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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 1 of 2 residents (Resident #12) reviewed. Specifically, there was no documented evidence risks and benefits were reviewed and informed consent was obtained prior to the placement of bilateral bed rails on Resident #12's bed. Additionally, the comprehensive care plan did not include the use of bed rails. Findings include: The facility policy, Bedrail Determination, dated 2/1/2024 documented the use of side rails or bed rails on beds would be permitted to provide greater independence however had the potential for entrapment and harm. The process included: - The resident was screened upon admission, readmission, or change of condition determining level of independence with bed mobility and transfers. - The resident was evaluated to identify appropriate alternative interventions to address a medical symptom prior to installing assist rails. - The resident was evaluated for risk of entrapment from assist bars prior to installation. - The risks and benefits were discussed and consent for installation was obtained. - The facility would review ongoing need for the assist rails quarterly and as needed. - The residents care plan was updated to reflect use of the assist rails. - The physician documented an order for [REDACTED]. - Maintenance was contacted for installation of assist rails. The blank facility form Informed Consent for Use of Assist Rails, listed the risks and benefits of the assist rails, the employee's name who reviewed the risks and benefits with the resident, the name of individual giving consent with the signature and date as well as a check mark if the consent was obtained via telephone. Resident #12 had [DIAGNOSES REDACTED]. The 12/21/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with bed mobility and transfers, and did not use bed rails. The Comprehensive Care Plan initiated 6/4/2021, documented the resident was at risk for falls related to fatigue and shortness of breath. Interventions included call bell in reach, use of handrails on walls, and evaluation for adaptive equipment ensuring the least restrictive devices. The resident had an activities of daily living performance deficit related to limited mobility. Interventions included independence with bed mobility. There was no documented use of bed rails. The 5/23/2024 Physical Therapist #24 progress note documented Resident #12 was assessed on 5/7/2024 as well as this day for bilateral assist rails. The resident required bilateral assist rails to maintain independence with bed mobility tasks as well as avoiding excessive desaturation (low oxygen levels) as the resident required increased assistance when attempted without assist rails. The 6/21/2024 Assist Rail Determination form completed by Registered Nurse Minimum Data Set Coordinator #23 (former Director of Nursing) documented Resident #12 displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed and expressed a desire to have assist rails for safety and/or comfort. The 12/20/2024 Assist Rail Determination form completed by Registered Nurse Minimum Data Set Coordinator #23 documented the resident did not display poor bed mobility or difficulty moving to a sitting position on the side of the bed and assist rails were not indicated at this time. There was no documented evidence the informed consent for the use of assist rails was obtained or the risks and benefits were reviewed with the resident or resident representative prior to their placement. During an observation and interview on 2/11/2025 at 10:37 AM, Resident #12 had bilateral assist bed rails on their bed. They stated they used the assist rails every day to get out of bed and would not be able to get out of bed without the assist rails. They did not recall anyone reviewing the risks and/or benefits or signing a consent form. During an observation on 2/13/2025 at 8:52 AM, Resident #12 was in bed sleeping with bilateral assist bed rails on their bed. The undated resident Kardex (care instructions) did not include the use of bed rails. During an interview on 2/13/2025 at 8:52 AM, Certified Nurse Aide #25 stated if a resident had assist rails it was documented in the care plan. Many residents had assist rails which were used to help with mobility, and they believed the assist rails required a consent. Maintenance placed the assist rails on the beds. They stated Resident #12 had assist rails which should be documented on the care plan. During an interview on 2/13/2025 at 8:59 AM, Licensed Practical Nurse #2 stated several residents had assist rails on their beds. They did not know if assist rails required a consent form or who put the assist rails on the beds. A resident could get entrapped between the bed and the assist rail and it was important for residents to know both the benefits and the risks of the assist rails. During an interview on 2/13/2025 at 9:07 AM, Licensed Practical Nurse Unit Manager #3 stated many residents had assist rails which required a provider order, an evaluation from Physical Therapy, a signed consent documenting risks and benefits, and a care plan. Maintenance put the bars on the beds. They stated Resident #12 had enabler bars, used them to get in and out of bed, and did not have an order or consent form. During an interview on 2/13/2025 at 10:06 AM, Rehabilitation Coordinator #9 stated all residents were evaluated on admission by a physical therapist for appropriateness of assist bars. If appropriate, the physical therapist documented the recommendation in the electronic record and notified nursing. Nursing was responsible for obtaining an order from the medical provider and obtaining the consent form. They stated Resident #12 was evaluated 5/23/2024 by Physical Therapist #24 who determined assist rails were appropriate and assist rails were on the resident's bed. They stated the assist rail determination form was completed by the Minimum Data Set Coordinator # 23. It was important to have an order and signed consent form as entrapment was a risk for the assist rails. During an interview on 2/13/2025 at 10:20 AM, Minimum Data Set Coordinator #23 stated their only involvement in the assist bars was completion of the assist rail evaluation for the Minimum Data Set Assessment. When completing the assist rail evaluation, they reviewed the physical therapy notes for the assist rail assessment, looked for an order from the provider, looked at the bed in the resident's room, or asked the resident. They noticed many residents did not have a consent form signed which was important because it reviewed the risks and benefits. During an interview on 2/13/2025 at 11:26 AM, the Director of Nursing stated all residents were evaluated on admission by physical therapy for their ability to move in bed and for assistance needed with positioning. If physical therapy determined assist rails were appropriate, nursing was notified, nursing added them to the care plan, obtained an order from the physician, and reviewed the risks and benefits with the resident who would then sign a consent. The Minimum Data Set assessment was updated annually documenting appropriateness of assist rails for each resident. It was important to follow the process because there was a risk of entrapment and not every resident was appropriate for the assist rails. They were notified 2-3 weeks ago that the process was not being followed by the Minimum Data Set Coordinator # 23. It was important to have an order and obtain a consent, for resident safety and so the resident knew the potential risks of using bed rails. 10NYCRR 415. 