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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 record review and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that residents' comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and as needed. This was evident in 2 of 22 sampled residents (Residents #35, #18). Specifically, 1. ) Resident #35's care plan related to Smoking was not reviewed and revised quarterly after each assessment, and 2. ) Resident #18's care plan was not reviewed and revised after a fall occurrence. The findings are: The facility policy and procedure titled Care Plans Comprehensive with a last revised date of 08/02/2024 documented that a comprehensive person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, the desired outcome is not met, and at least quarterly, with a scheduled quarterly minimum data set assessment. 1). Resident #35 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #35's cognition was intact. The annual Minimum Data Set assessment dated [DATE] documented that Resident #35 uses tobacco. A care plan related to Smoking was initiated for Resident #35 on 10/17/ 2019. The care plan documented that Resident #35 is a smoker and uses a cigarette holder during smoke sessions. The interventions include educating the resident on the benefits of the smoking cessation program, the rules/ policy, designated smoking areas, and that they will be regularly assessed for safety. The care plan was last revised on 03/08/ 2023. There was no documented evidence that the comprehensive care plan related to Smoking was reviewed and revised after each quarterly review assessments dated 01/13/2024, 04/14/2024, 07/15/2024, and 10/15/ 2024. On 01/08/2025 at 11:58 AM, Registered Nurse #1, who was the unit manager, was interviewed. Registered Nurse #1 stated that Resident #35 is a smoker and smokes in the smoking room. Registered Nurse #1 stated that the overnight nursing supervisor is responsible for updating the care plans. They stated that it is not documented that the care plan has been reviewed and revised. On 01/08/2025 at 12:16 pm, the Recreation Director was interviewed and stated that the nurse is responsible for initiating and updating the smoking care plan. On 01/08/2025 at 12:24 PM, the Director of Nursing was interviewed and stated that care plans are updated quarterly and as needed. The Unit Managers, Nursing Supervisors, and the Minimum Data Set Coordinator are responsible for updating the care plan. 2). Resident #18 was admitted to the facility with [DIAGNOSES REDACTED]. On 01/02/2025 at 11:23 AM, Resident #18 was interviewed and stated they fell before admission and also fell in the facility one time shortly after admission. The admission Minimum Data Set assessment dated [DATE] documented that Resident #18 had intact cognition and had impairment on one side of upper extremity. The assessment documented the resident required substantial/partial/moderate assistance and was dependent on staff for most activities of daily living. The care plan for fall dated 11/16/2024 documented that Resident #18 was at risk for falls/ had an actual fall related to deconditioning, gait/balance problems. A Registered Nurse Narrative Assessment note dated 11/18/2024 at 5:34 AM documented Resident #18 was observed sitting in wheelchair at nursing station and wheeled to the room by a Certified Nursing Assistant, where resident attempted to rise from wheelchair without applying the brakes. The note documented that at approximately 11:20 PM, Resident #18 was observed sitting on the floor on the left side of the bed. Resident had no injury noted on assessment, no complaint of pain or discomfort. There was no documented evidence that Resident #18's comprehensive care plan was reviewed and revised after the fall occurrence. On 01/07/2025 at 11:30 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #18's fall that occurred in (MONTH) should have been documented and updated in the resident's care plan for fall. On 01/08/2025 at 11:30 AM, the Director of Nursing was interviewed and stated that a resident's comprehensive care plan is initiated and updated by the Unit Manager. The Director of Nursing also stated that the Minimum Data Set Coordinator also ensure that residents' care plans are in place, and they are expected to review the resident's care plan quarterly and ensure that appropriate care plans are implemented for the residents. On 01/08/2025 at 12:20 PM, Minimum Data Set Coordinator was interviewed and stated that the Registered Nurse Managers are the ones that initiate and update the care plans. They stated that they make sure they do a quick review to check if there are missing care plans or if there is any care plan that needs to be updated and send the findings to the Director of Nursing or the Administrator. