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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure an assessment was completed to reflect the resident's status accurately. This was identified for one (Resident #128) of four residents reviewed for Dementia Care. Specifically, the Quarterly Minimum Data Set assessment for Resident #128 dated 1/6/2025 inaccurately reflected the resident as comatose. The finding is: The facility's policy titled Minimum Data Set Completion Assignment, last reviewed on 10/18/2023 documented that interdisciplinary care team members are assigned to specific Care Area Assessment which they have to document key findings regarding the resident's status based on the triggered care area. The care area assessment summary must be completed at the time of Minimum Data Set completion. The Minimum Data Set Coordinator is responsible for checking the completion of all Minimum Data Set 3. 0 assessments. Resident #128 was admitted with [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment dated [DATE] documented under item B0100 the resident's status as comatose. The remaining Section B (Hearing, Speech, and Vision) was left blank due to the resident's comatose status. The 5-day Minimum Data Set assessment dated [DATE] documented under item B0100 the resident as not being comatose in status, with adequate hearing, clear speech, and a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment. A Comprehensive Care Plan titled Cognition, dated 8/20/2024 and last revised on 10/31/2024 documented that the resident was able to make themselves understood. The interventions included monitor for changes in decline in cognitive status and allowing for ample time for the resident to absorb and respond to information provided. A physician's orders [REDACTED]. During an observation on 1/24/2025 at 2:48 PM the resident was sitting at a table in the unit dining room. The resident smiled and waved at the surveyor when greeted. During an interview on 1/24/2025 at 1:16 PM, Social Worker #1, stated they were responsible for completing the Minimum Data Set Assessment Section B (Hearing, Speech, and Vision). Social Worker #1 stated the resident was not comatose when they completed the 1/6/2025 assessment. Social Worker #1 further stated they made an error and documented the resident's status incorrectly under the Hearing, Speech, and Vision section of the Minimum Data Set assessment. During an interview on 1/24/2025 at 1:20 PM, the Minimum Data Set Assessment Coordinator stated the Minimum Data Set assessment dated [DATE] for Resident #128 was incorrect and should not have documented the resident status as comatose. The Minimum Data Set Assessment Coordinator stated this was an error. The Minimum Data Set Assessment Coordinator stated they do not review the Minimum Data Set individual sections for accuracy and only review the booklet for completion. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedFebruary 12, 2025 A: Immediate Correction Action 1. Resident #128 who still resides at the facility was not affected by this deficient practice. 2. The MDS for resident #128 was corrected to reflect ?ô0?Ø on 1/24/2025 3. Social Worker #1 was re-educated on MDS accuracy by the RN Nurse Educator B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The facility ran a report on Section B, question B0100 to see if any other residents were coded incorrectly and there was no inaccurate finding. C. Systematic Review to prevent re-occurrence 1. The facilities policy titled Minimum Data Set Completion Assignment dated 10/18/2023 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 2. The RN Nurse Educator will re-educate all staff that are assigned to complete the MDS assessment on MDS Assessment Accuracy. D. Quality Assurance: 1. The DNS devised an audit tool to ensure that all MDS Assessments are accurate 2. The DNS and or designee will audit 10 MDS assessments section B question B0100 weekly x 3 months and monthly there after for 1 year until 100% compliance is obtained to ensure that the MDS accuracy. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 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 initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #102) of six residents reviewed for Communication. Specifically, Resident #102 had a physician's orders [REDACTED]. The resident exhibited noncompliance and frequently removed the hearing aids; however, the comprehensive care plan for the hearing deficit was not updated to indicate the resident's behavior. The finding is: The facility's policy titled Care Plans dated 8/2022 documented the plan of care is reviewed on a quarterly and annual basis by the interdisciplinary team and or when the resident has a significant change in condition. Following the Minimum Data Set assessment schedule, the nursing department or designee will ensure that each care plan has been completed and updated within seven days of the end of the lookback period established by the Minimum Data Set schedule. Resident #102 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set assessment documented a Brief Interview for Mental Status score of 2, indicating the resident had severely impaired cognition. The Minimum Data Set assessment documented the resident used hearing aids. A Comprehensive Care Plan, titled Hearing Deficit effective 1/09/2025, documented the resident used hearing aids. The interventions included checking for the placement of the hearing aids each shift. A physician's orders [REDACTED]. The Treatment Administration Record for 1/2025 indicated documented evidence that the nurse placed the hearing aids in Resident #102's ears and removed them at bedtime. During an observation on 1/21/2025 at 10:14 AM, Resident #102 was not able to hear and did not respond to greetings. The resident was not wearing hearing aids in both ears. During a second observation on 1/22/2025 at 10:55 AM, Resident #102 was in their room in their wheelchair, with no hearing aids in their ears. During an interview on 1/24/2025 at 10:37 AM, Licensed Practical Nurse Charge Nurse #2 stated Resident #102 often refused to wear their hearing aids. The resident also had a behavior of removing the hearing aids and Licensed Practical Nurse Charge Nurse #2 did not notify anyone about the resident's behavior. Licensed Practical Nurse Charge Nurse #2 stated that the care plan for Hearing Deficit should have been updated to reflect the resident's behavior and noncompliance. During an interview on 1/27/2025 at 10:50 AM, the Director of Nursing Services stated the comprehensive care plan should have been updated to indicate the resident's refusal to wear or remove the hearing aids. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedFebruary 12, 2025 A: Immediate Correction Action 1. Resident #102 who still resides at the facility was affected by this deficient practice. 2. The CCP for resident #102 titled Hearing Deficit was updated to reflect the residents non-compliance with hearing aid usage on 1/24/2025 3. Charge Nurse #2 was counseled and re-educated on Care Plan timing and revision by the RN Nurse Educator on 2/5/25 B: Identification of Others 1. All residents that reside in the facility with hearing aids have the potential to be affected by this deficient practice. 2. The facility audited all residents that have the potential of same deficient practice and there were no negative findings. C. Systematic Review to prevent re-occurrence 1. The facilities policy titled Care Plan dated 8/2022 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 2. The RN Nurse Educator will re-educate all nurses on Care Plan Timing and Revision D. Quality Assurance: 1. The DNS devised an audit tool to ensure that all care plans are timely and revised according to the facilities policy and procedure. 2. The DNS and or designee will audit the care plans of 10 residents weekly x 3 months and there after monthly for 1 year or until 100% compliance is achieved. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 28, 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 initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that a person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's current medical and nursing needs was developed in a timely manner. This was identified for one (Resident #272) of two residents reviewed for Antibiotic use; for one (Resident #3) of two residents reviewed for Activities of Daily Living; and for one (Resident #19) of one resident reviewed for Respiratory Care. Specifically, 1) Resident #272 was readmitted to the facility on [DATE] with a Peripherally Inserted Central Catheter line to the Right Upper Arm; however, there was no care plan developed for the use and care of the Peripherally Inserted Central Catheter line until 1/24/2025, 7 days after admission. 2) Resident #3 had a Comprehensive Care Plan developed for Activities of Daily Living including Mobility, Ambulation, Transfers, Dressing, Grooming, Feeding, Bathing, Toileting, and Personal Hygiene. The Comprehensive Care Plan was not completed and did not include goals or interventions. 3) Resident #19 had a Comprehensive Care Plan titled Noncompliance, Impaired Judgement that did not document any goals or interventions. The findings are: The facility's policy titled Care Plans dated 8/2022 documented each resident will have care plans in place that reflect the resident's individual needs. Each resident's care plan will reflect person-centered care and include resident choices, preferences, goals, concerns/needs. The care plan should describe the services and care that is to be furnished to attain, maintain, or improve the resident's highest practicable physical, mental, and psychosocial well-being. The nursing department or designee will ensure that each care plan has been completed and updated. 