Review of Licensed Practical Nurse #3's statement dated 11/26/24 revealed Certified Nurse Aide #1 was doing care and Companion Aide #1 was assisting with care and Resident #22 was visibly agitated. During an observation on 1/6/24 at 8:01 AM Resident #22's room door was closed. Post knocking, Companion Aide #3 opened the door and Resident #22 was lying in bed resting with no distress noted. During an interview at this time Companion Aide #3 stated they provided hands on care for Resident #22 and they were also aware that Companion Aide #1 had provided hands on care. Companion Aide #3 stated the facility nurses and CNA's (certified nurse aides) were aware Companion Aides provided hands on care and were happy because it was less work for them. Companion Aide #3 also stated they were in charge of the hiring Companion Aides for Resident #22, and they performed the duties of a Case Manager for the family. Companion Aide #3 stated they were informed by Social Worker #1 of Companion Aide #1's inappropriate behavior towards Resident #22 that occurred 11/26/24 and that Companion Aide #1 no longer worked for the family and was not allo | Plan of Correction: ApprovedFebruary 19, 2025 A Informal Dispute Resolution (IDR) has been submitted by the facility regarding this deficiency. The facility is submitting this Plan of Correction (P(NAME)) to comply with the requirement. Resident #22s companion aide (#1) was immediately removed following incident and ?ôPrivate Hire Agreement?Ø was revoked, with private hire companion aide (#1) being restricted from the facility and the Canterbury Woods campus. Resident #22s responsible party who hired companion aide (#1) was notified of incident and revocation of ?ôPrivate Hire Agreement.?Ø Responsible party in agreement with actions taken. Social Worker #1 re-informed Companion aide #3 of ?ôCompanion aide?Ø policy via phone conference on 01/06/ 2025. Companion aide(s) #2 & #3 no longer provide services to resident #22, with Private Hire Agreements no longer in effect. Resident is presently doing well. All residents have the potential to be affected. All residents presently utilizing private hire companion aides were reviewed to ensure the following; a ?ôPrivate Hire Agreement?Ø is on file and signed for each private hire companion aide, which includes a completed Criminal background check. A companion aide informational letter is provided in our Resident Admission Packet, which outlines the ?ôCompanion Aide policy?Ø and that Companion aides are not permitted to provide direct hands on care to residents. The resident or responsible party sign these documents at time of admission. The ?ôCompanion aide?Ø policy will be distributed to all private hire companion aide(s) servicing residents in conjunction with the ?ôPrivate Hire Agreement.?Ø All responsible parties were also re-informed of ?ôCompanion aide?Ø policy via Memo distributed on 01/07/2025 by Social Worker # 1. When a resident or responsible party hires a companion aide, prior to the companion aide starting, the following shall occur; a ?ôPrivate Hire Agreement?Ø is first completed, which includes a completed Criminal background check. A companion aide informational letter is provided in our Resident Admission Packet, which outlines the ?ôCompanion Aide policy?Ø and that Companion aides are not permitted to provide direct hands on care to residents. The resident or responsible party will sign these documents at time of admission. The ?ôCompanion aide?Ø policy will be distributed to all private hire companion aide(s) servicing residents in conjunction with the ?ôPrivate Hire Agreement.?Ø The Facility will maintain a private hire Companion aide log which shall document for each resident in the Facility that has hired a companion aide or companion aides, the identity of such companion aides, the date on which such companion aides were provided the companion aide policy - including the policy that companion aides shall not provide hands-on care, and the date that the criminal background check on the companion aide was completed. Residents are monitored on a daily basis by certified nursing assistants (C.N.A.), licensed Charge nurses and Nursing Supervisors. Nursing Supervisors conduct walking rounds throughout her/his scheduled shift to ensure resident safety. Policy & procedures pertaining to private hire Companion aide(s) and the ?ôAbuse Prevention Program?Ø were reviewed, with review date. All Skilled Nursing Facility personnel were re-educated in accordance with the Directed In-service plan, to include ?ôCompanion aide?Ø policy and that private duty companion aides are not permitted to provide direct hands on care to residents, in addition to the ?ôAbuse Prevention Program?Ø and ?ôAbuse Reporting?Ø policy. Re-education will be conducted under the direct guidance of the Consultant instructor in collaboration with the Social Worker, Administrator and Director of Nursing. The Consultant and Administrator conducted a review of the following with the Social Worker; Companion aide policy, the completion of ?ôPrivate Hire Agreement,?Ø which includes a completed Criminal background check, companion aide informational letter being provided in our Resident Admission Packet, which outlines that Companion aides are not permitted to provide direct hands on care to residents and that the resident or responsible party sign these documents at time of admission. The Companion aide policy will be reviewed with residents at monthly Resident Council meetings by the Social Worker, Administrator, and/or Director of Nursing. ?ôPrivate Hire Agreements?Ø and corresponding documents of all private hire companion aides will be submitted and reviewed by the Social Worker bi-monthly at the Quality Assurance & Performance Improvement Committee meetings (i.e., QAPI), covering 01/2025 ÔÇ£ 06/ 2025. Random weekly audits of private hire companion aides will be conducted by Social Worker or designee to continue to ensure hands on care is not being provided by private hire companion aides. The results of audits will be submitted and reported by the Social Worker bi-monthly at the Quality Assurance & Performance Improvement Committee meetings (i.e., QAPI), covering 01/2025 ÔÇ£ 06/ 2025. After that time, it will be determined by the QAPI Committee at what frequency the auditing should continue. The Administrator will be responsible for the ongoing compliance of this plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 an Extended Recertification Survey completed 1/8/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for one (Residents #13) of one resident reviewed. Specifically, enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) were not initiated for a resident with pressure ulcers and staff did not wear