12(h)(1)(2) | Plan of Correction: ApprovedMarch 14, 2025 Resident #12s record was reviewed. Resident was evaluated for the appropriateness of bed rails. Resident was educated on risks and benefits of siderail use and consent was obtained on 2/13/ 2025. All residents with side rails were reviewed to ensure that education on risks and benefits of siderails was provided and consent was obtained. No other records were identified as deficient. All residents identified as having enablers or bed rails had a care plan that reflected their use and purpose. Clinical Nursing staff receive training on the bedrails policy and procedure including determination. The Director of Nursing will review records of all residents with siderails monthly to ensure that education on the risks and benefits was provided and that consent was obtained. The Audit tool will be reviewed quarterly with the Quality Assurance and Performance Improvement Meeting for 1 year to ensure compliance. Date of Correction: 2/13/2025 Person Responsible for Correction: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. Specifically, the main kitchen had multiple uncleanable surfaces, a leaking sink drain, stored pet beds, and unclean dishware. Findings include: The facility policy, Sanitary Conditions, dated 5/2024, documented food was stored, prepared, distributed, and served under sanitary conditions to prevent the spread of food borne illness and reduce practices which resulted in food contamination and compromised food safety. The following observations of the main kitchen were made on 2/11/2025: - at 10:10 AM there were rusty shelves in the walk-in cooler. - at 10:12 AM there were pet beds under the dry storage room racks. - at 10:15 AM clean dishware was stored in soiled pan on a rack by the hand sink. - at 10:15 AM the hand sink had bare wood holding it to the walls. - at 10:44 AM there was leaking plumbing into a bus pan under the 3-bay sink. - at 12:44 PM the bus pan under the 3-bay sink was catching drips and had food debris in with the collected drain line water. - at 12:46 PM the walk-in freezer had icing on the compressor lines. General Manager #19 stated the compressor lines were iced over for several months, and they were not sure if there was a work order to repair the icing on the compressor lines but there was a work order for the sink drain line. - at 12:52 PM Cook #22 was observed washing dishes, spraying them in the preparation sink beside the 3 bay sink. They stated it was the preparation sink, however they were using what was available to wash dishes - at 3:02 PM two cats were observed waiting to get into the dry storage room off the dining room. During a kitchen observation on 2/12/2025 at 2:56 PM clean dishes were stored in a soiled pan on a rack by the hand sink. During an interview on 2/11/2025 at 12:46 PM Cook #22 stated the sink had been leaking for the past year. During an interview on 2/12/2025 at 3:02 PM, General Manager #19 stated the rusty shelves and bare wood by the hand sink were not easily cleanable. They stated clean dishes should not be stored in the soiled pan by the hand sink. Pets were not allowed in the kitchen or storage rooms to prevent contamination. They were not sure why the 3-bay sink drain line had not been fixed. They stated the drain line issue could be the result of improper use of the prep sink. It was important to clean and store dishes properly to prevent contamination and bacterial growth. 10NYCRR 415. 14(h) | Plan of Correction: ApprovedMarch 14, 2025 Corrective Actions: The rusty shelves in the walk-in cooler have been sanded and painted. The pet beds in the dry storage area have been removed and the door remains closed to prevent them from entering. The clean dishware in pan was removed from the hand sink, rewashed and stored in their appropriate area. The hand sink was replaced and is secured properly to the wall. The leaking was fixed under the 3-bay sink. The service vendor was contacted to address the icing on the walk-in freezer lines. The dietary employees responsible for washing dishes received re-education from the dietary manager on how and where to wash and store dirty and clean dishes. All kitchen staff will be retrained on cleaning and maintaining a sanitary environment. Dietary Manager updated daily cleaning schedule to ensure kitchen maintained within sanitary conditions. Environmental audit of the kitchen will occur monthly with the Dietary Manager and Director of Environmental Services to ensure walk-in cooler and plumbing is working efficiently. The Environmental audit will include kitchen and food storage areas to ensure proper functioning of equipment and identification of unsanitary conditions. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Date of Correction: 3/7/2025 Person Responsible for Deficiency: Dietary Manager and Director of Environmental Services |
Scope: N/A
Severity: N/A
Citation date: February 13, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: N/A
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2025
Corrected date: N/A
Citation Details Based on observations and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 2/11/2025 1st floor dining room lunch meal and the 2/12/2025 1st floor dining room breakfast meal). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meal on 2/11/2025 and breakfast meal on 2/12/ 2025. Additionally, 11 anonymous residents during a resident council meeting and four residents (Residents #8, #12, #51 and #54) interviewed stated the food did not taste good, it was often served cold, and the vegetables were overcooked. Findings include: The facility policy, Nutrition and Food Service Department, revised 2/2019, documented the food service department provided high quality, nutritious, palatable, and attractive meals in a safe sanitary manner. The facility policy, Sanitary Conditions, dated 12/2024, documented food must be kept in hot-holding equipment at a product temperature of 140 degrees Fahrenheit or above. During an interview on 2/11/2025 at 10:32 AM, Resident #12 stated the consistency of the food was more ground than regular, the vegetables were mushy, and the food was often cold. During an interview on 2/11/2025 at 11:14 AM, Resident #8 stated the food was cold and the vegetables were overcooked and mushy. They stated they had a meeting with someone from the kitchen, was unable to recall who, and was told the menu was changing and they were hoping for improvements. During a resident group meeting on 2/11/2025 at 1:42 PM, 11 anonymous residents stated the food was cold, and mushy. The regular vegetables were overcooked, and often were pureed in consistency. When they notified staff their vegetables were pureed, staff told them they had to accommodate all resident's dietary consistencies. During a lunch meal observation on 2/11/2025 at 12:16 PM, on the 1st Floor, Resident #12 was served their lunch tray. A replacement tray was ordered, and Resident #12's original meal tray was tested . At 12:17 PM, Dietary Aide #16 verified the measured food temperatures. The hamburger was measured at 125. 2 degrees Fahrenheit, the cold dessert peach cobbler was 60. 5 degrees Fahrenheit, and the cranberry juice was 51. 4 degrees Fahrenheit. The hamburger was not hot, the bun was soggy, and the wax beans were overly soft. During a breakfast meal observation on 2/12/2025 at 8:23 AM, on the 1st Floor, Resident #51 was served their breakfast meal tray. A replacement tray was ordered, and Resident #51's original meal tray was tested . Resident #51 stated the food was always cold and the oatmeal was too thick and dry. Dietary Aide #17 verified the measured food temperatures. The scrambled eggs were 121. 6 degrees Fahrenheit, and the milk was 49. 5 degrees Fahrenheit. The eggs were not hot, the toast was cold and soggy, and the oatmeal was thick, pasty, dry, and chunky. During an interview on 2/12/2025 at 12:50 PM, Resident #54 stated the chicken alfredo noodles were cold, and broccoli was overcooked. They asked Dietary Aide #16 to heat it in the microwave. When it was returned to the resident, they stated the top of the dish was hot, but the middle was cold. The resident was not able to eat the meal and stated, this is a pile of mush. The broccoli was overcooked and mushy. During an interview on 2/12/2025 at 12:57 PM, Dietary Aide #16 stated residents complained the food was cold, they did not like the menu choices, and sandwiches were offered too frequently. They stated residents complained to Kitchen Supervisor #19 and a new menu was starting next week. They stated Resident #54 said their food was cold at lunch, so they heated it in the kitchen microwave. They did not test the temperature of the plate they heated, however stated it should be between 160-180 degrees Fahrenheit. The hamburger at 125. 2 degrees Fahrenheit was not hot enough. They looked at the broccoli on several different resident plates and stated it looked mushy and overcooked because the broccoli had too much water in it. They stated food was supposed to look and taste good. During an interview on 2/12/2025 at 1:07 PM, Certified Nurse Aide #18 stated residents complained about the food a lot. Complaints included the food did not look good, was not hot, and did not taste good. Residents often refused to eat the food and were offered alternatives. During an interview on 2/13/2025 at 8:59 AM, Licensed Practical Nurse #2 stated residents often complained about the entree and were offered an alternative. If a resident did not eat and was not offered an alternative, they could get malnourished. They stated they notified the Unit Manager when residents did not eat. During an interview on 2/13/2025 at 9:07 AM, Licensed Practical Nurse Unit Manager #3 stated residents often complained about the food saying it was not home cooked, it was cold, the vegetables were overcooked, and did not look appetizing. If a resident complained about their meal, they offered an alternative and notified the Kitchen Supervisor. If residents did not eat, they could lose weight and have other medical issues. During an interview on 2/13/2025 at 9:36 AM, General Kitchen Manager #19 stated they were responsible for updating resident menus, training staff, completing test trays, and overseeing the kitchen. They had complaints about the food. Most of the complaints were about the consistency of the oatmeal and sometimes food was not hot. They stated when food was not hot it was brought to the cook to test the temperature of the item before and after reheating it. Dietary aides were not allowed to heat up plates. Residents also complained vegetables were overcooked and mushy, however, the facility did not have a steamer and had to boil all the vegetables which caused them to retain water. Food should be served to residents at 140 degrees Fahrenheit. The hamburger served at 125. 