1) Resident #272 was admitted with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated the resident had intact cognition. The Minimum Data Set documented the resident received intravenous medications including antibiotics while being a resident. A Nursing progress note dated 1/17/2025 documented the resident was readmitted with a Peripherally Inserted Central Catheter line to the right upper extremity. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Comprehensive Care Plan dated 1/24/2025 was developed seven days after the physician's orders [REDACTED]. The care plan documented the resident has a Peripherally Inserted Central Catheter Line and was at risk for developing complications, infections, and impaired patency. Interventions included to flush the Peripherally Inserted Central Catheter line as per protocol or the physician's orders [REDACTED]. During an interview on 1/28/25 at 1:26 PM, Registered Nurse #2 stated they had completed the admission assessment for Resident #272 and should have initiated a care plan for the use and care of the Peripherally Inserted Central Catheter line; however, if they (Registered Nurse #2) had missed initiating the care plan, then the nursing supervisors on the next shift should have initiated the care plan. During an interview on 1/28/25 at 11:52 AM, the Director of Nursing Service stated that a care plan should be initiated within 48 hours for residents who were admitted with a Peripherally Inserted Central Catheter line. 2) Resident #3 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident required maximum assistance (the helper does more than half the effort) for dressing. The resident was dependent on two or more staff members for transfer from the bed to the chair. The Comprehensive Care Plan titled Activities for Daily Living: Mobility, Ambulation, Transfers dated 8/12/2024 documented no goals or interventions for the care plan. The Comprehensive Care Plan titled Activities for Daily Living: Dressing, Grooming, Feeding, Bathing, Toileting, and Personal Hygiene dated 8/12/2024 documented no goals or interventions for the care plan. During an interview on 1/24/2025 at 10:35 AM, Licensed Practical Nurse Charge Nurse #2 stated the resident's care plans should be reviewed quarterly and as needed to ensure that the care plans are complete and the interventions are resident-centered. Licensed Practical Nurse Charge Nurse #2 stated they did not know why Resident #3's activity of daily living care plans were not completed with goals and interventions. During an interview on 1/24/2025 at 3:43 PM, the Minimum Data Set Coordinator stated they were responsible for initiating the resident care plans upon admission. In (MONTH) 2024, the facility changed the Electronic Medical Record System, and other staff were assisting with updating the care plans. The Minimum Data Set Coordinator stated the resident had a quarterly care plan meeting held in (MONTH) 2024 and the interdisciplinary team should have identified that the resident's care plans for activities of daily living were not complete and had no goals and interventions. During an interview on 1/24/2025 at 4:03 PM, the Director of Social Work stated during the care plan meetings, the interdisciplinary team ensures that the care plans are complete and have resident-centered goals and interventions. Resident #3's care plans should have been reviewed during the (MONTH) 2024 quarterly care plan meeting. During an interview on 1/27/2025 at 10:56 AM, the Director of Nursing Services stated they expected the Care Plan for each resident to be timely, accurate, and complete. 3) The facility's Policy titled Oxygen dated 9/2021 documented that when a resident declines to have oxygen therapy as ordered, the licensed nurse must ensure the resident has a care plan for noncompliance. Resident #19 was admitted with [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident received oxygen therapy. A Comprehensive Care Plan titled Noncompliance, Impaired Judgement dated 11/19/2024 documented that the resident removes their oxygen tubing and self-ambulates when supervision is indicated; however, the care plan did not document any goals or interventions. A physician's orders [REDACTED]. During an observation on 1/21/2025 at 3:26 PM, Resident #19 was observed sitting in a wheelchair inside their room. An oxygen concentrator was observed next to the resident and was running at a rate of 2 liters per minute. The resident was not receiving oxygen therapy and the nasal cannula was observed on top of the oxygen concentrator next to the resident. During an interview on 1/24/2025 at 10:07 AM, Licensed Practical Nurse #4, the charge nurse, stated Registered Nurses initiate care plans and Licensed Practical Nurses can update the care plans. Li | Plan of Correction: ApprovedFebruary 12, 2025 A. Immediate Corrective Action: 1. Resident #272 who still resides in facility was affected by this deficient practice. 2. The CCP for resident #272 titled PICC/Central Line Care/Management of CVP Line was initiated on 1/24/25 to ensure the proper management of the PICC line. 3. RN #2 was counseled and re-educated regarding the initiation of resident centered plan of care. 4. Resident #3 who still resides in the facility was affected by this deficient practice. 5. The CCP for resident #3 was modified on 1/24/25 to reflect resident centered goals and interventions. 6. The Director of Social Work was counseled and re-educated to ensure resident centered goals and interventions are reflected on care plans and reviewed quarterly. 7. Resident #19 who still resides in the facility was affected by this deficient practice. 8. The CCP for resident #19 was modified on 1/24/25 to reflect resident centered goals and interventions. 9. The Director of Social Work was counseled and re-educated to ensure that the resident centered goals and interventions are reflected when the care plan is initiated. B. Identification of Others: 1. All residents that reside in the facility have been identified at risk for failure to develop and implement a comprehensive care plan. 2. The facility initiated an audit of all residents comprehensive care plans to ensure development and implementation. The residents discovered to be at risk of failure to develop and implement a comprehensive resident centered comprehensive care plans were identified and modified immediately. C. Systematic Review to Prevent Re-Occurrence: 1. The Interdisciplinary Care Plan Team reviewed the Care Plan Policy and Procedure and no changes were necessary. 2. All clinical staff responsible for care planning have been re-educated by the RN Educator to ensure development and implementation of a comprehensive care plan for all residents. 3. The DNS developed an audit tool to be utilized at initial, quarterly and annual care plan meetings to ensure that care plans are reviewed. 4. The DNS developed an audit tool to ensure development and implementation of all residents. Ten residents comprehensive care plans will be audited weekly for three months then quarterly thereafter for one year. D. Quality Assurance: 1. The DNS/Designee will report on the findings of the audit quarterly at the QAPI meeting. 2. Negative findings will be immediately be addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. This was identified for one (Resident #31) of four residents reviewed for Vision and Hearing. Specifically, a plastic cup containing two bottles of Refresh [MEDICATION NAME] eye drops and two bottles of [MEDICATION NAME] Lubricant eye ointment medications were observed on Resident #31's bedside table on ,[DATE]/ 2025. The Refresh [MEDICATION NAME] eye drops expiration date was documented as ,[DATE] and the resident was observed to self-administer the expired eye drops. The finding is: The facility policy titled Storage of Medication dated ,[DATE] documented that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Compartments containing drugs and biologicals shall be locked when not in use. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Resident #31 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident's cognition was intact. The Minimum Data Set assessment documented the resident had adequate vision and used corrective lenses. A Comprehensive Care Plan titled Sensory Deficit: Visual Deficit dated [DATE] documented interventions including Ophthalmology and Optometry consults as appropriate, encourage the resident to ask for assistance as needed, and maintain eyeglasses. There was no documentation in the resident's medical record of an assessment or a comprehensive care plan to self-administer medications. A physician's orders [REDACTED]. During an observation and interview on [DATE] at 10:34 AM, Resident #31 was observed lying in bed with their bedside table placed directly in front of the resident. A plastic cup was observed on the bedside table containing four bottles of eye drops including two Refresh [MEDICATION NAME] bottles and two [MEDICATION NAME] eye ointments. The resident took the Refresh [MEDICATION NAME] eye drops from the cup and self-administered the eye drops to the right eye. The Refresh [MEDICATION NAME] eye drops documented an expiration date of August 2024. The resident stated the nurses gave them the Refresh [MEDICATION NAME] to self-administer the eye drops. During an interview on [DATE] at 11:09 AM, Licensed Practical #5, the medication nurse, stated they were not aware Resident #31 had a plastic cup with four bottles of eye medications available to them in the room. Licensed Practical Nurse #5 stated the resident did not have a physician's orders [REDACTED]. During an interview on [DATE] at 11:14 AM, Licensed Practical Nurse #4 stated Resident #31 should not have had any medications including any expired medication in their room because they do not have a physician's orders [REDACTED]. During an interview on [DATE] at 4:08 PM, the Pharmacist stated that Refresh eye drops should discarded after the manufacturer's expiration date. The Pharmacist stated they do not recommend using any medication past the expiration date because the medication may become less effective. During an interview on [DATE] at 11:22 AM, the Director of Nursing Services stated Resident #31 should not have had any eye drops stored in the resident's room without an evaluation and a physician's orders [REDACTED]. The resident should not have had access to any expired medication. 