appropriate personal protective equipment during pressure ulcer care. The finding is: The policy titled Enhanced Barrier Precautions dated 5/2024, documented enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. Enhanced barrier precautions employed targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. An example of high-contact resident care activity requiring the use of gown and gloves for enhanced barrier precautions would include wound care (any skin opening requiring a dressing). Signs were to be posted on the door or wall outside the resident room indicating the type of precautions and personal protective equipment required along with the personal protective equipment to be available outside of the resident room. Review of the enhanced barrier precaution signage (a sign used by the facility that was supposed to be posted outside a residents door to indicate they required enhanced barrier precautions) documented that providers and staff must wear gloves and a gown for the following high-contact resident care activities: wound care (any skin opening requiring a dressing). Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/11/24 documented Resident #13 had moderate cognitive impairment, was understood, and usually understands. The assessment tool documented the resident had one stage II (partial-thickness skin loss into but not deeper than the dermis) pressure ulcer that was not present upon admission. The Comprehensive Care Plan dated 10/24/24 documented Resident #13 had actual altered skin integrity related to a partial thickness wound on their left heel. Interventions included to monitor skin per protocol, preventive skin interventions as per resident care guide, encourage meal/fluid consumption, skin team referral as needed, notify the medical doctor for adverse changes, and left heel bootie on at all times. The comprehensive care plan did not document that Resident #13 was on enhanced barrier precautions. During intermittent observations on 1/2/25 at 12:06 PM, 1/2/25 at 3:34 PM, 1/6/25 at 9:53 AM 1/6/25 at 3:16 PM and 1/8/25 at 8:11 AM, Resident #13 was in their room either in their recliner chair, wheelchair, or bed. There were no plastic precaution bins outside of their room and no enhanced barrier precaution signage on the door. During an observation and interview on 1/8/25 at 8:11 AM, Registered Nurse Supervisor #1 performed wound care to Resident #13 while the resident was in bed. Registered Nurse Supervisor #1 stated that they were unsure how long Resident #13 had a pressure ulcer to their left heel and left buttock, but it was longer than two weeks and they were chronic. The resident had an open area to their left buttock/hip area with slough (non-viable yellow, tan, gray, green or brown tissue) to the wound bed. Registered Nurse Supervisor #1 stated that they would describe the area as a stage II pressure ulcer that was open, had some slough to the wound bed but did not have any drainage. Registered Nurse Supervisor #1 cleansed the area with normal saline and applied any [MEDICATION NAME] dressing. The resident had had a large open area to their left heel. Registered Nurse Supervisor #1 stated the area appeared to be an unstageable pressure ulcer that had slough with dark eschar (dead tissue usually black, brown, or tan in color) to the wound bed that was moist with a large amount of serosanguineous (blood mixed with yellow/clear drainage) drainage. Brown drainage was noted to the outside of the old dressing prior to removal and on Resident #13 fitted bedsheet. Registered Nurse Supervisor #1 did not wear a gown during this observation. During an interview on 1/8/24 at 10:43 AM, Registered Nurse Supervisor #1 stated that when a resident was on enhanced barrier precautions, plastic bins were placed outside of the resident's door, and a precaution sign was to be hung on their door. Registered Nurse Supervisor #1 stated the purpose of enhanced barrier precautions was to protect oneself from the possibility of spreading an infection to themselves or others. They stated that Resident #13 was not on enhanced barrier precautions, and they did not wear a gown when performing pressure ulcer care. Registered Nurse Supervisor #1 stated they were unsure if residents with a chronic pressure ulcer should be on enhanced barrier precautions and would need to look at the signage. After review of the facility's enhanced barrier precautions signage, Registered Nurse Supervisor #1 stated Resident #13 should have been on enhanced barrier precautions because the signage stated, wound care: any skin opening requiring a dressing. During an interview on 1/8/25 at 11:18 AM, Registered Nurse Manager stated that a resident with any skin wounds should be on enhanced barrier precautions. They stated that Resident #13 was not on enhanced barrier precautions, that they should have been, and there was no reason but it was not followed through. Registered Nurse Manager stated the purpose of enhanced barrier precautions was for the protection from the resident getting a further infection and protecting the staff as well. During an interview on 1/8/25 at 2:48 PM, the Director of Nursing stated they were the facility's Infection Preventionist and that enhanced barrier precautions should be utilized on residents that need wound care and when there was any high-risk contact with the area. They stated they were responsible for implementing and ensuring residents that needed them, had enhanced barrier precautions in place. The Director of Nursing stated they were unsure if Resident #13 had enhanced barrier precautions implemented and assumed they did because Resident #13 had chronic pressure ulcers for a while. The Director of Nursing stated the purpose of enhanced barrier precautions was to protect to the resident from obtaining an infection in their wound and protect other residents and staff. NYCRR 415. 19(a)(2) | Plan of Correction: ApprovedFebruary 10, 2025 Enhanced barrier precautions were immediately implemented for Resident #13 at time of identification. Enhanced barrier precautions for Resident #13 will remain in effect in accordance with policy. There is a potential for all other residents to be affected. A medical record review of all residents was conducted by the New Director of Nursing (Infection Preventionist) (Start date of 12/23/2024) to ensure enhanced barrier precautions are in place in accordance with policy. No issues identified. Enhanced barrier precautions are implemented in accordance with policy by the RN Nurse Manager and/or Nursing Supervisor(s) in collaboration with Director of Nursing (Infection Preventionist). The ?ôEnhanced Barrier Precautions?Ø policy was reviewed by the New Director of Nursing (Infection Preventionist), with no required revisions. Our New Director of Nursing is aware of policy and requirements. The Director of Nursing reviewed and educated RN Nurse Manager and Nursing Supervisors on ?ôEnhanced Barrier Precautions?Ø policy, to include criteria for when residents are placed on enhanced barrier precautions. A medical record review will be conducted monthly by the Director of Nursing (Infection Preventionist) to ensure enhanced barrier precautions are in place in accordance with policy. A review will be completed for a six (6) month time period, covering 01/2025 ÔÇ£ 06/ 2025. The results of the audits will be reported by the Director of Nursing at the bi-monthly Quality Assurance & Performance Improvement (i.e., QAPI) Committee meetings. After that time, it will be determined by the QAPI Committee at what frequency the auditing should continue. The Director of Nursing will be responsible for the ongoing compliance of this plan. |