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedJanuary 30, 2025 Element 1 - Resident #35 care plan was reviewed by DNS all appropriate care plans reviewed and revised as needed. - Resident #18 care plan was reviewed by DNS all appropriate care plans reviewed and revised as needed. - An audit was completed on all residents with smoking care plans to ensure they were reviewed and revised as needed. - An audit was completed on all residents with recent falls within the last 30 days to ensure fall care plan was reviewed and revised as needed. Element 2 All residents had potential to be affected by the deficient practice Element 3 - The facilities policy titled Care Plans Comprehensive was reviewed no revisions at this time. - In service to all Registered Nurses and Licensed Practical Nurses on resident care plan timing and revision process is ongoing. -Audit tools in place to ensure smoking and fall care plans are reviewed and revised as needed, minimum quarterly for all residents. Bi-weekly for 2 weeks, monthly for 3 months. Element 4 - Audit tools in place to ensure care plans are reviewed and revised as needed minimum quarterly for all residents. - Any deficient findings will be addressed immediately - All audit findings will be reported to QAPI committee Monthly for 3 months Responsible Party: DNS/Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen observation. Specifically, 1. ) The walk-in refrigerator contained undated items. 2. ) A unit refrigerator contained spilled liquids and undated fruit cups and open drinks items. The findings are: The facility's policy titled Food Storage with a revision date of 05/10/2024 documented that food will be stored in an area that is clean, dry, and free from contaminants, stored at appropriate temperatures, and by methods designed to prevent contamination or cross contamination. All refrigerator units will be kept clean and in good working condition at all times. Perishable foods such as meat, poultry, fish, dairy products, fruits, and vegetables must be stored in the refrigerator immediately after receipt to assure nutritive value and quality. All food should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by date or discarded. Leftover food items will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. The undated facility's policy and procedure titled Food Storage Policy Quick Reference that was posted on the walk-in refrigerator documented: Sliced Deli Meat - date the day sliced - use by 2 days; Eggs - date the day received - use by 2 weeks of delivery; and Prepared Foods - date the day prepared - use by 2 days. The facility's policy and procedure titled Food-From Outside with a reviewed date of 06/01/2024 documented that all refrigerated foods will be discarded within 48 hours. Nursing staff will monitor the pantry refrigeration units for food and beverage disposal. The nursing staff will discard perishable foods on or before the discard date. 1. ) On 01/02/2025 at 9:17 AM, an initial kitchen observation was conducted with the Dietary Director and the following were observed: 5 trays (24 per tray) of unpackaged eggs that were undated, 4 undated bologna and cheese sandwiches, 1 open 5-pound container of peanut butter undated, the expiration date was unreadable. On 01/02/2025 at 9:35 AM, the Dietary Director was interviewed and stated that there should be dates on all refrigerated items; there should be a preparation date, open date, or the date the item was refrigerated. All these items should have been dated prior to storing the food in the refrigerator so they can be discarded within 48-72 hours. The Dietary Director further stated that it is their responsibility to ensure that all refrigerated items are labeled with dates. 2. ) On 01/02/2025 at 10:39 AM, the South Unit refrigerator was observed with spilled tan colored liquid on the bottom, two 4-ounce cups of facility prepared peaches that were undated and one 64-ounce cranberry juice that was open and undated. Registered Nurse #1 was interviewed and stated that all food should be clearly dated with the resident's name and date before it is placed in the refrigerator, all liquids should be dated with the opened date, and the refrigerator should have no standing liquids in the bottom as was observed. They stated that housekeeping cleans the unit refrigerator daily, but all the nurses on the floor should ensure contents of the refrigerator are correctly labeled and dated and discarded within 72 hours. On 01/06/2025 at 10:20 AM, the Associate Administrator was interviewed and stated that all food should be dated, sandwiches need a preparation date, and fruit cups and eggs should be dated if removed from the original containers with expiration dates on them. They stated that the peanut butter should be labeled with the date the jar was opened and then discarded on the manufacturer's expiration date. The Associate Administrator further stated that all dated food should be discarded in 48 hours. 01/07/2025 at 08:10 AM, the Director of Nursing Services was interviewed and stated that the nursing staff should discard any food or liquid found in the unit refrigerators that is not dated. They stated nursing supervisors are to ensure that this is performed daily during rounds and housekeeping should be notified if the refrigerator needs to be cleaned. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedJanuary 30, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 All food items stored in the refrigerators without proper labeling, opened food items without dates and the expired food items were discarded on ,[DATE]/ 25. And the refridgerators were cleaned on ,[DATE]/ 25. Element 2 All residents had potential to be affected by the deficient practice Element 3 The policy and procedures titled Food storage,Food from outside and Unit Food Storage was reviewed, with no revisions needed. The Ass Administrator or designee will inservice dietary and RN's, LPN's & CNA's on managing and maintaining proper food storage areas. Focus on ensuringfood is labeled, dated and discarded upon expiration. And that the refridgerators are cleaned regularly. The Asst administrator or designee will Round 2xs per week x4 weeks, then monthly x3mths Any issues will be immediately addressed. An Audit tool developed on this issue Element 4 The Ass. Administrator or designee will report findings to QA committee Monthly X 3 Months. Audit will include monitoring of shelving units to ensure they are free from dirt and that all food is labeled and discarded according to facility policy. Responsible party Administrator/designeee |
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, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1. ) Infection prevention and control practices were not maintained during medication administration. This was evident in 1 of 3 nurses observed for medication administration. 2. ) Staff failed to assist residents with hand washing or hand hygiene before meals. This was evident in 2 of 2 units observed during meals. 3. ) A resident's urinary drainage bag was observed touching the floor. This was evident in 1 (Resident #4) of 3 residents reviewed for Urinary Catheter out of 22 sampled residents. The findings are: 1. ) The facility's policy titled Infection Prevention and Control Program with a last revision date of 05/30/2024 documented that the facility adheres to 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. On 01/02/2025 at 12:54 PM, during medication administration observation, Licensed Practical Nurse #1 was observed administering Resident #3's finger stick blood sugar. Licensed Practical Nurse #1 placed the glucometer and insulin pen on Resident #3's blanket prior to checking the resident's blood sugar. The nurse then took the glucometer from the blanket, and without sanitizing, used it to check the resident's blood sugar. The nurse then took the insulin pen from the resident's blanket and without sanitizing, drew the units to inject to the resident. Licensed Practical Nurse #1 was interviewed and stated they should have used the resident's overbed table to place the glucometer and insulin pen. Licensed Practical Nurse #1 stated they usually use the table and a barrier to place the equipment, but the resident was using the table to eat, that was why they placed it on the resident's blanket. On 01/08/2025 at 11:39 AM, the Director of Nursing was interviewed and stated that the Nurse should know better that the glucometer and resident's insulin should not be placed on the resident's bed. 2. ) The facility policy titled Hand Hygiene with a revision date of 05/30/2024 documented the facility adheres to recommendations by the Center for Disease Control for the practice of hand hygiene in accordance with standard, enhanced barrier, and transmission-based precautions. The facility provides access to necessary supplies for hand hygiene for healthcare personnel, residents, and visitors. Hand hygiene facilities including sinks with soap, running water, disposable paper towels and alcohol-based hand rub are accessible in resident care areas and other areas of the facility as necessary. Residents are assisted with and or reminded to perform hand hygiene before and after meals and as needed or requested. On 01/02/2025 at 12:13 PM, during dining observation of the North and South units, Certified Nursing Assistants #2, #3, #4, and #5 were observed delivering and setting up meal trays in residents' rooms (Residents #41, #37, #72, #17, #54, and #24). The Certified Nursing Assistants did not assist the residents with hand hygiene, nor did they provide reminder to the residents to perform hand hygiene or wash their hands prior to eating lunch. Certified Nursing Assistant #2 was interviewed and stated they were supposed to give out sanitizing wipes to the residents with the meal trays, but they forgot to put wipes in the cart. Certified Nursing Assistant #3 and #4 were interviewed and both stated they were supposed to wash the residents' hands or use wipes if residents are unable to wash their own hands, but they forgot to provide the wipes. Certified Nursing Assistant #5 was interviewed and stated they thought someone else was doing the residents' hand hygiene prior to them delivering the meal trays. On 01/07/2025 at 08:19 AM, The Director of Nursing Services was interviewed and stated that the Certified Nursing Assistants are to provide sanitizing hand wipes to residents or assist the residents in sanitizing their hands prior to eating. 