10 NYCRR 415. 18(e)(,[DATE]) | Plan of Correction: ApprovedFebruary 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Immediate Corrective Action: 1. Resident #31 who still resides in the facility was affected by this deficient practice. 2. On 1/22/25, two Refresh Liquid Eye Drops and the two [MEDICATION NAME] Eye Lubricant were in the residents room and were not secured. The medications were removed from resident #31 room immediately with explanation provided to resident. 3. The Licensed Practical Nurse #5 was counseled and re-educated to ensure that medications are stored properly. B. Identification of Others: 1. All residents rooms were surveyed for risk of same. No resident was identified at risk of this deficient practice. 2. The Policy and Procedure titled Storage of Medications was reviewed by the Interdisciplinary Care Planning Team and no changes were made. C. Systematic Review to Prevent Re-Occurrence: 1. The Director of Nursing developed an audit tool to audit 10 residents to ensure safe storage of medications for residents who are care planned for self-administration and all areas where medications are stored. The audit tool will be completed weekly for 3 months and then quarterly for one year thereafter or until 100% compliance. 2. The DNS/Designee will be responsible for completion of audit. 3. All nursing staff were re-educated regarding safe storage of medications. E. Quality Assurance: 1. The DNS/Designee will report on the findings quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #5) of five residents reviewed for Nutrition. Specifically, Resident #5 had an 8. 48% significant weight loss in 90 days, from (MONTH) 2024 to (MONTH) 2025, which was not addressed by the Clinical Dietitian. The finding is: The facility's undated policy titled, Weight Monitoring documented, once weights have been recorded in the Electronic Medical Record (EMR), the unit Clinical Dietitian will review the resident's weight status over the specified period of time to identify any residents who have experienced a significant weight change. Significant weight change is defined as 5% weight loss/gain in 30 days, 7. 5% weight loss/gain in 90 days, and 10% weight loss/gain in 180 days. Residents experiencing a significant weight change will be referred to their attending Physician by the Clinical Dietitian for further review and interventions. The facility's policy titled, Weight Loss dated 2/2019 documented interventions initiated by the Dietitian will be evaluated for effectiveness when continued declines in weights are identified and evaluation and assessment will be conducted at a minimum if in one month there is a significant (weight) loss of 5% or a severe (weight) loss greater than 5%; in three months there is a significant (weight) loss of 7. 5% or a severe (weight) loss greater than 7. 5%; in six months there is a significant (weight) loss of 10% or a severe (weight) loss greater than 10%. The Primary Medical Doctor will be notified of any significant weight (loss) and will follow up accordingly. Resident #5 has [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognitive skills for daily decision-making. The resident required supervision or touching assistance of one person for eating. The resident's height was 60 inches and they weighed 122 pounds. The resident's Weight Trend documented that on 10/6/2024 the resident weighed 130. 9 pounds and on 1/1/2025 the resident weighed 119. 8 pounds which indicated an 11. 1 pounds or an 8. 48% significant weight loss in 90 days or three months. The physician's orders [REDACTED]. A review of the resident's Electronic Medical Record (EMR) on 1/24/2025 at 12:10 PM revealed no documented evidence that the resident's significant weight loss was addressed by the resident's Clinical Dietitian (Clinical Dietitian #1). During an interview on 1/24/2025 at 1:00 PM, Clinical Dietitian #1 stated the Certified Nursing Assistants take the residents' weights and document the weights on a worksheet on the unit. Clinical Dietitian #1 stated it was their (the Dietician's) responsibility to enter the residents' weights into the Electronic Medical Record (EMR). Clinical Dietitian #1 stated according to the facility's policy, if a resident gained or lost 5 pounds in one month, a reweigh is requested to determine the accuracy of the weight. Clinical Dietitian #1 stated they also generate a report of all significant weight losses by using a computer program every month, after the 10 th of the month, when all monthly weights should be obtained. During a subsequent interview on 1/24/2025 at 1:20 PM, Clinical Dietitian #1 stated when they enter a monthly weight into a resident's Electronic Medical Record, they do not look for a 7. 5% weight loss in three months, but mainly for a 5% weight loss from month to month. Clinical Dietitian #1 stated all resident weights have to be obtained by the tenth of the month; however, this month they ran the report for this month's weights on 1/22/ 2025. The report indicated Resident #5 had an 8. 48% weight loss in 90 days. Clinical Dietitian #1 stated they did not have the time to write any significant weight loss notes yet for the month of January 2025. Clinical Dietitian #1 stated the notes would be completed before the end of the month. During an interview on 1/24/2025 at 1:50 PM, the Chief Clinical Dietitian stated on the first of every month, Certified Nursing Assistants start to take residents' monthly weights which are usually completed within 5 days and all reweighs have to be done by the tenth of the month. The Chief Clinical Dietitian stated that all Clinical Dietitians are responsible for putting the weights into the Electronic Medical Record. If there is a weight gain or loss of five pounds from one month to the next, a reweigh must be obtained to ensure the accuracy of the weight. The Chief Clinical Dietitian stated a significant weight loss was 5% in one month, 7. 5% in three months, and 10% in six months. The Chief Clinical Dietitian stated that Clinical Dietitian #1 may not have been looking for 7. 5% weight losses in three months when entering monthly weights into the residents' Electronic Medical Records, but should have. During an interview on 1/27/2025 at 10:10 AM, Licensed Practical Nurse #1, who was the Charge Nurse on Resident #5's unit, stated the Clinical Dietitian reviews all the weights and if they see that a resident had significant weight loss, they inform any Nurse on the unit who then contacts the resident's Primary Physician to inform them of the significant weight loss. Licensed Practical Nurse #1 stated that Clinical Dietitian #1 never told them that the resident had a significant weight loss. Licensed Practical Nurse #1 stated that if they had been informed, they would have contacted the resident's Primary Physician and written a Nursing Progress Note. During an interview on 1/27/2025 at 11:10 AM, the Director of Nursing Services stated the Clinical Dietitians are responsible for identifying significant weight losses and reporting them to the Interdisciplinary Team (Nursing, Social Work, Rehabilitation, and Activities) during the morning report. A Unit Nurse should also be made aware. The nurse should notify the resident's Primary Physician of the significant weight loss to obtain any new orders to address the resident's weight loss, such as ordering blood work or nutritional supplements. 10 NYCRR 415. 12(i)(1) | Plan of Correction: ApprovedFebruary 12, 2025 A: Immediate Correction Action 1. Resident #5 who still resides at the facility was affected by this deficient practice. 2. The clinical dietician for resident # 5 reviewed the chart, initiated weekly weights, and added supplements. 3. Clinical Dietician # 1 was educated on the facility policy on weight loss and weight monitoring on 1/24/25 B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The Chief Clinical Dietician ran the weight loss report for the month of (MONTH) on all residents to see if there were any residents with unidentified significant weight loss. There were no negative findings. C. Systematic Review to prevent re-occurrence 1. The facilities policy titled Weight Loss dated 2/2019 was reviewed by the Administrator, Medical Director and DNS and no changes were made to the policy. 2. The facilities policy titled Weight Monitoring was reviewed by the Administrator, Medical Director and DNS and no changes were made to the body of the policy, an effective date of 1/25/25 was given. 2. The RN Nurse Educator will re-educate all Clinical Dieticians on Weight Loss and Weight Monitoring policies and procedures. D. Quality Assurance: 1. The DNS devised an audit tool to ensure that all residents experiencing weight loss are captured and documented according to the facilities policy and procedure. 2. The DNS and or designee will audit the weights of 10 residents weekly x 3 months and there after monthly for 1 year or until 100% compliance is achieved. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that injuries of unknown origin were reported by the covered individual including the Certified Nursing Assistants within 24 hours of identifying the injury. This was identified for one (Resident #273) of three residents reviewed for Skin Condition (non-pressure). Specifically, Certified Nursing Assistant #6 did not report a bruise of unknown origin on the back of Resident #273's left forearm when they identified the bruise on 1/18/ 2025. The finding is: The facility's Abuse Prevention policy dated 10/2022 documented that the facility staff are trained regarding the facility policies related to Abuse Prevention and Reporting at the time of orientation and at least annually thereafter. The orientation and in-service included but were not limited to identifying what constitutes abuse, neglect exploitation, and misappropriation of property, to report injuries of unknown origin, and to whom to make a report including the importance of reporting immediately. The facility's policy entitled Potential for Risk in Skin Integrity Prevention and Treatment last updated on 5/2011 documented the Certified Nursing Assistant was responsible for monitoring the resident's skin during activities of daily living care and reporting any changes in skin integrity immediately to the nurse in charge. Resident #273 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, which indicated intact cognition. The resident had no behavioral symptoms. The resident used a walker and had no functional limitations to the upper and lower extremities. The resident required partial to moderate assistance for dressing, toilet hygiene and personal hygiene, bed mobility, and transfers including toilet transfers. The resident received nutrition or hydration intervention to manage skin problems. The resident did not receive anticoagulant medications during the lookback period. The Admission Skin assessment dated [DATE] had no documentation of discoloration to the resident's left forearm. A Comprehensive Care Plan for Skin Integrity dated 1/2/2025 documented the resident was at risk for skin breakdown related to impaired mobility. Interventions included for the Certified Nursing Assistant to evaluate the resident's skin condition daily during care and to report any skin abnormalities to the nurse. A Review of the Baseline Care Plan dated 1/2/2025 lacked documented evidence of a bruise to the resident's left forearm. During an observation on 1/21/2025 at 2:36 PM, Resident #273 was sitting in their room in a wheelchair at their bedside. The resident was observed with a bruise to the left forearm. During an interview on 1/24/2025 at 2:07 PM, Certified Nursing Assistant #6 stated they usually care for the resident during the night shift (11:00 PM to 7:00 AM) and routinely perform skin checks and inform the nurses if there are any new changes to the resident's skin. Certified Nursing Assistant #6 stated they had seen the bruise on Resident #273's forearm when they worked on the previous weekend 1/18/2025-1/19/2025 overnight night shift. Certified Nursing Assistant #6 stated they did not report the bruise and thought someone already reported it. During an interview on 1/24/2025 at 2:46 PM, Licensed Practical Nurse #6 who was assigned to Resident #273 on the 7:00 AM to 3:00 PM shift stated they have cared for the resident since admission. Licensed Practical Nurse #6 stated they were not aware of the discoloration on the resident's left forearm. Licensed Practical Nurse #6 stated the resident usually wears long-sleeved shirts and they did not receive any report of a bruise on the resident's left forearm. Licensed Practical Nurse #6 stated that it was the Certified Nursing Assistant's responsibility to report any changes in the resident's skin to the nurses. During an interview on 1/24/2025 at 3:42 PM, the Wound Care Registered Nurse stated on 1/3/2025 they evaluated the resident's left elbow stage III pressure ulcer and did not recall the resident having any discoloration to their left forearm. The Wound Care Registered nurse did not notice the discoloration until today, 1/24/ 2025. During an interview on 1/27/2025 at 2:07 PM, Registered Nurse #4 stated they completed the admission assessment for Resident #273 on 1/2/ 2025. Registered Nurse #4 stated they completed a head-to-toe assessment and the resident did not have any discoloration or a bruise on their left forearm. Registered Nurse #4 stated when they completed their assessment if they had observed a discoloration on the resident's forearm that they would have documented the bruise in their skin assessment. During an interview on 1/28/2025 at 12:01 PM, the Director of Nursing Services stated that Certified Nursing Assistant #6 should have reported the bruise to the charge nurse or the supervisor. The Director of Nursing Services stated the supervisor should have then initiated an Accident/Incident Report to determine the root cause of the incident. The Director of Nursing Service stated they had initiated an investigation as soon as they were informed on 1/24/2025 and abuse was ruled out. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedFebruary 24, 2025 A: Immediate Correction Action 1. Resident #273 who still resides at the facility was affected by this deficient practice. 2. An Accident and Incident report was initiated. 3. Nursing Assistant #6 was counseled and re-educated on 1/30/25 Abuse Prevention and Reporting. B: Identification of Others: 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The facility conducted a skin assessment on 20 random residents to see if there were any changes in skin condition that were not reported. There were no findings noted. C. Systematic Review to prevent re-occurrence 1. The DNS devised an audit tool to ensure that all skin changes are reported and documented in a timely manner with the proper notifications to MD, family and governmental agencies if applicable. 2. The facilities policy titled Abuse Prevention dated 10/22 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 3. The facilities policy titled Potential for Risk in Skin Integrity Prevention and Treatment dated 5/2011 was reviewed by the Administrator, Medical Director, and DNS and no changes were made. 4. The RN Nurse Educator will re-educate all nurses, CNA's, housekeeping, maintenance, recreation, dietary, pastoral care, and ancillary staff on Abuse Prevention and Reporting 5. The RN Nurse Educator will re-educate all CNAs on monitoring the residents skin during ADLs and reporting any skin changes to the nurse. D. Quality Assurance: 1. The DNS and or designee will audit 10 residents weekly x 3 months and there after monthly for 1 year until 100% compliance is obtained to ensure that there have been no undocumented skin changes. 2. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 3. The DNS will report the findings of this audit quarterly at the QAPI meeting 4. The DNS/ designee is responsible for ensuring the correction of this deficient practice |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure all drugs and biologicals were stored in locked compartments under proper temperature controls. This was identified for one (Resident #31) of four residents reviewed for Vision and Hearing. Specifically, a plastic cup containing two bottles of Refresh [MEDICATION NAME] eye drops and two bottles of [MEDICATION NAME] Lubricant eye ointment medications were observed on Resident #31's bedside table on ,[DATE]/ 2025. The Refresh [MEDICATION NAME] eye drops expiration date was documented as ,[DATE] and the resident was observed to self-administer the expired eye drops. The finding is: The facility policy titled Storage of Medication dated ,[DATE] documented that drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Compartments containing drugs and biologicals shall be locked when not in use. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. Resident #31 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident's cognition was intact. The Minimum Data Set assessment documented the resident had adequate vision and used corrective lenses. A Comprehensive Care Plan titled Sensory Deficit: Visual Deficit dated [DATE] documented interventions including Ophthalmology and Optometry consults as appropriate, encourage the resident to ask for assistance as needed, and maintain eyeglasses. There was no documentation in the resident's medical record of an assessment or a comprehensive care plan to self-administer medications. A physician's orders [REDACTED]. During an observation and interview on [DATE] at 10:34 AM, Resident #31 was observed lying in bed with their bedside table placed directly in front of the resident. A plastic cup was observed on the bedside table containing four bottles of eye drops including two Refresh [MEDICATION NAME] bottles and two [MEDICATION NAME] eye ointments. The resident took the Refresh [MEDICATION NAME] eye drops from the cup and self-administered the eye drops to the right eye. The Refresh [MEDICATION NAME] eye drops documented an expiration date of August 2024. The resident stated the nurses gave them the Refresh [MEDICATION NAME] to self-administer the eye drops. During an interview on [DATE] at 11:09 AM, Licensed Practical #5, the medication nurse, stated they were not aware Resident #31 had a plastic cup with four bottles of eye medications available to them in the room. Licensed Practical Nurse #5 stated the resident did not have a physician's orders [REDACTED]. During an interview on [DATE] at 11:14 AM, Licensed Practical Nurse #4 stated Resident #31 should not have had any medications including any expired medication in their room because they do not have a physician's orders [REDACTED]. During an interview on [DATE] at 4:08 PM, the Pharmacist stated that Refresh eye drops should discarded after the manufacturer's expiration date. The Pharmacist stated they do not recommend using any medication past the expiration date because the medication may become less effective. During an interview on [DATE] at 11:22 AM, the Director of Nursing Services stated Resident #31 should not have had any eye drops stored in the resident's room without an evaluation and a physician's orders [REDACTED]. The resident should not have had access to any expired medication. 