Scope: N/A
Severity: N/A
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation and interviews conducted during the Extended Recertification survey completed on 1/8/25, the facility did not ensure the nursing staff information was posted daily and contained the required information for three of five days reviewed. Specifically, the facility did not post daily the current resident census, the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors. The finding is: The policy titled Direct Care Daily Staffing Numbers dated 2/03, documented the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Additionally, within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Intermittent observations made on 1/2/25 at 8:40 AM, 1/3/25 at 8:25 AM, 1/6/25 at 9:46 AM and 1/6/25 at 3:05 PM, revealed there was no posting of the Report of Nursing Staff Directly Responsible for Resident Care form at the nurse's station of Oxford Village, at the main reception area of the facility, or in any prominent place accessible to residents and visitors. The Skilled Nursing Assignment Sheet observed posted at the nurse's station on 1/2/25 at 8:40 AM, 1/3/25 at 8:25 AM and 1/6/25 at 9:46 AM, documented the current date, the name of the nursing supervisor, charge nurse, and certified nurse aides. The document did not include the resident census, or the total number and actual hours worked by licensed and unlicensed staff directly responsible for resident care. During an interview with Resident #18's family member on 1/3/25 at 2:30 PM, they stated that the actual staffing was never posted and was not visible to family members. Resident #18's family member stated that only the daily assignment sheet would be posted, and it did not accurately document what staff had showed up for work or who had called off. During an interview on 1/6/25 at 3:05 PM, the Staffing Coordinator #1 stated that they did not post the Report of Nursing Staff Directly Responsible for Resident Care form because they would post the daily Skilled Nursing Assignment Sheet. During an interview on 1/8/25 at 11:54 AM, the Staffing Coordinator #1 stated that it was the nursing supervisor's responsibility to complete the Report of Nursing Directly Responsible for Resident Care form within two hours of their shift starting and would be posted at the nurse's desk in a clear plastic stand next to the Daily Skilled Nursing Assignment Sheet. During an interview on 1/8/25 at 1:17 PM, Licensed Practical Nurse Supervisor #1 stated that the nursing supervisors were responsible to complete the Report of Nursing Staff Directly Responsible for Resident Care form each shift and would adjust with any staff changes that occurred during their shift. Licensed Practical Nurse Supervisor #1 stated this form had not previously been posted at the nursing desk until 1/7/ 25. They stated that prior to 1/7/25 this form would be completed and placed in a binder that was behind the nurse's desk not accessible to residents or family. Licensed Practical Nurse Supervisor #1 stated that it would be important to have it posted to provide transparency for residents and families so that they knew how many staff members were present in the building to provide resident care. They were not aware that it should have been posted in an accessible. During an interview on 1/8/25 at 11:58 AM, the Director of Nursing #1 stated that it was the nursing supervisor's responsibility to complete and post the Report of Nursing Staff Directly Responsible for Resident Care form daily. They stated they would expect this form to be updated every shift with any call offs to reflect the actual staff in the building. The Director of Nursing #1 stated it was important to have this posted so that residents and family members would know how many staff members were present in the building providing care. 10NYCRR 415. 13 | Plan of Correction: ApprovedFebruary 12, 2025 The ?ôDirect Care Daily Staffing?Ø sheet will continue to be posted daily in addition to the ?ôSkilled Nursing Assignment Sheet?Ø at the Nursing Secretary/ Staffing Coordinators desk (located on the Skilled Nursing Unit, which is a prominent place accessible to residents and visitors) in accordance with the ?ôDirect Care Daily Staffing Numbers?Ø policy. All residents have the potential to be affected. A review and education of the Direct Care Daily Staffing Numbers policy was conducted by the New Director of Nursing (Start date of 12/23/2024) with the Nursing Secretary/ Staffing Coordinator and all Nursing Supervisors to ensure they understand the policy and process for completing the Direct Care Daily Staffing sheet. The Nursing Supervisor on duty, Nursing Secretary/ Staffing Coordinator and Director of Nursing will ensure the Direct Care Daily Staffing sheet is posted daily in accordance with the Direct Care Daily Staffing Numbers policy. A review was conducted by the Director of Nursing and Administrator of the ?ôDirect Care Daily Staffing Numbers?Ø policy. No revisions required. A weekly audit will be conducted by the Director of Nursing of daily postings of the ?ôDirect Care Daily Staffing?Ø sheet. The results of the weekly audits will be reported by the Director of Nursing at the bi-monthly Quality Assurance & Performance Improvement (i.e., QAPI) Committee for a time period of four (4) months (02/2025 - 05/2025). After which time the QAPI Committee will determine at what frequency the auditing will continue. The Director of Nursing will be responsible for the ongoing compliance of this plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 a Complaint investigation (Complaint #NY 317) completed on an Extended Recertification survey with an exit date of 1/8/2025, the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #22) of six reviewed. Specifically, the facility did not report to the State Agency allegations of abuse within the two-hour required time frame. In addition, the facilities abuse reporting protocols have not been reviewed/revised since 2016. The finding is: The policy and procedure titled Abuse Reporting revised 11/28/16 documented the Director of Nursing and Administrator will be called and notified immediately, but not later than two hours after the allegation is made if the events of the allegation involve abuse or result in serious bodily injury. Verbal/written notices to agencies will be made within 24 hours of the occurrence and such notice may be submitted electronically via the NYSDOH (New York State Department of Health) Health Commerce System. The policy did not include the required 2-hour timeframe. 