3. ) The facility policy titled Urinary Catheter Guidelines with a last revision date of 09/11/2023 stated not to position urinary catheter drainage bag on the floor. On 01/06/2025 at 09:55 AM and at 10:18 AM, Resident #4 was observed lying in bed with their urinary catheter drainage bag and tubing touching the floor. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented that Resident #4 was cognitively impaired and was dependent in all activities of daily living, had a urinary catheter, and always incontinent of bowel. The physician orders [REDACTED]. The physician orders [REDACTED]. On 01/06/2025 at 10:19 AM, Licensed Practical Nurse #3 was interviewed and stated that the catheter tubing and drainage bag touching the floor is not a good practice. Licensed Practical Nurse #3 stated that the urine can backflow and go back up into the bladder which is an issue. They stated there is also an issue with sterility as catheter tubing and drainage bags should not be touching the floor putting the resident at risk for infections. On 01/06/2025 at 10:24 AM, Registered Nurse #1, who was the unit manager, was interviewed and stated that catheter tubing and bag touching the floor is an infection control issue. Registered Nurse #1 stated that all staff are aware that the catheter should be off the bed hanging below the level of the bladder without touching the floor. Registered Nurse #1 stated this is a very serious infection control issue particularly if a resident has a urinary tract infection as the urine can travel back up into their system. The bag touching the floor can introduce other types of bacteria into the catheter. On 01/07/2025 at 11:52 AM, the Director of Nursing was interviewed and stated that the catheter bag and tubing touching the floor was an unintentional act, and that it was a result of the staff putting the bed in the lowest position. The Director of Nursing stated that it was a breach in infection control. 10 NYCRR 415. 19 (a) (1-3) | Plan of Correction: ApprovedJanuary 29, 2025 Element 1 - Facility policy titled Infection Prevention and Control Program was reviewed by DNS no revisions needed. - Licensed Practical Nurse # 1 was in serviced by DNS on facility Infection Prevention and Control program. - Licensed Practical Nurse # 1 was in serviced by DNS on glucometer check process. - Resident # 3 was assessed by DNS no ill effects from deficient practice resident stable. - The facility policy titled Hand Hygiene was reviewed by DNS no revisions needed. - Certified Nurses Aides # 2, #3, #4 and #5 were in serviced by DNS on Hand hygiene policy specifically residents hand hygiene prior to meals. - Resident # 41, # 37, #72, #17, #54, and # 24 were assessed by DNS no ill effects from deficient practice. - The facility policy titled Urinary Catheter Guidelines was reviewed by DNS no revisions needed. - Resident # 4 was assessed by DNS no ill effects from deficient practice - Licensed Practical Nurse # 3 was in-serviced on Urinary catheter Guidelines policy Element 2 All residents had potential to be affected by the deficient practice Element 3 - In Service for all Registered Nurses and Licensed Practical Nurses on facility Infection Prevention and Control program. - In service for all Registered Nurses and Licensed Practical Nurses on Urinary catheter Guidelines policy. - In service for all Certified Nurses Aides on Hand hygiene policy specifically residents hand hygiene prior to meals. - Audit tool was created and in place to monitor resident hand hygiene before meals weekly times 4 weeks than monthly times three months then quarterly. - Audit tool was created and in place to monitor Licensed Practical Nurse process during resident fingerstick weekly times four weeks than monthly times three months than quarterly. - Audit tool was created and in place to monitor resident catheter tubing and bag placement weekly times 4 weeks than monthly times three months then quarterly Any deficient findings will be addressed immediately. Element 4 The DNS/Designee will report all findings to the QAPI committee. Monthly X 3 Months. Responsible Party: DNS/Designee |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025 the facility did not ensure the daily nurse staffing information included all the required information. Specifically, the daily posting of nurse staffing information did not include the actual number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care. This was evident during the review of the Staffing Task. The findings are: The facility policy and procedure titled Staffing- Posting of Hours, Payroll Based Journal Submission with a last revised date of 10/2022 documented staffing posting should include the facility name, current date, resident census, facility specific shift scheduled for the 24 hour period and the number and actual hours worked by the