2 and the eggs served at 121. 6 degrees Fahrenheit were not served at palatable temperatures. The thick and pasty oatmeal, the cold and soggy toast, and the overcooked broccoli were not palatable. Residents should be served food that was palatable. 10NYCRR 415. 14(d)(1)(2) | Plan of Correction: ApprovedMarch 14, 2025 The Dietary Shift supervisor or designee will conduct a tasting panel evaluation daily before every meal to ensure palatability of food served to the residents. Tasting Panel will include check for food texture, flavor and consistency. Foods found to be unpalatable will be corrected to correct consistency or replaced. The Dietary Manager, or designee, will perform three test trays weekly to ensure that food and drink is palatable, attractive and at a safe and appetizing temperature. Dietary employees will conduct pre-service temps and test trays will be tested for hot holding withing state guidelines. The Audits will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Date of Correction: 03/07/2025 Person Responsible for Correction: Dietary Manager |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025 - 2/13/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #57) reviewed. Specifically, Resident #57 was observed wearing their thoracolumbar sacral orthosis brace (TLSO brace, a spinal brace worn to limit movement of the spine to help with healing of spinal fractures) incorrectly, the comprehensive person-centered care plan did not address interventions for the thoracolumbar sacral orthosis brace, and staff involved in Resident #57's care were not educated on the application of the thoracolumbar sacral orthosis brace. Findings include: The undated facility policy, Durable Medical Equipment, documented the facility would ensure residents received medically necessary durable medical equipment as part of their comprehensive care plan and included: - A physician, nurse practitioner or therapist would assess the residents' medical needs and document in the care plan. - A physician order as needed based on the type of durable medical equipment. - Staff would be trained on the proper and safe use of the equipment based on the type of durable medical equipment. Resident #57 had [DIAGNOSES REDACTED]. The 12/21/2024 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, used a walker and wheelchair, had no impairment to upper and lower extremities, received occupational therapy and physical therapy, and had no splint or brace assistance. The 11/20/2024 hospital discharge summary documented a thoracolumbar sacral orthosis brace was prescribed, was to be worn when out of bed and when ambulating, could be donned/doffed (put on/taken off) at bedside, and was not required when in bed or sleeping. Obtain a thoracolumbar spine upright standing x-rays (attempted 11/16/2024 but patient could not stand). If the resident had any weakness in their lower extremity that was new, obtain magnetic resonance imaging (MRI) of the [MEDICATION NAME] lumbar spine urgently, and once obtained, the resident would require a referral to neurosurgery. The 11/20/2024 hospital pre-admission intake/referral documented the resident used a thoracolumbar sacral orthosis brace and it was to be worn when out of bed. Physician orders did not include the use of a thoracolumbar sacral orthosis brace or instructions for use. A 11/20/2024 at 2:53 PM progress note by Registered Nurse #20 documented the resident wore a thoracolumbar sacral orthosis brace while out of bed due to compression fractures. The Comprehensive Care Plan, initiated 11/20/2024 and revised 12/9/2024, documented the resident had a self-care performance deficit related to activity intolerance, confusion, impaired balance, and limited mobility. Interventions included a thoracolumbar sacral brace on for all out of bed activities; the registered nurse was responsible for the intervention. There were no further interventions documenting the care of or monitoring of the thoracolumbar sacral orthosis brace. The certified nurse aide care instructions as of 11/20/2024 documented under transfers the resident used a thoracolumbar sacral orthosis brace to be on for all out-of-bed activities. A 11/20/2024 physical therapy treatment encounter note electronically signed 11/21/2024 at 12:43 AM (no staff identified) documented staff and the resident's family member were educated and trained on justification and management of the thoracolumbar sacral orthosis brace as well as proper donning/doffing of the brace with good staff/family response. (At the time of the encounter note the resident was residing on Unit 1, the rehabilitation unit.) A Minimum Data Set progress note on 11/24/24 at 3:07 AM by Licensed Practical Nurse #21 documented the resident wore a thoracolumbar sacral orthosis brace while out of bed due to compression fractures. The 11/25/2024 admission history and physical by Physician #14 documented the resident was recently hospitalized with weakness and found to have a lumbar-1 compression fracture treated with bracing. The plan was to continue with bracing as directed, and to get an upright film (x-ray) when possible, when the resident was able to bear weight. The updated 11/26/2024 care conference summary documented: - recurring restorative occupational therapy, physical therapy, and speech language pathology to address deficits in transfers, ambulation, self-care and cognition in order to return to private residence with family member. - had potential for acute/chronic pain due to arthritis and burst lumbar-1 vertebrae. - family would need to learn how to place brace on which could be done by one individual. A 12/2/2024 at 2:58 PM Certified Occupational Therapy Assistant #6 treatment encounter documented skilled instruction was provided to resident and caregiver for training for donning (putting on) of the thoracolumbar sacral orthosis brace. Nursing progress notes documented: - on 12/7/2024 at 8:26 AM by the Director of Nursing, the resident was discovered sitting on the floor in their room leaning on their wheelchair and their back brace was not in place. The resident had no injuries and stated they were trying to go to bed. - on 12/8/2024 at 1:28 PM by Licensed Practical Nurse #2, the resident continued to be confused and took their thoracolumbar sacral orthosis brace off. - on 12/24/2024 at 9:47 AM by the Minimum Data Set Coordinator, the resident removed their back brace many times that morning. - on 12/25/2024 at 7:57 AM the Minimum Data Set Coordinator, the resident removed their back brace prior to sliding out of their wheelchair. Physician orders revised 1/20/2025 documented physical therapy 5 times/week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, group therapeutic activities, manual therapy, wheelchair management, hot/cold pack and gait therapy. There was no documentation for a thoracolumbar sacral orthosis brace. The certified nurse aide care instructions as of 2/13/2025 documented under transfers the resident used a thoracolumbar sacral orthosis brace, to be on for all out-of-bed activities. There was no documentation for application of the thoracolumbar sacral orthosis brace in the (MONTH) 2025 Treatment Administration Record or in the (MONTH) 2025 Certified Nurse Aide tasks documentation. The following of observations of Resident # 57 were made: - on 2/11/2025 at 10:52 AM seated in the common area near the elevator on unit 2 wearing a black, synthetic fabric brace with upper and lower attachments that were both resting above the resident's breasts, with bilateral black straps that were several inches above their shoulders (not resting on their shoulders). The resident stated it kept them from falling forward. - on 2/12/2025 at 10:39 AM returning from therapy with Physical Therapy Assistant #7; the brace was positioned on their breasts. Physical therapy assistant #7 stated the device the resident was wearing was