10 NYCRR 415. 18(e)(,[DATE]) | Plan of Correction: ApprovedFebruary 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Immediate Corrective Action: 1. On 1/22/25, the two Refresh Liquid Eye Drops and the two [MEDICATION NAME] Eye Lubricant were removed from resident #31 room with explanation provided to resident. The expired Refresh Liquid Eye Drops were discarded. 2. Resident #31 was assessed for self-administration as per request. The residents wishes for self-administration were assessed by the Interdisciplinary Care Plan Team and was deemed to be capable of self-administration. The attending physician was made aware and orders received for self-administration of Refresh Eye Drops. A locked box and key were issued to resident. The plan of care was updated to include self-administration. 3. The Licensed Practical Nurse #5 was counseled and re-educated to ensure that medications are stored properly, residents are promptly evaluated for potential for self-administration, a physician order [REDACTED]. B. Identification of Others: 1. All residents rooms were surveyed for risk of same. Individual request for self-administration and proper storage of medications were assessed by the Interdisciplinary Care Plan Team. Orders were received from the attending physician and orders updated as necessary to include self-administration. 2. All storage areas were inspected for expired medications. No expired medications were identified. C. Systematic Review to Prevent Re-Occurrence: 1. The facility Self-Administration Policy and Procedure was reviewed by the Interdisciplinary Care Plan Team. 2. The Director of Nursing developed an audit tool to audit 10 residents for expired medications, safe storage of medications, evaluation of residents to self-administer medications, and physician orders [REDACTED]. The audit tool will be completed weekly for 3 months and then quarterly for one year thereafter. 3. The DNS/Designee will be responsible for completion of audit. 4. All nursing staff were re-educated regarding expired medications, safe storage of medications, evaluation for self-administration, and physician orders [REDACTED]. D. Quality Assurance: 1. The DNS/Designee will report on the findings quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 1/21/2025 and completed on 1/28/2025, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #5) of five residents reviewed for Nutrition. Specifically, Resident #5 had an 8. 48% significant weight loss in 90 days, from (MONTH) 2024 to (MONTH) 2025, which was not addressed by their Primary Physician. The finding is: The facility's undated policy titled, Weight Monitoring documented, once weights have been recorded in the Electronic Medical Record (EMR), the unit Clinical Dietitian will review the resident's weight status over the specified period of time to identify any residents who have experienced a significant weight change. Significant weight change is defined as 5% weight loss/gain in 30 days, 7. 5% weight loss/gain in 90 days, and 10% weight loss/gain in 180 days. Residents experiencing a significant weight change will be referred to their attending Physician by the Clinical Dietitian for further review and interventions. The facility's policy titled, Weight Loss dated 2/2019 documented interventions initiated by the Dietitian will be evaluated for effectiveness when continued declines in weights are identified and evaluation and assessment will be conducted at a minimum if in one month there is a significant (weight) loss of 5% or a severe (weight) loss greater than 5%; in three months there is a significant (weight) loss of 7. 5% or a severe (weight) loss greater than 7. 5%; in six months there is a significant (weight) loss of 10% or a severe (weight) loss greater than 10%. The Primary Medical Doctor will be notified of any significant weight (loss) and will follow up accordingly. Resident #5 has [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderately impaired cognitive skills for daily decision-making. The resident required supervision or touching assistance of one person for eating. The resident's height was 60 inches and they weighed 122 pounds. The resident's Weight Trend documented that on 10/6/2024 the resident weighed 130. 9 pounds and on 1/1/2025 the resident weighed 119. 8 pounds which indicated an 11. 1 pounds or an 8. 48% significant weight loss in 90 days or three months. The physician's orders [REDACTED]. The Medical Progress Note dated 1/21/2025 documented that the resident was seen by their Primary Physician (Primary Physician #1) for their monthly visit on 1/18/2025; however, the current eight and change in weight portion of the visit was left blank. During an interview on 1/24/2025 at 1:20 PM, Clinical Dietitian #1 stated when they enter a monthly weight into a resident's Electronic Medical Record, they do not look for a 7. 5% weight loss in three months, but mainly for a 5% weight loss from month to month. Clinical Dietitian #1 stated all resident weights have to be obtained by the tenth of the month; however, this month they ran the report for this month's weights on 1/22/ 2025. The report indicated Resident #5 had an 8. 48% weight loss in 90 days. Clinical Dietitian #1 stated they did not have the time to write any significant weight loss notes yet for the month of January 2025. Clinical Dietitian #1 stated the notes would be completed before the end of the month. During an interview on 1/27/2025 at 10:10 AM, Licensed Practical Nurse #1, who was the Charge Nurse on Resident #5's unit, stated the Clinical Dietitian reviews all the weights and if they see that a resident had significant weight loss, they inform any Nurse on the unit who then contacts the resident's Primary Physician to inform them of the significant weight loss. Licensed Practical Nurse #1 stated that Clinical Dietitian #1 never told them that the resident had a significant weight loss. Licensed Practical Nurse #1 stated that if they had been informed, they would have contacted the resident's Primary Physician and written a Nursing Progress Note. During an interview on 1/27/2025 at 10:25 AM, the resident's Primary Physician (Primary Physician #1) stated they should have documented the resident's weight in their monthly review. Primary Physician #1 stated they did not realize they had left the monthly weight review section blank. Primary Physician #1 stated they had only compared this month's weight with the resident's weight from the month before and did not see a significant weight loss. Primary Physician #1 stated that the facility Dietitians and Nurses are pretty good in letting them know if a resident had a significant weight loss, but they were never informed that the resident had an 8. 48% significant weight loss from (MONTH) 2024 to January 2025. During an interview on 1/27/2025 at 10:40 AM, the Medical Director stated, The dietitians are excellent in contacting the Physician about weight loss, but the Primary Physician can also look at the weights (themselves) to see if there have been any significant weight losses. The Medical Director stated that the resident's Primary Physician was supposed to document the resident's weight in their monthly review and if a significant weight loss was identified, interventions such as supplements should be added. The Physician should document the cause of the weight loss. The Medical Director stated that all questions on a monthly visit template absolutely should be answered. 10 NYCRR 415. 15(b)(1)(i)(ii) | Plan of Correction: ApprovedFebruary 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A: Immediate Correction Action 1. Resident #5 who still resides at the facility was affected by this deficient practice. 2. Resident #5 was immediately placed on weekly weights. 3. Laboratory values ordered on [DATE] to identify any contributing factors. Values were in normal limits. 4. Physician #1 addressed weight loss in his monthly note. 5. Clinical Dietician #1 was counseled and re-educated to identify weight loss and follow facility Weight Monitoring Policy and Procedure. B: Identification of Others 1. All residents weights were reviewed and assessed for weight loss as outlined in the Weight Monitoring Policy and Procedure. No resident was identified as potential for the this deficient practice. 2. The RN Educator re-educated the Physician, Dieticians, and Nursing staff to identify residents with weight loss as outlined in the Weight Monitory Policy and Procedure. Upon identification of residents with weight loss proper notification. documentation of weight loss is mandated. C. Systematic Review to prevent re-occurrence 1. The facility Weight Monitoring Policy and Procedure was reviewed by the Interdisciplinary Care Planning Team and no changes were made. 2. The DNS developed a Weight Monitoring Audit tool to identify resident with weight loss identified by this deficient practice to ensure communication and documentation. Ten residents will be audited weekly and thereafter ten residents will be audited quarterly for one year or until 100% compliance. D. Quality Assurance: !. The DNS/Designee will review the findings of the Weight Monitoring Audit. Negative findings will be immediately addressed by the DNS/Designee with onsite in service and disciplinary action as needed. 2. The DNS/Designee will report the findings of this Weight Monitoring Audit quarterly at the QAPI meeting. 3. The DNS/Designee is responsible for ensuring the correction of this deficient practice. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details 483. 73 Emergency Preparedness The LTC facility must comply with all applicable Federal, State and local emergency preparedness requirements. The LTC facility must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The (facility) must develop and maintain an emergency preparedness plan that must be (reviewed) and updated at least every 2 years. The plan must do all of the following: * (For LTC Facilities at 483. 