following categories of nursing staff employed or contracted by the facility directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses and Certified Nurse's Aides. During multiple observations from 01/02/2025 through 01/07/2025, nurse staffing information was posted in the lobby near to the entrance of the building. The information that was documented on the form included the facility name, current date, number of nursing staff working and resident census. There was no documentation of the actual hours worked by the nursing staff. On 01/07/2025 at 11:42 AM, the Staffing Coordinator #1 was interviewed and stated they are responsible for posting the staffing schedules but was unaware that actual hours worked by nursing staff daily had to be listed. On 01/07/2025 at 11:52 AM, the Director of Nursing #1 was interviewed and stated that the total number of actual hours worked by nursing staff should be included in the nursing staffing information. 10 NYCRR 415. 13 | Plan of Correction: ApprovedJanuary 29, 2025 Element 1 The staffing template was corrected to reflect work hours. Updated sheet posted. Element 2 All residents had potential to be affected by the deficient practice Element 3 The policy & procedure for STAFFING ÔÇ£ POSTING OF HOURS, PAYROLL BASED JOURNAL SUBMISSION was reviewed and no revisions were necessary. HR was inserviced on STAFFING ÔÇ£ POSTING OF HOURS, PAYROLL BASED JOURNAL SUBMISSION policy. An audit tool was develeoped. Weekly rounds x4,Monthly x3 to ensure proper staffing posting. Element 4 Audit to be done by Administrator/designeee to review the findings of the weekly and Monthly Rounds. Findings of audit to be brought to QA comottee monthly x 3. Responsible party Administrator/designeee |
Scope: N/A
Severity: N/A
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on record review and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that the Acknowledgement and Consent form for Fingerprinting and Disclosure of Criminal History Record Information (Department of Health Criminal History Record Check Form 102) was accurate and complete before submitting a request for Criminal History Record Check. This was evident in 1 (Employee #3) of 4 employee records reviewed. Specifically, Employee #3's Criminal History Record Check Form 102 was not completed, signed, and dated by the Authorized Person. The findings are: The facility policy titled Criminal History Record Check / Fingerprinting with a revision date of 12/18/2024 documented it is the policy of the facility to ensure all persons who are direct caregivers to the residents, and/or those staff who have access to a resident, their living quarters or their property who are not licensed or credentialed will have a Criminal History Record Check Authorization Form completed. Employee #3 was hired as a Certified Nursing Assistant on 09/25/ 2024. A review of Employee #3's Acknowledgement and Consent form for Fingerprinting and Disclosure of Criminal History Record Check form 102 revealed that Section #3 was not completed, signed, or dated by the Authorized Person. On 01/07/2025 at 2:25 PM, the Human Resources Director, who was the facility's Authorized Person, was interviewed and stated that Employee #3 was hired on 09/25/ 2024. They stated they did not complete and sign Section #3 of Form 102 because Employee #3 was hired and did their paperwork through the staffing agency, The Human Resources Director stated Employee #3 signed Form 102 on 05/24/2023 and that they submitted the request for background check on 09/26/ 2024. On 01/07/2025 at 2:56 PM, the Administrator was interviewed and stated they conduct background checks on unlicensed employees that are both directly hired or hired through a staffing agency. The Administrator stated it is the Authorized Person's responsibility to ensure that the form was filled correctly and was signed. The Administrator stated that Employee #3 completed the consent form for background checking on 05/24/2023 and was submitted on 09/26/ 2024. They stated that Section 3 of the form was overlooked and was not completed. | Plan of Correction: ApprovedJanuary 30, 2025 Element 1 The employee is no longer active. Employee has been terminated on CHRC. Facility is now in compliance. Element 2 All residents had potential to be affected by the deficient practice Element 3 The policy for CHRC / FINGERPRINTING ÔÇ£ NY was reviewed and no revisions were necessary. The CHRC authorized Users were inserviced on CHRC / FINGERPRINTING ÔÇ£ NY policy. An audit tool was develeoped. Weekly rounds x4,Monthly x3 to ensure proper CHRC process is performed. Element 4 Audit to be done by Administrator/designeee to review the findings of the weekly and Monthly Rounds. Findings of audit to be brought to QA comottee monthly x 3. Responsible party Administrator/designeee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 1. 2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70: 400. 8 Uses Not Permitted. Unless specifically permitted in 400. 7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368. 