1. Resident #22 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 11/15/24 documented Resident #22 had severe cognitive impairments. Resident #22 required substantial/maximal assistance for toileting, toileting transfer, upper body dressing, lower body dressing, and for personal hygiene. The Accident and Incident Report signed by the Administrator and the Assistant Administrator documented on 11/26/24 between the hours of 8:00 AM and 9:00 AM Activities Aide #1 reported to the Licensed Practical Nurse Supervisors they heard screaming and thumping sounds coming from Resident #22's room. The Licensed Practical Nurse Supervisors went to Residents #22's room and the resident was receiving care at the bedside from CNA (Certified Nurse Aide #1) and a private companion aide. The report documented the resident was restrained by Companion Aide #1, their arms were grabbed, crossed, and held to the resident's chest. The Accident and Incident Report included a Management Investigation Report that documented the event occurred because Resident #22 did not want to get out of bed and the hired Companion Aide #1 did not respect the resident's wishes. The report documented the event was suspected abuse/mistreatment/neglect of the resident and the Regulatory Agency was notified on 11/27/ 24. Review of Social Worker #1's written statement attached to the Accident and Incident report dated 11/26/24 documented that Resident #22's family member reported to them at 2:00 PM on 11/26/24 that Certified Nurse Aide #1 reported to the family member that Companion Aide #1 was using inappropriate behavior towards Resident # 22. During an interview on 1/6/25 at 8:19 AM, Certified Nursing Aide #1 stated on the morning of 11/26/24, Companion Aide #1 insisted that Resident #22 got up and dressed; they pulled the residents blankets back and Resident #22 kicked Companion Aide # 1. Companion Aide #1 then forcefully grabbed the resident's arms and crossed them across the resident's chest to restrain them as they yelled, Stop, you will get dressed now! Resident #22 was screaming and crying. Licensed Practical Nurse Supervisor #1 and Licensed Practical Nurse #3 entered the room. Certified Nurse Aide #1 stated they would consider this abuse because they should not force a resident to do anything they don't want to. During an interview at 1/6/25 at 9:17 AM, Licensed Practical Nurse #3 stated Activities Aide #1 had told Licensed Practical Nurse Supervisor #1 they heard a thump and yelling in Resident #22's room, so they went to see what had happened. Resident #22 was screaming, distressed, and agitated. They stated they did not see any bruises on Resident #22 and did not see Companion Aide #1 touch the resident, so they were not certain if this was abuse. During an interview on 1/6/25 at 9:24 AM, Licensed Practical Nurse Supervisor #1 stated Activity Aide #1 reported they had heard screams and a thump in Resident #22's room. Upon arrival to the room, Resident #22 was screaming and agitated. Licensed Practical Nurse Supervisor #1 stated Companion Aide #1 overstepped their boundaries and were not to provide hands on care. There was no bruising noted on Resident #22, but they considered this abuse and reported the incident to the Assistant Administrator. During an interview on 1/6/25 10:27 AM, Activities Aide #1 stated during their rounds on the morning of 11/26/24, they passed Resident #22's room and heard a thump and someone yelled, Stop kicking me. They reported the concern to Licensed Practical Nurse Supervisor #1 and Licensed Practical Nurse # 3. During an interview on 1/6/25 at 11:38 AM, Resident #22's family member stated they were told by Certified Nurse Aide #1 that Companion Aide #1 physically grabbed their family member by the arms, put them across the resident's chest and yelled at them that they needed to get dressed. The family member stated they reported the incident to Social Worker #1 in the afternoon on 11/26/ 24. During an interview on 1/6/25 at 3:14 PM, the Administrator stated the incident that occurred on 11/26/24 with Resident #22 would not be considered abuse because the police did not get involved, the resident did not get hurt, and there was no psychological harm. They stated it was an isolated event and it was wrong but would not consider this abuse. The Administrator stated the facility reported the incident. During an interview on 1/7/25 at 3:24 PM, Social Worker #1 stated based on their understanding of the situation that occurred on 11/26/24, they felt Resident #22 was restrained by Companion Aide #1 and that would be considered abuse. Review of an email provided by the Administrator on 1/8/2025 dated 11/27/24 at 3:07 PM revealed the email was addressed to the Administrator and documented the Nursing Home Facility Incident Report was successfully submitted on 11/27/24 at 15:06 (3:06 PM). The report was not submitted within two hours of the alleged abuse. NYCRR 415. 4(b)(4) | Plan of Correction: ApprovedFebruary 14, 2025 Resident #22s companion aide (#1) was immediately removed following incident and Private Hire Agreement was revoked, with private hire companion aide (#1) being restricted from the facility and Canterbury Woods campus. Resident #22s responsible party who hired companion aide (#1) was notified of incident and revocation of Private Hire Agreement. Responsible party in agreement with actions taken. Social Worker #1 re-informed Companion aide #3 of Companion aide policy via phone conference on 01/06/ 2025. Resident is presently doing well. Report of resident #22's incident was filed with the Department of Health (i.e., DOH). All residents have the potential to be affected. An audit was conducted looking back six (6) months of all incident reports and investigation reports filed with the DOH. No other reports identified and required to be reported. A review of the ?ôAbuse Reporting policy and Abuse Prevention Program policy?Ø and regulation F609 was conducted by the Administrator and the New Director of Nursing (Start date of 12/23/2024) in collaboration with the Consultant. Clarification & revision to ?