a back brace for a compression fracture, which they had when they were admitted to the nursing home, and therapy at the facility had nothing to do with recommending it. - on 2/13/2025 at 9:25 AM being taken to physical therapy by Physical Therapy Assistant #7; the brace was positioned on their breasts. - on 2/13/25 at 10:11 AM returning from therapy with Physical Therapy Assistant #7; the front part of the brace was positioned on their breasts. Upon closer inspection, the back of the brace was firm with straps to the head support part of the brace. Physical Therapy Assistant #7 stated the front-facing part of the brace should be positioned with the smaller plate on their chest and the lower part of the fabric brace with Velcro around their abdomen. Due to the resident's body shape and not sitting up straight in their wheelchair the brace usually rested on their breasts. During an interview on 2/12/25 at 11:31 AM Ce | Plan of Correction: ApprovedMarch 14, 2025 The effected resident (#57) order for thoracolumbar sacral orthosis brace was updated by the physician. The residents care plan was updated to reflect the brace and interventions,and monitoring related. The resident had a follow-up with orthopedics and her brace was discontinued on 3/7/ 2025. All other residents with DME records were reviewed to ensure that they had proper physician order, and careplan included interventions and monitoring for the DME. No other residents were identified. Facility-wide training regarding TLSE DME was initiated on 3/3/ 2025. All clinical staff to receive training on DME specific to braces. Upon identifying a new brace, Therapy will initiate training and systematically ensure clinical staff receive training prior to caring for resident. The Director of Nursing will review records of residents with DME on a Bimonthly basis to ensure that there is an order, and care plan reflects DME and any intentions and monitoring is included in the record. The Audit tool and findings will be reviewed quarterly with the Quality Assurance and Performance Improvement committee. The findings will be monitored for 1 years to ensure compliance Date of Correction: 3/7/2025 Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized work area for 1 of 23 resident rooms (room [ROOM NUMBER] on Unit 1) reviewed. Specifically, resident call bell systems did not function as designed and residents did not have a means to contact direct caregivers while in the bathroom. Findings include: The facility policy, Call (NAME), last reviewed 2025, documented all staff were responsible for responding promptly to resident call bells. Failure to do so would result in disciplinary action. Staff must verbally acknowledge the resident upon entering the room. If the call bell was an emergent situation and required an immediate response, staff should call for back up and not leave the resident unattended. During a Resident Meeting on 2/11/2025 at 1:42 PM, 2 of 11 anonymous residents stated when the bathroom call bell was pulled it would flash outside of their door. If their room call bell was pushed at the same time to signal help from the room, it would cancel out the bathroom call light. 1 of 2 anonymous residents stated they were left in the bathroom for up to an hour before staff recognized they required assistance. Staff told them the room call light canceled out the bathroom call light. The following observations of room [ROOM NUMBER]'s call bell system were made: - on 2/12/2025 at 9:40 AM, the bathroom call bell was pulled. The light above the door frame was blue and flashed rapidly. A rapid beeping sound was heard in the hallway and at the nursing station. The call bell for the bed by the door was pushed and the flashing light outside of the door turned to a solid blue color and the rapid beeping sound disappeared. A slow, faint chirping sound was heard in the hall. The room was on nursing station call bell console displayed as a strobe-like flashing white light. - on 2/12/2025 at 10:02 AM, the light above the room door remained a solid blue. No staff answered the call light. - on 2/13/2025 at 9:27 AM, the bathroom call bell was pulled. The light above the door was blue and flashed rapidly. A rapid beeping sound was heard in the hall. At 9:29 AM, Licensed Practical Nurse #2 appeared at the doorway of room [ROOM NUMBER], looked in and walked away. They did not respond to the call bell. At 9:43 AM, the bathroom call bell was still activated and the light above the door remained a solid blue color with no sound. There were no staff observed in the vicinity. At 9:47 AM, Licensed Practical Nurse #2 responded to the call bell. Licensed Practical Nurse #2 activated the bathroom call bell and then activated the room call bell. The bathroom call light flashed blue rapidly above the door and when the room call light was pushed, the light above the door turned a solid blue color. During an interview on 2/13/2025 at 9:48 AM, Licensed Practical Nurse #2 stated the light above room [ROOM NUMBER]'s door flashed a rapid blue color and made a beeping sound to alert staff a resident was in the bathroom and needed assistance. They stated when they pushed the room call light, it cancelled out the bathroom call bell and the light stopped flashing. They were unsure why that occurred. They stated they were not sure how staff would know a resident was in the bathroom and needed assistance when the call light cancellation occurred. During an interview on 2/13/2025 at 10:38 AM Certified Nurse Aide #5 stated a flashing blue light above a room door signified that a resident needed assistance getting off the toilet. A regular room call bell would light up over the door as a solid blue color. They stated both indicated a resident required assistance, but a flashing blue light would be more emergent. The resident would need assistance in the bathroom as opposed to a room light where a resident might just need something else. During an interview on 2/13/2025 at 10:41 AM Licensed Practical Nurse Unit Manager #3 stated call bells should be answered in a timely manner. Maintenance should be alerted if a call bell did not work. They would verbally tell them or put a work order in. They were not aware of any call bell issues on the unit but acknowledged that some call bells cancelled each other out. They stated they were recently made aware that room [ROOM NUMBER]'s room call bell cancelled out the bathroom bell and had heard complaints from a resident council meeting. Staff would not know a resident needed assistance in the bathroom when this occurred and would put the resident at a higher risk for falls. They stated they thought maintenance was talking to their supervisor about the issue. There was no documented evidence a work order for room [ROOM NUMBER]'s call bell was submitted. During an interview on 2/13/2025 at 11:10 AM the Director of Environmental Services/Maintenance stated work orders were placed on a green slip by staff if there was an item that needed repair. They were not aware of any recent call bell work orders. There was a panel situated in between 2 resident beds in the rooms that could be opened to reset the call bell system if resident call bells did not work. They stated a resident's room call bell was on a cord. When the button was pushed, it would light in the room, above the outside of the room door and at the nursing station. A resident's bathroom call light would flash outside of the resident's room door and ring and flash at the nursing station. They knew room [ROOM NUMBER]'s room call bell cancelled out the bathroom call bell for approximately 6 months and no corrections had been attempted. They stated the manufacturer told them it was an old system and there was no fix. The call bell system overhaul was on the next budget meeting agenda. They stated if the light was lit up over the door, staff should still answer the call light. During an interview on 2/13/2025 at 12:32 PM the Director of Nursing stated they expected all staff to respond to a resident's call bell within 3 minutes. It was an unreasonable request at times for nursing, but any staff could respond to a call light and alert nursing if the request required a nursing task. They stated a bathroom bell would flash blue above a resident's room and was more emergent. They stated they were unaware of any call bell failures or cancellations. They stated if call bells were cancelled, a resident could be at a higher risk for falls and staff would not know they were in the bathroom. 10NYCRR 415. 