56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 10. 2. 3. 6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart mounted, provided that all of the following conditions are met: (1) The receptacles are permanently attached to the equipment assembly. (2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. (3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. (4)*The electrical and mechanical integrity of the assembly is regularly verified and documented. (5)*Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. 10. 2. 4 Adapters and Extension Cords. 10. 2. 4. 1 Three-prong to two-prong adapters shall not be permitted. 10. 2. 4. 2 Adapters and extension cords meeting the requirements of 10. 2. 4. 2. 1 through 10. 2. 4. 2. 3 shall be permitted. 10. 2. 4. 2. 1 All adapters shall be listed for the purpose. 10. 2. 4. 2. 2 Attachment plugs and fittings shall be listed for the purpose. 10. 2. 4. 2. 3 The cabling shall comply with 10. 2. 3. 10. 3 Testing Requirements - Fixed and Portable. 10. 3. 1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. Based on observation and staff interviews, during the Life Safety Recertification survey on (MONTH) 6, 2025, and (MONTH) 7, 2025, the facility did not ensure that extension cords and power strips were used in accordance with NFPA 70. Specifically, unmounted power strips were observed in use. The findings include but are not limited to: 1. Two unmounted power strips, which were daisy-chained, were noted in use in the Maintenance Office. 2. The recreation office had an unmounted power strip, powering computer equipment. At the time of the findings, the Director of Maintenance stated the power strips would be mounted or removed, an audit of the offices would be done, and administrative staff would be in-serviced. 2012 NFPA 101: 9. 1. 2 2011 NFPA 70: 400. 8, 10. 2 10 NYCRR 711. 2(a) | Plan of Correction: ApprovedFebruary 13, 2025 Element 1 Power Strips were removed from the Director of Maintenance's office, additionial outlets were installed. Power strip in Recreation office was mounted. Element 2 All residents had potential to be affected by the deficient practice Element 3 Maintenance director in-serviced on NFPA-101 (National Fire Protection Association) pertaining to electrical ÔÇ£ electrical Wiring. Specifically regarding mounting power strips. Routine maintenance rounds focused on use of power strips, weekly x4, and then monthly x 3. Element 4 Facility Director of Maintenance will audit rounds of electrical wiring with regards to power strips and extension cords in accordance with NFPA-101 National Fire Protection Association) daily x7, then weekly x4, then monthly x 3. Findings of Audit to be presented at Quality Assurance meeting monthly x 3. Responsible Party: Director of maintenance/designee |
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** NFPA 101: 9. 1. 2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 99: 6. 3. 2. 1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. 2011 NFPA 70: 314. 25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, lampholder, or luminaire canopy, except where the installation complies with 410. 24(B). 700. 10 Wiring, Emergency System. (A) Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as components of an emergency circuit or system. (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy. Based on observation and interviews during the Life Safety Code survey completed on (MONTH) 7, 2025, electrical components were not maintained in accordance with NFPA 101. Specifically, a cover was missing from an electrical junction box and electrical panels were not identified. The findings include but are not limited to: On a tour of the basement, it was observed 1) that a junction box on the ceiling of the kitchen lacked a cover. At the time of the finding, the Director of Maintenance stated that a light fixture had been removed. 2) there was no identification on the electrical panels across from resident room [ROOM NUMBER] and in the basement across from the Soiled Linen Room. At the time of these findings, the Director of Maintenance stated that the panels would be labeled and an audit of all panels would be conducted to ensure they are all identified. 2012 NFPA 101: 9. 1, 9. 1. 2 2012 NFPA 99: 6. 3. 2. 1 2011 NFPA 70: 314. 25, 314. 72, 700. 10, 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 Junction box cover was added on 2/7/ 25. Electrical Panel across room [ROOM NUMBER] was labeled and in the basment across from soiled Utility room Element 2 All residents had potential to be affected by the deficient practice Element 3 Maintenance director in-serviced on NFPA-101 (National Fire Protection Association) pertaining to Electrical Systems - Essential Electric System Maintenance and Testing. Specifically regarding to identifying electric panels. Routine maintenance rounds focused on labeled electric panels, weekly x4, and then monthly x 3. Element 4 Facility Director of Maintenance will audit rounds of labeled electric panels, weekly x4, then monthly x 3. Findings of Audit to be presented at Quality Assurance meeting monthly x 3. Responsible Party: Director of maintenance/designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 2. 