ôAbuse Reporting policy?Ø completed. The ?ôAbuse Reporting policy and Abuse Prevention Program policy?Ø were reviewed by Administrator and New Director of Nursing in collaboration with the Consultant. Clarification & revision to ?ôAbuse Reporting policy?Ø completed. All Skilled Nursing Facility personnel will be re-educated in accordance with the Directed In-service plan, to include ?ôCompanion aide?Ø policy and that private duty companion aides are not permitted to provide direct hands on care to residents, in addition to the ?ôAbuse Prevention Program?Ø and ?ôAbuse Reporting?Ø policy. Re-education will be conducted under the direct guidance of the Consultant instructor in collaboration with the Social Worker, Administrator and Director of Nursing. All staff receive in-service education on ?ôAbuse, Neglect and Exploitation?Ø annually, which includes immediately reporting allegations of abuse to the Nursing Supervisor. Incident reports will continue to be audited via interdisciplinary daily morning meetings to ensure 2-hour reporting requirement is met. Incident reports will continue to be submitted & reviewed by the Director of Nursing at the bi-monthly Quality Assurance & Performance Improvement (i.e., QAPI) Committee meetings. Investigation reports will continue to be submitted & reviewed by the Administrator at the bi-monthly QAPI Committee meetings, to include 2-hour reporting timeframe. The Administrator will be responsible for the ongoing compliance of this plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 Extended Recertification survey completed on 1/8/25, the facility did not ensure that a resident with pressure ulcers (ulcers on the skin due to prolong pressure) received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for one (Resident #13) of one resident reviewed. Specifically, there were lack of consistent weekly pressure ulcer assessments and ongoing monitoring for Resident #13's left heel and left buttock pressure ulcers, the assessments did not consistently include staging, measurements of size (length x width x depth), or a description of the wounds. Additionally, the assessments had conflicting documentation of treatment instructions and wound measurements for the pressure ulcers. The finding is: The undated facility policy titled Pressure Ulcer Prevention and Treatment documented that a complete wound assessment and documentation will be done upon initial finding then weekly on all pressure ulcers until they are healed or if there was a deterioration in the ulcer by the Skin team or designees. The policy documented the criteria to be included were site/location; stage; size to include length, width, and depth in centimeters; appearance of the wound bed; undermining/tunneling; surrounding skin; drainage; pain; and signs and symptoms of infection. Resident #13 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/11/24 documented Resident #13 had moderate cognitive impairment, was understood, and usually understands. The assessment tool documented the resident had one stage II (partial-thickness skin loss into but not deeper than the dermis) pressure ulcer that was not present upon admission. The Comprehensive Care Plan dated 10/24/24 documented Resident #13 had actual altered skin integrity related to a partial thickness wound on their left heel. Interventions included to monitor skin per protocol, preventive skin interventions as per resident care guide, encourage meal/fluid consumption, skin team referral as needed, notify the medical doctor for adverse changes, and left heel bootie on at all times. There was no documentation regarding the left buttock pressure ulcer. Review of the Treatment Record from (MONTH) 1, 2024-January 8, 2025, revealed Resident #13 had a treatment order with start date of 10/31/24 to apply [MEDICATION NAME] (a foam dressing designed to absorb wound drainage) bandage to their pressure ulcer on left buttock after cleansing with normal saline daily in the evening. Review of the untitled medical provider progress notes from 9/20/24- 11/12/24 the Medical Director documented on: -9/20/24, Resident #13 had an acute visit due to a new onset of an ulceration on their left heel in the medial aspect (the part that is closest to the body's midline). It was documented that the area was about 2. 5 x 1 centimeters and crescent shaped. -9/24/24, Resident #13 had an ulceration on their left heel, measuring 2 x 0. 5 centimeters, a quarter moon type shape with a clean wound bed. -11/12/24, Resident #13 was seen for a 60-day visit and they had a very superficial ulceration area 3 x 4 centimeters to their left heel. There was no further Medical Director documentation in the medical record regarding Resident #13's pressure ulcer of their left heel or left buttock. Review of the Interdisciplinary notes from 9/20/24-1/7/25 revealed on: -9/20/24 at 10:14 AM, Registered Nurse Manager documented Resident #13 was seen by the Medical Director due to a pressure injury to their outer aspect of the left heel. The area measured 2. 5 x 1 centimeters and was crescent shaped. There was no mention of stage or wound bed description. -10/30/24 at 10:18 PM, Licensed Practical Nurse #5 documented that Resident #13 had a small 2-centimeter open area noted to their left buttock. It was documented that a new order was received to place [MEDICATION NAME] dressing daily. There was no documented description of the wound. -12/11/24 at 2:22 PM, Licensed Practical Nurse #4 documented that Resident #13 presented with a left heel pressure injury that measured 3. 5 x 3. 6 centimeters with eschar (dead tissue usually black, brown, or tan in color) and slough (non-viable yellow, tan, gray, green or brown tissue). -12/18/24 at 12:22 PM, Licensed Practical Nurse #4 documented that Resident #13 was seen for skin rounds and was observed to have a stage II pressure ulcer on their left lower buttocks with scant serous drainage measuring 1 x 1. 5 centimeters. It was documented that the treatment was for a [MEDICATION NAME] dressing (a gel-like dressing that promotes healing) to be changed every three days and as needed. -12/26/24 at 2:27 PM, Registered Nurse Manager documented that Resident #13 was seen for skin checks, their left heel remained with pressure injury and the left lower buttock was resolving. -1/1/25 at 2:47 PM, Licensed Practical Nurse #4 documented that Resident #13 was seen for skin rounds and presented with a pressure ulcer to the lower buttocks. It was documented that Resident #13 had an unstageable pressure ulcer on the left heel that was 95% slough and 5% granulation tissue (red healing tissue). Review of Resident #13's Skin Evaluation form from 10/20/24-1/1/25 revealed on: -10/20/24 at 2:37 PM, Licensed Practical Nurse #4 documented the resident had an area to their left heel measuring 1. 