29 | Plan of Correction: ApprovedMarch 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** room [ROOM NUMBER] on unit one, bulbs were replaced on call bell system. The bathroom call light flashes a different color than the room call light. All resident rooms have a call bell system. All rooms will have the call light bulbs modified. All call light bulbs in all rooms will be replaced. The bathroom bulb will flash a different color than the room call light, alerted employees to the difference in location. All employees will be educated on the difference in bulb color and flashing. The Director of Environmental Services will audit the call system monthly to ensure that it is alerting staff appropriately. The Audit will be reported quarterly to the Quality Assurance and performance improvement Committee for 1 year to ensure compliance. Date of Correction: 3/6/2025 Person Responsible for Correction: Director of Environmental Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observation, interview and record review conducted during the Emergency Preparedness Plan (EPP) review in conjunction with a Life Safety Code Survey completed 2/11/2025 - 2/14/2025, the facility did not establish and maintain a comprehensive Emergency Preparedness Program, that was updated at least annually to include the date of the review and any updates made to the emergency plan based on the review. The deficient practice could affect all residents. Findings include: Review of the facility's Emergency Preparedness Plan was completed with the Administrator on 2/11/2025 at 3:16 PM. The facility had documentation the plan was last reviewed an updated 1/2/2024 and 11/10/ 2021. No other documentation was available. 42 CFR: 483. 73(b)(1) | Plan of Correction: ApprovedMay 5, 2025 The Emergency Management Plan was reviewed and Revised 3/6/ 2025. Each section of Emergency Management Plan reflects review date and if revisions occurred. All Department Managers will receive education on developing, maintaining, and reviewing/updating annually the emergency preparedness program. The Director of Environmental Services and Administrator will review Plan Quarterly to ensure it is updated and revised. Any changes or revisions will be reviewed with the Quality Assurance and Performance Improvement Committee Quarterly for 1 year to ensure compliance. Person Responsible for Completion: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on record review, observations, and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure patient care related electrical equipment (PCREE) was maintained in accordance with National Fire Protection Agency (NFPA) 99 for 2 of 3 patient care related electrical equipment. Specifically, the facility did not have a policy and documentation for the maintenance of the selected equipment. Findings include: The facility did not provide a policy for patient care related electrical equipment. During an observation on 2/11/2025 at 11:10 AM, the beauty shop contained hair dryer #0402C. The facility provided documentation that the hair dryer was last inspected on 8/14/ 2017. A sticker on the side of the unit documented an inspection 1/25 by the Director of Environmental Services. No other inspection documentation was available. During an observation on 2/11/2025 at 11:14 AM, a nebulizer was located at the second-floor nurse's station. The facility did not have inspection and maintenance information for the nebulizer prior survey. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were not able to locate any inspection information for the nebulizer, or additional information for the hair dryer. They were not sure when the nebulizer was put into service, but staff should have brought that to them for an inspection before it was used with a resident. They stated it was important all equipment was properly inspected and maintained for the safety of the residents and staff. 2012 NFPA 99: 10. 3, 10. 5. 2. 1, 10. 5. 2. 1. 2, 10. 5. 2. 5, 10. 5. 3, 10. 5. 6, 10. 5. 8 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The Director of Environmental Services removed the hair dryer from the facility due to its age and lack of necessity. The Nebulizer located at the second-floor nurses station was inspected and labeled, and added to the facilitys electrical equipment All staff were re-educated on the Electrical Equipment Policy and the necessity of inspection prior to use. The Director of Environmental Services will audit the electrical equipment monthly to ensure any are due for annual inspection. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure that 1 of 1 diesel emergency generators were properly maintained in accordance with National Fire Protection Association (NFPA) 99. Specifically, documented deficiencies were not corrected timely. Findings include: The facility's vendor reports from the routine preventative maintenance dated 12/11/2024, 6/26/2024, and 12/12/2023 documented the following: - the fuel lines had become hard and brittle and were beginning to crack. - the cooling system hoses were also hard, brittle, and seeping slightly. - the battery cable ends were temporary repair ends and should be permanent crimp style ends. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were aware of the concerns that had been noted by their vendor, but the facility was hesitant to make changes because of their long-term goals and plans on building the new facility. 2012 NFPA 101: 9. 1. 3. 1, 19. 5. 1 2012 NFPA 99: 6. 5. 3. 1, 6. 4. 3. 1 2012 NFPA 110 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 Estimate received from Vendor,(NAME)Cat, to replace fuel lines, cooling system hoses, and to change temporary repair ends to permanent crimp style battery cable ends. Estimate was approved and we are awaiting vendor repair date. Milton Cat scheduled to perform repairs on generator on 4/15/ 2025. Maintenance employees to receive education on reviewing generator maintenance invoices and addressing maintenance concerns and repairs. The Director of Environmental Services or designee will audit the vendor report from routine preventative maintenance every 6 months, or earlier if as needed visit occurs to address repair needs. The Audit will be reviewed with the Quality Assurance and Performance Committee at the quarterly meeting following the 6-month preventative maintenance to ensure compliance. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure 1 of 1 emergency generator remote annunciator panels were properly installed, as required. Specifically, the 85-kilowatt diesel generator's remote annunciator panel was not located in a readily observed regular work location. Findings include: During and observation and interview on 2/11/2025 at 2:08 PM, the emergency generator annunciator panel was located at the loading dock hall entrance. The Director of Environmental Services stated there was a camera at that location because it was the staff entrance, but staff did not work or monitor that location. 2012 NFPA 99: 6. 4. 1. 1. 17 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 Maintenance will relocate the annunciator panel to the first-floor nursing station when supplies are received. Conduit placed for wiring to run to new location. Panel to be relocated 4/15/2025 All employees received training on the new location of the annunciator panel, purpose of panel, and process if alarm sounds. The Director of Environmental Services will monitor the annunciator panel for proper functioning monthly. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observations and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not maintain the electrical system as required. Specifically, the main kitchen had an open junction box with exposed wires and not guarded against accidental contact by approved enclosures in accordance with NFPA 99, 2012 Edition, Section 6. Findings Include: During an observation and interview on 2/11/2025 at 12:52 PM, there was an open junction box with exposed wires on the wall above the window in the director's office in the main kitchen. The Director of Environmental Services stated that was from a clock that was removed. Several rooms in the facility had hard wired clocks, but they had been removed, and not gotten to covering the wiring that remained. NFPA 99, 2012 Edition, Section 6 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The open junction box in the main kitchen was repaired. A cover was installed over the exposed wires. Maintenance Employees received education on maintaining the electrical system by not leaving open junction boxes and exposed wires upon completing a task. The Director of Environmental services or designee will monitor outlets with monthly environmental rounds for exposed wires and open junction boxes. The Audit will be reviewed monthly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Emergency Preparedness Plan review in conjunction with the Life Safety Code Survey conducted 2/11/2025 - 2/14/2025, the facility did not maintain an appropriate Emergency Preparedness Plan training program