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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that the Minimum Data Set 3. 0 (MDS) assessment accurately reflected a resident's status. This was evident for 2 (Resident #237 and #436) of 38 total sampled residents. Specifically, the Minimum Data Set 3. 0 assessment for Resident #237 did not accurately reflect the resident's preferred activities and the Minimum Data Set 3. 0 assessment for Resident #436 did not accurately reflect the resident use of wander guard as alarm. The findings are: The facility policy titled MDS (Minimum Data Set) Guidelines for Completion with undated effective or revised date documented it is the policy of all Allure Facilities to ensure accurate and timely completion of Minimum Data Set for all residents in accordance with Federal and State Operation Manuel. 1) Resident #237 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment dated [DATE] documented Resident #237 was moderately cognitive impairment. The Minimum Data Set assessment also documented it was not very important for Resident # 237 to keep up with the news and to do their favorite activities. It also documented only Resident #237's representative participated in the assessment. The Comprehensive Care Plan related to recreation and leisure preferences initiated 7/29/2023 and last reviewed 9/10/2024 documented one of the goals was Resident #237 will pursue independent activities of their choice. The assessment titled Activities Evaluation dated 3/11/2024 documented it was very important for Resident #237 to keep up with the news and do their favorite activities. On 12/19/2024 at 10:44 AM, the Activities Director was interviewed and stated they did the activity assessment for Resident #237 in Minimum Data Set assessment and Activities Evaluation dated 3/11/ 2024. The Activities Director also stated it was very important for Resident #237 to keep up with the news and do their favorite activities. The Activities Director stated they were busy and coded by error as not very important for Resident #237 to keep up with news and to do their favorite activities for the activity preference in the Minimum Data Set assessment dated ,[DATE]/ 2024. 2) Resident #436 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented Resident #436 was moderately cognitive impairment and had no wandering behavior. The Minimum Data Set assessment also documented no alarms or restraint was used. The Minimum Data Set assessment further documented Resident #436 and representative did not participate in the assessment. Physician ordered wander guard to be placed to Resident #436's right wrist every shift with starting date on 12/1/2024 and the order was discontinued on 12/12/ 2024. The Comprehensive Care Plan related to elopement risk/wanderer initiated 12/1/2024 and last updated 12/12/2024 documented Resident # 436 had a wander alert at place. The Nursing Notes from 12/2/2024 to 12/11/2024 documented Resident #436 had wander guard placed at right wrist. On 12/19/2024 at 10:24AM, Registered Nurse #2 was interviewed and stated Resident #436 wandered around and tried to leave the facility when they were newly admitted to the facility on ,[DATE]/ 2024. Registered Nurse #2 also stated they put on a wander guard for Resident # 436 for safety on 12/1/2024 after obtaining the physician order [REDACTED].#2 stated Resident #436 did not like to have the wander guard on and tried to remove it. Registered Nurse #2 also stated they transferred Resident #436 to the secure unit at Unit 3W and removed the wander guard on 12/11/ 2024. On 12/19/2024 at 11:05AM, the Minimum Data Set Assessor was interviewed and stated they interviewed residents and staff, made observations, and reviewed medical record to collect data for Minimum Data Set assessments. The Minimum Data Set Assessor also stated they completed section P - Restraints and Alarms for Resident #436 in Admission Minimum Data Set assessment dated ,[DATE]/ 2024. The Minimum Data Set Assessor stated they did not recall if Resident #436 had a wander guard in place when the Minimum Data Set assessment was conducted. The Minimum Data Set Assessor reviewed the medical record and stated Resident #436 did have wander guard in place when they did the Minimum Data Set assessment. The Minimum Data Set Assessor also stated it was an error not to code wander guard as alarm in section P of the assessment. On 12/19/2024 at 11:13AM, the Minimum Data Set Coordinator was interviewed and stated they did not review the accuracy of the Minimum Data Set assessment. The Minimum Data Set Coordinator also stated their responsibility was to make sure the Minimum Data Set assessments were completed and submitted to Centers for Medicare & Medicaid Services in a timely manner. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F641 The MDS assessments for resident #237 were modified, and television was immediately provided to the resident. Resident #237 was re-interviewed, and the activity preference was updated to reflect the current choices. The Care Plan was updated and implemented. Activity staff will continue to monitor for changes in preference. On 12/19/2024, the MDS for resident #436 had not been locked for submission; therefore, no MDS modification was required. The MDS was reviewed and locked on 12/19/2024 and cued for submission, which was still within the allowable time frame. MDS Nurse was re-in-serviced to properly assess and review records to accurately reflect resident needs in MDS. Element 2 Residents at Risk: This practice could affect all residents. A full audit was conducted on all active MDS assessments within the last 90 days to identify any additional inaccuracies. No other issues were identified. Element 3 Systemic changes: The Policy and Procedures for MDS Guideline for Completion were reviewed, and no revisions were required. All RN Assessors were re-in-serviced on the Policy and Procedure MDS Guidelines for Completion, emphasizing that MDS accurately reflects the residents' current status with emphasis on Section P. Activities director/designees will cross-check Section F for MDS accuracy. Training includes proper data collection, resident interviews, and validation of information before transmission. The Activity Director will audit for accuracy every week to ensure the accuracy and consistency of the resident's preferences. Staff will complete the activity form on all comprehensive assessments, initiate and implement the care plan, and complete MDS. Activity will complete activity preference form on all comprehensive assessments and as needed if residents' preferences change. An audit tool was developed to monitor compliance Element 4 Monitoring of Corrective Action: To ensure ongoing accuracy, the MDS Coordinator/RN assessors and Activities Director will conduct random audits of 10% of completed MDS assessments weekly for 3 months. The audit results will be reported to the Administrator and Director of Nursing for compliance. Audit results will be reviewed in quarterly QAPI meetings for one quarter. If any trends of inaccuracy are noted, additional interventions will be implemented. QAPI Committee will determine if any further action is required. Element 5 Completion Date: February 12, 2025 Responsible Persons: MDS Coordinator, RN Assessors, Activities Director. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 3 (Residents #219, #237, and #436) of 4 residents reviewed for Activities out of 38 sampled residents. Specifically, Residents #219, #237, and #436 were not provided with activities that met their preferences and interests. The findings are: The facility policy titled Activity Planning with undated effective or revised date documented the Activity Leader records the recreational interests and needs of each resident on the form for that purpose upon admission. It also documented Activity Director plans a varied program of activities to meet the needs and stated preferences of each individual residents. The facility policy titled Activities with undated effective or revised date documented it is the policy of the facility to provide an activities program that is appropriate to the needs and interests of each resident that will encourage self-care, resumption of normal activities, maintenance of optimal self functioning and contact with the environment. 1) Resident #219 had [DIAGNOSES REDACTED]. On 12/12/2024 at 10:30 AM, Resident #219 stated they stayed in the room all the time and would like to watch television in the room like when they were back in the community. Resident #219 also stated the television set was removed for maintenance work and was not re-installed back since they moved back to the room for 3 weeks now. Resident #219 further stated they had no activity in the room. There was no television set observed in the room. There was a tablet observed on the bedside table for which Resident #219 stated they did not know how to use it. The Admission Minimum Data Set assessment dated [DATE] documented Resident #219 had no vision/no hearing problems. It also documented it was very important to keep up with the news and to do their favorite activities. It further documented only Resident #219 participated in the assessment. From 12/12/2024 at 10:30 AM to 12/19/24 at 09:10 AM, multiple observations were made of Resident #219 lying in the bed with no ongoing activities in their room. Resident #219 was also observed not being provided or offered alternate activities in their preferred interest. The Comprehensive Care Plan related to recreation and leisure preferences initiated 6/2/2024 and last updated 11/25/2024 documented one of the goals was Resident # 219 will pursue independent activities of their choice and will be provided their preferred activities. The assessment titled Activities Evaluation dated 5/21/2024 documented it was very important for Resident #219 to keep up with the news and do their favorite activities. The Census list documented Resident #219 moved from room [ROOM NUMBER]-B to room [ROOM NUMBER]-A on 12/3/ 2024. The Census list also documented Resident #219 moved back from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B on 12/5/ 2024. There was no documented evidence that a resident centered activity program that incorporated Resident #219's interests which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented after 12/5/ 2024. On 12/19/2024 at 09:13 AM, Certified Nursing Assistant #3 was interviewed and stated Resident #219 was cognitively intact, did not refuse care, and stayed in the bed most of time. Certified Nursing Assistant #3 stated Resident #219 had a television in the room before the maintenance department did the work in the room like 2 weeks ago. Certified Nursing Assistant #3 further stated the maintenance department had not installed the television back yet, since Resident #219 moved back to their original room in 406-B. Certified Nursing Assistant #3 stated Resident #219 had no activity in the room. Certified Nursing Assistant #3 also stated, they told recreational staff about no television in Resident #219's room and nothing was done so far. Certified Nursing Assistant #219 further stated, Resident # 219 liked to watch television in their room. On 12/19/2024 at 09:23 AM Activity Leader #1 was interviewed and stated they interviewed the residents and/or their representatives for their preferred activities. Activity Leader #1 also stated Resident #219 liked to watch TV in their room. Activity Leader #1 stated they were aware there was no television in Resident #219's room after the maintenance work was done in the room. Activity Leader #1 also stated they notified the maintenance department to install a television for Resident #219 after Resident #219 moved back to their room on 12/5/ 2024. Activity Leader #1 further stated nothing was done yet. 2) Resident #237 had [DIAGNOSES REDACTED]. On 12/12/2024 at 11:22 AM, Resident #237 was interviewed and stated they stayed in the room most of time, had no activities in the room, and wanted to be able to watch television in the room as before. Resident #237 also stated the staff moved the television set from their room for a while and did not install another one since then. There was no television set observed in the room. There was a tablet observed on the bedside table for which Resident # 237 stated they did not know how to use it. The Annual Minimum Data Set assessment dated [DATE] documented Resident # 237 had no problem in vision and hearing, was moderately cognitive impairment, and was not very important to keep up with the news and to do their favorite activities. It also documented only Resident # 237's representative participated in the assessment. From 12/12/2024 at 11:22 AM to 12/19/24 at 09:03 AM, multiple observations were made of Resident #237 lying in the bed or walking around by their bed with no ongoing activities in their room. Resident #237 was also observed not being provided or offered alternate activities in their preferred interest. The Comprehensive Care Plan related to recreation and leisure preferences initiated 7/29/2023 and last reviewed 9/10/2024 documented one of the goals was Resident # 237 will pursue independent activities of their choice. The assessment titled Activities Evaluation dated 3/11/2024 documented it was very important for Resident # 237 to keep up with the news and do their favorite activities. The Census list documented Resident # 237 stayed in room [ROOM NUMBER]-B since 8/21/ 2023. There was no documented evidence that a resident centered activity program that incorporated Resident #237's interests which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented after the television set was removed from the room with unknown date. On 12/19/2024 at 09:51 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #237 was alert and able make needs known, stayed in the room most of time, and had no activities in the room. Certified Nursing Assistant #2 also stated there was a tablet in the room for Resident # 237 to listen to music. Certified Nursing Assistant #2 further stated Resident # 237 did not know how to use the tablet. Certified Nursing Assistant #2 stated there was a television set in the room before and did not recall how long ago the television set was removed by the maintenance staff. Certified Nursing Assistant #2 also stated Resident # 237 sat at the bed most of time and had no activities in the room. On 12/19/2024 at 10:08 AM, Recreation Aide was interviewed and stated they interviewed Resident #237 for their preferred activities. Recreation Aide also stated Resident #237 liked to watch television in the room. Recreation Aide stated they provided a tablet to Resident #237 to listen to music and watch videos online. Recreation Aide also stated Resident #237 did not kn | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F679 Corrective Actions for Residents Identified: Interest and activity preferences of residents #219, #237, and #436 were reviewed. Televisions were immediately installed inside the rooms of the identified residents. Care Plans were updated, reflecting changes in interests or abilities. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The activities department audited to ensure all resident assessments and activities of choice were accurately provided based on their documented interest and needs. There were no more issues identified. Audit tool was developed to monitor compliance. Element 3 Systemic Changes: Policies and Procedures Regarding Resident Preferences and Activity Planning were reviewed; no revisions were required. Activity staff is being trained on the importance of individualized activities and how to incorporate them into daily care. Education will be provided on creative engagement techniques for residents with dementia or sensory impairments. In-service on effective communication between activity staff, CNA, LPNs and RN's , Social Service, and Rehab to ensure seamless integration of activities into daily routines. Tools such as Questionnaires and resident Council Meetings will gather feedback and suggestions, which will be used to refine the activity program continuously. Any outstanding findings will be immediately corrected and reported to the administrator. Element 4 Monitoring of Corrective actions: The Activities Director will conduct weekly checks for 90 days and monitor residents' participation and satisfaction with activities. Five to seven residents will be randomly selected to ensure that provided programs support their choice of activities. On a monthly basis, the Activities director will submit findings to the administrator. The Activity Director will report findings to the QAPI Committee quarterly for 3 quarters. QAPI Committee will determine if further action is required. Element 5 Date of completion: (MONTH) 12, 2025 Person Responsible: Activity Director. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details Based on observations and staff interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards of food service safety. Specifically, 1) staff was observed not wearing beard guard on multiple occasions or hair restraints appropriately in the kitchen. 