5 x 3 centimeters with 25% slough and serosanguineous drainage (drainage containing both blood and serum). There was no documented stage of the left heel pressure ulcer. -11/21/24 at 2:24 PM, Registered Nurse Manager documented the resident had a pressure injury to their left heel measuring 1. 5 x 3 centimeters with 25% slough and moderate amount of serosanguinous drainage. It was documented that the stage needed further assessment. -12/11/24 at 12:08 PM, Licensed Practical Nurse #4 documented the resident had a left heel unstageable pressure injury measuring 3. 5 x 3. 6 centimeters with eschar and slough. Licensed Practical Nurse #4 documented on a second form at 12:09 PM that the left heel pressure injury measured 1. 5 x 3 centimeters with 25% slough and 75% granulation tissue. The form documented that the stage needed further assessment. There were conflicting measurements documented on two different forms for the same area on the left heel. -12/18/24 at 12:16 PM, Licensed Practical Nurse #4 documented the resident had a stage II pressure injury to their left lower buttock measuring 4 x 3. 9 centimeters with light serous drainage (clear or yellow fluid). The treatment was a [MEDICATION NAME] dressing every other day. There was no documented description of the wound. Licensed Practical Nurse #4 documented on a second form at 12:31 PM that the stage II pressure injury on the left lower buttock measured 1 x 1. 5 centimeters with light serous drainage. The treatment was a [MEDICATION NAME] dressing every other day. There was no documented description of the wound. There were conflicting measurements documented on two different forms for the same area on the left lower buttock. Licensed Practical Nurse #4 documented a third form at 12:22 PM that the resident had a left heel unstageable pressure injury measuring 3. 5 x 3. 6 centimeters with eschar and slough. -12/26/24 at 2:25 PM, Registered Nurse Manager documented the resident had an unstageable pressure injury to their left heel that measured 5 x 3. 9 centimeters with eschar and slough. At 2:26 PM Registered Nurse Manager documented the resident had a stage II pressure ulcer to their left lower buttock measuring 0. 8 x 1 centimeters. There was no documented description of the wound and the treatment was a [MEDICATION NAME] dressing that was to be changed every other day. -1/1/25 at 2:57 PM, Licensed Practical Nurse #4 documented that Resident #13 had an unstageable pressure injury to their left heel that measured 6 x 4 centimeters with slough. The resident had a stage II pressure ulcer to their left lower buttocks measuring 1 x 1 centimeters. There was no documented | Plan of Correction: ApprovedFebruary 10, 2025 Resident #13 was assessed on 01/09/2025 by the RN Nurse Manager in accordance with the policy ?ôPressure Ulcer Prevention and Treatment Program,?Ø to include measurements of size, location, staging, description of wound, treatment orders and/or instructions. Resident #13 plan of care was updated accordingly. The RN Nurse Manager and New Director of Nursing (Start date of 12/23/2024) or designee, will continue to conduct weekly skin rounds on resident #13, documenting measurements of size, location, staging, description of wound, review of treatment orders and/or instructions, and updates to plan of care as indicated. Information will be documented in the residents electronic medical record (i.e., EMR) in the Skin section. Resident #13 was evaluated by Medical Director on 12/27/2024, 01/07/2025, 01/14/2025 and 01/22/2025, which included wound assessments; location, size and appearance. Resident was seen by Medical Directors Nurse Practitioner on 01/29/2025 and will be seen by Medical Director on 02/05/2025 for evaluation of wound status. There is a potential for all other residents to be affected. All residents presently on weekly skin rounds have been reviewed to ensure assessments include documenting measurements of size, location, staging, description of wound, review of treatment orders and/or instructions, and care plan updates as indicated. The RN Nurse Manager and New Director of Nursing or designee, will continue to conduct weekly resident skin rounds, documenting measurements of size, location, staging, description of wound, review of treatment orders and/or instructions, and care plan updates as indicated. Information will be documented in the residents electronic medical record (i.e., EMR) in the Skin section. All residents receive weekly body skin checks by licensed Charge nurses on her/his scheduled shower day. Residents skins are observed on a daily basis during hands on care by certified nursing assistants (i.e., C.N.A.). Any change in skin condition is immediately reported to the licensed Charge nurse and/or Nursing Supervisor. The licensed Charge nurse and/or Nursing Supervisor conduct follow-up, including notification of Medical Director in accordance with policy, implementation of treatment and care plan measures as indicated. Interdisciplinary AM Conference will continue to be a venue used to report resident status changes. The Pressure Ulcer Prevention and Treatment Program?Ø policy was reviewed by the New Director of Nursing, with no required revisions at present time. Our New Director of Nursing is aware of policy and requirements. The Director of Nursing reviewed and educated RN Nurse Manager on ?ôPressure Ulcer Prevention and Treatment Program?Ø policy; to include that weekly skin round assessments are accurately documented in the EMR Skin section and include measurements of size, location, staging, description of wound, treatment orders and/or instructions, updates to plan of care as indicated. A monthly medical record review will be completed by the Director of Nursing of any residents on weekly skin rounds; the review will include accurate documentation of weekly skin round assessments in the EMR Skin section (measurements of size, location, staging, description of wound, treatment orders and/or instructions, and care plan updates). The monthly medical record reviews conducted by the Director of Nursing will be completed for a four (4) month time period, covering 01/2025 ÔÇ£ 04/ 2025. The results of the audits will be reported by the Director of Nursing at the bi-monthly Quality Assurance & Performance Improvement (i.e., QAPI) Committee meetings. After that time, it will be determined by the QAPI Committee at what frequency the auditing should continue. The Director of Nursing will be responsible for the ongoing compliance of this plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 1/8/25, doors equipped with delayed egress locking mechanisms (a timed-release, magnetic