for staff. Specifically, the facility did not have documented evidence of completed annual Emergency Preparedness Plan training for 2 of 2 staff reviewed. The findings are: The facility's Emergency Preparedness Plan reviewed, documented facility staff should have received training at orientation and an annual in-service each year on emergency preparedness policies and procedures. The facility's training records for Licensed Practical Nurse #13 documented emergency preparedness training was completed on 7/11/ 2023. The facility did not have training records for 2024. The facility's training records for the Kitchen General Manager documented emergency preparedness training was completed in February 2024. The specific day of the training was not documented, and the facility did not have training records for 2023. During an interview on 2/11/2025 at 4:38 PM, the Administrator stated they were not able to locate any documentation for the emergency preparedness training that was completed in 2024 for Licensed Practical Nurse #13 because they were out on leave when the training was completed. They were not sure about the training the Kitchen General Manager received because they were contracted through another company, but they should have received the orientation training from the facility when they started in 2023. During an interview on 2/14/2025 at 2:26 PM, the Administrator stated they were not sure of the duration that Licensed Practical Nurse #13 was out in 2024, but thought it was about a month. They stated a second attempt at completing the training should have been made when they returned to work. 42 CFR: 483. 73(d)(1)(ii) | Plan of Correction: ApprovedMay 5, 2025 Licensed Practical Nurse #13 was provided Emergency Preparedness Training. Kitchen General Manager was provided Emergency Management Training. All Facility Staff were assigned Emergency Management Training to complete with exam at end to ensure competence. All Department Managers received education on Emergency Preparedness Training and ensuring their employees complete them on an annual basis. ?é?á Human Resources assigns Emergency Management training upon hire, and employees will not start work until training is completed. The training software automatically assigns the training on an annual basis to all employees. The Director of Nursing or designee will monitor the training record monthly to ensure all staff have completed the emergency management training. Audits will be reviewed Quarterly with the quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure that hazardous areas were maintained for 5 locations. Specifically, the tub room and activity office were also used as storage rooms but the rooms were not properly rated for storage, the clean linen room door hardware was not properly rated and the door assembly fire ratings were painted over, the therapy storage room had unsealed penetrations, and the kitchen dry storage rooms had multiple unsealed penetrations, the fire ratings painted over, and the door propped open by an unapproved door holder. The facility's Swing Door Assembly Inspection Criteria - Fire Rated Smoke Door Assemblies (existing) forms did not have documentation for the clean linen door, therapy storage room, and the kitchen dry storage room. The following hazardous area deficiencies were observed: - on 2/11/2025 at 11:28 AM, the tub room by room [ROOM NUMBER] was used as a storage room. Three lifts, a dining room chair, seated scale, 2 fall mats from resident rooms, and a resident's wheelchair were stored in the room. The room and door assembly were not fire rated, the door had a transfer grille, and the door was not self-closing. - on 2/11/2025 at 1:28 PM, the activities office was used for storage. The room was approximately 170 square feet, the room and door assemble were not fire rated, the door was propped open by an unapproved door holder, and the door was not self-closing. - on 2/11/2025 at 2:13 PM, the clean line room was approximately 80 square feet and used for linen storage. The door had a residential doorknob that was not fire-rated and the door's fire rated label was missing. - on 2/11/2025 at 2:16 PM, the therapy storage room had unsealed penetrations through the walls and ceiling. - on 2/11/2025 at 2:19 PM, the dry storage door was propped by an unapproved door holder, and the fire-rated labels were painted over. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were aware of the door deficiencies identified during survey and the regulations. They stated it was important that the hazardous areas were properly maintained for the safety of the residents and staff. 2012 NFPA 101 19. 3. 2. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The three lifts, dining room chair, scale, fall mats, and wheelchair were removed from the tub room. The magnetic holder was removed from the door to make it self-closing. The unapproved door holder was removed from the Activity office door, and door-closer installed making the door self-closing. All Maintenance Employees will be educated on hazardous areas, including identifying rooms used for storage and ensuring the doors are self-closing and properly rated. The linen room doorknob was replaced with a fire-rated knob. The door will be included in the quote for recertification/replacement with outside vendor. The Therapy Storage room unsealed penetrations through the walls and ceiling were sealed. The unapproved door holder was removed from the dry storage door. The door will be included in the quote for fire-rated re-certification/replacement. The Director of Environmental Services will Audit the tub room monthly with environmental rounds to ensure it is not used for storage, to ensure there are no unapproved [MEDICATION NAME] in use, and to monitor for any unsealed penetrations in the walls and sealings. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure ventilation equipment was properly maintained on 1 resident floor. Specifically, one ventilation unit was not working properly in a soiled utility room. Findings include: During an observation and interview on 2/11/2025 at 1:34 PM, the ventilation unit in the soiled utility room near resident room [ROOM NUMBER], was not working properly. The room had a strong foul odor and the vent did not have any draw. The Director of Environmental Services stated the vent should have been working because a vendor was up there the previous day and fixed the roof top unit. They stated the vent might have had an obstruction in the ductwork. 2012 NFPA 101: 19. 5. 2. 1, 9. 2, 2012 NFPA 90A: 5. 3. 1. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Maintenance employees cleaned the dampers and the duct work in the soiled utility room near resident room [ROOM NUMBER], which increased the suction of the exhaust fan. All maintenance and environmental services employees received education on ensuring vents are free of dust or debris to prevent obstruction in the duct work. The Director of Environmental services or designee will inspect the ventilation units/exhaust fans with monthly environmental rounds for proper functioning. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observations and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not provide emergency illumination that would operate automatically along the means of egress in accordance with NFPA 101, 2012 Edition, Section 19. 2. 8 and 7. 8. Specifically, the first-floor hall lights were all on a wall switch. Findings Include: During an observation on 2/11/2025 at 11:52 AM, the first floor did not contain any emergency lights, all the lights were controlled by the wall switch. When switched to the off position, the hallway did not have any illumination for the means of egress, and no emergency lighting was available. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated the lights ran off the generator, so they thought there was emergency lighting for the hall, but agreed if the switch was off, they would not work. They were aware of the requirement for the egress pathway to have illumination because it was important for evacuation so everyone could see, especially at night. 2012 NFPA 101: 19. 2. 9. 1, 7. 9 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The light switch was removed from one side of the hall on both north and south hallways on both the first and second floors, allowing the lights to offer continuous illumination. All Maintenance Employees will receive education on illumination on means of egress, including exit discharge and the importance of illumination in the event of an emergency and evacuation is necessary. The Director of Environmental Services or designee will audit lighting monthly to ensure the lights are in proper working order. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person Responsible: The Director of Environmental Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure that the fire doors throughout the facility were tested and maintained annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Specifically, the facility's fire door inspections documented repeated deficiencies, and they were not all inclusive of the fire doors in the facility. Findings include: The facility fire door inspections for 2023, and 2024 documented repeat deficiencies. The inspections were not all inclusive the of the fire doors in the facility as cited under K 321. Additional deficiencies were cited under K211 and K 225. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they did not realize the door inspections were not all inclusive, but they were aware that some deficiencies had not been corrected. They stated it was important the fire doors were properly maintained for the safety of the residents and staff. 2012 NFPA 101 19. 2. 1, 7. 2. 1. 15 2010 NFPA 80 Chapter 5 42 CFR 483. 70 (a)(1) NYCRR 415. 29, 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 Quote has been requested by Director of Facilities from an outside vendor known as Intertek, which specializes in inspecting fire and egress door assemblies to the NFPA 80 Standard. The doors from K321, K211, and K225 will be included in this quote. Intertek scheduled to arrive to facility for door repairs 4/9/ 2025. All maintenance and environmental services employees received education on ventilation units and maintaining them free of dust or debris to prevent obstruction in the duct work. All doors will be audited monthly with environmental rounds for proper labeling of fire-rating certification. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on record review, observations, and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergencies. Specifically, multiple fire doors were not maintained properly, and one direct exit had a tripping hazard at the door. Findings Include: The facility's Swing Door Assembly Inspection Criteria - Fire Rated Smoke Door Assemblies (existing) form dated 8/19/2023 documented the boiler room, kitchen main door, and the kitchen doors going to dining room door ratings were not legible or not present. On 8/28/2024 they documented the boiler room, kitchen main door, and the kitchen doors going to dining room door ratings were not legible or not present. The facility did not have documentation for the clean linen door, evening maintenance closet, and the kitchen dry storage room. The following fire door deficiencies were observed: - on 2/11/2025 at 12:00 PM, the addition consisted of two offices connected to the building by an exit passageway with a direct side exit and fire doors at either end. The new office side door was not fire rated. The fire doors were held open by magnetic holders not connected to the fire alarm system. - on 2/11/2025 at 1:37 PM, the North Stairwell had linoleum curling up about two inches in front of the exit door that created a tripping hazard. - on 2/11/2025 at 1:51 PM, the boiler room had the door assembly fire ratings painted over. - on 2/11/2025 at 2:17 PM, the kitchen door (from the service hallway) fire rating was not legible. - on 2/11/2025 at 3:03 PM, the kitchen double doors had fire-rated labels painted over and did not close and latch properly when tested . During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services, who witnessed the observations, stated they were not aware of all the doors identified during survey, but they were aware several had painted fire-rated labels. They stated it was important to have clear exits, to get out if they had to evacuate and doors were properly rated to protect in the event of a fire. 2012 NFPA 101: 19. 2. 1, 7. 1. 10. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Quote has been requested by Director of Facilities from an outside vendor known as Intertek, which specializes in inspecting fire and egress door assemblies to the NFPA 80 Standard. The quote will include effected boiler room, kitchen main door, kitchen doors going to dining room, clean linen door, evening maintenance closet, and the kitchen dry storage room for either re-certification and/or replacement. Intertek scheduled to be onsite for door repairs 4/9/ 2025. The Magnetic holders were removed from the fire doors that connect two offices to the building. A threshold was placed over the curled linoleum in the north stair well. All Maintenance Employees were educated on maintaining clear means of egress continuously and properly maintaining fire doors. The Director of Environmental services or designee will audit the doors monthly to ensure they are still fire-rated with legible tag, and no doors are held open by magnetic holder, unauthorized door [MEDICATION NAME], or floor obstructions blocking egress. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure that fire extinguishers were maintained in accordance with National Fire Protection Association 10 Standard for Portable Fire Extinguishers. Specifically, the annual fire extinguisher inspection report was a receipt that did not outline the maintenance or location of the fire extinguishers, a fire extinguisher in the evening maintenance closet had not been inspected monthly as required, and the past twelve months of inspections were not maintained on site. Findings include: The facility provided a receipt for annual maintenance of fire extinguishers for 15 fire extinguishers, on 9/13/2023, 23 fire extinguishers on 2/8/2024, and 23 fire extinguishers on 8/20/ 2024. The documentation did not outline the maintenance or location of the fire extinguishers within the facility. During an observation on 2/11/2025 at 2:10 PM, the fire extinguisher in the evening maintenance closet was tagger for annual inspection on 8/ 2024. The tag did not have monthly inspections documented for (MONTH) 2024 or October 2024. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were not aware that the one fire extinguisher monthly inspection was not completed for (MONTH) or October 2024. They stated they did not have the previous year's tags, so they only had inspection records to (MONTH) of last year. They stated it was important the fire extinguishers were properly maintained for the safety of the residents and staff. 2012 NFPA 101 19. 3. 5. 12, 9. 7. 4. 1 2010 NFPA 10 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The Vendor responsible for providing the annual fire extinguisher was contacted for a summary analysis outlining the maintenance and location of the fire extinguishers within the facility. The analysis will be maintained onsite. The vendor was requested to inspect the fire extinguisher in the evening maintenance closet. Vendor inspected the fire extinguisher in the evening maintenance closet on 3/20/ 2025. Maintenance employees received education on consistently maintaining portable fire extinguishers monthly, reviewing vendor invoices for details such as location of extinguishers, and keeping at minimum of 1 years' worth of inspections records onsite and readily available for review. The Director of Environmental Services or designee will audit all extinguishers monthly to ensure that monthly inspection is performed and documented adequately. The Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for one year to ensure compliance. Person Responsible for Completion: The Director of Environmental Services. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review conducted during the Life Safety Code survey 2/11/2025 to 2/14/2025, the facility did not ensure 1 of 1 automatic sprinkler systems were maintained. Specifically, documented deficiencies were not corrected timely and the dry sprinkler in the walk-in cooler was corroded. Findings include: Deficiencies not corrected timely: The facility's quarterly sprinkler inspection reports dated 8/18/2023, 11/22/2023, and 2/16/2024 documented the facility had dry sprinkler heads that were dated 2012 which were more than 10-years old. The facility provided documentation the dry sprinklers were changed on 3/11/ 2024. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were not aware the dry heads were not corrected timely, they did have them changed but were not aware that it was 2 years beyond the requirement. Corroded sprinkler: The facility's quarterly sprinkler inspection reports dated 11/27/2024 documented the sprinkler head in the cooler appeared free of corrosion. During an observation and interview on 2/11/2025 at 2:20 PM, the walk-in cooler sprinkler was coated with liquid that dripped down the sprinkler and the deflector plate was green with corrosion. The Director of Environmental Services stated they were not aware of any issues with the kitchen sprinklers, and not sure if the dry head had leaked at some point. 