2) the dry storage room was observed with an open box of beverage and food thickener was observed opened on two occasions and was noted with a paper cup in the open box while on the shelf. This was observed during the Kitchen facility task. The findings are: The facility's dietary policy and procedure titled Food Preparation and Handling revised 12/16/2024 documented all food will be prepared and handled using safe and sanitary methods. All staff will avoid bare hand contact with ready to eat food, as well as wear single use gloves and use serving utensils. This policy does not mention any uniform requirements in relation to food handling. The facility's dietary policy and procedure titled Sanitation Inspection and Checklist revised 12/16/2024 documented a basic sanitation inspection is completed at least monthly and a quarterly food safety and sanitation audit is conducted in the kitchen. The Food Service Director or designee will complete the Basic Sanitation inspection at least monthly. The Food Service Director or designee will complete the Food Safety and Sanitation Audit at least quarterly. All items not meeting standards will be followed up on, including in-service of staff as warranted. On 12/12/2024 from 9:21 AM to 10:10 AM, the initial observation of the kitchen was conducted with the Food Service Director. It was observed that the Food Service Director was not wearing a hair net when giving the surveyor the initial tour of the kitchen. It was observed that the Contracted Pest Control person onsite in the kitchen wearing a hat with no beard restraint with a noticeable beard as they went about their job. The Pest Control person left before they could be interviewed by the surveyor. On 12/12/2024 at 10:34 AM, Dietary Aide #4 was observed in the kitchen without a beard net. Dietary Aide # 10 was observed dropping off carts into the kitchen. During an interview on 12/12/2024 at 10:35 AM, Dietary Aide #10 stated that they have to take the beard net off when they are outside and they have to put it back on when they get in the kitchen and they were delivering carts from the unit to the kitchen, On 12/16/2024 at 04:29 PM to 04:42 PM, Dietary Aide # 2 was observed on the dinner tray line without a beard net scooping lentil soup with a ladle into cups and scooping gravy with a ladle onto mashed potatoes on a resident tray. Dietary Aide # 3 was observed getting an open pan of cheese pizza slices and placing it on the line and they were not wearing a beard net and had a noticeable beard and mustache present. During an interview on 12/16/2024 at 04:44 PM, Dietary Aide # 2 stated, that they took off their beard net when they stepped out of the kitchen to use the bathroom and they forgot to put it back on. They did not wear a beard net also because it hurts their ears, and they did not notice it was off. They should wear the beard net because hair can fall into the food. During an interview on 12/16/2024 at 04:45 PM, Dietary Aide #3 stated, they have a full beard, and they should wear a beard guard and anything can fall off their beard and into the residents food. On 12/17/2024 at 10:27 AM-10:36 AM, Dietary Aide # 4 was observed taking out the trash and then bringing back the empty can into the kitchen. They were wearing a beard net that was covering their chin but that had a visible mustache. During an interview on 12/17/2024 at 10:32 AM, Dietary Aide # 4, stated they should wear a beard net before they get in the kitchen, and they are available at the front door to the kitchen. They should wear it so no hair gets in the food. On 12/17/2024 at 11:39 AM, Dietary Aide #5 was observed without a beard guard walking through the kitchen with a visible beard present. During an interview on 12/17/2024 at 11:40 AM, Dietary Aide #5, stated they forgot to grab a beard net on the way into the kitchen. They should wear a beard net to protect hair from falling anywhere. During an interview on 12/19/2024 at 12:53 PM, the Dietary Supervisor, stated that staff should wear hair net, apron, beard guards as part of standard precautions when they are in the kitchen and especially when they are on the tray line. During an interview on 12/19/2024 at 01:00 PM, the Director of Food Services, stated staff should wear the following equipment in the kitchen gloves, aprons, bear nets, hair nets and mask if they have not gotten their flu shot. Hair nets and beard nets should be worn because hair can fall in food and the elderly immune systems are weak. Staff can get hair net and beard guard when they are coming in from the door. They did not notice that they were not wearing a hair net. During an interview on 12/19/2024 at 01:17 PM, the Assistant Director of Nursing/Infection Preventionist stated, they do weekly rounds of the kitchen, and they observe for cleanliness and if staff are wearing beard guards, hair nets and that food items are not left open or uncovered. 2. On 12/12/2024 at 09:55 AM, the dry storage room was observed. An open 25 pound box of instant food beverage thickening powder in a torn plastic bag was resting on the bottom shelf to the left wall of the door entrance. The box was labeled with order # 49 and dated 8/5/2024 by the food service vendor. There was visible dust on the shelf above the box. On 12/17/2024 at 11:10 AM, the dry storage room was observed again and the 25 pound box of instant food beverage thickening powder resting on the bottom shelf to the left wall of the door entrance with a tear in the plastic bag. There was a paper cup observed in the torn plastic bag in the box. The box was labeled with order # 49 and dated 8/5/2024 by the food service vendor. During an interview on 12/17/2024 at 11:13 AM, Dietary Aide # 4 was interviewed and stated, they look at the dry storage room two times a week and they also look at the expiration dates on the food boxes and look at food boxes that are opened. They do not know who tore the bag for the instant food beverage thickener and it should not be like that. They dust the shelves once a month. If the shelf is clean and the food should be covered so no dust material goes on the food product. During an interview on 12/17/2024 at 11:18 AM, the Director of Food Services stated that they look at the boxes in the dry storage every day and the last time they looked at the boxes was this past Monday. The thickener has to be in a container, and it should not be like that. The opened disposable cup should not be in there and there should be a measuring cup used instead. It should not be in an open box since anything can fall in there and it is ready to eat food and it is supposed to be covered and in a container. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedJanuary 10, 2025 Element 1 F812 Corrective Action: The Staff that were observed not wearing a beard net were immediately educated on wearing appropriate face beard covers inside the kitchen. All vendors will also be educated on the hair and beard coverings procedure. The open thickener box was removed, and the product was disposed of properly. A complete inspection of all dry storage areas was conducted to identify and remove any other improperly stored items. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All Dietary Staff were monitored to ensure compliance with beard and hair net coverings were in place. All dry storage areas were inspected to identify and remove any other improperly stored items. There were no issues that were identified. Element 3 Systemic Changes: Personal hygiene and protective equipment policies were reviewed to reflect strict enforcement of beard and hair nets. All dietary staff received mandatory in-service training on proper food safety protocols, including wearing hair and beard nets. Policies on food and dry storage were reviewed to ensure they included all food and beverages in dry storage that are labeled, and in approved containers. No revisions were required. Staff received training on proper storage requirements and food safety protocols. Audit tools are being developed to monitor compliance. Element 4 Monitoring of Corrective Action: Food Service Director will conduct daily spot checks to ensure compliance with personal protective equipment requirements. Non compliance will be documented and addressed with immediate corrective action. The Food Service director or designee will conduct daily inspections of storage area to ensure compliance with food safety protocols. Non compliance will result in retraining and possible disciplinary action. Monthly audits of kitchen and storage areas will be conducted, and results will be reviewed monthly with the administrator or a period of 6 months. On a quarterly basis the results will be presented by the Food Service director to the QAPI committee. The QAPI Committee will decide if further action is required. Element 5 Completion date: (MONTH) 19, 2025 Person responsible : Food Service Director and Food Service Supervisor. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 12/13/2024 to 12/19/2024, the facility did not ensure residents received adequate supervision to prevent accidents. This was evident for 1 (Resident #24) of 4 residents reviewed for accidents out of 38 total sampled residents. Specifically, Resident #24, who is cognitively impaired with agitated behaviors, sustained a laceration on right 3rd, 4th and 5th metatarsal resulting in a minimally displaced extra articular [MEDICAL CONDITION] third and 4th proximal phalanges. The findings are: The facility's policy and procedure titled Accident and Incident Report dated 07/2024, documented that As soon as possible, but no later than 24 hours post occurrence, complete the Accident/Incident Report. Fill in all spaces on the form, giving an exact description of the circumstances surrounding the accident or incident; Interview staff assigned to the care of the resident, and/or all staff assigned to the nursing unit on which resident resides; The Administrator, after discussion with the Director of Nursing, will reach a final decision if the accident is reportable to the Department of Health. Resident #24 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented resident's cognition as severely impaired, Brief Interview of Mental Status(BIMS) of 1, no behavioral symptoms, independent with bed mobility, supervision for eating, toilet use and transfers. The Minimum Data Set also documented Resident #24 is frequently incontinent of urine and always incontinent of bowel, no pain, takes an antipsychotic and an antianxiety medication and no alarm used. The Quarterly Minimum (MDS) data set [DATE] documented resident's cognition as severely impaired, BIMS1, physical behavioral symptoms, behavior of this type occurred 1 - days, independent with bed mobility, supervision for eating, toilet use and transfers. The Minimum Data Set also documented Resident #24 is frequently incontinent of urine and bowel, no pain, takes an antipsychotic, and no alarm used. The Comprehensive Care Plan focus created 10/30/22, last revised 08/2124, documented Resident #24 is placed on secured unit due to Psychological and Behavioral problems. Goals include avoid injury to staff or visitors, and to redirect residents' behavior so no staff, resident or visitor is injured, and that Resident/representative will be satisfied with placement on secured unit, review date 2/19/ 24. Target date 03/24/ 25. Interventions include to review resident's behavioral symptoms periodically to evaluate continued benefit of remaining on a secured unit and monitor resident for any changes in mood and behavior and report to Medical Doctor/Nursing. The Comprehensive Care Plan focus created 5/19/23 documented Resident #24 has a potential to be physically aggressive, last revised 09/19/2124, grabbing and reaching for others, related to Dementia, poor impulse control. Goals include Resident #24 will not harm self or others through the review date, 9/19/ 24. Interventions include communication to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. The Comprehensive Care Plan focus created on 09/18/24, documented Resident#24 has an alteration in musculoskeletal status related to a fracture of proximal phalanx of right lesser toe. Goals include will remain free of pain or at a level of discomfort acceptable through the review date, 11/10/ 24. Interventions include give [MEDICATION NAME] as ordered by Physician. monitor and document for side effects and effectiveness. A Nurse's Note dated 9/14/24 documented resident was very aggressive and combative during this tour towards residents and staff. All medication was administered. The resident was redirected several times, and s was made aware of behavior. The resident is now lying in bed after several hours of noncompliance. A Nurse's Note dated 9/15/24 documented Staff informed that Resident #24 was bleeding from their right foot. Residen t#24 was found sitting in their room with their right foot on the radiator. Upon assessment, resident noted to have laceration on her 3rd, 4th, and 5th metatarsal. Pressure applied to stop the bleeding immediately. Telehealth called and informed about the same. After assessment, the doctor instructed to send Resident #24 to the hospital for further evaluation. Emergency Medical Services arrived and took resident to the hospital. The facility incident report dated 9/15/2024 documented that Resident #24 was found sitting on a chair with their right foot on the radiator in the resident's room. Resident found to have laceration on the 3rd, 4th, and 5th metatarsal. The incident report documented in Part B section of the investigation, that resident assessed for bleeding, observed in the room with their right foot elevated on the radiator, and that Resident #24 unable to state what happened. Radiator was checked for sharp edges and was reported to maintenance. Resident transferred to the emergency room for further evaluation. Resident #24 returned with a [DIAGNOSES REDACTED]. foot closed. A review of the hospital's discharge summary dated 9/16/24, revealed that Resident #24 was evaluated for wound to right foot. The discharge summary documented that evaluation of patient with laceration to plantar aspect, X-Ray consistent with fracture. A [DIAGNOSES REDACTED]. Interventions documented included orthopedic surgery, laceration repair done by them, outpatient follow up. A Nurse's Note dated 9/17/24 documented post hospital visit: Resident seen this am with dressing to right foot. On Assessment, it was observed that Resident #24 had a small laceration under the 4th toe, no other laceration noted, no bleeding noted, dressing left dry and intact. It was reported via ER visit that resident sustained [REDACTED].#24 has a follow up appointment on 9/24/ 2024. An Orthopedic surgery clinic note dated 09/24/24 documented wound was washed out and closed by Orthopedics in the emergency department on 09/16/ 24. Physical exam included right lower extremity, sutures c/d/l, no wound dehiscence with 3cm laceration at plantar aspect of 4th toe proximal phalanx, no tendon visualized, 1. 5cm laceration at plantar aspect of 3rd toe proximal phalanx, , no tendon visualized, 0. 5cm superficial abrasion to plantar aspect of 2nd toe proximal phalanx. No purulent from either wound, no gross contamination. Documented X-ray of right toes, foot, ankle, fracture of 3rd and 4th toe proximal phalanx, presence of calcaneus ORIF. X-ray of right. toes, foot, ankle: fracture of 3rd and 4th toe proximal phalanx, presence of previous calcaneus ORIF hardware. Record review and staff interviews did not reveal that the accident dated 9/15/24 was reported to the New York State Department of Health. On 12/19/24 at 12:32 PM, Registered Nurse #1 was interviewed and stated that they were the Supervisor for that unit, the day the incident occurred in the afternoon, around 3:15PM. Registered Nurse #1 stated that the Staff on the unit called them to assess Resident #24 who was bleeding from a cut on Resident's #24 toes, on the plantar of the right foot. Registered Nurse #1 observed that the resident had their foot on top of the radiator and there was some bleeding observed, and that they, (Registered Nurse #1) saw that the radiator had some sharp edges. Registered Nurse #1 stated that Resident #24 was barefooted at the time and that the Resident #24 was unable to state what happened. Registered Nurse #1 also stated that they did not see any blood on the radiator and that they could not tell exactly how Resident #24's foot could get on top of the radiator. Registe | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F689 Corrective action for Resident Identified: Nursing conducted an immediate assessment of resident #24 to address their safety and supervision needs. Care plan for resident # 24 was updated to ensure safety and proper monitoring. A review of the resident's environment was conducted to ensure any necessary devices are in proper working order and available for use. Individualized interventions such as increased supervision i.e. spending more time supervised in the activities/dayroom to mitigate risks were implemented. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The facility conducted a environmental assessment for all residents to identify potential hazards and supervision needs. Results of this assessment were reviewed by the Administrator, DNS and ADNS. No other residents were found to be affected by this practice. Audit Tool was developed to monitor compliance. Element 3 Systemic Changes: The facility policy and procedure titled Accident and Incident Report was reviewed and no revision were required. Staff Education and training: The Risk Manager/ADNS will provide training to appropriate staff ( CNA, LPN, RN, maintenance, housekeeping, and social services and rehab on accident prevention, hazard identification, and the proper use of assistive devices. The training will emphasize the importance of timely reporting and addressing potential hazards. Routine Preventative room rounds conducted by all nursing staff are being implemented to ensure that resident's whose preference to remain in room receive adequate supervision to prevent any further occurrences. Element 4 Monitoring of Corrective Action On a weekly basis for one quarter the DNS, ADNS, and Medical Director will audit incident reports weekly to identify trends and ensure follow up action is completed. Monthly audits of care plans, supervision and environmental safety measures will also be monitored. The Maintenance director will conduct weekly routine environmental audits for 3 months to identify and eliminate physical hazards. On a monthly basis for 3 months the results of the audits will be reported to the administrator, any negative findings will be addressed immediately. The results of the audit will be presented to the QAPI Committee for 3 quarter's for monitoring and compliance. QAPI committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12,2025 Responsible Persons: Director of Nursing, ADNS and Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