locking mechanism) were not maintained. Specifically, doors equipped with delayed egress locking mechanisms did not have signage posted stating how the doors could be opened during a fire or other emergency. This affected one (West Unit) of two resident units. The finding is: 1a. Observation on the West Unit on 1/2/25 at 9:02 AM revealed the double doors that lead from the Homestead lounge to the West Unit patio were equipped with delayed egress locking mechanisms. At this time, the Facilities Manager tested the delayed egress locking mechanism by pushing on the right door leaf's crash bar, an alarm was heard at the vicinity of the door, and the door opened in 15 seconds. Continued observation revealed there was no signage posted at the doors that stated: Push Unit Alarm Sounds Door Can be Opened in 15 Seconds. During an interview at the time of the observation, the Facilities Manager stated the doors were equipped with delayed egress locks and wander guard system, they were not sure why the doors did not have signage on them, and the facility's doors that were equipped with the wander guard were checked weekly. 1b. Observation on the West unit on 1/3/24 at 7:57 AM revealed the double doors that lead from the Homestead lounge to the West Unit patio were equipped with delayed egress locking mechanisms. At this time, the Facilities Director tested the delayed egress locking mechanism by pushing on the right door leaf's crash bar, an alarm was heard at the vicinity of the door, and the door opened in 15 seconds. The observation also revealed an illuminated exit sign was installed above the doors. During an interview on 1/3/25 at 7:59 AM the Facilities Director stated the West Unit double doors that lead from the Homestead lounge to the West Unit patio were equipped with delayed egress locking mechanisms. The Facilities Director further stated that during the last survey completed in 2023 these doors had electromagnetic locking mechanisms installed on them with a keypad on the Homestead lounge side of the doors and the delayed egress function of the mechanisms had been switched off. The Facilities Director also stated a contractor had installed an electronic keypad on the patio side of these double doors in the First Quarter of 2024 and they must have switched the delayed egress mechanism function for these doors back on when they installed the new keypad. The Facilities Director also stated they were not aware the delayed egress function had been switched back on and the contractor had not informed them or the facility of this. During an interview on 1/6/24 at 10:39 AM the Facilities Director stated the facility's doors that were equipped with delayed egress locking mechanisms were checked during the weekly wander guard checks. Review of Quality Assurance for Wander Guard Door Security Weekly Wander Guard Audit logs revealed the facility's doors that were equipped with wander guard were checked weekly from 6/6/23 through 12/28/23 and from 1/1/24 through 12/24/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2, 19. 2. 1, 19. 2. 2. 2. 4, 7. 2, 7. 2. 1. 6. 1, 7. 2. 1. 6. 1. 1 | Plan of Correction: ApprovedFebruary 7, 2025 The Facilities Director had our third party vendor that installed the two new keypads on the double doors in Homestead come out on 01/06/ 2025. During installation in 2024, the vendor placed the dipswitch to delayed egress which the doors never had delayed egress on them. Vendor placed the dipswitch back to non-delayed egress on 01/06/ 2025. All residents have the potential to be affected. Facilities Supervisor will conduct monthly inspections as part of our monthly environmental audits of all facility exit doors to ensure proper egress functionality. Facilities Director has reviewed requirements regarding egress doors. A review of the requirements regarding egress doors will also be conducted by the Facility Director with the Facility Manager and Facility Supervisor. The Facility Supervisor will conduct monthly egress door audits to ensure they are not delayed egress and that they are functioning properly. The monthly audits will be submitted by the Facilities Director at the bi-monthly Quality Assessment & Performance Improvement (i.e., QAPI) Committee meetings. The Facilities Director will be responsible for the ongoing compliance of this plan. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 1/8/25, the fire alarm system was not maintained. Specifically, batteries associated with the fire alarm system were not load voltage tested semi-annually. This affected two (North Unit and West Unit) of two resident units. The finding is: Observation on 1/2/25 from 8:40 AM to 4:03 PM revealed a fully addressable fire alarm system was installed throughout the facility. Review of Fire Alarm System Test Inspection Reports from the contractor that inspected, tested , and maintained the building's fire alarm system revealed the building's fire alarm system was inspected and tested annually on 12/13/23 and 11/22/ 24. Further review of the reports revealed the load voltage testing of the batteries associated with the fire alarm system were documented on the reports. During an interview on 1/3/24 at 3:18 PM the Facilities Director stated the facility's fire alarm system was inspected and tested annually. The Facilities Director further stated they had spoken with a representative of the contractor that inspected, tested , and maintained the building's fire alarm system and the representative stated the contractor inspected and tested the facility's fire alarm system annually and the contractor did not conduct semiannual load voltage testing of the batteries associated with the fire alarm system. The Facilities Director also stated the facility had no documentation that the batteries associated with the fire alarm system had been load voltage tested semi-annually in 2023 and 2024. Review of an email from the contractor that inspected, tested , and maintained the building's fire alarm system dated 5/31/23 documented the facility had a fully addressable fire alarm system. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 9. 6, 9. 6. 1, 9. 6. 1. 3 2010 NFPA 72: 14. 2. 2, 14. 2. 2. 1, 14. 3, 14. 3. 1, Table 14. 3. 1, 14. 4, 14. 4. 5, Table 14. 4. 