73(a):) Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. Based on document review and staff interviews, the facility did not ensure that its Emergency Preparedness Plan was reviewed and/or updated at least annually in accordance with 42 CFR 483. 73(a) The findings are: On (MONTH) 22, 2025, at approximately 11:37 AM, document review of the Emergency Preparedness plan revealed that the last updated and/or revision was conducted on 10/18/ 2022. A sheet titled: Approval and Implementation listed as Administrator and Director of Building Services former personnel and did not reflect the current Administrator and current Director of Building Services. On (MONTH) 24, 2025, at approximately 9:40 AM, the Administrator stated that they have not updated the Emergency Preparedness Plan since they started on the role as Administrator in May 2024. Further stating that they will review and update the Emergency Preparedness plan. 42 CFR 483. 73(a) | Plan of Correction: ApprovedFebruary 21, 2025 I. Immediate corrective action. On 01/24/2025 A review and update was conducted for Emergency Management Plan Upon inspection of the facility's Emergency Preparedness Binder. The Emergency Management Plan was found to be current with all regulatory requirements. The reviewed by sheet was signed and dated and put in the front of the binder for compliance. Identification of Others II. Identification of other residents. To further ensure compliance and safety, all sections of the binder were reviewed in its entirety to ensure it had retained inspection sheets their label/tab; this audit did not yield any insufficiencies or concerns for compliance and safety. III. Systemic Changes 1. The Administrator and Maintenance Director have been provided a comprehensive and detailed in-service regarding 'E-004', inclusive of but not limited to: the deficiencies observed during the environmental survey lead by the NYS DOH, staff responsibility in continuous auditing, and the immediate reporting of findings to the Director of Maintenance or Administrator as applicable, so corrective action or repair may immediately ensue. All binders, and their respective sections, will be appropriately labeled as we proceed. The Emergency Manual will be inspected annually and sign the reviewed by sheet and dated 2. An audit tool has been created and implemented by the Director of Maintenance to identify any/all potential deficiencies of 'E- 004'. This audit will occur monthly for the first three months of its implementation, then after, quarterly three times. IV. Quality assurance All audits of'E-004' and any subsequent findings will be presented with the Administrator and interdisciplinary team at quality assurance and performance improvement (QAPI) meetings, held on a monthly basis. V. Individual Responsible for Correction. The Director of Maintenance is responsible for the completion of this correction |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details 2011 NFPA 70: 517. 40 Essential Electrical Systems for Nursing Homes and Limited Care Facilities. (A) Applicability. The requirements of Part III, 517. 40(C) through 517. 44, shall apply to nursing homes and limited care facilities. 2011 NFPA 70: 517. 41 Essential Electrical Systems. (A) General. Essential electrical systems for nursing homes and limited care facilities shall be comprised of two separate branches capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate branches shall be the life safety branch and the critical branch. (99: A. 4. 5. 2. 2. 1) 2011 NFPA 70: 517. 42 Automatic Connection to Life Safety Branch. The life safety branch shall be installed and connected to the alternate source of power so that all functions specified herein shall be automatically restored to operation within 10 seconds after the interruption of the normal source. No functions other than those listed in 517. 42(A) through (G) shall be connected to the life safety branch. The life safety branch shall supply power for the following lighting, receptacles, and equipment. (A) Illumination of Means of Egress. Illumination of means of egress as is necessary for corridors, passageways, stairways, landings, and exit doors and all ways of approach to exits. Switching arrangement to transfer patient corridor lighting from general illumination circuits shall be permitted, providing only one of two circuits can be selected and both circuits cannot be extinguished at the same time. (B) Exit Signs. Exit signs and exit directional signs. (C) Alarm and Alerting Systems. Alarm and alerting systems, including the following: (1) Fire alarms (2) Alarms required for systems used for the piping of nonflammable medical gases (D) Communications Systems. Communications systems, where used for issuing instructions during emergency conditions. (E) Dining and Recreation Areas. Sufficient lighting in dining and recreation areas to provide illumination to exit ways. (F) Generator Set Location. Task illumination and selected receptacles in the generator set location. (G) Elevators. Elevator cab lighting, control, communications, and signal systems. (99: 4. 4. 2. 2. 2. 2(6), 4. 5. 2. 2. 2(7)) 2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6. 1* Applicability. 2012 NFPA 99: 6. 1. 1 This chapter shall apply to new health care facilities as specified in Section 1. 3. 1999 NFPA 99: Chapter 16 Nursing Home Requirements 1999 NFPA 99: 16-1 Scope. This chapter addresses safety requirements of nursing homes. 1999 NFPA 99: 16- 3. 3 Electrical System Requirements. 1999 NFPA 99: 16- 3. 3. 2 Essential electrical distribution systems shall conform to the Type 2 systems as described in Chapter 3. 1999 NFPA 99: 3- 5. 2 Distribution (Type 2 EES). 1999 NFPA 99: 3- 5. 2. 1 General. The distribution requirements for Type 2 essential electrical systems shall conform to those listed in 3- 4. 2. 1. 1999 NFPA 99: 3- 5. 2. 2. 1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3- 5. 2. 2. 2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA-101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, ''Gas and Vacuum Systems'' (d)* Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 footcandles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3- 5. 2. 2. 3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3- 5. 2. 2. 3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3- 5. 2. 2. 3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas-task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for air- borne infectious isolation rooms. 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c)* Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a.* The outside design temperature is higher than`207F (- 6. 77C), or b. The outside design temperature is lower than `207F (- 6. 77C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3- 4. 1. 1. 1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throwover facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3- 5. 2. 2. 2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. Based on observation and document review (i.e., posted electrical panel directories), the facility did not ensure that its Type 2 Essential Electrical System was maintained in accordance with NFPA 99 - Health Care Facilities Code and NFPA 70: National Electrical Code. Specifically, the Emergency (Life Safety) Branch wiring was not separated from the Critical Branch wiring. This was noted for the Emergency Panels located on the first and second floor of the facility. The findings are: On (MONTH) 23, 2025, between 11:30 AM - 12:30 PM, during the Life Safety Code recertification survey, observation of the posted circuit directories for the Emergency Power panels labeled as LPEDD and LPEHH, indicates that the panels contained loads from both the Emergency and the Critical Branch. The Emergency panel labeled as LPEHH | Plan of Correction: ApprovedFebruary 26, 2025 I. The facility contacted electrical company on 2/12/25 to separate the branch circuits completion date of 3/17/ 25. II. Anyone has the potential to be affected. III. The maintenance department were educated on NFPA 101 Electrical System ÔÇ£ Essential Electrical systems on 2/12/25 Director of Maintenance. IV. The maintenance director will monitor the work to ensure successful relocation of the branch circuits to the proper panels. Any finds will be reported to QAPI. V. Responsible party: Director of Maintenance/ Designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: 6. 1* Applicability. 2012 NFPA 99: 6. 1. 2 The following paragraphs of this chapter shall apply to new and existing health care facilities: (1) 6. 3. 2. 2. 4. 2 (2) 6. 3. 2. 2. 6. 1 (3) 6. 3. 2. 2. 6. 2(F) (4) 6. 3. 2. 2. 8. 5(B)(2), (3), and (4) (5) 6. 3. 2. 2. 8. 7 (6) 6. 3. 4 (7) 6. 4. 1. 1. 17. 5 (8) 6. 4. 2. 2. 6. 2(C) (9) 6. 4. 2. 2. 6. 3 (10) 6. 4. 4 (11) 6. 5. 4 (12) 6. 6. 2. 2. 3. 2 (13) 6. 6. 3. 1 (14) 6. 6. 4 2012 NFPA 99: 6. 5. 4. 1 Maintenance and Testing of Essential Electrical System. 2012 NFPA 99: 6. 5. 4. 1. 1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 2012 NFPA 99: 6. 5. 4. 1. 1. 1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6. 4. 1. 1. 7 and 6. 4. 3. 1. 1999 NFPA 99:3- 5. 4. 1. 1 Maintenance and Testing of Alternate Power Source and Transfer Switches. (a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the 10-second interval specified in 3- 4. 1. 1. 8 and 3- 5. 3. 1. 1999 NFPA 99: 3- 4. 1. 1. 8 + Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. 1999 NFPA 99: 3- 5. 3. 1 Source. The emergency system shall be installed and connected to the alternate source of power specified in appropriate time-lag intervals following the restoration of the 3- 4. 1. 1. 2 and 3- 4. 1. 1. 