9. 1 Emergency lighting shall be provided in accordance with Section 7. 9. 2012 NFPA 101: 7. 9. 3. 1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7. 9. 3. 1. 1, 7. 9. 3. 1. 2, or 7. 9. 3. 1. 3. 2012 NFPA 101: 7. 9. 3. 1. 1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (3) Functional testing shall be conducted annually for a minimum of 1?é½ hours if the emergency lighting system is battery powered. (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. Based on record review and staff interview, the facility did not ensure that the testing of emergency lighting systems was performed in accordance with the 2012 NFPA 101 Life Safety Code. Specifically, the annual 90-minute test was not conducted on battery pack emergency lighting that serves the facility. The findings are: On (MONTH) 7, 2024, at approximately 9 AM, during the Life Safety Code recertification survey, a binder with the building maintenance documents was provided. A review of the emergency lighting form listed monthly testing of 30 seconds from (MONTH) 2024 through December 2024. The test recorded on (MONTH) 31, 2024, was 30 minutes. On (MONTH) 7, 2025, at approximately 2:00 PM, the Administrator was made aware during the exit interview. 2012 NFPA 101: 19. 2. 9. 1; 7. 9. 3. 1; 7. 9. 3. 1. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 12, 2025 Element 1 The annual 90-minute test was conducted on battery pack emergency lightings that serves the facility on 2/11/ 25. Element 2 All residents had potential to be affected by the deficient practice Element 3 Maintenance director in-serviced on NFPA-101 (National Fire Protection Association) pertaining to electrical ÔÇ£ Testing of required emergency lighting systems and frequency of 90 Minute test. Routine maintenance rounds focused emergency electrical lighting testing, weekly x4, and then monthly x 3. Element 4 Facility Director of Maintenance will audit rounds of emergency electrical lighting testing, in accordance with NFPA-101 National Fire Protection Association) weekly x4, then monthly x 3. Findings of Audit to be presented at Quality Assurance meeting monthly x 3. Responsible Party: Director of maintenance/designee |
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** 2012 NFPA 101: 19. 3. 5. 1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9. 7, unless otherwise permitted by 19. 3. 5. 5. 2012 NFPA 101: 19. 3. 5. 4 The sprinkler system required by 19. 3. 5. 1 or 19. 3. 5. 3 shall be installed in accordance with 9. 7. 1. 1(1). 2012 NFPA 101: 9. 7. 1. 1 Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems 2010 NFPA 13: 8. 1. 1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles: (1) Sprinklers shall be installed throughout the premises. (2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler. (3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. 8. 5. 5. 3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8. 5. 5. 3. 8. 6. 3. 3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. 8. 15. 3. 2. 1 In noncombustible stair shafts having non-combustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. Based on observations and staff interviews during the life safety recertification survey, the facility did not ensure that sprinkler heads were installed according to the manufacturer's instructions. The findings include but are not limited to: On a tour of the resident floor, in resident room [ROOM NUMBER], one of the four sprinkler heads was of a different temperature rating. At the time of the finding, the Director of Maintenance stated the vendor would come in to change it immediately. On a tour of the basement on 1/07/2015, at 1:00 PM, it was noted that a pendent sprinkler was closer than 4 inches from the wall in the corridor, adjacent to the conference room. At the time of the findings, the Director of Maintenance stated that the pendent sprinkler would be replaced with a sidewall sprinkler and 2012 NFPA 101 2010 NFPA 13 10NYCRR 711. 2(a) 10 NYCRR 415. 29 | Plan of Correction: ApprovedFebruary 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 On 1/7/25 sprinkler head in room [ROOM NUMBER] was replaced. On 1/8/25 pendent sprinkler in the basement was changed. Element 2 All residents had potential to be affected by the deficient practice Element 3 Maintenance director in-serviced on NFPA-101 (National Fire Protection Association) pertaining to having the correct temperature rating for fire sprinkler and the placement of the fire sprinklers. Routine maintenance rounds focused fire sprinklers, weekly x4, and then monthly x 3. Element 4 Facility Director of Maintenance will audit rounds of fire sprinklers, in accordance with NFPA-101 National Fire Protection Association) weekly x4, then monthly x 3. Findings of Audit to be presented at Quality Assurance meeting monthly x 3. Responsible Party: Director of maintenance/designee |