5 | Plan of Correction: ApprovedFebruary 11, 2025 A third party vendor does our annual testing of the building fire system panels (Battery backup). The Facilities Director will contact the third party vendor that inspects, tests, and maintains the facility's fire alarm system to ensure the vendor completes semi-annual load voltage testing of all batteries associated with the facility's fire alarm system. Last inspection of battery back-up of the building fire system panels was conducted on 10/07/ 2024. The Facilities Director contacted the vendor to ensure the vendor inspects the backup batteries semi-annually going forward. Next inspection by third party vendor is scheduled for 02/17/ 2025. All residents have the potential to be affected. The Facilities Director conducted an initial audit to ensure there were no other batteries associated with the facility's fire alarm system that were not load voltage tested semi-annually. The Facilities Director will conduct reviews of the semi-annual inspection reports from the third party vendor to ensure battery back-up testing is conducted semi-annually. Next inspection by third party vendor is scheduled for 02/17/ 2025. The Facilities Director has reviewed requirements regarding semi-annual testing of the fire panels battery backups. The semi-annual reviews conducted by the Facilities Director will be submitted by the Facilities Director at the bi-monthly Quality Assessment & Performance Improvement (i.e., QAPI) Committee meetings. The Facilities Director will be responsible for the ongoing compliance of this plan. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 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 Life Safety Code survey completed on 1/8/25, smoke barriers walls were not maintained. Specifically, smoke barrier walls were not complete from floor to ceiling deck, not designed to have at least a 30-minute fire resistance rating, and not designed to resist the passage of smoke, due to penetrations through the smoke barrier walls. This affected the Occupational Therapy/ Physical Therapy room and the main corridor. The findings are: 1a. Observation above the ceiling tile in the Occupational Therapy/ Physical Therapy room on 1/2/25 at 1:39 PM revealed a six in long by six inch wide open unsealed penetration through the gypsum board smoke barrier wall that separated the Occupational Therapy/ Physical Therapy room from the rear wall of the corridor restrooms located in the main corridor across from the Administrator's office. Further observation of this smoke barrier wall revealed a three foot long the three foot wide area of the gypsum board smoke barrier wall had been removed. 1b. Observation above the ceiling tile in the Occupational Therapy/ Physical Therapy room on 1/2/25 at 1:48 PM revealed a 22 foot long by three foot wide area of the of the gypsum board smoke barrier wall that separated the Occupational Therapy/ Physical Therapy room from the main corridor was missing. Further observation revealed an unprotected steel beam was observed in the area where the gypsum board smoke barrier wall was missing. Continued observation revealed this smoke barrier wall separated the Occupational Therapy/ Physical Therapy room from the main corridor located across from the Nutrition office and the Reception office. During an interview at the time of the observation the Facilities Director stated the Occupational Therapy/ Physical Therapy room was being remodeled and they were not aware of any issues with the smoke barrier walls. 1c. Observation above the ceiling tile in the main corridor on 1/2/25 at 1:55 PM revealed a two inch long by two inch wide penetration around two, one quarter inch blue colored electrical wires that were installed through the smoke barrier wall that separated the main corridor from the Occupational Therapy/ Physical Therapy room was filled with an orange [MEDICATION NAME] foam. Further observation revealed the penetration was in the smoke barrier wall located across from the Nutrition office and the Reception office. During an interview at the time of the observation the Facilities Director stated they were not aware the orange foam had been used in the smoke barrier wall and the facility did not use orange foam to seal penetrations in smoke barrier walls. The Facilities Director further stated the two blue electrical wires were data lines and the Information Technology (IT) department had not done any recent work in this area of the building. 1d. Observation on 1/2/25 at 1:58 PM above the ceiling tile in the main corridor revealed a two inch long by two inch wide open unsealed penetration around a one quarter inch gray electrical wire that was installed through the smoke barrier wall located across from the Nutrition office and the Reception office. During an interview at the time of the observation the Facilities Director stated the gray electrical wire was a data line. Review of the facility's architectural drawings in the presence of the Facilities Director revealed the smoke barrier walls that were observed above the ceiling tile in the Occupational Therapy/ Physical Therapy room and the main corridor revealed they were part of the walls that were labeled as Smoke Area D on the Level One Overall Plan Sheet Number A- 0. 1 of the drawings that were marked as issued for construction 9/15/ 97. Further review of the facility's architectural drawings revealed a set of cross corridor doors located in the main corridor near the Occupational Therapy/ Physical Therapy room were labeled as smoke doors and were installed in part of walls that were labeled as Smoke Area D. Review of the facility supplied First Floor, floor plan of the Oxford Village showed the smoke barrier walls that were observed above the ceiling tile in the Occupational Therapy/ Physical Therapy room and the main corridor revealed they were part of the facility's smoke barrier walls. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7, 19. 3. 7. 3, 8. 5, 8. 5. 1, 8. 5. 2, 8. 5. 2. 1, 8. 5. 2. 2, 8. 5. 2. 3 | Plan of Correction: ApprovedFebruary 6, 2025 Smoke Barrier walls in identified locations were not completely sealed from ceiling to roof deck. The Facilities Director had both the Facility Manager and Facility Supervisor seal all penetrations identified and sealed the open penetrations with fire sealant that is capable of maintaining the smoke resistance of the smoke barrier and meets the current NFPA standards. The Facilities Director inspected each area to ensure code compliance. All residents have the potential to be affected. The Facilities Director has reviewed requirements regarding smoke barriers. A review of the requirements of smoke barriers was also conducted by the Facilities Director with the Facility Manager and Facility Supervisor. The Facilities Supervisor will inspect all smoke barriers as part of the monthly environmental inspections. The Facilities Director will conduct monthly reviews of the inspection reports completed by the Facility Supervisor. The monthly inspections will be submitted by the Facilities Director at the bi-monthly Quality Assessment & Performance Improvement (i.e., QAPI) Committee meetings. The Facilities Director will be responsible for the ongoing compliance of this plan. |