3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source. Based on document review and staff interviews, the facility did not ensure that the generator was inspected and tested in accordance with NFPA 99 Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Specifically, there was no evidence that the generator was capable of supply service within 10 seconds. This was noted for the only generator serving the facility. The findings are: On (MONTH) 24, 2025, at approximately 10:16 AM, record review of the emergency generator logs, monthly full load test did not include the transfer time, as a result, it could not be verified that the generator was capable of supplying service within 10 seconds. On (MONTH) 24, 2025, at approximately 10:45 AM, the Director of Building Services stated that they will add the transfer time in the monthly load test. On (MONTH) 24, 2025, at approximately 11:05 AM, maintenance staff stated that they have been working at the facility for approximately [AGE] years and never been asked for the transfer time, further stating that the generator starts within 5 seconds and that moving forward they will record it. 2012 NFPA 99: 6. 1*, 6. 1. 2, 6. 5. 4. 1, 6. 5. 4. 1. 1, 6. 5. 4. 1. 1. 1 1999 NFPA 99:3- 5. 4. 1. 1, 3- 4. 1. 1. 8, 3- 5. 3. 1 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 26, 2025 I. Generator log sheets were immediately updated to include transfer times for each test. II. Anyone has the potential to be affected. III. The maintenance department was educated on NFPA 101 Electrical System Maintenance and testing by Director of Maintenance on 2/12/ 25. IV. Audit tool was created to ensure generator logs included transfer time sections going forward. Audits will be conducted by the director of maintenance or monthly for 12 months. V. Responsible party: Director of Maintenance/ Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1999 NFPA 99: 3- 1. 2 Specific requirements for wiring and installation on equipment are covered in NFPA 70, National Electrical Code. 2011 NFPA 70: 110. 26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. (A) Working Space. Working space for equipment operating at 600 volts, nominal, or less and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110. 26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code. (B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitable guarded. 2012 NFPA 99: 6. 3. 3. 2. 1 The physical integrity of each receptacle shall be confirmed by visual inspection. Based on observation and staff interview, the facility did not ensure that its electrical system was in compliance with NFPA 70: National Electrical Code and NFPA 99: Health Care Facilities Code. Specifically, minimum clear spaces for electrical equipment were not maintained and an emergency receptacle observed in disrepair. This was noted on two of three floors within the facility. The findings are: On (MONTH) 23, 2024, between 9:40 AM - 3:30 PM, during the Life Safety Code recertification survey, it was observed the storage of assorted items, less than 3 ft apart from electrical panels. Locations included but not limited to: -On the second floor in the clean holding room 229. - On the second floor, in the clean holding room by room 268. -On the first floor, in the clean holding room [ROOM NUMBER] A. On (MONTH) 23, 2024, at approximately 11:10 AM, in the nurse station on the second floor, the receptacle EHH-CKT#9 was observed in disrepair. The Director of Building Services, who was present at the time of observations, stated that they will move the items away from the electrical panels and repair the receptacle. 1999 NFPA 99: 3- 1. 2 2011 NFPA 70: 110. 26 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Items have been removed from 3ft around the electrical panel. Clean holding rooms 229, 268 on the second floor and first floor clean holding room [ROOM NUMBER] were removed and replaced. Nurse station receptacle EHH-CKT#9 was repaired 02/28/ 2025. II. Anyone has the potential to be affected. III. The maintenance department were educated on NFPA 101 Electrical System ÔÇ£ other on 2/12/25 by Director of Maintenance. IV. The facility created an audit tool to ensure there are no items stored within 3ft of electrical panels and that all receptacles are in working condition. Audits will be conducted weekly for 1 month and monthly for 3 months. V. Responsible party: Director of Maintenance/ Designee. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details 2010 NFPA 72: 14. 3. 1* Unless otherwise permitted by 14. 3. 2 visual inspections shall be performed in accordance with the schedules in Table 14. 3. 1 or more often if required by the authority having jurisdiction. 2010 NFPA 72: 14. 4. 5. 3. 1 Sensitivity shall be checked within 1 year after installation. 2010 NFPA 72: 14. 4. 5. 3. 2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14. 4. 5. 3. 3. 2010 NFPA 72: 14. 6. 2. 4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14. 6. 2. 4: (1) Date (2) Test frequency (3) Name of property 2010 (4) Address (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number (6) Name, address, and representative of approving agency(ies) (7) Designation of the detector(s) tested (8) Functional test of detectors (9)*Functional test of required sequence of operations (10) Check of all smoke detectors (11) Loop resistance for all fixed-temperature, line-type heat detectors (12) Functional test of mass notification system control units (13) Functional test of signal transmission to mass notification systems (14) Functional test of ability of mass notification system to silence fire alarm notification appliances (15) Tests of intelligibility of mass notification system speakers (16) Other tests as required by the equipment manufacturer's published instructions (17) Other tests as required by the authority having jurisdiction (18) Signatures of tester and approved authority representative (19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested , device abandoned in place) 2010 NFPA 72: 14. 6. 3. 2 Upon request, a hard copy record shall be provided to the authority having jurisdiction. Based on record review and interviews, the facility did not ensure that records of all inspections, testing, and maintenance were provided upon request in accordance with NFPA 72: National Fire Alarm and Signaling Code. Specifically, the last fire alarm report and last smoke detectors' sensitivity test were not provided for review. This was observed for the Fire Alarm System serving the whole facility. The findings are: On (MONTH) 24, 2025, at approximately 10:30 AM, during the Life Safety Code recertification survey, records of the last fire alarm system inspection provided for review included only a fire alarm vendor invoice dated 11/01/ 2024. The invoice states as description of services: Fire Inspection Services 11/01/2024-04/30/ 2025. A document that includes the full fire alarm system inspection report as specified in 2010 NFPA 72: 14. 6. 2. 4, and the last smoke detectors sensitivity test was not provided for review. On (MONTH) 24, 2025, at approximately 10:45 AM, the Director of Building Services stated that the fire alarm inspection and smoke detector sensitivity test was performed the previous week and that they will ask the company for the report. No other document that evidences the fire alarm system inspection was provided for review by the end of the survey. NFPA 72: 14. 3. 1*, 14. 4. 5. 3. 1, 14. 4. 5. 3. 2, 14. 6. 2. 4*, 14. 6. 3. 2 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 26, 2025 I. Fire alarm company was called to set up sensitivity testing on (MONTH) 24th. Sensitivity testing is scheduled for (MONTH) 14th. A binder was immediately created by the Director of Maintenance to ensure proper documentation of all fire alarm systems/ smoke detectors inspections including sensitivity testing on all required equipment. The fire inspection company was called on (MONTH) 24th t forward all proof of previous inspection going back 12 months. II. Anyone has the potential to be affected. III. The maintenance department has been educated by Director of Maintenance on 2/12/25 regarding 2010 NFPA 72 14. 5. 3. 1. 2. 3. IV. Facility has developed an audit tool to monitor complaint record keeping for smoke detectors and fire alarm system inspections including sensitivity testing. Audits shall be conducted after annual inspection has been completed and copy of report will be sent to Administrator by the Director of Maintenance on all system inspections. All findings will be reported to QAPI committee V. Responsible party: Director of Maintenance/Designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 7. 1. 4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101: 19. 7. 1. 6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 2012 NFPA 101: 4. 7. 4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 2012 NFPA 101: 4. 7. 6* A written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner. Based on document review and staff interview, the facility did not ensure that fire drill written records included which emergency fire conditions were simulated during each fire drill in accordance with NFPA 101: Life Safety Code. Specifically, on various fire drill reports the condition that caused the simulated fire drill and fire alarm activation was not documented. This was observed in six of 12 fire drills. The findings are: On (MONTH) 22, 2025, at approximately 2:40 PM, record review of the fire drills for the past 12 months revealed that the drills conducted from 08/17/24 to 01/15/25 did not include the scenario simulated during the fire drill, as a result it could not be determined that the drills were conducted under varying conditions. The fire drill reports included under comment section: Code red was called, all rooms closed, good response from staff; but did not include the scenario played. On (MONTH) 24, 2025, at approximately 2:10 PM, the Director of Building Services, stated that they will add the scenario to the fire drills. 