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 5 2011 NFPA 25 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The walk-in cooler Sprinkler head was wiped free of debris. Maintenance employees educated on ensuring sprinkler heads remain free of corrosion and debris, reviewing invoices to ensure they are accurate, and repairs done timely, and maintaining a current records onsite and readily available for review. The Director of Environmental services will monitor sprinklers system monthly with environmental rounds to ensure no corrosion or debris present. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement committee for 1 year to ensure compliance. Person responsible for Completion: Director of Environmental Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observations and interview during the Life Safety Code recertification survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure stairwells were properly maintained in 1 location. Specifically, the fire-rated door label in the north stairwell was painted over. Findings include: The 8/19/2023 Swing Door Assembly Inspection Criteria - Fire Rated Smoke Door Assemblies, documented the second-floor north stairwell door rating label was not legible. The 8/28/2024 Swing Door Assembly Inspection Criteria - Fire Rated Smoke Door Assemblies, documented the second-floor north stairway door rating label was not legible. During an observation on 2/11/2025 at 11:07 AM, the second-floor north stairwell door assembly fire-rated label was painted over. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were not aware that the label was painted over. They knew it was a requirement, and it was important for the label to be visible for the evacuation of residents and knowing the door was properly rated. 2012 NFPA 101: 19. 2. 2. 3, 19. 2. 2. 4, 7. 2 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Quote has been requested by Director of Facilities from an outside vendor known as Intertek, which specializes in inspecting fire and egress door assemblies to the NFPA 80 Standard. The quote will include second-floor north stairwell door. Intertek scheduled 4/9/2025 for door repairs. All Maintenance employees received education on Stairways and smokeproof enclosures and identifying if doors are properly rated to protect in the event of a fire. The Director of Environmental services will audit the doors monthly to ensure they are still fire-rated with legible tag, and no doors are held open by magnetic holder, unauthorized door [MEDICATION NAME], or floor obstructions blocking egress. Audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible: Director of Environmental Services |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details Based on observation, interview and record review conducted during the Emergency Preparedness Plan (EPP) review in conjunction with a Life Safety Code Survey completed 2/11/2025 - 2/14/2025, the facility failed to ensure that subsistence needs for residents and staff were maintained. Specifically, the plan did not account for staff and visitors for emergency water, and the temperature dependent medication supply was not supported by the emergency generator. Findings include: The facility's Emergency Preparedness Plan, that was last updated 1/2/2024 by the previous Administrator, documented the facility kept 1 gallon of water per resident per day for 3 days for a total of 240 gallons. The plan did not account for staff or visitors. During an observation and interview on 2/11/2025 at 11:18 AM, the medication room refrigerator on the second floor was plugged into a regular outlet, not supported by the emergency generator. Licensed Practical Nurse #13 stated they did not have a an emergency supply of cold medications, the only refrigerated medications were in the medication room refrigerator. During an interview on 2/11/2025 at 3:16 PM, the Administrator stated the facility maintained 1 gallon of water per resident per day for three days. They did not have a cold supply of medications, only what was in the medication room refrigerators, and they were not aware those were not supported by the emergency generator. The Director of Environmental Services stated the generator supported the heating and air conditioning systems, the kitchen walk-in coolers, the red outlets, and the other building components for life safety. During an observation on 2/11/2025 at 4:07 PM, the first-floor medication refrigerator was plugged into a regular outlet. During an interview on 2/14/2025 at 2:26 PM, the Administrator stated the medication refrigerators should have been supported by the emergency generator. 42 CFR: 483. 73(b)(1) | Plan of Correction: ApprovedMay 5, 2025 Loss of Food Service Policy has been revised to reflect that additional water will be on hand to account for staff and others, including volunteers or unexpected visitors. All Department Managers received education on the updated Emergency Preparedness Plan as pertains to the water supply on hand and that emergency medication refrigerators need to be on generator outlet. ?é?á The refrigerator on the second-floor medication room was placed on a generator outlet for use for temperature dependent medication supply during an emergency. Will review the Loss of Water and Loss of Food Supply as part of the Emergency Preparedness Plan Quarterly. Will Review any updates with Quality Assurance and Performance Improvement Committee Quarterly for 1 year to ensure compliance. Person Responsible For Completion: Director of Environmental Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 14, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey conducted 2/11/2025 to 2/14/2025, the facility did not ensure electrical equipment had approved wiring and electrical outlets in accordance with NFPA 70, 2011 Edition for 6 rooms. Specifically, the director of nursing office, nursing main supply room, first floor nurse's station, the main kitchen, foyer, and therapy department had outlets that were not protected from water with a proper ground fault circuit interrupter and power strips located on the floor. Findings include: The following electrical outlets were observed: - on 2/11/2025 at 10:47 AM, a coffee pot in the director of nursing office was plugged into a regular outlet, outlet was about 7 feet from the sink on the opposite wall. - on 2/11/2025 at 11:43 AM, the nursing main supply room had a power strip located on the linoleum floor behind the desk. Purchaser #26 stated staff swept and mopped the floor when they did come in to clean. - on 2/11/2025 at 11:54 AM, the first-floor nurse's station had a water cooler plugged into a red outlet that did not have a ground fault circuit interrupter. - on 2/11/2025 at 12:57 PM, the main kitchen had a regular outlet for a residential refrigerator that was about 6 feet from the 3-bay sink. - on 2/11/2025 at 1:47 PM, a water cooler in the foyer was plugged into a regular outlet that did not have a ground fault circuit interrupter. - on 2/11/2025 at 3:13 PM, the therapy department had a water cooler, coffee makers, and [MEDICATION NAME] that were plugged into regular outlets. During an interview on 2/14/2025 at 8:32 AM, the Director of Environmental Services stated they were aware that outlets had to be protected from water, but they did not realize the power strip on the floor were not properly protected or the number of water containing electrical equipment the facility had that was not properly protected. 2012 NFPA 101: 19. 5. 1, 9. 1. 2 2011 NFPA 70 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The Outlet in the Director of Nursing Office was replaced with a ground fault circuit interrupter. The Power Strip in the nursing main supply room was mounted to the wall. A ground fault circuit interrupter was added to the red outlet at the first-floor nurses station. The outlet in the main kitchen 6 feet from the 3-bay sink was changed to a ground fault circuit interrupter. The outlet in the foyer was changed to a ground fault circuit interrupter. The outlets in the therapy department were changed to ground fault circuit interrupters. All maintenance employees received education on electrical outlets and the need for ground fault circuit interrupter outlets for any water containing electrical equipment and approved power strips should be properly mounted and not present in close proximity to water. The Director of Environmental services or designee will audit outlets monthly and install ground fault circuit interrupters where any water products are contained. The audit will be reviewed quarterly with the Quality Assurance and Performance Improvement Committee for 1 year to ensure compliance. Person Responsible for Completion: Director of Environmental Services |