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: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) Certified Nursing Assistant (CNA) #8 was assisting multiple residents to perform hand hygiene in the dining room and did not clean their hands in between residents (2) Licensed Practical Nurse #3 who was observed performing wound care did not ensure infection control practices were maintained during a dressing change. This was evident during Dining Observation and Infection Control tasks. The findings are: The facility policy and procedure titled Hand washing reviewed (MONTH) 2024 documented hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Employees must wash their hand for twenty to thirty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with residents, after handling potentially contaminated with blood, body fluids or secretions, after removing gloves. In most situations the preferred method o f and hygiene is with alcohol-based hand rub, if hands are not visibly soiled used alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all of the following situation before and after direct contact with residents, before after contact wait a resident intact skin., after contact with objects in the immediate vicinity of the resident and after removing gloves. Hand hygiene is always the final step after removing and disposing of persona protective equipment, The use of gloves does not replace hand washing/hand hygiene. 1. On 12/12/2024 at 11:36 AM to 11:49 AM, the 2nd Floor dining area opposite the elevators was observed. Certified Nursing Assistant # 5 was observed assisting to get residents ready for the lunch meal by handing out hand wipes with their bare hands to the residents. Residents placed the used hand wipes into a plastic bag held by Certified Nursing Assistant # 5. Certified Nursing Assistant #5 took a used piece of paper from Resident #271 and assisted them to clean their hands with a hand wipe which was then placed in a plastic bag. Certified Nursing Assistant #5 then gave Resident #35 a hand wipe with their bare hands which after being used was placed in a plastic bag. No hand hygiene was observed between residents. Certified Nursing Assistant #5 assisted a resident to lock their wheelchair at the dining table with their bare hands. Certified Nursing Assistant #5 proceeded to give the resident in the wheelchair a hand wipe with their bare hands to wipe their hands. Certified Nursing Assistant #5 then donned gloves and assisted the resident to clean their hands. Certified Nursing Assistant #5 discarded the used hand wipe. Certified Nursing Assistant #5 then assisted another resident to adjust the paper clothing protector. a Then Certified Nursing Assistant #5 removed their gloves and washed their hands at the sink in the dining room. During an interview on 12/17/2024 at 02:35 PM, Certified Nursing Assistant #5 stated that they did not notice that they did not wash their hands during dining. For infection control they should wash their hands in-between residents. Bacteria can be on your hands, and it can transfer to other residents. 2. Resident # 94 was admitted to the facility with [DIAGNOSES REDACTED]. The facility's policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, updated 07/2024, documented that the Physician will authorize orders related to wound treatments, including dressings and applications of topical agents. The facility's policy titled, Enhanced Barrier Precautions, last revised 03/25/24, documented that Enhanced Barrier Precautions, refers to an infection control intervention designed to reduce transmission of multi drug resistant organisms that employ targeted gown and gloves use during high contact resident care activities. The policy further stated that Enhanced Barrier Precautions are indicated for residents including those with wounds, even if the resident is not known to be infected or colonized with multidrug- resistant organisms. The Annual Minimum (MDS) data set [DATE], documented Resident #94's cognition as severely impaired, resident has a pressure ulcer/injury, is at risk of developing pressure ulcers/injuries, has a Stage 4 pressure ulcer that was present upon admission/entry or reentry and uses pressure reducing device for chair, bed. The physician's orders [REDACTED]. 2. 2x 1. 2cm for 30 days. The physician's orders [REDACTED]. On 12/17/24 at 10:52 AM, Licensed Practical Nurse #3 was observed for wound care to the sacrum, for Resident # 94. Licensed Practical Nurse #3 entered Resident #94's room, placed some supplies on the resident's mattress, and washed their hands, and put on a pair of gloves. Licensed Practical Nurse #3 then pulled down Resident #94's trousers, took a drape from the supplies on the bed, and place it under Resident #94's buttocks as they positioned Resident #94 on their side. Licensed Practical Nurse #3 tore open some gauze packets and cleaned the wound and placed the dirty gauze on the bed next to the other supplies. Licensed Practical Nurse #3 then took off their gloves and placed a clean pair of gloves on. Licensed Practical Nurse #3 then place the Santyl ointment (treatment for [REDACTED].#94's incontinent briefs and pulled back up Resident #94's trousers. Licensed Practical Nurse #3 then gathered all the discarded garbage in their hands and threw them in a garbage. Licensed Practical Nurse#3 then took off their gloves and washed their hands. At no time was Licensed Practical Nurse #3 wearing a gown. On 12/17/24 at 11:00 AM, immediately after the wound care observation, Licensed Practical Nurse #3 was interviewed and stated that they forgot to wash their hands between glove changes and that they knew that after each glove change, they were taught to wash their hands. Licensed Practical Nurse #3 stated that they were in-serviced on Enhanced Barrier Precautions and that they were supposed to use a gown when they were doing the treatment. On 12/17/24 at 11:30 AM, the Wound Care Coordinator was interviewed and stated, that their role is to do weekly rounds with the wound care provider and do initial assessments on the residents. The Wound Care Coordinator also stated that they do training for the other nurses who are trained on the proper techniques for wound care, including being taught to wash their hands between glove changes. On 12/18/24 at 02:53 PM, the Registered Nurse Manager #4 assigned to Unit 4East was interviewed and stated, that they usually do in-services for the Staff on the units, and that all Staff were educated on Enhanced Barrier Precautions. The Registered Nurse Manager #4 also stated that they observe the wound care nurses who do wound care daily, and that the Registered Nurse Managers do spot checks to ensure compliance on wound care techniques. On 12/18/24 at 04:35 PM, the Director of Nursing was interviewed and stated that all Staff was educated on Enhance Barrier Precautions and that and the Infection Control Preventionist will follow up on ensuring that Infection Control practices are maintained. The Director of Nursing also stated that the Licensed Practical Nurse #3 was educated, and competencies were done on wound care practices when Licensed Practical Nurse | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F880 The CNA's who were observed failing to follow hand hygiene particularly in between resident interactions were in-serviced. Provided on the spot training and counseling to the CNAs regarding proper hand washing. Ensured all hand washing wipes were available in the dining room and other resident care areas. The identified LPN was immediately educated and retrained on proper infection prevention and control protocols, including hand hygiene and the use of personal protective equipment. All residents involved were assessed for any potential risks of infection. No adverse outcomes were identified. Element2 All residents have the potential to be affected by this practice. The Infection Control Practitioner/or designee will monitor all CNA's, LPNs and RNS for adherence to proper infection control practices, proper handwashing an the proper use of personal equipment will be included in this routine monitoring. Immediate corrective action, such as re -education or disciplinary action will be implemented for identified infection control breaches. Training sessions will be documented, and staff will be required to demonstrate competency. Audit Tool was developed to monitor for compliance. Element 3: Systemic changes: On (MONTH) 10, 2025 the Administrator, Medical Director, Director of Nursing and Infection Preventionist reviewed the facility's Infection Control Policy and Procedures for Handwashing between residents and the proper use' of personal protective equipment no revisions were required. Education will be provided to all CNAs, LPN and RNS related to general infection prevention and control practices. Education will emphasize the staff member's responsibility for proper handwashing. Education will continue to be provided to all staff during orientation and annually and on an as needed basis related to general infection prevention and control practices and protocol. In addition to hand hygiene competency upon hire and annually, facility will conduct periodic hand hygiene competencies on handwashing and infection control practices. Element 4 Monitoring of corrective action: The facility will develop an audit tool to monitor compliance with Infection Prevention and Control protocol related to proper hand washing. On a weekly basis for one quarter, DNS/designee, will observe 2-5 direct care staff for proper handwashing technique and proper use of PPE. Any outstanding issue will be addressed immediately. All audit findings will be reported to the Administrator monthly for 3 months. All audit findings will be reported to the QAPI Committee for 1 quarter for evaluation, discussion and follow up, at this time the QAPI Committee will make a determination for the need for ongoing auditing. The Infection Preventionist will continue to report a summary of all infection control activities and audit findings to the QAPI Committee for one quarter. The QAPI Committee will determine is further action is required. Element 5 Persons responsible: Director of Nursing and Infection Preventionist. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the Recertification/Complaint survey (NY 742) conducted between 12/12/2024 and 12/19/2024, the facility did not ensure that all allegations of abuse and injury of unknown origin were thoroughly investigated. Specifically, (1) Injury of unknown origin observed on Resident #251 was not thoroughly investigated and (2). Resident-to-resident altercation involving Residents #214, #268 and #589 was not thoroughly investigated. This was evident for 1 of 3 complaint investigations and for 3 of 3 residents reviewed for Accidents out of 38 total sampled residents. The findings are: The facility policy and procedure titled Abuse Prevention and Reporting with revision date (MONTH) 2024 documented Physical Abuse includes, but not limited to hitting, slapping, punching, biting, and kicking. The policy documented facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown origin source and misappropriation of resident property and report the results of all investigation to proper authorities within specific timeframe. The policy further documented will ensure that all alleged violations are reported immediately, but not later than two hours after the alleged allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury or not later than 24 hours. 1. Resident #251 was admitted to the facility 01/27/2024, with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #251 had severe impairment in cognition, and impairment on both sides of lower and upper extremities. The Minimum Data Set also documented that the resident requires Substantial/maximal assistance/total dependent of staff for most activities of daily living. Minimum Data Set documented that Resident had no behavioral symptoms directed towards others. The Comprehensive Care Plan for Behavior dated 2/21/2024, last updated 8/11/24, documented that Resident #251 has a behavior problem, agitated when redirected by staff, and can be potentially physically aggressive (towards staff) related to unspecified dementia. With goals including Resident will receive redirection with less aggression based on the medication adjustment. Interventions included: - Administer medications as ordered; Monitor/document for side effects and effectiveness; Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. The Comprehensive Care Plan for Fall dated 1/27/24, last updated 11/11/24, documented that Resident #251 is at High risk for falls related to Deconditioning, Gait/balance problems, altered mental status, Dementia, [MEDICAL CONDITION], generalized muscle weakness 2/22/2024 Possible witnessed fall. Goals included: - Resident will be free of falls while in the facility through the review date; Will not sustain serious injury through the review date; will have decreased opportunity for falls and falls related injuries through the review date. Interventions included: - Monitor for changes in cognitive function; Provide reality orientation for periods of increased confusion; Assist with toileting as needed; Needs prompt response to all requests for assistance; Assist with toileting upon awakening, before/after the meals and at bedtime; Frequent monitoring while in bed. Intake Number NY 742 dated 03/01/24 documented that complainant reported that they received a call from the facility that Resident fell on [DATE]; The family visited Resident on 2/25/24 and noted that the right eye was completely closed, and a knot noted on resident's forehead. Complainant reported that they were not receiving a consistent explanation on when the resident was last seen or how resident fell . Complainant stated that the staff are dismissive towards their request for a meeting with the staff. On 12/12/24 at 11:32 AM, Resident #251's family (Complainant) was interviewed and stated that they received the call that resident fell and hit the head, when resident was visited the mark noticed on the resident head and face seemed as if resident got punched in the face; statement by the staff is not consistent, and they refused to play the camera to view resident's movement prior incident. Family stated they requested clarification from the staff to rule out that resident was not attacked or punched by somebody because resident has Alzheimer's behavior and could not state how the injury occurred but there was no positive response received from the facility. On 12/12/24 at 10:02 AM, Resident #251 was observed in bed being fed by a staff, resident is unable to answer any question due to cognition impairment. Progress note Nursing dated 2/19/2024 15:43 documented that Resident slept most of this shift; was woken at intervals for meals; woke at the end of the shift and was seated in the wheelchair in the Day Room. Progress note Nursing -Behavior Note dated 2/21/2024 16:08 documented that Resident was observed alert with confusion, very agitated and difficult to redirect, was constantly going to other residents' rooms. When staff redirected the resident back to the room, he got agitated, and attempted to be physically aggressive. Monitoring ongoing. Progress note Nursing dated 2/22/2024 08:40 documented: Report received that Resident #251 was bleeding from forehead. Upon assessment, resident sustained [REDACTED]. Nurse Practitioner notified and requested to evaluate the resident. There is no documented evidence of how Resident #251 sustained the injury in the resident's chart. Progress note Nursing dated 2/22/2024 10:41 documented that Resident #251 was alert and verbally responsive with period of confusion, left unit at 9:58 am with Emergency Service for Cat Scan due to hematoma on right side of the forehead. Progress note Communication with Rehab dated 2/22/2024 11:200 documented Referral for Occupational, Physical, Speech therapies; Reason for Referral: possible unwitnessed Fall. Progress note Physician dated 2/22/2024 11:38 documented requests to see Resident #251 with swelling on right forehead; seen and examined at the bedside. Physician documented that on 2/22/24, nurse reported that resident has swelling on right forehead 7 cm x 7 cm.; resident could not mention what happened. Assessment: - Unspecified Injury of head; Plan: Will order Cat Scan of head without contrast. Progress note Therapy-Communication with Rehab dated 2/22/2024 15:04 documented Reason for Referral: status [REDACTED]. Resident remarked of discomfort to touch; unable to recount sequence of events leading to fall, however, Resident did state that they fell from the bed. Resident is Alert and oriented x 1 and is an unreliable historian. Nursing staff stated it was an unwitnessed fall noting that Resident was observed with swelling to right forehead this morning. There is no documented evidence in the progress notes by all the interdisciplinary team members that the injury sustained by Resident #251 was known or witnessed by any staff. As per the Facility's Accident/Incident Report reviewed dated 2/22/2024, Certified Nursing Assistant #4's statement documented that they were gathering supplies when they saw Resident #251 walked into room [ROOM NUMBER]; they went to redirect the resident and observed a bump on the resident's head. Resident Incident Report completed by the Shift Supervisor on 2/22/24 documented that Resident was observed at 7:20 am 2/22/2024 with unwitnessed bump on right forehead, the incident was unwitnessed, resident was walking in the hallway and was observed with a bump to the right forehead, resident unable to | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F610 Corrective Actions for Residents Identified: No Further occurrences related to abuse, including injury of unknown origin, resident-to-resident altercation, neglect, and mistreatment, were identified by the ADNS/Risk Manager. All accidents/incidents will be reviewed and reported immediately if they meet the reporting criteria but not later than 2 hours. Abuse care plans are in place for all 3 residents, #251,#214,#268, and #589 (no longer in the facility). Resident #251 is placed in the hallway or the dining room with activities for close observation. Resident #214 is placed in the hallway or in the dining room with activities for close observation. Resident #268 is placed at the nursing station with activities for close observation. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The ADNS and DNS completed an audit tool to review accidents/incidents investigated in the past three months to determine whether an occurrence is abuse, neglect, injury of unknown origin, or mistreatment. This alleged deficient practice has not identified similar findings or adverse effects. Element 3 Systemic Changes: The Administrator, Director of Nursing, Assistant Director of Nursing, and Medical Director will continue to review and revise, as indicated, the policies and procedures related to Abuse Prevention, including timely reporting of all allegations and or observations of abuse to the Administrator and other officials as outlined in the regulations and State Law. The ADNS will in-service staff in all departments on abuse prevention, focusing on initiating an investigation of abuse allegations. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: ADNS (Risk Manager) or designees will review the 24-hour report and all accidents or incidents to ensure there are no allegations that need to be investigated or any occurrences that require investigation for the next 4 weeks. The DNS will audit all AI weekly for four weeks to ensure that outstanding issues and incidents requiring investigation are compliant and have no outstanding issues. DNS will report to the Administrator DNS will report to QAPI for one quarter. QAPI Committee will determine if further action is required. Elemnet5 Completion Date: (MONTH) 12, 2025 Responsible Person: Director of Nursing, Assistant Director of Nursing, and Administrator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. Specifically, 1) Eighteen individual expired [MEDICATION NAME] lock flush syringes were stored on medication room on 2 West and 2 East Units. This was evident for 2 of 6 units (2 West and 2 East) during the Medication Storage Task. The findings are: 1. The facility policy and procedure titled Medication Storage updated 07/2024 documented the facility safety of resident by proper storage of medications. The facility following state and federal regulations as well as recommendations made by a medications manufacturer or supplier. Medications must be removed and disposed of immediately if they are expired. The Medication room inspections for the facility from (MONTH) to (MONTH) 2024 were reviewed and it documented that expired medications were found in subsequent inspections. On 12/16/ at 10:05 AM to 11:22 AM, Licensed Practical Nurse # 4 accompanied the surveyor to the Medication Room on 2 West. The following was observed in a cabinet above the counter and in the container on the counter with intravenous fluids contained a total of 3 [MEDICATION NAME] flushes. There was 2 [MEDICATION NAME] 50 USP unit per 5 ml (10 USP per milliliter) flushes with lot number 7 expiration date 08/01/2024 and 1 [MEDICATION NAME] 50 USP unit per 5 ml (10 USP per milliliter) flushes with lot number flush 2 expiration date 09/01/ 2024. There was 1 bag of 1000 milliliter 5 percent intravenous [MEDICATION NAME] with lot # Y 7 expiration date October 2024. During an interview on 12/16/2024 at 11:22 AM, Licensed Practical Nurse #4 stated that the Medication Room is stocked once a week and the old dates are placed in the back and the newer dates are pulled forward. Housekeeping found a whole set of normal saline and [MEDICATION NAME] flushes while cleaning the cupboard in the medication room and put them together and did not throw the items out. They looked at the intravenous supplies on Friday and looked at the items in the medication room draws. Housekeeping found the [MEDICATION NAME] flushes and we were supposed to go through the medication to see what was still good. If medication expired, they are taken downstairs and they did not notice the intravenous fluid was expired. During an interview on 12/16/2024 at 11:28 AM, Registered Nurse #2 stated they were not sure the last time they looked at the intravenous medication. Usually there are no residents on intravenous fluids. [MEDICATION NAME] flushes used for central line flush every shift to prevent blood clots. The intravenous fluids is expired in October 2024. The [MEDICATION NAME] flushes expired in (MONTH) 2024 and September 2024. We should not have expired items due to resident safety and facility protocol. We barely use [MEDICATION NAME] flushes. During an interview on 12/16/2024 at 11:36 AM, Housekeeper #5 stated the medications were at the bottom of the cupboard in the medication room and they did not want to throw them out, so they left it for nursing to sort them out. They clean the medication room two times a week. There was wood in the cupboard that was blocking getting to where the items were found. Licensed Practical Nurse #4 saw the items present after they finished cleaning. On 12/16/2024 at 11:59 AM to 12:04 PM, Licensed Practical Nurse #11 accompanied the surveyor to the medication room on 2 East. There was 6 individually wrapped [MEDICATION NAME] 50-unit flushes. There were labeled with lot 2 and expiration date of 09/01/2024 in a plastic bag in the middle drawer below the counter. During an interview on 12/16/2024 at 12:06 PM, Licensed Practical Nurse #11 stated that they looked in the medication room cabinets today and stated this in not their normal unit and they float. The flushes should not have any expired items in medication room and expired medication are unsafe. During an interview on 12/16/2024 at 12:10 PM, Registered Nurse #10 stated they check the medication room weekly or at least once a month. The last time they looked at the medication room they were not aware the expired medication was there. The last time they looked at the [MEDICATION NAME] flushes was in April 2024. The [MEDICATION NAME] expired in (MONTH) 2024 and should be discarded for medication safety and resident safety. It should not be used. The effectiveness of the medication is not the same can be altered or more potent or less potent depending on the medication. During an interview on 12/16/2024 at 12:40 PM, Registered Nurse #7 the Unit Manager stated they look at the medication room daily and they looked at the medication flushes and they take turns with the other unit manager. We are not supposed to have expired medication in the medication room and with expired medication don't know the affect and the manufacturer is not responsible for outdated items used. We have a pharmacy that does monthly reviews. During an interview on 12/19/2024 at 11:45 AM, The Consultant Pharmacist was interviewed and stated each month they do the medication room inspections, and any expired or unlabeled medication are documented in their report. They always email the inspection report, and they are printed right away. The facility should not have expired items on their carts or medication rooms. [MEDICATION NAME] flushes should be discarded past their expiration date. During an interview on 12/19/2024 at 01:14 PM, the Assistant Director of Nursing/Infection Preventionist stated they do rounds daily at least 6 times a day and almost hourly. They look at 2 to 3 medication rooms daily and also look at the medication carts. They have not looked at the flushes on the unit. They have looked at the intravenous fluids last week and whatever is expired should be removed from the unit. There should be no expired medication on the units. If medications are expired there can be something wrong with it and it can cause harm to the resident. 10 NYCRR 415. 18(e)(1-4) | Plan of Correction: ApprovedJanuary 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F 761 Immediate corrective Action: The expired [MEDICATION NAME] was removed from the medication room on 2 West and 2 East and discarded immediately on ,[DATE]/ 2024. The RNs and the medication nurses on duty were in-serviced on medication storage on ,[DATE]/ 2024. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All medication carts and storage rooms were inspected for medications and biologicals beyond their expiration date, and none were found. Element 3 Systemic changes: The facility policy titled Medication Storage was reviewed, and no revisions were needed. All nurses are being in-serviced on Medication Storage policy and procedure. A new process is being implemented for medication storage monitoring to ensure compliance (LPN to check med carts daily; Unit RN to check med rooms daily). An audit tool was developed to monitor for compliance. Element 4 Monitoring of Corrective Changes: On a weekly basis for one quarter, DNS or designee will inspect 2 medication rooms and 2 medication carts, to ensure compliance with medication storage. Any outstanding issues will be addressed immediately. On a monthly basis, DNS or designee, will report findings to Administrator. On a monthly basis, DNS or designee will report findings to QAPI Committee. QAPI Committee to determine if further action is required. Element 5 Monitoring of Corrective Action: Completion Date: (MONTH) 19, 2025 Director of Nursing ADNS/ Designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. This was evident during the environmental observation. Specifically, 1) A live rodent was observe caught in a box trap in the dining room while residents were present. 2) Flies were observed flying on the units during the survey (2 West and 4 West). This was evident for the Environmental task. The findings include: The facility policy titled Pest Control with a revision date of 05/2024 documented that the facility will maintain an effective pest control program that eradicates and controls common household pests and rodents. The facility maintains a written agreement with a qualified outside pest service to provide comprehensive pest control services on a weekly basis and scheduled basis. Ensure use of appropriate chemicals to control pests, use of a variety of methods in controlling certain seasonal pests (indoor and outdoor methods), external perimeter and outlying buildings or structures. The facility meets with the Pest Control technician on a weekly basis before and after the service to communicate any issues with the building that may need additional treatment and to get a verbal report from the technician on the status of pest control within the building. Written reports are reviewed on a weekly basis from the pest control company outlining steps that have been taken and issues that need to be followed up. These issues are reviewed at morning report with the entire team. During environmental observations on 12/12/2024 from 11:46 AM - 03:40 PM the following was noted on Unit 2 West . A black fly was observed flying on the unit by the nurse's station and in the hallway by 2 West -Room # 238. During an observation on 12/13/2024 at 10:54 AM, a black fly was noted flying in room [ROOM NUMBER] on Unit 2 West and at the unit nurse's station. During an observation on 12/17/2024 at 10:16 AM, the atrium was observed and there was a door facing the security desk leading to the outside with stored equipment that included floor buffers, 2 recliners, hose, planting pot, planting shovel. There were noticeable roach droppings on the furniture. The bait traps were observed, and one had a date of 10/31/2024 written on top of the white bait paper box. During an observation on 12/17/2024 at 12:54 PM, a black fly was observed flying on Unit 4 West by the nurse's station. During an interview on 12/17/2024 at 01:09 PM, the Unit Clerk was interviewed and stated the Director of housekeeping deals with traps on the unit. The flies were noticed today on the unit and we are supposed to write a note in pest control book. During an observation on 12/17/2024 at 02:32 PM, a black fly was observed in the hallway on the 2nd floor day room area on Unit 2 West. During an interview on 12/17/2024 at 02:40 PM. Certified Nursing Assistant # 5 stated they may see a rat run on the floor early in the morning randomly in the unit dining room. They see pest control on a monthly basis. Last week they saw a rat running in the dining room at 07:30 AM. There are no resident complaints of roaches and flies. During an observation on 12/18/2024 at 08:16 AM a black fly in the hallway on the 4th floor leading to Unit 4 West. During an interview on 12/18/2024 at 11:16 AM, Resident # 35 stated that they see mice in their room. They are dangerous and they can eat a whole bunch of your body. Some people leave food and tissue paper on the ground and rats eat and they come back for some more food. If mice are here and the kitchen should be full of mice because this is where they have food. During an interview on 12/18/2024 at 11:17 AM, Resident #221 stated that they saw a mouse in their room the night before. During an interview on 12/18/2024 at 02:53 PM, Maintenance Worker #2 stated they have noticed no vermin and no issues on the unit in the past. One time they saw a mouse on the trap in one of their rooms and in the process of cleaning last year and better now. Vermin pose an infection control issue. During an interview on 12/18/2024 at 03:04 PM, the Maintenance technician stated they have seen dead mice while cleaning the radiator 2 weeks ago and they have noticed a dead mice noted in resident room. There are sticky pad traps to check. They log sightings in the pest control book and the exterminator comes two times a week and need additional attention they add additional treatment. During an interview on 12/18/2024 at 03:14 PM, the Director of Maintenance stated they do rounds daily. They look for safety issues, look for signs of vermin penetration and they are here sometimes when the pest control person visits the building. During an observation on 12/19/2024 at 10:50 AM, a black fly was noted on the electric panel in the kitchen by the hand washing sink. During an interview on 12/19/2024 at 01:18 PM, the Infection Preventionist stated they have noticed on the unit an occasional fly especially if food is left out and no mice, flies or roaches were observed. They stated they have not looked at the staff lounge on the main floor. Vermin post a threat of disease and infection, and the infections can be transmitted to the residents. They are updated on pest control issues by the maintenance books and the Director of Housekeeping inform them what is found. 10 NYCRR 415. (5) (h)(1) | Plan of Correction: ApprovedJanuary 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F925 Corrective Action: The Housekeeping and Maintenance Director responded to,2 West Dayroom, Nurses' station, room [ROOM NUMBER], 238,239, 4 West Nursing Station, 4 West Hallway, Kitchen, and Atrium, to check all areas for flies and rodents. Any exposed food was either discarded or placed inside a plastic container. The Exterminator treated all areas on 12/26/24, 1/225/ and 1/6/ 25. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The Housekeeping and Maintenance Directors immediately inspected all areas in the building no other pest control issues were identified. Element 3 Systemic Change: The Pest Control Policy was reviewed, no changes were required. All Dietary, Housekeeping, Maintenance, Nursing (CNA's, LPN, RN's) Activities, Rehab, are being in-serviced on the procedure to follow when any areas within the facility require treatment. The Pest Control Company, in addition to 3 weekly visits, will be available for additional visits on an as-needed basis. An audit tool was developed to monitor compliance. Element 4 Monitoring: 3 times per week for one quarter, the Food Service Director/Designee will conduct rounds and audits for sanitation and signs of pest activity. Any adverse findings will be logged into the pest control book and reported to the administrator. For one quarter, the director of maintenance or designee will audit the environment weekly to assist in monitoring pest control service. Any issues identified will be responded to immediately, and reports will be made to the administrator weekly. The results of all audits will be reported to the QAPI Committee quarterly for 2 Quarters/six months. QAPI Committee will determine if further action is required. Element 5 Date of Correction: (MONTH) 12, 2025 Persons responsible, Food Service, Housekeeping and Maintenance Directors. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure menus were followed. This was evident for 5 residents (Resident # 97, Resident # 156, Resident # 212, Resident # 252 and Resident # 271) observed during the Dining Observation task. Specifically, food items were omitted or substituted, and residents were not informed of the changes. The findings include: The policy and procedure titled, Menu Item Substitutions reviewed 1/12/2024 documented menus will be followed as written unless a substitution is warranted in the event of unavailability of an item, unforeseen event, temporary inability to prepare the item or a special meal. A menu substitution item substitution list shall be maintained on file. Food service staff will consult with the director of food and nutrition services or designee on any needed menu substitutions. All changes to the menu (including the date, menu items substitution, reason for the substitution will be recorded on the menu substitution log. Records of menu items substitutions shall be retained for at least six months or per state and local guidelines. Daily menu items substitutions shall be written on the menu and visible for residents to see. The policy and procedure titled Resident Food Preferences reviewed on 12/2024 documented nutritional assessments will include an evaluation of individual food preferences. The Food Services Department will offer a limited number for food substitutes for individuals who do not want to war the primary meals. The residents clinical record (orders, care plan or other appropriate locations) will document the resident likes and dislikes and special dietary instructions or limitation such as altered food consistency and caloric restrictions. The Dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. 1. Resident #97 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3. 0 dated 09/27/2024 documented Resident #97 was severely impaired. On 12/12/2024 at 05:40 PM, Resident #97 dinner tray was observed and contained yellow rice, chicken, carrot and green beans and pepper, applesauce and tea. There was no milk on Resident #97, and it was crossed out on the tray. On 12/12/2024 at 05:41 PM, Resident #97 was asked if they like milk and they did not respond. 2. Resident #156 had [DIAGNOSES REDACTED]. The Discharge Minimum Data Set Assessment 3. 0 dated 06/19/2024 documented Resident #156 was moderately impaired cognition. On 12/12/2024 at 05:06 PM dinner was observed on the 2nd floor. Resident #156 was served a tray which contained chopped chicken, yellow rice, green beans, carrots, red pepper and apple sauce. The had whole milk was crossed out on the tray ticket. 3. Resident #212 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set 3. 0 dated 11/12/2024 documented Resident # 212 was severely cognitively impaired. On 12/12/2024 at 05:11 PM dinner tray was observed on the 2nd floor. Resident # 212 was served a tray which contained chopped chicken, yellow rice, applesauce, 4-ounce milk and soup. The assorted juice was crossed out. 4. Resident #252 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #252 had severely impaired cognition. On 12/12/2024 at 12:09 PM, Resident #252 was served a lunch tray that contained baked fish, white rice (double), peas and carrots (double), mandarin oranges, 4-ounce whole milk. Two cups of tossed salad was crossed out on resident tray ticket. There was no tartar sauce on resident's lunch tray. On 12/21/2024 at 12:10 PM, Resident #252 was asked if they liked salad but did not respond to the surveyor. 5. Resident #271 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #271 had severely impaired cognition. On 12/12/2024 at 12:02 PM, Resident #271 was served their lunch tray that contained mandarin orange, milk, white rice, vegetables, coffee. The salad on their tray ticket was crossed out. No substitute was written on the ticket. On 12/12/2024 at 5:08 PM, Resident #271 was served a dinner tray that contained chicken leg, yellow rice, applesauce, and soup. Resident #271 lunch tray ticket included baked chicken, white rice, mandarin orange, whole milk, coffee and the 1 cup of tossed salad was crossed out. On 12/12/2024 at 5:10 PM, Resident #271 was asked if they liked salad and did not respond to the surveyor. Resident #271 requested gravy for their chicken. On 12/12/2024 at 12:02 PM - 12:27 PM, lunch trays were observed Resident #271 tray had mandarin oranges, 4-ounce whole milk, white rice, mixed vegetables and coffee. Salad was crossed out on the tray ticket (no substitute was written on the ticket. Resident #252 tray was observed with baked fish, white rice, peas and carrots, mandarin oranges, 4-ounce whole milk, double white rice, peas and carrots, no tartar sauce on tray and ticket states 2 cups of tossed salad which is crossed out. On 12/12/2024 at 12:03 PM, Resident # 271 requested gravy for their food. The menu substitution slips were reviewed and did not contain any food substitutions for the missing items on the residents trays that included tossed salad, whole milk and tartar sauce. During an interview on 12/12/2024 at 12:23 PM, Certified Nursing Assistant #7, stated that they check the residents trays before the get it. They stated that the [MEDICATION NAME] milk is missing for the resident and family leave a note if milk not there give Ensure and they have a prescribed shake and Ensure from their family member. They let the kitchen know if a food item is missing from the tray so they can send it up. The milk is always here. Pureed broccoli is vegetable, Milk given at breakfast and juice is sent in a container and we pour. During an interview on 12/12/2024 at 05:21 PM, Certified Nursing Assistant #6 was interviewed and stated they checked the resident's trays and there is nothing missing from the trays and some residents don't want soup, so they don't put on the tray. Cross out means they don't have the food item downstairs and residents may get a replacement sometimes put on the menu. On 12/12/2024 at 04:43 PM, Dinner trays were observed. Resident #97 tray was observed with yellow rice, chicken, carrot, green beans and red pepper, applesauce, tea and the milk was crossed out on their ticket. Resident #156 was observed with chopped chicken, yellow rice, green beans, carrots and red pepper and applesauce on tray and the whole milk on their ticket was crossed out. Resident # 212 tray with yellow rice, chopped chicken, apple sauce, 4-ounce milk and soup and ticket had assorted juice crossed out. Resident # 97 tray was observed with yellow rice, chicken, carrot, green beans, bell pepper and applesauce. The milk was crossed out on the tray ticket. Resident #212 tray was observed with yellow rice, chopped chicken, apple sauce, 4-ounce milk, soup on the tray. Assorted juice crossed was out on the tray ticket. During an interview on 12/12/2024 at 05:23 PM, Registered Nurse # 5 stated that they make sure the ticket is correct and they check the trays. When a food item is crossed out it means is not being served with the tray. If a food item is missing tell kitchen staff if bring up oversite or substitute for something else. During an interview on 12/12/2024 at 05:26 PM, Resident #156 stated that they li | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F803 Corrective Actions for Residents Identified: The Registered Dietitian reviewed menus for residents #97,#156,#212, #252, and #271 to ensure they met their nutritional needs as per national guidelines (e.g., Dietary Guidelines for Americans, RDA). The Registered Dietitian interviewed residents or resident representatives #252, #271, and #212 to review and discuss their meal preferences. Meal tickets were adjusted to reflect their preferences. Residents #97 and #156 were discharged , and no changes were required. Dietary staff immediately received training on following planned menus and compliance with meal tickets. Element 2 All residents have the potential to be affected by this practice. All residents were immediately audited to ensure all dietary preferences were being met. All meal tickets were reviewed to ensure that what was printed on the resident's meal ticket was being served; no issues were identified. Element 3 Systemic Changes: Policy and Procedure for Resident food Preferences were reviewed, and no revisions were required. All menus will be reviewed and approved quarterly by a licensed RD to ensure nutritional adequacy and compliance with guidelines. Monthly Food Committee meetings will be scheduled to ensure menus reflect resident preferences while maintaining nutritional needs. Food purchasing, inventory management, and meal preparation will be implemented to ensure timely adherence to planned menus. Dietary staff will be in-serviced regarding menu preference, menu item substitution, and adherence to meal tickets on the tray line. The new process was implemented to notify residents of any menu substitution by posting changes in each nursing unit. This new process will be discussed at the next resident council meeting on (MONTH) 21, 2025. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Actions: 10 resident trays will be audited daily for 30 days to confirm that meals served match planned menus, resident preferences, and nutritional standards are being met. Documentation will be maintained of all menu changes, resident-specific adjustments, and training sessions. The RD will conduct quarterly audits x 2 quarters to monitor menu compliance and resident preferences, including nutritional analysis. The audit results will be shared with the administrator monthly. QAPI Integration will include menu compliance as a standing agenda in QAPI Meetings for 2 quarters. The Audit results, including resident feedback and RD recommendations, will be reviewed during QAPI meetings to identify and implement further improvements for 2 quarterly meetings. QAPI Committee will make sure to figure out if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Persons Responsible: Registered Dietitian, Food Service Director, and food Service supervisor. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that the physician reviewed the resident's total program of care. This was evident for 1 resident (Resident #71) of 2 residents reviewed for [MEDICAL TREATMENT], out of 38 sampled residents. Specifically, there were no physician's order for [MEDICAL TREATMENT] and the care and treatment for [REDACTED].#71, who was on [MEDICAL TREATMENT]. The findings are: The facility's policy titled Medication Order Reconciliation updated 07/24, documented that reconciliation will occur during admissions, discharge, transfers, order changes and routine reviews. The responsibilities include that the nursing staff will verify and update records, the pharmacist will conduct regular reviews and identify potential issues and the Physician will provide clear orders and address discrepancies. The facility's policy titled [MEDICAL TREATMENT], updated 07/24 documented that the purpose of this policy is to provide continuous monitoring of residents with End Stage [MEDICAL CONDITIONS]. Resident #71 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented resident's cognition as intact, dependent on staff for bed mobility, chair/bed transfers, no toileting attempted, supervision or touching assistance for eating, always incontinent of urine, frequently incontinent of bowel, received scheduled pain medication regimen, on a therapeutic diet, and is on [MEDICAL TREATMENT]. The Quarterly Minimum (MDS) data set [DATE] documented resident's cognition as intact, dependent on staff for bed mobility, chair/bed transfers, no toileting attempted, supervision or touching assistance for eating, always incontinent of urine, frequently incontinent of bowel, received scheduled pain medication regimen, on a therapeutic diet, and no [MEDICAL TREATMENT]. The Physician's orders dated 12/9/24 documented Renal diet, regular texture, thin consistency, fluid Restriction 1500 ml/day: Dietary 720 ml/day, Nursing 780 ml/day. Nursing: 7-3: 300 ml 3-11: 300 ml 11-7: 180 ml and a pitcher by bedside. On 12/16/24 11:15 AM Resident # 71 was observed sitting in their room in their wheelchair, alert and oriented to name. Resident #71 stated that that they will be going to [MEDICAL TREATMENT] today at 1:00PM. There was no documented evidence of physician orders documenting that Resident #71 goes to [MEDICAL TREATMENT], the frequency of [MEDICAL TREATMENT], or the monitoring of the permcath for [MEDICAL TREATMENT]. The Comprehensive Care Plan focus documented Resident #71 needs [MEDICAL TREATMENT] related to End Stage [MEDICAL CONDITION] (left chest wall Permcath), created 8/19/ 2024. Goals include that the resident will have no signs/symptoms of complications from [MEDICAL TREATMENT] through the review date, 8/20/ 24. Interventions include to monitor/document/report as needed any signs/symptoms of infection to access site, redness, swelling, warmth, or drainage. A Nurse's Note dated 12/16/24 documented Resident #71 going on [MEDICAL TREATMENT]. Safety precautions active. A Nurse's Note dated 12/13/2024 documented Resident #71 returned from [MEDICAL TREATMENT] in stable condition. AV graft site intact dressing clean and dry no sign of bleeding noted. A Nurse's Note dated 12/11/2024 documented Resident #71 was readmitted on [DATE] from the hospital with [DIAGNOSES REDACTED].#71 goes to [MEDICAL TREATMENT] on Monday, Wednesday Friday, Renal diet, regular texture, thin consistency. A Physician's Note dated 12/04/2024 documented s patient is seen for follow up, recently readmitted to the facility, End Stage [MEDICAL CONDITION], on maintenance [MEDICAL TREATMENT] 3 times a week, Patient denies symptoms presently and that patient had [MEDICAL TREATMENT] session on hold today secondary to low hemoglobin. The Physician's note also documented that [MEDICAL TREATMENT] will be restarted only with hemoglobin greater than 7. On 12/19/24 at 11:19 AM, Certified Nursing Assistant #12 was interviewed and stated that they are the primary Certified Nursing Assistant on the 7-3 shift. Certified Nursing Assistant #12 also stated that Resident #71 needs 2 persons assist for transfers and goes to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Certified Nursing Assistant #12 stated that the nurse will give a report of the residents that are on [MEDICAL TREATMENT]. On 12/17/24 at 11:58 AM Registered Nurse Manager #2 was interviewed and stated that when a resident is admitted , the orders are reconciled with Licensed Nurse that admits the resident and with the Registered Nurses. Registered Nurse Manager #2 also stated that it is not necessary for an order in the system, since there is a communications book that lists where the resident goes for [MEDICAL TREATMENT] and the time that they go. Registered Nurse Manager #2 said that the doctor would monitor to see if any labs were done that the doctor would monitor the results. Registered Nurse Manager #2 said that the Staff is aware that Resident #71 is on [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays at 1PM. On 12/18/24 at 04:15 PM, the Director of Nursing was interviewed and stated that when a resident is admitted /readmitted , the reconciliation is done with the Registered Nurse Supervisors to ensure that all orders are reconciled. The Director of Nursing also stated that the resident was readmitted on [DATE] and that the order was omitted by error since, the order was there prior to the resident's readmission. The Director of Nursing also stated that the Licensed Nurses are all aware that the orders must be reconciled when there is an admission and a readmission. On 12/19/24 11:25 AM the Medical Doctor was interviewed and stated they are the Licensed Practitioner for any issues with Resident # 71. The Medical Doctor also stated that Resident #71 is stable now and that they check the order and the medications. The Medical Doctor stated that they don't know what happened at the time, but Resident #71 had an order previously, and that these orders are reviewed whenever the resident has a complaint or concerns. The Medical Doctor also stated that they review the chart and the orders when they see the resident believed that when Resident #71 was last readmitted , someone missed the order. 10 NYCRR 415. 15(b)(2)(iii) | Plan of Correction: ApprovedJanuary 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F711 Corrective Actions for Residents Identified: Resident # 71 was seen by an attending physician on 12/19/ 2024. During the visit, the resident's total program of care, including medications and treatments, was reviewed and documented. Resident # 71 received [MEDICAL TREATMENT] without interruption of services; Resident # 71 had an order placed immediately. The Care Plan was initiated on 8/19/2024 and has been reviewed and updated for [MEDICAL TREATMENT]. Element 2 Residents at Risk: All Residents receiving [MEDICAL TREATMENT] have the potential to be affected by this practice. A list of current residents receiving [MEDICAL TREATMENT] in the past three months was obtained, and the Medical Record was audited to ensure that all physician orders [REDACTED]. No Other issues were identified. Audit tool was developed to monitor compliance Element 3 Systemic Changes: Policy and Procedure for physician's orders [REDACTED]. All Registered Nurses are being educated on the importance of timely physician visits, documentation review, and order accuracy. The nursing supervisor will review care notes weekly to ensure all visits and orders are correctly documented. An audit tool was created to confirm that all physician orders [REDACTED]. Element 4 Quality assurance Monitoring: Conduct weekly audits for 90 days to ensure compliance with physician visits, regulations, care note reviews, and orders. Findings will be reported to the administrator monthly, and any negative findings will be corrected immediately. On a quarterly basis, x 3 quarters ADNS or designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Element 5: Persons Responsible: Completion Date: (MONTH) 12, 2025 Director of Nursing Services: Oversee the P(NAME) implementation and staff education. Medical Director: Collaborate with physicians to ensure timely visits and documentation. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the Recertification /Complaint survey (NY 742) conducted between 12/12/2024 and 12/19/2024, the facility did not ensure that all alleged violations involving abuse and injury of unknown origin were reported immediately to the New York State Department of Health, but not later than 2 hours after the alleged abuse and injury were observed. Specifically, (1) an injury of unknown origin found on resident #251's forehead was not reported; (2) Resident-Resident physical abuse resulting to injury involving 3 residents was not reported (Residents #214, #268, and #589); and (3) Injury of unkown origin found on Resident #24's toes was not reported. This was evident for one of three residents investigated for complaints and 4 out of 4 residents reviewed for Accidents out of 38 sampled residents. The findings are: The facility's policy and procedure titled Accident and Incident Report dated 07/2024, documented that As soon as possible, but no later than 24 hours post occurrence, complete the Accident/Incident Report. Fill in all spaces on the form, giving an exact description of the circumstances surrounding the accident or incident; Interview staff assigned to the care of the resident, and/or all staff assigned to the nursing unit on which resident resides; The Administrator, after discussion with the Director of Nursing, will reach a final decision if the accident is reportable to the Department of Health. The facility's policy and procedure titled Abuse, Neglect, Exploitation, and mistreatment of [REDACTED]. and procedures. There is no documented evidence of the reporting time frame to the New York State Department of Health. 1). Resident #251 was admitted to the facility 01/27/2024, with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #251 had severe impairment in cognition, and impairment on both sides of lower and upper extremities. The Minimum Data Set also documented that the resident requires Substantial/maximal assistance/total dependent of staff for most activities of daily living. Minimum Data Set documented that Resident had no behavioral symptoms directed towards others. The Comprehensive Care Plan for Behavior dated 2/21/2024, last updated 8/11/24, documented that Resident #251 has a behavior problem, agitated when redirected by staff, and can be potentially physically aggressive (towards staff) related to unspecified dementia. With goals including Resident will receive redirection with less aggression based on the medication adjustment. Interventions included: - Administer medications as ordered; Monitor/document for side effects and effectiveness; Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. The Comprehensive Care Plan for Fall dated 1/27/24, last updated 11/11/24, documented that Resident #251 is at High risk for falls related to Deconditioning, Gait/balance problems, altered mental status, Dementia, [MEDICAL CONDITION], generalized muscle weakness 2/22/2024 Possible witnessed fall; with the goals including Resident will be free of falls while in the facility through the review date; Will not sustain serious injury through the review date; will have decreased opportunity for falls and falls related injuries through the review date. Interventions included: - Monitor for changes in cognitive function; Provide reality orientation for periods of increased confusion; Needs prompt response to all requests for assistance; Frequent monitoring while in bed. Intake Number NY 742 dated 03/01/24 documented that complainant reported that they received a call from the facility that Resident fell on [DATE]; The family visited Resident on 2/25/24 and noted that the right eye was completely closed, and a knot noted on resident's forehead. Complainant reported that they were not receiving a consistent explanation on when the resident was last seen or how resident fell . Complainant stated that the staff are dismissive towards their request for a meeting with the staff. On 12/12/24 at 11:32 AM, Resident #251's family (Complainant) was interviewed and stated that they received the call that resident fell and hit the head, when resident was visited the mark noticed on the resident head and face seemed as if resident got punched in the face; statement by the staff is not consistent, and they refused to play the camera to view resident's movement prior incident. Family stated they requested clarification from the staff to rule out that resident was not attacked or punched by somebody because resident has Alzheimer's behavior and could not state how the injury occurred but there was no positive response received from the facility. Progress note Nursing dated 2/22/2024 08:40 documented: Report received that Resident #251 was bleeding from forehead. Upon assessment, resident sustained [REDACTED]. Nurse Practitioner notified and requested to evaluate the resident. There is no documented evidence of how Resident #251 sustained the injury in the resident's chart. Progress note Physician dated 2/22/2024 11:38 documented requests to see Resident #251 with swelling on right forehead; seen and examined at the bedside. Physician documented that on 2/22/24, nurse reported that resident has swelling on right forehead 7 cm x 7 cm.; resident could not mention what happened. Progress note Therapy-Communication with Rehab dated 2/22/2024 documented that Resident noted with large hematoma to right forehead with observed frank blood. Resident remarked of discomfort to touch; unable to recount sequence of events leading to fall, however, Resident did state that they fell from the bed. Nursing staff stated it was an unwitnessed fall noting that Resident was observed with swelling to right forehead this morning. There is no documented evidence in the progress notes by all the interdisciplinary team members that the injury sustained by Resident #251 was known or witnessed by any staff. As per the Facility's Accident/Incident Report reviewed dated 2/22/2024, Certified Nursing Assistant #4's statement documented that they were gathering supplies when they saw Resident #251 walked into room [ROOM NUMBER]; they went to redirect the resident and observed a bump on the resident's head. Resident Incident Report completed by the Shift Supervisor on 2/22/24 documented that Resident was observed at 7:20 am 2/22/2024 with unwitnessed bump on right forehead, the incident was unwitnessed, resident was walking in the hallway and was observed with a bump to the right forehead, resident unable to detail the incident. Pressure dressing applied. Accident/Incident Investigation Summary dated 2/26/24 documented that Resident observed with bump on right forehead. Resident unable to state what happened; right forehead oozing frank red blood. No change in Level of consciousness; Seen by Medical Doctor, ordered to transfer to emergency room for Cat Scan. The Summary conclusion is The investigation has revealed that there is no cause to believe any alleged resident abuse, mistreatment or neglect has occurred. There is no documented evidence in the Accident/Incident investigation summary that revealed that the injury observed on the resident's forehead was witnessed, or to show that the source of the injury was known. On 12/16/24 at 12:20 PM, an interview was conducted with Certified Nursing Assistant # 5. Certified Nursing Assistant #5 stated that they were assigned to Resident #251 on 2/22/24 7 am to 3 pm shift, when they made rounds on t | Plan of Correction: ApprovedJanuary 16, 2025 Element 1 F609 Corrective action for Residents Identified: No Further occurrences related to abuse, including injury of unknown origin, resident-to-resident altercation, neglect, and mistreatment, were identified. All accidents and incidents meeting the criteria will be reported immediately, but not later than 2 hours. Resident #589 is no longer in the facility. Resident #251 is placed in the hallway or the dining room with activities for close observation. Resident #214 is placed in the hallway or the dining room with activities for close observation. The abuse care plan was updated for resident #24 to ensure the resident is free from abuse. The abuse care plan was updated for resident #251 to ensure the resident is free from abuse. The abuse care plan was updated for resident #214 to ensure the resident is free from abuse. Resident #589 is no longer in the facility. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The DNS, ADNS, and the Administrator reviewed the audit of all accidents/incidents completed and submitted in the past three months to identify and determine whether an occurrence is an abuse, neglect, injury of unknown origin, or mistreatment, and whether reporting requirements/criteria are met according to regulation and State law. No outstanding events requiring reporting to the NYSDOH or other entities were found. An audit Tool was developed to monitor compliannce. Element 3 Systemic Change. The facility Policy and Procedure titled Resident Abuse, Mistreatment, and Neglect was reviewed, and no revision is required. The facility Policy and Procedure titled Reporting Abuse to State Agencies and Other Entities was reviewed and no revision is required. The education on policy and procedure titled Reporting Abuse to State Agencies and Other Entities will be added to the Abuse Prevention and Reporting module and will be provided to all RNs, LPNs, and CNAs during orientation, annually and as needed. The Facility investigation team, led by the ADNS, will continue to review all accidents/incident reports weekly for the next 90 days to identify if there is any occurrence of resident abuse, neglect, mistreatment, or injury of unknown origin that meets reporting requirements, these occurrences will be reported timely according to regulation and State Law. Element 4 Monitoring of Corrective Action: The Administration, Nursing Administrative staff and Director of Social Service will monitor for compliance during random and routine rounds on the units. For one quarter bi-weekly, the ADNS/designee will use an audit tool to interview 5-7 staff members from different disciplines for knowledge and understanding of abuse reporting protocols. ADNS/designee will report audit findings to DNS and Administrator monthly. The ADNS will audit all submitted accidents/incidents reports weekly for 90 days to ensure compliance with reporting requirements and report findings to the Administrator. On a Quarterly basis x 3 quarter the ADNS/designee will report findings to the QAPI Committee The QAPI Committee will determine if further action is required Element 5 Completion Date: (MONTH) 12, 2025 Responsible Person: Assistant Director of Nursing & Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the residents' right to a safe, clean, comfortable, and homelike environment was maintained. Specifically multiple observations were made of resident rooms were observed with wood furniture scratched veneer, missing key holes, missing handles to dressers or wall cabinets, bedside tables were observed with missing paint on the lower leg areas. 2. ) resident rooms were observed with mismatched paint, holes in dry wall and duct tape on the floor, missing tile and/or grimy tile. 3. ) resident's wheelchair was observed with torn cushion and enteral feeding pumps and poles on 2 East and 2 West unit was observed with cream-colored stains on the pump and pole bottoms. 4). the whirlpool tub was noted to be dirty with discarded items inside and unit shared bathrooms were observed with discolored damaged or missing tiles. 4. ) the step leading to the trash dumpster was noted to be rusty with hole in metal stairs on the left side of the steps. 5). the wall behind in the 2nd floor dining room refrigerator and false pantry was observed with holes in back wall area. This was evident in 5 out of 6 units observed (2 East, 2 West, 3 East, 3 West and 4 West). The findings are: The facility's policy titled Cleaning and Disinfecting Resident Care Items and Equipment reviewed (MONTH) 2024 documented resident shared equipment including shared items and durable medical equipment shall be cleaned and disinfected according to the current Centers of Disease Control recommendations for disinfection and the Occupational Safety Health Administration Bloodborne Pathogens Standard. Durable medical equipment such as enteral feeding pumps, intravenous poles shall be cleaned after usage on the Environment Protection Agency registered antimicrobial list recommended by public health authorities. Medical storage equipment such as medication/treatment carts, cardiopulmonary resuscitation carts shall be cleaned when visibly soiled and on as needed basis. The facility policy titled 7 Step Cleaning Progress reviewed (MONTH) 2024 documented rooms the policy is to establish an efficient cleaning process and maintain a sanitary physical environment. Rooms will be cleaned thoroughly cleaned monthly or as needed. The following was observed during multiple observations conducted from 12/12/2024 to 12/19/ 2024. a.) Kitchen observations on 12/12/2024 from 09:21 AM - 10:58 AM, 12/16/2024 at 04:29 PM and 12/18/24 01:13 PM, include leaking kitchen kettle, cracked tile on the floor and missing tile. There is a gap in the wall edge by refrigerator #3 by wall mixer, cracked tile around the drain by the kettle and prep area, cracked tile by the stove partially replaced. The metal shelf of the kitchen holding washed dishes has grease residue on the metal shelves. Cracked corners on the resident fiberglass meal trays. Cracked floor and baseboard tiles in the dish room. Cracked floor tile under freezer # 2. Cracked tile by prep station thawing sink opposite refrigerator # 1. Visible hole under the sink pipe in the kitchen dish room. During an interview on 12/17/2024 at 11:28 AM, Dietary Aide # 7 stated, the kitchen tiles have been broken and maintenance comes to fix them when water comes up from floor drain areas. During an interview on 12/17/2024 at 10:32 AM, Dietary Aide # 4 stated, the leaking cooking kettle makes a puddle on the floor. There was a puddle in the kitchen at least 1-time last week after it rained heavy, and maintenance came to take care of it. b). On 12/17/24 at 10:29 AM, during kitchen trash disposal task with Dietary Aide # 4 the metal walking stairs leading to the bottom of the facility trash compactor were observed to be damaged. There was stored wheelchair parts visible under stairs area. On 12/19/2024 at 12:44 PM main floor staff dining lounge past the kitchen on lobby floor noted with black colored droppings under sink, food stain in freezer and bottom drawer noted with light brown colored food stain on the bottom of the lower drawers. c.)2nd Floor shared dining room by the elevator was observed from 12/12/2024 to 12/19/2024 with no radiator cover, metal exposed under mounted wall television area and the ice machine vent was dusty. There was a noticeable hole in the wall behind the refrigerator with a gap in between the refrigerator and the false pantry. 2nd Floor -2 East unit - on 12/12/2024 at 3:09PM and 12/17/2024 at 03:14PM, 12/17/2024 at 3:35PM - 3:37PM, the following was observed room [ROOM NUMBER]E-209 enteral feeding pump with dried cream-colored stains back of the pump. room [ROOM NUMBER]E - 206 has 6 strip of duct tape on floor holding tile down. The trash can by A bed is covered with a brown colored stain on the outside. 2 East- fan by room [ROOM NUMBER]E-222 noted to be dusty and has a white ribbon inside the fan and stamped with sticker inspected 8/20/ 2024. Metal fan by room [ROOM NUMBER]E-211 and 2E-215 dusty on outside with stamped inspected 7/16/ 2024. 2nd Floor on 12/12/2024 at 12/12/2024 at 04:46 PM, 12/17/2024 at 03:14 PM and 12/17/2024 at 03:40 PM, Elevator # 1- left and right lower edge damage to dry wall. Elevator # 2nd number elevator left lower edge and right side exposing dry wall covered with duct tape. Elevator # 3 has damage to dry wall on the 1/3 on left and ?é?? right side. 2 East -room [ROOM NUMBER] - 4 pieces of black duct tape holding floor tiles. 2 East shower room [ROOM NUMBER]/17/24 03:17 PM to 03:20PM, there was a gap in tile under sink in shower opposite nurses' station in 3 areas, shower drain with brown colored debris around hole in the drain cover. Large shower chair with rusty wheels. Large bathtub was dusty. The large bathtub contained the following a gray colored commode, pair of discarded vinyl gloves, empty bucket, brown colored debris on tub jets. Hoyer canvas blue wrap by the arms trap areas noted to be dusty on the fabric. d.) 2 West unit - room [ROOM NUMBER] P - on 12/12/2024 02:45 PM, 12/16/2024 at 10:38 AM and 12/17/2024 at 03:00 PM, the call light box on the wall was noted hanging from the wall over the resident's headboard on 12/12/ 2024. ) On 12/12/2024 at 02:49 PM, 12/16/2024 at 02:53 PM, 12/17/2024 02:57 PM and 12/18/2024 07:57 AM, room [ROOM NUMBER] P enteral feeding pump noted with cream-colored stains on the pump back area and pole noted with cream-colored stains on the bottom of the pole and the resident's floor. Air conditioning/heater unit damaged on left side by window bottom, unit is dusty with grey colored dust, dried leaves in adjustment knob. On 12/12/24 02:58 PM, 12/13/24 09:35 AM, the following was observed. room [ROOM NUMBER] wall divider by sink with chipped wood and air conditioning/heater unit dusty and unit crash cart with dusty bottom area. Medication Cart in the nurse's station observed with dust. room [ROOM NUMBER] enteral feeding pole with cream colored feeding on bottom dried and on enteral feeding pump front and back area. Air conditioning/heater unit dried leaves, gray colored dust in vent area. 2 West bathroom- tub with stains in tub, plastic cup on right side of seat, white towel, belt with white colored dust, shower chair for larger residents with brown colored stain on bottom area, cracked tile under sink on left edge approximately 1 ?é¾ x ?é½ inch. Bottom wheels for larger shower chair with rust on all 6 wheels. Wound Care treatment cart for 2 West on - 12/18/24 09:41 AM empty sharps container noted with cream colored tape affixed to the right side of the sharps container holder horizontally to keep it closed. Environment 2 West- 12/12/24 11:46 AM 2 West Hoyer lift dusty plastic foot pad and missing paint on both Hoyer leg area. 2 West Medication room on 12/16/2024 at 10:05 AM veneer on cabinet door labeled pill crusher and thermometer had ripped veneer on upper cabinet middle left door. During an interview on 12/18/2024 at 08:29 AM, the Housekeeper #1 stated, when they clean the bedside table, they scrape down the table and mop it to get the floor clean. They are not sure who they report to if the table bottom is crusty or missing paint. This is where the residents eat, and residents put their feet on, | Plan of Correction: ApprovedJanuary 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F584 Element 1 Immediate Corrective Action: The Maintenance Director Food Service Director immediately took action to correct the deficiencies identified in the kitchen. A 1/2-inch quick Valve was replaced to correct the leak on the kettle. The Quarry floor tile has been ordered, and all cracked kitchen tiles will be replaced throughout the kitchen. The gap in the wall edge by refrigerator #3 will be repaired. Metal shelving in the kitchen holding washed dishes was immediately cleaned. Cracked flooring and baseboard tiles in the dish room were replaced. The cracked floor tile identified in freezer #2 has been removed and will be replaced with quick-dry cement and epoxy. Next, work will begin on Refrigerator # 1, and the floor will be replaced. The dish room handwashing sink opening has been closed in the tile surrounding the pipe. The Metal Stairs identified by the compacter were replaced on (MONTH) 14, 2025, and the wheelchair parts stored were removed. The Housekeeping and Maintenance Directors immediately acted to correct the deficiencies identified in the nursing units. 2 East: The Director of Housekeeping audited to ensure that all feeding pumps were cleaned. Any pumps with stains, including E209, W203, and W238, were immediately cleaned or replaced. In E206, the floor tile was replaced, the duct tape was removed, and the garbage can was replaced with a new one. The drywall on the elevator bank on 2 East elevators #1, #2, and #3 was repaired and replaced withe corner guards. The fan was cleaned and removed. 2 East: The 3 areas identified with a gap around the piping in the shower rooms under the sink were filled, the shower drain cleaned, and the drain cover replaced. All debris noted in the century tub was removed and cleaned. Hoyer canvas was removed for routine cleaning. The Director of Maintenance did a whole house audit to ensure all a/c units were clean and dust-free. Areas identified were immediately cleaned to include the following rooms: W238, W203, W208, E318, E E302, E311, E308, E315, E306 E302, E317 and the 4 units on 4 West Dayroom. 2 West Medication Room: The company who built the cabinets was contacted to replace the peeling veneer on the upper middle cabinet door. The kitchenette and refrigerator/freezer in the staff lounge were cleaned immediately. 2 W room [ROOM NUMBER]P, the call light box was replaced on the wall. room [ROOM NUMBER]: The chip noted in the barn door was filled in, and the door was repainted. The medication Cart on 2 West was removed and cleaned. 2 West Main shower room debris identified in the century tub was removed, and the tub was cleaned. The bariatric shower chair was removed and cleaned, and any rusty wheels will be replaced. The cracked tile under the sink was replaced. The sharps container on the Wound Care Cart was adhered correctly to the cart to ensure it was closing. 2 West Lobby Area: The baseboard heater cover had fallen off and was clipped back on. The ice machine vent was cleaned immediately. The hole in the wall behind the refrigerator was repaired, and the gap between the fridge and the false pantry will be repaired as we proceed. 3 East: Brookstone Developers will begin renovating the following rooms starting (MONTH) 20, 2025: 3 East Rooms 300, 318, 306,339, 303, 311,308,317, 309, 315,305, 304, 302, 308. This will include replacing ceiling tiles and grids, flooring, painting walls, nightstands, overbed tables, wardrobe closets, a handwashing sink inside resident rooms, and new tile and showers inside each resident's bathroom. 3 West: Brookstone Developers completed the renovation of the 3 West Main Shower Room and removed the Century Tub. This renovation includes new ceiling tiles, lighting and grids, fixtures, tile, and flooring. All old equipment, such as commodes, has been discarded. Pantry: All areas within the pantry were cleaned, and the metal ladle in the drawer under the microwave was discarded. 3 West: Medication carts. In (MONTH) 2023, Specialty Pharmacy provided Crown Heights Center with new medication carts; each unit has 2 medication carts and 1 treatment cart. The housekeeping department schedules the monthly cleaning of medication carts using a pressure washer. During this process, the Director of Housekeeping will in-service the staff to clean the bottom of the medication cart. All medication carts identified as being dusty or soiled were immediately cleaned. 4 West: The 4th-floor hallway and the opposite side of the elevators were repainted. room [ROOM NUMBER] was completely renovated and painted. W 417 Resident Room chair was replaced. 5 Tier Linen cart with a cracked left edge was repaired. Bedside tables will be replaced in the following rooms: W400,414,406,403,408,407,409,417,421,432,428, 405. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The Food Service Director immediately audited all trays. Any cracked trays will be removed. The Director of Maintenance and the Director of Housekeeping conducted a visual inspection of the entire facility, and no other issues were identified. Element 3 Systemic changes: Policies and procedures were reviewed, and no revisions were necessary. On (MONTH) 6, 7, and 8th, maintenance and housekeeping staff were in-serviced to maintain a safe, clean, and comfortable environment. The housekeeping director is responsible for ensuring all equipment is clean and operable. The director of maintenance is responsible for ensuring preventative environmental rounds are routinely conducted and any identified issues are corrected immediately. An audit tool has been developed to monitor compliance. Element 4 Monitoring of Corrective Action: On a weekly basis for 6 months, Maintenance and Housekeeping directors will conduct environmental audits. The maintenance and housekeeping director will report findings to the administrator monthly. Any issues identified will be corrected as soon as possible. Maintenance and housekeeping directors will report findings to the QAPI Committee for two quarters. The QAPI Committee will determine if any further action is required. Element 5 Responsibility: Director of Maintenance, Housekeeping Director, and the Administrator. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 1. 6. 1 limits existing health care occupancies to the building construction types shown in Table 19. 1. 6. 1 Construction Type Limitations. Table 19. 1. 6. 1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the building housing the existing health care occupancy was observed to be Type II (000) construction. This was noted on four of four floors. The findings are: During the life safety survey of 12/17/2024, between 8:30 am and 11:00 am, it was noted that the facility is currently working to create a rated ceiling system throughout the facility to address the previously cited non-compliant building construction type. A time limited waiver, which expires 0n 10/31/2025, is in place while the required repairs are completed. At the exit conference on 12/17/2024 at approximately 1:20 pm, the Administrator stated that the work is underway and expected to be completed before the expiration date of the time limited waiver. 2012 NFPA 101: 19. 1. 6. 1 10NYCRR 711. 2(a)(1) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 K 161 Corrective Action: The facility was approved for a limited-time waiver with an expiration date of (MONTH) 31, 2025. Brookstone Contractors began the current ceiling replacement with materials and assemblies that are UL-listed to provide a 2-hour rating, and this project started on (MONTH) 19, 2024. Project Status: Lobby: All ceiling grids, tiles, and lighting have been replaced throughout the lobby, kitchen, IT Room, and all non-clinical areas. 2 East: Dayrooms/Common area grids, ceiling tiles, and lighting have been completed. 3 West: Dayroom/Common area grids, ceiling tiles, and lighting have been completed. 3 East: Dayroom Common area grids, ceiling tiles, and lighting have been replaced Work to begin on (MONTH) 11, 2025, in the following resident rooms: E 300, 302, 303, 304,305,306, 308,309,311,315,317, 318, 339, 4 East Completed. 