2012 NFPA 101: 19. 7. 1. 4*, 19. 7. 1. 6, 4. 7. 4*, 4. 7. 6* 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 26, 2025 I. The facility immediately added the scenario simulated to the Fire Drill Report for all fire drills going forward. II. Anyone has the potential to be affected. III. The maintenance director was educated on 2012 NFPA 101: 4. 7. 4 on 2/12/25 by the Corporate Director of Maintenance. IV. The facility created an audit tool to ensure fire drills include a simulated scenario when conducted. Audits will be conducted by the Director of Maintenance monthly for 12 months. All findings will be reported on QAPI. V. Responsible party: Director of Maintenance/ Designee. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 28, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99: 4. 1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. 2012 NFPA 99: 4. 1. 1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 2012 NFPA 99: 4. 1. 2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 2012 NFPA 99: 4. 1. 3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 2012 NFPA 99: 4. 1. 4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 2012 NFPA 99: 4. 2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. Based on documentation review and staff interview, the facility did not ensure that a formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99 Health Care Facilities Code. Specifically, documentation of a risk assessment describing the facility's building system categories was not provided at time of survey. The findings are: On (MONTH) 24, 2025, at approximately 1:20 PM, review of the documentation provided by the facility did not include a NFPA 99 risk assessment for building system categories. On (MONTH) 24, 2025, at approximately 2:40 PM, during the exit interview, the Administrator and the Director of Building Services acknowledged the findings. The facility was not able to provide documentation of a building systems risk assessment by the end of survey. 2012 NFPA 99: 4. 1*, 4. 1. 1*, 4. 1. 2*, 4. 1. 3, 4. 1. 4, 4. 2* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 26, 2025 I. The facility immediately began to create a risk assessment document. Risk assessment is completed and went into effect on 2/12/ 25. II. Anyone has the potential to be affected. III. The maintenance department was educated on NFPA 101 fundamentals ÔÇ£ building system categories on 2/12/25 by Director of Maintenance. IV. The facility created an audit tool to ensure the risk assessments include all required sections and are completed. Audit will be conducted upon creation to risk assessments and assessed quarterly. V. Responsible party: Director of Maintenance/ Designee. |
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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 28, 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: January 28, 2025
Corrected date: N/A
Citation Details 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 (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2010 NFPA 13: 7. 7. 1. 4 Obstruction to Discharge. Automatic sprinklers shall not be obstructed by auxiliary devices, piping, insulation, and so forth, from detecting fire or from proper distribution of water. 2010 NFPA 13: 8. 5. 5. 1* Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8. 5. 5. 2 and 8. 5. 5. 3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A. 8. 5. 5. 1. ) 2010 NFPA 13: 8. 5. 5. 2. 2 Sprinklers shall be positioned in accordance with the minimum distances and special requirements of Section 8. 6 through Section 8. 12 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures. 2010 NFPA 13: 8. 6. 1 General. All requirements of Section 8. 5 shall apply to standard pendent and upright spray sprinklers except as modified in Section 8. 6. 2010 NFPA 13: 8. 6. 5. 1. 1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8. 6. 5. 2 and 8. 6. 5. 3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. 2010 NFPA 13: 8. 6. 5. 1. 2* Sprinklers shall be arranged to comply with one of the following arrangements: (1) Subsection 8. 5. 5. 2, Table 8. 6. 5. 1. 2, and Figure 8. 6. 5. 1. 2(a). 2011 NFPA 25: 4. 3. 1* Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. 2011 NFPA 25: 4. 4* Inspection. System components shall be inspected at intervals specified in the appropriate chapters. 2011 NFPA 25: 5. 1. 1. 2 Table 5. 1. 1. 2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. 2011 NFPA 25: 5. 1. 2 Valves and Connections. Valves and fire department connections shall be inspected, tested , and maintained in accordance with Chapter 13. 2011 NFPA 25: 5. 2. 1. 1* Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25: 5. 2. 1. 1. 1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). 2011 NFPA 25: 5. 2. 1. 1. 2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (6) Painting unless painted by the sprinkler manufacturer 2011 NFPA 25: 10. 3. 7. 1 Main Drain Tests. 2011 NFPA 25: 10. 3. 7. 1. 2 Static and residual water pressures shall be recorded respectively before, during, and after the operation of the fully opened drain valve. 2011 NFPA 25: 13. 4. 2 Check Valves. 2011 NFPA 25: 13. 4. 2. 1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. Based on observation and staff interview the facility did not ensure that sprinklers were maintained and tested in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems and NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Specifically, sprinkler heads noted to be in close proximity to light fixtures, dusted and corroded; and sprinkler system inspection records did not contain evidence that sprinkler system components were tested at required time intervals and contain all required information. This was observed for the sprinkler system serving the whole facility. The findings are: On (MONTH) 23, 2024, between 9:40 AM - 3:30 PM, during the Life Safety Code recertification survey, the following was observed in the presence of the Director of Building Services: -A light fixture observed installed approximately 2 inches close to the sprinkler head in the residents' donation clothes storage room on the second floor. This arrangement will block the sprinkler's discharge and its proper distribution of water. - A light fixture observed installed approximately 1 inch close to the sprinkler head in the dietary office closet on the second floor. This arrangement will block the sprinkler's discharge and its proper distribution of water. -The sprinkler head inside the walk in refrigerator in the kitchen observed with heavy dust accumulation. - The sprinkler head inside the walk in refrigerator by mechanical room in the basement was observed with signs of corrosion. On (MONTH) 24, 2025, at approximately 11:14 AM, document review of the sprinkler system inspection records did not include the check valve inspection. A vendor invoice dated 10/17/2023 with work description: Performed 5-year Internal Inspection of Internal Piping, did not specify if the required 5 year check valve inspection was performed at the same time. A report named :Automatic Sprinkler Systems - Inspection, Testing, and Maintenance of Wet Pipe Sprinkler Systems, dated 10/10/2023, specifies: This report covers Five year. Five Year: -Obstruction inspection - no foreign or obstructing material found - check mark on Yes. -Check Valve - Internal moves freely, in good condition. No check mark. On (MONTH) 24, 2025, at approximately 11:30 AM, document review of the last sprinkler system inspection report provided for review and dated 10/03/24, under section Devices - Drain did not record the value of the supply and residual water pressure. On (MONTH) 24, 2025, at approximately 11:45 AM, the Director of Building Services stated that they will contact the company that performed the sprinkler system inspection and ask for the 5-yr check valve inspection and the last Sprinkler System inspection report for the inspection completed on 01/22/ 25. No other document was provided for review by the end of the survey. 2012 NFPA 101 2010 NFPA 13 2011 NFPA 25 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedMarch 3, 2025 I. All sprinklers were audited to ensure proper location and free of dust to ensure proper distribution of water from the sprinkler head, no other issues were found. The light fixtures identified during survey for being to close to the sprinkler heads have been relocated allowing for proper distribution of water. Sprinkler company was called on (MONTH) 24th to schedule onsite tech to relocate the sprinkler head in the donation storage room, the dietary office. Sprinkler heads for the walk-in refrigerator has been ordered and will be replaced by 3/7/ 25. II. Sprinkler company was called on (MONTH) 24th to review and update the most recent 5-year sprinkler system inspection to ensure completed information this including the check valves and all boxes are checked off properly. Documents were received on 2/28/ 25. Sprinkler company has also supplied paper work showing that the supply and residual water pressure was completed. III. Anyone has the potential to be affected. IV. The maintenance department has been educated on LSC K-353 NFPA 101 Sprinkler System Maintenance and Testing by Director of Maintenance V. Facility has developed an audit tool to ensure sprinkler inspections are properly documented and complete. Facility has developed an audit tool to ensure sprinkler heads are clear of fixtures that would impede the proper distribution of water, dusted and corrosion free. Audits will be completed by the Director of Maintenance after each inspection. Audits will be conducted on sprinkler heads monthly for 3 months. All finds to be reported to QAPI. VI. Responsible party: Director of Maintenance/Designee. |