4 West: Dayroom Common area grids, ceiling areas, and lighting have been completed. Work on the following resident rooms has been completed : 400, 402, 404, 406, 408, 410. Element 2: All residents have the potential to be affected by this practice. Element 3 The maintenance director oversees the project to ensure Interim Life Safety plan compliance. Staff members responsible for facility maintenance are trained on the periodic inspection of fire-rated ceiling systems. The facility will communicate quarterly updates to the Department of Health. Element 4: Monitoring: The maintenance director will audit weekly measures such as fire watch during construction, increased fire drills, and staff training at the facility. The results of this audit will be reported to the administrator monthly. The maintenance director will submit quarterly reports to the QAPI Committee for 3 quarters. The QAPI Committee will determine if any further action is required. Element 5: Person Responsible: Director of Maintenance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2010 NFPA 9910. 2. 4 Adapters and Extension Cords. 10. 2. 4. 1 Three-prong to two-prong adapters shall not be permitted. 10. 2. 4. 2 Adapters and extension cords meeting the requirements of 10. 2. 4. 2. 1 through 10. 2. 4. 2. 3 shall be permitted. 10. 2. 4. 2. 1 All adapters shall be listed for the purpose. 10. 2. 4. 2. 2 Attachment plugs and fittings shall be listed for the purpose. 10. 2. 4. 2. 3 The cabling shall comply with 10. 2. 3. 2011 NFPA 70 10. 5. 2. 3 Adapters and Extension Cords. 10. 5. 2. 3. 1 Adapters and extension cords meeting the requirements of 10. 2. 4 shall be permitted to be used. 10. 5. 2. 3. 2 Three-to-two-prong adapters shall not be permitted. 10. 5. 2. 3. 3 The wiring shall be tested for all of the following: (1) Physical integrity (2) Polarity (3) Continuity of grounding at the time of assembly and periodically Thereafter 2011 NFPA 70: 400. 8 Uses Not Permitted. Unless specifically permitted in 400. 7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368. 56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 2011 NFPA 70: 590. 2 All Wiring Installations. (A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (B) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation. 590. 3 Time Constraints. (A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes. (C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work. (D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Based on observation, staff interview and record review the facility did not follow its policy for the use of relocatable power strips. This occurred in the employee cafeteria on the first floor. The findings include: On 12/16/24 at approximately 9:50 AM, a refrigerator in the 1st floor employee cafeteria was found to be plugged into a relocatable power strip. The facility's policy regarding power strips states power strips must not be connected to high amperage loads . In addition, there were no records for the periodic testing of any power strips located in the building. At the time of this finding the Director of Maintenance stated that this would be corrected. 2012 NFPA 99 2011 NFPA 70 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Corrective Action Th refrigerator in the first floor employee cafeteria was immediately unplugged from the relocatable power strip and plugged directly into a wall outlet to comply with the facility policy and ensure safety. a comprehensive inspection of all power strips throughout the facility was conducted to identify any other instances of improper use such as high amperage being connected to power strips. No other issues were identified. The facility's policy regarding the proper use of power strips was reviewed no revisions were required. Element 2 All residents have the potential to be affected by tis practice, however no other residents were affected by this practice. Element 3 The maintenace staff will receive training on the policy with emphasis on the risks associated with improper power strip usage and how to identify appropraiete utlets for high- amerage appliances. The maintenance director will develop a log to monitor power strips and ongoing compliance and safety. Element 4 The maintenance director will conduct random monthly audits of power strip usage in the building to ensure ongoing compliance. Audit results will be reviewed and submitted to the administrator monthly. The maintenance director will submit results of the audit on a quarterly basis for 3 quarters to identify any patterns or recurring issues for 6 months. The QAPI Committee will determine if further action is required. Element 5 Person Responsible: The Maintenace Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2102 NFPA 101 19. 5 Building Services. 19. 5. 1 Utilities. 19. 5. 1. 1 Utilities shall comply with the provisions of Section 9. 1. 9. 1. 2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70 210. 8 Ground-Fault Circuit-Interrupter Protection for Personnel. Ground-fault circuit-interruption for personnel shall be provided as required in 210. 8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location. (B) Other Than Dwelling Units. All 125-volt, singlephase, 15- and 20-ampere receptacles installed in the locations specified in 210. 8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms (2) Kitchens (3) Rooftops (4) Outdoors Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426. 28 or 427. 22, as applicable. Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590. 6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection. (5) Sinks - where receptacles are installed within 1. 8 m (6 ft) of the outside edge of the sink. 2011 NFPA 70: 700. 10 Wiring, Emergency System. Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency 2011 NFPA 70: 110. 27 Guarding of Live Parts. (\ Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. Based on observation and staff interview, the facility did not maintain all components of the electrical system in a safe manner. This occurred on the first floor of the building. The findings include: During the life safety survey on 12/16/24, between 9:00 am and 1:00 pm, the following were noted: 1) Electrical circuit panels were found to be unlocked in areas accessible to the public in locations, including but not limited to: 2) Electrical circuit panels were found to be lacking panel directories in locations, including but not limited to: 3) Non- GFCI outlets were located within 6' of a sink in the employee cafeteria on the 1st floor, and connected to a fish tank in the atrium off of the lobby. 2012 NFPA 101 2011 NFPA 70 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Immediate Corrective Action: All circuit panels identified as unlocked were immediately secured with compliant locking mechanisms. All electrical circuits panels were checked for complete directories. Any electrical circuit panels found lacking directories were corrected. Element 2 All residents have the potential to be affected by this practice no however no resident were harmed by this specific practice. All areas were checked for similar deficiencies. None were found. Element 3 Systemic Changes: A policy has been implemented requiring all electrical panels in public area to be locked at all times. The maintenance staff have been in-serviced on the revisions to this policy to ensure compliance on securing electrical panel as a part of safety compliance. Element4 Monitoring: The maintenance director will audit all outlets monthly that are near water sources throughout the facility to identify any additional non compliant areas. The maintenance director will audit all electrical panels monthly for directories throughout the facility to identify any additional non compliant areas. The maintenance director and consultant from Ridgefield Associate will inspect records and maintenance logs quarterly to ensure sustained adherence to electrical safety standards. The results of all audits will be reported to the administrator for compliance. Any areas identified as non compliant will be corrected immediately. The maintenance director will report the results of all audits to the QAPI Committee Quarterly for a period of 3 quarters. The QAPI Committee will determine if any further action is required. Element 5 Person Responsible : Maintenance director |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101 9. 6. 1. 6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. Based on document review and staff interview during the recertification survey, the facility did not ensure that measures were put in place to provide for occupant safety during an impairment of the fire alarm system [MEDICATION NAME] greater than 4 hours. The findings include: During the document review portion life safety survey on 12/17/24, at approximately 10:00 AM, a review of the facility's maintenance, inspection and testing documents revealed that the facility did not include a policy and procedure detailing actions to be taken if any part of the fire alarm system was impaired. At the exit conference on 12/17/24 at approximately 1:40 PM, the Administrator state that the facility would create this policy. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Corrective Action: On (MONTH) 12, 2025 The facility developed a comprehensive policy and procedure to outline the actions to be taken in the event of any impairment to the fire alarm system. The policy includes: Immediate notification procedures for staff, residents and local fire authorities. Temporary fire watch procedures, as per NFPA 101, Life Safety Code guidelines. Vendor contacted to correct impairment Documentation of the impairment and actions taken Element2 Residents at Risk While no resident's were affected by this practice the potential existed for all residents to be affected by this deficient practice. Element 3 Systemic Changes: Policy and procedure on Fire Watch was created. All maintenance and administrative staff will be trained on the newly developed fire alarm impairment policy. Updated maintenance checklist will be implement to include a review of the fire alarm system and requirement to verify that the impairment procedures are readily available The facility contracts with a vendor to perform routine inspections and testing to proactively prevent system impairments Audit was created to monitor compliance with the requirements of a Fire Watch. Element 4 Monitoring: The maintenance director will conduct monthly audits of fire safety documentation to ensure adherence to the fire alarm impairment policy. Results of the audit will be reported to the administrator monthly. Any deficiencies identified during the audits will be addressed immediately and retraining will be provided if necessary. The Results of the audit will also be reported quarterly to the QAPI Committee quarterly for 2 quarterly meetings. QAPI Committee will determine if further action is required. Element 5 Person responsible: The Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 2. 1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8. 7. 1. 2012 NFPA 101: 19. 3. 2. 1. 2* Where the sprinkler option of 19. 3. 2. 1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8. 4. Based on observation and staff interview, the facility did not ensure that all hazard areas were enclosed in accordance with 2012 NFPA 101. This occurred on the first floor of the facility. The findings include: During the life safety survey on 12/16/24, between 9:00 am and 12:00 pm, the following were noted: 1) In the generator room one wall had a plywood wall covering which was not labelled as being fire resistant. The concrete wall surrounding this room had an opening of approximately 3 by 4', communicating with the adjacent automatic transfer switch room. The opening allowed space for equipment from the automatic transfer switch room. In addition, the door to this room was found to be propped open. 2) In the automatic transfer switch room (which was not provided with sprinkler coverage) , there were missing ceiling tiles exposing the unprotected steel beams above. In addition, penetrations in the walls were sealed with fire blocking foam rather than an approved, rated fire stopping material. 3) The door to the trash compactor room was not self-closing and did not latch into the frame due to a missing door handle and latch. 4) The door to the boiler room was missing door hardware, leaving an opening in the door which would allow the passage of smoke into the corridor. 5) The 1st floor maintenance shop room door was held open with a magnet, not tied to the fire alarm system. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 K321 Corrective Action: The maintenance director immediately audited all areas within the building to ensure any hazardous area has a 1-hour fire resistance rating, and the areas shall be separated from other spaces by smoke partitions in accordance with 2012 edition of NFPA 101. The following corrections have been made: On 12/20/2024, the concrete wall surrounding the generator room had an opening of 3- 4', communicating with the adjacent transfer switch room. This area has been sealed with concrete blocks to comply with a 1-hour fire rating. The tiles missing in the automatic transfer switch room were replaced. On (MONTH) 13, 2025, the door to the trash compacter room had the hardware replaced to include a panic bar door handle and latch to ensure the door was self-closing. On (MONTH) 13, 2025, the hardware on the boiler room door was replaced to ensure it was self-closing and did not allow the penetration of smoke. All penetrations in the walls that were sealed with fire blocking foam have been removed and replaced with an approved fire rated stopping material. Element 2 Residents at Risk: While no other residents were affected by this practice the potential existed for all residents and staff to be affected by this practice. All hazardous areas were inspected for similar deficiencies. None were found. Element 3 The policy and procedure for hazardous doors was reviewed and revised. All maintenance staff will be in- serviced on 2012 NFPA 101 19. 3. 2. 3 hazardous areas shall be safeguarded with a 1 hour fire rating. Documentation checklist for Life Safety Code Standards Observations will be implemented and include all components of hazardous areas shall be safeguarded by a fire barrier having a one hour resistance rating. Any negative findings will be addressed immediately. Audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director or designee will inspect all Hazardous Areas to ensure all areas are safeguarded by a fire barrier having a 1- hour fire resistive rating. The findings of all these audits to inspect all Hazardous Areas to ensure a 1-Hour Fire Rating will be reviewed monthly and reported to the Administrator. The maintenance director or designee will report findings to the QAPI Committee quarterly for a period of 6 months. QAPI Committee will determine any further actions. Element 5 Person Responsible: Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 2. 8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7. 8. 7. 8 Illumination of Means of Egress. 7. 8. 1 General. 7. 8. 1. 1* Illumination of means of egress shall be provided in accordance with Section 7. 8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7. 8. 1. 2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7. 8. 1. 2. 2. 7. 8. 1. 4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0. 2 ft-candle ( 2. 2 lux) in any designated area. 7. 8. 1. 2. 3* Energy-saving sensors, switches, timers, or controllers shall be approved and shall not compromise the continuity of illumination of the means of egress required by 7. 8. 1. 2 Based on observation and staff interview, the facility did not ensure that all illumination required for egress were prevented from being operated manually. This occurred on the 1st floor of the building. The findings include: During the life safety survey on 12/16/24, at approximately 11:15 AM, it was noted that the 1st floor egress passageway leading from stair C was equipped with a set of switches that shut off all lights in this area. At the time of these findings, the Director of Maintenance stated that this deficiency would be corrected. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1: Corrective Action: The light switches from stair c that shut off all lights in the 1st floor egress passageway were disconnected. The light source was reconnected to ensure that egress lighting is permanently powered and cannot be manually deactivated during building occupancy. Element 2: All residents have the potential to be affected by this practice. No residents were found to be harmed by this practice. All means of egress were inspected for similar deficiencies. None were found. Element 3: The policy for means of egress will be revised to reflect this new revision. Maintenance staff will be educated on this new revision. Element 4: Monitoring : The maintenance director will monitor all the stairwells monthly to ensure the handrails and landings are marked per NFPA 101 Illumination means of egress. The audit results will be reported to the administrator, and any areas of non-compliance will be immediately corrected. The maintenance director will report for one quarter the results of the audit to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance Director. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 2 Means of Egress Requirements. 19. 2. 1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19. 2. 2 through 19. 2. 11. 19. 2. 3. 5 The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving s stretchers. 19. 2. 3. 4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following: (1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width. Based on observation and staff interview, the facility did not ensure that all means of egress were kept free of impediments to egress, and that all corridors were maintained at least 48 in width. This was noted on the first floor of the facility. The findings include: During the life safety survey of 12/16/2024, between 9:00 AM and 12:00 PMthe following were noted: 1) In the first-floor corridor near the morgue, combustible items including wheelchairs and a floor polishing machine, were stored next to the door to the adjacent corridor. 2) In the first-floor corridor behind the kitchen, numerous boxes were stored on either side of the corridor, narrowing the corridor to less than the required 48. This storage was stated by the facility to be temporary but was noted to be in place on 12/16/24 at 10:30 AM and 12/17/24 at 9:15 am. 3) The discharge from stair B leads to a sprinklered parking structure and then out to a gate leading to the public way. This gate was locked and a means to open it was not made available to all staff. At the time of these findings, the Director of Maintenance stated that these deficiencies would be corrected. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 K 211. Immediate Corrective Action: The maintenance and housekeeping director immediately removed the wheelchairs, floor polishing machines, and other obstructive items stored near egress routes. All boxes observed in the corridor were removed. Metro Fire Alarm system and Technology tied the garage gate to the fire alarm system on (MONTH) 6, 2025 ; the gate now opens when the Fire alarm is activated. Element2: All residents have the potential to be affected by this practice. The maintenance and housekeeping director immediately audited all hallways within the building to ensure means of egress were not blocked, and no other issues were identified. Element 3: The fire alarm system's policy and procedure were reviewed, and the installation of an automatic parking lot gate opening will be added to the policy. All staff will be in-serviced for this new procedure. Maintenance and security will be trained to ensure that the gate is opened due to fire alarm activation and that it immediately closes when the alarm has been cleared. Element 4: The maintenance and housekeeping director will audit all corridors weekly to ensure they are free of impediments to egress and maintained at 48 in width. Results will be reported to the administrator monthly. On a monthly basis for three quarters, the maintenance and housekeeping director will report findings to the QAPI Committee for review. QAPI Committee to determine if further action is required. Element 5: Persons responsible: Maintenance and housekeeping director. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 3. 5. 12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9. 7. 4. 1. 9. 7. 4 Manual Extinguishing Equipment. 9. 7. 4. 1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 7. 2 Inspection. 7. 2. 1 Frequency. 7. 2. 1. 1* Fire extinguishers shall be manually inspected when initially placed in service. 7. 2. 1. 2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 7. 2. 2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items: (1) Location in designated place (2) No obstruction to access or visibility (3) Pressure gauge reading or indicator in the operable range or position (4) Fullness determined by weighing or hefting for selfexpelling- type extinguishers, cartridge-operated extinguishers, and pump tanks (5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers (6) Indicator for nonrechargeable extinguishers using pushto- test pressure indicators 7. 2. 2. 1 In addition to 7. 2. 2, fire extinguishers shall be visually inspected in accordance with 7. 2. 2. 2 if they are located where any of the following conditions exists: (1) High frequency of fires in the past (2) Severe hazards (3) Locations that make fire extinguishers susceptible to mechanical injury or physical damage (4) Exposure to abnormal temperatures or corrosive atmospheres 7. 2. 2. 2 Where required by 7. 2. 2. 1, the following inspection procedures shall be in addition to those addressed in 7. 2. 2: (1) Verifying that operating instructions on nameplates are legible and face outward (2) Checking for broken or missing safety seals and tamper indicators (3) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle Based on observation, staff interview and record review, the facility did not provide records indicating that all the extinguishers throughout the facility had undergone monthly inspections. This occurred on all four floors of the building. The findings include: During the life safety survey on 12/16/24 at approximately 10:00 AM, it was noted that the fire extinguisher located in the 1st floor atrium had a hang tag which had no monthly inspections recorded. A vendor was observed changing the tag on this extinguisher shortly before this finding. At the time of the finding, the Director of Maintenance stated that the vendor was in the building that morning to conduct monthly inspections and it was their policy to take the old tags off the extinguishers if the record was full. However, there was no inspection recorded on the new extinguisher tag. A subsequent inspection of extinguishers on floors 1-4 revealed that no inspections were recorded for any of the extinguishers in the building. On 12/17/24 at approximately 10:15 AM, during a review of testing and maintenance documents, the facility provided a fire extinguisher inspection log. This log did not contain a complete inventory of all extinguishers in the building. 2012 NFPA 101 2010 NFPA 10 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Immediate Corrective Action: All fire extinguishers in the building including the 1st floor atrium, were inspected immediately to ensure compliance with fire safety standards. The maintenance staff will ensure that each extinguishers has a correctly dated inspection tag. Old hangtags will only be removed after transferring all record to the new tag. A specific protocol was established for transitioning all records to the new tag. A specific protocol will be established for transitioning between old and new tags to prevent lapses in inspection documentation. A meeting will be held with the vendor to review their inspection responsibilities and documentation standards. Element 2 All residents have the potential to be affected by this practice however no residents were affected as a result of this practice. Element 3 Systemic Changes: Policy was reviewed and revised to reflect that old hand tags will only be removed after transferring all record to the new tag. A specific protocol will be stablished for transitioning between old tags to prevent lapses in inspection documentation. The maintenance will implement a Fire Extinguisher log to ensure compliance. The maintenance director will audit to ensure all fire extinguisher's are inspected and documentation up to date. Element 4 The maintenance director will audit to ensure all fire extinguisher's are inspected monthly and documentation up to date. The maintenance director will monitor compliance and report findings to administrator monthly. The maintenance director will report findings to the QAPI Committee on a quarterly basis for 3 quarters. QAPI Committee will determine if further action is required. Element 5 Person responsible : Maintenance director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
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. 2010 NFPA 139. 1. 1. 7* Support of Non-System Components. Sprinkler piping or hangers shall not be used to support non-system components. Based on observation and staff interview the facility did not ensure that all areas of the nursing home were protected by the automatic sprinkler system. This occurred on the first floor of the building. The findings include: During the life safety survey on 12/16/24 at approximately 10:45 AM, the following were noted: 1) There was no sprinkler protection underneath stair D at the first- floor lowermost landing. 2) The atrium located off of the lobby was provided with sprinklers above the windows on one side of the space. However, it was not clear if these sprinkler heads would provide the necessary coverage for the entire space, which measured approximately 30' by 40'. 3) In the fire pump room, electrical BX cable was found to be suspended from sprinkler piping. At the exit conference on 12/17/24, at approximately 1:35 PM, the Administrator stated that the sprinkler vendor would be called to address these issues. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Immediate Corrective Action : The facility immediately consulted a licensed fire protection vendor to add a head to provide sprinkler coverage under stairway D. The fire protection vendor conducted a through assessment to verify sprinkler head placements above the Atrium/Lobby windows, additional sprinkler heads will be added every 7 feet to ensure necessary coverage for the entire space in the atrium. The BX cable suspended from sprinkler piping was immediately secured using appropriate non-piping support brackets to comply with NFPA 2012 101 19. 3. 5. 1 requirements. All sprinkler piping in the facility was inspected to ensure no other electrical cables or utilities are improperly supported. The maintenance director visually inspected the entire facility no other issues were identified. Element2 Residents at Risk: While no residents were affected by this practice the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: Maintenance and engineering staff were retrained on sprinkler system requirements including: Proper sprinkler head placement and overage. Prohibition of using sprinkler pipes for utility support. Updated the facility's preventive maintenance program to include a semi annual review of sprinkler systems by our Life Safety Consultant from Ridgefield Associates. Maintenance logs will be reviewed by the maintenance director monthly to ensure compliance. Element 4: Monitoring: The maintenance director will conduct monthly inspections of sprinkler systems coverage and utility compliance. Quarterly audits of sprinkler systems will be conducted by an external fire protection contractor and Ridgefield Associates for the next 12 months. Audit results will be reported to the administrator for compliance, any negative findings will be corrected immediately. The maintenance director will report for the next 3 quarters the results of the inspections to the QAPI Committee. QAPI Committee will determine if further action is required. Element 5 Person responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 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. 2011 NFPA 25 5. 2* Inspection. 5. 2. 1 Sprinklers. 5. 2. 1. 1* Sprinklers shall be inspected from the floor level annually. 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). 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. Based on observation and interview, the facility did not inspect, test and maintain all components of the sprinkler system in accordance with 2011 NFPA 25. The findings include: During the life safety survey of 12/16/24 and 12/17/24, between 9:00 am and 1:00pm, the following were noted: 1) Sprinkler heads were missing escutcheons in the spaces including but not limited to: the 1st floor IT room, the secondary ATS room on the 1st floor next to the IT room, the 1st floor oxygen storage room, the exit passageway leading from the 1st floor landing of stair C. 2) No record of the 5 year internal pipe inspection was found in the maintenance, testing and inspection records. At the time of these findings, the Director of Maintenance stated that these issues would be corrected. 2012 NFPA 101 2011 NFPA 25 10 NYCRR 711. 2(a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Corrective Action: 1) The facility installed escutcheon plates on the identified sprinklers on the 1st floor next to the IT room, the secondary ATS room on the 1st floor next to the IT room, the 1st floor oxygen storage room, the exit passageway leading from the 1st floor landing of stair C. 2) The facility engaged our licensed sprinkler inspection and testing vendor to complete the 5 year internal pipe inspection, testing was completed on (MONTH) 8, 2025. Element 2 While no residents were affected by this practice the potential exists for residents to be affected by this practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy requirements to maintain the sprinkler system training will included: Inspection and testing requirements for the Automatic Sprinkler system in accordance with 2012 NFPA 25, and the maintenance of all components of the sprinkler system. Audit tool was developed to monitor compliance. Element 4: Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis for 3 quarters/6 months. The QAPI Committee will determine is further action is required. Element 5: Person Responsible: Maintenance director |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2011 NFPA 25 15. 1 General. 15. 1. 1 Minimum Requirements. 15. 1. 1. 1 This chapter shall provide the minimum requirements for a water-based fire protection system impairment program. 15. 1. 1. 2 Measures shall be taken during the impairment to ensure that increased risks are minimized and the duration of the impairment is limited. 15. 2 Impairment Coordinator. 15. 2. 1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter. 15. 4 Impaired Equipment. 15. 4. 1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service. 15. 4. 2 The impaired equipment shall include, but shall not be limited to, the following: (1) Sprinkler systems (2) Standpipe systems (3) Fire hose systems (4) Underground fire service mains (5) Fire pumps (6) Water storage tanks (7) Water spray fixed systems (8) Foam-water systems (9) Fire service control valves 15. 6. 1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. 15. 6. 2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. 15. 5. 2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. Based on document review and staff interview, the facility did not prepare and maintain a policy for actions to be taken if the sprinkler system is out of service. The findings include: On 12/16/2024 at approximately 9:45AM, the sprinkler head in a closet on the 1st floor ,which was stated to be under construction, was found to be fitted with a protective cover. This cover would render the sprinkler head inoperable in the event of an emergency. It was not clear how long the sprinkler head had remained covered, and there was no record of a fire watch being conducted in this area while the sprinkler head was impaired. On 12/17/24, a review of the facility's sprinkler documents and emergency preparedness policy revealed that there was no policy in place for the protection of occupants if the automatic sprinkler system was out of service for greater than 10 hours. At the exit conference on 12/17/24 at approximately 1:40 pm, the facility's Administrator stated that they would develop a policy for this. 2011 NFPA 25 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1 Corrective Action: The protective cover was removed to immediately upon identification to restore full operability of the sprinkler head. A facility wide-inspection was conducted to ensure no other sprinkler heads were obstructed or otherwise impaired. All sprinkler heads were confirmed to be in proper working condition. A policy was developed and implemented to address the following: Procedures for protecting occupants when the sprinkler system or a portion of it is out of service for more than 10 hours, including interim life safety measures. Routine inspection of sprinkler systems during construction or maintenance projects. Prohibition of any action that impairs the functionality of sprinkler systems without proper documentation, risk assessment, and notification. Element 2 Residents at Risk: While no residents were affected by this practice the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy and requirement's to maintain the sprinkler system training will include: Recognizing and reporting conditions that impair sprinkler system operations. Steps to implement life safety measures when sprinklers are out of service. Audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly review all to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on quarterly basis. The QAPI Committee will determine mine if further action is required. Element 5 Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 2 Means of Egress Requirements. 19. 2. 1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19. 2. 2 through 19. 2. 11. 7. 2. 2. 1 General. 7. 2. 2. 1. 1 Stairs used as a component in the means of egress shall conform to the general requirements of Section 7. 1 and to the special requirements of 7. 2. 2, unless otherwise specified in 7. 2. 2. 1. 2. 7. 2. 2. 5. 5. 1 Exit Stair Treads. Exit stair treads shall incorporate a marking stripe that is applied as a paint/coating or be a material that is integral with the nosing of each step. The marking stripe shall be installed along the horizontal leading edge of the step and shall extend the full width of the step. The marking stripe shall also meet all of the following requirements: (1) The marking stripe shall be not more than 1?2 in. (13 mm) from the leading edge of each step and shall not overlap the leading edge of the step by more than 1?2 in. (13 mm) down the vertical face of the step. (2) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm) and a maximum width of 2 in. (51 mm). (3) The dimensions and placement of the marking stripe shall be uniform and consistent on each step throughout the exit enclosure. (4) Surface-applied marking stripes using adhesive-backed tapes shall not be used. 7. 2. 2. 5. 5. 2 Exit Stair Landings. The leading edge of exit stair landings shall be marked with a solid and continuous marking stripe consistent with the dimensional requirements for stair treads and shall be the same length as, and consistent with, the stripes on the steps. 7. 2. 2. 5. 5. 3 Exit Stair Handrails. All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements: (1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. 7. 2. 2. 5. 5. 4 Perimeter Demarcation Marking. Stair landings, exit passageways, and other parts of the floor areas within the exit enclosure shall be provided with a solid and continuous perimeter demarcation marking stripe on the floor or on the walls or a combination of both. 2012 NFPA 101: 7. 2 Means of Egress Components. 2012 NFPA 101: 7. 2. 1 Door Openings. 2012 NFPA 101: 7. 2. 1. 1 General. 2012 NFPA 101: 7. 2. 1. 1. 1 A door assembly in a means of egress shall conform to the general requirements of Section 7. 1 and to the special requirements of 7. 2. 1 2012 NFPA 101: 7. 2. 1. 15. 2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80: 4. 2. 1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that all egress stairs were maintained in accordance with 2012 NFPA 101. This occurred in all four of the facility's stairwells. The findings include: During the life safety survey on 12/16/24 and 12/17/24, between 9:00 am and 12:00pm, the following were noted: 1) In egress stairs A, B, C and D, the handrails and landings were lacking the required contrasting colored marking stripes. 2) The door at the first-floor landing was lacking the required fire rating label. At the time of these findings, the Director of Maintenance stated that these deficiencies would be corrected. 2012 NFPA 101 2010 NFPA 80 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedJanuary 13, 2025 Element 1: Immediate Corrective Action: A full inspection of all stairways used as a means of egress was audited to identify areas lacking compliant marking stripes and was conducted by the maintenance director. The maintenance staff immediately began marking the handrails and landings in all areas noted for compliance. The facility engaged a licensed Fire Door vendor to inspect and affix a fire rating tag on the identified fire door on the 1st floor landing. Element 2: All residents have the potential to be affected by this practice. No residents were harmed due to this practice. Element # 3 The policy and procedure for Egress and marking stripes were reviewed, and revisions have been made on means of egress and marking of handrails and landings. The maintenance director was educated on the means of egress requirements, explicitly marking the handrails and landings in all stairwells. Education and training will be given to all staff on the markings of handrails and landings. Element 4: Monitoring of Corrective Action: The maintenance director or designee will audit all stairwells and fire doors weekly to ensure that all handrails and landings are appropriately marked in accordance with 2021 NFPA 101. The results of this audit will be reported to the administrator monthly. The maintenance director will report the findings of this audit for one quarter to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Maintenance director |